What does Biden's student loan forgiveness mean for you? Learn more about the three-part plan here.

What to Know About Transgender Health Insurance—as You Transition

A medical transition is expensive. Here’s what you need to know to prepare.

Written by Lindsey Danis / August 29, 2022

Quick Bites

  • About half the U.S. blocks trans-affirming health care coverage, but changes are afoot in Washington, D.C.
  • "Medical necessity," insurer type and location are three key factors determining whether insurance covers transitioning.
  • Requesting transition care policy details from prospective insurers can help you find the best coverage possible.

Health care is a human right, yet transgender and nonbinary individuals often experience barriers to accessing and paying for health care coverage. The landscape of trans health care is complex and evolving, and the laws are different for private insurers than for state Medicaid programs.

If you live in a state that protects transgender patients, how do you find out what care is covered, and how do you prove that it’s medically necessary? And in less trans-friendly states, can you afford to pay out of pocket for treatment that's covered elsewhere?

Understanding your coverage options and the range of expected costs for a given procedure can help you budget and plan for care.

Inside this article

  1. How health care coverage varies
  2. Whether transitioning is covered
  3. Finding trans-inclusive coverage
  4. Frequently asked questions

Does health care coverage vary based on biological sex?

Under the Affordable Care Act (ACA), health insurers must not set higher premiums based on sex.[1]

While the ACA bans sex-based discrimination in theory, it’s a often different story in practice when it comes to trans health care.

States control their health insurance marketplaces and set their own laws regarding care. Currently, 27 states block trans-affirming medical care. Patients in those states are denied coverage that trans individuals in accepting states can receive.

Alert

To better protect trans and nonbinary individuals, the current administration in the White House is considering expanding the sex-based discrimination clause to explicitly cover gender identity and sexual orientation, too. If this change is made law, health insurers would have 60 days after passage to cover affirming care.[2]

Is transition covered by health insurance?

The answer to this question depends on three variables, including whether…

  • Your care is deemed medically necessary

  • You have private insurance or Medicaid

  • Where you live

Within health care, medical necessity means treatment is within acceptable standards of care, effective for treating the patient’s condition and not done for convenience.[5]

Let’s unpack the term with an example. Consider a trans patient who wants a facial feminization treatment. A letter of medical necessity can make the case that the procedure treats gender dysphoria and the insurer will approve the claim. Conversely, the insurer could argue the surgery is cosmetic, not medically necessary and deny coverage.

Laws are clearer regarding procedures that cisgender and transgender patients undergo. If health insurance companies cover a procedure for cis patients, they are prohibited from excluding the same care for trans patients. Take reconstructive breast surgery. It’s covered after a mastectomy, so insurers also have to cover gender-affirming reconstructive surgery [6].

Olivia Hunt, a policy director for the National Center for Transgender Equality, points out the financial burden obtaining a medical necessity letter can place on trans people. "If a plan does not include coverage for mental and behavioral health, that can become an extra out of pocket cost that falls to the insured," says Hunt.

While medical necessity and insurer type is critical in determining coverage, so is your location. Consider the following examples [3-4]:

  • Arizona, Alabama and Arkansas limit gender-affirming care for youth.

  • Texas is attempting to pass a law that would criminalize gender-affirming care for youth.

  • Florida passed legislation in 2022 excluding or limiting Medicaid coverage for medically necessary transition-related care. This means trans Floridians with private insurance can have prescription hormones covered while those with Medicaid are turned down.

Shopping for trans-inclusive health insurance

If you're buying health insurance via the federal government’s Marketplace, HealthCare.gov notes you have to use the name on your Social Security card and the sex on your legal documents. Assuming you've already updated your gender with Social Security, you're good to go. 

If you haven't yet changed your gender marker, either delay purchasing health insurance or apply for insurance with the gender that matches your Social Security documentation. 

Your Social Security card doesn't list your gender, but the Social Security Administration does track gender markers. If the insurance company discovers a mismatch in the records, they could refuse to cover services. Bottom line: Avoid an administrative headache by making sure all records match. 

Now, what if you have insurance while undergoing a transition and want to change a gender marker? Do you just call them up and explain it? If you buy your plan on the Marketplace, you can log in and update your information with a few clicks. If that doesn't work, there's a call center to update documentation.[7]

How Much Is Health Insurance?

How Much Is Health Insurance?

Health insurance can cost thousands a year, but your total costs are dependent on the plan you choose and how much care you need.

Find out more

Advice on buying health insurance when you’re trans

"There's really no substitute for doing your research,” says Hunt. “Every insurance plan will be different—even two plans from the same provider might have wildly different requirements and cover different treatments and procedures.”

  • To learn about coverage, contact insurance companies and request a copy of their transition care policy.

  • If you already have a trusted healthcare provider, check if they're in-network before switching insurance plans, Hunt says. For those without a go-to provider for gender-affirming care, Hunt recommends taking the time to confirm that a plan provides access to eligible providers who are accepting new patients. 

  • Hormone replacement therapy drugs are usually covered by insurance, Hunt says. However, copays can vary. She recommends double-checking drug copays or out-of-pocket costs before selecting an insurance plan.

Frequently asked questions

How much does transgender health care cost?

The Philadelphia Center for Transgender Surgery maintains a price list for affirming procedures that can help individuals estimate the potential out-of-pocket costs for care. Feminization surgery can cost anywhere from $3,000 to $40,000 depending on the desired procedures. Top surgery can cost $10,000. Hormone replacement therapy can cost $1,500.[8] The National Center for Transgender Equality recommends patients apply for preauthorization for transition-related care. If the preauthorization is denied, patients can appeal the denial with assistance from an attorney.

Does insurance cover hormone replacement therapy?
How much does hormone replacement therapy cost?
How can I tell what procedures are covered by my insurer?
Article Sources
  1. “Women’s Health Insurance Coverage,” Kaiser Family Foundation, Nov. 8, 2021, https://www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage.
  2. Antonita Madonna, “Proposal seeks to address health coverage barriers for transgender community, impact uncertain,” Thompson Reuters, Jan. 18 2022, https://www.thomsonreuters.com/en-us/posts/investigation-fraud-and-risk/transgender-health-coverage/.
  3. “Protecting Healthcare for Transgender Floridians,” Lambda Legal, https://www.lambdalegal.org/protecting-healthcare-for-trans-floridians.
  4. “Healthcare Laws and Policies,” Movement Advancement Project, https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies.
  5. “WPATH Policy Statements, Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A.” World Professional Association for Transgender Health, Dec. 21, 2016, https://www.wpath.org/newsroom/medical-necessity-statement.
  6. “Know Your Rights: Health Care,” National Center for Transgender Equality, Sep. 2021, https://transequality.org/know-your-rights/health-care.
  7. “Transgender Health Care,” HealthCare.gov, https://www.healthcare.gov/transgender-health-care/.
  8. Billie Simmons, “The Hidden Costs of Transitioning,” Daylight, https://www.joindaylight.com/magazine/the-hidden-costs-of-transitioning.

About the Author

Lindsey Danis

Lindsey Danis

Lindsey Danis is a writer covering food, travel and personal finance. She's written about personal finance for Business Insider, NextAdvisor, The Penny Hoarder, and elsewhere.

Full bio

Related Content