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Aetna Agrees to Expand Coverage for Gender-Affirming Surgeries

One of the nation’s largest health insurers is agreeing to pay for breast augmentation for some trans women.

By Reed Abelson

Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. By 2019, she finally thought her insurance company, Aetna, would pay for it, only to find that it considered the procedure cosmetic, not medically necessary, and refused to cover it.

“I knew from my case, it wasn’t cosmetic,” said Ms. Escolastico, who contacted a lawyer after she lost her appeal last year. “I knew I had to fight for this,” she said.

Ms. Escolastico’s surgery is now scheduled for February. Working with the Transgender Legal Defense and Education Fund, a nonprofit that advocates transgender rights , and Cohen Milstein Sellers and Toll, a large law firm that represents plaintiffs, she and a small group of trans women persuaded Aetna to cover the procedure if they can show it to be medically necessary.

To qualify, the women would need to demonstrate that they had persistent gender dysphoria, undergo a year of feminizing hormone therapy and have a referral from a mental health professional.

The shift by Aetna represents an important evolution in how health insurers view the medical needs of transgender individuals . While some insurers offer a broad range of surgeries for trans women if they are deemed medically necessary, others exclude breast augmentation and other treatments as merely cosmetic.

“This has the potential to be a transformative moment,” said Kalpana Kotagal, a partner at Cohen Milstein.

Insurers have typically covered genital reassignment surgery as medically necessary. But transgender women and others say breast augmentation is also a necessary treatment for individuals who receive a diagnosis of gender dysphoria. “There is no question from a medical perspective,” said Noah E. Lewis, the director of the Trans Health Project at the fund.

In addition, he said, it is illegal for a health insurer to deny coverage of medical care because of someone’s gender identity. “It’s a really simple matter of discrimination,” he said.

Aetna, which is owned by CVS Health, had been actively reviewing the need for breast augmentation surgery for trans women, said Dr. Jordan Pritzker, senior director of clinical solutions for the insurer. He said he had talked to numerous doctors who provide the surgery.

“Our decision to update our clinical policy bulletin is consistent with many changes we have made over the years to better serve the needs of the L.G.B.T.Q. community,” Dr. Pritzker said in a statement.

Aetna said it would also reimburse some trans women who were denied coverage but had the surgery. The company said it was actively reaching out to individuals who had sought authorization for their surgeries and were denied.

Cora Brna was denied coverage for breast augmentation surgery two years ago, when she tried to schedule it at the same time that she was undergoing genital reassignment, which was covered by Aetna. “I was devastated,” she said.

“I felt like a group of people were deciding whether I was or was not a woman,” said Mrs. Brna, 32, who works as a health care worker in Pittsburgh and was one of the women who petitioned Aetna. She went ahead with the genital surgery but had the procedure to augment her breasts only after it was covered by a different health plan.

Aetna’s new policy also comes at a time when the federal government is re-examining whether denying some types of care to transgender individuals is discriminatory. Under the Affordable Care Act, insurers cannot discriminate against individuals on the basis of gender identity, and most insurance companies provide coverage for people who require gender reassignment surgery. But the law never mandated a specific benefit or detailed exactly what services the insurers would cover, said Katie Keith, who teaches law at Georgetown University and closely follows this area of the law.

“It’s almost like a parity issue,” she said.

While the Trump administration sought to undo protections for transgender individuals with a rule last June , the issue is still being sorted out in the courts, said Ms. Keith, who also pointed to the recent Supreme Court decision that said gay and transgender workers are protected from workplace discrimination under civil rights law.

The new Biden administration has already issued an executive order saying it will enforce civil rights laws that protect people from discrimination on the basis of gender identity.

Major insurance companies are uneven in their coverage. Health Care Service Corp., which offers Blue Cross plans in five states, will pay for breast augmentation and other services for trans women if they are deemed medically necessary. The insurer said it developed these policies in accordance with guidelines established by the World Professional Association for Transgender Health, a nonprofit.

But other major insurers, including Anthem and UnitedHealthcare, continue to view the surgery as cosmetic, since they do not generally cover the procedures for women without the gender dysphoria diagnosis. They say they are not discriminating against trans women.

Anthem says its “medical policy is applied equitably across all members, regardless of gender or gender identity.”

And UnitedHealthcare said in a statement that its “coverage for gender dysphoria treatment is comprehensive and, depending on members’ benefit plans, current coverage may include physician office visits, mental health services, prescription drugs and surgery to address gender dysphoria.” It added that it uses “evidence-based medicine to make coverage policy decisions,” which are regularly updated.

But lawyers for the women involved in the Aetna agreement say they are looking closely at the policies of other insurers to see if they can make the same case that their refusal to offer coverage is discriminatory. “This is something that needs to be changed across the industry,” said Ms. Kotagal of Cohen Milstein.

Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. More about Reed Abelson

After advocacy by transgender women, Aetna…

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After advocacy by transgender women, aetna agrees to expand insurance coverage for gender-affirming surgeries.

Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. By 2019, she finally thought her insurance company, Aetna, would pay for it, only to find that it considered the procedure cosmetic, not medically necessary, and refused to cover it.

“I knew from my case, it wasn’t cosmetic,” said Escolastico, who contacted a lawyer after she lost her appeal last year. “I knew I had to fight for this,” she said.

Escolastico’s surgery is scheduled for February. Working with the Transgender Legal Defense and Education Fund, a nonprofit that advocates transgender rights, and Cohen Milstein Sellers and Toll, a large law firm that represents plaintiffs, she and a small group of trans women persuaded Aetna to cover the procedure if they could show it to be medically necessary.

To qualify, the women would need to demonstrate that they had persistent gender dysphoria, undergo a year of feminizing hormone therapy and have a referral from a mental health professional.

