The Obama administration is considering whether Medicare, its health care program for older and disabled adults, should regularly cover sex reassignment surgery.

The Centers for Medicare and Medicaid Services is requesting public comments over the next month to aid officials in determining whether a standard that would require coverage for such surgeries is warranted. Spurring the process is a request to the agency by Nehael Jae Shields, 53, who says she has been trying for several years to receive a range of surgical procedures for treatment related to being born intersex, a condition when a person is born with an anatomical makeup that doesn't fit the typical male or female definition.

Though raised male, Shields says she began openly identifying as female in 2009. A former advertising illustrator, she says she went on disability through Medicare because she faced debilitating anxiety and depression as a result of being unable to seek treatment for being intersex.

"In my 40s I decided I couldn't do it anymore," she says. "I couldn't. My depression was getting worse. … I started fighting for health care."

Until May 2014, Medicare – which offers health coverage for those 65 or older but also covers people who are disabled – would not cover procedures for sex reassignment surgery. The ban was put in place in the 1980s, when sex reassignment surgeries were considered experimental.

Now, leading representatives of the medical community – including the American Psychiatric Association and the American Medical Association – support the procedures as medically necessary and safe for those with gender dysphoria, the medical term for people who identify with a different anatomical gender than the one they were born with.

The Department of Health and Human Services lifted the ban last year after Denee Mallon, a transgender woman and Army veteran, filed a lawsuit in 2013, and coverage is now permitted for certain Medicare beneficiaries when a procedure is deemed reasonable and medically necessary. However, no specific national standard was set for when and whether sex reassignment surgery should be covered, with the decision essentially left up to regional Medicare payment contractors.

"It left a vacuum," Shields says. "Even though they had an affirmative ruling on coverage, no one knew it."

It is unknown precisely how many people would be impacted by a decision to cover sex reassignment under Medicare, which covers around 49 million people. A 2011 paper by the Williams Institute – a think tank at the University of California-Los Angeles that conducts research on gender identity law – estimated that 0.3 percent of adults identify as transgender. Trans people have reported they fear coming forward about their identity because of discrimination in the workplace and fear of rejection from family members, says Sarah Warbelow, legal director at the Human Rights Council.

"These costs are not extraordinary," David Stacy, government affairs director for the Human Rights Campaign, says of criticisms some might have about putting tax dollars toward sex reassignment procedures. "Many will never pursue the surgery for various reasons, such as other physical conditions that make it more risky."

Sex reassignment surgery can include genital reconstruction; a bilateral mastectomy, which is removal of the breasts; or a hysterectomy, an operation in which the uterus is removed. Full transition surgeries, including procedures involving plastic surgeons, can cost $100,000 if paid for out of pocket.

After gathering information, the Centers for Medicare and Medicaid Services will issue a proposed rule, which also will come with a public comment period. Afterward, the agency will issue a final coverage determination.

A decision to require Medicare to extend care may prompt an outcry from social conservative groups, which expressed both moral and fiscal concerns when the ban was first lifted.

The decision also would be particularly significant because private insurers tend to follow the same protocols as Medicare. In September, the Obama administration proposed a rule that would ban health care providers and insurance companies from discriminating against people based on gender identity, though the proposal falls short of requiring health plans to pay for gender transition.

Being transgender was once labeled as a pre-existing condition by insurance companies, who would raise premiums on patients or deny them coverage. They also would broadly link various medical conditions to being transgender, refusing reimbursement.

Earlier this year, an analysis by U.S. Census Bureau economist Benjamin Cerf Harris indicated that trans people most often make a gender transition in their mid-30s – based on when they register such changes with the Social Security Administration – though transgender women often begin the process later in life than transgender men.

"As our society is more accepting and becomes better educated on what it means to be transgender, we are going to see people seeking surgeries in their 20s and 30s and not feeling like they have to wait until they are older to come out," Warbelow says, adding that those who are older and seeking surgery have done so because of a cultural shift in the U.S. "In earlier points of their life it was completely unsafe for them to pursue it," she says.

In a study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 71 percent of transgender people said they hid their gender or gender transition to try to avoid discrimination.

Caitlyn Jenner, who received widespread media attention for coming out as a transgender woman, did not do so until she was 65. During an interview with Vanity Fair, she said, "If I was lying on my deathbed and I had kept this secret and never ever did anything about it, I would be lying there saying, 'You just blew your entire life. You never dealt with yourself,' and I don't want that to happen."

For some, pursuing surgery later in life might not be advantageous. If someone has a heart condition, for example, a surgeon might be cautious about putting him or her under anesthesia, as they would with people of any age, the Human Rights Campaign says.

But researchers are taking a closer look at care for trans people. A study led by Johns Hopkins University and published in the Journal of General Internal Medicine indicated sex reassignment surgery and hormone treatment for transgender people is cost-effective, finding the treatments do not cost much more than treatment for depression, substance abuse and HIV/AIDS – all of which can affect trans people and are common among those who cannot undergo transition, according to the researchers.