http://www.nclrights.org/publications/tgclients.htm[1] Medicare And CHAMPUS
Medicare does not pay for sex reassignment surgeries.Medicare Program: National Coverage Decisions, 54 Fed. Reg. 34555, 34572 (Aug. 21, 1989). Sex reassignment surgeries are also excluded from the Civilian Health and Medical Program of the Uniformed Services. 32 C.F.R. @ 199.4(e)(7).
[2] Medicaid
In contrast, there is no exclusion of sex-reassignment under the federal Medicaid statute. As a result, almost every court that has ever considered the issue has concluded that States cannot categorically exclude sex reassignment surgeries from Medicaid coverage.47 Despite these holdings, many state Medicaid statutes contain a blanket exclusion for procedures related to sex-reassignment.48
In addition, even in states with positive case law on this issue, as a practical matter, it is extremely difficult to obtain Medicaid reimbursement for medical procedures related to sex-reassignment (especially surgery). This is true for a number of reasons, including, among others: (1) the front line Medicaid staff who process Medicaid claims often automatically deny claims from transsexual persons based on the mistaken belief that the procedures are cosmetic or experimental, or based on the mistaken belief that the procedures are categorically excluded; (2) transsexual persons and their health care providers often fail to submit adequate documentation supporting the medical necessity of particular procedures, based on a lack of familiarity with the legal requirements for showing medical necessity; (3) advocates and attorneys often fail to provide adequate representation for transsexual persons, based on prejudice, ignorance, or an inability to find information and models of good advocacy; (4) health care providers who specialize in transgender issues often do not accept Medicaid patients.
Transsexual people who have completed sex reassignment are also frequently denied routine medical treatments appropriate to their new sex. In the first published decision to address this form of discrimination, the Superior Court of Massachusetts held that a transsexual woman who had undergone sex reassignment over 25 years earlier could not be denied medically necessary breast reconstruction surgery simply because she is transsexual. Beger v. Division of Medical Assistance (2000 Mass. Super. LEXIS 126).