The shift by Aetna represents an important evolution in how health insurers view the medical needs of transgender individuals. While some insurers offer a broad range of surgeries for trans women if they are deemed medically necessary, others exclude breast augmentation and other treatments as merely cosmetic.

“This has the potential to be a transformative moment,” said Kalpana Kotagal, a partner at Cohen Milstein.

Insurers have typically covered genital reassignment surgery as medically necessary. But transgender women and others say breast augmentation is also a necessary treatment for individuals who receive a diagnosis of gender dysphoria. “There is no question from a medical perspective,” said Noah Lewis, director of the Trans Health Project at the fund.

In addition, he said, it is illegal for a health insurer to deny coverage of medical care because of someone’s gender identity. “It’s a really simple matter of discrimination,” he said.

Aetna, which is owned by CVS Health, had been actively reviewing the need for breast augmentation surgery for trans women, said Dr. Jordan Pritzker, senior director of clinical solutions for the insurer. He said he had talked to numerous doctors who provide the surgery.

“Our decision to update our clinical policy bulletin is consistent with many changes we have made over the years to better serve the needs of the LGBTQ community,” Pritzker said in a statement.

Aetna said it would also reimburse some trans women who were denied coverage but had the surgery. The company said it was actively reaching out to individuals who had sought authorization for their surgeries and were denied.

Cora Brna was denied coverage for breast augmentation surgery two years ago, when she tried to schedule it at the same time that she was undergoing genital reassignment, which was covered by Aetna. “I was devastated,” she said.

“I felt like a group of people were deciding whether I was or was not a woman,” said Brna, 32, who works as a health care worker in Pittsburgh and was one of the women who petitioned Aetna. She went ahead with the genital surgery but had the procedure to augment her breasts only after it was covered by a different health plan.

Aetna’s new policy comes at a time when the federal government is reexamining whether denying some types of care to transgender individuals is discriminatory. Under the Affordable Care Act, insurers cannot discriminate against individuals on the basis of gender identity, and most insurance companies provide coverage for people who require sex reassignment surgery. But the law never mandated a specific benefit or detailed exactly what services the insurers would cover, said Katie Keith, who teaches law at Georgetown University and closely follows this area of the law.

“It’s almost like a parity issue,” she said.

While the Trump administration sought to undo protections for transgender individuals with a rule last June, the issue is still being sorted out in the courts, said Keith, who also pointed to the recent Supreme Court decision that said gay and transgender workers are protected from workplace discrimination under civil rights law.

The new Biden administration has already issued an executive order saying it will enforce civil rights laws that protect people from discrimination on the basis of gender identity.

Major insurance companies are uneven in their coverage. Health Care Service Corp., which offers Blue Cross plans in five states, will pay for breast augmentation and other services for trans women if they are deemed medically necessary. The insurer said it developed these policies in accordance with guidelines established by the World Professional Association for Transgender Health, a nonprofit.

But other major insurers, including Anthem and UnitedHealthcare, continue to view the surgery as cosmetic, since they do not generally cover the procedures for women without the gender dysphoria diagnosis. They say they are not discriminating against trans women.

Anthem says its “medical policy is applied equitably across all members, regardless of gender or gender identity.”

And UnitedHealthcare said in a statement that its “coverage for gender dysphoria treatment is comprehensive and, depending on members’ benefit plans, current coverage may include physician office visits, mental health services, prescription drugs and surgery to address gender dysphoria.” It added that it uses “evidence-based medicine to make coverage policy decisions,” which are regularly updated.

But lawyers for the women involved in the Aetna agreement say they are looking closely at the policies of other insurers to see if they can make the same case that their refusal to offer coverage is discriminatory. “This is something that needs to be changed across the industry,” said Kotagal of Cohen Milstein.

c.2020 The New York Times Company

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Does Insurance Cover Gender-Affirming Care?

How much does gender-affirming surgery cost, how much does gender-affirming medication cost, other ways to pay for gender-affirming care and surgery, tips for financing gender-affirming care and surgery, bottom line.

• Health Insurance

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

Key Takeaways

• Health insurance generally covers gender-affirming care.
• Not all plans cover all procedures, or the process can be murky and require preauthorization and appeals.
• Gender-affirming care can cost tens of thousands of dollars.

Major insurance companies recognize transgender-related care as being medically necessary and have put policies in place outlining coverage criteria. However, at least 20 states have passed legislation limiting coverage of gender-affirming care for people up to age 18. And some transgender people may still be denied coverage of hormone treatments or transition-related surgery by an insurer.

An estimated 1.6 million Americans at least 13 years old identify as transgender, according to a June 2022 estimate.

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

Gender-affirming care is the phrase used by most medical groups for dysphoria treatment. This care includes 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 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 2022 rule from the Biden Administration noted that “categorical coverage exclusions or limitations for all health services related to gender transition are discriminatory” and that a covered entity can’t deny or limit coverage or claims, or charge more in cost-sharing related to gender transition.

However, insurance is regulated at the federal and state level based on whether it is an ACA, public, or employer plan, so the rule doesn’t apply evenly to all insurers. Coverage and requirements vary based on state, employer, plan type, and more.

Investopedia / Candra Huff

Determining What Your Plan Covers

Plan members can generally find out what’s available 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 gender dysphoria treatment claim coverage. Requirements might include:  

• One or two letters from a therapist containing specific information
• Being on hormones for a year
• Being at least 18 years old to have surgery.

Some plans may still list exclusions for certain procedures. Even if an exclusion exists in the documentation, the next step is to apply for pre-authorization or pre-approval. This earns a plan’s approval in advance for claims and may even be successful if an exclusion is evident—as it allows an appeal.

