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Transgender health care

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Plans with transgender exclusions

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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
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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.

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

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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

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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

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Obama Defends Health Rights for Transgender Americans

The Department of Health and Human Services stopped short of requiring gender transition services to be covered.

ACA Protects Trans Rights

Andrew Harnik | AP

President Barack Obama speaks in Alaska on Wednesday.The Obama administration proposed a rule banning health care discrimination against transgender patients on Thursday.

The Obama administration on Thursday released a proposed rule that would ban health care providers and insurance companies from discriminating against people based on their gender identities, though it fell just short of requiring health plans to pay for gender transition.

Instead, it spelled out practices that would constitute discrimination. If a doctor says it is medically necessary for a patient who has gender dysphoria to get a hysterectomy, for instance, then insurers who refuse to cover it will have to demonstrate other instances in which they had covered medically necessary hysterectomies. The agency then would determine whether discrimination had occurred because the patient was transgender.

Hillsboro, Missouri School Divided Over Transgender Student

Sept. 2, 2015

The long-awaited proposed rule, which came from the Department of Health and Human Services, fits into part of the administration's mission to close discrimination gaps, particularly in regards to to sex, sexual orientation and gender identity. It also comes justs after the Supreme Court recognized a constitutional right for same-sex couples to marry.

The public will have until Nov. 6 to respond to the proposed rule, which also includes questions from the agency about whether it should contain a religious exemption and how it should approach prohibiting discrimination on the basis of sexual orientation.

President Obama's health care law, the Affordable Care Act, does not allow a health insurance company to turn away people with disabilities based on pre-existing conditions, and does not allow for women to be covered differently from men. Earlier this year, the agency released another rule clarifying the responsibilities that health insurance companies have to cover contraception.

As the components of Obamacare have rolled out, various areas of contention and clarification have arisen, including who picks up the tab for gender-reassignment surgery, hormone therapy and counseling. Leading medical groups, including the American Medical Association, support the position that gender transition is medically necessary.

In a statement, Mara Keisling, executive director of the National Center for Transgender Equality, said the proposed rule had the potential to be life-saving for trans people, and her organization was thrilled the administration had recognized the exclusions as discrimination. "The medical and scientific consensus for years has been that transition-related care is medically necessary and should be covered by insurance," she said. "Many systems have voluntarily covered these services because it is the right thing to do from a medical perspective, from a fairness perspective, and because it can save them money."

When the rule becomes final, it will apply to health insurance plans sold through federal- and state-run marketplaces, and to Medicaid, Medicare and the Children's Health Insurance Program. It will also apply to any doctor, hospital or clinic that accepts government funding. A doctor could not refuse to treat patients who are transgender, nor could they refuse to allow the patients to use facilities such as restrooms that are consistent with the gender they identify.

LGBT Health Care: What to Consider

Lisa Esposito July 29, 2015

A provider also could not deny someone medically necessary treatment for ovarian cancer, for instance, just because she identifies as a man.

The Office for Civil Rights has been collecting complaints from people who say they were refused care because of being transgender. "Sadly, we have ample evidence that there continues to be a persistent discrimination in the health care industry," Jocelyn Samuels, director at the Department of Health and Human Service's Office for Civil Rights, said in a call with reporters Thursday.

Even though the rule specifically applies to providers and payers who are part of government funded health care, the private medical community follows similar protocols, as the government's rules set the standards for the industry.

"This proposed rule is an important step to strengthen protections for people who have often been subject to discrimination in our health care system," Sylvia Burwell, secretary for Health and Human Services, said in a statement. "This is another example of this administration's commitment to giving every American access to the health care they deserve."

American's Health Insurance Plans, the trade group for insurers, is still reviewing the proposed rule and had not issued a statement at press time.

Join the Conversation

Tags: LGBT rights , health care , HHS , health insurance , discrimination , transgender people

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HHS Announces Proposed Rule to Strengthen Nondiscrimination in Health Care

The proposed rule affirms protections consistent with President Biden’s executive orders on nondiscrimination based on sexual orientation and gender identity, and on protecting access to reproductive health care.

Today, the U.S. Department of Health and Human Services (HHS) announced a proposed rule implementing Section 1557 of the Affordable Care Act (ACA)(Section 1557) that prohibits discrimination on the basis of race, color, national origin, sex, age, and disability in certain health programs and activities. This 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.

The proposed rule affirms protections against discrimination on the basis of sex, including sexual orientation and gender identity consistent with the U.S. Supreme Court’s holding in Bostock v. Clayton County ,and reiterates protections from discrimination for seeking reproductive health care services. Strengthening this rule is part of the Biden-Harris Administration’s commitment to advancing gender and health equity and civil rights, as laid out in President Biden’s executive orders on Preventing and Combatting Discrimination on the Basis of Gender Identity or Sexual Orientation , Protecting Access to Reproductive Healthcare Services , and Advancing Racial Equity and Support for Underserved Communities .

“This proposed rule ensures that people nationwide can access health care free from discrimination,” said Secretary Xavier Becerra. “Standing with communities in need is critical, particularly given increased attacks on women, trans youth, and health care providers. Health care should be a right not dependent on looks, location, love, language, or the type of care someone needs.”

“Now more than ever, we must stand up for those around the country whose voices often go unheard, to let them know we stand with them and are working to ensure they can access health care free from discrimination.  Today’s proposed rule is a giant step in working to ensure that goal is met,” said Acting HHS Office for Civil Rights (OCR) Director Melanie Fontes Rainer.  “I am proud of our staff who worked on this important rule that strengthens Section 1557 and who work every day to help support these goals. This proposed rule affirms our commitment to uphold the law and protect the civil rights of all people who access or seek access to health programs or activities.”

“Strengthening Section 1557 supports our ongoing efforts to provide high-quality, affordable health care and to drive health equity for all people served by our programs,” said Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure. “This work will help eliminate avoidable differences in health outcomes experienced by those who are underserved and provide the care and support that people need to thrive."

The Section 1557 Notice of Proposed Rulemaking (NPRM) seeks to address gaps identified in prior regulations. In order to advance protections under this rule it:

• Reinstates the scope of Section 1557 to cover HHS’ health programs and activities.
• Clarifies the application of Section 1557 nondiscrimination requirements to health insurance issuers that receive federal financial assistance.
• Aligns regulatory requirements with Federal court opinions to prohibit discrimination on the basis of sex including sexual orientation and gender identity.
• Makes clear that discrimination on the basis of sex includes discrimination on the basis of pregnancy or related conditions, including “pregnancy termination.”
• Ensures requirements to prevent and combat discrimination are operationalized by entities receiving federal funding by requiring civil rights policies and procedures.
• Requires entities to give staff training on the provision of language assistance services for individuals with limited English proficiency (LEP), and effective communication and reasonable modifications to policies and procedures for people with disabilities.
• Requires covered entities to provide a notice of nondiscrimination along with a notice of the availability of language assistance services and auxiliary aids and services.
• Explicitly prohibits discrimination in the use of clinical algorithms to support decision-making in covered health programs and activities.
• Clarifies that nondiscrimination requirements applicable to health programs and activities include those services offered via telehealth, which must be accessible to LEP individuals and individuals with disabilities.
• Interprets Medicare Part B as federal financial assistance.
• Refines and strengthens the process for raising conscience and religious freedom objections.

