will insurance cover gender reassignment surgery

An official website of the United States government

Here's how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

Transgender health care

A transgender person’s assigned sex at birth doesn’t match their gender identity, expression, or behavior.

Refer to glossary for more details.

Applying for Marketplace coverage

Sex-specific preventive services.

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

Plans with transgender exclusions

An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You'll get the "Summary of Benefits and Coverage" (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.

You are leaving HealthCare.gov

You're about to connect to a third-party site. Select Continue to proceed or Cancel to stay on this site.

• Search Search Please fill out this field.

Does Insurance Cover Gender-Affirming Care?

How much does gender-affirming surgery cost, how much does gender-affirming medication cost, other ways to pay for gender-affirming care and surgery, tips for financing gender-affirming care and surgery, bottom line.

• Health Insurance

In many cases, health insurance in the U.S. covers gender-affirming care. However, whether or not your insurance plan covers a specific gender-affirming treatment depends on your state, employer, and the plan’s benefits.

Key Takeaways

• Health insurance generally covers gender-affirming care.
• Not all plans cover all procedures, or the process can be murky and require preauthorization and appeals.
• Gender-affirming care can cost tens of thousands of dollars.

Major insurance companies recognize transgender-related care as being medically necessary and have put policies in place outlining coverage criteria. However, at least 20 states have passed legislation limiting coverage of gender-affirming care for people up to age 18. And some transgender people may still be denied coverage of hormone treatments or transition-related surgery by an insurer.

An estimated 1.6 million Americans at least 13 years old identify as transgender, according to a June 2022 estimate.

Health insurers generally cover an array of medically necessary services that affirm gender or treat gender dysphoria, according to the American Medical Association. Gender dysphoria is a condition that occurs when someone feels a conflict between the sex they were assigned at birth and the gender they now identify with.

Gender-affirming care is the phrase used by most medical groups for dysphoria treatment. This care includes hormones, surgery, or counseling. The care aligns a person’s gender identity with gender expression in appearance, anatomy, and voice.

In 2010, the federal Affordable Care Act banned health insurance discrimination based on sexual orientation and gender identity. Before the law’s passage, medically necessary gender-affirming surgeries and hormones often weren’t covered by insurers.

A 2022 rule from the Biden Administration noted that “categorical coverage exclusions or limitations for all health services related to gender transition are discriminatory” and that a covered entity can’t deny or limit coverage or claims, or charge more in cost-sharing related to gender transition.

However, insurance is regulated at the federal and state level based on whether it is an ACA, public, or employer plan, so the rule doesn’t apply evenly to all insurers. Coverage and requirements vary based on state, employer, plan type, and more.

Investopedia / Candra Huff

Determining What Your Plan Covers

Plan members can generally find out what’s available in their member booklet. This should have been given to you when you got the policy or, if it’s an employee plan, when you joined the company. It may be called a certificate of coverage, a benefit plan, a summary plan description, a certificate of insurance, or something similar.

This document should describe the insurer’s clinical evidence criteria to qualify for gender dysphoria treatment claim coverage. Requirements might include:  

• One or two letters from a therapist containing specific information
• Being on hormones for a year
• Being at least 18 years old to have surgery.

Some plans may still list exclusions for certain procedures. Even if an exclusion exists in the documentation, the next step is to apply for pre-authorization or pre-approval. This earns a plan’s approval in advance for claims and may even be successful if an exclusion is evident—as it allows an appeal.

"Many [patients] call their insurance carrier and are told services will not be covered, and on that basis never attempt to file a claim,” says an article on the San Francisco-based UCSF Gender Affirming Health Program’s website. “Transgender individuals and their health providers should be aware that unless a denial is in writing, it is not a denial and cannot be appealed.

Typically, documentation submitted to the health plan shows why the treatment is medically necessary or explains the legal problems with an exclusion. Not getting preauthorization can lead to a claim denial, even if a procedure is covered. For example, many plans routinely require preauthorization for all surgeries of any kind for anyone.

If denied a preauthorization request or a claim, an attorney, health care advocate, or your human resources department may be able to help with filing an appeal. Appeals should include individualized, extensive documentation of a service’s medical necessity and appropriateness, and a comprehensive overview of the transition process of gender transition.

Here, we list four types of health insurance and how they might cover gender-affirming care.

Employer-Provided Insurance

Altogether, 24 states and the District of Columbia prohibit transgender exclusions in private health insurance coverage, according to the nonprofit LGBTQ+ advocacy organization Movement Advance Project, leaving 26 states without such protections.

However, health coverage benefits that a private employer provides can vary based on whether the employer fully funds the plan. If funded by the employer, the plan is governed by the federal law ERISA, the Employee Retirement Income Security Act , which overrides any state nondiscrimination law. The employer decides what health care is or is not covered.

Employer-based plans are governed in the state where the plan was issued, not where you live.

Up to 91% of businesses on the 2022 Human Rights Campaign’s Corporate Equality Index-rated businesses offer at least one transgender-inclusive plan option, up from 0 in 2002.

Affordable Care Act Plan Coverage

Individuals can buy their own health insurance policies, often with the help of federal subsidies, through the Healthcare.gov marketplace. Most insurers are getting rid of transgender-specific exclusions, which ACA regulation explicitly banned.

Still, policies vary by state and in what they cover. Health insurance policies may feature exclusions for items such as “services related to sex change” or “sex reassignment surgery” to deny coverage.

Around 6% of Silver Marketplace plans specifically exclude coverage for exclusions for treatment of gender dysphoria, according to a survey by Out2Enroll, an organization connecting the LGBT+ community with health care coverage.

Check a policy’s terms of coverage for a full explanation of which procedures and services are covered or excluded. You can also use a state-based Trans Insurance Guide from Out2Enroll to find a plan with the coverage you want.

Medicare and Medicaid Coverage

Nearly 10,000 transgender Americans 65 and older are enrolled in Medicare or Medicare Advantage. Under these plans, medically necessary care—including some gender-affirming procedures—is covered. Coverage by Medicare Advantage plans may vary, so try to get preauthorization before accessing transition-related services, suggests the National Center for Transgender Equality.

On a state-by-state basis, Medicaid coverage is uneven for lower-income people seeking gender-affirming care. Medicaid programs cover transgender-related care in 26 states and the District of Columbia. Meanwhile, programs in nine states bar coverage of transgender-related care for people of all ages, and programs in two states prohibit coverage of transgender-related care for minors.

Military and Veteran Coverage  

Active military members can access gender-affirming hormonal treatment and therapy for gender dysphoria. Tricare, the health benefits provider for military members, does not usually cover gender-affirming surgeries. However, a waiver may be requested and granted in some cases for medically necessary gender-affirming surgery.  

The Veterans Health Administration offers gender-affirming health care, including hormones and prosthetics, mental health care, and other health care. Coverage for gender-affirming surgery has traditionally been denied but is currently undergoing a review.

For just one person, the cost of gender-affirming care might range from $25,000 to $75,000, according to estimates from the HRC Foundation.

Gender-affirming surgeries may include top surgery (breast removal or augmentation), bottom surgery, vocal surgery, and face and body surgeries such as browlifts, jawline contouring, Adam’s apple removal, and forehead reduction.

Bottom surgery may include:

• Phalloplasty : Creation of penis 
• Metoidioplasty : Phallus created from existing genital region tissue. 
• Hysterectomy : Uterus and cervix removal  
• Nullification surgery : Creating a gender-neutral look in the groin
• Oophorectomy : Removal of one or both ovaries
• Vaginoplasty and vulvoplasty : Creation of vagina and vulva 
• Orchiectomy : Testicle removal 

Research published in 2022 by The Journal of Law, Medicine & Ethics detailed the costs of gender-affirming surgery from 1993 to 2019. The chart below shows the average costs of five of the most common gender-affirming procedures within a commercially insured population over the span of those years.

However, not all transgender people desire surgery. According to 2019 statistics, only 28% of transgender women get any type of surgery, and only 5%–13% receive genital surgery. Surgery is more common among transgender men, with 42%–54% getting some type of surgery; up to 50% get genital surgery.  

Gender-affirming medication is far more common. Up to 65% of transgender people received gender-affirming hormone therapy in 2019, up from 17% in 2011, according to The Journal of Law, Medicine & Ethics. The study notes the costs of gender-affirming medication from 1993 to 2019.  

Another 2022 study from Vanderbilt University found that masculinizing hormones run $29.76 to $463.54 per fill while feminizing hormones cost $12.95 to $180.98. Much of the cost depends on the delivery method, such as injection or gel. The authors note that “the most cost-effective hormone therapies were oral estrogen and injectable testosterone esters.”

One 2020 survey found that among insured respondents taking gender-affirming hormones, almost 21% reported that their claims were denied. This group (and those uninsured) were more likely to take non-prescription hormones from unlicensed sources, which may not be monitored for quality and potentially lead to health risks.

Other costs are involved as well. For example, at Planned Parenthood of South, East, and North Florida, gender-affirming hormone treatment costs between $95 to $105. Lab monitoring may need to be run to ensure health while taking hormones, which can average $26 to $142 per visit.

Aside from health insurance, how can you pay for gender-affirming care or surgery? Here are 10 options.

Payment Plans 

Some healthcare providers offer payment plans directly or through lenders that let you pay off medical bills over time.

You might take out a personal loan or even a type of personal loan called a medical loan to cover expenses related to gender-affirming care or surgery. A medical loan is just a personal loan used to pay for medical expenses.

Credit Cards 

Credit cards may be another avenue for covering the costs of gender-affirming care or surgery, although these tend to have higher interest rates. You may see promotional materials for the CareCredit credit card in your provider’s office, but other credit cards can pay for the same healthcare costs, often with a better interest rate and without the dangerous deferred interest feature that CareCredit cards have. You’re better off with a regular credit card that has a promotional 0% purchase rate offer.

Even with health insurance, hormone therapy may be less expensive if you comparison shop and use pharmacy programs, such as GoodRx.

Surgery Grants

Several organizations offer grants for people seeking gender-affirming care or surgery, such as the Darcy Jeda Crobitt Foundation and the Jim Collins Foundation.

Health Accounts 

If you have a flexible spending account (FSA) or Health Savings Account (HSA) , consider allocating some account money for gendering-affirming care or surgery.

Health Reimbursement Agreement 

A health reimbursement agreement (HRA) is an employer-funded group health plan that reimburses employees for qualified medical expenses, which might include gender-affirming care or surgery.

Home Equity Line of Credit (HELOC) 

You could take out a home equity line of credit to cover the costs of gender-affirming care or surgery. With this type of loan, you typically can borrow up to a specific percentage of your home equity. Interest rates on HELOCs are generally lower than those on a personal loan, because your home serves as collateral. Just realize that if you can’t repay the loan, your could lose your home. 

Friends-and-Family Loans 

If you’ve got supportive friends or relatives, they might be willing to chip in money to pay for your gender-affirming care or surgery. Just make sure you have a written agreement and repayment plan.

Crowdfunding

You might consider setting up a crowdfunding campaign on a platform like GoFundMe to raise money from friends, relatives, colleagues or strangers.