"Many [patients] call their insurance carrier and are told services will not be covered, and on that basis never attempt to file a claim,” says an article on the San Francisco-based UCSF Gender Affirming Health Program’s website. “Transgender individuals and their health providers should be aware that unless a denial is in writing, it is not a denial and cannot be appealed.

Typically, documentation submitted to the health plan shows why the treatment is medically necessary or explains the legal problems with an exclusion. Not getting preauthorization can lead to a claim denial, even if a procedure is covered. For example, many plans routinely require preauthorization for all surgeries of any kind for anyone.

If denied a preauthorization request or a claim, an attorney, health care 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, and a comprehensive overview of the transition process of gender transition.

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 26 states without such protections.

However, health coverage benefits that a private employer provides can vary based on whether the employer fully funds the plan. If funded by the employer, the plan is governed by the federal law ERISA, the Employee Retirement Income Security Act , which overrides any state nondiscrimination law. The employer decides what health care is or is not covered.

Employer-based plans are governed in the state where the plan was issued, not where you live.

Up to 91% of businesses on the 2022 Human Rights Campaign’s Corporate Equality Index-rated businesses offer at least one transgender-inclusive plan option, up from 0 in 2002.

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 are getting rid of transgender-specific exclusions, which ACA regulation explicitly banned.

Still, policies vary by state and in what they cover. Health insurance policies may feature exclusions for items such as “services related to sex change” or “sex reassignment surgery” to deny coverage.

Around 6% of Silver Marketplace plans specifically exclude coverage for exclusions for treatment of gender dysphoria, according to a survey by Out2Enroll, an organization connecting the LGBT+ community with health care coverage.

Check a policy’s terms of coverage for a full explanation of which procedures and services are covered or excluded. You can also use a state-based Trans Insurance Guide from Out2Enroll to find a plan with the coverage you want.

Medicare and Medicaid Coverage

Nearly 10,000 transgender Americans 65 and older are enrolled in Medicare or Medicare Advantage. Under these plans, medically necessary care—including some gender-affirming procedures—is covered. Coverage by Medicare Advantage plans may vary, so try to get preauthorization before accessing transition-related services, suggests the National Center for Transgender Equality.

On a state-by-state basis, Medicaid coverage is uneven for lower-income people seeking gender-affirming care. Medicaid programs cover transgender-related care in 26 states and the District of Columbia. Meanwhile, programs in nine states bar coverage of transgender-related care for people of all ages, and programs in two states prohibit coverage of transgender-related care for minors.

Military and Veteran Coverage  

Active military members can access gender-affirming hormonal treatment and therapy for gender dysphoria. Tricare, the health benefits provider for military members, does not usually cover gender-affirming surgeries. However, a waiver may be requested and granted in some cases for medically necessary gender-affirming surgery.  

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

For just one person, the cost of gender-affirming care might range from $25,000 to $75,000, according to estimates from the HRC Foundation.

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 vagina and vulva 
• Orchiectomy : Testicle removal 

Research published in 2022 by The Journal of Law, Medicine & Ethics detailed the costs of gender-affirming surgery from 1993 to 2019. The chart below shows the average costs of five of the most common gender-affirming procedures within a commercially insured population over the span of those years.

However, not all transgender people desire surgery. According to 2019 statistics, only 28% of transgender women get any type of surgery, and only 5%–13% receive genital surgery. Surgery is more common among transgender men, with 42%–54% getting some type of surgery; up to 50% get genital surgery.  

Gender-affirming medication is far more common. Up to 65% of transgender people received gender-affirming hormone therapy in 2019, up from 17% in 2011, according to The Journal of Law, Medicine & Ethics. The study notes the costs of gender-affirming medication from 1993 to 2019.  

Another 2022 study from Vanderbilt University found that masculinizing hormones run $29.76 to $463.54 per fill while feminizing hormones cost $12.95 to $180.98. Much of the cost depends on the delivery method, such as injection or gel. The authors note that “the most cost-effective hormone therapies were oral estrogen and injectable testosterone esters.”

One 2020 survey found that among insured respondents taking gender-affirming hormones, almost 21% reported that their claims were denied. This group (and those uninsured) were more likely to take non-prescription hormones from unlicensed sources, which may not be monitored for quality and potentially lead to health risks.

Other costs are involved as well. For example, at Planned Parenthood of South, East, and North Florida, gender-affirming hormone treatment costs between $95 to $105. Lab monitoring may need to be run to ensure health while taking hormones, which can average $26 to $142 per visit.

Aside from health insurance, how can you pay for gender-affirming care or surgery? Here are 10 options.

Payment Plans 

Some healthcare providers offer payment plans directly or through lenders that let you pay off medical bills over time.

You might take out a personal loan or even a type of personal loan called a medical loan to cover expenses related to gender-affirming care or surgery. A medical loan is just a personal loan used to pay for medical expenses.

Credit Cards 

Credit cards may be another avenue for covering the costs of gender-affirming care or surgery, although these tend to have higher interest rates. You may see promotional materials for the CareCredit credit card in your provider’s office, but other credit cards can pay for the same healthcare costs, often with a better interest rate and without the dangerous deferred interest feature that CareCredit cards have. You’re better off with a regular credit card that has a promotional 0% purchase rate offer.

Even with health insurance, hormone therapy may be less expensive if you comparison shop and use pharmacy programs, such as GoodRx.

Surgery Grants

Several organizations offer grants for people seeking gender-affirming care or surgery, such as the Darcy Jeda Crobitt Foundation and the Jim Collins Foundation.

Health Accounts 

If you have a flexible spending account (FSA) or Health Savings Account (HSA) , consider allocating some account money for gendering-affirming care or surgery.

Health Reimbursement Agreement 

A health reimbursement agreement (HRA) is an employer-funded group health plan that reimburses employees for qualified medical expenses, which might include gender-affirming care or surgery.

