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 to assist processing of claims under original Medicare . 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.
What If I Need Hormone Therapy
- For pubertal suppressants: You must reach puberty level of Tanner Stage II which is determined by your doctor. You need a medical professional to provide documentation that you are eligible and ready for the treatment and other requirements, such as proof that you understand the outcomes, risks, and benefits of beginning hormone therapy and that you have the necessary psychological and social support.
- For cross-sex hormones:
- If you are over 18 years old, you need a medical professional to provide documentation that it is medically necessary.
- If you are 16-17 years old, you need a medical professional to provide documentation that you are eligible and ready for the treatment and other requirements, such as proof that you understand the outcomes, risks, and benefits of beginning hormone therapy and that you have the necessary psychological and social support.
- If you are under 16, you need a medical professional to provide documentation that you are eligible and ready for the treatment and other requirements, such as proof that you understand the outcomes, risks, and benefits of beginning hormone therapy and that you have the necessary psychological and social support and your health insurance companys prior approval.
What Laws Protect Me
- The Health Care Rights Law, as part of the Affordable Care Act prohibits sex discrimination, including anti-transgender discrimination, by most health providers and insurance companies, as well as discrimination based on race, national origin, age, and disability. Under the ACA, it is illegal for most insurance companies to have exclusions of transition-related care, and it is illegal for most health providers to discriminate against transgender people, like by turning someone away or refusing to treat them according to their gender identity. On May 5th, 2021, the Biden Administration and HHS announced that the Office for Civil Rights will interpret and enforce Section 1557 and Title IXs prohibitions on discrimination based on sex to include:
Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in covered health programs or activities. The update was made in light of the U.S. Supreme Courts decision in Bostock v. Clayton County and subsequent court decisions. Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The HHS has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint at:
- Puerto Rico private insurance
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Alaska Medicaid Must Cover Gender
Starting this month, Alaska Medicaid can no longer deny coverage to transgender Alaskans undergoing gender-affirming treatment.
Thats following the January settlement of a class action lawsuit filed by Swan Being, a transgender woman from Homer who said Alaska Medicaid refused to cover costs related to hormone treatment in 2019.
Being sued the Alaska Department of Health and Social Services, which oversees Alaskas Medicaid program, and department commissioner Adam Crum. She alleged the states policies discriminated against transgender Alaskans and violated the 14th Amendment, which grants all Americans equal treatment under the law.
Being was the first to file the case. Robin Black and Austin Reed, both of Anchorage, joined as plaintiffs in 2020.
Up until now, Alaska was one of 10 states that still explicitly denied Medicaid coverage for gender-affirming treatment, including surgery, hormone treatment and therapy. Similar lawsuits are currently in motion in West Virginia and Georgia, said Carl Charles, an attorney with Lambda Legal. He co-counseled the case alongside the Anchorage-based Northern Justice Project.
Charles said that kind of gender-affirming health care is life-saving for transgender people. And he said its particularly important to protect access to that health care when its contingent upon employment.
Being received hormone replacement therapy and, in 2019, planned to travel from Homer to Anchorage for further treatment.
Applying For Marketplace Coverage
When you apply for Marketplace coverage as a transgender person, you should use the first, middle, and last name that are on your Social Security card. If you get a letter or email stating that you need to take additional action because your name doesnt match the name on file with the Social Security Administration , you can go back to your application and update your name.
On your Marketplace application, its also recommended that you select the sex that appears on the majority of your other legal documents, such as your drivers license or Social Security card. While the Marketplace doesnt check an applicants sex against any other government record, including SSA, some state Medicaid agencies may verify your sex against available records. Note: The information you put on your Marketplace application will go to your health insurance company.
If you change your name and/or sex after you enroll in a plan, you should be able to update the information when you log in. If you have trouble updating this information, contact the Marketplace Call Center.
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Formulary Exception Process For Prescription Drugs
Standard. 72 hours for insurer decision.
Expedited. 24 hours for insurer decision when your health, life, or ability to regain maximum function is in danger, or if you are currently being treated with a non-formulary prescription drug.
Final Denial. If your insurer denies your formulary exception request, its a final adverse determination. You do not have to appeal with your insurer. You can request an external appeal with DFS.
Applicability. Individual & small group coverage and, beginning on renewal in 2020, large group coverage.
Know Your Rights In Health Care
Federal and state laws – and, in many cases, the U.S. Constitution – prohibit discrimination in health care and insurance because you’re transgender. That means that health plans arent allowed to exclude transition-related care, and health care providers are required to treat you with respect and according to your gender identity.