When you’re financing gender-affirming care or surgery, follow these tips:

Shop Around 

A number of online tools such as Hospital Cost Compare and Healthcare Bluebook allow you to compare costs for the same procedures and treatments offered by different healthcare providers. This homework could save you a lot of money.

Explore Your Options 

Even if health insurance covers a procedure or treatment, you must cover some out-of-pocket costs. Therefore, consider looking into surgery grants, crowdfunding, friends-and-family loans or other methods to bridge the monetary gap.

Check the Interest Rate 

Be sure to investigate how much you’ll pay to borrow money if you go down that road. With the CareCredit card, for example, the APR may be higher than a regular credit card or a personal loan. 

Try Negotiating or a Payment Plan

You can negotiate with a healthcare provider to lower the costs of gender-affirming care or surgery. For instance, a healthcare provider might discount your services if you agree to pay off your medical bills quickly. If a healthcare provider isn’t willing to provide a discount, they might let you make interest-free payments as part of a payment plan.

Ask About Financial Assistance

Some nonprofit healthcare providers offer financial assistance programs that cover all or some of your medical expenses.

What Are the Different Types of Gender-Affirming Care?

Various types of gender-affirming care include puberty-blocking medication, hormone therapy, top surgery, bottom surgery, nullification surgery, laser hair removal, facial feminization surgery, speech therapy, and mental health services.

How Much Does Gender-affirming Care Cost in the U.S?

The cost of gendering-affirming care varies widely, depending on the type of procedure or treatment involved. For one person, gender-affirming care might cost anywhere from $25,000 to $75,000, according to estimates from the Human Rights Campaign Foundation. Health insurance may or may not cover these costs to varying degrees.

Does Insurance Cover Puberty Blockers?

According to one study, insurance companies cover puberty blockers 72% of the time. The estimated out-of-pocket cost for a 3-month supply ranges between $9,500 and $39,000.

The campaign for transgender rights in the U.S. has experienced victories and setbacks in recent years—in some cases affecting coverage of gender-affirming care. Even amid progress made, some people still encounter problems securing health insurance coverage for gender-affirming care or covering out-of-pocket costs. Getting coverage for care may require preauthorization, documentation of medical necessity, and an appeal. This may prompt use of alternative financing methods like crowdfunding, credit cards, loans, or grants.

U.S. Department of Health and Human Services. “ HHS Announces Prohibition on Sex Discrimination Includes Discrimination on the Basis of Sexual Orientation and Gender Identity .”

The Williams Institute at UCLA. " How Many Adults and Youth Identify as Transgender in the United States? "

American Medical Association. “ Transgender Coverage Issue Brief .”

First Report Managed Care. “ Transgender Patients: Calculating the Actual Cost .”

UCSF. " Health Insurance Coverage Issues for Transgender People in the United States .”

Transgender Health Insurance. " Health Insurance - Understanding Your Plan ."

HRC. " Corporate Equality Index 2022. "

Society for Evidence-Based Gender Medicine. “ Sweden’s Karolinska Ends All Use of Puberty Blockers and Cross-Sex Hormones for Minors Outside of Clinical Studies .”

BlueCross BlueShield of Tennessee. “ BlueCross BlueShield of Tennessee Medical Policy Manual .” 

Movement Advancement Project. " Medicaid Coverage of Transgender-Related Health Care ."

HealthCare.gov. “ Transgender Health Care .”  

U.S. Department of Veterans Affairs. "VHA LGBTQ+ Health Program. "

Williams Institute, UCLA School of Law. “ Medicaid Coverage for Gender-Affirming Care ,” Page 1.

National Center for Biotechnology Information. “ Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information .”

British Columbia Nurses’ Union. “ Position Statement: Gender-Affirming Care .”

Journal of General Internal Medicine. " Gender-Affirming Hormone Therapy Spending and Use in the USA, 2013–2019. "

Annals of Family Medicine. "Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey ."

Aetna. “ Gender Affirming Surgery .”

Current Problems in Pediatric and Adolescent Health Care. " Gender Affirming Medical Care of Transgender Youth ."

• Guide to Finance for LGBTQ+ People 1 of 18
• LGBTQ+ Marriage and Personal Finance 2 of 18
• The Costs of LGBTQ+ Family Planning 3 of 18
• Mortgage Lending for LGBTQ+ People 4 of 18
• Banks that Support the LGBTQ+ Community 5 of 18
• LGBTQ+ Credit Barriers: Why They Exist and How to Avoid Them 6 of 18
• Top LGBTQ+ Financial Influencers to Learn From 7 of 18
• Paying for College as an LGBTQ+ Student 8 of 18
• LGBTQ+ Representation in the Workforce 9 of 18
• LGBTQ+ Pay Gap and Unemployment 10 of 18
• Health Insurance for LGBTQ+ People 11 of 18
• How Being Nonbinary Affects Getting Life Insurance 12 of 18
• Qualifying for Life Insurance When You're Transgender 13 of 18
• Does Insurance Cover Gender-Affirming Care? 14 of 18
• How to Invest in LGBTQ+-Friendly Companies 15 of 18
• Preparing for Retirement as an LGBTQ+ Person 16 of 18
• Social Security Benefits for for Same-Sex Couples: History and How Survivors Benefits Work 17 of 18
• Finding LGBTQ+ Friendly Retirement Options 18 of 18

• Terms of Service
• Editorial Policy
• Privacy Policy
• Your Privacy Choices

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• COVID-19 Vaccines
• Occupational Therapy
• Healthy Aging
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

Does Health Insurance Cover Transgender Health Care?

For transgender Americans, access to necessary health care can be fraught with challenges. Section 1557 of the Affordable Care Act (ACA) prohibits discrimination on a wide variety of grounds for any "health program or activity" that receives any sort of federal financial assistance.  

But the specifics of how that section is interpreted and enforced are left up to the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR). Not surprisingly, the Obama and Trump administrations took very different approaches to ACA Section 1557. But the Biden administration has reverted to the Obama-era rules.

In 2020, the Trump administration finalized new rules that rolled back the Obama administration's rules. This came just days before the Supreme Court ruled that employers could not discriminate against employees based on sexual orientation or gender identity. The Trump administration's rule was subsequently challenged in various court cases.

And in May 2021, the Biden administration issued a notice clarifying that the Office of Civil Rights would once again prohibit discrimination by health care entities based on sexual orientation or gender identity.

The Biden administration subsequently issued a proposed rule in 2022 to update the implementation of Section 1557 and strengthen nondiscrimination rules for health care. The proposed rule " restores and strengthens civil rights protections for patients and consumers in certain federally funded health programs and HHS programs after the 2020 version of the rule limited its scope and power to cover fewer programs and services. "

Section 1557 of the ACA

ACA Section 1557 has been in effect since 2010, but it's only a couple of paragraphs long and very general in nature. It prohibits discrimination in health care based on existing guidelines—the Civil Rights Act, Title IX, the Age Act, and Section 504 of the Rehabilitation Act—that were already very familiar to most Americans (i.e., age, disability, race, color, national origin, and sex).

Section 1557 of the ACA applies those same non-discrimination rules to health plans and activities that receive federal funding.

Section 1557 applies to any organization that provides healthcare services or health insurance (including organizations that have self-insured health plans for their employees) if they receive any sort of federal financial assistance for the health insurance or health activities.

That includes hospitals and other medical facilities, Medicaid , Medicare (with the exception of Medicare Part B ), student health plans, Children's Health Insurance Program, and private insurers that receive federal funding.

For private insurers, federal funding includes subsidies for their individual market enrollees who purchase coverage in the exchange (marketplace). In that case, all of the insurer's plans must be compliant with Section 1557, not just their individual exchange plans.

(Note that self-insured employer-sponsored plans are not subject to Section 1557 unless they receive some type of federal funding related to health care activities. The majority of people with employer-sponsored health coverage are enrolled in self-insured plans.)

To clarify the nondiscrimination requirements, the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR) published a 362-page final rule for implementation of Section 1557 in May 2016.

At that point, HHS and OCR clarified that gender identity "may be male, female, neither, or a combination of male and female." The rule explicitly prohibited health plans and activities receiving federal funding from discrimination against individuals based on gender identity or sex stereotypes.

But the rule was subject to ongoing litigation, and the nondiscrimination protections for transgender people were vacated by a federal judge in late 2019.

And in 2020, the Trump administration finalized new rules which reversed much of the Obama administration's rule. The new rule was issued in June 2020, and took effect in August 2020. It eliminated the ban on discrimination based on gender identity, sexual orientation, and sex stereotyping, and reverted to a binary definition of sex as being either male or female.

Just a few days later, however, the Supreme Court ruled that it was illegal for a workplace to discriminate based on a person's gender identity or sexual orientation. The case hinged on the court's interpretation of what it means to discriminate on the basis of sex, which has long been prohibited under US law. The majority of the justices agreed that "it is impossible to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex."

The Biden administration announced in May 2020 that Section 1557's ban on sex discrimination by health care entities would once again include discrimination based on gender identity and sexual orientation.

And in 2022, the Biden administration published a new proposed rule for the implementation of Section 1557, rolling back the Trump-era rule changes and including a new focus on gender-affirming care (as opposed to just gender transition care).

Are Health Plans Required to Cover Gender Affirming Care?

Even before the Obama administration's rule was blocked by a judge and then rolled back by the Trump administration, it did not require health insurance policies to " cover any particular procedure or treatment for transition-related care ."

The rule also did not prevent a covered entity from " applying neutral standards that govern the circumstances in which it will offer coverage to all its enrollees in a nondiscriminatory manner ." In other words, medical and surgical procedures had to be offered in a non-discriminatory manner, but there was no specific requirement that insurers cover any specific transgender-related healthcare procedures, even when they're considered medically necessary.

Under the Obama administration's rule, OCR explained that if a covered entity performed or paid for a particular procedure for some of its members, it could not use gender identity or sex stereotyping to avoid providing that procedure to a transgender individual. So for example, if an insurer covers hysterectomies to prevent or treat cancer in cisgender women, it would have to use neutral, non-discriminatory criteria to determine whether it would cover hysterectomies to treat gender dysphoria.

And gender identity could not be used to deny medically necessary procedures, regardless of whether it affirmed the individual's gender. For example, a transgender man could not be denied treatment for ovarian cancer based on the fact that he identifies as a man.

But the issue remained complicated, and it's still complicated even with the Biden administration's proposed rule to strengthen Section 1557's nondiscrimination rules.

Under the 2016 rule, covered entities in every state were prohibited from using blanket exclusions to deny care for gender dysphoria and had to utilize non-discriminatory methods when determining whether a procedure will be covered. But that was vacated by a federal judge in 2019.

However, the new rules proposed in 2022 by the Biden administration " prohibit a covered entity from having or implementing a categorical coverage exclusion or limitation for all health services related to gender transition or other gender-affirming care. "

As of 2023, HealthCare.gov's page about transgender health care still states that " many health plans are still using exclusions such as “services related to sex change” or “sex reassignment surgery” to deny coverage to transgender people for certain health care services. Coverage varies by state. "

The page goes on to note that " transgender health insurance exclusions may be unlawful sex discrimination. The healthcare law prohibits discrimination on the basis of sex, among other bases, in certain health programs and activities ."

