For many trans folks, navigating the United States health care system can be complicated. Transgender individuals often struggle when it comes to finding health care providers who understand the nuances of trans health care. Not all providers are cognizant of the use of consistent and respectful pronoun usage.
Plus, it can be difficult to understand how health insurance does or does not cover care.
One important thing up front: Federal and state law prohibits most public and private health plans from discriminating against a person because they are transgender. And this means that, on the whole, it is illegal for your health insurance plan to refuse to cover medically necessary transition-related care.
This means that a health plan can’t have a categorical exclusion of transition-related care. And a health plan can’t have a categorical exclusion of a specific transition-related procedure either. Your health insurance company also can’t place limits on coverage for transition-related care if it covers the same procedure for non-transgender people. And thanks to the Affordable Care Act, health care plans also cannot refuse to enroll you in a plan, cancel your coverage, charge you higher rates, or deny you coverage because of your gender identity.
But just because most health insurance plans should provide coverage for medically necessary transition-related care, doesn’t mean that discrimination doesn’t still exist—and many plans also have exclusions for transition-related care. For help avoiding discrimination in the health system, grab our guide to finding a LGBT-inclusive provider.
Trying to figure out how much gender-affirming surgery might cost you? Here’s what to know about how your health insurance may or may not cover that care.
Is gender-affirming surgery ever covered by health insurance?
Yes, sometimes health insurance coverage includes gender-affirming surgery.
It’s important to note that it’s not a requirement for a single health insurance plan to cover any specific kind of procedure.
For private insurers who do cover gender-affirming surgery, a patient must first prove that the procedure is medically necessary. While the details of this may vary from plan to plan, it often consists of getting one to two letters of referral from a qualified mental health professional, a “persistent, well-documented” case of gender dysphoria, and the proven ability to make fully informed decisions.
A 2018 study published in JAMA Surgery, the surgical journal of the American Medical Association, found that gender-affirming surgery accounted for just 11 percent of all encounters coded with gender identity disorder codes between 2000 and 2014, but that the number of individuals receiving gender-affirming surgery is on the rise. More than half of the individuals receiving gender-affirming surgery during that period did not have coverage by health insurance. But the amount of patients who identified as self-payers decreased over that time period. That means that the number of people who did not have insurance coverage for their gender-affirming surgery also decreased.
Medicare and Medicaid did start to provide coverage for this kind of care in 2014. Still, decisions are made on a case-by-case basis after medical necessity is evaluated. Researchers also found that the coverage of gender-affirming surgery by private insurance has increased. It went from 25.6 percent between 2000 and 2011 to 45.2 percent in 2014.
Do Marketplace (aka Affordable Care Act or Obamacare) plans cover gender-affirming surgery?
Just like with private insurance, coverage of gender-affirming surgery by Marketplace plans varies by health insurance company and by state. According to HealthCare.gov, before enrolling in any Marketplace plan, you should check the complete terms of coverage included in the “evidence of coverage” or “certificate of coverage” that accompany a given plan. This document will give the full explanation of what’s covered and what’s excluded by a given plan.
To see Marketplace (Obamacare) health plans and prices, enter your zip code below.
If you need help applying for insurance or have questions, you can call our Consumer Advocates at (872) 228-2549.
Some plans that exclude coverage for gender-affirming surgery use language like “all procedures related to being transgender are not covered.” They may have prohibitive language around words like “gender change,” “gender reassignment surgery,” “transsexual,” “gender identity disorder,” and “gender identity dysphoria.”
Don’t forget that your health plan should cover transition-related care, though. You may have to prove that gender-affirming surgery is medically necessary via additional documentation from providers. But, you should be able to access this care. Your insurance company may also require a preauthorization letter for your gender-affirming surgery; you can find a template for this here.
What should you do if your plan has transgender exclusions?
Again, coverage of transition-related care varies greatly between insurer and state. But is your right to receive a given service if it is covered for other people on your plan. Don’t forget that you always have the right to appeal a decision regarding coverage made by your insurance company if you believe you have been wrongly denied coverage. You can also check this list to see how various insurance plans cover and do not cover various forms of transgender-specific health services.
Denied coverage or your plan has an exclusion? You may need to work with your health plan to explain why such denials are illegal. And keep in mind that transgender health insurance exclusions may be unlawful sex discrimination. The health care law prohibits discrimination on the basis of sex, among other bases, in certain health programs and activities. If you believe a Marketplace plan is unlawfully discriminating, you should contact marketconduct@cms.hss.gov.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.