Does Medicare cover Gender Affirmation Surgery?

Can I claim my Gender Affirmation Surgery or Gender Confirmation Surgery on Medicare & my Health Fund?

An increasing number of people are seeking Gender Affirmation or Confirmation Surgery. As the popularity of this surgery grows, many patients often have inquiries regarding the financing of such an operation. As with other surgical procedures, certain specific rules must be met in order for you to be eligible for cover.

Will Private Health Insurance (PHI) cover Gender Affirmation or Gender Confirmation surgery?

In order to request cover for gender surgery from your private health insurance, you must first be eligible for a Medicare item number.

We recommend you consult with your health fund in order to get the correct information regarding;

  • The conditions under which you can apply for cover
  • The level and extent of your health fund cover required

Gender Dysphoria

Gender dysphoria refers to the condition of feeling that your psychological and emotional identity does not match with your birth gender. Whilst, it can cause serious distress and anxiety, gender dysphoria is not a mental illness.

In 2007 Australian Research Centre in Sex, Health & Society published ‘Tranznation: A report on the health and well being of sex and gender diverse (Trans) gender people in Australia and New Zealand’ the publication shared the following statistics;

  • A large majority of trans people (87.4 %) had experienced at least one form of stigma or discrimination
  • Over half (53.4%) reported verbal abuse
  • One third (33.6%) had received threats of violence or intimidation
  • Nearly one in five (18.6%) had experienced a physical attack or other kinds of violence

Transgender people are also likely to experience bullying in schools, workplaces and other social situations.

Reasons for wanting to have Gender Affirmation/Confirmation surgery

Whilst Transgender people do not need medical intervention to have valid identities many choose to transition. This can involve Social and/or Medical transitioning.

  • Social transitioning: refers to going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
  • Medical Transitioning involves taking hormones and/or surgically removing or modifying genitals and reproductive organs. This is what we refer to when talking about Gender Affirmation or confirmation surgery.

Medicare Item Numbers for Gender Surgery

MBS Item Numbers:

  • Total mastectomy (FTM breast removal) surgery
    • 31519 – Breast, total mastectomy
  • Free grafting surgery
    • 45451 –  Free Grafting (full thickness)
  • Tracheal Shave – Adam’s Apple Reduction
    • 41879 – Tracheoplasty

There is NO Medicare rebate for purely Cosmetic Breast Surgery – like Chest Augmentation with Implants or Breast Augmentation.

Will Medicare Cover Gender Affirmation/Confirmation surgery for medical reasons?

Medicare and Private Health Insurance function on the basic principle that all procedures of an aesthetic nature are not eligible for cover. However, if your condition affects your normal daily functioning, then there is a possibility that your insurance provider will, to some extent, help finance your procedure. The procedure must be medically justified and compliant with Medicare criteria. In every other case, neither Medicare nor private health insurance will not cover the costs.

There are many types of gender affirmation surgeries – often split into “top surgeries” and “bottom surgeries,” depending on the area of the body.

BOTTOM surgeries.

  • There are also multiple types of bottom surgeries available for individuals who wish to change their genital appearance.
    • For MTF or MTN, vaginoplasty and penile inversion techniques are used to construct a sensate vagina.
    • For FTM or FTN, phalloplasty and metoidioplasty are surgeries used to construct a neopenis. Scrotoplasty and testicular implants may also be used to construct a scrotum.

TOP surgeries.

  • There are multiple types of top surgeries.
    • For Female to Male (FTM) or Female to Non-Binary (FTN), top surgery involves removing breast tissue and flattening the chest.
    • While, Male to Female (MTF) or Male to Non-Binary (MTN), involves using breast implants (Breast Augmentation) to increase the size and volume of the breasts.

Medicare may also cover; Hormone therapy and counselling. While, additional procedures, such as laser hair removal, tracheal shave surgery, and facial feminization surgery, may also be performed as part of your gender affirmation, these surgeries are generally considered cosmetic in nature, are normally not covered by Medicare.

Research to find out if Medicare and the MBS Covers Your Gender Affirmation/Confirmation Surgery Procedure

  • You can download a complete MBS benefits scheme to find out more about the categorization, codes, and conditions for each procedure.
  • If you are looking for a specific procedure, you can use a built-in search function to browse through the categorization faster.
  • If the desired procedure is not listed in the MBS categorization, Medicare is not offering reimbursement for that specific surgery.

Why is Medicare for  Gender Affirmation/Confirmation Surgery confusing a lot of patients seeking Plastic or Cosmetic Surgery?

Each plastic surgery is strictly individualized and modified for each patient. Gender affirmation/confirmation is more of a process because the gender affirmation process encompasses a whole range of procedures that will vary from patient to patient.