Home Equity Line of Credit (HELOC) 

You could take out a home equity line of credit to cover the costs of gender-affirming care or surgery. With this type of loan, you typically can borrow up to a specific percentage of your home equity. Interest rates on HELOCs are generally lower than those on a personal loan, because your home serves as collateral. Just realize that if you can’t repay the loan, your could lose your home. 

Friends-and-Family Loans 

If you’ve got supportive friends or relatives, they might be willing to chip in money to pay for your gender-affirming care or surgery. Just make sure you have a written agreement and repayment plan.

Crowdfunding

You might consider setting up a crowdfunding campaign on a platform like GoFundMe to raise money from friends, relatives, colleagues or strangers.

When you’re financing gender-affirming care or surgery, follow these tips:

Shop Around 

A number of online tools such as Hospital Cost Compare and Healthcare Bluebook allow you to compare costs for the same procedures and treatments offered by different healthcare providers. This homework could save you a lot of money.

Explore Your Options 

Even if health insurance covers a procedure or treatment, you must cover some out-of-pocket costs. Therefore, consider looking into surgery grants, crowdfunding, friends-and-family loans or other methods to bridge the monetary gap.

Check the Interest Rate 

Be sure to investigate how much you’ll pay to borrow money if you go down that road. With the CareCredit card, for example, the APR may be higher than a regular credit card or a personal loan. 

Try Negotiating or a Payment Plan

You can negotiate with a healthcare provider to lower the costs of gender-affirming care or surgery. For instance, a healthcare provider might discount your services if you agree to pay off your medical bills quickly. If a healthcare provider isn’t willing to provide a discount, they might let you make interest-free payments as part of a payment plan.

Ask About Financial Assistance

Some nonprofit healthcare providers offer financial assistance programs that cover all or some of your medical expenses.

What Are the Different Types of Gender-Affirming Care?

Various types of gender-affirming care include puberty-blocking medication, hormone therapy, top surgery, bottom surgery, nullification surgery, laser hair removal, facial feminization surgery, speech therapy, and mental health services.

How Much Does Gender-affirming Care Cost in the U.S?

The cost of gendering-affirming care varies widely, depending on the type of procedure or treatment involved. For one person, gender-affirming care might cost anywhere from $25,000 to $75,000, according to estimates from the Human Rights Campaign Foundation. Health insurance may or may not cover these costs to varying degrees.

Does Insurance Cover Puberty Blockers?

According to one study, insurance companies cover puberty blockers 72% of the time. The estimated out-of-pocket cost for a 3-month supply ranges between $9,500 and $39,000.

The campaign for transgender rights in the U.S. has experienced victories and setbacks in recent years—in some cases affecting coverage of gender-affirming care. Even amid progress made, some people still encounter problems securing health insurance coverage for gender-affirming care or covering out-of-pocket costs. Getting coverage for care may require preauthorization, documentation of medical necessity, and an appeal. This may prompt use of alternative financing methods like crowdfunding, credit cards, loans, or grants.

U.S. Department of Health and Human Services. “ HHS Announces Prohibition on Sex Discrimination Includes Discrimination on the Basis of Sexual Orientation and Gender Identity .”

The Williams Institute at UCLA. " How Many Adults and Youth Identify as Transgender in the United States? "

American Medical Association. “ Transgender Coverage Issue Brief .”

First Report Managed Care. “ Transgender Patients: Calculating the Actual Cost .”

UCSF. " Health Insurance Coverage Issues for Transgender People in the United States .”

Transgender Health Insurance. " Health Insurance - Understanding Your Plan ."

HRC. " Corporate Equality Index 2022. "

Society for Evidence-Based Gender Medicine. “ Sweden’s Karolinska Ends All Use of Puberty Blockers and Cross-Sex Hormones for Minors Outside of Clinical Studies .”

BlueCross BlueShield of Tennessee. “ BlueCross BlueShield of Tennessee Medical Policy Manual .” 

Movement Advancement Project. " Medicaid Coverage of Transgender-Related Health Care ."

HealthCare.gov. “ Transgender Health Care .”  

U.S. Department of Veterans Affairs. "VHA LGBTQ+ Health Program. "

Williams Institute, UCLA School of Law. “ Medicaid Coverage for Gender-Affirming Care ,” Page 1.

National Center for Biotechnology Information. “ Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information .”

British Columbia Nurses’ Union. “ Position Statement: Gender-Affirming Care .”

Journal of General Internal Medicine. " Gender-Affirming Hormone Therapy Spending and Use in the USA, 2013–2019. "

Annals of Family Medicine. "Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey ."

Aetna. “ Gender Affirming Surgery .”

Current Problems in Pediatric and Adolescent Health Care. " Gender Affirming Medical Care of Transgender Youth ."

• Guide to Finance for LGBTQ+ People 1 of 18
• LGBTQ+ Marriage and Personal Finance 2 of 18
• The Costs of LGBTQ+ Family Planning 3 of 18
• Mortgage Lending for LGBTQ+ People 4 of 18
• Banks that Support the LGBTQ+ Community 5 of 18
• LGBTQ+ Credit Barriers: Why They Exist and How to Avoid Them 6 of 18
• Top LGBTQ+ Financial Influencers to Learn From 7 of 18
• Paying for College as an LGBTQ+ Student 8 of 18
• LGBTQ+ Representation in the Workforce 9 of 18
• LGBTQ+ Pay Gap and Unemployment 10 of 18
• Health Insurance for LGBTQ+ People 11 of 18
• How Being Nonbinary Affects Getting Life Insurance 12 of 18
• Qualifying for Life Insurance When You're Transgender 13 of 18
• Does Insurance Cover Gender-Affirming Care? 14 of 18
• How to Invest in LGBTQ+-Friendly Companies 15 of 18
• Preparing for Retirement as an LGBTQ+ Person 16 of 18
• Social Security Benefits for for Same-Sex Couples: History and How Survivors Benefits Work 17 of 18
• Finding LGBTQ+ Friendly Retirement Options 18 of 18

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Insurance Coverage for Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on March 13, 2024.