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Is Hormone Therapy For Older Men Included In Insurance Coverage
A universal health plan gives everyone access to health services, medical treatments, and surgical procedures that they will need. In the United States, there are three ways that residents can avail themselves of health insurance: individual plans, employer-sponsored health plans, and government-based programs like Medicare and Medicaid.
Medicare is the primary health insurance program for persons with disabilities and for citizens who are 65 years of age and above. On the other hand, Medicaid coverage has no age limit and is open to all low-income individuals with limited means to fund their health care and medical needs.
In terms of long-term care for older women and men, the benefits of Medicare coverage may be limited. Medicare offers four different insurance programs: hospitalization coverage , medical insurance , Medicare Advantage , and prescription drug .
While Part A and Part B can provide coverage for the necessary gender affirmation surgery and other medical procedures, they may not pay for the costs of your hormone medications. You may opt to subscribe to the Medicare Advantage Plan Part C or Medicare Part D to get coverage for prescription drugs needed for hormone therapy.
Whats The Difference Between Medically Necessary And Cosmetic Procedures
As a transgender person, gender-affirming surgeries can have a significant effect on your well-being. However, not all procedures are covered by Medicare. To qualify for Medicare coverage, procedures must be classified by the insurance company as medically necessary rather than cosmetic.
Coverage for transgender procedures is typically limited to those that change primary sex characteristics, including:
- For people assigned female at birth and transitioning: Removal of breasts, ovaries, and uterus, and genital reconstruction
- For people assigned male at birth and transitioning: Removal of the penis, testicles, and prostate gland and genital reconstruction
While trans individuals often undergo other procedures to make their appearance match their gender identity, such as facial contouring or hair transplants, Medicare designates these procedures as cosmetic and does not cover them.
RELATED: Speak with a licensed Medicare insurance agent by calling: .
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How Can I Help
- Head to NCTEs Health Action Center to see the latest on health care and how you can help fight for transgender peoples right to get the health care they need
- If you are facing discriminatory treatment, consider sharing your story with NCTE so we can use it in advocacy efforts to advance public understanding and policy change for transgender people. If you successfully resolved a health care situation, we want to hear about that as well.
What If Your Surgery Is Denied
Because transition-related surgery is decided on a case-by-case basis, your request may be denied.
However, if you and your doctor believe the surgery is reasonable or medically necessary, you can appeal Medicares decision.
Original Medicare beneficiaries can fill out a Redetermination Request Form to appeal. Medicare has 60 calendar days to respond.
Medicare Advantage beneficiaries must directly contact their plan provider to appeal. Medicare Advantage plans have 30 to 60 calendar days to make a decision on your case.
Organizations such as the National Center for Transgender Equality highly recommend that beneficiaries consult with a lawyer before filing an appeal.
You can appeal Medicares decision up to four times after your first appeal.
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Mental Health Care Benefits For Transgender People With Medicare
You have access to mental healthcare professionals through Medicare Part B. Services available to you include:
One time preventive visit to assess your depression risk
Free annual depression screening
Some transgender affirming mental healthcare providers treat Medicare beneficiaries. Such providers would be competent at addressing mental health needs of transgender people.
Unless you get extra help with your bills, you would be responsible for out-of-pocket costs. These costs include your plan’s premiums, deductibles, coinsurance, and copayments.
Does Coverage Vary Depending On Where I Am Or What Type Of Plan I Have Have
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:
You can search for specific local policies on CMSâ website.
Whether you have Original Medicare or private Medicare , 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 . 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 .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 NCTEâs Health Coverage Guide. NCTE will soon include specific Medicare language for Medicare Advantage plans on this resource.
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Treatment Your Insurer Is Required To Cover
Medically Necessary Treatment. Your insurer must cover medically necessary treatment for gender dysphoria.
- The benefits must otherwise be covered under your health insurance policy . If your employer has more than 100 employees, some benefits, like prescription drugs, are not required to be covered.
- Your health insurance policy cant exclude medically necessary gender-affirming treatment as a category of treatment.
- Check your health insurance policy. You can request a copy by calling the Member Services number on your health insurance ID card or asking your employer.
- Your doctor may recommend treatment, but your insurer might not agree it is medically necessary.
Cost-sharing for Treatment. You may have a deductible, copayment, or coinsurance.
- A deductible is the dollar amount that you need to pay before services will be covered. If your deductible is $1,000, your health insurance policy wont pay anything until youve paid $1,000 for covered services.
- You may also have a copayment or coinsurance that you will need to pay for treatment.
- Your insurer cant apply annual limits or lifetime limits on most treatment.
