Is Gender Reassignment Surgery Covered By Medicaid


Alaska Medicaid Must Cover Gender

Iowa court: Medicaid can cover sex reassignment surgery

Starting this month, Alaska Medicaid can no longer deny coverage to transgender Alaskans undergoing gender-affirming treatment.

Thats following the January settlement of a class action lawsuit filed by Swan Being, a transgender woman from Homer who said Alaska Medicaid refused to cover costs related to hormone treatment in 2019.

Being sued the Alaska Department of Health and Social Services, which oversees Alaskas Medicaid program, and department commissioner Adam Crum. She alleged the states policies discriminated against transgender Alaskans and violated the 14th Amendment, which grants all Americans equal treatment under the law.

Being was the first to file the case. Robin Black and Austin Reed, both of Anchorage, joined as plaintiffs in 2020.

Up until now, Alaska was one of 10 states that still explicitly denied Medicaid coverage for gender-affirming treatment, including surgery, hormone treatment and therapy. Similar lawsuits are currently in motion in West Virginia and Georgia, said Carl Charles, an attorney with Lambda Legal. He co-counseled the case alongside the Anchorage-based Northern Justice Project.

Charles said that kind of gender-affirming health care is life-saving for transgender people. And he said its particularly important to protect access to that health care when its contingent upon employment.

Being received hormone replacement therapy and, in 2019, planned to travel from Homer to Anchorage for further treatment.

How Does Medicare Decide If Your Gender Affirmation Is Covered

It can sometimes be difficult to determine whether Medicare will cover a service or not. Coverage decisions for Medicare plans are generally governed by the following factors:

  • Federal laws. These laws determine what benefits insurance companies offer and whos licensed to provide these services in your state.
  • National coverage laws. These decisions are made by Medicare directly and determine what is and isnt covered.
  • Local coverage laws. These decisions are made by companies and determine whether something is medically necessary or not under Medicare.

The best way to determine if your gender affirmation procedure is covered by your Medicare plan is to speak with your doctor directly.

Will Private Health Insurance Cover Gender Confirmation Surgery

  • It will pick up the tab on that 15-25% that Medicare didn’t pay on treatments you received in a private clinic.
  • It will cover your accommodation and theatre fees for any treatments that are on the MBS.
  • It can pay for some of the hormone prescriptions that Medicare won’t cover.
  • It can help out with additional psychology sessions if you feel you need them.

Keep in mind, there will typically be a waiting period before you can claim for most treatments. These can be anywhere from 2-12 months depending on the treatment.

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Does Medicare Cover Gender Reassignment Surgery

  • Seniors who are ready to transition may wonder, “Does Medicare cover gender reassignment surgery?” Learn Medicare’s guidelines for approving this surgery.

More and more transgender Americans are seeking gender reassignment surgery so they may function biologically as their chosen gender, but the terms regulating reimbursement for the procedure vary by insurer. Because older adults who are ready to transition often receive their medical benefits through Medicare, they should understand their coverage options before proceeding.

If you’re a Medicare beneficiary who’s found yourself asking, “Does Medicare cover gender reassignment surgery?” the answer is maybe. That’s because decisions regarding gender reassignment procedures are usually made on a case-by-case basis. If the surgery is deemed medically necessary by a Medicare-approved physician, a percentage of surgical expenses may be covered by your Medicare plan.

To understand Medicares rules for reimbursement, it’s helpful to understand more about gender dysphoria and gender reassignment surgery.

How Painful Is Top Surgery

Iowa court: Medicaid can cover sex reassignment surgery

Its encouraged that pain medication is used when needed, but patients typically find that pain during recovery is very minimal and subsides after a couple of days. Apart from some pain, patients will experience slight discomfort from the swelling and bruising of the chest, but this can be managed with ice packs.

Can you feel your nipples after top surgery?

You may experience random, shooting pains for a few months after your surgery. You can expect some loss of feeling in your nipples and chest wall skin. This usually improves over the next six months or so, but sensation may never be normal.

