Is my gender-affirming care covered?

There are three main kinds of coverage, and each follows different rules:

• Marketplace or individual plans: regulated by your state's insurance department. Some states require these plans to cover gender-affirming care; others don't.
• Employer plans: "self-funded" employer plans follow federal rules, not state rules. Ask HR for the plan's exclusions list.
• Medicaid: each state decides, and some states exclude this care by law.

Federal nondiscrimination rules (Section 1557 of the Affordable Care Act) and Marketplace benefit rules are being changed and challenged in court, so check the current status at the official sources below.

• ☐Do you have a written clinical policy for gender-affirming care? Please send it to me.
• ☐Is [service + billing code from my provider] covered under my plan? Does it need prior authorization?
• ☐Does my plan have an exclusion for gender-affirming or 'sex-trait modification' services?
• ☐Is my plan fully insured or self-funded? (This decides whether state law applies.)
• ☐Which in-network surgeons or clinics offer this service?
• ☐Can I have a reference number for this call?

• ☐Ask for the denial in writing, with the reason and the policy it's based on.
• ☐Note your appeal deadline (often 180 days for an internal appeal).
• ☐Ask your provider for a letter of medical necessity that cites WPATH SOC 8.
• ☐File an internal appeal, then an external review by an independent reviewer if denied again.
• ☐Contact your state insurance department, or free legal help below, if a state law protects you.

• HealthCare.gov — transgender health care

  Federal Marketplace guidance on coverage.

• HHS Office for Civil Rights — Section 1557

  Current status of federal nondiscrimination rules, and how to file a complaint.

• Movement Advancement Project — health care maps

  State-by-state tracker of insurance and Medicaid policies.

• Lambda Legal help desk

  Free legal information for LGBTQ+ people facing discrimination.

• Transgender Legal Defense & Education Fund

  Trans Health Project: help with insurance denials and appeals.

• Out2Enroll

  Help choosing a Marketplace plan as an LGBTQ+ person.