Navigating insurance coverage for gender affirmation surgery can be complex, but many insurance providers now recognize these forms of healthcare for transgender individuals as medically necessary and thereby deserving of coverage. This guide aims to simplify the process of finding and applying for insurance coverage for gender-affirmative surgery, also known as gender confirmation surgery.

The GCC’s list of insurance providers that cover gender-affirming surgeries

Below you can find a list of insurance providers for which our team has successfully obtained approval for top surgery procedures from here. If you don’t see your insurance listed here or are unsure, you can schedule a free, virtual consultation so our team can verify this information for you. Unfortunately, Medicare does not cover any of our procedures at this time.

*  This list does not guarantee insurance coverage for top surgery and successful approvals may vary on a number of factors, such as the type of plan for each insurance company.

How to Get Coverage: An Overview

The following information is meant to give you an overview of all the components you will need to take into consideration in finding an insurance plan that will cover your gender-affirming surgery.

• Contact your insurance provider directly to inquire about coverage for gender reassignment surgery. You can start by calling the phone number on your insurance card.
• Review your insurance policy or member handbook carefully for any exclusions or limitations related to transgender healthcare.
• Consult the Transgender Legal Defense & Education Fund (TLDEF) for a list of insurance companies known to offer coverage for gender affirmation procedures.
• Get enrollment help from Out2Enroll once you are ready to sign up for health coverage to understand your options.
• Coverage Exclusions: Federal and state laws prohibit discrimination against transgender individuals by most public and private insurance health plans. This means insurance companies must cover transition-related care that’s medically necessary and it is illegal for them to deny coverage, in most cases. Some plans may still have exclusions in their policies, but you can ask for an exception or request the removal of the exclusion.
• Medical Necessity: Virtually all major insurance companies now recognize that gender-affirming medical care for transgender patients is medically necessary. However, the specifics of what procedures or treatments are covered will depend on each insurance plan. Most of them will require letters from healthcare providers to support medical necessity. You can find a list of therapists that can provide support letters for insurance coverage through GALAP .
• Referral Letters: To secure insurance coverage, patients will need 1-2 letters from healthcare providers. Besides a therapist support letter,  if GCC surgeons are not in-network providers, you will need a referral letter from your Primary Care Physician.
• Financial Options: If your insurance provider does not cover gender-affirming surgery, other options include paying out-of-pocket, taking out a personal loan, or seeking financial help from charities and organizations.

Identifying Insurance Providers That Cover Gender Affirming Surgery

If you live in the United States, here’s a list of resources to help you identify insurance providers offering coverage for gender-affirming surgery:

• Transgender Legal Defense & Education Fund (TLDEF) provides a list of insurance companies that have coverage for gender-affirming care.
• Campus Pride provides a list of colleges and universities by state that cover gender-affirming surgery or hormone therapy under student health insurance.
• Our Insurance Advocacy Team here at the Gender Confirmation Center has successfully secured coverage for surgery from the insurance companies mentioned above.

Navigating Insurance Policies for Gender Affirming Surgery

The National Center for Transgender Equality created a guide to help navigate getting your insurance to cover gender-affirming care. This process can be summarized in 3 steps below:

• Learn what your insurance plan covers for gender-affirming care by calling your insurance company and ask what medical policies on gender dysphoria treatment are applicable to your plan. You may also find this information in the Member Handbook provided by your insurance.
• Determine the type of insurance you have (self-funded vs fully insured) to see if there are exclusions or limitations on healthcare coverage for transition-related care. Self-funded plans (e.g. insurance through work, school, or government employment) typically have exclusions or limitations to coverage that may be exempt from state protection laws. You may need to request your employer or school to remove the exclusion before insurance can cover surgery.
• Gather necessary documentation , such as letters from healthcare providers (i.e. mental health provider). Some insurance companies require at least 2 letters.
• Submit a pre-authorization request to your insurance provider by writing a letter to explain why the procedure is necessary and why refusing to provide coverage may be illegal.
• Follow up with your insurance to ensure the request is being processed or check on its status. Your insurance will send you a notification if your request has been approved or denied.

Navigating this process can be challenging but our Insurance Advocacy team works directly with your insurance for each step of this process until the insurance company reaches a decision for the preauthorization request. This service is provided free of charge for our patients to ensure the best chance of success in getting their surgery covered.

Overcoming Challenges in Insurance Coverage for Gender Affirming Surgery

• Denial of preauthorization request or claim for reimbursement: Understanding the reason for denial can help determine your options for appealing this decision. Seeking legal assistance from a lawyer may help facilitate this process.
• Dealing with out-of-network coverage: Insurance companies usually have a list of “in-network” healthcare providers that are covered by a particular plan. While some patients are restricted to these in-network providers (i.e. HMO plans), others may have the option to see out-of-network providers if the in-network options are not qualified (i.e., PPO plans). For example, your insurance may restrict you to seek care from a surgeon who can perform mastectomies but may not have training in gender-affirming techniques. In such cases, you have the right to seek out an out-of-network provider who is qualified in gender-affirming surgery, as the in-network provider cannot fulfill your specific needs. It’s essential to understand that the insurance may initially refuse coverage for out-of-network surgeons or facilities, but this decision can be challenged through the appeals process.
• Consider an independent review for denials : If the insurance company continues to deny coverage, you may have the option to request an independent review by a third-party organization. This review can provide an unbiased evaluation of your case and potentially overturn the denial.

