Does Medicare Cover Gender Reassignment Surgery?

Original Medicare (Part A and Part B) will cover gender reassignment surgery, but there are some guidelines of which you should be aware if you are planning such a procedure. Also known as gender confirmation surgery or gender affirmation surgery, your Original Medicare coverage will help you pay when it is medically necessary.

In addition to gender-affirming surgeries, Medicare will also provide coverage for doctor visits and hospitalization following your surgery. Below, we outline how Medicare covers gender reassignment surgery.

Does Medicare Cover Transgender Surgery?

Gender reassignment (or gender confirmation) surgery changes sex characteristics from one gender to the other. Some examples of this surgery include:

• Transmasculine bottom surgery: Removes female sex organs to create male genitalia through a phalloplasty
• Top surgeries
• Transfeminine surgery removes a penis and testicles to create a transgender vagina.

Until 2014, Original Medicare would not cover gender confirmation surgery due to outdated thinking involving LGBTQ+ healthcare.

Today, Original Medicare provides coverage for gender confirmation surgery on a case-by-case basis in the same way it applies such standards for various other treatments and procedures.

To receive coverage, your doctor must deem the procedure medically necessary. However, the Centers for Medicare & Medicaid Services (CMS) does not have a national precedent for approving or denying gender affirmation surgery. Thus, Medicare will decide if the surgery is medically necessary based on your state and local precedents.

To be considered a good candidate for gender reassignment surgery, you should:

• Have a diagnosis of gender dysphoria
• Provide proof of counseling
• Provide evidence of hormone therapy

In recent years, LGBTQ+ healthcare has become a national priority and Medicare follows suit with coverage.

If you face denial of coverage you feel rightfully entitled to, the Medicare appeals process is there to help you file an appeal and receive protection.

Does Medicare Cover Top Surgery?

Classifying top surgeries under Medicare means determining whether the procedure is necessary or cosmetic.

Your Medicare plan will cover surgeries that are medically necessary, but not for cosmetic purposes.

For example: During a female-to-male or female-to-nonbinary transition, Original Medicare will pay for the removal of breasts and reconstruction of your chest. In a male-to-female or male-to-nonbinary transition, things are a bit different. While Medicare will cover necessary top surgeries to complete the transition, it will not cover breast enhancements for cosmetic reasons.

Navigating top surgery can be complex, as it depends on the situation at hand. The key is to remember is that your coverage applies when the surgery is related to your medical needs rather than aesthetics.

Does Medicare Cover Facial Feminization Surgery?

Unfortunately, Medicare will not cover facial feminization surgery to reduce the size of facial features such as one’s nose or chin. This is because these procedures have no medical benefit and are only used as a form of cosmetic surgery to enhance your appearance.

Additionally, your Medicare coverage does not include vocal cord surgeries, body contouring, and hair removal procedures for the same reason.

Does Medicare Cover Transgender Hormones?

Hormone therapy for transgender people is covered by Original Medicare when it is medically necessary for the patient.

In these cases, Medicare Part D Prescription Drug plans and Medicare Advantage plans with drug coverage will cover the hormone therapy medication based on the plan’s formulary.

Medicare Coverage for Gender Affirming Surgery

Original Medicare coverage will work in different ways to help mitigate your healthcare costs when receiving gender-affirming surgery:

• Medicare Part A focuses on covering the costs of your hospital stay, if necessary
• Medicare Part B is there to cover outpatient procedures
• Medicare Part D covers prescription drugs such as hormone therapy

All Medicare coverage continues to depend on whether your procedures are medically necessary.

However, transgender and non-binary individuals are entitled to the right to receive healthcare. Thus, Medicare covers preventive care regardless of gender markers.

This includes prostate exams, mammograms, colonoscopies, etcetera.

Medicare Advantage Plans and Gender Affirmation Surgery

By law, Medicare Advantage (Part C) plans must offer the same coverage as Original Medicare. No matter which plan you have, if your procedure qualifies, you will be covered.

Yet, your Medicare Advantage coverage may come with additional guidelines regarding your gender confirmation surgery.

For these reasons, it is essential to pre-authorize your gender-affirming surgery with your Medicare Advantage plan before receiving healthcare treatments related to your transition.

This is because private companies manage Medicare Advantage plans. So, there are extra guidelines to follow including referrals and networks.

Remember, depending on your Medicare Part C plan, you may not be covered outside of your network. So if you cannot find a doctor within your network that performs a gender-affirming surgery, your costs will be much higher.

How to Find Sex Reassignment (SRS) Surgeons That Accept Medicare

Undergoing gender confirmation surgery takes a healthcare team that is prepared to handle the uniqueness of this procedure. Original Medicare alone will provide coverage, but there are many other expenses that can increase your costs.

A Medicare Supplement plan (Medigap) can help mitigate high expenses for gender-affirming surgery, and the licensed insurance agents at MedicareFAQ are here to help you find the right plan for your needs.

Contact us today at the number above, or fill out our online rate form to explore Medigap plans in your area. Our insurance representatives can help you find affordable coverage for your gender confirmation surgery.

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