Is Gender Reassignment Surgery Covered By Medicaid


Medicare Coverage For Transgender Surgery

Judge rules Iowa Medicaid denial of sex change surgery unlawful

Medicare covers necessary surgery to change primary sex characteristics from one gender to the other.

Covered surgeries might include:

  • Transmasculine bottom surgery to remove female sex organs and create male genitalia
  • Breast removal surgery
  • Transfeminine surgery to remove the penis and testicles and create female genitalia

Medicare Part B covers outpatient services. If youre hospitalized for your surgery, Part A pays for it.

With Medicare, you can see any doctor that accepts Medicare. To get the most coverage, make sure your doctors accept Medicare.

Approval For Chest Surgery

To be approved for chest surgery youll need:

  • one assessment recommending surgery from a qualified doctor or nurse practitioner
  • the assessment must confirm that you:
  • have a diagnosis of persistent gender dysphoria
  • have completed 12 months of continuous hormone therapy with no breast enlargement if youre seeking breast augmentation

After being approved for chest surgery, your family doctor or nurse practitioner can refer you to a specialist who can perform the surgery.

Formulary Exception Process For Prescription Drugs


Standard. 72 hours for insurer decision.

Expedited. 24 hours for insurer decision when your health, life, or ability to regain maximum function is in danger, or if you are currently being treated with a non-formulary prescription drug.

Final Denial. If your insurer denies your formulary exception request, its a final adverse determination. You do not have to appeal with your insurer. You can request an external appeal with DFS.

Applicability. Individual & small group coverage and, beginning on renewal in 2020, large group coverage.

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What Benefits Does Medicaid Cover

In general, Medicaid provides more comprehensive benefits at a lower cost than private insurance coverage. Benefits for adults enrolled in Medicaid vary, however, between states and by program. For those enrolled in traditional Medicaidthe coverage available to those who were eligible for Medicaid prior to the Affordable Care Act, including pregnant people and people with disabilitiesthere is a core set of benefits required by law, including but not limited to:

  • Doctor visits
  • Inpatient and outpatient hospital services
  • Some mental health services
  • Family planning services and supplies
  • Long-term care facility services
  • Transportation to medical services
  • Laboratory and X-ray services
  • Early and Periodic Screening, Diagnostic, and Treatment services for children and adults younger than age 21

In addition to this list of mandatory services, states also have the flexibility within the parameters of federal guidance to offer a range of optional services, which typically include outpatient prescription drug coverage, dental services, and case management services, among others. More than 60 percent of state Medicaid spending is on optional services, which testifies to the degree to which states choose to offer coverage for optional services because of their importance to the health of Medicaid enrollees. Because they are not required by federal law, however, optional benefits are vulnerable to being lost as a result of state budget cuts.

  • Ambulatory patient services
  • Prescription drugs
  • Approval For Genital Surgery

    Iowa court: Medicaid can cover sex reassignment surgery

    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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    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.

    Does Medicare Cover Transgender Health Care

    Medicare covers medically necessary services regardless of gender. In this article, we review options available to transgender people with Medicare plans.

    Each Medicare plan and insurance product we feature has been independently selected and reviewed by our editorial team in conjunction with our partners at Medicare Expert USA. If you make a purchase using the links included, may be compensated.

    Key Takeaways:

    • Eligible Medicare enrollees have access to Medicare regardless of gender.

    • Medicare covers hormone therapy under Part D when prescribed.

    • Gender reassignment surgery is covered by Medicare on a case-by-case basis. The surgery must be approved by the insurer.

    • Transgender people are protected by law from discrimination in health care.

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    Nbc Outtransgender Plaintiffs Sue Alabama Over State Id Laws

    Good and Beal sued the agency in 2017. In June, Judge Arthur Gamble of the Judicial District 5 Court ruled that a 1995 Iowa Department of Human Services policy denying Medicaid coverage for sex reassignment surgery violates the states 2007 Civil Rights Act, which added gender identity to the states list of protected classes.