Exploring Financial Aid Options for Gender Affirming Surgery

• Surgery Grants: Organizations and programs may offer grants or financial aid to help cover the costs of surgery. The GCC works with various organizations to help with costs of surgery. Learn more about them here.
• CareCredit: GCC has partnered with CareCredit to help patients finance the costs of surgery. Patients can apply for this credit card to see if they qualify and figure out what payment plan options are available.

Advocating for Comprehensive Insurance Coverage

The Affordable Care Act prohibits discrimination based on gender identity, which can be leveraged when seeking coverage for gender-affirming surgery. Despite this, many still face challenges with access or coverage of medically necessary transition related care. Recently, these states have limited protections for transgender youth after passing laws banning their access to gender-affirming care.

Navigating insurance coverage for gender-affirming surgery can be challenging, but our Insurance Advocacy team is dedicated to ensuring access to care for our patients. The National Center for Transgender Equality and Transgender Legal Defense and Education Fund also provides a comprehensive list of resources to help patients find and get insurance coverage for gender-affirming care.

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Dr. Scott Mosser Suite 1010, 450 Sutter St San Francisco, CA 94108 Phone: (415) 780-1515 Fax: ( 628) 867-6510

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Policy: Gender Affirming Surgery Policy Number: 0615 Last Update: 2023-08-08

This policy applies to Medicaid

Breast Reconstruction:

Requirements for breast augmentation (implants/lipofilling): Note:  More than one breast augmentation is considered not medically necessary. This does not include the medically necessary replacement of breast implants (see CPB 0142 - Breast Implant Remova l).

Youth Services:

For Breast Removal: For members less than 18 years of age, completion of one year of testosterone treatment, unless hormone therapy is not desired or medically contraindicated For Breast Augmentation: Completion of six months of feminizing hormone therapy (12 months for adolescents less than 18 years of age) prior to breast augmentation surgery, unless hormone therapy is not desired or medically contraindicated) For Gonadectomy: Six months of continuous hormone therapy as appropriate to the member's gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated. For Genital Reconstruction: Six months of continuous hormone therapy as appropriate to the member’s gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated. 

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Updated on Nov 27, 2023

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Does Health Insurance Cover Transgender Health Care?

For transgender Americans, access to necessary health care can be fraught with challenges. Section 1557 of the Affordable Care Act (ACA) prohibits discrimination on a wide variety of grounds for any "health program or activity" that receives any sort of federal financial assistance.  

But the specifics of how that section is interpreted and enforced are left up to the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR). Not surprisingly, the Obama and Trump administrations took very different approaches to ACA Section 1557. But the Biden administration has reverted to the Obama-era rules.

In 2020, the Trump administration finalized new rules that rolled back the Obama administration's rules. This came just days before the Supreme Court ruled that employers could not discriminate against employees based on sexual orientation or gender identity. The Trump administration's rule was subsequently challenged in various court cases.

And in May 2021, the Biden administration issued a notice clarifying that the Office of Civil Rights would once again prohibit discrimination by health care entities based on sexual orientation or gender identity.

The Biden administration subsequently issued a proposed rule in 2022 to update the implementation of Section 1557 and strengthen nondiscrimination rules for health care. The proposed rule " restores and strengthens civil rights protections for patients and consumers in certain federally funded health programs and HHS programs after the 2020 version of the rule limited its scope and power to cover fewer programs and services. "

Section 1557 of the ACA

ACA Section 1557 has been in effect since 2010, but it's only a couple of paragraphs long and very general in nature. It prohibits discrimination in health care based on existing guidelines—the Civil Rights Act, Title IX, the Age Act, and Section 504 of the Rehabilitation Act—that were already very familiar to most Americans (i.e., age, disability, race, color, national origin, and sex).

Section 1557 of the ACA applies those same non-discrimination rules to health plans and activities that receive federal funding.

Section 1557 applies to any organization that provides healthcare services or health insurance (including organizations that have self-insured health plans for their employees) if they receive any sort of federal financial assistance for the health insurance or health activities.

That includes hospitals and other medical facilities, Medicaid , Medicare (with the exception of Medicare Part B ), student health plans, Children's Health Insurance Program, and private insurers that receive federal funding.

For private insurers, federal funding includes subsidies for their individual market enrollees who purchase coverage in the exchange (marketplace). In that case, all of the insurer's plans must be compliant with Section 1557, not just their individual exchange plans.

(Note that self-insured employer-sponsored plans are not subject to Section 1557 unless they receive some type of federal funding related to health care activities. The majority of people with employer-sponsored health coverage are enrolled in self-insured plans.)

To clarify the nondiscrimination requirements, the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR) published a 362-page final rule for implementation of Section 1557 in May 2016.

At that point, HHS and OCR clarified that gender identity "may be male, female, neither, or a combination of male and female." The rule explicitly prohibited health plans and activities receiving federal funding from discrimination against individuals based on gender identity or sex stereotypes.

But the rule was subject to ongoing litigation, and the nondiscrimination protections for transgender people were vacated by a federal judge in late 2019.

And in 2020, the Trump administration finalized new rules which reversed much of the Obama administration's rule. The new rule was issued in June 2020, and took effect in August 2020. It eliminated the ban on discrimination based on gender identity, sexual orientation, and sex stereotyping, and reverted to a binary definition of sex as being either male or female.

Just a few days later, however, the Supreme Court ruled that it was illegal for a workplace to discriminate based on a person's gender identity or sexual orientation. The case hinged on the court's interpretation of what it means to discriminate on the basis of sex, which has long been prohibited under US law. The majority of the justices agreed that "it is impossible to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex."

