Groups Want CMS to Expand Gender Reassignment Coverage

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By Michael D. Williamson

June 3 — Medicare should reconsider its plan to keep gender reassignment coverage decisions in the hands of local contractors, advocates for the transgender community said June 3.

Failure to extend coverage for gender reassignment procedures on a national basis will hurt those with gender dysphoria, Dan Bruner, senior director of policy at Whitman-Walker Health, told Bloomberg BNA.

Contrary to what the Centers for Medicare & Medicaid Services asserted June 2 in its proposed decision memo, there is significant evidence indicating that gender reassignment surgeries help people suffering with gender dysphoria, Bruner said. Whitman-Walker Health is a federally qualified health center in the nation's capital that serves lesbian, gay, bisexual and transgender persons and their families.

The CMS explained that gender dysphoria, previously known as gender identity disorder, is “a classification used to describe persons who experience significant discontent with their biological sex and/or birth gender.” Researchers have found that 0.5 percent of individuals are transgender, the memo said.

Local Medicare administrative contractors should continue determining whether beneficiaries should receive coverage for the gender reassignment procedures, the proposed decision memo said (107 HCDR, 6/3/16).

The CMS launched the national coverage determination process for the reassignment procedures in December 2015 (233 HCDR, 12/4/15). Making a national coverage determination would take local contractors out of the process.

Comments received by the CMS after it started the national coverage determination process, which were due in January, indicated insurers and providers backed national Medicare coverage for the surgeries. A Bloomberg BNA analysis of the 106 comments received on the matter by the January deadline found no private or public organization of national recognition wrote the agency to oppose the reassignment surgery national coverage determination process (03 HCDR, 1/6/16).

Confusion With Status Quo

Leaving coverage decisions to contractors would mean beneficiaries, providers and the contractors would remain confused about Medicare's ability to pay for gender reassignment surgeries, Anand Kalra, the health programs manager at the Transgender Law Center in Oakland, Calif., said.

Hopes were raised that the CMS would start paying for the surgeries nationally after the Health and Human Services Departmental Appeals Board, in 2014, invalidated a policy that blocked Medicare coverages of the procedures, Kalra told Bloomberg BNA.

According to the website for the National Center for Transgender Equality, the DAB's 2014 decision invalidated the Medicare policy of categorically excluding coverage of “transition-related surgery, regardless of medical need.” The group said this means coverage decisions will be made on an individual basis.

The decision to keep local contractors in charge of coverage determinations may mean the CMS is misinterpreting the DAB's ruling, Kalra said. Furthermore, he said that the proposed decision memo shows there's confusion within the CMS about how to handle coverage of the reassignment procedures.

Next Steps

The CMS is asking for comments (under reference number CAG-00446N) on the proposed decision memo by July 2, according to a separate agency tracking sheet.

In the interim, Whitman-Walker Health will continue to pursue individual claims for coverage that the clinic is handling for its patients, Bruner said. The health clinic also intends to file comments on the proposed decision memo and will urge the CMS to cover gender reassignments on a national basis, he said.

Kalra urged the CMS to look at the evidence. The CMS needs “to make sure that their analysis reflect the most current understanding of the evidence,” he said, adding that major professional societies, such as the American Medical Association and the Endocrine Society, have found that gender reassignment surgery is a useful treatment for people with gender dysphoria.

A final decision on whether to cover the gender reassignment surgeries on a national level should be issued by Aug. 31, according to the tracking sheet.

To contact the reporter on this story: Michael D. Williamson in Washington at

To contact the editor responsible for this story: Brian Broderick at

For More Information

The proposed decision memo is at

The agency tracking sheet is at

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