The page advises that " if you believe a plan unlawfully discriminates, you can file complaints of discrimination with your state’s Department of Insurance, or report the issue to the Centers for Medicare & Medicaid Services by email to  [email protected] ." (note that this language existed on that page in 2020 as well.)

State Rules for Health Coverage of Gender Affirming Care

Prior to the 2016 guidance issued in the Section 1557 final rule, there were 17 states that specifically prevented state-regulated health insurers from including blanket exclusions for transgender-specific care and 10 states that prevented such blanket exclusions in their Medicaid programs. And as of 2023, the list of states that ban specific transgender exclusions in state-regulated private health plans has grown to 24, plus the District of Columbia.

Starting in 2023, Colorado became the first state to explicitly include gender-affirming care in its benchmark plan (used to define essential health benefits ), ensuring that all individual and small-group health plans in the state must provide that coverage.

While Section 1557 was initially a big step towards equality in health care for transgender Americans, it does not explicitly require coverage for sex reassignment surgery and related medical care. And the implementation of Section 1557 has been a convoluted process with various changes along the way. Most recently, the Biden administration has restored nondiscrimination protections based on gender identity.

Do Health Insurance Plans Cover Sex Reassignment?

It depends on the health insurance plan. This description from Aetna  and this one from Blue Cross Blue Shield of Tennessee are good examples of how private health insurers might cover some—but not all—aspects of the gender transition process, and how medical necessity is considered in the context of gender-affirming care.

Since 2014,  Medicare has covered medically necessary sex reassignment surgery , with coverage decisions made on a case-by-case basis depending on medical need. And the Department of Veterans Affairs (VA) has announced in June 2021 that it has eliminated its long-standing ban on paying for sex reassignment surgery for America's veterans.

But Medicaid programs differ from one state to another, and there are pending lawsuits over some states' refusals to cover gender transition services for Medicaid enrollees.

Over the last several years, many health plans and self-insured employers have opted to expand their coverage in order to cover sex reassignment surgery and other gender-affirming care. But although health coverage for transgender-specific services has become more available, it is still far from universal.

This issue is likely to face protracted legal debate over the coming years, and coverage will likely continue to vary from one state to another and from one employer or private health plan to another.

Many health plans in the U.S. are subject to ACA Section 1557, which prohibits discrimination based on gender. But this section is implemented via HHS rules, which have changed over time: The Obama administration issued rules to protect people from gender-related discrimination in health care, the Trump administration relaxed those rules, and the Biden administration has proposed changes to strengthen them once again.

A Word from Verywell

If you're in need of gender-affirming medical care, you'll want to carefully consider the specifics of the health policy you have or any that you may be considering. If you think that you're experiencing discrimination based on your gender identity, you can file a complaint with the Office of Civil Rights . But you may find that a different health plan simply covers your needs more comprehensively.

US Department of Health and Human Services. Section 1557 of the Patient Protection and Affordable Care Act .

Keith, Katie. Health Affairs. HHS Will Enforce Section 1557 To Protect LGBTQ People From Discrimination . May 11, 2021.

U.S. Department of Health and Human Services. HHS Announces Proposed Rule to Strengthen Nondiscrimination in Health Care . July 25, 2022.

United States DoJ. Overview of Title IX of the education amendments of 1972 . Updated August, 2015.

DHS.  Nondiscrimination in health programs and activities . Effective July 18, 2016.

Keith, Katie. Health Affairs. Court Vacates Parts Of ACA Nondiscrimination Rule . October 16, 2019.

Department of Health and Human Services. Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority . June 12, 2020.

SCOTUS Blog. R.G. & G.R. Harris Funeral Homes Inc. v. Equal Employment Opportunity Commission . Argued October 2019; Decision issued June 15, 2020.

U.S. Department of Health and Human Services. HHS Announces Prohibition on Sex Discrimination Includes Discrimination on the Basis of Sexual Orientation and Gender Identity . May 10, 2021.

National Center for Transgender Equality. Know your rights: medicare .

HealthCare.gov. Transgender Health Care .

Health Affairs. LGBT protections in affordable care act section 1557 . June 2016.

LGBT Map. Health Care Laws and Policies .

U.S. Department of Health and Human Services. Biden-Harris Administration Greenlights Coverage of LGBTQ+ Care as an Essential Health Benefit in Colorado . October 12, 2021.

Military Times. VA to Offer Gender Surgery to Transgender Vets for the First Time . June 19, 2021.

Fleig, Shelby. Des Moines Register. ACLU of Iowa Renews Effort to Overturn Law Restricting Public Funds for Trans Iowans' Transition-Related Care . April 22, 2021.

By Louise Norris Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

North Carolina Health News

News. Policy. Trends. North Carolina.

Read all of our joint coverage with The Charlotte Ledger here. 

Victory for lgbtq: blue cross nc expands coverage for trans surgeries.

By Elizabeth Thompson

After what LGBTQ advocates say was a record-breaking year for anti-transgender legislation, they are celebrating a small victory in North Carolina.

Blue Cross NC, formerly known as Blue Cross and Blue Shield of North Carolina, will now include coverage for gender-affirming facial surgery and voice therapy for transgender and gender-nonconforming people as medically necessary care. The move follows advocacy from the Transgender Legal Defense & Education Fund (TLDEF), on behalf of  Equality NC , the LGBTQ Center of Durham and two transgender women.

“Across the country, health insurance companies are increasingly recognizing the need to end systemic denials of lifesaving gender-affirming health care for transgender people,” said Noah Lewis , director of the Trans Health Project at TLDEF, in a press release.

The nationwide trend to remove the exclusion of gender-affirming care follows President Joe Biden’s May declaration that the Department of Health and Human Services will prohibit discrimination of LGBTQ people by health care organizations that receive federal funding. In addition, a June 2020 Supreme Court decision found that discrimination based on sexual orientation and gender identity at work violated federal civil rights laws .

LGBTQ advocates in North Carolina say this is just the beginning.

Expanded coverage

Kathryn Vandegrift, a transgender woman from Asheville who was one of the two women TLDEF advocated for, scheduled her facial surgery for July 18, after about a year of waiting. She said it means that she “might finally actually be able to exist fully as myself,” in an interview with NC Health News.

“Having these repeated denials during the course of the last year was just a devastating process to endure,” Vandegrift said. “The lack of treatment makes my body really hard to live in, it’s uncomfortable. I’m happy about the opportunity to move past that.”

Vandegrift approached Equality NC, a statewide organization that advocates for LGBTQ rights, last year after she realized her Blue Cross NC insurance would not cover facial surgery. 

It could have cost anywhere from $20,000 to $50,000 out of pocket, according to Healthline , a consumer health and wellness website.

“It’s not that the surgery itself is unduly expensive,” Lewis said, in an interview. “It’s just that nobody can afford to pay for surgeries out of pocket.”

Since Equality NC uses Blue Cross NC as its insurer for employees, Equality NC used its status to pressure the company to expand its coverage, said Executive Director Kendra Johnson , in an interview. This victory is an example of how people and institutions can use their status as patrons or customers to advocate for changes, Johnson said.

“That is the role we would like everyone to play in terms of advocacy,” Johnson said. “To protect the folks who are most marginalized and ensure that they have access to critical, life saving services.”

Blue Cross NC expanded its coverage on facial surgery, genital and chest procedures, tracheal shave and voice lessons effective July 1, spokeswoman Jami Sowers said in a statement to NC Health News .

“Blue Cross and Blue Shield of North Carolina has long recognized the importance of gender dysphoria as a medical condition and has covered treatments related to gender affirmation as a standard benefit on all plans,” Sowers said. “As part of an ongoing review process that includes practicing physicians both employed by and independent of Blue Cross NC, Blue Cross NC has made updates to its Gender Affirmation Surgery and Hormone Therapy Policy .”

A victory that counts

Advocates lauded the victory despite what they called a bad year for anti-LGBTQ legislation.

Nationwide, state legislatures introduced more than 100 bills to restrict transgender people’s right s, including a bill in North Carolina that would prevent doctors from performing gender-affirming surgery on people younger than 21, a bill to limit school sports participation for transgender athletes and another bill which would allow medical providers to refuse to participate in a health care service that violates their conscience.

The change also comes as at least 30 transgender or gender-nonconforming people have been killed in the U.S. in 2021 , according to the Human Rights Campaign — including at least three women killed in North Carolina.

This victory is much bigger than it seems because it helps transgender and gender-nonconforming people avoid discrimination, said Dana Cea, an online therapist from Wilson, North Carolina, who identifies as queer.

“If we look at what insurance covers,” Cea said, “it’s really looking at what is deemed medically necessary.”

Discrimination against transgender and gender-nonconforming people in the medical field can have an impact on their health — especially when it comes to preventative care, Johnson said. One-third of respondents in a 2015 report from the National Center for Transgender Equality reported at least one negative experience with a health care provider related to being transgender and one-quarter of respondents reported that they did not seek health care because they were worried about being discriminated against.

For this reason, Johnson said transgender people face barriers to accessing health care for anything from the common cold to cardiac problems to COVID-19.

The fight continues

The most recent change will allow Vandegrift to start the first part of surgically transitioning.

“If we get a positive outcome, people won’t be able to tell I’m trans just from looking at me,” she said.

But other North Carolinians in Vandegrift’s situation may still not be covered for some gender-affirming surgeries. TLDEF and Lambda Legal are currently suing the state of North Carolina for denying access to gender-affirming care to people on the North Carolina State Health Plan.

The process of actually qualifying for these surgeries is also riddled with barriers, Cea said. 

People looking for gender-affirming surgery must first get a diagnosis of gender dysphoria — which Cea called a “Catch-22” – since it’s still classified as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The World Health Organization moved “gender identity disorder” and “gender incongruence” from its list of mental illnesses in 2019 to its sexual health chapter, so transgender people can receive care without being considered mentally ill.

After their diagnoses, people looking for gender-affirming surgery may be required by their surgeon or insurance to provide a letter from their therapist affirming that they have an ongoing relationship in order to get the surgery.

All of those appointments cost money — and mental health services are often under-covered by insurance. A 2019 report by the governmental consulting agency Milliman found that 17.2 percent of behavioral office visits were to an out-of-network provider, compared to 3.2 percent for primary care office visits.

“I’ve received requests for letters, and this is requested by insurance, it’s also requested by surgeons or the medical providers, and sometimes it requires an ongoing relationship with the provider,” Cea said. “So I, for example, would have to put in the letter not only some of the personal details and background of this individual and their relationship to their gender, and then I’m also giving this diagnosis, which can be detrimental, considering that it’s considered a mental diagnosis instead of physical diagnosis.”

Johnson and Equality NC are working to broaden health care systems’ knowledge of the LGBTQ community through education, since “there’s very limited content that’s given specifically to the LGBTQ-plus population,” she said.

“Transgender health care is health care,” Vandegrift said, “and health care is a human right. I don’t think anyone should be denied medical care that they need.”

Republish This Story

Republish our articles for free, online or in print, under a Creative Commons license.

