Medicare is insurance for Americans over 65 – or under 65 with certain health conditions. With more than 1.4 million U.S. citizens identifying as transgender, many questions come up in the LGBTQ+ community regarding medical coverage.
Today we’ll discuss Medicare coverage for members of the LGBTQ+ community. We’ll start with the services, procedures, and treatments covered. Then, we’ll break down the features of each process and what’s required for Medicare to approve them.
The three most common Medicare coverage questions in conversation with LGBTQ+ clients are gender dysphoria, gender reassignment surgery, and hormone therapy.
Most services for these three treatments will be covered under Medicare Part B. They will also require proof of specific treatments. Confirmation from your healthcare provider that they are medically necessary will also be required.
The feeling of discomfort or distress in people that identify as a sex other than their assigned gender at birth or sex-related characteristics is the definition of gender dysphoria, according to the Mayo Clinic.
At some point in their lives, members of the LGBTQ+ community generally feel gender dysphoria. Some members of the community feel entirely at ease in their bodies. Medicare only covers services considered medically necessary, making a diagnosis of gender dysphoria key to Medicare coverage for different aspects related to members of the LGBTQ+ community.
Medicare covers inpatient and outpatient mental health therapy for individuals diagnosed with gender dysphoria. These services also extend to individuals that have already completed gender reassignment surgery and need additional support.
Another helpful therapy for LGBTQ+ individuals is Hormone therapy.
Estrogen therapy is used when a male-to-female or non-binary transition occurs. This therapy is generally paired with antiandrogens to introduce feminine characteristics and suppress masculine features.
Testosterone therapy is used when transitioning from female to male or non-binary. It helps suppress feminine characteristics and induces masculine features.
Not every LGBTQ+ individual elects to go through hormone therapy. It’s considered medically necessary for individuals who go through the physical transition.
Gender reassignment surgery is used to help LGBTQ+ individuals transition their appearance to match the gender they identify with. Your healthcare provider must have provided a diagnosis of gender dysphoria and deemed that gender assignment surgery is medically necessary.
You may be required to show proof of counseling and hormone therapy before Medicare will approve the gender reassignment surgery.
This procedure requires a group of surgeries to accomplish the transition.
These surgeries are typically divided into top and bottom surgeries. Medicare will provide coverage for the transmasculine bottom and top surgery and transfeminine bottom surgery.
Medicare will cover most surgeries, except for breast augmentation for male to female or male to non-binary individuals. Keep in mind that Medicare doesn’t cover cosmetic surgeries. Some examples that are not covered by Medicare include:
Coverage for outpatient services necessary for the transition will be covered by Medicare Part B. This includes doctors’ visits and lab work. If surgery is performed as an inpatient, it’ll be covered by Medicare Part A. Generally, hormone treatments are covered under Medicare Part D.
Medicare has made changes to be more inclusive of the LGBTQ+ community and provides medical treatment, counseling, and surgery related to the community members. Remember that while Medicare Advantage plans are required to cover the same items as Original Medicare, they do have their own authorization and approval processes. So, they may have different requirements for approval.
Is Medicare helpful when it comes to services specific to the LGBTQ+ community? In what way? What could be improved?