The Biden administration announced in May 2020 that Section 1557's ban on sex discrimination by health care entities would once again include discrimination based on gender identity and sexual orientation.

And in 2022, the Biden administration published a new proposed rule for the implementation of Section 1557, rolling back the Trump-era rule changes and including a new focus on gender-affirming care (as opposed to just gender transition care).

Are Health Plans Required to Cover Gender Affirming Care?

Even before the Obama administration's rule was blocked by a judge and then rolled back by the Trump administration, it did not require health insurance policies to " cover any particular procedure or treatment for transition-related care ."

The rule also did not prevent a covered entity from " applying neutral standards that govern the circumstances in which it will offer coverage to all its enrollees in a nondiscriminatory manner ." In other words, medical and surgical procedures had to be offered in a non-discriminatory manner, but there was no specific requirement that insurers cover any specific transgender-related healthcare procedures, even when they're considered medically necessary.

Under the Obama administration's rule, OCR explained that if a covered entity performed or paid for a particular procedure for some of its members, it could not use gender identity or sex stereotyping to avoid providing that procedure to a transgender individual. So for example, if an insurer covers hysterectomies to prevent or treat cancer in cisgender women, it would have to use neutral, non-discriminatory criteria to determine whether it would cover hysterectomies to treat gender dysphoria.

And gender identity could not be used to deny medically necessary procedures, regardless of whether it affirmed the individual's gender. For example, a transgender man could not be denied treatment for ovarian cancer based on the fact that he identifies as a man.

But the issue remained complicated, and it's still complicated even with the Biden administration's proposed rule to strengthen Section 1557's nondiscrimination rules.

Under the 2016 rule, covered entities in every state were prohibited from using blanket exclusions to deny care for gender dysphoria and had to utilize non-discriminatory methods when determining whether a procedure will be covered. But that was vacated by a federal judge in 2019.

However, the new rules proposed in 2022 by the Biden administration " prohibit a covered entity from having or implementing a categorical coverage exclusion or limitation for all health services related to gender transition or other gender-affirming care. "

As of 2023, HealthCare.gov's page about transgender health care still states that " 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. Coverage varies by state. "

The page goes on to note that " transgender health insurance exclusions may be unlawful sex discrimination. The healthcare law prohibits discrimination on the basis of sex, among other bases, in certain health programs and activities ."

The page advises that " if you believe a plan unlawfully discriminates, you can file complaints of discrimination with your state’s Department of Insurance, or report the issue to the Centers for Medicare & Medicaid Services by email to  [email protected] ." (note that this language existed on that page in 2020 as well.)

State Rules for Health Coverage of Gender Affirming Care

Prior to the 2016 guidance issued in the Section 1557 final rule, there were 17 states that specifically prevented state-regulated health insurers from including blanket exclusions for transgender-specific care and 10 states that prevented such blanket exclusions in their Medicaid programs. And as of 2023, the list of states that ban specific transgender exclusions in state-regulated private health plans has grown to 24, plus the District of Columbia.

Starting in 2023, Colorado became the first state to explicitly include gender-affirming care in its benchmark plan (used to define essential health benefits ), ensuring that all individual and small-group health plans in the state must provide that coverage.

While Section 1557 was initially a big step towards equality in health care for transgender Americans, it does not explicitly require coverage for sex reassignment surgery and related medical care. And the implementation of Section 1557 has been a convoluted process with various changes along the way. Most recently, the Biden administration has restored nondiscrimination protections based on gender identity.

Do Health Insurance Plans Cover Sex Reassignment?

It depends on the health insurance plan. This description from Aetna  and this one from Blue Cross Blue Shield of Tennessee are good examples of how private health insurers might cover some—but not all—aspects of the gender transition process, and how medical necessity is considered in the context of gender-affirming care.

Since 2014,  Medicare has covered medically necessary sex reassignment surgery , with coverage decisions made on a case-by-case basis depending on medical need. And the Department of Veterans Affairs (VA) has announced in June 2021 that it has eliminated its long-standing ban on paying for sex reassignment surgery for America's veterans.

But Medicaid programs differ from one state to another, and there are pending lawsuits over some states' refusals to cover gender transition services for Medicaid enrollees.

Over the last several years, many health plans and self-insured employers have opted to expand their coverage in order to cover sex reassignment surgery and other gender-affirming care. But although health coverage for transgender-specific services has become more available, it is still far from universal.

This issue is likely to face protracted legal debate over the coming years, and coverage will likely continue to vary from one state to another and from one employer or private health plan to another.

Many health plans in the U.S. are subject to ACA Section 1557, which prohibits discrimination based on gender. But this section is implemented via HHS rules, which have changed over time: The Obama administration issued rules to protect people from gender-related discrimination in health care, the Trump administration relaxed those rules, and the Biden administration has proposed changes to strengthen them once again.

A Word from Verywell

If you're in need of gender-affirming medical care, you'll want to carefully consider the specifics of the health policy you have or any that you may be considering. If you think that you're experiencing discrimination based on your gender identity, you can file a complaint with the Office of Civil Rights . But you may find that a different health plan simply covers your needs more comprehensively.

US Department of Health and Human Services. Section 1557 of the Patient Protection and Affordable Care Act .

Keith, Katie. Health Affairs. HHS Will Enforce Section 1557 To Protect LGBTQ People From Discrimination . May 11, 2021.

U.S. Department of Health and Human Services. HHS Announces Proposed Rule to Strengthen Nondiscrimination in Health Care . July 25, 2022.

United States DoJ. Overview of Title IX of the education amendments of 1972 . Updated August, 2015.

DHS.  Nondiscrimination in health programs and activities . Effective July 18, 2016.

Keith, Katie. Health Affairs. Court Vacates Parts Of ACA Nondiscrimination Rule . October 16, 2019.