Republish this article

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

• You can copy and paste this html tracking code into articles of ours that you use, this little snippet of code allows us to track how many people read our story.
• Please do not reprint our stories without our bylines, and please include a live link to NC Health News under the byline, like this: By Jane Doe North Carolina Health News
• Finally, at the bottom of the story (whether web or print), please include the text:North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org. (on the web, this can be hyperlinked)

by Elizabeth Thompson, North Carolina Health News July 22, 2021

This <a target="_blank" href="https://www.northcarolinahealthnews.org/2021/07/22/victory-for-lgbtq-blue-cross-nc-expands-coverage-for-trans-surgeries/">article</a> first appeared on <a target="_blank" href="https://www.northcarolinahealthnews.org">North Carolina Health News</a> and is republished here under a Creative Commons license.<img src="https://i0.wp.com/www.northcarolinahealthnews.org/wp-content/uploads/2021/10/cropped-favicon02.jpg?fit=150%2C150&amp;ssl=1" style="width:1em;height:1em;margin-left:10px;"><img id="republication-tracker-tool-source" src="https://www.northcarolinahealthnews.org/?republication-pixel=true&post=34386" style="width:1px;height:1px;">

Elizabeth Thompson

Elizabeth Thompson is our Report for America corps member who covers gender health and prison health topics. Thompson is a UNC Chapel Hill graduate who has covered Texas politics for The Dallas Morning News’ Washington bureau, she's been a reporter for The Raleigh News & Observer and PolitiFact NC, and worked for GrepBeat, the tech news website.

• Share full article

Advertisement

Supported by

Aetna Agrees to Expand Coverage for Gender-Affirming Surgeries

One of the nation’s largest health insurers is agreeing to pay for breast augmentation for some trans women.

By Reed Abelson

Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. By 2019, she finally thought her insurance company, Aetna, would pay for it, only to find that it considered the procedure cosmetic, not medically necessary, and refused to cover it.

“I knew from my case, it wasn’t cosmetic,” said Ms. Escolastico, who contacted a lawyer after she lost her appeal last year. “I knew I had to fight for this,” she said.

Ms. Escolastico’s surgery is now scheduled for February. Working with the Transgender Legal Defense and Education Fund, a nonprofit that advocates transgender rights , and Cohen Milstein Sellers and Toll, a large law firm that represents plaintiffs, she and a small group of trans women persuaded Aetna to cover the procedure if they can show it to be medically necessary.

To qualify, the women would need to demonstrate that they had persistent gender dysphoria, undergo a year of feminizing hormone therapy and have a referral from a mental health professional.

The shift by Aetna represents an important evolution in how health insurers view the medical needs of transgender individuals . While some insurers offer a broad range of surgeries for trans women if they are deemed medically necessary, others exclude breast augmentation and other treatments as merely cosmetic.

“This has the potential to be a transformative moment,” said Kalpana Kotagal, a partner at Cohen Milstein.

Insurers have typically covered genital reassignment surgery as medically necessary. But transgender women and others say breast augmentation is also a necessary treatment for individuals who receive a diagnosis of gender dysphoria. “There is no question from a medical perspective,” said Noah E. Lewis, the director of the Trans Health Project at the fund.

In addition, he said, it is illegal for a health insurer to deny coverage of medical care because of someone’s gender identity. “It’s a really simple matter of discrimination,” he said.

Aetna, which is owned by CVS Health, had been actively reviewing the need for breast augmentation surgery for trans women, said Dr. Jordan Pritzker, senior director of clinical solutions for the insurer. He said he had talked to numerous doctors who provide the surgery.

“Our decision to update our clinical policy bulletin is consistent with many changes we have made over the years to better serve the needs of the L.G.B.T.Q. community,” Dr. Pritzker said in a statement.

Aetna said it would also reimburse some trans women who were denied coverage but had the surgery. The company said it was actively reaching out to individuals who had sought authorization for their surgeries and were denied.

Cora Brna was denied coverage for breast augmentation surgery two years ago, when she tried to schedule it at the same time that she was undergoing genital reassignment, which was covered by Aetna. “I was devastated,” she said.

“I felt like a group of people were deciding whether I was or was not a woman,” said Mrs. Brna, 32, who works as a health care worker in Pittsburgh and was one of the women who petitioned Aetna. She went ahead with the genital surgery but had the procedure to augment her breasts only after it was covered by a different health plan.

Aetna’s new policy also comes at a time when the federal government is re-examining whether denying some types of care to transgender individuals is discriminatory. Under the Affordable Care Act, insurers cannot discriminate against individuals on the basis of gender identity, and most insurance companies provide coverage for people who require gender reassignment surgery. But the law never mandated a specific benefit or detailed exactly what services the insurers would cover, said Katie Keith, who teaches law at Georgetown University and closely follows this area of the law.

“It’s almost like a parity issue,” she said.

While the Trump administration sought to undo protections for transgender individuals with a rule last June , the issue is still being sorted out in the courts, said Ms. Keith, who also pointed to the recent Supreme Court decision that said gay and transgender workers are protected from workplace discrimination under civil rights law.

The new Biden administration has already issued an executive order saying it will enforce civil rights laws that protect people from discrimination on the basis of gender identity.

Major insurance companies are uneven in their coverage. Health Care Service Corp., which offers Blue Cross plans in five states, will pay for breast augmentation and other services for trans women if they are deemed medically necessary. The insurer said it developed these policies in accordance with guidelines established by the World Professional Association for Transgender Health, a nonprofit.

But other major insurers, including Anthem and UnitedHealthcare, continue to view the surgery as cosmetic, since they do not generally cover the procedures for women without the gender dysphoria diagnosis. They say they are not discriminating against trans women.

Anthem says its “medical policy is applied equitably across all members, regardless of gender or gender identity.”

And UnitedHealthcare said in a statement that its “coverage for gender dysphoria treatment is comprehensive and, depending on members’ benefit plans, current coverage may include physician office visits, mental health services, prescription drugs and surgery to address gender dysphoria.” It added that it uses “evidence-based medicine to make coverage policy decisions,” which are regularly updated.

But lawyers for the women involved in the Aetna agreement say they are looking closely at the policies of other insurers to see if they can make the same case that their refusal to offer coverage is discriminatory. “This is something that needs to be changed across the industry,” said Ms. Kotagal of Cohen Milstein.

Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. More about Reed Abelson

• Find a plan

• Health Insurance
• Data & Insights
• Resource Center
• For Carriers

Transgender health care: Does health insurance cover gender-affirming surgery?

By HealthSherpa

Share this post

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.

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. R esearchers 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 [email protected].

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights .

Leave a Comment Cancel Reply

Save my name, email, and website in this browser for the next time I comment.

This site uses Akismet to reduce spam. Learn how your comment data is processed .

Have you experienced a major life event?

You may be eligible to enroll outside of the open enrollment period..

Looking to enroll in health insurance?

Click on the button below to shop and compare plans, 1 out of 2 people pay under $10/month, grab this free guide.

More Health Insurance Articles

MAY 9, 2022

New enrollment period for...

There is a new Special Enrollment Period (SEP) that enables qualifying consumers to...

NOVEMBER 7, 2021

How much does ACA health...

Uninsured right now and don’t want to be? Then you’re likely wondering how much...

OCTOBER 21, 2021

Your Quick Guide to the 2022...

The Affordable Care Act (ACA) ensures that all eligible Americans get an opportunity once...

Press Enter to Begin Search /  Esc to close popup

Yes, please! I would love the free PDF

Enter your email below to download a PDF containing all of this plan's coverage details

• About Us History Jobs, Fellowships & Internships Annual & Financial Reports Racial Justice at NCTE Contact Us
• Support NCTE
• Get Updates
• Press Tips for Journalists Releases

Know Your Rights

Health care.

Read Our Covid-19 Guides

See these resources for more information about your rights during COVID-19:

• A Know Your Rights Guide for Transgender People Navigating COVID-19   (PDF)
• Una guía para que las personas transgénero navegando la COVID-19 conozcan sus derechos   (PDF)

Know Your Rights in Health Care

Federal and state laws - and, in many cases, the U.S. Constitution - prohibit discrimination in health care and insurance because you're transgender. That means that health plans aren’t allowed to exclude transition-related care, and health care providers are required to treat you with respect and according to your gender identity.

Updated October 2021 

What are my rights in insurance coverage?

Federal and state law prohibits most public and private health plans from discriminating against you because you are transgender. This means, with few exceptions, that it is illegal discrimination for your health insurance plan to refuse to cover medically necessary transition-related care.

Here are some examples of illegal discrimination in insurance:

• Health plans can’t have automatic or categorical exclusions of transition-related care . For example, a health plan that says that all care related to gender transition is excluded violates the law.
• Health plans can’t have a categorical exclusion of a specific transition-related procedure. Excluding from coverage specific medically necessary procedures that some transgender people need is discrimination. For example, a health plan should not categorically exclude all coverage for facial feminization surgery or impose arbitrary age limits that contradict medical standards of care.
• An insurance company can’t place limits on coverage for transition-related care if those limits are discriminatory . For example, an insurance company can’t automatically exclude a specific type of procedure if it covers that procedure for non-transgender people. For example, if a plan covers breast reconstruction for cancer treatment, or hormones to treat post-menopause symptoms, it cannot exclude these procedures to treat gender dysphoria.
• Refusing to enroll you in a plan, cancelling your coverage, or charging higher rates because of your transgender status : An insurance company can’t treat you differently, refuse to enroll you, or limit coverage for any services because you are transgender.
• Denying coverage for care typically associated with one gender : It’s illegal for an insurance company to deny you coverage for treatments typically associated with one gender based on the gender listed in the insurance company’s records or the sex you were assigned at birth. For example, if a transgender woman’s health care provider decides she needs a prostate exam, an insurance company can’t deny it because she is listed as female in her records. If her provider recommends gynecological care, coverage can’t be denied simply because she was identified as male at birth.

What should I do to get coverage for transition-related care?

Check out NCTE’s Health Coverage Guide for more information on getting the care that you need covered by your health plan.

If you do not yet have health insurance, you can visit our friends at Out2Enroll to understand your options.

Does private health insurance cover transition-related care?

It is illegal for most private insurance plans to deny coverage for medically necessary transition-related care. Your private insurance plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. 

To understand how to get access to the care that you need under your private insurance plan, check out NCTE’s Health Coverage Guide .

Does Medicaid cover transition-related care?

It is illegal for Medicaid plans to deny coverage for medically necessary transition-related care. Your state Medicaid plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. Some states have specific guidelines on the steps you have to take to access care. You can check if your state has specific guidelines here .

To understand how to get access to the care that you need under your Medicaid plan, check out NCTE’s Navigating Insurance page.

My plan has an exclusion for transition-related care. What should I do?

There are many reasons why your plan might still have an exclusion for transition-related care in general or for a specific procedure. This does not mean that your plan will not cover your care. Sometimes plan documents are out of date, or you can ask for an exception by showing that this care is medically necessary for you.

If you get insurance through work or school, you can advocate with your employer to have the exclusion removed.

NCTE’s Health Coverage Guide has more information on how to access care and remove exclusions.

Does Medicare cover transition-related care?

It is illegal for Medicare to deny coverage for medically necessary transition-related care.