    In its appeal, the agency argued that its policy wasnt discriminatory because neither transgender nor non-transgender individuals were able to use Medicaid benefits for gender-reassignment surgery, which it said is performed primarily for psychological purposes. It also argued that the policys explicit exclusion of gender-reassignment surgeries was an example of cosmetic, reconstructive, and plastic surgeries that are excluded from coverage.

    Yet the Iowa Supreme Court upheld the lower courts decision on Friday, arguing that Good and Beal were denied sex reassignment surgery because they were related to gender identity disorders. It also asserted that Medicaid does authorize payment for some cosmetic surgeries that serve psychological purposes, such as to help disfiguring scarring and congenital anomalies.

    The Iowa Department of Human Services did not respond to NBC News’ request for comment.

    What Is Gender Dysphoria

    Governor Pritzker announces Medicaid will cover gender reassignment surgery

    Gender dysphoria is a clinical diagnosis often given to individuals who experience distress or discomfort because their gender identity doesnt match their sex-related physical characteristics. Although gender dysphoria is often associated with transgender or nonbinary individuals and can occur in children, teens and adults, not all gender-nonconforming or gender-diverse people experience it.

    Gender dysphoria is not considered a mental health condition. However, if the resulting anxiety, depression and stress aren’t treated, they may lead to serious mental health issues. The discomfort related to gender dysphoria may be addressed through psychotherapy or treatments that help align an individual’s physical appearance with their gender identity. This may include gender reassignment surgery.

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    Insurance And The Wpath Standards

    There are several different surgeries that people may be interested in for gender alignment or confirmation. In addition, there are often specific guidelines for coverage for each surgery.

    As a general rule, many insurers are turning to the WPATH Standards of Care as guidelines to establish eligibility for surgery coverage. These are also known as the WPATH criteria or WPATH requirements.

    WPATH is the acronym for the World Professional Association for Transgender Health. Formally known as the Harry Benjamin Society, WPATH is not without controversy.

    What Is Medicaid And Whom Does It Cover

    Medicaid is a public program that provides health coverage for low-income individuals who fall into a range of eligibility categories, including people living with a disability, people who are pregnant, and people with dependent children. Medicaid is a means-tested entitlement program, meaning that eligibility is linked to individual or family income, and the program is required to cover all individuals who meet eligibility requirements. Medicaid is primarily administered by states within parameters set by federal law, and the program is jointly financed by states and the federal governmenton average, the federal government pays 53 cents of every $1 spent by states on their Medicaid programs.

    When the ACA was signed into law in 2010, it substantially modified Medicaids eligibility rules. Specifically, the ACA required state Medicaid programs to cover all individuals making up to 138 percent of the federal poverty level, or FPL. In 2016, the FPL stands at $11,880 for an individual and $24,300 for a family of four. When the U.S. Supreme Court considered the constitutionality of the ACA in June 2012, however, it ruled that the federal government cannot compel the states to expand Medicaid, leaving the decision of whether or not to expand the program to governors and state legislatures. As of July 2016, 31 states and the District of Columbia have expanded their Medicaid programs to cover all individuals with incomes up to 138 percent of the FPL.

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    Does Health Insurance Cover Testosterone Therapy Generally Yes But What If It Doesnt

    Usually, your health insurance does cover testosterone therapy if your medical care provider can show a need.

    However, not everyone has health insurance.

    And sometimes, even when you have health insurance, you may be stuck paying out of pocket for one reason or another. For instance, your hormone levels may not be technically low enough to demonstrate a need to your health insurance company, but you may still be experiencing symptoms.

    Fortunately, the cost of testosterone replacement therapy is very reasonable, even when paying out of pocket.

    Generally, $299 a month is enough to cover the cost of weekly testosterone injections, injections that you can get quickly and easily, without a long wait. We also offer flexible hours and multiple locations, giving you the ability to get therapy when and where it best suits you.

    Most of our patients who pay out of pocket find that the benefits of feeling happy, healthy, and like themselves again far outweigh the coststhey see the value in therapy.

    Does Medicare Cover Hormone Replacement Therapy

    Iowa court: Medicaid can cover sex reassignment surgery

    Many Medicare Advantage plans may cover prescription drugs, which maycover hormone replacement therapydrugs.

