Medicare is one of America’s most important health programs, providing health insurance for tens of millions of adults over 65 and people with disabilities. As with private insurance, transgender people sometimes encounter confusion about what is covered or barriers to accessing coverage—both for transition-related care and for routine preventive care.
Medicare covers routine preventive care, including mammograms, pelvic and prostate exams. Medicare has to cover this type of care regardless of the gender marker in your Social Security records, as long as the care is clinically necessary for you. The Medicare manual has a specific billing code (condition code 45) to assist processing of claims under original Medicare (Parts A and B). This billing code should be used by your physician or hospital when submitting billing claims for services where gender mis-matches may be a problem.
Medicare also covers medically necessary hormone therapy for transgender people. These medications are part of Medicare Part D lists of covered medications and should be covered when prescribed. Private Medicare plans should provide coverage for these prescriptions. All Medicare beneficiaries have a right to access prescription drugs that are appropriate to their medical needs.
For many years, Medicare did not cover transition-related surgery due to a decades-old policy that categorized such treatment as "experimental." That exclusion was eliminated in 2014, and there is now no national exclusion for transition-related health care under Medicare.
In practice, this means coverage for transition-related care will be decided on a case-by-case basis, no different than how Medicare handles coverage for most other medical treatments. For example, in 2015 the Medicare Appeals Council issued a decision ordering a Medicare plan to pay for transition-related surgery for a transgender woman because it was reasonable and necessary to treat gender dysphoria.
Some Medicare Advantage plans and local Medicare contractors have specific policies for coverage of transition-related care that serve as guidelines for their decision to authorize coverage.
No, it should not. Medicare should provide coverage of medically necessary transition-related care regardless of your state.
Whether you have Original Medicare (Part A and B) or private Medicare (Medicare Advantage), Medicare should provide coverage of medically necessary transition-related care. The same should be true for prescription drugs.
However, if you have Medicare Advantage you should make sure to consult your member handbook for more details about your plan (see this helpful video from Transcend Legal on how to find your booklet and understand your coverage). You should also find out if your plan has a specific medical policy with specific Medicare Advantage guidelines and conditions on coverage for transition-related care (these are some examples of these types of policies). If you have a Medicare Advantage plan, we recommend you apply for preauthorization before accessing transition-related care.
If you experience a denial of coverage you believe to be inappropriate (including coverage of preventive services or transition-related care), you may file an appeal. We highly recommend that you consult with a lawyer before doing so
Original Medicare (Parts A and B) beneficiary cards no longer list gender. Your Medicare insurance records will typically be based on Social Security data.
As a reminder, the gender marker you have in the Medicare record system should not impact access to care. Medicare should provide access to all clinically appropriate services for your body, including services typically considered to be “sex specific” (such as pap smears or prostate exams). The Medicare manual has a specific billing code (condition code 45) to assist processing of claims under original Medicare (Parts A and B). This billing code should be used by your physician or hospital when submitting billing claims for services where gender mis-matches may be a problem.
If you encounter disrespect, harassment or other discrimination or inappropriate treatment related to being transgender, you may make a complaint. For problems when making inquiries or appeals in a private Medicare Advantage or Part D plan, you may file a complaint or grievance with your plan. For any other customer service problems, we recommend contacting your regional Center for Medicare and Medicaid Services (CMS) office.
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