Is this the biggest news of the last 2 years? It’s certainly up there with the Macy v. Holder decision and the overturning of the Defense of Marriage Act. Today will likely be remembered forever as a milestone triumph for transgender persons in the United States.

What happened is this – the US Department of Health and Human Services ruled that Medicare cannot automatically exclude coverage for gender reassignment surgery if it is medically needed. You can read the full decision at this link here.

The scientist in me, however, forces me to strike a cautionary note for those celebrating the news. So please note the following:

1. It does not mandate that transsexual surgery (as they term it) is covered in all cases. Claimants may still be denied coverage for other reasons that are allowable under the law. What those reasons may be, however, are not known at this time (and indeed, there may be none which apply).
2. Note that only specific types of transsexual surgery are covered. From the decision: “For the male-to-female, transsexual surgery entails castration, penectomy and vulva-vaginal construction. Surgery for the female-to-male transsexual consists of bilateral mammectomy, hysterectomy and salpingooophorectomy, which may be followed by phalloplasty and the insertion of testicular prostheses.” Note that breast implants are not covered, nor facial feminization surgery, since they are still considered cosmetic surgeries.
3. It does not necessarily change anything immediately for some Medicare insurers, and may not take effect with some until January 1, 2015.
4. This ruling does not impact Medicaid, nor Veteran’s health coverages, as those are administered separately.
5. Note that you may not have a choice in the surgeon to perform your bottom surgery. Medicare may choose to cover only the “lowest cost provider,” and there is also a chance that Medicare’s physician reimbursement levels are low enough that some GRS surgeons may choose not to accept Medicare.
6. Also note that some surgeons are already booked to capacity right now – for example, I have learned that Dr. Bowers is currently scheduling surgeries for late 2015. Even if the floodgates are opened for surgery, there may be a considerable backlog at surgeon’s offices. This may also lead to a flood of new surgeons who may not have the experience and skills of the current group of established surgeons (but then, everyone has to start somewhere…).
7. Finally, note that in most cases Medicare will not cover surgery performed outside the US. So if you had your heart set on surgery in Thailand or Quebec, you may still have to pay for most of the expenses out of pocket.

The good news is that while you may believe this only applies to Medicare patients, many private health insurers and their subscriber companies base their coverages on what is or isn’t allowed under Medicare. So it is certain that this will have a “trickle-down” effect starting in 2015, when most policies are renewed.

So let’s celebrate, everyone! We won a major victory!

GLAD / News / Medicare to Update Healthcare Standards for Transgender Patients.