Does health insurance cover gender affirmation surgery?

Is gender affirmation surgery covered by Medicare?

Yes, but only partly. Medicare can cover some of the individual treatments associated with gender affirmation surgery, including surgeries, medications, tests and consultations. Approved treatments are listed on the Medicare Benefits Schedule (MBS), but you will still need your doctor's referral to get covered. Here are some examples of the treatments that Medicare can pay towards, including the medicare item number:

Medicare can also cover your GP visits, blood tests, psychological counselling and a few prescriptions – again, with the right referrals from your doctor.

Unfortunately, out-of-pocket expenses are unavoidable and can be significant. This because specialist care for trans people and those with gender dysphoria is in extremely short supply in Australia. Most procedures are performed privately, where fees are likely to be high. Medicare will pay up 75-85% pf the MBS fee, but you could still be left with thousands of dollars to pay on your own.

What Medicare won't cover

There are a few treatments that Medicare won't pay for at all. Along with the expenses mentioned above, you will also need to come up with the full amount for the following unless you have private health insurance:

• Your accommodation and theatre fees (since you'll be in a private clinic)
• Cosmetic surgery that is considered not medically necessary (such as breast implants and cosmetic facial reconstruction)
• Some medications for hormone replacement therapy (HRT)

Will private health insurance cover gender affirmation surgery?

Luckily, private health insurance can cover you in some of the areas that Medicare falls short. Here's where it can help:

• It will pick up the tab on that 15-25% that Medicare didn't pay on treatments you received in a private clinic.
• It will cover your accommodation and theatre fees for any treatments that are on the MBS.
• It can pay for some of the hormone prescriptions that Medicare won't cover.
• It can help out with additional psychology sessions if you feel you need them.

Remember that there will typically be a waiting period before you can claim for most treatments. These can be anywhere from 2-12 months, depending on the treatment.

What level of private health cover will you need?

Here are some tips to help make sure you get the right cover:

• Double-check the MBS item numbers with your insurer. Every insurer is different, so your best bet is to double-check that your insurer doesn't exclude or restrict any treatments you plan on having. The most accurate way of doing this is to get your MBS item numbers from your doctor so you can relay this to the insurer and get an estimate of costs, or a heads up on any restrictions.
• Get a hospital policy that covers you in a private clinic. This is the minimum that you need, covering you for treatment in a private hospital, but depending on the surgery you need, you might need more comprehensive cover.
• Get a top extras policy. Some extras policies will cover prescriptions that Medicare won't, but you'll need a top-level extras policy if you want your HRT prescriptions covered.
• Cover for the "gap". This is the difference between what Medicare and private health insurance covers and what the surgeon charges. Some insurance providers have agreements with specific surgeons so that you can reduce these out-of-pocket expenses.

How much does gender affirmation surgery cost in Australia?

Outside of government guidelines, there's no hard and fast rule in Australia for how much each specific surgery is priced. Excluding contributions from Medicare or private health insurance, it can cost upwards of $30,000, depending on what treatments you need. This includes surgery fees, specialist visits, hospital accommodation, anesthesiologist fees, counselling and hormone therapy.

To give you a better idea of how much the total cost of different gender affirming surgeries is in Australia, we've collected the average price range and whether they're covered by Medicare or private health insurance.

The prices were based on a mix of the Medical Cost Finder, TransHub, & select clinics and should only be used as a guide. *

• Top surgery

  It can cost approximately $4,000 to $20,000 for female-to-male (FTM) top surgery in Australia. It may be possible to get a Medicare benefit for your surgeon, anaesthetist and assistant fees, but only if you can prove that your top surgery is "medically necessary"; that is, essential to your health and not simply a cosmetic issue. Unfortunately, in Australia, proving this can be tricky. Having said that, it's still worth speaking to your doctor to see if you can get covered.

  The Australian Professional Association for Trans Health (AusPATH) has a list of surgeons who can perform top surgery in Australia here.

• Hysterectomy

  The cost of a hysterectomy can be quite different depending on which procedure is used to perform the surgery and which surgeon you choose. Costs we've seen online range from $10,000 up to $15,000 for Australian private clinics. By and large, hysterectomies are considered a medically necessary part of gender affirmation, and you may be able to receive Medicare and private health cover if you qualify.

• Orchietomy

  An orchiectomy is a procedure that surgically removes testes and can cost between $3,000 and $10,000 in Australia. This is usually considered a medically necessary part of gender affirming care and a portion of this may be covered by Medicare or private health.

• Facial surgery

  This can include things like tracheal shaving, nasal surgery and forehead reduction. Facial surgery can cost between $5,000 to $40,000 in out of pocket costs. While it can be difficult, facial surgeries can be considered medically necessary for individuals with severe gender dysphoria. In our experience this can be a bit ambiguous, so it's a good idea to check with your doctor first.