For many years, Medicare did not cover transition-related surgery due to a decades-old policy that categorized such treatment as "experimental." That exclusion was eliminated in May 2014, and there is now no national exclusion for transition-related health care under Medicare. Some local Medicare contractors have specific policies spelling out their coverage for transition-related care, as do some private Medicare Advantage plans.

To learn more about your rights on Medicare, check out NCTE’s Medicare page.

Does the Veterans Health Administration (VHA) provide transition-related care?

The Veterans Health Administration (VHA) provides coverage for some transition-related care for eligible veterans. However, VHA still has an arbitrary and medically baseless exclusion for coverage of transition-related surgery.  On June 19th, The US Department of Veterans Affairs announced that they will begin the process to expand health care services available to transgender veterans to include gender confirmation surgery. Currently, the Veterans Health Administration (VHA) provides care for thousands of transgender veterans, including some transition-related medical care. We expect the rule will finalize in approximately two years.

For more information FAQs by VHA are found here.

For more information about VHA and transition-related care, check out NCTE’s VAH Veterans Health Care page.

Does TRICARE cover transition-related care?

TRICARE provides coverage for some transition-related care for family members and dependents of military personnel. However, TRICARE still has an exclusion for coverage of transition-related surgery.

What are my rights in receiving health care?

Which health providers are prohibited from discriminating against me?

Under the Affordable Care Act, it is illegal for most health providers and organizations to discriminate against you because you are transgender. The following are examples of places and programs that may be covered by the law:

• Physicians’ offices
• Community health clinics
• Drug rehabilitation programs
• Rape crisis centers
• Nursing homes and assisted living facilities
• Health clinics in schools and universities
• Medical residency programs
• Home health providers
• Veterans health centers
• Health services in prison or detention facilities

What types of discrimination by health care providers are prohibited by law?

Examples of discriminatory treatment prohibited by federal law include (but are not limited to):

• Refusing to admit or treat you because you are transgender
• Forcing you to have intrusive and unnecessary examinations because you are transgender
• Refusing to provide you services that they provide to other patients because you are transgender
• Refuse to treat you according to your gender identity, including by providing you access to restrooms consistent with your gender
• Refusing to respect your gender identity in making room assignments
• Harassing you or refusing to respond to harassment by staff or other patients
• Refusing to provide counseling, medical advocacy or referrals, or other support services because you are transgender
• Isolating you or depriving you of human contact in a residential treatment facility, or limiting your participation in social or recreational activities offered to others
• Requiring you to participate in “conversion therapy” for the purpose of changing your gender identity
• Attempting to harass, coerce, intimidate, or interfere with your ability to exercise your health care rights

What are my rights related to privacy of my health information?

The Health Insurance Portability and Accountability Act (HIPAA) requires most health care providers and health insurance plans to protect your privacy when it comes to certain information about your health or medical history. Information about your transgender status, including your diagnosis, medical history, sex assigned at birth, or anatomy, may be protected health information. Such information should not be disclosed to anyone—including family, friends, and other patients—without your consent. This information should also not be disclosed to medical staff unless there is a medically relevant reason to do so. If this information is shared for purposes of gossip or harassment, it is a violation of HIPAA.

What Can I Do If I Face Discrimination?

Seek preauthorization for care and appeal insurance denials

You shouldn’t be denied the care that you need just because you’re transgender. That's illegal.

To access transition-related care, we recommend applying for preauthorization before any procedures to understand whether your plan will cover it. You should also consider appealing insurance denials that you believe are discriminatory. We recommend you consult an attorney before filing any appeals.

Check our NCTE’s Health Coverage Guide for more information on how to get the care that you need covered.

Contact an attorney or legal organization

If you face discrimination from a health care provider or insurance company, it may be against the law. You can talk to a lawyer or a legal organization to see what your options are. A lawyer might also be able to help you resolve your problem without a lawsuit, for example by contacting your health care provider to make sure they understand their legal obligations or filing a complaint with a professional board.

While NCTE does not take clients or provide legal services or referrals, there are many other groups that may give you referrals or maintain lists of local attorneys. You can try your local legal aid or legal services organization, or national or regional organizations such as the National Center for Lesbian Rights, Lambda Legal, the Transgender Law Center, the ACLU, and others listed  on our   Additional Resources page  and in the  Trans Legal Services Network .

File discrimination complaints with state and federal agencies

Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The U.S. Department of Health and Human Services has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint.  If you face any of ther kind of discrimination or denial of care based on your gender, disability, age, race, or national origin, or if your health care privacy was violated, you can still file a complaint with the   U.S. Department of Health and Human Services, Office for Civil Rights .

Here are some other places you can file health care complaints:

• Private insurance: File a complaint with your state insurance department. You can find information about your state department here:  https://www.naic.org/state_web_map.htm .
• Hospitals: File a complaint with the Joint Commission, which accredits most hospitals. You can find more information or submit a complaint online at  http://www.jointcommission.org .
• Nursing home, board and care home, or assisted living facility: Contact your local long-term care ombudsman. You can locate an ombudsman here:  http://www.ltcombudsman.org/ombudsman .
• HIPPA violations: file a complaint with the U.S. Department of Health and Human Services (HHS): https://www.hhs.gov/hipaa/filing-a-complaint/index.html
• Federal Health Employee Benefits Program: File a complaint with the Office of Personnel Management ( [email protected] ) or the Equal Employment Opportunity Commission ( https://www.eeoc.gov/federal/fed_employees/complaint_overview.cfm ).
• Veterans Health Administration: File a complaint with the Veterans Administration’s External Discrimination Complaints Program or contact a Patient Advocate at your VA Medical Center. Find out more here:  http://www.va.gov/orm/  and  http://www.va.gov/health/patientadvocate .
• Employee health plan: File a complaint with the Equal Employment Opportunity Commission ( https://www.eeoc.gov/federal/fed_employees/complaint_overview.cfm ).
• TRICARE (military health care): File a complaint with TRICARE ( http://tricare.mil/ContactUs/FileComplaint.aspx ).

Other state and local agencies: If you face discrimination, you may be able to file a complaint with your state’s human rights agency. You can find a list of state human rights agencies here:  http://www.justice.gov/crt/legalinfo/stateandlocal.php .

What Laws Protect Me?

Federal protections

• The Health Care Rights Law, as part of the Affordable Care Act (ACA)  prohibits sex discrimination, including anti-transgender discrimination, by most health providers and insurance companies, as well as discrimination based on race, national origin, age, and disability. Under the ACA, it is illegal for most insurance companies to have exclusions of transition-related care, and it is illegal for most health providers to discriminate against transgender people, like by turning someone away or refusing to treat them according to their gender identity. On May 5th, 2021, the Biden Administration and HHS announced that the Office for Civil Rights will interpret and enforce Section 1557 and Title IX’s prohibitions on discrimination based on sex to include: 
• Discrimination on the basis of sexual orientation.
• Discrimination on the basis of gender identity.

Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in covered health programs or activities.  The update was made in light of the U.S. Supreme Court’s decision in Bostock v. Clayton County and subsequent court decisions. Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The HHS has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint at: https://www.hhs.gov/ocr/complaints

• The Health Insurance Portability and Accountability Act (HIPAA)  protects patients’ privacy when it comes to certain health information, including information related to a person’s transgender status and transition. It also gives patients the right to access, inspect, and copy their protected health information held by hospitals, clinics, and health plans.
• The Americans with Disabilities Act  prohibits discrimination in health care and other settings based on a disability, which may include a diagnosis of gender dyshoria.
• Medicare and Medicaid regulations  protect the right of hospital patients to choose their own visitors and medical decision-makers regardless of their legal relationship to the patient. This means that hospitals cannot discriminate against LGBT people or their families in visitation and in recognizing a patient’s designated decision-maker.
• The Joint Commission hospital accreditation standards  require hospitals to have internal policies prohibiting discrimination based on gender identity and sexual orientation.
• The Nursing Home Reform Act  establishes a set of nursing home residents’ rights that include the right to privacy, including in visits from friends or loved ones; the right to be free from abuse, mistreatment, and neglect; the right to choose your physician; the right to dignity and self-determination; and the right to file grievances without retaliation.

State and local nondiscrimination laws  prohibit health care discrimination against transgender people in many circumstances.

A large number of states also have explicit policies that prohibit anti-transgender discrimination in private insurance and Medicaid, like exclusions of transition-related care.

• California  private insurance ( PPO regulation ,  HMO general guidelines  and  HMO guidelines on surgery coverage ) and  Medicaid
• Colorado   private insurance  and  Medicaid
• Connecticut   private insurance  and  Medicaid
• Delaware   private insurance
• District of Columbia   private insurance  and  Medicaid
• Hawaii   private insurance and Medicaid
• Illinois  private insurance ( regulations and bulletin ) and Medicaid
• Maine  private insurance and  Medicaid
• Maryland   private insurance  and  Medicaid
• Massachusetts   private insurance  and  Medicaid
• Michigan   Medicaid
• Minnesota   private insurance  and  Medicaid
• Montana  private insurance  and  Medicaid
• Nevada  private insurance  and  Medicaid
• New Hampshire  private insurance  and  Medicaid
• New   Jersey  private insurance and Medicaid
• New Mexico  private insurance 
• New York  private insurance ( coverage ,  code mismatches ,  updated policy ) and Medicaid ( general Medicaid policy ,  criteria for authorization of procedures )
• Oregon  private insurance  and Medicaid ( general policy --refer to Guideline Note 127--and  facial feminization policy )
• Pennsylvania  private insurance  and  Medicaid
• Rhode   Island  private insurance  and  Medicaid
• Vermont  private insurance  and  Medicaid
• Virginia   private insurance
• Washington   State  private insurance  and  Medicaid
• Wisconsin   Medicaid
• Puerto Rico   private insurance

Remember: Just because your state isn’t listed here doesn’t mean you’re not protected. Check out NCTE’s Health Coverage Guide for more information about getting coverage for the care that you need. 

How Can I Help?

• Head to NCTE’s Health Action Center to see the latest on health care and how you can help fight for transgender people’s right to get the health care they need
• Share your story. If you are facing discriminatory treatment, consider  sharing your story  with NCTE so we can use it in advocacy efforts to advance public understanding and policy change for transgender people. If you successfully resolved a health care situation, we want to hear about that as well.

Additional Resources

Government agencies.

