Does Medicare cover Gender Affirmation/Confirmation surgery?

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Can I claim my Gender Affirmation/Confirmation surgery on Medicare?

With the development of medicine and the growing acceptance of transgenderism, an increasing number of people are stepping forward and declaring themselves transgender.

Transgender refers to a person whose gender and personal identity is different from that of the gender they were born.

*Here we only analyze the procedure of the gender affirmation/confirmation surgery of changing gender from woman to man.*

So, does Medicare cover gender reassignment surgery by which a biologically born woman wants to change their gender to become a transgender man? 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 rules must be met in order for your insurance provider to partially or fully cover the costs.

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

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

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

  • The conditions under which you can apply for cover
  • The extent of PHI cover
  • As well as, other operations cost information.

Furthermore, in certain cases, patients can choose to apply for Early Release of Super Funds to help cover surgery costs. However, this process requires compliance with certain government rules. Even then, there is no guarantee that your funds will be released. This is especially true in cases when the surgery is for purely aesthetic reasons.

Gender Dysphoria

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

However, stress that builds as a result of feeling different, homophobic or transphobic attitudes from others and trauma for bullies or alienation from family and friends can all contribute to a decline in mental health. If you believe that there is an effect on your mental health, know that you are not alone. There are many resources out there to help you.

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.

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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.

  • 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/confirmation surgery
  • Social transitioning: refers to going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender

Gender Confirmation surgery is one of the most complex operations in the field of plastic surgery. It not only changes the complete external physical appearance of the individual but their overall identity as well.

Different ways people cope with Gender Dysphoria;

  • Some seek psychological help to accept their body as it is.
  • While others satisfy their need by dressing in different clothing. Whether that be masculine or feminine.
  • Individuals often also change the style of their hair to better reflect their emotional identity. For example, cutting their hair short, growing it long, wearing a wig and deciding to shave/wax or not.
  • Surgery to medically change your gender to that of which you identify is the most drastic and permanent option.

Today, gender surgeries are not only becoming more common and more accessible but they are also becoming faster, and more efficient. Accordingly, more and more women are choosing to go through the long process of gender reassignment, which, in addition to the operation itself, includes psychological counselling as well as hormone therapy.

While society still has a long way to go in terms of accepting and supporting persons that are LBGTQ(IA+) we have come a long way over the last decade. The increase in awareness, acceptance and tolerance has allowed more people to openly acknowledge their true internal identities and manifest them externally. This in turn has increased the popularity of gender reassignment surgery and similar medical procedures.

In short, one of the main reasons why individuals today decide to have sex-change surgery is as simple and as complicated as they are unable to continue living in a body that they do not feel is their own.

Aesthetic Reasons for Gender Affirmation/Confirmation surgery

The problem of accepting the physical characteristics of the female body is the main reason why people opt for gender affirmation/confirmation surgery. At the beginning of the process,  after deciding to change their gender, a trans person (with the body of a woman), goes through psychological counselling, followed by hormonal therapy with male hormones, also known as testosterone.

Hormone therapy causes physical changes such as hair growth and muscle gain. Furthermore,  many people are not happy with their breasts after hormonal therapy alone, so they decide to undergo a mastectomy.

The process of physically transforming from a woman into a man ends with a sex change operation. This removes the uterus, ovaries, fallopian tubes and includes the implantation of the testicles and shaping of the penis.

Functional Reasons for Gender Affirmation/Confirmation surgery

In addition to aesthetic reasons, patients can opt for Gender Affirmation/Confirmation surgery for functional reasons, in order to facilitate and improve their quality of life.

Reasons for Gender Affirmation/Confirmation surgery can include;

  • The mismatch between perceiving oneself as a man and one’s female body can cause serious psychological problems that result in a worsening of the physical condition (Gender Dysphoria)
  • Gender dysphoria in women causes a lack of sexual desire and a feeling of discomfort during sexual intercourse.
  • Gender reassignment and gaining male sexual characteristics; broad shoulders, body hair, deeper voice, straight chest, male genitals in trans men results in a feeling of self-confidence, relaxation, and satisfaction with their own body,
  • After surgery, most claim to feel sexually comfortable for the first time.

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How Do I Qualify for the Medicare Rebate?

To be eligible for rebates for gender reassignment surgery, you must meet certain Medicare criteria.

The Australian Government uses a numbered list of services through the Medicare Benefits Schedule (MBS) to determine which procedures are subject to rebates.

BREAST, total mastectomy falls under the third category of procedures – therapeutic procedures, and a subgroup of General Surgery.

FREE GRAFTING (full thickness), to 1 defect, excluding grafts for male pattern baldness falls under the third category of procedures – therapeutic procedures, and a subgroup of Plastic And Reconstructive Surgery.

MBS Code for total mastectomy surgery is:

31519 – Breast, total mastectomy

MBS Code for free grafting surgery is:

45451 –  FREE GRAFTING (full thickness)

For more information, you can download our Medicare and Health Insurance Guide

A Guide to Medicare and Health Insurance

Medicare and Health Insurance Guide

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

Medicare and PHI 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.

