Health insurance for gender affirming care can be overwhelmingly complex in the USA. Getting an answer to “What does my plan cover?” can take hours. Federal law, state law, employer plans, individual plans, ACA, Medicaid, Medicare: they all have different requirements and hoops to jump through. For minoritized people, there may be more barriers to care. Historically, protections against discrimination in health insurance for transgender people have been spotty or absent — or discrimination has been codified into law.
Even if your insurance covers gender affirming care, there may be very specific conditions to getting care paid for such as age, therapist letters, hormone use, etc., that using your insurance is not accessible. Even if your insurance will pay for procedures and have few prior authorization requirements, it may be difficult to find a provider near you! It all adds up!
Thankfully, although we don’t yet have universal protections for gender affirming care, things are changing.
Federal laws prohibit discrimination against trans people in public and private insurance plans. Many state laws do, as well. Thanks to recent changes, refusing to cover medically necessary transition-related services and care is considered discriminatory for most insurance plans, and is illegal.
We all know that it still happens.
Healthcare Rights for Transgender People
What is Considered Discriminatory?
Excluding all transition-related care.
Excluding a specific transition-related procedure for everyone.
Limiting coverage for procedures related to transition if they are not limited for everyone.
Changing the terms of your insurance (coverage, rates, enrollment eligibility,) because you are transgender.
Refusing to cover care that is associated with a gender marker such as breast, prostate, and cervical cancer screenings.
How Are You Protected?
Any health service that receives funding from the Department of Health and Human Services is required to comply with laws prohibiting discrimination on the basis of race, color, national origin, disability, age, religion, or sex (includes pregnancy, sexual orientation and gender identity.) Examples of services which may receive federal funding are state, federal, and local agencies that provide medical or nutritional assistance, ACA plans, student health plans, the Children’s Health Insurance Program, and private practice providers who care for patients with Medicaid.
Routine preventive care
Medically necessary hormone therapy
Medically necessary transition-related surgery
Coverage should not vary by state, but definitions of “medically necessary” and prior authorization requirements may.
The VA covers:
Gender affirming hormone treatment
This summer (2021,) the VA started the rulemaking process to expand coverage to include gender-affirming surgeries – coverage might not be available until 2023, however.
For more information: https://www.patientcare.va.gov/LGBT/
Not all ACA plans receive federal funding.
All ACA plans should cover preventative services for transgender people at no cost. You may need a prior authorization to satisfy medically necessary requirements.
As of this past summer, the Biden administration issued a notice that ACA plans are prohibited from discriminating on the basis of sexual orientation or gender identity.
This does not, however, mean that insurance plans are required to cover all gender-affirming procedures. If they do exclude procedures from coverage, they have to exclude those procedures for everyone.
State Plans – Medicaid
Medicaid plans are regulated at the state level. Some plans are affirming, and some are not. We’ll be discussing state by state information next week.
Employer and Individual Plans
Employer plans and individual plans are also regulated at the state level. More information next week!
What does my plan cover?
The first step to finding out what your plan covers is through your plan documents. You might find coverage information through the 4-page brochure sent by your HR department for employer plans, but the best and most comprehensive source is your plan booklet. Insurers are required by law to publish plan booklets, but they might not be easy to find, and they might not contain. You may need to contact your insurance company to obtain a copy of your summary of benefits and coverage.
We love the Trans Health Insurance Tutorial from TLDEF’s Trans Health Project for step by step instructions on learning about your coverage and getting coverage.
We also provide care navigation services for our patients. See our care navigation page for information.
Once you have your plan documents:
- Look for exclusion information. If you’re looking at your documents online, an easy way to find exclusion information is to search for “gender.” If nothing is listed, you may need to contact your insurance provider directly.
- If you need to contact your insurance company, you will likely need to know the specific diagnosis codes and procedure codes for the care you want. We’ll be talking more about this in two weeks.
Next week: Changes in Washington State insurance law for 2022 and other states. There are exciting changes happening!
Resources and For More Information:
Verywell Health: Does Health Insurance Cover Transgender Health Care?
HRC’s List of Businesses with Transgender-Inclusive Health Insurance Benefits (limited to large companies)