Medicare Rebates are subject to change and review

MBS Item codes can change or be eliminated from the Medicare rebate schedule. If your surgery is currently eligible for a Medicare rebate, it may be best to perform your procedure sooner rather than later.

Tips For Claiming Your Gender Affirmation/Confirmation Surgery

  • Gender affirmation surgery is not for everyone. Some patients choose to live with gender dysphoria or just undergo hormone therapy without ever choosing to undergo gender affirmation surgery.
  • Ask your doctor to show you photos of patients before and after surgery. This will give you an idea of what to expect from surgery.
  • Gender surgery is often one of the last steps. Before that, you will undergo;
    • A comprehensive psychological analysis, to diagnose Gender Dysphoria.
    • Then, you will need to undergo a minimum of one year of hormone therapy.
    • After which you will be able to undergo a series of gender affirmation surgery.

When phoning Medicare and Health funds

  • Before each application;
    • Know your stuff
    • Visit the Medicare website
    • And, make as many phone calls as you need to ensure you have all the information you need to apply.
  • We recommend that you communicate with agents electronically so that you have a written record of each information exchange. However, if it is easier for you to communicate by telephone or do not use email, request written confirmation from the agent for each conversation.
  • Organisation is key. Keep your papers in order, preferably in chronological order. This includes; findings, conversations, requests, and official correspondence.
  • Unfortunately, Coco Ruby doesn’t provide assistance with Medicare or Health Fund processing. This is solely the patient’s responsibility. However, we do list the Medicare code(s) on your Quote and on your Invoice(s). So, if you are eligible for a Medicare rebate code or health fund rebate, this can help you when it comes to submitting your paperwork.

Our Gender Affirmation Surgeon

Dr Patrick Briggs, Specialist Plastic Surgeon, Melbourne MED0001537010

FRACS, Fellow of the Royal Australasian College of Surgeons
FRCSI, Royal College of Surgeons of Ireland
FRCS, Fellowship of the Royal Colleges of Surgeons

Dr Patrick Briggs is an internationally trained, Specialist Plastic Surgeon with over 20 years’ experience.

Furthermore, he is experienced in BreastBodyFace and Gender Confirmation Surgery having performed over 4500 Surgeries in private practice.

If you want to find out more about this procedure book a consultation.

More Information about Your Procedure

Medical References – Sources;

  1. https://www.healthline.com/health/medicare/does-medicare-cover-gender-affirmation#does-medicare-cover-it
  2. https://www.healthdirect.gov.au/gender-confirmation-surgery
  3. https://www.healthdirect.gov.au/lgbti-mental-health
  4. Find out more about a Gender Affirmation Surgery Melbourne by Dr Patrick Briggs

Disclaimer

The content available on our website is meant solely for educational and informational purposes. It is not intended to serve as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of your physician or qualified healthcare provider with any medical inquiries or concerns you may have. Never disregard professional medical advice or delay seeking it based on information obtained from this website. The author and publisher of this content do not provide any warranty regarding the accuracy, applicability, or completeness of the information presented herein. Any actions taken based on the information in this article are solely at your own risk. Disclaimer Page.

Last updated: 29/11/2023
Author profile image
Lyshai Brombara
Lyshai - Patient Liaison Manager at Coco Ruby Plastic Surgery in Melbourne, Victoria, Australia. Lyshai appreciates the organisation required to get things done in today’s hectic life. Her role as Patient Experience Manager Lyshai is a great guide for your plastic surgery journey.

Specialist Plastic Surgeons and ENT (Ear, Nose and Throat) Surgeon

With a wealth of experience and training, our Specialist Plastic and ENT (Ear, Nose and Throat) Surgeons are dedicated to best-practice patient care and education, customising Surgery for each and every patient to best meet their needs and desired surgical outcomes.

What to do next?

Our Patient Liaison Team can assist with any questions you may have when considering a procedure. You can send in an enquiry form below or call our Melbourne Clinic between 9 am – 5 pm Monday to Friday.

Phone 1300 599 990, Email us: enquiries@cocoruby.com.au or Book a FREE 15-minute Phone Chat with our Patient Liaison Manager or a Consultation with a Surgeon.


Disclaimer: Results depend on individual patient circumstances and can vary significantly. Results may also be impacted by a variety of factors including your lifestyle, weight, nutritional intake and overall health. Consult your Specialist Plastic Surgeon for details. This information is general in nature and is not intended to be medical advice nor does it constitute a doctor-patient relationship. Surgery risks and complications will be covered in detail during a consultation with your Surgeon.