Department of Health and Human Services Office for Civil Rights: http://www.hhs.gov/ocr/office/index.html

Links to State and Local Human Rights Agencies: http://www.justice.gov/crt/legalinfo/stateandlocal.php

HealthCare.Gov: https://www.healthcare.gov/transgender-health-care/

Partner resources, best practices and standards of care

Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies, Lambda Legal, HRC, & New York Bar: http://www.lambdalegal.org/publications/fs_transgender-affirming-hospital-policies

Healthcare Equality Index, Human Rights Campaign http://www.hrc.org/campaigns/healthcare-equality-index

National Center for LGBT Health Education: http://www.lgbthealtheducation.org/

• National LGBT Health Education Center’s  guide to best practices for front-line health care staff
• National LGBT Health Education Center’s  guide to providing health care to non-binary people
• National LGBT Health Education Center’s  guide to making health care forms LGBT-inclusive

National Resource Center on LGBT Aging: http://www.lgbtagingcenter.org

RAD Remedy’s  guide to providing competent care for trans people

Transgender Law Center’s  guide to organizing community clinics

Clinical standards of care for transgender people

• WPATH Standards of Care
• Endocrine Society Clinical Guideline
• Center for Excellence for Transgender Health

Mental Health Resources

Trans LifeLine

National suicide prevention hotline

US: 877-565-8860Canada: 877-330-6366

https://www.translifeline.org/

National Alliance on Mental Illness (NAMI)

National network of mental health care providers, as well as a provider database

http://www.nami.org/Find­-Support/LGBTQ Help Line   800­-950-­6264

National Council for Behavioral Health

National network of community behavioral health centers, as well as a provider database

http://www.thenationalcouncil.org/

SAMHSA (Substance Abuse and Mental Health Services Administration)

A national database for local professionals and agencies that provide addiction recovery services and mental health care.

https://findtreatment.samhsa.gov/

800-662-HELP (4357)

Health provider resources

National Association of Free and Charitable Clinics (NAFC) Clinics around the United States that offer basic health care for those without insurance or experiencing homelessness. http://www.nafcclinics.org/

RAD Remedy Community­-sourced list of trans-­affirming healthcare providers https://www.radremedy.org/

Insurance resources

Resources to help transgender people select and enroll in insurance 

https://out2enroll.org

TransHealth Health and guidance for healthcare providers, as well as a list of trans­affirming health clinics in Canada, the United States, and England. http://www.trans-­health.com/

Transcend Legal Transcend Legal helps people get transgender-related health care covered under insurance. https://transcendlegal.org/

TransChance Health Helps transgender people navigate health care and insurance to receive respectful, high-quality care, and get transition-related care covered  

https://www.transchancehealth.org/

JustUs Health Leads the work to achieve health equity for diverse gender, sexual, and cultural communities in Minnesota, including the  Trans Aging Project  and a  Trans Health Insurance guide https://www.justushealth.mn

Transition-related financial support

Jim Collins Foundation Financial support for transition-related expenses for people without insurance or who have been excluded by insurance http://jimcollinsfoundation.org/apply/

Point of Pride Annual Transgender Surgery Fund Provides direct financial assistance to trans folks who cannot afford their gender-affirming surgery https://pointofpride.org/annual-transgender-surgery-fund/

Community Kinship Life Surgery Scholarship Provides the trans community with assistance while having a sense of community and kinship http://cklife.org/scholarship/

Transformative Freedom Fund (Colorado) Supports the authentic selves of transgender Coloradans by removing financial barriers to transition related healthcare https://transformativefreedomfund.org/

Kentucky Health Justice Network Trans Health Advocacy Works to help Trans Kentuckians access the healthcare they need, as well as reaffirm our autonomy and community http://www.kentuckyhealthjusticenetwork.org/trans-health.html

Join Our Mailing List

• Skip to main content
• Keyboard shortcuts for audio player

Health Care

Colorado now requires gender-affirming care to be covered by private health insurance.

Sarah McCammon

Lauren Hodges

Christopher Intagliata

Colorado now requires private health insurance plans to cover gender-affirming care for trans people like facial bone remodeling and hormone therapy. Health advocates say it's a very big deal.

SARAH MCCAMMON, HOST:

Most insurance policies in the U.S. don't cover what's known as gender-affirming care, things like hormone treatment and surgeries that help transgender people live in bodies that reflect their gender identity. But Colorado now says health insurers it regulates must cover gender-affirming care by 2023. And that is a very big deal, according to Andrew Miller. His job at Denver Health, the big public hospital in Denver, is to educate doctors and others about how to treat LGBTQ patients equitably and effectively. Andrew joins us now. Thank you so much for being with us.

ANDREW MILLER: Thank you so much for having me.

MCCAMMON: Can you just begin by giving me an example of the kinds of treatments that are not being covered that now will be?

MILLER: Absolutely. Generally, what we're talking about for this plan is things like hormone replacement therapy and then different gender-affirming surgeries such as chest reconstruction or breast augmentation, facial feminization surgeries as well as things like hair removal or electrolysis.

MCCAMMON: I understand, Andrew, that you're a trans person yourself. Can you talk at all about the ways that these treatments affect mental health for trans people?

MILLER: So when I was able to start hormone therapy, when I was able to receive gender-affirming surgeries, it was the first time that I was able to look in the mirror and actually see myself, to walk in public and have others see me as the way that I've seen myself my whole life. We recognize transgender communities face high rates of suicidality. And often what we see shift is when folks can feel at home in their body, their ability to want to stay, my ability to want to stay and thrive as a transgender person was transformed by access to gender-affirming care.

MCCAMMON: And at the moment in Colorado and most of the country, what kind of coverage do most health insurance policies provide when it comes to gender-affirming care?

MILLER: Yeah. So that's a tough one. What we found is that often health insurance programs fail to specify what care is actually covered for transgender and non-binary patients. A survey found by Out2Enroll did find that 7% of health care plans did explicitly exclude some procedures for transgender patients. Oftentimes, it is up to the transgender and non-binary person and their medical provider really to try to navigate what can be covered and what isn't covered even if a medical professional deems it medically necessary to have this coverage treated.

MCCAMMON: And what reasons have insurance companies given in the past for not covering these kinds of procedures? Do they claim it will drive up costs, for example?

MILLER: Yeah, I think cost is a big one that comes in with that. And what we recognize is oftentimes transgender and non-binary folks have been left out of medical research. And so it is only now in the last five, 10 years that we are able to have research backing that this is deemed medically necessary care. And so for this now to be covered as an essential health benefit, I think, is a very large statement that our lives are worthy and necessary and our care is medically necessary.

MCCAMMON: People have been pushing for this - for health insurance companies to broaden their coverage to include gender-affirming care - for years now. Why is this only happening now?

MILLER: You know, I think a big part of that does have to do with the Biden administration. You know, we know on President Biden's first day in office that he signed an executive order preventing discrimination on the basis of gender identity or sexual orientation. And then in May, the Department of Health and Human Services announced it will interpret and enforce ACA's prohibition on sex discrimination to include gender identity and sexual orientation. This has allowed the state of Colorado to receive the necessary support from the federal government.

MCCAMMON: Andrew Miller is an LGBTQ health education trainer at Denver Health. Thanks so much for joining us.

MILLER: Thank you for having me.

MCCAMMON: And if you or someone you know may be considering suicide, you can call the National Suicide Prevention Lifeline at 1-800-273-TALK. That's 1-800-273-8255.

Copyright © 2021 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

TLDEF's Trans Health Project

Gender affirmation surgery.

Policy: Gender Affirmation Surgery Policy Number: HUM-0518-020 Last Update: 2023-09-28

Please ctrl + F to find the correct document titled "gender affirmation surgery" and download the pdf.

Back to top

Updated on Nov 27, 2023

The independent source for health policy research, polling, and news.

Update on Medicaid Coverage of Gender-Affirming Health Services

Ivette Gomez , Usha Ranji , Alina Salganicoff , Lindsey Dawson , Carrie Rosenzweig, Rebecca Kellenberg, and Kathy Gifford Published: Oct 11, 2022

• Issue Brief

Transgender and nonbinary adults often face challenges and barriers to accessing needed health services and face worse health outcomes than their cisgender peers. Transgender adults are mo re likely than cisgender adults to be uninsured, report poor health, have lower household incomes, and face barriers to care due to cost. Given their lower incomes, Medicaid plays an important role in health coverage for transgender people. A 2019 report by the Williams Institute estimated that among the 1.4 million transgender adults living in the United States, approximately 152,000 had Medicaid coverage.

Medicaid is the country’s health coverage program for low-income people and is jointly funded by the federal government and states. Under Medicaid, states must cover certain mandatory benefits , such as inpatient and outpatient services, home health services, and family planning services. While there are no specific federal requirements regarding coverage or exclusion of gender-affirming health care services as a category of Medicaid benefits, there are rules regarding comparability requiring that services must be equal in amount, duration, and scope for all beneficiaries within an eligibility group.

Medicaid benefits are subject to Section 1557 of the Affordable Care Act (ACA), the law’s major non-discrimination provisions, which prohibit discrimination based on sex. The Biden Administration recently proposed a new rule on Section 1557 that explicitly states that it interprets, and will enforce, sex-based protections to include sexual orientation and gender identity. The administration had already asserted this position in guidance stating that under 1557 protections, “categorically refusing to provide treatment to an individual based on their gender identity is prohibited discrimination” and it returns to a position more closely aligned to that under the Obama administration but walked back under the Trump administration.

Despite these protections, some states have recently moved to implement or consider actions aimed at limiting access to gender-affirming health care, particularly for youth. This has included restrictions on coverage of benefits as well as bans on the provision of gender-affirming care by health care providers. A number of lawsuits are pending.

What gender affirming services do states report covering through Medicaid?

The standards of care for gender-affirming health services set by the World Professional Association for Transgender Health include hormone therapy, surgeries, fertility assistance, voice and communication therapy, primary care, and behavioral health interventions. Additionally, the Endocrine Society supports gender-affirming care in their clinical practice guidelines . Together, these guidelines form the standard of care for treatment of gender dysphoria. Gender-affirming care is highly individualized, and while not all transgender and nonbinary individuals will want or seek any or all of these medically necessary services, limiting access to them can lead to negative and life threating outcomes. Major U.S. medical associations, such as the American Medical Association , the American College of Obstetricians and Gynecologists , the American Academy of Nursing , the American Psychiatric Association , among others , have issued statements underscoring the medical necessity of gender-affirming care.

In a survey of states on coverage of sexual and reproductive health services conducted in Summer 2021, KFF and Health Management Associates (HMA) asked states about coverage of five gender-affirming care services: gender-affirming counseling, hormones, surgery, voice and communication therapy, and fertility assistance for transgender enrollees (Questions presented in Appendix Table 1 ). Because the survey focused on adult access, states were not asked about puberty blocking hormones. States were asked if a service was covered, excluded from coverage, or whether coverage was not addressed in state policy or statute for adults over the age of 21, as of July 1, 2021. Services that are not addressed in state policy or statute may or may not be covered by the state, or coverage may vary by case. The survey instrument was distributed via email to state Medicaid directors and where applicable, Medicaid agency staff working on women’s health and reproductive health issues. Forty-one states and the District of Columbia responded to the survey. Tennessee responded to the survey but did not answer questions related to gender-affirming services. Survey findings are summarized in Figure 1 and Table 1 and highlights are presented below.

Overall coverage of gender-affirming care:

As detailed below, many state Medicaid programs cover aspects of gender-affirming health services. However, only two of the 41 states responding to this survey, Maine and Illinois, reported covering all five services. Two states, Alabama and Texas, reported they do not cover any of these services under Medicaid.

Gender-Affirming Hormone Therapy:

Gender-affirming hormone drugs include estrogen, anti-androgens, and progestins (feminizing hormones), as well as testosterone and other agents (masculinizing hormones). Under federal law, and subject to exceptions for a few drugs or drug classes, state Medicaid programs are required to cover all drugs from manufacturers that have entered into a rebate agreement with the Secretary of Health and Human services under the federal Medicaid Drug Rebate program . Twenty-five states reported covering gender-affirming hormones, and 10 of these states require prior authorization. Thirteen states said coverage was not addressed in state statute or policy, and three states— Alabama , Hawaii , and Texas —exclude coverage of gender-affirming hormone therapy.