- Check your health insurance policy, because the deductibles, copayments, or coinsurance may be different depending on the services you are getting.
Discrimination. Your insurer cant discriminate against you because of your sexual orientation, gender identity or expression, or transgender status.
What Do I Need To Show In Order To Receive Coverage For Other Transition
Medicaid covers other surgeries, such as breast augmentation surgery, facial feminization surgery, etc. if medical necessity is shown and prior approval is received from your health insurance company. This means that Medicaid requires the two letters described above showing a determination of medical necessity by a qualified medical professional.
- If you are seeking breast augmentation, you must have received hormone therapy for at least two years, during which time breast growth has been negligible, the meaning of which is dependent on your body type and particular situation.
The most important thing to keep in mind is that if you need transition-related treatment, you have the right to request it, and if you are denied, you have the right to appeal the denial. You should act quickly because there are time limits on when you can file an appeal.
Questions? Need help filing an appeal? Contact Legal Aid at the Access to Benefits Helpline on the first and third Tuesdays of the month from 9:30 a.m. 12:30 p.m. at 888-663-6880. Be sure to keep all letters and paperwork associated with your claim.
What Does Colorados Recent Announcement Mean
To help address the barriers that many transgender people continue to face, Colorado amended its marketplace EHB benchmark plan to provide greater clarity on how insurers should cover gender-affirming care. Under the ACA, insurers in the individual and small-group markets must cover 10 categories of EHB. HHS gave states flexibility to choose from among existing health plans to identify the benefit benchmark and specify the details of what must be covered in each category.
In updating its EHB benchmark plan, Colorado affirmed that insurers were already required to cover gender-affirming care, but made changes to reflect the need to be more explicit, more comprehensive, and less variable. This additional clarity is expected to increase access to care for transgender enrollees. Colorado also made other changes to its benchmark plan that will benefit transgender people and other Coloradans for instance, requiring coverage of an annual mental health wellness exam. These changes will apply to ACA coverage in the individual and small-group markets beginning in 2023.
Improvements Under The Affordable Care Act
Access to health insurance undoubtedly improved under the Affordable Care Act . The uninsured rate among low- and middle-income transgender people dropped from 59 percent in 2013 to 25 percent in 2017. There also has been a documented decline in the use of broad transgender exclusions over time.
An annual analysis from Out2Enroll shows that most insurers that offer silver marketplace plans through HealthCare.gov did not incorporate transgender exclusions in their individual market plans beginning with the 2017 plan year. This was the first year that Obama-era rules barred such categorical transgender exclusions from many private plans.
There also has been a documented increase in the inclusion of plan language that explicitly confirms that some or all medically necessary treatment for gender dysphoria is covered. For 2021, nearly half of HealthCare.gov insurers incorporated this affirmative coverage language, up from 18 percent in 2017.
Despite some remaining gaps, coverage has improved significantly as a result of the ACA, and there is continued momentum for the coverage of gender-affirming care in other types of plans as well. To date, 24 states and the District of Columbia, including Colorado, have additionally prohibited transgender exclusions in state-regulated health insurance. Private sector employers and state Medicaid programs are also adopting clear policies to affirm transgender-inclusive coverage.
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Many Medicare Advantage Plans Cover Prescription Drugs
Medicare Advantage plans are sold by private insurance companies as an alternative to Original Medicare. Every Medicare Advantage plan must cover everything that Original Medicare covers, and most Medicare Advantage plans may offer prescription drug coverage.
Some Medicare Advantage plans may also offer additional benefits, such as:
Plans With Transgender Exclusions
Many health plans are still using exclusions such as services related to sex change or sex reassignment surgery to deny coverage to transgender people for certain health care services. Coverage varies by state.
Before you enroll in a plan, you should always look at the complete terms of coverage that are included in the Evidence of Coverage, Certificate of Coverage, or contract of insurance. This contains the full explanation of which procedures and services are covered or excluded under each plan. Plans might use different language to describe these kinds of exclusions. Look for language like All procedures related to being transgender are not covered. Other terms to look for include gender change, transsexualism, gender identity disorder, and gender identity dysphoria.
You can access the full terms of coverage through a plans Summary of Benefits and Coverage. If youre still not sure about how services would be covered or excluded, you should contact your health plan directly by phone.
These transgender health insurance exclusions may be unlawful sex discrimination. The health care law prohibits discrimination on the basis of sex, among other bases, in certain health programs and activities.
If you believe a plan unlawfully discriminates, you can file complaints of discrimination with your states Department of Insurance, or report the issue to the Centers for Medicare & Medicaid Services by email to .
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