Know your rights

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Medicare

Sample Medicare Health Insurance card.

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

 

 

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