Health insurance companies can no longer use pre-existing conditions as a reason to deny you coverage or charge you more. For transgender people, this means that having a diagnosis of "gender identity disorder" in your health record or having previously gotten healthcare related to gender transition can no longer be used as a reason to refuse to sell you a health insurance plan or to charge you more for coverage.
With that barrier removed, there are still ongoing questions about what transition-related and gender-specific care you can expect your insurance plan to cover. The ACA prohibits discrimination based on gender identity, so we expect that health plans offered through the state marketplaces will cover some transition-related care, as long as those kinds of services are covered for other people on that plan. If your plan denies you coverage for a service or procedure that is covered for other people on your plan, you have experienced discrimination. You can appeal the denial with the insurance company, and if the company denies the appeal, you have the right to ask for an external review of the plan's decision. You can also file a complaint with your state's insurance commissioner or with the Office for Civil Rights at the U.S. Department of Health and Human Services – click here for more information about filing a complaint. You can also share your experiences and concerns via the HealthCare.gov help hotline at 1-800-318-2596.
Types of care likely to be covered include mental health counseling, hormone replacement therapy, and organ removal (orchiectomy, hysterectomy/oophorectomy). Gender confirmation surgeries and procedures such as electrolysis may or may not be covered, depending on the plan.
You also have the right to free gender-specific preventive care (such as mammograms, pap smears, and prostate exams) that your provider recommends as medically appropriate. Plans cannot limit these services based on your sex assigned at birth, gender identity, or the gender listed or otherwise recorded by the plan or insurance company. If you encounter any challenges in accessing these services, you can appeal the denial with the insurance company or file a complaint.
Unfortunately, assisters may not know the specifics of which benefits are covered in which plans, but you can ask for help in finding this information. The best way to find out for sure what will and won’t be covered is to look up the plans that you are eligible for and ask the insurer(s) for the "Evidence of Coverage" or "Certificate of Coverage" (the full list of covered benefits) for that plan. If your plan denies you coverage for a service or procedure that is covered for other people on your plan, you have experienced discrimination. You can appeal the denial with the insurance company, and if the company denies the appeal, you have the right to ask for an external review of the plan’s decision. If you experience any form of discrimination, have a transgender exclusion in your plan, or if your coverage is denied, you should contact a legal organization for help. You can also file a complaint with your state insurance department – visit this page to connect with your state insurance regulators. It can be frustrating to file a complaint, but this is especially important given the lack of clarity about what must be covered. You can also share your experiences and concerns via the HealthCare.gov help hotline at 1-800-318-2596.
As you look at the "Certificate of Coverage" or "Evidence of Coverage," the following questions will be useful to consider in comparing plans and selecting the plan that is best for you. If coverage for care related to gender transition is part of what is important for you, keep a close eye out for the "exclusions" and "limitations" on coverage. Exclusions for things like "services related to sex change" or "sex reassignment surgery" should no longer be appearing in plans sold through the marketplaces. If you see this type of exclusion in your policy, please contact a legal organization or file a complaint with your state insurance department. For more information, visit HealthCare.gov's page on transgender health.
The enrollment process may include completing forms where gender boxes do not correspond to how you identify. In order to minimize confusion during enrollment, we suggest filling these forms out according to the sex you believe is on file with the Social Security Administration, or according to the sex that's on the majority of your legal identification documents such as a driver's license or passport. If you have questions about how to change the sex on file with the Social Security Administration, the National Center for Transgender Equality has created a guide for trans people and the SSA.
- Is hormone therapy covered for individuals on this plan? NOTE: If hormone therapy is covered for anyone using the specific plan you are evaluating, it should be covered for transgender individuals. The ACA makes it illegal for plans to discriminate by offering some people services that they deny to others.
- Is there a co-pay for hormone therapy? What is the co-pay amount?
- Is there a limit on hormones or hormone injections? What is the limit?
- Is there a network of trans-friendly doctors and/or doctors who have training working with or currently serve trans clients?
- Is my current healthcare provider covered by the plan?
- If you don't have a current healthcare provider, but would like to find a trans-friendly provider, check out GLMA: Healthcare Providers Advancing LGBT Equality. They keep a list of self-identified providers with experience working with the LGBT community. RAD Remedy is also available as a resource. Once you identify a provider on the GLMA or Rad Remedy list, you can ask which plans work with that provider.
- Are there local doctors/doctors within 30 miles who can provide services to transgender individuals?
- If not, will the plan provide travel reimbursements?
Questions in red are ones that assisters may not be able to answer because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider.« Previous Section: HIV/AIDSNext Section: Reporting Discrimination »