Original Medicare (Part A and Part B) may cover gender reassignment surgery, but only in limited instances and only on a case-by-case basis.
Some Medicare Advantage (Part C) plans may cover gender reassignment surgery if a specific case meets strict criteria that are decided on a case-by-case basis.
As of August 2016, the Centers for Medicare and Medicaid Services (CMS) have not issued a national coverage determination (NCD) on gender reassignment surgery for Medicare beneficiaries who suffer from gender dysphoria.1
When will Medicare pay for gender reassignment surgery?
Gender reassignment surgery includes surgical procedures that help people achieve a physical appearance that coincides with their preferred gender. This can include:
- “Top” surgery involving the breast tissue (removal or addition)
- “Bottom” surgeries involving removal of the ovaries, uterus and vagina in women, or penis, scrotum and prostate in men, accompanied by genital reconstruction
Medicare may not cover your gender reassignment surgery. Beneficiaries who seek gender reassignment surgery (also called gender-affirming surgery) may have been diagnosed with gender dysphoria.
Gender dysphoria was once also known as gender identity disorder. The term is used to describe significant psychological discomfort a person may have with their biological sex or gender assigned at birth.
If Medicare covers your gender-affirming surgery, Medicare Part A or Part B may cover some of your costs, depending on where your procedure is done:
- The hospital and inpatient care costs related to the gender reassignment surgery are typically covered by Medicare Part A (Hospital Insurance)
- Any doctor’s services related to the gender reassignment surgery are typically covered by Medicare Part B (Medical Insurance)
How much does gender reassignment surgery cost with Medicare?
If you meet Medicare’s criteria for gender reassignment surgery, Medicare may cover some of the costs associated with the procedure.
Depending on whether Part A or Part B covers your surgery, you may have to pay some of the following costs:
- Part A deductible
- Part A coinsurance
- Part B deductible
- Part B coinsurance or copayment
Medicare Part A deductible is related to inpatient hospital costs
The Medicare Part A deductible is $1,364 per benefit period in 2019.
A benefit period starts as soon as you are admitted for inpatient hospital care and ends when you haven’t received inpatient care for 60 consecutive days. You must meet the Part A deductible for each benefit period before your Part A coverage kicks in.
Medicare Part A coinsurance
After you meet your Part A deductible, you may be required to pay Part A coinsurance costs for hospital stays that last longer than 60 days:
- Days 1-60 spent in the hospital: $0 coinsurance for each benefit period
- Days 61-90: $341 coinsurance per day of each benefit period in 2019
- Days 91 and beyond: $682 coinsurance per each “lifetime reserve day” after day 90 for each benefit period in 2019
- Beyond lifetime reserve days: you pay all costs
You cannot get more lifetime reserve days once they are gone.
Medicare Part B deductible related to outpatient expenses
As of 2019, the Medicare Part B deductible is $185 per year. You must meet this deductible before your Part B coverage will kick in for the year.
Medicare Part B coinsurance or copayment
You are typically responsible for 20 percent of the Medicare-approved amount for most doctor’s services once your deductible is met.
There is no annual limit on how much you could pay for the Part B coinsurance in a given year. If your gender reassignment surgery is performed as outpatient surgery, your Part B coinsurance or copayment costs could add up quickly.
We recommend speaking with your doctor directly for specific cost and coverage information.
Medicare Advantage plans include an out-of-pocket spending limit
Medicare Advantage plans are sold by private insurance companies as an alternative to Original Medicare, and they are required to cover everything that Original Medicare covers.
If your gender reassignment surgery would be covered by Original Medicare, it would also be covered by a Medicare Advantage plan.
If you have a Medicare Advantage plan and are considering gender reassignment surgery, you should speak directly with your plan carrier for more information about whether or not your plan will cover the surgery.
Some Medicare Advantage plans may also offer additional benefits that Original Medicare doesn’t cover, such as:
- Prescription drug coverage
- Routine dental, hearing and vision care
- Health and wellness program benefits, such as free gym memberships
To learn if you are eligible to enroll in a Medicare Advantage plans and to find plans that are available where you live, call to speak with a licensed insurance agent today.
Compare Medicare Advantage plans in your area
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