This might sound like a totally irrelevant and dumb question. After all, if you have made it through the majority of your life with the physical attributes that you have, now being 65 years of age or older, why bother to pursue top surgery? You probably have adapted and, with your elder status, there are likely increased risks for surgery at this point in your life.
Do you really want to take these chances?
Well, this is not as straightforward as most people think.
Why?
Most people assume that you have to be 65 years of age or older in order to be on Medicare. This is largely true. However, Medicare is also available to those who are younger than 65 and who have specific disabilities. So, yes, there are many people who are on Medicare and are under 65 years of age.
And yes, there are transgender individuals who are 65 and older who DO WANT gender affirming surgery.
Around 75% of all transgender Medicare beneficiaries are under 65 years of age (Identifying the Transgender Population in the Medicare Program). This is the subset that would be the more likely to pursue top surgery. However, and somewhat ironically, it was the persistence and legal challenges of a 75 year old transgender individual that ultimately led to Medicare no longer being able to refuse coverage for any gender confirming surgery.
So, if you are a transgender individual truly wanting to undergo top surgery and just happen to have Medicare insurance, you do want to know whether or not Medicare will cover top surgery.
The answer to this question is that Medicare does cover top surgery (as well as other gender confirming surgical procedures). There are, however, several caveats and stipulations.
The surgery must be what it considers to be medically necessary.
Medicare will not cover any procedure that it considers to be cosmetic in nature. Furthermore, there MUST be a diagnosis of gender dysphoria.
The following are the absolute minimum requirements of Medicare that must be met in order to be considered for coverage for top surgery (and other gender confirming procedures):
- The person seeking gender confirming surgery must be at least 18 years old.
- There must be a diagnosis of gender dysphoria that is well supported.
- There must be mental health evaluation and therapy by a qualified mental health provider that is of at least 12 months in duration.
- The individual must fully adopt the lifestyle of the desired gender continuously for at least 12 months.
- The person must be on gender affirming hormone therapy for at least 12 continuous months (unless medically contraindicated).
- A letter written by a qualified mental health professional which substantiates a diagnosis of gender dysphoria and other enumerated criteria.
- Mental health and medical conditions must be stable and controlled.
- A specific surgical plan has been determined to meet the patient’s specific needs.
- The person seeking surgery must be of sound mind and capable of fully understanding the risks and benefits of the gender affirming procedure.
Having met these criteria, a determination can then be made as to whether the procedure will be approved for coverage by Medicare.
For more information or to schedule your top surgery consultation with us, you can either call our office at (480) 451-3000 or send us an email.
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona
