Is Gender Reassignment Surgery Covered by Health Insurance?
Gender reassignment, affirmation, or confirmation are used interchangeably to indicate the surgeries and procedures aligning one’s gender identity with their physical body. The services and procedures to reaffirm one’s gender can be expensive when paying out-of-pocket, and many states do not yet explicitly mandate such coverage. Some private health plans offer coverage of gender reassignment but are dependent on meeting strict criteria.
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Is Gender Reassignment Surgery Covered by Health Insurance?
Federal nondiscrimination laws and policies aim to protect LGBTQ people from being denied health insurance coverage or coverage of certain medical procedures based on sexual orientation or gender identity. Unfortunately, 27 states do not have LGBTQ inclusive insurance protections, and one state explicitly permits insurers to refuse coverage of gender-affirming care.
According to Dr. Kyle Zrenchik, Ph.D., ACS, LMFT, and Co-founder of All In Consulting, LLC, no mainstream health insurance company is allowed to discriminate against someone for their sexual identity or refuse to insure one because of their sexual identity. Many states require insurance companies to cover trans-specific healthcare, including gender-affirming care.
What is Gender Reassignment Surgery?
Gender reassignment is also known as gender affirmation or confirmation surgery. According to the Cleveland Clinic, gender affirmation refers to the procedures that assist people in transitioning to their self-identified gender. This may include facial surgery and top or bottom surgery. People may pursue this surgery to match their physical body to gender identity, also known as gender dysphoria.
Gender identity refers to an individual’s own concept of male, female, a blend of both, or neither. According to the American Medical Association (AMA), approximately 1.4 million adults in the United States identify as transgender, but not all transgender people experience gender dysphoria.
We spoke with Dr. Kyle Zrenchik, who emphasizes that “the diagnosis of Gender Dysphoria (GD) is a bit controversial. Many argue that it unfairly places the “pathology” on the patient, making it appear that it is their emotional distress that is the problem instead of their biology and being born into the wrong body. Many argue that the problem is better understood in our conceptualization of gender and sex and the ways that fail people who fall outside the binary.
Conversely, the diagnosis of Gender Dysphoria is the basis that currently justified the coverage of medical care. Care should not be provided unless there is a problem. Someone should not be treated for a disorder or disease unless they conclusively have one. So, at least in our current medical system, the diagnosis of GD is needed to advocate for this type of care to be provided and paid for by insurers. If the disorder no longer exists, then providers have nothing to “treat,” and insurers have nothing to pay for, says Dr. Zrenchik.
Health Insurance Coverage of Gender Reassignment
The AMA says that a national survey of transgender individuals found that 25 percent of respondents experienced an issue with their health insurance provider directly relating to being transgender in the past year. Of those seeking coverage for hormone therapy, 25 percent had been denied coverage, and 55 percent of those seeking coverage for transition-related surgery were denied coverage.
Transgender individuals have important considerations when considering the health insurance marketplace for care. When you apply for Marketplace coverage as a transgender individual, you should use your first, middle, and last name as they appear on your Social Security card. It is also recommended that you select the sex that appears on most of your other legal documentation. If you change your name or sex after you enroll in a health plan, you should be able to update this information when you log in.
Medicaid Trans-Specific Health Coverage by State
There are many nuances associated with transgender-related care. Some states explicitly cover transgender health coverage and care, while others explicitly cover transition-related care. Similarly, some states do not have any policies in place, while others have specific exclusions.
Below is a breakdown of the Medicaid health coverage by the state of transgender and transition-related care.
|Explicitly Covers Transition-Related Care||Explicitly Covers Transgender Health Coverage & Care||No Explicit Policy Covers Transgender Health Coverage & Care||Explicitly Excludes Transgender Health Coverage & Care|
|District of Columbia||Kansas||Nebraska|
|New Hampshire||South Dakota|
Medicare Coverage of Transition-Related Care
Medicare covers transition-related care based on a case-by-case basis to determine need. Routine preventative care is covered regardless of gender markers, such as mammograms and pelvic or prostate exams. Hormone therapies are covered under Medicare Part D when prescribed, and private Medicare programs should also cover these therapies.
Some Medicare Advantage plans have their own specific policies regarding coverage for transition-related services that determine whether they authorize coverage. Determine your Medicare eligibility here.
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Private Health Insurance Coverage of Transition-Related Care
Private health insurance plans can set their own regulations of covering transition-related care and gender reassignment, so long as it does not provide less than the state-mandated care requirements. Some health insurance policies regarding the treatment of gender dysphoria vary by state. You should refer to your state-specific guidelines for coverage specifics.
Below is a list of private health insurance companies and their requirements for coverage of gender-affirming surgeries. This is not an exhaustive list of health insurance coverage of transition-related care but highlights some available offerings of major health insurance providers.
Aetna considers gender-affirming surgery medically necessary when certain criteria are met relevant to the surgery or procedures requested. Aetna explicitly states that they do not consider the reversal of gender-affirming surgery for gender dysphoria medically necessary but list out the requirements for breast removal, breast augmentation, gonadectomy, and genital reconstructive surgery. For most transition-related procedures, Aetna requires:
- Referral letters from qualified mental health professionals
- Persistent and well-documented gender dysphoria
- The capacity to make fully informed decisions and consent to treatment
- Must be 18 years of age, or one year completion of hormone therapy
Anthem and Amerigroup
Similarly, Anthem and Medicaid insurer Amerigroup have nearly the same requirements for gender-affirming surgeries. They note that procedures are considered medically necessary when there is a significant functional impairment, and the procedure can be expected to improve such impairment. In general, the following criteria must be met for the surgeries and procedures to be deemed medically necessary:
- The individual is at least 18 years of age.
- The individual has the capacity to make fully informed decisions and consent for treatment.
- The individual has been diagnosed with gender dysphoria
- The individual has undergone 12 months of continuous hormone therapy when recommended by a mental health professional and provided under the supervision of a physician
- Referrals from qualified mental health professionals
There may be additional requirements related to the specific surgeries. If all criteria are not met for the desired procedure, they may not be considered medically necessary and not covered by these providers.
Cigna offers coverage for the treatment of gender dysphoria but varies across plans. Coverage of hormonal therapy drugs or other drugs related to transition-related care is covered as a medical or pharmacy benefit, which varies across plans.
Medically necessary treatment of gender dysphoria and/or gender reassignment surgeries and related procedures may include any of the following services when offered in the member’s benefit plan:
- Behavioral health services
- Hormonal therapy
- Laboratory testing to monitor hormonal therapy
- Age-related and gender-specific services such as preventative health as appropriate to the biological anatomy
- Gender reassignment and related surgery
To be considered medically necessary, similar requirements as other health insurers apply. For procedures related to gender reassignment, an individual must be 18 years or older and receive recommendations for sex reassignment surgery by qualified mental health professionals with written documentation submitted to the surgical physician.
Health insurance provider, Emblem also has similar requirements when it comes to coverage of gender-affirming surgeries. These services will be covered for members 18 years of age or older and those with the capacity to make informed decisions and consent for treatment. Such patients must have letters from qualified health professionals with whom they have an established and ongoing relationship.
The purpose of these letters is to verify the patient has a persistent and well-documented case of gender dysphoria, having also received hormone therapy for a minimum of 12-months before seeking surgery. Additionally, patients must prove they have lived for at least 12 months in the gender role they identify and received mental health counseling during this time.
The following procedures are excluded from Emblem’s coverage:
- Cryopreservation, storage, and thawing of reproductive tissue
- Reversal of genital and/or breast surgery
- Reversal of surgery to revise secondary sex characteristics
- Reversal of any procedure resulting in sterilization
The emblem also notes that coverage is not available for any surgeries or procedures that are purely cosmetic and performed to enhance appearance, but not for treating gender dysphoria. Certain services, procedures, or surgeries may also be reviewed on a case-by-case basis, such as hair transplantation, voice therapies, gluteal augmentations, etc.
