Take one mental health support letter from Column A and one surgery referral letter from Column B and call your surgeon in the morning. Then call insurance.

It can feel like there’s a mountain of paperwork to wade through when accessing gender affirming healthcare, and insurance speak sure feels like it is too complicated to wade through sometimes. Here’s some tips on LETTERS.

What’s the difference between an assessment/support letter and a referral letter?

Both types of letters confirm that a professional who has sufficient training has evaluated the individual and verified that they have an appropriate diagnosis, understand what the next step is, and are ready for the next step, whether it be starting hormones or surgery (or other!)

The letter should:

• State that the individual has the capacity to consent to care.
• Include the care that is being sought.
• Include a brief mental health history or physical health history, as appropriate.
• And include a statement that the individual is ready for the desired care.

Who Might Ask For A Letter?

• A hormone provider may ask for a letter from a mental health provider to start hormones.
• A surgeon may ask for a letter from a mental health provider regarding emotional readiness for surgery.
• A surgeon may ask for a letter from a hormone prescriber/primary care provider regarding physical readiness for surgery.
• An insurance company may ask for a letter from a mental health provider or prescribing physician before they pay for prescriptions, procedures, equipment or surgeries.

Also

• Governmental agencies may require a letter before changing identification documents.
• State laws may require evaluation by a mental health provider or documentation of the informed consent process before starting hormones or getting surgery.

How Do I Find Out What Letter I Need?

Starting Hormones

• Many Informed Consent prescribers do not require a mental health support letter, as the informed consent process determines that an individual has the understanding and ability to make decisions about their own medical care.
• Ask your potential provider.
• QueerDoc follows an informed consent model, which means that most folx do not need mental health letters of support to access gender affirming care with us.

Surgery – the Surgeon

• Check your surgeon’s website or ask their care coordinator. Here’s an example from MozaicCare in San Francisco: (https://www.mozaiccare.net/letters):

Your Insurance Company

• Call your insurance company and ask about their gender affirming care policy and your coverage.
  • Stay tuned for a self-help tool.
  • Helpful Resources for Navigating Insurance
  • Insurance Dictionary
  • What Does My Plan Cover? Health Insurance for Gender Affirming Care
  • Tips For Talking To Insurance: Procedures, Policies, Payments, and Appeals:
  • 10/23 Is Insurance Required to Cover Gender Affirming Care in WA State?
• Hate the phone? You may be able to find information about required letters in your plan documents or your plan’s policy. A copy of your plan documents may be in your electronic account.
• Plan policy documents can sometimes be found online.
  • A good search phrase is “name of insurance gender affirming care policy.”
• Example: Washington State Medicaid (Apple Health)
  • Two letters: one from a mental health provider and one from your hormone prescriber or primary care provider. (see below screenshot)

• Example: Aetna
  • Note: Aetna’s requirements 1 – 5 are the same for surgical procedures. Additional requirements can include hormone therapy and risk factor assessments. Also note that items #2 and #4 could be satisfied with a surgery referral letter in addition to a mental health support letter.

Who Can Write A Letter?

Your surgeon’s office or insurance company may also require that the letter is written by a provider with specific training and licensing. It might not be obvious what that training is.

See Washington Apple Health:

And Aetna’s:

Identification Document Changes

• Advocates for Transgender Equality have a great ID Documents Center for state-by-state and federal name and gender change information.
• In Florida? See Florida Name Change.

How Does QueerDoc Fit Into The Puzzle?

Letters for Identification Document Changes

Book a 30-minute Legal Transition Consult appointment with a provider who is licensed in the state where you live (it doesn’t have to be where your documents are recorded.) At that appointment, they will establish a clinician-patient relationship, and, if able, write a clinician’s letter, then mail you a copy or copies of that letter. You do not have to be a QueerDoc patient! You can find info on pricing here.

Letters to document medical readiness for surgery

We are currently providing surgery referral letters only to individuals who are also receiving medical care with us. Book a 30-minute Medical Surgery Referral Consult with your provider. You can find info on pricing here.

Letters to document mental health readiness for surgery

We expect to be offering Mental Health Surgery Referral Consults in the coming months. Pricing info will be available here. Stay tuned for more info!

Where Else Can I Get A Mental Health Letter?

The Gender Affirmative Letter Access Project is currently under development. When active, their directory is an excellent resource for letters. Each provider in The GALAP directory has pledged to donate some time each month towards free letters for gender affirming care. These providers may also accept new patient paid appointments for letters.

Check for licensed providers in your area via an affirming directory:

• Our Virtual Resources page links to some directories.
• Our State-Based Resources pages link to providers in the states we serve.
• Check for recommendations via your local community resources. Where’s your local LGBTQ+ community

Some History

WPATH (the World Professional Association for Transgender Health) is an international group of providers, researchers, and community members who regularly evaluate the published evidence about transgender medicine and develop guidelines for providing gender affirming care. They released version 8 of the Standards of Care in 2022. Many providers and insurance companies base their coverage and documentation requirements on the WPATH Standards of Care.

In SOC8 for adults, WPATH recommends that no letters be required. Further if an assessment letter should be required it can be written by ANY member of the care team (not just a mental health provider). Earlier versions required two letters. This lowers barriers to care, and we love it, but insurance companies and surgeon’s offices and hormone providers don’t HAVE to follow WPATH recommendations. You may still be asked to supply multiple letters of support.

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