Gender Affirming Surgery:

Gender-affirming surgery can include chest surgery, genital surgery, facial surgery, and other surgical procedures aimed at helping a transgender or nonbinary person transition to their self-identified gender. Not all transgender or nonbinary individuals seek or want surgical treatments. Twenty-three of the 41 responding states reported covering gender-affirming surgery for adults through their state Medicaid programs. Nine states reported coverage was not addressed in state statute or policy, and nine states reported that they excluded gender-affirming surgery from coverage. This survey did not ask states to specify what surgical procedures they cover, but some states provided additional details, which can be found in Appendix Table 2 .

Ten of 23 covering states require prior authorization. For example, Colorado requires a clinical diagnosis of gender dysphoria and that the patient has lived in their preferred gender for 12 continuous months. Colorado and Wisconsin also require that the patient has completed 12 continuous months of hormone therapy.

Voice and Communication Therapy

Some transgender people have challenges with developing a voice that matches their gender identity. Voice therapy services can encompass a range of treatments that address pitch, intonation, articulation, pragmatic speech and other aspects of communication.

Thirteen of the 41 responding survey states report that they cover gender-affirming speech or voice therapy services, some requiring prior authorization. Ten of the survey states reported that they exclude coverage for gender-affirming voice therapy services, and 18 states responded that they have not addressed this coverage in their state policy.

Fertility Services:

A broad array of diagnostic and treatment services are available to assist with achieving a pregnancy. Diagnostics typically include lab tests, semen analysis and imaging studies, or procedures of the reproductive organs. Treatment services include medications, reproductive system procedures to allow for pregnancy, and an array of other interventions to help an individual achieve pregnancy, such as intrauterine insemination (IUI) and in-vitro fertilization (IVF). While federal rules require states to cover most prescription medications under Medicaid, there is an exception that allows states to exclude coverage for fertility medications.

Fertility services can be unaffordable without insurance coverage but few states (11) cover services for any beneficiaries, regardless of gender identity. In this survey, just three states ( Illinois , Maryland , and Maine ) reported covering fertility services as part of gender-affirming care. Of these three states, Illinois is the only one that reported covering services for beneficiaries without exceptions. More than half of states (29) reported that they exclude coverage for fertility services for transgender individuals, and nine states responded that they have not addressed this coverage in their state policy ( Table 1 ).

Mental Health Counseling:

Transgender and nonbinary individuals may seek mental health services to address issues related to their gender identity and transition but may also seek care to address issues that are not related to their gender transitions. As noted, in some cases a diagnosis of gender dysphoria is required before gender-affirming services can be accessed.

Twenty-seven states reported covering mental health counseling and services specifically related to gender affirming health services, 11 states reported coverage was not addressed in their state statute or policy, and three states, Alabama , Kansas , and Texas , reported that they exclude this benefit.

Some states reported requiring that transgender and non-binary Medicaid enrollees receive mental health assessments prior to receiving hormone therapy or having gender-affirming surgeries. For example, Delaware requires prior authorization for mental health counseling related to gender-affirming care, and Connecticut reported that depending on the type of service, prior authorization may be required.

The need for coverage of and access to medically necessary gender-affirming care has been recognized by leading medical and health professional organizations. However, some states have enacted laws banning the provision of gender-affirming health services to youth, and coverage for gender-affirming health services is uneven in state Medicaid programs. In most states, there is variation in coverage for specific services and some states do not have policies addressing coverage in their state Medicaid programs, potentially leaving many low-income transgender and nonbinary individuals without access to medically necessary health services.

Since this survey was conducted, the Biden Administration has proposed a new rule on Section 1557, which is consistent with their prior guidance, and proposes that excluding coverage for gender-affirming care constitutes sex discrimination. In addition, beyond what is stated in rulemaking by the current or previous administrations, some courts have found that the statue itself (i.e., sex non-discrimination provisions) protects against health care discrimination based on gender identity and sexual orientation. For example, a federal district court permanently enjoined the Wisconsin Medicaid program from categorically excluding gender-affirming services from coverage, relying on the statute. Similarly, in recent months, federal courts have ruled the Georgia and West Virginia must cover gender-affirming care in their Medicaid programs. Most recently, in June 2022, Florida’s Medicaid agency announced it would ban coverage of gender-affirming health services in the state. The policy went into effect in August and was challenged in court a few weeks later (with the case still pending). States that do not cover components of gender-affirming care may be in violation of Sec. 1557 of the ACA. However, there are a number of pending legal challenges to the Sec. 1557 rule as well as over specific Medicaid state policies related to coverage of gender-affirming services which will be important to watch moving forward to fully understand this evolving landscape.

• Women's Health Policy

news release

• Few State Medicaid Programs Report Covering a Broad Range of Gender-Affirming Health Services for Adults

Also of Interest

• Demographics, Insurance Coverage, and Access to Care Among Transgender Adults
• Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S.
• Youth Access to Gender Affirming Care: The Federal and State Policy Landscape
• Recent and Anticipated Actions to Reverse Trump Administration Section 1557 Non-Discrimination Rules

Transgender Health Program

• Enter keyword Search

Transgender Health Program: Insurance Information

OHSU clinics accept many kinds of insurance, including the Oregon Health Plan and many Medicare plans. Some services require prior authorization and referrals.

If you have insurance

Many insurance plans cover some transition-related services. Oregon requires health insurers to cover medically necessary treatments related to gender dysphoria if those treatments are covered for other conditions.

Private insurance

Check your member handbook or call the member services number on your insurance card to find out what may be covered.

Terms to look for: Gender dysphoria, gender identity disorder, sexual/gender reassignment or transgender health.

Oregon Health Plan

The Oregon Health Plan covers hormone therapy and some surgical services for transgender and gender-nonbinary patients. Talk to your health care provider and coordinated care organization to find out what services they may provide.

Learn more:

• The Oregon Health Authority has information about Oregon Health Plan benefits .

For patients

• For providers

Employer-provided benefits

If you get health insurance through your job, you should have a summary of benefits. Talk with your company’s benefits specialist or human resources manager about what’s covered.

If you don’t have insurance

Choosing a plan.

Oregon Health Plan: The Oregon Health Plan is the state’s Medicaid program for low-income people. You can apply online if you haven’t already been denied coverage.

Individual marketplace: HealthCare.gov , run by the federal government, helps you shop for and enroll in affordable health insurance. What you pay is based mostly on your income. You can enroll early November through mid-December or after certain life-changing events, such as losing your previous health insurance.

Medicare: This federal program is for people 65 and older and certain younger people with disabilities. Medicare.gov can help you find a plan.

Senior Health Insurance Benefits Assistance Program: This Oregon network of trained volunteers helps Medicare patients of all ages get coverage.

Seniors and People with Physical Disabilities Offices: This Oregon agency , a branch of the Department of Human Services, can help you find services.

Find an agent or application assistant: Visit the Oregon.gov help page to find someone near you to help you find the right coverage.

Help from health insurance agents and Medicare agents is free, but some insurance agents get a commission for recommending an insurer’s plan. For free unbiased help, look for Medicare volunteers and community partners on the Oregon.gov help page.

Recommended community partners: These organizations have expertise in transgender and gender-nonconforming health:

• Cascade AIDS Project offers help to anyone.
• Outside In , which helps homeless and marginalized youths, has a trans services coordinator: 503-535-3828 .
• Project Access Now helps vulnerable communities access health care.

What to ask

These questions can help you decide on an insurance plan, according to the Strong Families Network:

What is covered? When talking to customer service representatives, ask for the “Evidence of Coverage” or “Certificate of Coverage,” a full list of covered benefits for the plan.

What’s not covered? Pay attention to services or treatments specified as exclusions or limitations.

What’s covered for non-trans patients? If hormone therapy, chest surgery and hysterectomies are covered for anyone on the plan, they should be covered for transgender and gender-nonbinary members. In Oregon, it is illegal for insurers to cover services for some people and deny them to others.

Are there hormone therapy co-pays? If so, how much are they? Is there a limit on hormones or hormone injections? If so, what is it?

Is my health care provider covered by the plan ? Check whether your doctor is in the plan’s network.

Is there a network of trans-friendly doctors with training in gender-diverse care? If you want to find a gender-affirming provider,  GLMA: Health Professionals Advancing LGBT Equality  can help. Once you identify someone, ask which plans work with the provider.

Other questions to ask:

• Are there doctors within 30 miles who can serve trans and gender-nonbinary patients?
• Are mental health services available for gender-diverse people and their families, and are visits for gender-related needs covered?
• What kinds of documents are needed to receive services?
• Do I need to change my legal ID to get coverage as a person who is trans-identified?
• Are procedures such as facial gender-confirmation surgery covered?

Dealing with claims

These tips can help you navigate the claims process with your insurer:

• If your insurance is through your employer, contact your company’s benefits specialist or human resources manager.
• Have an advocate nearby or on call, ready to help you handle the stress.
• Be prepared to be misgendered. Many insurance companies don’t train their call-center staff on etiquette for transgender and gender-nonbinary patients.
• Have your group number, plan number and, if you have an online account with your insurer, your username and password.
• Research your plan and be prepared to explain your benefits package. Know what’s included and excluded. Call-center staffers don’t always distinguish well among the insurer’s various plans.
• You may need to ask for a supervisor. Be patient and polite, and remember they’re humans on the other end of the line.
• If you’re told you need a certain form, ask to have a blank copy emailed to you. Use the company’s name for any form, which can help representatives work faster.

These tips can help:

• Don’t despair. You can appeal.
• If you get an operator who can’t help, calmly ask for someone else.
• Don’t accept partial payment. A partial payment can be appealed.
• If you’re insured through work, ask your human resources manager or benefits specialist for help.
• If your employer has a policy on nondiscrimination, inclusion and diversity, you can use it to appeal.
• Find out if your plan has an explicit policy on parity.
• Some claims are denied more than once, even when a procedure is covered.
• If your doctor or benefits specialist finds a successful appeal for the same procedure, remove identifying information and include it with your appeal. This can help you avoid multiple denials.

OHSU resources

Visit our Billing and Insurance page to find:

• Information about our billing process
• Hospital costs
• Numbers to call if you need help
• Answers to frequent questions
• Information about financial assistance

Oregon resources

The Oregon Department of Consumer and Business Affairs has information about finding insurance, getting help paying for it, and your rights.

Request services

Please fill out an online form:

• I am seeking services for myself.
• I am seeking services for someone else.

Other questions and concerns

Contact us at:

• 503-494-7970
• [email protected]

Refer a patient

• Please complete our  Request for Transgender Health Services referral form   and fax with relevant medical records to  503-346-6854 .
• Learn more on our  For Health Care Professionals  page.

• MyNewMarkets.com
• Claims Journal
• Insurance Journal TV
• Academy of Insurance
• Carrier Management

Featured Stories

• Progressive Records 5-Fold Increase in Q1 Net Income
• Zurich to Halt Coverage of New Fossil-Fuel Exposures

Current Magazine

• Read Online

Maine Lawmakers Approve Liability Shield for Abortion and Gender Care Providers

The Democratic-controlled Maine Legislature gave final approval Friday to a bill that would protect health care workers who provide abortion and gender-affirming care from legal action brought in other states.

If signed by Democratic Gov. Janet Mills, Maine would join more than a dozen states that shield medical providers and others from out-of-state investigations regarding abortions. Republicans were firmly against the bill to shield against out-of-state lawsuits.

The Maine Senate voted 21-13 on Friday, a day after a 76-67 vote in the House.

The votes came after attorneys general in 16 states, including Tennessee, threatened legal action if Maine proceeded with a shield law preventing out-of-state repercussions for those who provide abortions and what they called “gender transition surgeries for children.”

Maine Attorney General Aaron Frey called those accusations “meritless” and said shield laws were necessary due to other states’ efforts “to punish beyond their borders lawful behavior that occurs in Maine and other states.”

“Harmony between our states would be best preserved and promoted by the exercise of restraint by all parties seeking to control health care related policy choices in other states,” Frey said previously in a statement.

There was spirited debate over the measure in Maine.

On Thursday, the Maine House censured two lawmakers after one of them accused legislative colleagues of bringing the wrath of God in the form of a mass shooting and recent storms by enacting such laws. The lawmaker, and another who agreed with him, were required to provide a formal apology on the House floor to be allowed to speak and to vote.

“We are grateful and proud of all of the lawmakers in the legislature who endured threats of violence, abhorrent political rhetoric and rampant disinformation to stand and vote to protect safe, legal, medical care in Maine,” said Lisa Margulies, from Planned Parenthood Maine Action Fund.

Gender Care

Abortion is legal in Maine at all stages of pregnancy with a doctor’s approval. And lawmakers last year approved a bill to allow 16- and 17-year-olds to receive limited gender-affirming care, which does not include surgery, in some cases without parental consent. However, Maine law does not permit gender-reassignment surgery without parental consent for minors.

Since the U.S. Supreme Court overturned Roe v. Wade in 2022 and ended a nationwide right to abortion, states have moved in opposing directions. Most of those under Republican control now have bans or other restrictions in place. Fourteen states now ban abortion in all stages of pregnancy, with limited exceptions. Most Democrat-dominated states have moved to protect access.

At least 13 states have shield laws protecting medical providers and others from out-of-state investigations regarding abortions — and at least nine, including Maine, have executive orders laying out similar policies.

It’s a similar situation with gender-affirming care for minors.

At least 24 states have adopted laws in the past three years banning or limiting treatments including puberty blockers, hormone therapy and gender-affirming surgery — which is rare for younger patients — for minors. At least 12 states have shield laws that apply to gender-affirming care and two have executive orders.

Associated Press writer Geoff Mulvihill in Cherry Hill, New Jersey, contributed to this report.

Topics Legislation Maine

Was this article valuable?

Thank you! Please tell us what we can do to improve this article.

Thank you! % of people found this article valuable. Please tell us what you liked about it.

Here are more articles you may enjoy.

Written By David Sharp

Interested in legislation .

Get automatic alerts for this topic.

• Categories: East News Topics: abortion providers , gender-affirming care
• Have a hot lead? Email us at [email protected]

Insurance Jobs

• Sr. Consultant, Actuarial & Analytics - Hartford, CT
• Operational Enablement Manager-Lead Consultant - Chicago, IL
• Claim Data Product Owner - Hartford, CT
• CCC-Frontline Sales-Assoc Mgr - Chicago, IL
• CL Certificate of Insurance Specialist – REMOTE - Remote

• Squeezed from All Sides: Restaurants Pressured by Labor, Food, Insurance Costs
• Extreme Weather, Cyber Risks Top Concerns When Insuring Farms
• 3 Areas for Agents to Focus Growth Efforts in 2024 As the Hard Market Continues
• Majority of Underwriters Predict Cyber Risks Grow 'Greatly' in 2024: Survey
• What's to Come in 2024: AI Expansion, More Catastrophes, Network Consolidation

• Travelers Survey: Distracted Drivers Making US Roads More Dangerous
• Supreme Court Allows More Transport Workers to Bypass Arbitration and Sue Employers
• US Senate Committee to Hold Hearing on Boeing Safety Culture Report
• Dutch Chipmaker Nexperia Hacked by Cyber Criminals
• Johnson Controls Unit to Pay $750M to Settle 'Forever Chemicals' Lawsuit

• April 18 Waiting on the Grand Reopening: Business Income Essentials
• April 25 Getting Back to Work: Workers' Comp and the Social Determinants of Health
• May 2 Rules of Engagement in Selling
• May 9 Cannabis and the Homeowners' Policy

• Get The Facts

Addressing misinformation: Access to gender-affirming care for all partners

• Share this post on Facebook
• Share this post on Twitter
• Share this post on LinkedIn
• Share this post on Reddit
• Share this post on WhatsApp
• Share this post on Email

We are deeply concerned by false information being spread about the comprehensive health coverage we offer to all eligible partners, including many who work as little as 20-hours a week.

Unfounded allegations made by others accusing Starbucks of withholding gender-affirming care from our partners at stores with union activity are both misleading and could deter partners from pursuing essential care.  To be clear: All partners enrolled in Starbucks health benefits have access to industry-leading gender-affirming care benefits regardless of organizing activity or representation status.

Since  2013 , Starbucks health insurance plans have included coverage for gender-affirming surgery. In 2018, Starbucks expanded  health insurance plan coverage to include procedures that were previously considered cosmetic — including hair removal, facial feminization and hair transplants, among others.

At no time has Starbucks taken away — or threatened to take away — benefits currently provided to any partner.

In fact, Starbucks  recently  extended medical travel reimbursement coverage for individuals who are required to travel for access to gender-affirming care. The enhancement, extended to partners regardless of union status, provides any individual enrolled in Starbucks health insurance — including eligible dependents of partners — reimbursement for eligible travel expenses when gender-affirming care is not legally accessible in their state of residence and there are no doctors available within 100 miles of their residence.  

As an expansion of existing health insurance coverage, these benefits were legally  implemented  at all stores as Starbucks has a long history of making similar adjustments to benefits plans.

It is unfortunate that others continue to spread inaccurate information that has mislead partners into believing they lost health benefits critical to their mental and physical well-being. 

At Starbucks, partner well-being has always been our top priority and we are proud to serve the best benefits for hourly retail work, including comprehensive and inclusive health plans. Looking forward, we will continue to ensure our partners have equitable  access  to quality benefits and care. We encourage all partners to get the facts about the benefits made available them at Starbucks .

Ontario resident who wants both a vagina and penis wins public funding for unique surgery

Ontario has been ordered to pay for surgery for a resident who is seeking to have a vagina constructed while leaving their penis intact.

Denying the procedure would infringe on the person’s Charter-protected right to security of the person, an Ontario court said in its ruling.

The unanimous decision by a three-member panel of judges of Ontario’s Divisional Court could expand access to a novel “bottom surgery” for people who identify as non-binary, meaning neither fully male nor fully female.

The Ontario resident, identified in court documents as K.S., has been locked in a legal battle with the Ontario Health Insurance Plan since 2022, when OHIP denied a funding request to have a penile preserving vaginoplasty performed at a clinic in Austin, Texas.

The surgery, which is not available anywhere in Canada, involves creating a vaginal canal, or opening, without removing the penis.

K.S., 33, was born male but identifies as female dominant and uses a feminine name.

OHIP denied her request for funding, arguing that the procedure is not included on its list of sex-reassignment procedures, and is therefore not an insured service.

K.S. appealed OHIP’s decision to Ontario’s Health Services Appeal and Review Board, arguing that forcing her to have her penis removed would invalidate her identity and be akin to an illegal act of conversion therapy.

She also worried about the risk of complications and urinary incontinence from the urological rerouting, and the risk of orgasm dysfunction. She argued the procedure she is seeking abroad is like standard vaginoplasties performed in Ontario, but without the additional procedure, namely, the penectomy.

The appeal board overturned OHIP’s decision, ruling that a vaginoplasty is among the genital surgeries listed for public coverage and need not inherently include removal of the penis. The board therefore ruled the procedure eligible for public funding.

OHIP appealed the board’s decision to the Divisional Court, arguing the review board erred in finding a penis-sparing vaginoplasty is specifically listed as an insured service, and that it failed to consider that the unorthodox procedure is considered an experimental procedure in Ontario, and, therefore, not eligible for funding.

Just because vaginoplasty is listed as an insured service doesn’t mean any type of vaginoplasty qualifies, OHIP argued in court.

The court disagreed. Vaginoplasty and penectomy are listed as discrete, separate services on Ontario’s list of surgeries eligible for funding, the court said. “The fact that most people who have a vaginoplasty have it done in a way that also involves a penectomy” doesn’t change the provision. If the province had intended for only one type of vaginoplasty to be insured (vaginoplasty with penis removal) it should have drafted the list differently, the court said.

The court said the appeal board’s conclusion was also consistent with standards of care developed by the World Professional Association for Transgender Health (WPATH) — an influential group whose guidelines for gender-affirming care for children and youth were found to lack “developmental rigour”  in a sweeping review released this week.

The WPATH standards “expressly refer to vaginoplasty without penectomy as a surgical option for some non-binary people,” Justice Breese Davies wrote in the court ruling.

While the court said it didn’t need to address Charter arguments, if there was any ambiguity concerning what should or should not be covered, the review board’s interpretation was also consistent with Charter values of equality and security of the person, the court added.

“The Charter-protected right to security of the person safeguards individual dignity and autonomy,” Davies wrote. Requiring a transgender or non-binary person born male “to remove their penis to receive state funding for a vaginoplasty would be inconsistent with the values of equality and security of the person.”

“Such an interpretation would force transgender, non-binary people like K.S. to choose between having a surgery (penectomy) they do not want, and which does not align with their gender expression to get state funding, on the one hand, and not having gender affirming surgery at all, on the other,” Davies wrote.

“Such a choice would reinforce their disadvantaged position and would not promote their dignity and autonomy.”

OHIP’s appeal was dismissed, and the province ordered to pay K.S. $20,000 to cover legal costs.

“This is a significant win for the transgender and non-binary communities,” K.S.’s lawyer, John McIntyre, told CTV News Toronto.

“We hope that OHIP decides to accept the decision of the court rather than seeking leave to appeal so that K.S. can move forward with her surgery she has been trying to get for years now.”

“K.S. is very happy with this unanimous decision,” McIntyre said in an email to the National Post. “The Divisional Court determined the existing language of the Health Insurance Act and the Schedule of Benefits clearly provided coverage for the procedure she sought.”

In earlier reports, National Post was told that gender-affirming surgeries at the Texas clinic range from US$10,000 to $70,000, depending on what is done.

National Post

• Court to decide if Ontario must pay for surgery to make vagina if patient also wants to keep penis
• Jamie Sarkonak: Public must pay for gender-affirming surgeries abroad

Our website is the place for the latest breaking news, exclusive scoops, longreads and provocative commentary. Please bookmark nationalpost.com and sign up for our daily newsletter, Posted, here .