Many types of gender affirmation surgeries exist; they are 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 FTM or FTN, top surgery involves removing breast tissue and flattening the chest.
    • While, for MTF or MTN, it involves using breast augmentation to increase the size of the breasts.

Furthermore, back in 2016, the CMS (Centers for Medicare & Medicaid Services) announced that it wouldn’t be issuing a national coverage determination for gender affirmation/confirmation surgery. Instead, gender affirmation surgery is covered if it’s deemed medically necessary by local MACs (Medicare Administrative Contractors) and Medicare Advantage plans on a case-by-case basis.

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 reassignment process encompasses a whole range of procedures that will vary from patient to patient.

Accordingly, all patients are different and come up with different ideas and qualifications for the procedure, they have different wishes and expectations which sometimes do not coincide with real possibilities.

Most women opt for gender reassignment surgery because the discrepancy between feeling like a man and living in a woman’s body has such a negative effect on their psyche and general health that the need for a sense of belonging and freedom will outweigh the fear of the length and seriousness of the transformation process.

In these operations (of course there are always exceptions), it is not a desire to improve the physical appearance but the primordial need to harmonize the physical and spiritual, the unification of the body with the feeling of belonging.

If your condition affects your health and psychological condition to such an extent, provided that all other conditions are met, there is a possibility that Medicare will cover a certain part of your costs, especially if you have a referral.

Life-Changing Effects of Gender Affirmation/Confirmation Surgery

Gender surgery, more precisely the whole gender reassignment procedure, is the most extreme set of medical procedures that includes a whole series of psychological preparation of the patient, hormone therapy, and ultimately a series of plastic surgeries that completely change a person’s biological characteristics.

The number of plastic surgeries will vary, depending not only on the physical predispositions of each patient and the results of hormone therapy but also the patient’s wishes.

Except for extreme changes in appearance that result in increased self-confidence and feelings of satisfaction, the biggest changes a patient experiences are psychological ones.

Before any operation that drastically changes the physical appearance, it is important that you have the psychological help of a doctor. This is especially true in gender reassignment surgery, it can make the whole transition and the reaction of society after the transition easier on the 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.

Top Tips for dealing with Medicare regarding your claim

  • Known the fundamental difference between cosmetic and plastic surgery. Plastic surgery (also known as plastic reconstructive surgery) is subject to rebates while aesthetics are not.
  • If your request for rebates is approved, it is very unlikely that you will receive full financial compensation.
  • If you operate solely for aesthetic reasons, your request for rebates will undoubtedly be denied.
  • Gender reassignment surgery is extremely expensive and can reach tens of thousands of dollars. So, if you do not have the financial means for such an outlay, ask about the possibilities of covering the costs/part of the costs.
  • Medicare and PHI differ in both terms and scope of coverage. So, ask your private health fund directly about the scope of coverage.
  • When submitting the request, include as much detail as possible. Thoroughly, explain your problem and support the request with medical records, findings and photographs.
  • Enclosing a doctor’s referral with your request will improve your chances of reimbursement, even if it is only a partial one.

Further Tips For Claiming Your Gender Affirmation/Confirmation Surgery

  • Gender reassignment surgery is not for everyone. Some patients choose to live with gender dysphoria or just undergo hormone therapy without ever choosing to undergo gender reassignment surgery.
  • After gender reassignment, it is impossible to go back to the way you were before, even if you arent happy with the outcome. Therefore, it is vital that before making a final decision you take time to think, counsel, and gather information.
  • Gender reassignment surgery does not address gender dysmorphia in all patients. Some patients are dissatisfied with their appearance after the operation or they thought they would lose all-female physical characteristics immediately.
  • 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.
  • The process of gender reassignment is time-consuming and largely depends on your mental state. So don’t expect to start and complete the transformation process in a year. Sex surgery is just the last step. 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 reassignment surgery.
  • Unfortunately, not all people are open enough and willing to accept a person who has chosen to change there gender. Prepare yourself mentally for this and express your condition and wishes to your loved ones early enough. You will need the support of those close to you.

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When phoning Medicare and Health funds

  • The procedure for requesting the return of the rebate is usually lengthy and quite stressful.
  • 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, CocoRuby 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.

More Information about Your Procedure

You can Download  Free Procedure Guides on your chosen surgery.

Also, our FAQs page might help you find out more about the procedure you are interested in, and other patients’ experience.

For more information about pricing and payment methods, please visit our page on Surgery Payment options.

You can also talk to our Patient Care Team from 8 am – 6 pm Monday to Friday on 1300 264 811

Phone 1300 264 811 or send us an enquiry form, below.

*Disclaimer: Individual results can vary significantly from patient to patient. The information we provide is general.  For further information on what to expect for your preferred procedures, arrange to see one of our Specialist Plastic Surgeons for a full-history and surgical consultation. Read further information about surgical outcome variability on our Disclaimer page.

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.verywellhealth.com/sex-reassignment-surgery-2710288
  4. https://www.healthdirect.gov.au/lgbti-mental-health

 

Last updated: 17/02/2021
Author profile image
Michelle Staughton
Michelle Staughton - Patient Liaison Manager at Coco Ruby Plastic Surgery in Melbourne, Victoria, Australia