Preventative Services for Medicare Beneficiaries with Gender Dysphoria
Medicare Part B includes coverage for preventative services. Preventative services can include things such as mammograms and pelvic exams. These services aren’t limited by your gender as assigned at birth, or the gender listed on your records. If a service is medically necessary for you, it will be covered. Visits to your primary care physician and recommended specialists for care are also included in your Part B coverage.
Medicare Advantage Options with Gender Dysphoria
(Parts A and B)
Includes inpatient and outpatient services. However, if you are interested in additional benefits like Part D prescription drug coverage or vision, dental, or hearing, you may be left wanting. Enrolling in a Medicare Advantage plan may close the gap in coverage.
Offered by private insurance companies, supplies all of the care that Original Medicare offers, and some offer prescription drug coverage as well. Medicare Advantage plans often provide savings by including additional benefits with lower premiums, copays or deductibles.
Does Medicare Cover Top Surgery and Bottom Surgery (Gender affirmation surgeries)?
For many medical services, coverage under Medicare is determined by whether the care or treatment is deemed medically necessary. Transition-related surgeries – also known as gender affirmation surgery, and top or bottom surgery – are covered if you have documented gender dysphoria and meet the treatment criteria.
The criterion for this treatment includes:
- Well-documented and persistent gender dysphoria
- 12 or more months of continuous hormone therapy
- 12 or more months living in the gender role that you’re transitioning to
- No serious medical or mental health concerns, or controlled via medication
- Two recommendations from qualified mental health professionals
Medicare does not cover transition surgeries and treatment it deems cosmetic, including:
- Body contouring
- Facial contouring
- Hair removal or implantation
- Vocal surgery
Prescription Drug Plan Coverage with Gender Dysphoria
Original Medicare (Parts A and B) do not include prescription drug coverage. You can get this coverage through a dedicated Prescription Drug Plan (Part D) or through a Medicare Advantage plan (Part C) that includes prescription drug coverage. If you are prescribed hormone therapy or other prescription medications, it should be covered by your Medicare prescription drug plan.
When you are enrolling in your Part D or Part C plan, a licensed insurance agent can look up specific doctors or prescriptions to make sure to find a plan that includes the specialists and hormone therapy medications needed for gender dysphoria care.
Frequently Asked Questions
Transition-related surgeries, also known as gender affirmation surgery, and top or bottom surgery, are covered if deemed medically necessary and you have documented gender dysphoria and meet the treatment criteria.
Annual Enrollment Period (AEP)
Medicare Annual Enrollment Period runs each year from October 15 to December 7. What is the Annual Enrollment Period vs. Open Enrollment Period?
Initial Enrollment Period (IEP)
Your Initial Enrollment Period generally surrounds your 65th birthday but may occur if you otherwise become eligible for Medicare for the first time.
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Last Updated: November 1, 2022 MULTIPLAN_ETQEZMwebsite_0722_M