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Northams Budget Would Guarantee Transgender Health Services For Medicaid Enrollees

By: Ned Oliver– January 4, 2021 12:06 am

Tucked away in the 750-page revised budget Gov. Ralph Northam presented last month is a single line that his administration says would guarantee that transgender enrollees in Virginias expanded Medicaid program have access to gender-affirming care.

This is an important equity issue and a critical part of making our commonwealth welcoming and inclusive of all, Northams spokeswoman, Alena Yarmosky, said in an email.

If the General Assembly agrees to the language, Virginia would become at least the 19th state to explicitly affirm that transgender care is covered by its Medicaid program, according to statistics gathered last year by UCLA School of Law.

Another 12 states have adopted laws or regulations expressly banning coverage of gender-affirming care for transgender Medicaid enrollees, UCLAs review found.

Virginia is one of 20 states with no express policy on the issue.

Leaders of the states Medicaid program said the care, which can range from counseling to hormonal therapy and gender reassignment surgeries, is already covered by all six of the health insurance providers that administer Virginias Medicaid program.

But they said making the states policy on the issue clear and unambiguous is an important step forward.

To me its not a political issue, its an issue of health and health care, he said.

by Ned Oliver, Virginia MercuryJanuary 4, 2021

Medigap Plans Can Help Cover Gender Affirmation Surgery Medicare Costs

If your gender reassignment surgery is covered by Medicare, a Medicare Supplement Insurance plan can help pay for some of your out-of-pocket Medicare costs like deductibles and copays.

A licensed agent can help you decide on a Medicare option that works for you. Call today to speak with a licensed agent and compare the Medigap plans that are available where you live.

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What Level Of Private Health Cover Will You Need

Here are some tips to help make sure you get the right cover:

  • Double-check the MBS item numbers with your insurer. Every insurer is different, so your best bet is to double-check that your insurer doesn’t exclude or restrict any treatments you plan on having. The most accurate way of doing this is to get your MBS item numbers from your doctor so you can relay this to the insurer and get an estimate of costs, or a heads up on any restrictions.
  • Get a hospital policy that covers you in a private clinic. This is the minimum that you need, covering you for treatment in a private hospital, but depending on the surgery you need, you might need more comprehensive cover.
  • Get a top extras policy. Some extras policies will cover prescriptions that Medicare won’t, but you’ll need a top-level extras policy if you want your HRT prescriptions covered.
  • Cover for the “gap”. This is the difference between what Medicare and private health insurance covers, and what the surgeon charges. Some insurance providers have agreements with specific surgeons so that you can reduce these out-of-pocket expenses.

Approval For Genital Surgery

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To be approved for genital surgery, youll need:

  • two assessments recommending surgery
  • one of the assessments must be from a doctor or nurse practitioner
  • both assessments must confirm:
  • you have a diagnosis of persistent gender dysphoria
  • have completed 12 continuous months of hormone therapy
  • you have lived 12 continuous months in the gender role you identify with

If you have surgery before getting approval from the ministry, the cost of the surgery will not be covered.

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Tricare Providers & Regional Coverage

TRICARE providers include military clinics and hospitals as well as in-network civilian providers. TRICARE has an extensive network of contracted providers that you can choose from.

There are TRICARE-authorized providers through regional contractors, either through East Region Network Providers or West Region Network Providers. Your regional contractor depends on where you live.

Through your regional contractor, you will find a comprehensive network of providers. For vision services, depending on your plan, you can typically use either the optometry clinic at a military hospital or clinic, or an in-network and contracted civilian optometrist.

Your plan will dictate if you need a referral or prior authorization for vision services and treatment. Treatment often starts with your primary care manager.

Talk to your primary care provider to discuss your TRICARE health and vision coverage, and how your specific plan works. You can also contact a TRICARE representative directly for more information on plans, coverage options, payment information, and what services you can receive.

