Medicare Benefits for Transgendered People


MEDICARE BENEFITS AND

TRANSGENDERED PEOPLE

August 2011

National Center for Transgender Equality ▪ 1325 Massachusetts Avenue NW, Suite 700, Washington, DC 20005

(202) 903-0112 ▪ ncte@transequality.org ▪ www.TransEquality.org

Medicare is one of America’s most important health programs, providing health insurance for millions of
older adults and people with disabilities. As with private insurance, transgender people sometimes encounter
limitations in their Medicare coverage or confusion about what is covered – both for transition-related care
and for routine preventive care. This document provides an overview of benefit questions that may arise for
transgender people, and information on what to do in response to an initial denial of coverage.
WHAT DOES MEDICARE COVER FOR TRANSGENDER PEOPLE?
Medicare covers routine preventive care regardless of gender markers.
Medicare covers routine preventive care for all eligible persons, including mammograms, pelvic and prostate exams.
Medicare and many private plans may automatically refuse coverage of services that appear inconsistent with a
gender marker in Social Security records as a means of preventing erroneous or fraudulent billing, with the unintended
consequence of denying claims for procedures that many transgender people need. Medicare beneficiaries have a
right to access services that are appropriate to their individual medical needs. Later in this document we discuss what
to do when coverage is wrongly denied due to an apparent gender discrepancy.
Medicare covers medically necessary hormone therapy.
Medicare also covers medically necessary hormone therapy. These medications are part of Medicare Part D prescription
drug plan formularies (lists of covered medications) and should be covered when prescribed. Sometimes coverage
may be initially wrongly refused due to an apparent inconsistency of the hormones with a gender marker in a person’s
records. Nevertheless, Medicare beneficiaries have a right to access prescription drugs that are appropriate to to their
medical needs.
Medicare does not cover sex reassignment surgery.
Medicare currently does not cover sex reassignment surgery for transgender people. This exclusion is due to a
decades-old policy that categorizes such treatment as “experimental.” NCTE is working to have this outdated policy
re-evaluated on the basis of current science, but this process may take several years. This exclusion applies only to
surgical procedures and should not apply to pre-surgical labs, post-surgical follow-up care, or any other medically
appropriate treatment for a transgender beneficiary that is generally a covered service.
WHAT DO I DO WHEN COVERAGE IS DENIED?
Original Medicare
To address inappropriate denials of coverage, the Center for Medicare and Medicaid Services (CMS) has approved a
special 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
discrepancies may be a problem. When used with standard billing codes doctors use for specific procedures, this code
alerts Medicare’s computer system to ignore an apparent gender discrepancy and allow your claim to be processed.
Details are explained in the Chapter 32 of the Medicare Claims Processing Manual
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