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Health insurance provider United Healthcare has similar parameters to the other providers listed above to receive breast augmentation or genital surgery. One must be 18-years of age and with the ability to make informed health decisions and provide consent.
They must have a well-documented case verified by qualified health care providers to have the following services be considered a medically necessary and proven benefit:
- Bilateral mastectomy or breast reduction
- Clitoroplasty (creation of clitoris)
- Hysterectomy (removal of the uterus)
- Labiaplasty (creation of labia)
- Laser or electrolysis hair removal in advance of genital reconstruction prescribed by a physician for the treatment of
- Gender Dysphoria
- Metoidioplasty (creation of penis, using clitoris)
- Orchiectomy (removal of testicles)
- Penectomy (removal of the penis)
- Penile prosthesis
- Phalloplasty (creation of penis)
- Salpingo-oophorectomy (removal of fallopian tubes and ovaries)
- Scrotoplasty (creation of scrotum)
- Testicular prostheses
- Urethroplasty (reconstruction of the female urethra)
- Urethroplasty (reconstruction of the male urethra)
- Vaginectomy (removal of the vagina)
- Vaginoplasty (creation of a vagina)
- Vulvectomy (removal of the vulva)
For specifics on gender dysphoria treatment for United Healthcare members in these states:
Health Insurance Coverage of Gender Reassignment Frequently Asked Questions (FAQs)
Navigating the health insurance market can be especially discriminatory toward the LGBTQ community. Most health plans do not offer comprehensive care for transition-related services, and policies vary by state. Below, we answered a few frequently asked questions regarding health coverage of transition-related care.
Is it challenging to navigate the health insurance market when asked for birth/legal names or biological sex, etc., for someone who does not identify with their birth name or legal identity?
There is no question that there is a challenge that trans folk face when they are in the process of changing their names and sex. Insurance companies deny claims if the information they have on their end does not match exactly what is sent over. In fact, insurance companies often require providers to list the sex of the client, either Male or Female, for a claim to be paid, says Dr. Zrenchik.
Without insurance, how much do gender reassignment surgeries cost?
According to Dr. Zrenchik, the cost for Gender Reassignment surgery (also known as Gender-Affirmative surgery or Gender Confirmation Surgery) costs roughly $20,000-$25,000. This may or may not include the other associated costs, including loss of income during recovery, travel costs, psychotherapy, or complications arising from Surgery.
Without insurance, how else can I get financial assistance for trans-related care?
The Jim Collins Foundation raises money to fund gender-affirming surgeries for those without the means to pay for it themselves. You can apply for funding through their website, but note that the 2022 grant cycle is closed, and the 2023 grant cycle will open in May of 2022.
Point of Pride also offers an Annual Transgender Surgery Fund, which requires a completed application to be eligible. The application period begins at midnight EST on November 1 and runs until midnight EST on November 30, 2021. You can still apply even if you have health insurance.
Southern Equality has the Darcy Jeda Corbitt Foundation offering grants providing financial assistance for transition-related expenses. These grants are for legal name changes for residents in North Dakota, hormone replacement therapy, and gender-affirming surgeries. The Loft and TUFF are also financial assistance programs for costs associated with gender affirmation based requiring an application.
State guidelines vary on access to coverage for gender reassignment. While some publicly-funded policies include transition-related and gender reassignment care, some states either have no policy or explicitly exclude such coverage. Coverage can be found for some private health insurance providers but require strict criteria to be met before coverage is considered.
Ashley Brooks works in Healthcare Consulting and graduates with her MPH in September of 2022 from George Washington University, but graduated with her B.S. in Health Science from James Madison University in 2019. Ashley has been with Mira since June of 2021 and shares the passion for creating affordable healthcare coverage for all!