Many insurance providers offer coverage for gender affirmation surgery. If people cannot get insurance coverage, other options include paying out of pocket, taking out a personal loan, or seeking financial help from charities and organizations.
Many options can help people cover the costs of gender affirmation surgery, sometimes also called gender confirmation surgery.
Most of the major insurance providers recognize the need for transgender-related healthcare and provide plans that cover this surgery, according to the Transgender Legal Defense & Education Fund (TLDEF).
This article looks at how to find and apply for insurance coverage, as well as other financial options if a person’s insurance provider does not cover gender affirmation surgery.
People will need to check individual insurance companies to see if they cover gender affirmation surgery.
TLDEF provides a list of insurance companies that offer gender affirmation procedures.
However, even if an insurance provider appears on the list, people will need to check their individual plan to make sure it covers transgender care.
Some insurance companies will include blanket exclusions on transgender-related care. This means they will not offer coverage for transgender healthcare.
When selecting an insurance provider and plan, people considering gender affirmation surgery should make sure there is no exclusion on transgender care.
To do this, an individual can check with the insurance company or read through plan documents before buying the insurance plan.
If people are applying for insurance through an employer, they can ask for a written response from human resources to check if they have an exclusion.
If people have a particular surgeon or healthcare facility in mind, they can use an insurance provider’s find-a-doctor search tool on their website to check if the surgeon is in their network.
Networks may vary between different plans, so people can try to search within a specific plan. It may be easier and more affordable to work with in-network providers, rather than providers not in an insurance provider’s network, TLDEF recommends.
People may also want to check to see if an insurance plan includes coverage for prescription medications, such as hormones. An individual can search the insurance provider’s formulary, which is a list of drugs that the plan covers.
Scenario 1: The insurance plan covers the surgery
If people have a health insurance plan that covers gender affirmation surgery, people will need to take steps to ensure they meet certain guidelines that insurance companies require.
Insurance companies may use criteria from the standards of care published by the World Professional Association for Transgender Health (WPATH) as their guidelines for providing coverage for gender affirmation surgeries.
The WPATH guidelines recommend one letter from a healthcare professional for those seeking top surgery and two letters for those seeking bottom surgery.
Most insurance companies may require a letter from a mental health professional, detailing a person’s gender dysphoria and the medical need for the surgery.
They may also want a letter from a healthcare professional, detailing whether a person has been taking hormone therapy and, if so, for how long for.
Scenario 2: The health insurance plan covers the surgery, but the surgeon does not have an agreement with the insurance provider
An out-of-network surgeon is one who does not have an agreement with the insurance provider.
According to TLDEF, if a surgeon is out of network, people can ask them for paperwork, such as an itemized bill, that makes it easier for the insurance company to provide reimbursement.
If a plan does not offer out-of-network coverage, people may ask for a network gap exception. A network gap exception means an insurance provider agrees to treat the surgeon as in network.
People may require a letter from their surgeon explaining the specialty of their service. People may also need to provide details showing the transgender-related care that the in-network surgeons provide is not suitable for them.
Another option is to make a single-case agreement. This involves a surgeon negotiating a rate of reimbursement with the insurance provider before carrying out the procedure. This means people do not have to make a payment upfront.
Scenario 3: The insurance plan covers the surgery, but there are no qualified surgeons in network
If people do not have any out-of-network coverage with their insurance plan and there is no qualified in-network surgeon to provide gender affirmation surgery, the insurance provider must cover a qualified out-of-network surgeon.
If there is no qualified in-network surgeon, people can request that the insurance provider treats the out-of-network surgeon as in network.
People may consider paying out of pocket if an insurance provider does not cover the costs of gender affirming surgery.
If people do not have the funds to pay out of pocket and they feel comfortable sharing their plans for surgery, they may want to consider fundraising initiatives, such as crowdfunding.
Alternatively, people may be able to apply for a personal loan to cover surgery costs.
Financial aid for gender affirmation surgery
Several grants offer financial assistance for gender affirmation surgery, which people may be eligible to apply for.
Examples of grants that can help totally or partially fund gender affirmation surgery include:
Many insurance providers cover transgender-related healthcare, including gender affirmation surgery.
People will need to check that an individual plan covers surgery, as well as if their preferred surgeon is in network and what out-of-pocket expenses they may have to pay.
People may require one or more letters from healthcare professionals when applying for insurance coverage.
If people are unable to get insurance coverage, or if they require financial help covering out-of-pocket expenses, other options are available, such as grants or personal loans.