Does Medicare Cover Transgender Health Care?

Key Takeaways:

• Eligible Medicare enrollees have access to Medicare regardless of gender.

• Medicare covers hormone therapy under Part D when prescribed.

• Gender reassignment surgery is covered by Medicare on a case-by-case basis. The surgery must be approved by the insurer.

• Transgender people are protected by law from discrimination in health care.

Health Care Options Available to Transgender People Through Medicare

Besides basic Part A and Part B, there are also other available services to transgender people. These treatment routes may be recommended by your doctor if you have gender dysphoria. Your healthcare provider can evaluate you and make a diagnosis.

Gender dysphoria may cause distressing disharmony between your expressed gender and your physically assigned gender. Treatment of gender dysphoria includes:

• Mental health care: behavioral therapy and psychotherapy

• Hormone therapy

• Gender reassignment surgery (GRS)

Mental Health Care Benefits for Transgender People with Medicare

You have access to mental healthcare professionals through Medicare Part B. Services available to you include:

• One time preventive visit to assess your depression risk

• Free annual depression screening

• Diagnostic tests

• Psychotherapy

• Psychiatric evaluation

Some transgender affirming mental healthcare providers treat Medicare beneficiaries. Such providers would be competent at addressing mental health needs of transgender people.

Unless you get extra help with your bills, you would be responsible for out-of-pocket costs. These costs include your plan's premiums, deductibles, coinsurance, and copayments.

Does Medicare Cover Hormone Therapy for Transgender People?

Medicare covers medically necessary hormone therapy for transgender people. The therapy would be deemed "medically necessary" if prescribed by a health professional. This hormone therapy prescription may be in connection with gender dysphoria. It is usually given in preparation for GRS.

To get this coverage under Original Medicare, you will need a prescription drug plan (Part D).

Private Medicare Advantage plans usually bundle Part A, Part B, and Part D coverage with extra benefits. This coverage will be helpful as your health providers assess your response to treatment. Generally, hormone therapy may be feminizing or masculinizing. Feminizing hormone therapy may use:

• Medications that block male hormone testosterone

• Female hormone, estrogen

Masculinizing hormone therapy may use:

• Male hormone, testosterone

If your doctor considers this therapy medically necessary, your Part D benefits will cover the cost of the hormones. Under Medicare Part B, your doctor visits and routine lab work are covered. Depending on your plan, you may still have to pay out of pocket for premiums, deductibles, copayments, and coinsurance.

Does Medicare Cover Gender Reassignment Surgery?

Medicare covers medically necessary GRS on a case-by-case basis. These decisions are made by local insurers who process Medicare claims. If you are diagnosed with gender dysphoria, your doctors and mental health care team may recommend GRS. For private MA enrollees, the decision of whether GRS is necessary is made by their plans. The surgery can include:

• Genital reconstruction

• Breast or chest surgery

When approved, your GRS would be covered by Medicare Part A and Part B. Part A would meet the costs of your hospital and inpatient care while Part B would cover your healthcare provider fees. However, you would be responsible for standard out-of-pocket costs including:

• $1,408 Part A deductible

• Part A — coinsurance depending on length of hospital stay

• Part B deductible — starts at $144.60 and increases by income tier

• Part B coinsurance or copayment

For the majority of services covered by Original Medicare, you would pay about 20% of bills, unless you supplement your coverage with a Medicare Supplement plan. The costs of Medicare Advantage plans vary by provider, but have annual spending limits. Many of these plans charge $0 premiums.

What Can You Do if You Are Denied Medicare Access as a Transgender Person?

According to Section 1557, you are protected from discrimination on the basis of sex in health care. Beyond that, companies that contract with Medicare must observe non-discrimination laws.

The Centers for Medicare and Medicaid Services (CMS) has received complaints about transgender people being denied access to Medicare Part A and Part B. These access issues were largely caused by certain procedures being considered appropriate only for specific genders.

Consequently, if the gender indicated on a person's Social Security card was not consistent with a health service, some insurance claims were rejected. Common healthcare services linked to such issues include:

• Mammograms

• Pelvic exams

• Prostate exams

Your provider may be able to use billing codes provided by the CMS to override access issues. If you are wrongfully denied access to gender related health care, you can:

• Appeal — With this option, you have the right to receive a fair review of the health plan's decision in a timely manner. You may either appeal internally for review by your insurance provider, or externally for decisions to be made by an independent third party.

• File a complaint — Report your access issues to the CMS by email to marketconduct@cms.hhs.gov, or contact your state's Department of Insurance. You can also:

  • Call 1-800-368-1019, or 1-800-537-7697 (for TTY users) to file a complaint with the Department of Health and Human Services.

  • File a Civil Rights complaint.

  • Write to the Office of Civil Rights at the address: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201.

Grace Kisirkoi works in higher education and is a writer who specializes in finance.