What are my rights in insurance coverage?
Federal and state law prohibits most public and private health plans from discriminating against you because you are transgender. This means, with few exceptions, that it is illegal discrimination for your health insurance plan to refuse to cover medically necessary transition-related care.
Here are some examples of illegal discrimination in insurance:
- Health plans can’t have automatic or categorical exclusions of transition-related care. For example, a health plan that says that all care related to gender transition is excluded violates the law.
- Health plans can’t have a categorical exclusion of a specific transition-related procedure. Excluding from coverage specific medically necessary procedures that some transgender people need is discrimination. For example, a health plan should not categorically exclude all coverage for facial feminization surgery or impose arbitrary age limits that contradict medical standards of care.
- An insurance company can’t place limits on coverage for transition-related care if those limits are discriminatory. For example, an insurance company can’t automatically exclude a specific type of procedure if it covers that procedure for non-transgender people. For example, if a plan covers breast reconstruction for cancer treatment, or hormones to treat post-menopause symptoms, it cannot exclude these procedures to treat gender dysphoria.
- Refusing to enroll you in a plan, cancelling your coverage, or charging higher rates because of your transgender status: An insurance company can’t treat you differently, refuse to enroll you, or limit coverage for any services because you are transgender.
- Denying coverage for care typically associated with one gender: It’s illegal for an insurance company to deny you coverage for treatments typically associated with one gender based on the gender listed in the insurance company’s records or the sex you were assigned at birth. For example, if a transgender woman’s health care provider decides she needs a prostate exam, an insurance company can’t deny it because she is listed as female in her records. If her provider recommends gynecological care, coverage can’t be denied simply because she was identified as male at birth.
What should I do to get coverage for transition-related care?
Does private health insurance cover transition-related care?
It is illegal for most private insurance plans to deny coverage for medically necessary transition-related care. Your private insurance plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials.
To understand how to get access to the care that you need under your private insurance plan, check out NCTE’s Health Coverage Guide.
Does Medicaid cover transition-related care?
It is illegal for Medicaid plans to deny coverage for medically necessary transition-related care. Your state Medicaid plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. Some states have specific guidelines on the steps you have to take to access care. You can check if your state has specific guidelines.
My plan has an exclusion for transition-related care. What should I do?
There are many reasons why your plan might still have an exclusion for transition-related care in general or for a specific procedure. This does not mean that your plan will not cover your care. Sometimes plan documents are out of date, or you can ask for an exception by showing that this care is medically necessary for you.
If you get insurance through work or school, you can advocate with your employer to have the exclusion removed.
NCTE’s Health Coverage Guide has more information on how to access care and remove exclusions.
Does Medicare cover transition-related care?
It is illegal for Medicare to deny coverage for medically necessary transition-related care.
For many years, Medicare did not cover transition-related surgery due to a decades-old policy that categorized such treatment as “experimental.” That exclusion was eliminated in May 2014, and there is now no national exclusion for transition-related health care under Medicare. Some local Medicare contractors have specific policies spelling out their coverage for transition-related care, as do some private Medicare Advantage plans.
Does the Veterans Health Administration (VHA) provide transition-related care?
The Veterans Health Administration (VHA) provides coverage for some transition-related care for eligible veterans. However, VHA still has an arbitrary and medically baseless exclusion for coverage of transition-related surgery. On June 19th, The US Department of Veterans Affairs announced that they will begin the process to expand health care services available to transgender veterans to include gender confirmation surgery. Currently, the Veterans Health Administration (VHA) provides care for thousands of transgender veterans, including some transition-related medical care. We expect the rule will finalize in approximately two years.
For more information, see the FAQs by VHA.
For more information about VHA and transition-related care, check out NCTE’s VAH Veterans Health Care page.
Does TRICARE cover transition-related care?
TRICARE provides coverage for some transition-related care for family members and dependents of military personnel. However, TRICARE still has an exclusion for coverage of transition-related surgery.
If you are an active military member and want to understand your coverage while serving, check out these resources from our friends at SPART*A.
What are my rights in receiving health care?
Which health providers are prohibited from discriminating against me?
