The CMS is considering whether Medicare should pay for sex change operations.
The agency is also considering paying for treatment to treat gender dysphoria, which describes individuals who experience significant discontent with their biological sex or birth gender, according to a notice released Thursday night.
In addition to gender reassignment, therapeutic options for gender dysphoria include behavioral and psychotherapies and hormonal treatments.
The CMS didn't cover gender dysphoria or gender reassignment surgery until 2014, when HHS' Appeals Board struck down a previous national coverage decision forbidding payment for sex reassignment surgeries and gender dysphoria. That opened the door for Medicare's regional contractors to pay for treatment.
The cost for gender reassignment surgery can be as high as $50,000 for women transitioning to men, and male-to-female reassignment can be $7,000 to $24,000, transgender advocates say.
In pursuing a national coverage determination, the CMS wants public comment on whether the science backs improved health outcomes from gender dysphoria and gender reassignment surgery.
Comments are due Jan. 2. The agency expects to release a proposed coverage decision in June and make a final decision by next fall.
The announcement comes amid a general liberalization of policies for treating transgender persons. Earlier this year, HHS issued a proposed rule that would apply an anti-discrimination section in the Affordable Care Act to everyone. Previously, civil rights laws enforced by HHS' Office for Civil Rights were limited to discrimination based on race, color, national origin, disability and age. The recent rule clarified that civil rights protections will further block discrimination based on sex, which the agency says includes gender identity.
The latest move comes 18 months after a federal board ruled that Medicare could no longer automatically deny coverage requests for sex reassignment surgeries. From 1981 through 2014, Medicare had a National Coverage Determination that explicitly excluded transition-related surgeries and medical care for transgender individuals since such care was considered experimental.
However, the board's decision didn't guarantee coverage for sex reassignment surgery. It gave individuals the right to submit physician documentation to local coverage contractors stating surgery was recommended in their individual case.
“The last step was about removing obstacles, this step is about creating a path to coverage,” said Jennifer Levi, a lawyer who directs the Transgender Rights Project of Gay & Lesbian Advocates and Defenders.
Some beneficiaries have been able to get surgeries since the ruling. But it's been a cumbersome process and taxing on providers who have had to navigate local coverage bureaucracies, transgender advocates say.
“Bandwidth is an issue across the board,” said Elizabeth Sekera, clinic director at Lyon-Martin Health Services, a San Francisco community health center that focuses on women, lesbians and transgender individuals. “It now takes a lot of time and paperwork. Having a clear path for getting that care is important. Without it, we risk providers getting bogged down and possibly not offering the services.”
Also, without a NCD, regional Medicare offices can still deny coverage for transition-related care, said Milo Primeaux, an LGBT rights project staff attorney at the New York-based Telesca Center for Justice.
While it's unlikely many seniors would pursue sex-change operations, Medicare coverage decisions can be very influential since they are often followed by other payers, experts said. It's estimated that at least 700,000 individuals in the U.S. are transgender, according to federal data. There are no estimates on how many of those are seniors.