Department of Health and Human Services. Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority . June 12, 2020.

SCOTUS Blog. R.G. & G.R. Harris Funeral Homes Inc. v. Equal Employment Opportunity Commission . Argued October 2019; Decision issued June 15, 2020.

U.S. Department of Health and Human Services. HHS Announces Prohibition on Sex Discrimination Includes Discrimination on the Basis of Sexual Orientation and Gender Identity . May 10, 2021.

National Center for Transgender Equality. Know your rights: medicare .

HealthCare.gov. Transgender Health Care .

Health Affairs. LGBT protections in affordable care act section 1557 . June 2016.

LGBT Map. Health Care Laws and Policies .

U.S. Department of Health and Human Services. Biden-Harris Administration Greenlights Coverage of LGBTQ+ Care as an Essential Health Benefit in Colorado . October 12, 2021.

Military Times. VA to Offer Gender Surgery to Transgender Vets for the First Time . June 19, 2021.

Fleig, Shelby. Des Moines Register. ACLU of Iowa Renews Effort to Overturn Law Restricting Public Funds for Trans Iowans' Transition-Related Care . April 22, 2021.

By Louise Norris Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

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Transgender health care

A transgender person’s assigned sex at birth doesn’t match their gender identity, expression, or behavior.

Refer to glossary for more details.

Applying for Marketplace coverage

Sex-specific preventive services.

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

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An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You'll get the "Summary of Benefits and Coverage" (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.

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Does Aetna Insurance Cover Gender Reassignment Surgery?

Gender identity is a personal matter, and as such, every individual has the right to determine their own gender. This includes transgender individuals, who may choose to transition from one gender to another. While a number of insurance companies now cover gender reassignment surgery (GRS), some do not. If you are considering GRS but are uncertain if your insurance company will cover it, be sure to check out their policy before making a decision. And if your insurance company doesn’t cover GRS yet, don’t give up hope. There are ways to get coverage without having to go through the hassle of filing a claim or fighting with an insurance company. Read on for more information on how to get coverage for GRS without breaking the bank.

Gender reassignment surgery is covered by most health insurance plans, including Aetna. This surgery can help people who identify as the opposite gender live in their correct gender role. It can include everything from hormone therapy to surgery. There are a few things to keep in mind if you’re considering this type of surgery: first, it’s not always easy to find a surgeon who will do the surgery and care for you afterwards. Second, many insurance companies don’t cover all of the costs associated with gender reassignment surgery. If you have questions about coverage or want more information, speak with your insurance company or doctor.

Aetna Coverage for Gender Reassignment Surgery

Gender reassignment surgery, also known as transgender surgery or gender confirmation surgery, is treatment to change the sex characteristics of a person. This includes changes such as hormones, hair removal, and/or surgical procedures. Aetna insurance covers gender reassignment surgery in certain cases. If you are approved for the surgery by your doctor and meet all other eligibility requirements, Aetna will pay for the surgery. You must first visit a doctor who will evaluate your medical condition and determine if the surgery is appropriate for you. The procedure may be covered if it is necessary to correct a physical disorder that has an effect on your mental or emotional health. Surgery may not be covered if it is solely for cosmetic purposes or for sexual gratification.

The Cost of Gender Reassignment Surgery

Gender reassignment surgery, also known as gender confirmation surgery, is a surgical procedure that is used to change the physical characteristics of a person’s body to match their gender identity. Gender reassignment surgery can be performed on any part of the body, and can include procedures such as facial reconstruction, breast augmentation, and genital reconstruction. There are several types of insurance that may cover gender reassignment surgery. Some health insurance plans may cover the cost of gender reassignment surgery if it is medically necessary treatment. Some employers may also provide coverage for employees who need gender reassignment surgery in order to maintain their employment status. However, it is important to check with your insurer or employer before scheduling any type of surgery in order to ensure coverage is available. The cost of gender reassignment surgery can vary depending on the particular procedure being performed. The average cost for a typical transgender-related surgical procedure ranges from $2,000 to $8,000. In some cases, additional medical procedures may be required after the initial surgery in order to improve the patient’s overall quality of life. Therefore, the total cost of a gender reassignment procedure could range from $10,000 to $40,000 or more.

What Are the Risks of Gender Reassignment Surgery?

The risks of gender reassignment surgery include infection, internal bleeding, and scarring. The most common complication is facial nerve damage, which can cause paralysis. Other potential risks include: – Sexual dysfunction – Psychological issues, such as anxiety or depression – Increased risk of suicide or self-harm – Long term medical problems, such as heart disease or arthritis

The Benefits of Gender Reassignment Surgery

Gender reassignment surgery, or gender affirmation surgery, is a surgical procedure that can help transgender people better understand their true gender. The benefits of gender reassignment surgery include improved emotional well-being, more self-confidence, and a greater sense of satisfaction with one’s body. Gender reassignment surgery can also improve overall health by alleviating underlying issues such as anxiety and depression. In some cases, it can even result in decreased rates of suicide. Gender reassignment surgery is not only beneficial for transgender people; it’s also often life-saving for those who suffer from serious mental health conditions. There are a variety of types of gender reassignment surgery available, and each has its own set of benefits and risks. Some patients opt for reconstructive surgeries, which may help to rebuild features that were lost as a result of the transition process. Other patients choose to have medical procedures that target specific areas of the body where dysphoria exists. Regardless of the type of surgery chosen, all patients should be fully informed about the possible risks and benefits before making any decisions. Gender reassignment surgery is an incredibly complex and highly personal procedure. It’s important that patients have access to quality care from qualified surgeons who are familiar with the latest techniques and technologies. Aetna recognizes the importance of providing coverage for gender reassignment surgeries in accordance with applicable state laws and our company policy on transgender health care coverage.

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