Does Medicaid Cover Testosterone Replacement? Medicaid does not pay for testosterone replacement therapy, nor do most private health insurance plans. The good news is that there are other options to help you afford this treatment.
About Medicaid Coverage
First, a little background: Medicaid is a state-funded program that helps low-income Americans pay for medical care. It is administered by the state, so rules and guidelines can vary, depending on where you live. Many gender-affirming procedures are covered under Medicaid in some states, but not all. If you’re looking for coverage for your procedure, you’ll have to look into your specific program to see if it is covered. Coverage varies from plan to plan and from state to state.
If your state covers gender affirmation procedures, you will probably qualify for them if you meet the other requirements for Medicaid based on your income level.
Medicaid Coverage Criteria for Testosterone Replacement
Generally speaking, the following requirements must be met in order for a person to qualify for Medicaid coverage of testosterone replacement therapy:
- Diagnosis of low testosterone. This is usually diagnosed through blood tests.
- Functional impairment. This means that the low testosterone levels are affecting your health or well-being in some way (for example, causing fatigue, sexual dysfunction or decreased muscle mass). Having a specific diagnosis of hypogonadism isn’t strictly necessary to get coverage under most state Medicaid programs; functional impairment alone can qualify you if it’s caused by low levels of testosterone.
- Following doctor’s orders. You need to be under the care of an approved provider and follow their advice about appropriate treatment options—generally a prescription for TRT medication, such as injections or gels that supplement your body’s natural production of testosterone.
- Citizenship or legal residency status. To receive Medicaid benefits, you must be either a U.S. citizen or a legal resident (green card holder) who has been living in the country for at least five years—or younger than five years but still meets certain other conditions based on immigration status (such as having entered the country legally with asylum status). If you were born outside the United States and have not yet received citizenship, check with your Medicaid office about how to verify your immigration status and apply for benefits if you meet these criteria.
- Residency within a qualifying state and income limits within those states’ income guidelines are also required to receive Medicaid coverage for TRT services.
The Verdict: Does Medicaid Cover Testosterone Replacement Therapy?
This may not be a question you expect to answer, but since you’re here, we’ll tell you what we know. Medicaid does cover testosterone replacement therapy and associated costs for those who qualify for Medicaid assistance. The criteria for qualifying for assistance and what specific costs are covered vary from state to state so your eligibility and coverage will depend on where you live.
If your doctor has determined that TRT is medically necessary, it’s likely that your state will cover at least some of the treatment costs. Many states cover testosterone replacement therapy as long as it is deemed medically necessary; however, certain states have specific guidelines or requirements that must be met before anyone can receive TRT coverage under Medicaid. For example, in Massachusetts, there must be six months of documentation on low testosterone levels before receiving approval by the state program Medical Director or another qualified physician.
Under certain circumstances, Medicaid may cover part or all of the costs associated with your testosterone replacement therapy.
Medicaid is a federal and state government program that provides health insurance for low-income citizens of the United States. Under certain circumstances, Medicaid may cover part or all of the costs associated with your testosterone replacement therapy.
If You Are A Transgender Person
Medicaid covers TRT for transgender people in all states except Idaho, Indiana, Nebraska, North Carolina, South Carolina, and Wisconsin. Even in these states, however, there are certain localities that provide coverage for transgender patients. For instance, Madison County’s Medicaid does cover TRT for transgender patients. If you are not sure whether your Medicaid plan offers coverage for testosterone replacement therapy ask your doctor to obtain prior authorization (a way to determine if you would benefit from a specific treatment before it is given) before beginning treatment.
If You Have Hypogonadism
Hypogonadism is an endocrine system disorder in which the body doesn’t produce enough hormones because the testes or ovaries do not function properly. This causes symptoms such as decreased sex drive and infertility. Without treatment, hypogonadism can lead to osteoporosis and a high risk of fractures later in life. Because hypogonadism is considered a medical condition and not cosmetic by nature Medicaid will occasionally cover testosterone replacement therapy depending on the state you live in and other personal factors such as age and general health status