Does Health Insurance Cover Gender-Affirming Surgery?

Transgender people have fought for a long time to get equal rights. One area that has seen great advancement is the healthcare industry. In the last few decades, the medical community has shifted from seeing transgenderism as a disorder and has finally begun to see it as another part of human nature. And, in 2010, the Affordable Care Act made sure that transgender individuals don’t need to worry about being denied healthcare. Section 1557 of the ACA prohibits discrimination based on gender identity, and says that health insurance cannot refuse coverage for transgender individuals.

transgender word spelled out in colorful beads

Despite these positive steps, gender-affirming surgery can be difficult for some to get. While insurance companies cannot deny coverage to transgender individuals, they do not have to cover gender-affirming surgery. You have to do some research on whether your insurance company offers it, and you have to meet certain criteria to be eligible for coverage.

Transition-Related Care and the ACA

Section 1557 prohibits discrimination based on existing guidelines of the Civil Rights Act, Title IX, the Age Act, and Section 504 of the Rehabilitation Act. Although it prohibits discrimination based on gender identity, it does not necessarily require health insurance companies to “cover any particular procedure or treatment for transition-related care.” In other words, these companies cannot deny coverage to anyone, but they do not have to  cover any specific transgender-related healthcare procedure, even if it is considered medically necessary.

On the other hand, gender identity cannot be used to deny treatment that is medically necessary, even if it does not match with the individual’s preferred gender. For example, a transgender man with an intact cervix cannot be denied treatment or screenings for cervical cancer based on the fact that he identifies as a male. If you do not receive the treatment you need and you believe that you were wrongly denied coverage, you have the right to appeal any decision based on Section 1557. 

Do Some Plans Cover Surgery?

two doctors in surgery room

Many plans have exclusions for transition-related care, because no plan is required to cover any specific kind of procedure. There are, though, some insurance companies and some plans that include coverage for gender-affirming surgery. Private insurers who do cover it will require you to prove that the procedure is medically necessary. 

Proving Medical Necessity

african american hand holding a piece of paper with the other hand holding a pen writing on paper
In order to prove medical necessity, you must obtain one to two letters of referral from a licensed mental health professional

Details differ from plan to plan, but in general you will have to get prior authorization from your doctor proving that gender-affirming surgery is medically necessary. In most cases you will need to:

  • Obtain one to two letters of referral from a licensed mental health professional
  • Provide well-documented proof of a persistent case of gender dysmorphia
  • Prove you have the ability to make fully informed decisions
  • Obtain any other required pre-authorization letters

Both private insurance companies and the Marketplace offer plans that cover gender-affirming surgeries, but not all do. When searching for a plan that provides this coverage, you should check the “evidence of coverage” or “certificate of coverage” that comes with a plan. This document lays out in detail what is covered and what is not. Look for sentences like “All procedures related to being transgender are not covered.” Other terms to look for include “gender change,” “transsexualism,” “gender identity disorder,” and “gender identity dysphoria.”

Transgender individuals and the LGBTQ+ community have had a long struggle to get equality, including in the insurance industry. EZ cares and we want to help you find a plan that offers the coverage you need and deserve. To compare quotes on plans for free, enter your zip code in the bar above, or to speak to one of our agents, call 888-350-1890.

About The Author:
Cassandra Love

With over a decade of helpful content experience Cassandra has dedicated her career to making sure people have access to relevant, easy to understand, and valuable information. After realizing a huge knowledge gap Cassandra spent years researching and working with health insurance companies to create accessible guides and articles to walk anyone through every aspect of the insurance process.

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