Does Insurance Cover Gender-Affirming Care?

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

Key Takeaways

• Health insurance generally covers gender-affirming care.
• Not all plans cover all procedures, however, and the process can be murky and require preauthorization.
• Gender-affirming care can cost tens of thousands of dollars without insurance coverage.

Major insurance companies today generally recognize transgender-related care as being medically necessary. However, at least 24 states have passed new laws or enacted new policies limiting coverage of gender-affirming care for people up to age 18. And some transgender people may still be denied coverage for certain procedures by their insurers.

1.6 million

The estimated number of Americans age 13 or older who identify as transgender, according to a 2022 study.

Does Insurance Cover Gender-Affirming Care?

Health insurers generally cover an array of medically necessary services that affirm gender or treat gender dysphoria, according to the American Medical Association, which reaffirmed its advocacy for such care in 2023. Gender dysphoria is a condition that occurs when someone feels a conflict between the sex they were assigned at birth and the one they now identify with.

Gender-affirming care is the phrase used by most medical groups for dysphoria treatment. This care can include 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 (ACA) 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 2024 rule from the Department of Health and Human Services stated that covered entities (a term that includes both insurance plans and providers such as doctors) could not “deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for specific health services related to gender transition or other gender-affirming care if such denial, limitation, or restriction results in discrimination on the basis of sex.”

However, insurance is also regulated at the state level and rules can vary based on whether it is an ACA, public, or employer plan, so they don’t apply evenly to all insurers.

Determining What Your Plan Covers

Policyholders and plan members can generally find out what’s available to them 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 claim coverage. For example, to begin hormone therapy, the requirements might include a diagnosis of gender dysphoria from a licensed mental health professional.

Some plans may list exclusions for certain procedures. Even if an exclusion exists in the documentation, it can still be worthwhile to apply for pre-authorization or pre-approval for the procedure to obtain an official decision. For one thing, as the Transgender Legal Defense & Education Fund, notes, “the plan booklet may simply be out of date.”

Even if you’re turned down, that is not necessarily the final word. If a preauthorization request or a claim is denied, an attorney, healthcare 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.

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 half the states without such protections.

However, health coverage benefits that a private employer provides can vary based on whether the employer buys its coverage from an insurance company or is funding the plan itself. If the employer’s plan is self-funded, it is governed by the federal law ERISA, the Employee Retirement Income Security Act, which overrides any state nondiscrimination law. The employer can decide what health care is or is not covered.

In the Human Rights Campaign’s 2023-2024 Corporate Equality Index, a record 94% of the companies it evaluated offered at least one transgender-inclusive plan option.

Important

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

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 have eliminated transgender-specific exclusions, which ACA regulations explicitly ban.

Still, policies vary by state and in what they cover. As the Healthcare.gov website notes, “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.”

It suggests that before enrolling in a plan, consumers should carefully review its terms: “Plans might use different language to describe these kinds of exclusions. Look for language 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.'”

Fortunately, according to Out2Enroll, an organization connecting the LGBT+ community with healthcare coverage, when it recently reviewed silver Marketplace options in 32 states it found that “the vast majority of insurers did not use transgender-specific exclusions” and that “40% of plans had language indicating that all or some medically necessary gender-affirming care would be covered by the plan.” (ACA coverage is broken down into bronze, silver, gold, and platinum plans, with silver being a moderately priced level.)

Out2Enroll also has state-specific Transgender Health Insurance Guides on its website for help in choosing a plan.

Medicare and Medicaid Coverage

About 6% of transgender adults receive their health coverage from Medicare, the federal insurance program primarily for Americans over age 65. Under these plans, medically necessary care—including some gender-affirming procedures—is covered. Private Medicare Advantage plans should abide by the same rules as traditional Medicare, but patients on such plans should try to get preauthorization before accessing transition-related services, the National Center for Transgender Equality advises.

