If you’re transgender and are eligible for Medicare, you may have questions about what Medicare coverage looks like. We want to make understanding Medicare coverage as easy as possible.
Original Medicare Coverage
If you are transgender, you’re eligible for all the standard coverage offered under Original Medicare (Medicare Parts A and B). Original Medicare includes coverage for visits with your primary care physician and specialists. Coverage for services is provided based on medical necessity, not your current gender or the gender you were assigned at birth. For example, services such as mammograms or prostate exams will be covered.
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Original Medicare Coverage Unique to Transitioning/ Transgender Individuals
That said, there are some medical needs unique to transgender individuals, like gender-affirming or gender confirmation surgery. Surgery to affirm your transitioned gender is generally covered if it’s deemed medically necessary. Medicare does recognize this treatment as necessary for individuals experiencing gender dysphoria, although you may be required to meet certain criteria before the surgery is approved, which is a standard process for many medical treatments under Medicare.
The criterion for this treatment includes:
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Well-documented and persistent gender dysphoria
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12 or more months of continuous hormone therapy
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12 or more months living in the transitioned gender role
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No serious medical or mental health concerns, or controlled via medication
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Two recommendations from qualified mental health professionals
Gender affirming procedures that are deemed medically necessary typically only include those that change primary sex characteristics (often referred to as “top” and “bottom” surgeries).
Medicare will typically cover necessary tests to diagnose gender dysphoria. Medicare also covers treatment for gender dysphoria.
Medicare and Hormone Therapy
Medicare Parts A and B do not include coverage for any prescription drugs, but private insurance plans with prescription drug coverage should cover hormone therapy and other medications you may need. There are two main options to obtaining prescription drug coverage through Medicare:
Transgender Care Not Covered Under Medicare
Many procedures that may be part of your transition are often not deemed medically necessary by Medicare and will not be covered. These procedures may include facial and body contouring, hair implantations or removal, vocal alterations, and more.
If you are looking for specific coverage, you may find comparing available plans helpful. Licensed insurance agents are able to look up doctors, prescriptions, and unique coverage to plans in your area to help you make an informed decision about your Medicare coverage.
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Enrollment Eligibility
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.
Special Enrollment Period (SEP)
You may be eligible if you experience a qualifying life event such as moving to a new zip code, losing employer coverage, or change in Medicaid status.
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