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Timeframe For Insurers To Make Medical Necessity And Out

72 hours of receipt of your request for treatment.

72 hours of receipt of your request for treatment.

Pre-Service for care you have not received yet

3 business days of receipt of necessary information or 60 days if no information is received. Your insurer must ask for any information within 3 business days of receiving your preauthorization request, and you and your provider have 45 days to send the information.

15 days of receipt of necessary information or 60 days if no is information received. Your insurer must ask for any information within 15 days of receiving your request, and you and your provider have 45 days to send the information.

Concurrent for an ongoing course of treatment

1 business day of receipt of necessary information or 60 days if no information is received. Your insurer must ask for any necessary information within 1 business day, and you and your provider have 45 days to send the information.

Post-Service for care you received

30 days of receipt of necessary information or 60 days if no information is received. Your insurer must ask for any information within 30 days, and you and your provider have 45 days to send the information.

30 days of receipt of necessary information or 60 days if no is information received. Your insurer must ask for any information within 30 days, and you and your provider have 45 days to send the information.

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The Medicaid Program And Lgbt Communities: Overview And Policy Recommendations

As Medicaid celebrates its 51st birthday, recent and future changes to the program can help ensure that its benefits reach everyone who needs them, including LGBT people and their families.

In 1965, President Lyndon B. Johnson signed the Social Security Amendments Act, creating dual programsMedicaid and Medicarethat have dramatically improved access to health care for some of the nations most vulnerable communities. Nearly 50 years later, President Barack Obama signed the Affordable Care Act, or ACA, setting in motion one of the most significant set of changes to Medicaid since the programs inception.

This issue brief reviews the characteristics and benefits of Medicaid as they relate to LGBT individuals, including why the Medicaid program is essential to the health of LGBT communities. It also looks at how the program could be improved to ensure greater access to quality coverage for LGBT people and their families.

Is Gender Confirmation Surgery Covered By Medicare

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Yes, but only partly. Medicare can cover some of the individual treatments associated with gender confirmation surgery including surgeries, medications, tests and consultations. Approved treatments are listed on the Medicare Benefits Schedule , but you will still need your doctor’s referral to get covered. Here are some examples of the treatments that Medicare can pay towards:

  • Vaginal reconstruction
  • Exploration of spermatic cord

Medicare can also cover your GP visits, blood tests, psychological counselling and a few prescriptions again, with the right referrals from your doctor.

Unfortunately though, you’ll still face significant out-of-pocket expenses. This is because specialist care for trans people and those with gender dysphoria is in extremely short supply in Australia. Most surgeries are performed privately and private doctors are free to charge more than what a public facility would . Because there is such a short supply, fees are likely to be high. Medicare will pay 75-85% of the MBS fee but you could still be faced with thousands of dollars left to pay.

What Medicare won’t cover

There are a few treatments that Medicare won’t pay for at all. Along with the expenses mentioned above, you will also need to come up with the full amount for the following, unless you have private health insurance:

  • Your accommodation and theatre fees
  • Cosmetic surgery that is considered not medically necessary
  • Some medications for hormone replacement therapy

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Transgender And Gender Dysphoria

Being transgender is not a mental condition. Not everyone who is transgender has gender dysphoria, and not everyone with gender dysphoria will want to undergo gender affirming surgery.

While gender affirmation surgery may be medically necessary to treat gender dysphoria, Medicare does not cover what it considers to be cosmetic procedures. There are specific exclusions from coverage for:

  • Blepharoplasty
  • Rhinoplasty
  • Rhytidectomy
  • Voice modification procedures

Cpt Codes Covered If Selection Criteria Are Met:

