For many years, gender transition-related surgeries and medical care were rarely, if ever, covered by insurance. Despite the fact that gender-affirming surgeries are associated with positive health benefits, such procedures were long unfairly deemed cosmetic. Fortunately, times have changed.
Today, many transgender surgeries are covered partially or entirely by insurance – including Medicare and Medicaid. There are more legal protections than ever before ensuring transgender patients have access to the care they deserve. Below, we will provide a brief overview of getting insurance coverage for gender-affirming procedures.
Your Basic Legal Rights
Understanding your rights as a patient gives you foundational knowledge that helps you apply for insurance coverage. Any healthcare plan excluding all gender transition-related care is illegal, first and foremost, but there are some other basic rules you should understand.
Healthcare plans legally cannot:
- Have a categorical exclusion of specific transition-related procedures as this is considered discrimination. (For example, your healthcare plan cannot exclude all forms of female feminization surgery.)
- Place discriminatory limits on coverage for transition-related care (For example, a plan that offers breast reconstruction as part of cancer treatment cannot deny breast reconstruction to treat gender dysphoria.)
- Refuse to enroll you in a plan, cancel your coverage, or charge you a higher rate because you are transgender
- Deny coverage for care typically associated with one gender (For example, if a transgender man needs a PAP smear, an insurance company cannot deny this procedure because he is listed as male on medical records)
While these rules provide you with a great degree of legal protection, insurance companies unfortunately sometimes attempt to circumvent these regulations. This is why understanding your legal rights going into filing your claim is vital.
Transgender Surgery Cost: Learn What Your Plan Covers
Even with modern legal protections, not every insurance plan covers every procedure. Refer to your health plan’s handbook and medical policy listing to review their coverage for transgender-specific care. This should give you a rough idea of how much of the cost your insurance will cover and what you can expect to pay out of pocket. Your medical team may be able to help you with this step as criteria can be very complex, and those in healthcare have experience navigating insurance claims.
Medicare and Medicaid started providing some coverage for transgender healthcare in 2014, although decisions are still made on a case-by-case basis. It is illegal for Medicare, Medicaid, and private insurance companies to deny medically necessary transition-related care. However, certain states and insurance policies have strict guidelines regarding the stipulations for what is and is not considered medically necessary.
Even though major medical groups overwhelmingly acknowledge the medical necessity of transition-related care, insurance providers can find ways to bypass legal regulations. A specific surgery, for example, could be deemed cosmetic. This is one reason why knowing the legal rights discussed above is essential. If your claim is illegally denied, understanding your rights can help you file an appeal.
Transgender Surgery Cost: Applying For Coverage
Filing for preauthorization can help secure coverage, although not every plan allows or requires this (more on that below). Preauthorization, or prior authorization, is a formal means of asking that your insurance provider approve your claims before the procedure. While it is not always an absolute guarantee, it can help give you and your medical team a clearer picture of whether insurance will cover your treatment plan. Preauthorization can also help give you a fuller understanding of your own financial responsibility, allowing you to budget for treatment.
Most plans require your patient to write a letter for preauthorization that explains your treatment plan and why it is medically necessary. Different insurance plans will require different information be included, and you may need to make a case for your treatment being medically necessary. Your medical team can help you with this step, and there are online resources such as this template from Transequality.org.
Some plans either do not offer preauthorization or will tell you it’s unnecessary as the procedure is covered under your plan. In some cases, you will need to file for reimbursement after undergoing treatment rather than applying for coverage beforehand.
What Do I Do If My Plan Denies Me?
First, refer to your plan’s handbook to look up the policy for filing an appeal and follow that process closely. How to file an appeal varies significantly from plan to plan, and there may also be state-specific regulations. We strongly recommend reaching out to a lawyer if it is within your budget. Many insurance companies attempt to bypass anti-discrimination laws for transgender patients, so you may be able to take legal action if your provider illegally denies you coverage.
If your claim is denied, talk to your medical team. A quality medical team will advocate for you and assist you with the appeal process. Remember, healthcare professionals have extensive experience dealing with insurance companies and may know workarounds you don’t.
Do not give up if your claim is denied. You have rights as a transgender patient. While a denial may be a setback, you have options, and most patients can eventually get coverage – even if it means changing insurance providers.
Transgender Surgery Cost: The Bottom Line
Transgender patients have more legal rights and protections today than in the past. As a result, it is much harder for insurance companies to deny coverage by deeming gender-affirming surgeries cosmetic. While there is still a chance your claim will be denied, a good healthcare team can help you file an appeal and eventually access the care you need.
While every insurance provider is different, we want to help ensure care is affordable for all our patients. We are happy to help you work with your provider to go over your options. Get in touch with our team to get started.
