Medicare & Transgender Older Adults
Transgender older adults have unique health care needs. Medicare is working to address them.
It has been almost 10 years since the Department of Health and Human Services (HHS) changed longstanding policy and began coverage of medically necessary gender-affirming surgeries. In that time there has been significant clarification of Medicare policies for many services accessed by transgender adults. Here are some basics.
Gender Identification
Gender does not appear on Medicare cards. Medicare records, however, include a gender marker based on one’s Social Security record. If one’s gender identifier has changed with the Social Security Administration, that change will also be reflected in Medicare records.
Choosing the Best Medicare Coverage
Transgender individuals need to choose carefully among their Medicare coverage options—e.g., when deciding whether to enroll in Original fee-for-service Medicare or in a private Medicare Advantage plan. That choice may impact enrollees’ access to the providers they know and trust. Affordability of prescription drugs may vary markedly among prescription drug plans; it’s important to compare plans to identify those offering coverage of the drugs which meet an individual’s needs. Assistance with those choices is available through local State Health Assistance Programs (SHIPs; shiphelp.org), which provide personal, unbiased help to Medicare beneficiaries.
Surgeries
Medicare approves coverage of medically necessary gender-affirming surgeries to address gender dysphoria on a case-by-case basis. The medical necessity standard is the same whether one gets Medicare coverage through Original fee-for-service Medicare or through a Medicare Advantage plan. Although determinations are on a case-by-case basis, Medicare looks to the guidelines contained in the World Professional Association for Transgender Health (WPATH) Standards of Care. When supporting requests for Medicare coverage, providers should address how a case meets WPATH standards.
As with any type of care, an individual must use doctors who take Medicare. (Not all health care providers participate in Medicare.) If an individual is covered under a Medicare Advantage plan, they would usually need to use doctors who are in the plan’s network or get permission to go outside of the network.
Transition-Related Drugs
Medically-necessary hormones to address gender dysphoria are generally covered under Medicare Part D (Medicare’s prescription drug plan). You usually need prior authorization for coverage to be approved.
Sex-Specific Procedures
Medicare will not deny coverage for procedures that are sex-specific just because the gender identifier in a Medicare record reflects a different gender identity. An identifier showing one as male, for example, cannot be the basis for denying coverage of a pelvic examination if it is medically appropriate. Medicare has created a special billing code, condition code 45, for such procedures. If a provider uses this code in connection with these procedures, it can help avoid improper denials of coverage.
If one is denied coverage for any surgery, procedures, or drugs and believes coverage should have been provided, there is an option to file an appeal. Directions on filing an appeal appear in the denial letter. Getting the cooperation and support of a medical provider is important to a successful appeal. It can also be helpful to consult with a local legal services program or a private attorney.
Discrimination in Health Care
Federal law protects from discrimination based on sex—including sexual orientation and gender identity—by health entities or care providers who receive federal funds, either directly or indirectly. Anyone experiencing discrimination can file a complaint with the Office of Civil Rights at HHS (hhs.gov/civil-rights). Someone receiving Medicare through a Medicare Advantage plan can also file a grievance.
Policy Watch
HHS recently proposed rules to strengthen protections against discrimination and expand the range of providers subject to its regulations. The proposed regulations are very specific in addressing the health needs of transgender people.
They proposed rules would prohibit limits on health services based on gender assigned at birth or gender identity; denials of services for gender transitions or gender-affirming care that would be provided to individuals for other purposes; and any policies or practices that would separate or treat individuals differently on the basis of sex in a way that is not consistent with the individual’s gender identity.
In addition, the proposed rule clarifies that sex discrimination includes discrimination based not only on sexual orientation and gender identity, but also on the basis of sex stereotypes and sex characteristics, including intersex traits. Final rules are expected sometime in 2023. ▼