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4 Things You Need to Know About Medicare Enrollment and Gender Dysphoria

It’s important to know your rights and what healthcare benefits are available to you. If you’re eligible for Medicare—U.S. citizen 65 or older, or under 65 with a disability, ERDS, or ALS—here’s what you need to know about gender dysphoria before you face Medicare enrollment.

  1. Medicare doesn’t limit coverage for preventative services by gender
  2. Medicare includes coverage for preventative services such as mammograms and pelvic exams. These services aren’t limited by your gender as assigned at birth, or the gender on your records. If a service is medically necessary for you, it’ll be covered.

  3. Gender confirming surgeries can be covered under Medicare
  4. 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-confirming surgery, and top or bottom surgery—are covered if you have documented gender dysphoria and meet the criteria for this treatment.

    Criteria include:

    • Well-documented and persistent gender dysphoria
    • 12 or more months of continuous hormone therapy
    • 12 or more months living in the gender role you’re transitioning to
    • No serious medical or mental health concerns or under control
    • Two recommendations from qualified mental health professionals

    Medicare doesn’t cover transition surgeries and treatment it deems cosmetic, including body contouring, facial contouring, hair removal or implantation, and vocal surgery.

Hormone therapy and other medications are covered by Medicare prescription drug plans

Medicare Parts A and B (Original Medicare) don’t include prescription drug coverage. You can get this coverage through a dedicated prescription drug plan (Part D) or through a Medicare Advantage Plan with prescription drug coverage (Part C). If you’re prescribed hormone therapy, it should be covered by your Medicare prescription drug plan.

Visits to your doctors are covered under Medicare Part B

Medicare Part B covers visits to your primary care physician and recommended specialist care. If you enroll in a Medicare Advantage Plan, you may be restricted to the plan’s network of providers, but your care will still be covered.

Get Help with Medicare Enrollment

We’re here to make Medicare easier to understand, from start to finish. To find out what Medicare plans and benefits you may be eligible for, call us at 1-800-991-4407 / TTY 711, 10 a.m. to 9 p.m. Eastern, Monday through Friday. Our Medicare Advocates are happy to help you evaluate plans for the benefits that matter to you.