Some 21% of transgender adults receive Medicaid, the joint federal and state health insurance plan for low-income Americans. On a state-by-state basis, Medicaid coverage is uneven. Medicaid programs explicitly cover transgender-related care in 26 states and the District of Columbia. Meanwhile, programs in 10 states bar coverage of transgender-related care for people of all ages, and programs in three states prohibit coverage of transgender-related care for minors.

Military and Veteran Coverage  

Active military members can access some types of gender-affirming care. TRICARE, the health benefits provider for military members, says it “covers hormone therapy and psychological counseling for gender dysphoria. TRICARE generally doesn’t cover surgery for the treatment of gender dysphoria. However, active duty service members may request a waiver for medically necessary, gender affirming surgery.”

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

How Much Does Gender-Affirming Surgery Cost?

The cost of gender-affirming care might range from $25,000 to $75,000, according to an estimate from the Human Rights Campaign.

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 JAMA Surgery found that while gender-affirming surgery can be costly, insurance (for patients who have it) will often cover most of the cost. Looking at phalloplasty and vaginoplasty procedures specifically, it reported:

However, not all transgender people desire surgery. According to 2019 research statistics, only 28% of transgender women get any type of surgery, and only 4% to 13% receive genital surgery. Surgery is more common among transgender men, with 42% to 54% getting some type of surgery; up to 50% get genital surgery.

How Much Does Gender-Affirming Medication Cost?

Gender-affirming medication is far more common than surgery. As many as 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 costs of gender-affirming medications can vary widely. While they are often at least partially covered by insurance, they also come with out-of-pocket costs, which may continue through the patient’s lifetime.

For example, a study in the Journal of General Internal Medicine reported that, “in 2019, median prices for feminizing and masculinizing hormone therapy ranged from $6.76 to $91.15 and $31.82 to $398.99, respectively.” At the same time, patients’ “median out-of-pocket costs ranged from $5.00 to $10.71 and $10.00 to $12.86 for feminizing and masculinizing hormone therapy, respectively.” Those prices refer to a 30-day supply.

Other costs can be involved as well. For example, patients who are taking hormones may need periodic blood tests to monitor their health.

Note

A 2020 study in Annals of Family Medicine found that among insured respondents taking gender-affirming hormones, almost 21% reported that their claims were denied. This group (and those who are uninsured) were more likely to take nonprescription hormones from unlicensed sources, which may not be monitored for quality and potentially carry serious health risks.

Other Ways to Pay for Gender-Affirming Care and Surgery

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

Payment Plans 

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

Loans

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 cab be another avenue for covering the costs of gender-affirming care or surgery, although they tend to have very high interest rates if you run a balance.

Coupons 

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, such as the Jim Collins Foundation, offer grants for people seeking gender-affirming care or surgery.

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 if you are anticipating it.

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 Loan or Line of Credit (HELOC) 

You could take out a home equity loan or line of credit to cover the costs of gender-affirming care or surgery. With these types of loans, you can typically borrow up to a certain percentage of your home’s equity. Interest rates 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. To avoid misunderstandings, it’s usually best to 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 even strangers.

Tips for Financing Gender-Affirming Care and Surgery

When you’re financing gender-affirming care or surgery, you may be able to save some money if you 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. Doing this homework could save you a lot of money.

Check the Interest Rate Before You Borrow 

Be sure to investigate how much you’ll pay to borrow money if you decide to go the credit card or loan route. 

Try Negotiating or Set up a Payment Plan

You can sometimes 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 will 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. A common range is anywhere from $25,000 to $75,000, according to the Human Rights Campaign. Health insurance may cover these costs to varying degrees.

Does Insurance Cover Puberty Blockers?

According to one 2019 study, about 31% of the plans it looked at online claimed to cover puberty blockers. That makes it all the more important for patients and their families to shop around for insurance.

The Bottom Line

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, some people still encounter problems obtaining health insurance to cover such care or paying the out-of-pocket costs involved. People who expect to need gender-affirming care will want to read their insurance plan’s coverage details carefully and ask questions if they’re unsure about what’s covered.

Read the original article on Investopedia.