• Breast implants

  Breast implants or breast augmentation can cost between $7,000 and $16,000. In Australia, this type of surgery is considered a cosmetic surgery. As a result, it's fairly difficult to access medicare rebates or private health cover unless you can prove the procedure is medically necessary.

Is hormone therapy covered by Medicare and private health insurance?

Medicare will cover your visit to the endocrinologist plus any blood work they do. As for the medication itself, it's a mixed bag. Medicare pays for some hormones through the Pharmaceutical Benefits Scheme (PBS), but they won't pay for others.

Since you might need a few medications, there's a good chance you won't be covered for some of them. Luckily private health insurance can help you here too, by offering a refund on certain medications that aren't covered by the PBS.

Important note: Medicare can deny you cover for certain medications if you're registered as the gender that you do not identify with (for example, men are not normally supposed to take estrogen). So if you are transitioning from male to female, you'll need to update your gender details with Medicare and other government departments before you can get estrogen.

Is psychological treatment covered?

The good news is that both Medicare and private health insurance can help cover your psychologist sessions. Anyone with a Medicare card can get up to 10 sessions per year covered. All you have to do is see a GP and ask them to put you on a mental health treatment plan. Depending on your psychologist, the rebates available on the plan may cover all or part of their fee. So, you may not be out of pocket any amount, or there could be a gap payment owing.

A private health insurance extras policy can also be used on top of Medicare to cover the gap payments, or to use towards additional sessions. You can also use it on its own to get a contribution towards your psychology appointments if you don't have a mental health care plan; in this case, you don't have to see a GP or get a mental health treatment plan. You can just book directly with the psychologist.

Frequently asked questions

• Can you legally change your gender in Australia?

  As of July 2013, anyone in Australia has the right to update their gender with any government agency. You can do so by submitting one of the following:

  • A statement from a registered medical practitioner or a registered psychologist
  • A valid Australian government travel document, such as a passport
  • A state or territory birth certificate (you can have your gender and/or name changed by filling out the appropriate forms from your local Births, Deaths and Marriages Registry)
  • A document from your local Birth, Deaths and Marriages Registry recognising your change of name and/or gender

• Is top surgery covered by Medicare or private health insurance?

  It may be possible to get a Medicare benefit for your surgeon, anaesthetist and assistant fees, but only if you can prove that your surgery is "medically necessary"; that is, essential to your health and not simply a cosmetic issue. Unfortunately, in Australia, proving this can be tricky, despite the World Professional Association for Transgender Health (WPATH) stating that top surgery is "not merely another set of elective procedures". Having said that, it's still worth speaking to your doctor to see if you can get covered.

  It may be possible to get a medicare benefit for your surgeon, anaesthetist and assistant fees, but only if you can prove that your surgery is "medically necessary" and not a cosmetic decision.

• Where can I learn more about gender affirming surgery?

  There are quite a few national organisations that offer support, services and counselling to transgender people all around Australia. Here are a few you can reach out to:

  • Headspace
  • A Gender Agenda
  • Gender Centre
  • Trans Health Australia

  Headspace provides mental health and wellbeing support, information and services to young people around Australia.

  Web: www.headspace.org.au

  A Gender Agenda provides advocacy, training and community development for Australia's sex- and gender-diverse community.

  Web: www.genderrights.org.au

  The Gender Centre provides a wide range of services and activities designed to help people with gender issues make informed choices.

  Web: www.gendercentre.org.au

  Trans Health Australia is an advocacy and support network that aims to improve the delivery of medical, health and wellbeing services to members of the transgender and transsexual community.

  Facebook: Trans Health Australia

  There are also several state- and territory-based support and service organisations, so keep an eye out for one in your area.

Written by

Cameron Thach

Writer

With a background in writing across education, Web3, and finance, Cameron’s mission is to create content that speaks directly to readers in a way that’s easy to understand, helping them navigate complex topics with confidence. Cameron studied a Bachelor of Commerce, Economics and Marketing at Macquarie University, graduating in 2019. See full bio

Co-written by

Gary Ross Hunter

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Gary Ross Hunter has over 6 years of expertise writing about insurance, including life, health, home, and car insurance. Having reviewed hundreds of product disclosure statements and published over 800 articles, he loves simplifying complex insurance topics for everyday readers. Gary has contributed to major outlets like Yahoo Finance, The Sydney Morning Herald, and news.com.au, and holds a Bachelor of Arts (Honours) in English Literature from the University of Glasgow, along with a Tier 2 General Advice certification, ensuring his work adheres to ASIC’s RG146 standards. See full bio

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