While the Department is undertaking this rulemaking, both the statute and the current regulation are in effect. If you believe that you or another party has been discriminated against on the basis of race, color, national origin, sex, age, or disability, visit the OCR complaint portal to file a complaint online.

HHS encourages all stakeholders, including patients and their families, health insurance issuers, health care providers, health care professional associations, consumer advocates, and government entities, to submit comments through regulations.gov.

Public comments on the NPRM are due 60 days after publication of the NPRM in the Federal Register.  The Department will also be conducting a Tribal consultation meeting on August 31, 2022, from 2:00 p.m. to 4:00 p.m. Eastern Daylight Time. To participate, you must register in advance at https://www.zoomgov.com/meeting/register/vJIsfu-rqzksEl2T8gUp_lDrWBqkU0223CY .

The NPRM may be viewed or downloaded at: https://www.federalregister.gov/public-inspection/2022-16217/nondiscrimination-in-health-programs-and-activities .

A fact sheet on the NPRM is available in English and 16 languages at:  https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html .

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

By HealthSherpa

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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 .

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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

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• v.7(12); 2019 Dec

Navigating Insurance Policies in the United States for Gender-affirming Surgery

Wess a. cohen.

From the Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, N.J.

Alexa M. Sangalang

Margaret m. dalena, haripriya s. ayyala, jonathan d. keith, background:.

Patients with gender dysphoria seeking to undergo gender affirmation surgery are often challenged by lack of insurance coverage. The authors aim to review gender affirmation surgery policies and to highlight discrepancies between qualifying criteria across top insurance companies in the United States.

The top 3 insurance companies in each state within the United States were determined by market share. Each insurance policy was analyzed according to coverage for specific “top surgeries” and “bottom surgeries.” Policies were obtained from company-published data and phone calls placed to the insurance provider.

Of the total 150 insurance companies identified, policies related to gender- affirming surgery were found for 124. Coverage for gender-affirming surgery varies by insurance company, state, and procedure. Most insurance companies, 122 of 124 (98%), covered chest masculinization, but only 25 of 124 (20%) of insurance companies covered nipple-areola complex reconstruction. Additionally, 36 of 124 (29%) insurance companies covered chest feminization. Vaginoplasty is covered by 120 of 124 (97%) insurance companies. Despite high rates of vaginoplasty coverage, vulvoplasty is only covered by 26 of 124 (21%) insurance companies. Phalloplasty and metoidioplasty are covered by 118 of 124 (95%) and 115 of 124 (93%) of insurance companies, respectively. Slightly more than half, 75 of 124 (60%) insurance companies covered penile prosthesis.

Conclusions:

As gender-affirming surgery insurance coverage increases, the policies regarding them remain inconsistent. Standardized policies across insurance companies would further increase access to gender-affirming surgery.

INTRODUCTION

Approximately 1.4 million adults and 150,000 teens in the United States identified as transgender as of 2015. 1 Many of these individuals have been diagnosed with gender dysphoria—the distress that is caused by a discrepancy between a person’s gender identity and the gender they were assigned at birth. Transfemales (TFs) are individuals assigned male at birth who identify as female, whereas transmales are individuals assigned female at birth who identify as male. Transgender patients frequently endure lack of acceptance, harassment, and assault, likely contributing to depression rates as high as 62%, as compared to rates of 16% in the general population. 2 Additionally, suicide rates have been cited to be as high as 45% in this population. 3

Gender-affirming surgery can provide life-changing results for transgender patients and has been shown to significantly improve patients’ self-esteem and functioning. 4 These surgeries range from chest wall contouring procedures, such as mastectomy and breast augmentation, to penile and neovaginal reconstruction, and have proven to be effective in treating gender dysphoria. 5 , 6 Despite the profound positive impact gender affirmation surgery provides, insurance coverage has been historically limited. 7 However, in 2014, Medicare and Medicaid lifted the 1981 exclusion of transition-related care, and in 2017 an addendum to the Affordable Care Act banned discrimination on the basis of gender identity. 8 , 9 Since then, some private insurers have increased coverage for gender affirmation surgery. 10 , 11

Historically, most patients undergoing gender-affirming surgery have been self-pay. However, sociopolitical changes and expanding health insurance coverage have led to an increased incidence of gender-affirming surgery. 6 , 12 , 13 Despite this, more than half of patients within the past year were denied insurance coverage for gender-affirming surgeries. 14 The World Professional Association for Transgender Health, a nonprofit, interdisciplinary professional and educational organization devoted to transgender health, has set guidelines for which surgeries should be deemed medically necessary. Nonetheless, insurance coverage remains fragmented, inconsistent, and unclear to navigate.

Uncertainty surrounding insurance coverage for gender-affirming surgery contributes to confusion for providers and patients. It is critical for both plastic surgeons and transgender patients to be aware of the various insurance policies and potential hurdles for gender affirmation surgeries. The ability to navigate insurance policies will dramatically improve access to care for a traditionally underserved community. The authors aim to provide an overview of the current coverage atmosphere in the United States for gender affirmation surgeries and to highlight the challenges when navigating insurance policies. Although surgeons who routinely perform these surgeries may be familiar with the results described, the vast majority of plastic surgeons will not be. Additionally, this is the first manuscript to compile national insurance data on commonly performed gender-affirming surgeries.

The top 3 private insurance companies of each state in the continental United States were determined by market share as published by the Kaiser Family Foundation, a nonprofit, nonpartisan organization. Insurance companies were stratified into large and small group insurance companies by Kaiser. Only large groups were used in this study and were defined as having 101 or more employees. Policies as of December 11, 2018, from each insurance company regarding gender-affirming surgery were then obtained either by company-published online data or via phone call inquiry. Procedures analyzed for top surgery coverage were mastectomy, breast augmentation, and nipple-areola complex (NAC) reconstruction. Bottom surgery analysis included penectomy, clitoroplasty, labiaplasty, vaginoplasty, vulvoplasty, vaginectomy, vulvectomy, phalloplasty, metoidioplasty, penile prosthesis, scrotoplasty, testicular prosthesis, and urethroplasty. Coverage was determined if the medical policy’s stated procedures were considered medically necessary and eligible for coverage. Exclusions were noted when the medical policy explicitly stated such procedures were not covered.

Coverage for gender-affirming surgery varies by insurance company, state, and procedure. Of the total 150 insurance companies identified, policies were found for 124. Three insurance companies had no written policy regarding gender affirmation surgery, and 23 insurance companies did not provide policy information after online and phone call inquiry (Fig. ​ (Fig.1). 1 ). Among the 123 insurance companies where policies were found, 3 of these companies stated that they cover genital surgery but did not specify which specific surgeries are included.

Insurance company inclusions and exclusions.

Top Surgery

Although most insurance companies, 122 of 124 (98%), covered mastectomy, 1 excluded mastectomy as medically necessary in the treatment of gender dysphoria (Fig. ​ (Fig.2). 2 ). Only 25 of 124 (20%) of insurance companies covered NAC reconstruction. 35 of 124 (28%) companies excluded NAC reconstruction coverage specifically. Only 36 of 124 (29%) insurance companies covered breast augmentation, whereas more than half, 84 of 124 (68%), of insurance companies deemed breast augmentation as not medically necessary (Figs. ​ (Figs.3 3 and ​ and4 4 ).

Chest masculinization coverage.

Chest feminization coverage.

Insurance company coverage of top surgery.

Bottom Surgery: Male to Female

Vaginoplasty is covered by 120 of 124 (97%) of insurance companies, and penectomy is covered by 118 of 124 (95%) insurance companies (Fig. ​ (Fig.5). 5 ). Additionally, clitoroplasty is covered by 114 of 124 (92%) companies and labiaplasty is covered by 116 of 124 (95%) of companies. Despite high rates of vaginoplasty coverage, vulvoplasty is only covered by 26 of 124 (21%) insurance companies (Fig. ​ (Fig.6 6 ).

Vaginoplasty coverage.

Bottom surgery: MtF.

Bottom Surgery: Female to Male

Vaginectomy is covered by 110 of 124 (89%) of insurance companies; however vulvectomy is only covered by 47 of 124 (38%). Phalloplasty and metoidioplasty are covered by 118 of 124 (95%) and 115 of 124 (93%) of insurance companies, respectively (Fig. ​ (Fig.7). 7 ). Slightly more than half, 75 of 124 (60%) insurance companies covered penile prosthesis, and 7 (6%) insurance companies specifically excluded its coverage (Fig. ​ (Fig.8). 8 ). Scrotoplasty is covered by 104 of 124 (84%) of insurance companies; however, 7 (6%) insurance companies explicitly state its exclusion of coverage. One hundred two of 124 (82%) insurance companies covered testicular prosthesis, yet 10 of 124 (8%) of insurance companies excluded it. Although a total of 117 insurance companies covered urethroplasty, only 69 of these covered urethroplasty in both female-to-male (FtM) and male-to-female (MtF) gender affirmation surgery. The remaining 48 insurance companies only covered urethroplasty in FtM surgery (Fig. ​ (Fig.9 9 ).

Phalloplasty coverage.

Penile prosthesis coverage.

Bottom surgery: FtM.

Gender-affirming surgeries improve patient well-being, cosmesis, and sexual function. 15 Unfortunately, financial burden is a frequently reported barrier to gender-affirming care. 16 , 17 Transgender patients specifically encounter economic hardship with almost half earning less than $10,000 annually. 17 Not coincidentally, gender-affirming surgery can improve a patient’s income which manifests a public good. 18 Therefore, insurance coverage is critical for transgender patients seeking gender-affirming surgery. Despite these benefits, insurance coverage for gender-affirming surgery, while increasing, remains unreliable and vague. 19 Although we did not observe geographic trends that correlated to a political map, the northeast and midatlantic regions trended toward broader coverage.

Chest Masculinization

An overwhelming number of insurance companies covered FtM mastectomy. Breasts are a strong female-identifying characteristic, 20 and therefore these patients often try to conceal their breasts either by wearing loose clothing or by binding their breasts, which may lead to skin damage, intertriginous infections, and even cellulitis. 21 However, less than 20% of insurance companies covered NAC reconstruction, whereas another 25% implicitly exclude NAC reconstruction coverage (Fig. ​ (Fig.4). 4 ). This is most likely because MtF chest contouring is not done for oncologic reasons, and therefore the NAC does not necessarily need to be removed. However, the male nipple is located laterally and inferiorly as compared to the female nipple and not accounting for this by means of free nipple grafting may lead to unsatisfactory aesthetic results and may add to dysphoria. 22 , 23

Chest Feminization

Chest feminization was not deemed medically necessary by almost 75% of health insurers (Fig. ​ (Fig.4). 4 ). TF patients seek to solidify their feminine gender frequently through breast surgery. Although chest feminization significantly increases patient satisfaction, many insurance companies continue to consider breast augmentation equivalent to a cisgendered female desiring larger breasts and therefore consider it a cosmetic procedure. In fact, the current procedural terminology (CPT) code recognized by insurance companies is for bilateral augmentation mammoplasty with prosthetic implant: a traditional cosmetic code. 10 However, when performing these procedures on TFs, it is reconstructive and should be covered by insurance. Coverage for breast implants may be further complicated by the inherent risks of placing a foreign body into a patient, which may lead to infection, capsular contracture, breast implant-associated anaplastic large cell lymphoma, cosmetic deformity, and need for additional procedures. 24

Bottom Surgery

The majority of insurance companies covered “bottom” surgeries. More than 90% of companies covered penectomies (Fig. ​ (Fig.6). 6 ). This is most likely because most health-care professionals believe that genitalia is what defines an individual’s sex. 25 Moreover, if gender dysphoria is defined as discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth, 26 then bottom surgery can be considered a direct treatment. 17

Bottom Surgery: MtF

The associated procedures with penectomies for vaginal reconstruction, including clitoroplasty, labiaplasty, and vaginoplasty, were also covered by more than 90% of insurance companies (Fig. ​ (Fig.6). 6 ). This supports the idea that most professionals agree that the creation of the corresponding genitalia would inherently treat the dissociation between their gender identity and sex assigned at birth. Although a penectomy is the first step in constructing female genitalia, it is clear that most insurance companies believe that creating a functional vagina that can receive penetrative intercourse and shortening the urethra are important.

Interestingly, less than one-third of insurance companies covered a vulvoplasty, which is the creation of the external appearance of female genitalia without the creation of the vaginal canal (Fig. ​ (Fig.6). 6 ). This may be an option for patients who are older, have higher BMI, or have preexisting conditions such as prostatic radiation as the complication rate and risk profile is significantly lower than a vaginoplasty. Additionally, vulvoplasty was still associated with high levels of satisfaction. 27 It is unclear if insurance companies consider this procedure “cosmetic” and therefore justify not covering it.

Bottom Surgery: FtM

Similar to MtF bottom surgeries, the majority of FtM bottom surgeries were covered by insurance companies. Vaginectomy and related FtM bottom surgeries including phalloplasty and metoidioplasty were covered by more than 85% of companies (Fig. ​ (Fig.9). 9 ). Similar to penectomies, insurance companies agree that the removal of the genitals, ie, vaginectomy, can treat gender dysphoria. However, unlike MtF procedures, FtM procedures can also include procedures that increase function in addition to aesthetics such as penile prosthesis, which was covered by less than half of the insurance companies. Insurance companies may contend that phalloplasties without prosthesis already improve quality of life and sexual function 28 and therefore penile prosthesis is not necessary. However, penile prosthesis with or without inflation could further increase sexual satisfaction by providing penetrative intercourse. 29 , 30 Further studies are needed to delineate patient satisfaction with and without penile prosthesis.

Interestingly, more than 80% of companies cover a scrotoplasty and testicular prosthesis (Fig. ​ (Fig.9). 9 ). It is unclear why such a high proportion of insurance companies cover these nonfunctional procedures, but have chosen to forgo coverage of NAC reconstruction: similarly nonfunctional, but aesthetically native. The high rate of coverage of these procedures further demonstrates medical insurance companies possible opinion that genital surgery is a direct treatment for gender dysphoria, despite their lack of consistency regarding vulvoplasty. Urethroplasty is covered by more than 90% of insurance companies as it is necessary to lengthen the urethra when creating a neophallus to achieve normal micturition (Fig. ​ (Fig.9 9 ).

Criteria for Surgery

We encountered little consistency in which procedures insurance companies would cover, mirroring our own practice frustrations. The World Professional Association for Transgender Health provides standard-of-care guidelines and a list of surgical procedures that may be useful in treating MtF and FtM patients and is often utilized as a guide for insurance companies and health-care providers. 31 However, we found little uniformity in criteria for coverage for any gender-affirming surgery within or between states. At a minimum, documentation of persistent gender dysphoria by a qualified mental health professional and further criteria including capacity, age of majority, no other significant medical or mental health problems, hormone therapy, and real-life experience may should be obtained.

Future Directions

Although we were unable to deduce any geographic or insurance company trends to coverage, we believe this presents an opportunity for those performing gender-affirming surgeries to advocate for their patients. Surgeons will need to continue to communicate with one another, publish their results, and lobby the government as well as the insurance companies to expand coverage and increase transparency. Additionally, as the construct of “gender” continues to morph from binary to nonbinary and gender fluidity, gender-affirming surgeons must continue to understand their patients’ needs.

CONCLUSIONS

As the demand for gender-affirming surgery continues to increase, it is critical for both the patient and physician to understand how to navigate insurance coverage policies. Greater awareness and transparency will improve access to care for a traditionally marginalized group of society. Additionally, more research is needed to delineate best practices for gender-affirming surgeries and their correlated patient-reported outcome measures.

Published online 11 December 2019.

Presented at the American Society for Reconstructive Microsurgeons, Palm Desert, California, February 2019.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Gender-Affirming Benefits: Best Practices for Group Health Plans

• Gender-Affirming Benefits: Best Practices for Group Health P...

Our webinar , “ Gender-Affirming Benefits: Best Practices for Group Health Plans,” reviewed legal developments in the shifting landscape of transgender benefits and best practices that group health plans should keep in mind as they evaluate how to cover transgender care. Watch the recording here.  

I. INTRODUCTION

Federal legislative and regulatory activity related to employer-sponsored group health plans shows no signs of slowing, particularly with the issuance of interpretive guidance regarding the transparency and surprise-billing rules enacted by the Consolidated Appropriations Act, 2021. States also have been active, both in their regulation of licensed health-insurance carriers and by aggressively seeking ways to regulate self-funded arrangements at the margins. The latter trend has already manifested in laws governing reproductive health, which received significant attention following the US Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization . (For more information on the impact of the Dobbs decision, visit McDermott’s Post- Roe Resource Center .) Now, attention has also turned to whether − and to what extent − group health plans must cover gender-affirming medical or surgical treatments (gender-affirming care), especially regarding minors.

Group health plan sponsors encounter coverage of gender-affirming care differently, depending on whether they purchase insurance or self-fund their health benefits. Fully insured plans must follow applicable state mandates, while self-funded plans generally have more flexibility in plan design. However, employers will struggle with certain state laws related to travel for the purpose of gender-affirming care, irrespective of plan funding. The issues they encounter are similar to the questions concerning reproductive health that have followed the Dobbs decision.

The World Health Organization defines gender-affirming care (which incudes but is not limited to gender-reassignment surgery) to include a range of social, psychological, behavioral and medical interventions “designed to support and affirm an individual’s gender identity” when it conflicts with the gender they were assigned at birth. Interventions fall along a continuum, from counseling, to changes in social expression, to medications such as hormone therapy.

The World Professional Association for Transgender Healthcare, an influential standard-setting organization, publishes internationally accepted clinical guidelines for gender-affirming care, the most recent of which addresses for the first time the treatment of adolescents, providing that an inquiry into whether gender-affirming care is appropriate must be determined case by case, based on an assessment of emotional and cognitive maturity.

II. APPLICABLE LAWS

The ERISA Preemption Doctrine

The Employee Retirement Income Security Act (ERISA) bars the application of “any and all State laws insofar as they now or hereafter relate to any employee benefit plan … ” The term commonly used for this broad prohibition against state involvement in ERISA plans is “ERISA preemption” of state law. There are some exceptions to ERISA preemption of state law, primarily allowing states to enforce insurance, banking and securities laws of general application. Thus, for example, a state may not be able to regulate a benefit plan directly, but within limits it can regulate an insurance company that insures plan benefits, which in turn affects fully insured plans. Any state law requiring or barring coverage of gender-affirming care would likely be preempted for self-funded ERISA plans, although it may impact fully insured plans. However, state criminal laws of general application are not preempted.

Section 1557 of the Affordable Care Act

Section 1557 of the Affordable Care Act (ACA) prohibits discrimination on the basis of race, color, national origin, sex, age or disability in a health program or activity, any part of which receives federal financial assistance.  A 2022 proposed regulation issued by the US Department of Health and Human Services (HHS) would modify prior to make clear that discrimination based on gender identity is prohibited. This position is in accord with the Supreme Court’s ruling in Bostock v. Clayton County, Georgia , which held that the references to “sex” in Title VII of the Civil Rights Act include sexual orientation and gender identity. Where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the Americans with Disabilities Act.

The Mental Health Parity Act

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) generally requires that group health plans and group health insurance issuers ensure that the financial requirements and treatment limitations applicable to mental health/substance use disorder (MH/SUD) benefits are no more restrictive than those applicable to medical surgical (M/S) benefits ( e.g. , more restrictive lifetime or annual dollar limits, financial requirements or treatment limitations) and that there are no separate financial requirements or treatment limitations applicable to MH/SUD benefits.

Gender dysphoria is generally considered a mental-health condition; thus, MHPAEA might impose limits on cost-sharing for gender-affirming care to match the limits imposed on a plan’s M/S benefits.

State Laws Protecting Access to or Barring Gender-Affirming Care

States have increasingly passed laws to penalize parents aiding minors in accessing gender-affirming care, permitting individuals to file for damages against providers who violate such laws, limiting insurance coverage or payment for gender affirming services, or prohibiting the use of state funds for such services. Other states have established “shield” laws, which protect access to gender-affirming care. (For a survey of gender-affirming care state law, see KFF’s Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions .

The Health Insurance Portability and Accountability Act (HIPAA)

State laws penalizing or discouraging gender-affirming care may seek to gain access to health records of individuals receiving such care. This information is protected health information (PHI) under HIPAA. HIPAA permits, but does not require, covered entities and business associates to disclose PHI without individual authorization when such disclosure is required by law. Examples of such requirements include, but are not limited to, information requests in court-ordered warrants, subpoenas, or summons issued by a court or grand jury. States may attempt to leverage this “required by law” exception to PHI disclosures under HIPAA to impose sanctions or penalties. HHS issued a proposed rule that would bar this approach in the context of reproductive health, and it has also expressed the view in sub-regulatory guidance that this use does not meet the “required by law” definition.

III. APPROACHES TO COVERAGE OF GENDER-AFFIRMING CARE

Group health plan sponsors, third-party administrators and other health plan service providers must determine how best to navigate potentially conflicting and rapidly shifting laws, regulations, and changing cultural norms and clinical standards relating to gender-affirming care, especially in relation to minors:

• Fully insured plans must follow the terms of underlying group health insurance policies, which are required to follow applicable state law.
• Although self-funded plans have greater plan-design latitude, categorically denying access to gender-affirming care may violate Section 1557 of the ACA. This poses a challenge for  self-funded plans that cover individuals in multiple states, including those that have restricted or prohibited gender-affirming care. While ERISA should preempt state civil laws on the subject, the extent to which preemption extends to state criminal laws is unclear.
• Self-funded plans may implement medical travel benefit plans to supplement their coverage in states that restrict or prohibit gender-affirming care, similar to the increase in medical travel benefits post- Dobbs .
• Laws and regulations regarding gender-affirming care for minors are still shifting, although federal policy and current clinical standards appear to favor covering gender-affirming care for minors on a case-by-case basis where medically necessary.

Group health plan sponsors, third-party administrators and other health plan service providers should understand the costs of their plan design options and assess gender-affirming care coverage, especially in light of conflicting federal and state laws, increased litigation in several states ( e.g. , Texas ), regulatory guidance, and increased enforcement of ERISA fiduciary duties with respect to health and welfare plans. Please contact the authors or your regular McDermott lawyer if you have any questions regarding gender-affirming care coverage and the implications for your organization.

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Fresh Challenges To State Exclusions On Transgender Health Coverage

Keren Landman

Anna Lange, who works for the sheriff's office in Houston County, Ga., discovered that her health insurance plan excludes transgender services. She is seeking to challenge that policy. Audra Melton for NPR hide caption

Anna Lange, who works for the sheriff's office in Houston County, Ga., discovered that her health insurance plan excludes transgender services. She is seeking to challenge that policy.

When Sgt. Anna Lange moved with her young family from Columbus, Ga., to the state's more rural Houston County, her main priority was being able to stay near her son.

After five years of marriage — and many more years of internal turmoil — Lange had realized that despite being assigned male at birth, she'd felt female her entire life.

She had decided to undergo gender transition and knew it would eventually end her marriage. She also knew her soon-to-be ex-wife would want to move back home to Houston County, an hour and a half's drive from Columbus.

"I wasn't going to be that far from my son," Lange said. "It wasn't like I was thinking of, you know, the super-open community," she said with more than a hint of sarcasm.

Although she'd loved working at the police department in Columbus, she took a job with a national insurance company in Houston County, hoping for a more accepting, less conservative environment than law enforcement.

She found the corporate structure so stifling, she didn't even make it out of training. Within three months, she was once more wearing a badge and gun as a patrol officer at the Houston County Sheriff's Office. She's been there since 2006 and has been promoted twice.

That's why it stung so much when she learned late last fall that the county's employee health insurance plan wouldn't cover any of her transition-related surgery. Although federal law prohibits health insurance plans from discriminating against transgender individuals, the plan adopted by Houston County specifically excludes trans-related health care from coverage.

The exclusion came as a shock. After Lange was told by Anthem Blue Cross and Blue Shield that her insurance would cover gender-confirmation surgery — and had her New York City-based surgeon confirm it — she traveled to Manhattan last November for a consultation. Shortly after she returned, she received a letter informing her that her employer's plan would not, in fact, cover her procedure.

She then contacted Transcend Legal , a New York City-based nonprofit organization, and is now represented by Noah Lewis, the organization's executive director. After the Houston County Board of Commissioners didn't respond to a Jan. 16 letter from Lewis requesting that the board remove the exclusion, Lange and Lewis made their request in person during a meeting of the board on Feb. 19. Their request was denied; Lange now plans to sue Houston County in district court.

"The board is not considering any changes to the law at this time," said Houston County Attorney Tom Hall in response to Lewis' request, adding that he'd directed the commissioners themselves not to comment given the possibility of future litigation.

Lange's is one of two Georgia cases challenging transgender exclusions in employee health plans. Skyler Jay, a trans man who appeared on an episode of the popular Netflix series Queer Eye, is currently suing his employer, the University of Georgia, in a lawsuit challenging its health plan's similar exclusion. Jay is also represented by Lewis.

Within the past six months, transgender government employees in Wisconsin and Iowa have won similar cases and were awarded a total of $900,000 by juries. "It's definitely going to be more expensive for them to defend it in court," said Lewis of the Georgia state employee policy exclusion adopted by Houston County. "They can avoid that result by just voluntarily removing the exclusion."

Lange grills burgers for friends Mike Balducci and Heather Buchanon-Romano at home. Audra Melton for NPR hide caption

Lange grills burgers for friends Mike Balducci and Heather Buchanon-Romano at home.

Gender dysphoria is the American Psychiatric Association's name for the distress caused by discordance between one's assigned gender at birth and the gender they identify as. Multiple major medical societies, including the American Medical Association, have endorsed the medical necessity of treating gender dysphoria with "gender-affirming care," which may include hormones, surgeries or neither.

As the medical community has shifted from viewing gender-affirming care as cosmetic to understanding it as medically necessary, many insurers , including Medicare and many Medicaid programs, have likewise shifted to covering both surgical and nonsurgical trans-related health care.

Alongside them, the law has evolved to forbid discrimination against trans Americans. Section 1557 of the Affordable Care Act prohibits entities that receive federal funding for health coverage from denying coverage based on sex, gender identity and sex stereotyping. And the Americans with Disabilities Act and Title VII of the Civil Rights Act have also been broadly interpreted by courts to protect transgender individuals from discrimination.

Despite both medical and legal consensus, 30 states allow health insurance plans to exclude transgender-related health care from coverage. Most of these states are in the South, Midwest and Great Plains, and most have a relatively high proportion of rural residents.

Shots - Health News

Telemedicine takes transgender care beyond the city.

Shortages in rural health care workforces, low rates of insurance coverage, and long distances from health care facilities have made it challenging for many Americans outside urban areas to find high-quality, affordable health care. Transgender people in rural areas often face particularly acute challenges when it comes to finding competent providers and obtaining health insurance.

Douglas Knutson , a psychologist who studies health and resiliency among LGBTQ populations at Southern Illinois University, said rural trans populations often have high rates of anxiety, depression and suicidality.

That doesn't mean they're all eager to flee. Connections to home, land, language and heritage are powerful, said Knutson: "People have specific reasons for living in rural areas."

Lange certainly does. Although she would love to be in a more welcoming environment, she remains in Houston County because of her son. "I'm a good parent," she said. "I love him too much and I'm not going anywhere."

She also has no intention of leaving law enforcement. If she did, she'd be leaving behind a retirement plan. Plus, she was recently promoted to sergeant in criminal investigations, and she finds it deeply satisfying to help people and solve crimes.

Lange enjoys her job working in criminal investigations and was recently promoted to sergeant. Audra Melton for NPR hide caption

Lange enjoys her job working in criminal investigations and was recently promoted to sergeant.

When trans people challenge employers' policies in stereotypically conservative settings, they often encounter resistance, said Knutson. "There's the feeling, 'Why does the battleground have to be here? ' " he said.

Although it might seem easier to switch employers than fight an unwelcoming institution for equal treatment, he said, job searches are often expensive and require a financial cushion that many people – especially public servants — don't have. Additionally, he said, for many, "there's a commitment to vocation"; like Lange, many people simply like their jobs.

Studies assessing the financial implications of covering transgender-related health care have demonstrated that the cost of care to insurers, including hormones and surgical therapies, is relatively small. Hormone therapy, which around 75 percent of transgender people seek, starts at $20 to $80 a month and is usually taken for the duration of a person's life after transition. Surgeries range widely in type and cost anywhere from $5,000 to $50,000 each, although many trans people don't desire surgical treatment.

Perhaps of even greater significance is the finding that providing this coverage is cost-effective . Untreated gender dysphoria leads to high rates of adverse — and expensive – outcomes, including HIV infection, depression, suicidality and drug abuse. The cost of accepting these outcomes outweighs the cost of treating their cause.

Still, state and local governments have pursued costly court battles to maintain these exclusions. "Officials look at this as a political issue instead of as the medical and equal employment issue that it should be," said Harper Jean Tobin, policy director of the National Center for Transgender Equality.

Lange hangs out at home with friends Balducci and Buchanon-Romano, who came over for a cookout. Audra Melton for NPR hide caption

Lange hangs out at home with friends Balducci and Buchanon-Romano, who came over for a cookout.

Although there is no consensus on transgender acceptance, according to the Pew Research Center, 39 percent of Americans surveyed in 2017 said society hasn't gone far enough in accepting transgender people. Thirty-two percent said society has gone too far and 27 percent said society's response has been about right.

Respondents were divided along partisan lines, with 60 percent of Democrats saying society hasn't done enough compared with 12 percent of Republicans saying that.

Nevertheless, said Tobin, persistent transgender stigma in certain circles causes some lawmakers to assume that inclusive policies will be unpopular in their communities.

"Increasingly," she said, "I think they'd be surprised."

Keren Landman, a practicing physician and writer based in Atlanta, covers topics in medicine and public health.

• transgender discrimination
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Obamacare Now Pays for Gender Reassignment

The nation’s health law opens the door for transgender people to gain coverage for gender reassignment surgeries they previously could not afford.

KFF Health News

BSIP/UIG Via Getty

By Anna Gorman, Kaiser Health News

Devin Payne had gone years without health insurance—having little need and not much money to pay for it.

Then Payne, who had a wife and four children, realized she could no longer live as a man.

In her early 40s, she changed her name, began wearing long skirts and grew out her sandy blond hair. And she started taking female hormones, which caused her breasts to develop and the muscle mass on her 6-foot one-inch frame to shrink.

The next step was gender reassignment surgery. For that, Payne, who is now 44, said she needed health coverage. “It is not a simple, easy, magical surgery,” said Payne, a photographer who lives in Palm Springs. “Trying to do this without insurance is a big risk. Things can go wrong … not having the money to pay for it would be awful.”

Payne learned in the fall that she might qualify for subsidies through the state’s new insurance marketplace, Covered California, because her income fell under the limit of $46,000 a year. She eagerly signed up in March for a Blue Shield plan for about $230 a month, and began making preparations for the surgery that would change her life.

A ‘Pre-existing Condition’

Among the less-talked-about implications of the Affordable Care Act is the relief it is providing to many transgender people, many of whom are low-income and who have struggled to obtain health coverage.

Getting jobs that offer insurance often has been difficult for transgender people and the cost of purchasing plans on the private market can be prohibitive. Some have been denied policies altogether after being diagnosed with “gender identity disorder,” often considered a pre-existing condition.

Without insurance, many people were unable to afford the hormones, surgeries and counseling needed to complete their transition. Nor would they have been covered in the event of surgical complications, which can include infections.

“We are still dependent on insurance and the medical community for us to be able to live authentically,” said Aydin Kennedy, coordinator of the transgender health program at St. John’s Well Child and Family Center in Los Angeles.

Now, federal law prohibits health insurance companies from discriminating against transgender people, and it bars insurers from denying coverage based on pre-existing conditions. That makes it possible for more transgender people to purchase private plans. And in states that expanded their Medicaid programs, those with low incomes may get free coverage.

The federal anti-discrimination regulations have yet to be written, but California insurance regulators have said that companies must treat transgender patients the same as other patients. For example, if plans cover hormones for post-menopausal women, they must also cover them for transgender women. Medicare, the program for the elderly and disabled, lifted its ban on covering sex reassignment surgery earlier this year.

“The law and policy are on a transgender person’s side for the first time,” said Anand Kalra, program administrator at the Oakland-based Transgender Law Center.

Conservative and religious groups oppose using government funds for transgender surgeries, questioning whether they are medically necessary, ethical or effective.

“We would oppose sex change operations all together,” said Peter Sprigg, senior fellow at the Family Research Council in Washington, D.C. “But as a public policy issue, we would feel particularly strongly that taxpayers shouldn’t be asked to pay for it.”

A few obstacles remain for transgender patients. Not many doctors specialize in transgender care. And while the law opens the door to insurance coverage, insurers can set conditions and don’t automatically approve payment.

“Insurance companies are making up their own rules as they go along,” said Kalra of the Transgender Law Center.

‘Feeling Complete’

Growing up in Kansas, Payne remembers trying on her mother’s clothes and dressing as a girl every year for Halloween. She dreamt of having another life after this one, as a girl. But Payne said she mostly suppressed her feelings and tried to live up to the expectations for a male.

“I put it out of my head,” she said.

She married a woman she met at work and they had four children, now ages 7 to 22. But she never felt comfortable in the traditional role of father and provider.

“I was just horrible at it because it wasn’t who I was,” she said. So Payne became the primary caretaker, playing the “mommy role” as she worked from home doing software development for pharmaceutical companies.

She felt increasingly anxious, and in late 2012, a therapist helped her to realize that she was meant to live as a woman. Payne said her entire outlook on life changed when she started taking female hormones.

“All my anxiety and all of the bad things that I felt inside were just completely washed away,” she said.

Payne told her wife, who was upset. She told Payne: I married a man, not a woman—but she also admitted that she wasn’t entirely surprised. With mixed feelings, Payne’s wife stayed in the marriage, and the family moved from Kansas to California, in part so Payne could be more comfortable living as a transgender woman. They rented a small house in a middle-class neighborhood on the outskirts of Palm Springs and sent their children to the public school.

Late last year, Payne’s wife, who had battled alcoholism for years, died of liver disease.

Payne said the children worried how people would react to her transition, but she said they soon realized it wasn’t as big of a deal as they had feared. When Payne brought birthday cupcakes to her 7-year-old daughter’s classroom last year, the children asked if she was a girl or a boy. After Payne told them she was a girl, “They just wanted their cupcakes.”

In California, Payne found transgender friends and became an advocate within the community. “You find out that there is a whole world of people out there,” said Payne, who wears little makeup or jewelry and calls herself a “T-shirt and skirt kind of a girl.”

Payne was ready for the surgery. She started calling the approved providers in Blue Shield’s preferred provider network. But they were booked up for months, or years. She felt she couldn’t wait—she wanted to do the surgery while her children were on summer vacation so they could go to her parents’ house in Kansas as she recovered. She found an out-of-network doctor in Palo Alto who would do the surgery about a month later.

“The time was right and I wanted to get it done,” she said.

Her Blue Shield policy said that gender reassignment surgery—which uses existing tissue to construct female genitalia—could be covered if patients met certain guidelines. For example, she had to be diagnosed with gender identity disorder and have an “expressed desire” to live as a member of the opposite sex.

By the scheduled date, Blue Shield had authorized the operation but hadn’t determined exactly how much it would pay for an out-of-network provider. Payne got a cashier’s check for nearly all her savings, $27,000, to pay the doctor, hoping her insurance plan would reimburse most of it. She worried about all the other expenses too, including the hospital stay, lab work and anesthesiology services.

The day of the surgery at Sequoia Hospital in Redwood City, Payne said, she remembers being wheeled into the operating room and feeling very calm. When she woke up, with oxygen still attached and wearing her hospital gown, a friend told her that the surgery had gone well, without any immediate complications.

Later that day, she had just enough energy to type a few words on her Facebook profile: “Feeling complete.”

Grateful for Coverage

On a boiling afternoon in early July, about six weeks after the operation, Payne and her friends sat outside on the patio next to a pool. Misters sprayed above them, and Payne’s cat and two dogs wandered beneath their feet.

Payne said she did suffer a few complications later—some swelling and an infection—but she recovered with medication and support from friends.

She is still trying to figure out how much she has to pay out-of-pocket for the surgery and hospital stay—and how much of that her insurance plan will reimburse. Payne said she believes the lab work, pathology, anesthesiology services and follow-up doctor’s visits were all covered. But recently she got a statement saying she was on the hook for $17,000 of the total cost of the surgery.

Payne believes that the government and insurance companies should help cover such operations. The population of transgender patients who want surgery is small, and she said they are less likely to suffer mental health problems once they have it.

Payne said she will be grateful for whatever coverage she can receive. Her friend Jenny Taylor, who is staying with her during the recovery, has had an even harder time with her insurance.

An outgoing transgender woman who laughs easily and wears colorful outfits and painted nails, Taylor purchased a policy through the insurance exchange in Tennessee. But she soon learned her doctor wasn’t in the plan’s network and that she had to pay cash for everything, with no hope of reimbursement.

“My insurance, even though I finally got it, was useless,” she said.

The policy also wouldn’t pay for her hormones. A pharmacist told her the medication was for women—and her identification still listed her as a male. Taylor recently moved to Palm Springs and said she now plans to apply for insurance through Covered California.

“I was really frustrated,” she said. “We’re just trying to be ourselves, at the end of the day.”

Payne agreed, saying she finally feels like her body matches what she knows to be true—that she is a woman. “It seems more natural,” she said.

Kaiser Health News is an editorially independent program of the Kaiser Family Foundation .

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Critics blast NY’s proposed ‘Equal Rights Amendment’ they say strips parents of their rights over kids’ transgender surgery

C ritics are raging against New York’s proposed “Equal Rights Amendment,” claiming the Nov. 5 ballot measure could curb the rights of parents when it comes to allowing minors to undergo gender reassignment surgery.

New York voters don’t yet know much about the particulars of the ERA, which could codify abortion rights in the state constitution — advanced by Gov. Kathy Hochul and Democrats who run the state legislature.

The broad language of the proposal — dubbed Proposition One — has sparked a fierce debate over what could happen if it gets passed, with opponents claiming it’ll lead to kids possibly being able to get serious medical procedures without their parents’ OK and allow transgender females to compete in women’s sports.

“Proposition One would strip the legal rights of parents with school age children to know about crucially important things happening with their kids, including controversial gender transformation procedures” the Coalition to Protect Kids said in a statement.

“Schools would be required to permit biological males to compete on girls’ sports teams if voters approve this amendment.”

The proposal asks voters whether they support or oppose adding language to the constitution that people cannot be denied rights based on their “ethnicity, national origin, age, and disability” or “sex, including sexual orientation, gender identity, gender expression, pregnancy, pregnancy outcomes, and reproductive healthcare and autonomy.”

Coalition to Protect Kids NY Executive Director Greg Garvey said the ERA should instead be called “The Parent Replacement Act,” because it “opens the floodgates” for the government wielding more authority over children than their parents on some of the most important decisions of their lives.

“Any decent lawyer will take one look at the Proposition One language and say, ‘you’ve got to be kidding me,’” said Garvey. 

“This ballot initiative is written so broadly and so poorly that it could cause irreparable harm to children and families,” he added.

“Governor Hochul and her woke Albany colleagues have a lot of explaining to do.”

The group’s website includes a video saying a school could help a 7-year-old girl “try life as a boy” and help her transition without her mother “ever knowing” under the amendment, adding, “Do you think that’s OK?”

The Coalition to Protect Kids also claims that laws that determine the legal age to purchase and/or consume alcohol or cannabis, elder abuse and statutory rape could all be weakened because they might arguably “‘discriminate’ based on age.”

