Does Insurance Cover Gender-Affirming Care? (2024)

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

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

Does Insurance Cover Gender-Affirming Care?

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

Gender-affirming care is the phrase used by most medical groups for dysphoria treatment. This care can include hormones, surgery, or counseling. The care aligns a person's gender identity with gender expression in appearance, anatomy, and voice.

In 2010, the federal Affordable Care Act (ACA) banned health insurance discrimination based on sexual orientation and gender identity.Before the law's passage, medically necessary gender-affirming surgeries and hormones often weren't covered by insurers.

A 2024 rule from the Department of Health and Human Services stated that covered entities (a term that includes both insurance plans and providers such as doctors) could not "deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for specific health services related to gender transition or other gender-affirming care if such denial, limitation, or restriction results in discrimination on the basis of sex."

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

Determining What Your Plan Covers

Policyholders and plan members can generally find out what's available to them in their member booklet. This should have been given to you when you got the policy or, if it's an employee plan, when you joined the company. It may be called a certificate of coverage, a benefit plan, a summary plan description, a certificate of insurance, or something similar.

This document should describe the insurer's clinical evidence criteria to qualify for claim coverage. For example, to begin hormone therapy, the requirements might include a diagnosis of gender dysphoria from a licensed mental health professional.

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

Even if you're turned down, that is not necessarily the final word. If a preauthorization request or a claim is denied, an attorney, healthcare advocate, or your human resources department may be able to help with filing an appeal. Appeals should include individualized, extensive documentation of a service's medical necessity and appropriateness.

Here, we list four types of health insurance and how they might cover gender-affirming care.

Employer-Provided Insurance

Altogether, 24 states and the District of Columbia prohibit transgender exclusions in private health insurance coverage, according to the nonprofit LGBTQ+ advocacy organization Movement Advance Project, leaving half the states without such protections.

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

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

Affordable Care Act Plan Coverage

Individuals can buy their own health insurance policies, often with the help of federal subsidies, through the Healthcare.gov Marketplace. Most insurers have eliminated transgender-specific exclusions, which ACA regulations explicitly ban.

Still, policies vary by state and in what they cover. As the Healthcare.gov website notes, "Many health plans are still using exclusions such as 'services related to sex change' or 'sex reassignment surgery' to deny coverage to transgender people for certain health care services."

It suggests that before enrolling in a plan, consumers should carefully review its terms: "Plans might use different language to describe these kinds of exclusions. Look for language like 'All procedures related to being transgender are not covered.' Other terms to look for include 'gender change,' 'transsexualism,' 'gender identity disorder,' and 'gender identity dysphoria.'"

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

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

Medicare and Medicaid Coverage

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

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

Military and Veteran Coverage

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

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

How Much Does Gender-Affirming Surgery Cost?

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

Gender-affirming surgeries may include top surgery (breast removal or augmentation), bottom surgery, vocal surgery, and face and body surgeries such as browlifts, jawline contouring, Adam's apple removal, and forehead reduction.

Bottom surgery may include:

• Phalloplasty:Creation of penis
• Metoidioplasty: Phallus created from existing genital region tissue.
• Hysterectomy: Uterus and cervix removal
• Nullification surgery: Creating a gender-neutral look in the groin
• Oophorectomy: Removal of one or both ovaries
• Vaginoplasty and vulvoplasty: Creation of vagin* and vulva
• Orchiectomy: testicl* removal

Research published in 2022 by JAMA Surgery found that while gender-affirming surgery can be costly, insurance (for patients who have it) will often cover most of the cost. Looking at phalloplasty and vaginoplasty procedures specifically, it reported: