medicare guidelines for gender reassignment surgery

• About Us History Jobs, Fellowships & Internships Annual & Financial Reports Racial Justice at NCTE Contact Us
• Support NCTE
• Get Updates
• Press Tips for Journalists Releases

Know Your Rights

Medicare is one of America’s most important health programs, providing health insurance for tens of millions of adults over 65 and people with disabilities. As with private insurance, transgender people sometimes encounter confusion about what is covered or barriers to accessing coverage—both for transition-related care and for routine preventive care. 

What Does Medicare Cover for Transgender People?

Medicare covers routine preventive care regardless of gender markers. Medicare covers routine preventive care, including mammograms, pelvic and prostate exams. Medicare has to cover this type of care regardless of the gender marker in your Social Security records, as long as the care is clinically necessary for you. The Medicare manual has a specific billing code (condition code 45) to assist processing of claims under original Medicare (Parts A and B). This billing code should be used by your physician or hospital when submitting billing claims for services where gender mis-matches may be a problem.

Medicare covers medically necessary hormone therapy. Medicare also covers medically necessary hormone therapy for transgender people. These medications are part of Medicare Part D lists of covered medications and should be covered when prescribed. Private Medicare plans should provide coverage for these prescriptions. All Medicare beneficiaries have a right to access prescription drugs that are appropriate to their medical needs.

Medicare covers medically necessary transition-related surgery. For many years, Medicare did not cover transition-related surgery due to a decades-old policy that categorized such treatment as "experimental." That exclusion was eliminated in 2014, and there is now no national exclusion for transition-related health care under Medicare.

In practice, this means coverage for transition-related care will be decided on a case-by-case basis, no different than how Medicare handles coverage for most other medical treatments. For example, in 2015 the Medicare Appeals Council issued a decision ordering a Medicare plan to pay for transition-related surgery for a transgender woman because it was reasonable and necessary to treat gender dysphoria.

Some Medicare Advantage plans and local Medicare contractors have specific policies for coverage of transition-related care that serve as guidelines for their decision to authorize coverage.

Does coverage vary depending on where I am or what type of plan I have have (Original Medicare, Medicare Advantage, Medicare Part D)?

No, it should not. Medicare should provide coverage of medically necessary transition-related care regardless of your state .

However, depending on where you live, your Medicare local contractor may have specific guidelines for coverage of transition-related care. Here are some local guidelines NCTE is aware of:

• Palmetto GBA (applicable in Alabama, Georgia, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia)
• Noridian Healthcare Solutions (applicable in Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming)
• Noridian Healthcare Solutions (applicable in American Samoa, California, Guam, Hawaii, Nevada, Northern Mariana Islands)

You can search for specific local policies on CMS’ website .

Whether you have Original Medicare (Part A and B) or private Medicare (Medicare Advantage), Medicare should provide coverage of medically necessary transition-related care . The same should be true for prescription drugs.

However, if you have Medicare Advantage you should make sure to consult your member handbook for more details about your plan (see this helpful video from Transcend Legal on how to find your booklet and understand your coverage). You should also find out if your plan has a specific medical policy with specific Medicare Advantage guidelines and conditions on coverage for transition-related care ( these are some examples of these types of policies). If you have a Medicare Advantage plan, we recommend you apply for preauthorization before accessing transition-related care.

To find out more about the preauthorization process, please access NCTE’s Health Coverage Guide . NCTE will soon include specific Medicare language for Medicare Advantage plans on this resource.

For prescription medications that are transition-related, we recommend you request a “coverage determination” from your Medicare Part D or Medicare Advantage plan. You can find more information on this guide and access a model coverage determination form .

What Do I Do if Coverage is Denied?

If you experience a denial of coverage you believe to be inappropriate (including coverage of preventive services or transition-related care), you may file an appeal. We highly recommend that you consult with a lawyer before doing so ( these are some organizations that might be able to help).

For more information about filing appeals, you can refer to Medicare’s official guide and the Medicare website .

How Do I Change the Gender Marker with Medicare?

Original Medicare (Parts A and B) beneficiary cards no longer list gender. Your Medicare insurance records will typically be based on Social Security data. To learn more about updating your name and gender marker with Social Security, check out our ID Documents center .