The group New Yorkers for Equal Rights denied that the amendment strips parents of their rights.

“These claims simply aren’t true. This amendment is about making sure our fundamental rights and reproductive freedoms are protected and never at risk of becoming a political football,” said Sasha Ahuja, campaign director of New Yorkers for Equal Rights.

The pro-amendment group, in a statement Monday, also said, “If passed, the NY ERA would provide the most comprehensive list of protected categories of any state in the country — safeguarding New Yorkers’ rights, as well as serving as a model for other states.”

Members of the pro-ERA group include 1199SEIU United Healthcare Workers East, Planned Parenthood, North Star, New York Immigration Coalition, the Civil Liberties Union, NEW Pride Agenda, National Institute for Reproductive Health Action Fund, NAACP, Make the Road New York and New York State United Teachers.

New York already has among the strongest abortion laws in the country and long been a pro-choice, with critics questioning whether such a controversial issue belongs in the constitution.

“It’s an ‘anything goes’ amendment,” said state Conservative Party chairman Gerard Kassar, whose party will campaign against the ERA.

He also said Democrats are looking to “change the conversation” away from problems they own — such as the migrant crisis and crime.

A lawsuit has been filed in Livingston County Supreme Court claiming that the legislature approved the proposed amendment going to the voters before getting a legal opinion from state Attorney General Letitia James’ Office.

There’s also been a recent public backlash in New York against permitting trans females from competing in women’s sports, leading to a controversial ban in some sporting venues in Nassau County.

Even one of the world’s most famous transgender females — Caitlyn Jenner — the former 1976 Olympic decathlon champion as Bruce Jenner — is opposed.

Additional reporting by Vaughn Golden

She's running for U.S. Senate and is trying to ban gender-affirming care for minors in RI

PROVIDENCE – For Republican state Rep. Patricia Morgan , gender-affirming surgery or treatment for minors, and the participation of transgender athletes in school sports, are issues on which to mount a U.S. Senate campaign.

In an email recently sent by her campaign, Morgan, R-West Warwick, flagged a hearing taking place Tuesday on her legislation to ban – and prohibit the use of public funds for – "gender reassignment" treatments for minors. It would also require minors currently taking "puberty-blocking drugs or cross-sex hormones" to stop doing so by Jan. 1, 2025.

Morgan, who hopes to replace incumbent U.S. Sen. Sheldon Whitehouse, wrote in her email: "Activist educators and health care workers, driven more by ideology than by genuine concern for well-being, are targeting our children."

Rather than offering "proven therapeutic interventions" to children struggling with mental health, their self-image and their family situations, Morgan argues that "ideologues offer a dangerous and deceitful promise: that all their problems can simply be medicated or surgically cut away."

What do the bills do?

The West Warwick legislator and two of her House Republican colleagues – Reps. Brian Rea and Robert Quattrocchi – have dubbed their bill, H7884, the "Rhode Island's Children Deserve Help Not Harm Act ." It's one of two gender-related bills they sponsor that will be considered by House committees this week.

The first bill:

• Bans any "gender-transition procedures" and hormone therapies on those under the age of 18.
• Opens any doctor who performs such procedures to civil suits and discipline by the state's medical licensing board.

The second bill, called the " The Fairness in Women's Sports Act" (H7727) , will be heard Wednesday in the House Education Committee and would:

• Ban "students of the male sex" from women's or girls' sports.
• In the event of a dispute, require a doctor's note attesting to the student's sex based on the "student's internal and external reproductive anatomy," hormone levels and genetic makeup.

Why is Morgan sponsoring the bills?

First up in the House on Tuesday is a hearing by the House Health & Human Services Committee on the gender-transition bill that has already drawn a heavy stream of comments for and against the legislation.

In an interview Tuesday, Morgan told The Journal that about two dozen parents have told her they believe their children – or others they've heard about – are being "manipulated" into seeking gender-affirming treatments.

She cited a pending malpractice lawsuit against the Thundermist Health Clinic by a former patient who alleges she was in "unstable psychiatric condition," with eight distinct personalities, when she sought and received "transgender affirming treatment" from agenda-pushing doctors at the clinic.

But despite sending an email blast from her campaign account on the bills, Morgan says the issue is not central to her platform.

"No, it's not going to be the thing that I base my run for the U.S. Senate on," Morgan said. "But I do still think that it's a very important issue that we must tackle to protect children."

"Parents are being manipulated, emotionally blackmailed into agreeing to give their children puberty-blockers by this statement: 'Do you want a dead child or a child with a different gender?'" she continued.

More: State Republican lawmaker Patricia Morgan is quietly running for the U.S. Senate

Testimony in favor of the bill

• "Please pass this bill," wrote David and Theresa Casale of Lincoln. "What is being done to this generation of children is a disgrace. Evil is only way to describe it."
• "This bill is not anti-trans; it's pro-child. It's about recognizing that children cannot, and do not, have the capacity to give informed consent to life-altering medical procedures. It's about protecting them until they are of an age where they can make these decisions with a full understanding of the consequences," wrote Kimberly Trow of Coventry.
• "Children do not have the mental capacity, especially when they are in crisis, depressed, suicidal or just angry at their parents or the world, to make the kind of alterations to their bodies that this bill would prevent. Allow them to make these crucial decisions as adults," echoed Laura Rom of Charlestown.

Testimony against the bill

Most, though not all, who opposed the bill acknowledged a personal connection to the population it would affect.

• "My name is Eliza and I'm a cisgender, queer freshman in high school with many trans and genderqueer friends. Do not let H7884 pass. Many people close to me have not been able to access gender-affirming care, and for those who have had access to it, it has improved their mental health tremendously. If anything, we need more access to this life-saving care. Yes, life-saving. I have been extremely close to losing multiple transgender friends to suicide after their depression and dysphoria fed off each other," the teen wrote.
• Writing as the "proud parent of a bright and beautiful transgender teen, Amber Ward, of Bristol, urged "swift and decisive action" to dispense with this "hateful and deeply harmful anti-transgender legislation." "I appeal to your decency and your humanity," she wrote the legislators. "It is well and credibly documented that anti-LGBTQ+ laws and policies adversely impact the mental health of youth."
• And finally, Alice Kasumi Ellis, of Woonsocket, wrote as "someone who is a transgender woman and was prescribed Estradiol(Estrogen) and Spironolactone, an anti-androgen, at the age of 15 in conjunction with common medical practices for the treatment of Gender Dysphoria." "In fact I would most likely not be alive today without receiving such treatment at that time in my life," she wrote. "What contributes to struggles with my mental health are not [Hormone Replacement Therapy] or Puberty Blockers, but the exact societal stigma and bigoted language in this bill and others of its ilk that makes me feel alienated from society and afraid for my safety due to the constant harassment and violence I have personally faced, along with that of my community."