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If you or someone you know are pursuing gender reassignment surgery, you may wonder what can be covered by insurance or Medicare. In this article, we’ll specifically address the question, does Medicare cover top surgery?
Medicare indeed covers medically necessary gender reassignment surgery. But does it include coverage for procedures involving chest masculinization or feminization?
In this article, we answer the question in clear, plain English.
Does Medicare Cover Top Surgery?
The short answer is maybe; Medicare may cover the cost of treatments for top surgery. But not 100% of the time.
As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your top surgery. Below we look at what these are so you know what to expect.
Original Medicare Coverage of Top Surgery
Original Medicare (Medicare Part A and Part B) may provide coverage for top surgery. This plan provides coverage for your top surgery if it is considered medically necessary.
Often, Original Medicare covers FTM (female to male) top surgery and is considered medically necessary to cope with gender dysphoria.
Note that Original Medicare does not provide coverage for MTF (male to female) top surgery. In that situation, you will have to pay 100 percent for your MTF top surgery.
In order to get coverage for top surgery, your healthcare provider must first order the operation.
When is surgery considered medically necessary?
Previously, Original Medicare considered gender reassignment surgery to be a type of cosmetic surgery. That changed in 2014.
By 2016, however, the Center for Medicare and Medicaid Services, or CMS, announced there is no National Coverage Determination (NCT).
Instead, the local Medicare Administrative Contractors (MACs) will decide if your gender reassignment surgery is medically necessary.
When is Coverage provided by Part A?
Coverage for FTM top surgery is provided by Medicare Part A if your FTM top surgery takes place in an inpatient setting. Part A will cover 100 percent of the costs of hospital stays for up to 60 days.
Worry not because, from the 61st day up to 90 days, Medicare Part A still provides coverage. However, you will pay a copayment each day. After 90 days, Medicare Part A will no longer provide coverage.
Additionally, Medicare Part A provides 60 lifetime reserve days. If you have them, they will still provide coverage for your hospital stay after 90 days, but you will be responsible for a daily copayment.
When is Coverage provided by Part B?
On the other hand, Part B covers FTM top surgery when in an outpatient setting (which is often). Once approved, Medicare Part B covers 80 percent of the costs of FTM top surgery.
You will pay for the remaining 20 percent.
Medicare Advantage Coverage of Top Surgery
Medicare Advantage plans (Medicare Part C) also provide coverage for FTM top surgery. Part C plans have to cover everything that Original Medicare covers.
These plans, however, can provide coverage for some procedures, treatments and services that Original Medicare does not.
And, unlike Original, some Advantage plans may provide coverage for MTF top surgery and other necessary reassignment services.
However, each plan is different, so you’ll need to check to see which ones may cover MTF top surgery, what other benefits the plans provide, and how much the plan costs.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series, including: Does Medicare cover Breast Cancer Screening Ultrasound?