This page is all about navigating insurance for trans-related health care! Spoiler alert: Insurance companies suck! They don’t really want to pay for trans health care, so if you’re trying to get anything covered by insurance (hormones, surgeries, laser hair removal, etc.) you’re probably going to need to fight for it a bit.
The information here is all based on my experience, but I intend to check-back in and add information as I learn more. If you are trying to work with your insurance company to get care, please reach out to me and I will gladly help you find resources and figure out a process. The following steps are a basic framework that help me think about getting coverage.
1. What do I want and when do I want it?
First thing to figure out is what kind of care you want/need and when you want to receive the care. For me, I knew I wanted top surgery and I wanted to get it during a window of time on my summer break.
For this first step, you want to really research and learn as much as you can about the care you’re trying to get. The more you know about the care, the better you’ll be able to explain why you need it, which a lot of doctors/insurance agents will obnoxiously ask you to do. Practice explaining why you need care, and try to demonstrate as best you can that you know what you’re asking for and that you know it’s right for you. It’s shitty that doctors and insurance agents often start in opposition to trans folks who want trans-related health care, but the more you can argue for yourself, the better it is.
A note about timing: if you have a particular window of time during which you want to get surgery or start hormones, you’ll want to start the process of working with your insurance company as early as you can. For surgery, some offices have a really long waiting list, and sometimes the fight with the insurance company can take a really long time.
2. Does my insurance cover this procedure?
After you’ve figured out the care you need, you’ll want to figure out if your insurance covers that particular type of care. In California, it is legally required that insurance cover transition-related health care. That is the law. If your insurance company says they don’t cover it, you can work around that because they are actually legally required to do so. MediCal also pays for surgery and hormones. I don’t know what the case is in other states, but I’m looking for a website or database that has gathered that info and will post it here when I find it.
For folks who don’t have insurance, there are also medical clinics in many communities in California that can provide hormones. I’m sure these clinics are in other states as well, and I’ll post back if I find some sort of database.
If you’re in a state where insurance companies are not required to cover transition-related care, I really recommend reaching out to a community center nearby, or contacting a friend or community member who can help you figure out a payment plan. I’m not really sure what to do in this case myself, but if you’re reading this and you need help figuring out how to fund your surgery, inbox me and together we can think of ways to fund raise and move forward.
3. What kind of Gatekeeper system does my insurance have?
Almost every insurance company will make you jump through hoops to prove that you really need care. It’s disgusting. In an ideal world, everyone would have bodily autonomy and could determine what they need and when they need it without having to prove anything to anyone else (but I digress). So insurance companies require you to take certain steps before they agree to cover your procedure.
For top surgery most insurance companies require that you get a letter from gender-specialized therapist and from a primary care physician, explaining that they agree you need surgery. For bottom surgery insurance companies often require that you are on hormones for 12 months before getting surgery, in addition to getting letters from therapists and physicians and surgeons. These requirements are going to change based on the insurance you have, but they should state up front the requirements for each procedure.
An important thing to note here is that often insurance companies will say that you need to be on hormones before getting surgery. That’s bull shit. If you don’t want to go on hormones, but you do want surgery, you can do that.
4. How do I get a doctor or therapist to write me a letter?
This can be a bit tricky sometimes because there are many medical professionals who think, like the insurance companies, that they should act as gatekeepers for your well being. I really recommend speaking with other trans or queer people in your community to find “LGBTQ friendly” doctors. Book an appointment with them, when you meet with them explain that you need them to write a letter. This can be hard. Please if you can, bring a buddy with you to the appointment who can help you explain things. Some doctors will write a letter after one or two visits. Try to find those doctors.
You may need to try a few doctors before picking one to write your letter (as time and money allows you to do so). If you want surgery but a doctor says you need to go on hormones first, find a different one.
5. What happens if my insurance company says they won’t cover it?
If you’ve provided all the information and letters the insurance company has asked for, and they still say no, then you can start an appeals process. It’s long and frustrating, but in California it’s required by law. My family and I appealed twice to our insurance company before then filing a claim with the State Board of Health. At that point the insurance company assigned us a case manager who called and spoke more in depth with my parents. Eventually they agreed to pay.
We were helped throughout this process by Trans Family Support Services in San Diego. If there’s a community center near you, I really recommend reaching out to find an advocate or someone who has gone through the process before and can guide you.
That’s a lot of information! I’ll continue to check back in and update this as I learn more. Please contact me if you want me to add anything or if there’s something I need to correct in the information I’ve provided. Godspeed, Spiderman.
breast2chest 