    The drugs that are covered by a Medicare Advantage plan or a Medicare Part D prescription drug plan may vary. To find out what drugs are covered by your plan, you should refer to your plan formulary, or list of drugs that are covered by the plan.

    A licensed insurance agent can help you compare Medicare Advantage plans that are available in your area and help you find a plan that may cover your hormone replacement therapy drugs.

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    Does Health Insurance Cover Testosterone Therapy For Women

    Again, it all depends on your health insurance company, but insurance usually only covers testosterone for women who have specific medical diagnoses.

    Why does health insurance sometimes cover testosterone therapy for men but not for women?

    The answer lies with the FDA.

    Unfortunately, the FDA does not currently consider low testosterone to be a diagnosable condition for women in and of itself.

    However, health insurance often covers the cost of testosterone replacement therapy for you if youve been previously treated for certain types of breast or mammary cancer, and there may be other instances where your specific insurance plan will cover the cost.

    So, does health insurance cover testosterone therapy for women? Usually, it depends on your plan.

    We will check with your health insurance provider to find out exactly what is and is not covered.

    Is Gender Reassignment Surgery Covered By Health Insurance

    Gender reassignment, affirmation, or confirmation are used interchangeably to indicate the surgeries and procedures aligning oneâs gender identity with their physical body. The services and procedures to reaffirm oneâs gender can be expensive when paying out-of-pocket, and many states do not yet explicitly mandate such coverage. Some private health plans offer coverage of gender reassignment but are dependent on meeting strict criteria.

    Mira provides an affordable health coverage option for as little as $45 per month and does not discriminate based on gender identity or sexual orientation. With Mira, you have discounted rates to doctorâs office and urgent care visits and even up to 80 percent discounted rates on over 1,000 prescriptions. Try Mira today.

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    When You Or Your Provider Submit A Claim To Your Insurer

    Your insurer is required to send you an explanation of benefits form when it does not pay your claim in full. The explanation of benefits must include the following information.

    Provider name.

    Amount your insurer will pay after deductible, copayments, or coinsurance.

    Explanation of any denial or reason for not paying the full amount.

    Insurers telephone number and information on how to appeal any denial of benefits.

    Does Medicare Cover Hormone Therapy For Transgender People

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    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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    How Do Bioidentical Hormones Work

    Why Are Bioidentical Hormones Better Than Other Hormone Therapies?

    Bioidentical hormones are often considered a safer and better alternative than traditional hormone replacement. Several years ago, the most common hormone replacement therapy was done with synthetic hormones, which were not structurally compatible with the human body and had high risks of unintended side effects.

    Bioidentical hormones, on the other hand, have such a similar structure to human hormones that the body cannot tell the difference. Additionally, bioidentical hormones are derived from natural sources, which significantly decreases the risk of adverse side effects and are more easily absorbed by the body.

    What Is Gender Reassignment Surgery

    Gender reassignment is also known as gender affirmation or confirmation surgery. According to the Cleveland Clinic, gender affirmation refers to the procedures that assist people in transitioning to their self-identified gender. This may include facial surgery and top or bottom surgery. People may pursue this surgery to match their physical body to gender identity, also known as gender dysphoria.

    Gender identity refers to an individualâs own concept of male, female, a blend of both, or neither. According to the American Medical Association , approximately 1.4 million adults in the United States identify as transgender, but not all transgender people experience gender dysphoria.

    We spoke with Dr. Kyle Zrenchik, who emphasizes that âthe diagnosis of Gender Dysphoria is a bit controversial. Many argue that it unfairly places the âpathologyâ on the patient, making it appear that it is their emotional distress that is the problem instead of their biology and being born into the wrong body. Many argue that the problem is better understood in our conceptualization of gender and sex and the ways that fail people who fall outside the binary.

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    Alaska Medicaid Must Cover Gender

    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.

    What Is Hormone Therapy

    Iowa court: Medicaid can cover sex reassignment surgery

    Hormone therapy is when you take medication to help you look and feel more like the gender you really are. It’s usually the first step of your journey towards transitioning and will make you look more like the other sex. For example, individuals born as female will take androgens which will make them look more masculine. Those born male will take oestrogen and anti-androgens which will make them look more feminine.

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