Medicare may provide coverage for gender reassignment surgery, also called gender affirmation surgery, if a doctor deems it medically necessary. A person can appeal the decision if surgery is denied.
While Medicare coverage is nationwide, states may vary in policies and guidelines. Individuals should check their state policies of coverage to check whether gender affirmation surgery may be covered.
This article discusses gender affirmation surgeries, Medicare coverage, enrollment, and costs.
Glossary of Medicare terms
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare does not cover procedures that it considers cosmetic surgery. Until 2014, it did not cover surgeries to confirm a person’s gender at all. It later changed that rule to include surgeries for medical reasons, including gender affirmation.
Despite this change, the Centers for Medicare & Medicaid Services (CMS) has not created a national policy. This means a person’s individual plan will decide whether the surgery is medically necessary.
This online tool can help an individual find more information about their local state policies.
Medicare Advantage
Medicare Advantage (Part C) plans are sold by private companies.
These plans combine the benefits of parts A and B (Original Medicare) and generally provide the same coverage. Some plans also pay for medications.
However, because there is no nationwide policy on access to gender affirmation surgery, a person’s Medicare Advantage plan can decide whether the surgery is considered necessary and reasonable.
Individuals must go to doctors who accept Medicare. If the person has a Medicare Advantage plan, then they must go to doctors who are within their network. If they would like to use a doctor outside of the Medicare Advantage network, they must get permission to do so.
To find out if coverage is available, a person can check with their plan, or use the Medicare online tool.
Part D
Medicare Part D pays for hormone therapy to address gender dysphoria. However, if a person does not have Medicare Part D or Medicare Advantage, they may have to pay for prescription medications themselves. Prior authorization is also generally required in order for coverage to be approved.
Learn more about Original Medicare vs. Medicare Advantage.
Individuals age 65 years and older can enroll in Medicare. Some younger people with certain disabilities or health conditions, such as end stage renal disease, can also qualify for Medicare.
People can enroll online through Social Security or at their local Social Security office.
A person can enroll in Medicare at various times during the year. Medicare enrollment periods include:
- Initial enrollment period (IEP): The IEP begins 3 months before a person can sign up for Medicare on their 65th birthday and ends 3 months after their 65th birthday.
- Open enrollment (OEP): Medicare OEP runs from October 15 to December 7 each year. During this time individuals can join, drop, or change plans.
- Medicare Advantage OEP: This runs from January 1 to March 31 each year. During this period, people with Medicare Advantage can make changes to their plans.
- Special enrollment period (SEP): SEPs are times when people can sign up for Medicare or make changes to their plan due to specific circumstances.
If a person does not sign up for Medicare during one of these specific times, they may be charged a late penalty fee.
Learn more about Medicare enrollment periods.
Most people do not pay a premium for Part A. However, if a person does not qualify for premium-free Part A, they must pay a premium. In 2024, the monthly premium for Part A is $505, according to a Medicare fact sheet.
If a person goes to the hospital, they have a $1,632 deductible for every benefit period. There is no coinsurance if a person is discharged within 60 days.
The standard premium for Medicare Part B in 2024 is $174.70 each month, plus a $240 annual deductible cost. After a person pays the deductible, Medicare pays 80% of the allowable costs. The coinsurance is 20% of the charges.
Premiums for Medicare Advantage plans or Part D plans vary depending on the company providing the plans. An online tool can help people find and compare plan costs.
The cost of gender affirmation surgery with Medicare depends on which surgeries a person requires and what medications they need after surgery. Individuals will likely pay the $1,632 Medicare Part A deductible for some of the major surgeries. They will also generally pay the Part B deductible and 20% coinsurance on any outpatient procedures.
Gender affirmation surgery is usually the last step in the process of changing from one sex to the other. The surgery can help a person with gender dysphoria transition to another sex.
The process usually begins with psychotherapy to determine whether a person is ready to go through a permanent physical change. Following that decision, the next phase usually
Males typically take estrogen and females take androgens (male sex hormones).
The purpose of hormone therapy is to change a person’s physical appearance. For example, females who take androgens may develop facial hair, while males who take estrogen may experience weight redistribution and changes in the skin.
There can be complications from therapy, however. Estrogen therapy
Androgen therapy may increase blood pressure, insulin resistance, and cholesterol levels.
Healthcare professionals may ask a person to take on the role of the desired sex, socially and professionally, for up to a year before surgery.
Surgery is the final step in gender affirmation. It may take several surgeries to complete the change from male to female or female to male.
Learn more about gender affirmation surgeries.
The aim of the surgery is to give an individual the appearance and function of their desired gender.
To achieve this, a person may need to have several surgeries. As such, the surgical team often includes a plastic surgeon, urologist, gynecologist, and an ear, nose, and throat specialist.
Surgeries may include several steps, depending on the desired changes.
Female to male
This may include:
- mastectomy or breast reduction
- nipple graft
- removal of the uterus and ovaries
- closure of the vagina
- creation of a penis and scrotum
- extension of the urethra through the penis, via a tube from the bladder to the outside of the body
- penile implant
- synthetic testicles
- voice surgery
- liposuction
Male to female
This may include:
- facial feminization
- nose surgery
- eyebrow lift
- jaw surgery
- chin reduction
- enhancement of cheekbones
- lip lift
- female hairline
- laser hair removal
- hair reconstruction
- liposuction
- voice change
- reduction of the Adam’s apple
- breast augmentation
- removal of penis and scrotum
- creation of vagina, clitoris, and labia
Medicare pays for gender affirmation surgery and hormone replacement therapy, as long as the surgery is deemed medically necessary. A person typically requires several surgeries to complete the gender affirmation process.
Medicare Advantage plans may apply different rules when considering approval for surgeries. Individuals should check their plans for more information.
A person must pay the same premiums and deductibles as they would for other surgeries or medical treatments.