As a reminder, the gender marker you have in the Medicare record system should not impact access to care . Medicare should provide access to all clinically appropriate services for your body, including services typically considered to be “sex specific” (such as pap smears or prostate exams). The Medicare manual has a specific billing code (condition code 45) to assist processing of claims under original Medicare (Parts A and B). This billing code should be used by your physician or hospital when submitting billing claims for services where gender mis-matches may be a problem.

What If I Am Treated With Disrespect?

If you encounter disrespect, harassment or other discrimination or inappropriate treatment related to being transgender, you may make a complaint. For problems when making inquiries or appeals in a private Medicare Advantage or Part D plan, you may file a complaint or grievance with your plan. For any other customer service problems, we recommend contacting your regional Center for Medicare and Medicaid Services (CMS) office . You can also share your experience with NCTE to aid in our advocacy efforts.

Information About Filing Appeals and Complaints

How Do I File an Appeal? http://www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html

Medicare Prescription Drug Coverage: How to Request a Coverage Determination, File an Appeal, or File a Complaint http://www.cms.gov/partnerships/downloads/11112.pdf

Forms and other information for prescription drug appeals https://www.cms.gov/MedPrescriptDrugApplGriev/

Contact Information for Regional CMS (Medicare) Offices CMS Regional Offices

Additional Resources

For general Medicare information 1-800-MEDICARE (633-4227)

Medicare Claims Processing Manual, Chapter 32 - Addressing Gender Discrepancies (See Section 240) http://www.cms.gov/manuals/downloads/clm104c32.pdf  

Medicare Interactive - A Resource from the Medicare Rights Center http://www.medicareinteractive.org

Medicare & You  https://www.medicare.gov/medicare-and-you

State Health Insurance Assistance Programs  https://www.shiptacenter.org/about-medicare/regional-ship-location

Join Our Mailing List

Speak with a Licensed Insurance Agent 877-388-0596 - TTY 711 (M-F 8am-9pm, Sat 9am-8pm EST)

Does Medicare Cover Gender Reassignment Surgery?

Individuals considering gender reassignment surgery may have concerns about their accessibility to quality healthcare and coverage if they receive Medicare benefits. Routine preventive care and transition-related services are vitally important to prepare for gender reassignment surgery, but there can be some confusion about Medicare coverage for transgender individuals.

Medicare is a federal program that provides health insurance for individuals 65 years of age or older, and some people under the age of 65 with certain disabilities. When you become eligible for Medicare, you can choose to get your benefits through Original Medicare or a Medicare Advantage (MA) plan. MA plans are offered by private insurance companies but are required to provide at least the same coverage as Original Medicare Part A and Part B.

Most people qualify for Part A (Hospital Insurance) automatically, but many enroll in Part B (Medical Insurance) as soon as they are eligible to receive important healthcare coverage for doctor visits, preventive care, and more, without incurring any penalty fees for enrolling later. All eligible Medicare recipients are covered for benefits regardless of their gender. Due to certain services and supplies being categorized as appropriate for one gender or another, initial coverage may be denied if your current gender does not match your original Social Security records. If you are denied coverage for gender-specific services, such as mammograms, pelvic exams, or prostate exams, you can appeal. The Centers for Medicare & Medicaid Services (CMS) has procedures in place to address these claims and special billing codes to assist medical providers in providing appropriate services based on individual needs and necessary care.

Hormone Therapy

In preparation for gender reassignment surgery, Medicare will cover hormone therapy through Part D prescription drug coverage. If you have Original Medicare, you will need to be enrolled in a stand-alone Prescription Drug Plan (PDP). Many Medicare Advantage plans include prescription drug coverage. If coverage is initially denied due to inconsistency with Social Security gender records, an appeal can be made to provide a Medicare recipient with access to medications they require to meet their specific needs.

  Gender Reassignment Surgery

The Centers for Medicare & Medicaid Services has not issued a national coverage determination on gender reassignment surgery, and therefore, leaves coverage determination up to local Medicare Administrative Contractors (MACs). According to CMS, coverage will be based on whether the surgery is considered “reasonable and necessary for the individual beneficiary after considering the individual’s specific circumstances. For Medicare beneficiaries enrolled in Medicare Advantage (MA) plans, the initial determination of whether or not surgery is reasonable and necessary will be made by the MA plans.”