13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet 1.1 cm to 2.5 cm 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet 2.6 cm to 7.5 cm 13133 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet each additional 5 cm or less 13160 Secondary closure of surgical wound or dehiscence, extensive or complicated 14021 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs defect 10.1 sq cm to 30.0 sq cm 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet defect 10 sq cm or less 14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet defect 10.1 sq cm to 30.0 sq cm 14301 Adjacent tissue transfer or rearrangement, any area defect 30.1 sq cm to 60.0 sq cm 14302 Adjacent tissue transfer or rearrangement, any area each additional 30.0 sq cm, or part thereof 15002 -15003 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar , or incisional release of scar contracture, trunk, arms, legs first 100 sq cm or 1% of body area of infants and children. + each additional 15100 – 15101 Split-thickness autograft, trunk, arms, legs first 100 sq cm or less, or 1% of body area of infants and children + each additional 1% 15574 15750 19318 Nipple/areola reconstruction

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Lyme Disease Is A Great Example

Once again, the IDSA guidelines for the diagnosis and treatment of Lyme disease provide a concrete example of these conflicts of interest. The IDSA guidelines have been widely criticized as inadequate and disastrous for those infected with the disease. The Attorney General of Connecticut, Richard Blumenthal, was even prompted to conduct an anti-trust investigation of the IDSA, suspecting that the guidelines process was tainted by the panel members conflicts of interest.

Will Medicare Supplement Insurance Help Cover The Costs Of Gender Reassignment Surgery

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Medigap policies will help cover these costs if Medicare approves your procedure. Depending on your plan, your benefits could cover some, most, or all of the following expenses:

  • Your Medicare Part A deductible
  • Your Medicare Part B deductible
  • Blood transfusions after 3 pints
  • Your Medicare Part A coinsurance
  • Your Medicare Part B coinsurance
  • Your Medicare Part B excess charges

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Androgens For Women Sexual Desire Disorders

Reis and Abdo evaluated the use of androgens in the treatment of a lack of libido in women, comparing 2 periods, i.e., before and after the advent of the phosphodiesterase type 5 inhibitors. These researchers also analyzed the risks and benefits of androgen administration. They searched the Latin-American and Caribbean Health Sciences Literature, Cochrane Library, Excerpta Medica, Scientific Electronic Library Online, and Medline databases using the search terms disfunção sexual feminina/female sexual dysfunction, desejo sexual hipoativo/female hypoactive sexual desire disorder, testosterona/testosterone, terapia androgênica em mulheres/androgen therapy in women, and sexualidade/sexuality as well as combinations thereof. They selected articles written in English, Portuguese, or Spanish. After the advent of phosphodiesterase type 5 inhibitors, there was a significant increase in the number of studies aimed at evaluating the use of testosterone in women with hypoactive sexual desire disorder. However, the risks and benefits of testosterone administration have yet to be clarified.

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How Else Might I Pay For Testosterone

If youre eligible for Medicaid, you may be able to receive coverage for hormone replacement therapy through your Medicaid plan instead of going through Medicare or Medicare Advantage. Some medications may be covered under prescription discount programs. You can sign up for the program and receive a card to present at the pharmacy counter. This is a way that many people routinely save money on their prescription drugs.

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Does Medicare Cover Hormone Therapy For Transgender People

Medicare covers medically necessary hormone therapy for transgender people. The therapy would be deemed medically necessary if prescribed by a health professional. This hormone therapy prescription may be in connection with gender dysphoria. It is usually given in preparation for GRS.

To get this coverage under Original Medicare, you will need a prescription drug plan .

Private Medicare Advantage plans usually bundle Part A, Part B, and Part D coverage with extra benefits. This coverage will be helpful as your health providers assess your response to treatment. Generally, hormone therapy may be feminizing or masculinizing. Feminizing hormone therapy may use:

  • Medications that block male hormone testosterone

  • Female hormone, estrogen

Masculinizing hormone therapy may use:

  • Male hormone, testosterone

If your doctor considers this therapy medically necessary, your Part D benefits will cover the cost of the hormones. Under Medicare Part B, your doctor visits and routine lab work are covered. Depending on your plan, you may still have to pay out of pocket for premiums, deductibles, copayments, and coinsurance.


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