Under the Affordable Care Act, it is illegal for most health providers and organizations to discriminate against you because you are transgender. The following are examples of places and programs that may be covered by the law:
- Physicians’ offices
- Community health clinics
- Drug rehabilitation programs
- Rape crisis centers
- Nursing homes and assisted living facilities
- Health clinics in schools and universities
- Medical residency programs
- Home health providers
- Veterans health centers
- Health services in prison or detention facilities
What types of discrimination by health care providers are prohibited by law?
Examples of discriminatory treatment prohibited by federal law include (but are not limited to):
- Refusing to admit or treat you because you are transgender
- Forcing you to have intrusive and unnecessary examinations because you are transgender
- Refusing to provide you services that they provide to other patients because you are transgender
- Refuse to treat you according to your gender identity, including by providing you access to restrooms consistent with your gender
- Refusing to respect your gender identity in making room assignments
- Harassing you or refusing to respond to harassment by staff or other patients
- Refusing to provide counseling, medical advocacy or referrals, or other support services because you are transgender
- Isolating you or depriving you of human contact in a residential treatment facility, or limiting your participation in social or recreational activities offered to others
- Requiring you to participate in “conversion therapy” for the purpose of changing your gender identity
- Attempting to harass, coerce, intimidate, or interfere with your ability to exercise your health care rights
What are my rights related to privacy of my health information?
The Health Insurance Portability and Accountability Act (HIPAA) requires most health care providers and health insurance plans to protect your privacy when it comes to certain information about your health or medical history. Information about your transgender status, including your diagnosis, medical history, sex assigned at birth, or anatomy, may be protected health information. Such information should not be disclosed to anyone—including family, friends, and other patients—without your consent. This information should also not be disclosed to medical staff unless there is a medically relevant reason to do so. If this information is shared for purposes of gossip or harassment, it is a violation of HIPAA.
What Can I Do If I Face Discrimination?
Seek preauthorization for care and appeal insurance denials
You shouldn’t be denied the care that you need just because you’re transgender. That’s illegal.
To access transition-related care, we recommend applying for preauthorization before any procedures to understand whether your plan will cover it. You should also consider appealing insurance denials that you believe are discriminatory. We recommend you consult an attorney before filing any appeals.
Contact an attorney or legal organization
If you face discrimination from a health care provider or insurance company, it may be against the law. You can talk to a lawyer or a legal organization to see what your options are. A lawyer might also be able to help you resolve your problem without a lawsuit, for example by contacting your health care provider to make sure they understand their legal obligations or filing a complaint with a professional board.
While NCTE does not take clients or provide legal services or referrals, there are many other groups that may give you referrals or maintain lists of local attorneys. You can try your local legal aid or legal services organization, or national or regional organizations such as the National Center for Lesbian Rights, Lambda Legal, the ACLU, and others listed on NCTE’s Additional Resources page and in the Trans Legal Services Network. In addition, please check out Transgender Legal Defense & Education Fund (TLDEF)’s www.transhealthproject.org, to receive help on a denial.
File discrimination complaints with state and federal agencies
Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The U.S. Department of Health and Human Services has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint. If you face any of ther kind of discrimination or denial of care based on your gender, disability, age, race, or national origin, or if your health care privacy was violated, you can still file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.
Here are some other places you can file health care complaints:
- Private insurance: File a complaint with your state insurance department. Learn more about information about your state department.
- Hospitals: File a complaint with the Joint Commission, which accredits most hospitals. You can find more information or submit a complaint online.
- Nursing home, board and care home, or assisted living facility: Contact your local long-term care ombudsman.
- HIPPA violations: File a complaint with the U.S. Department of Health and Human Services (HHS)
- Federal Health Employee Benefits Program: File a complaint with the Office of Personnel Management (FEHB@opm.gov) or file a complaint with the Equal Employment Opportunity Commission
- Veterans Health Administration: File a complaint with the Veterans Administration’s External Discrimination Complaints Program or contact a Patient Advocate at your VA Medical Center.
- Employee health plan: File a complaint with the Equal Employment Opportunity Commission
- TRICARE (military health care): File a complaint with TRICARE
- Other state and local agencies: If you face discrimination, you may be able to file a complaint with your state’s human rights agency.
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