Related articles:

Medicare Part D: Medicare Prescription Drug Coverage

What is Medicare Parts A & B

Medicare Part C

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, Simply, UnitedHealthcare®, Wellcare, WellPoint

Need A Medicare Advantage Quote?

Request A Free Consultation For Medicare Advantage Plans

TLDEF's Trans Health Project

Gender affirmation surgery.

Policy: Gender Affirmation Surgery Policy Number: HUM-0518-020 Last Update: 2023-09-28

Please ctrl + F to find the correct document titled "gender affirmation surgery" and download the pdf.

Back to top

Updated on Nov 27, 2023

The page could not be loaded. The CMS.gov Web site currently does not fully support browsers with "JavaScript" disabled. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with "JavaScript" disabled. Instructions for enabling "JavaScript" can be found here. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available.

An official website of the United States government

Here's how you know

The .gov means it's official.

Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.

The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Gender Dysphoria and Gender Reassignment Surgery

History of considerations, email this document to yourself or someone else.

An asterisk ( * ) indicates a required field. This email will be sent from you to the recipient email address(es) you enter. Please do not use this feature to contact CMS. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom of every MCD page.

Submission of Public Comment

Page help for nca - gender dysphoria and gender reassignment surgery (cag-00446n), national coverage analysis (nca).

This page displays your requested National Coverage Analysis (NCA). The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections. When an NCD is under consideration, either a new review or a reconsideration, there are numerous documents that support the process. These documents are considered the NCA. They include tracking sheets to inform the public of the issues under consideration and the status (i.e., Pending, Closed) of the review, information about and results of MEDCAC (formerly known as MCAC) meetings, Technology Assessments, and Decision Memoranda that announce CMS's intention to issue an NCD. These documents, along with the compilation of medical and scientific information currently available, any FDA safety and efficacy data, clinical trial information, etc., provide the rationale behind the evidence-based NCDs.

Printing a Document to PDF

Frequently Asked Questions (FAQs)

Are you a provider and have a question about billing or coding.

Please contact your Medicare Administrative Contractor (MAC). MACs can be found in the MAC Contacts Report .

Do you have questions related to the content of a specific Local Coverage Determination (LCD) or an Article?

Are you a beneficiary and have questions about your coverage, are you looking for codes (e.g., cpt/hcpcs, icd-10), local coverage.

For the most part, codes are no longer included in the LCD (policy). You will find them in the Billing & Coding Articles. Try using the MCD Search to find what you're looking for. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. The list of results will include documents which contain the code you entered.

Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. All other Codes (ICD-10, Bill Type, and Revenue) have moved to Articles for DME MACs, as they have for the other Local Coverage MAC types.

National Coverage

NCDs do not contain claims processing information like diagnosis or procedure codes nor do they give instructions to the provider on how to bill Medicare for the service or item. For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM).

In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy.

How do I find out if a specific CPT code is covered in my state?

Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. (You may have to accept the AMA License Agreement.) Look for a Billing and Coding Article in the results and open it. (Or, for DME MACs only, look for an LCD.) Review the article, in particular the Coding Information section.

If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. The contractor information can be found at the top of the document in the Contractor Information section (expand the section to see the details).

If you don’t find the Article you are looking for, contact your MAC .

Did you receive a Medicare coverage denial?

Was your Medicare claim denied? Here are some hints to help you find more information:

1) Check out the Beneficiary card on the MCD Search page.

2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. Your information could include a keyword or topic you're interested in; a Local Coverage Determination (LCD) policy or Article ID; or a CPT/HCPCS procedure/billing code or an ICD-10-CM diagnosis code. Try entering any of this type of information provided in your denial letter.

3) Contact your MAC .

4) Visit Medicare.gov or call 1-800-Medicare.

It is Thursday and the weekly MCD data isn’t refreshed?

Are you having technical issues with the medicare coverage database (mcd), mcd session expiration warning.

Your MCD session is currently set to expire in 5 minutes due to inactivity. If your session expires, you will lose all items in your basket and any active searches. If you would like to extend your session, you may select the Continue Button.

Reset MCD Search Data

If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues.