Medicare pays for several gender affirmation treatments when medically necessary. Different parts of Medicare cover different elements of gender affirmation.
Gender affirmation is a series of procedures that help a transgender person’s body match their gender identity. Doctors used to refer to these procedures as “gender reassignment surgery,” and some still refer to it as gender confirmation.
Several treatments, including hormone therapy and counseling, can support a transgender individual during their transition. Medicare may cover these treatments in some cases.
This article explains the coverage for gender affirming care for Medicare beneficiaries.
If gender affirming care is medically necessary for a particular individual and they are over the age of 18 years, Medicare will fund the procedure. However, this was not always the case.
Up until 2014, Medicare deemed gender affirmation to be experimental. However, the organization updated its ruling in 2014 after considering newer studies on the medical necessity of gender affirmation services for transgender individuals who chose to receive them.
Local Medicare Administration Centers (MACs) determine the medical necessity of individual cases. In 2016, the Centers for Medicare & Medicaid Services (CMS) issued a statement deferring decisions around the medical necessity of gender affirmation treatment to local centers on a case-by-case basis.
However, in 2024, the Department of Health and Human Services (HHS) finalized a ruling related to gender affirmation care in Section 1557 of the Affordable Care Act, which provides nondiscrimination protections.
The ruling bans state administrators from completely denying cover for gender affirmation on the basis of sex, stating that people must receive treatment consistent with their gender identity.
Learn about the importance of gender affirming care.
Medicare pays for gender affirming care that doctors deem medically necessary. The coverage may include:
- psychotherapy
- hormone therapy
- gender affirmation surgery
Hormone therapy
Medicare covers hormone therapy, which people receive during any of the above transitions.
When someone assigned male or intersex at birth transitions, they can take estrogen to develop feminizing characteristics. In estrogen therapy, they may also take medications called antiandrogens to suppress male sex-linked hormones.
People transitioning can undergo testosterone therapy to induce masculine characteristics and suppress estrogen.
Gender affirmation surgery
Gender affirmation surgery refers to a range of surgeries that empower transgender individuals to alter their physical appearance in line with their gender identity.
Medicare pays for these when a doctor confirms their medical necessity, so long as an individual has a diagnosis of gender dysphoria and has worked through a gender affirmation plan with a doctor. However, Medicare does not cover cosmetic procedures.
Medical professionals commonly divide these procedures into top and bottom surgeries depending on which half of the body they affect.
Top surgery refers to surgeries that masculinize the chest by removing breast tissue or feminize the chest by using breast implants.
Bottom surgeries include procedures that affect the internal and external genitals. Medicare covers several procedures that can reconstruct the genitalia, including the following:
- phalloplasty and metoidioplasty to construct a penis in transmasculine surgeries
- testicular implants and scrotoplasty to construct a scrotum in transmasculine surgeries
- penile inversion and vaginoplasty to construct a vagina that retains tactile and sexual sensation
- oophorectomy, which is the removal of the fallopian tubes and uterus
- hysterectomy, which is the removal of the uterus
- orchiectomy, which is the removal of the testicles
Learn more about Medicare and gender affirmation surgery.
Psychotherapy
Medicare covers psychotherapy relating to gender dysphoria and for those who require support after surgery. Gender dysphoria refers to a psychological conflict between a person’s sex assigned at birth and their gender identity.
Different parts of Medicare cover different aspects of gender affirming care:
- Part A covers gender affirmation surgery and other services a person receives during treatment that requires an inpatient stay in the hospital.
- Part B covers doctor’s office visits, diagnostic testing for hormone therapy, and any mental health services a person receives during gender affirmation.
- Part C, or Medicare Advantage, is a privately administered plan that covers any services included in Medicare parts A and B. Many Medicare Advantage plans include coverage for prescription hormone therapy medications.
- Part D is prescription drug coverage, meaning it pays for hormone therapy medications.
- The Medicare supplement plan Medigap pays for out-of-pocket costs, such as deductibles, coinsurance, or copayments up to a limit.
The cost of gender affirming care under Medicare depends on which surgeries and treatments a person receives.
Many people do not pay a Part A deductible. If they are ineligible for free Medicare Part A, the premium will cost up to $505 per month in 2024.
Part A also has a deductible, which an individual must pay before Medicare becomes responsible for surgical and in-hospital costs. In 2024, this is $1,632 per benefit period.
Medicare pays for any in-hospital treatments for the first 60 days of a benefit period.
Part B has an income-dependent monthly premium, which is $174.70 for most people. For some people, this cost will be higher.
For outpatient treatments under Part B, an individual must pay 20% of the final bill.
Part D premiums and benefits vary per policy, but Medicare has provided an online tool to help compare policy costs.
When did Medicare start covering gender affirmation surgery?
Medicare started covering gender affirmation surgery in 2014. However, local Medicare Administration Centers determined coverage on a case-by-case basis.
Does Medicare cover top surgery?
Medicare covers top surgeries that are medically necessary for gender affirmation but will not pay for cosmetic procedures such as a breast lift.
Does Medicare cover facial feminization surgery?
Medicare does not pay for facial feminization surgery, as insurance companies generally consider this to be a cosmetic procedure.
Medicare pays for medically necessary gender affirmation for transgender people who meet certain criteria, such as having a gender dysphoria diagnosis.
Medicare Part A covers inpatient procedures such as top and bottom surgery. Part B covers consultations, psychotherapy, and tests such as blood tests. Part D covers prescription medication, such as hormone therapy.
People seeking gender affirming care will still need to cover some out-of-pocket costs, such as coinsurance and deductibles. Medicare also does not pay for procedures they consider to be cosmetic, such as facial feminization.