FTM Top Surgery Insurance Coverage:
What You Need to Know
The tides are turning: more and more insurance companies in the United States are accepting the medically necessity of Gender Reassignment Surgeries (GRS) and are covering FTM chest surgery.
The medical necessity of GRS has been affirmed by the American Medical Association (pdf), American Psychiatric Association, and World Professional Organization for Transgender Health (pdf), as well as insurance companies such as Aetna.
State Non-Discrimination Laws
There are a number of states that now prohibit discrimination and legally require insurance companies to provide transgender health coverage:
- Oregon - Oregon removes barriers to transition-related care (Jan 2013)
- California - California’s Ban on Transgender Exclusions in Health Insurance - FAQ (April 2013)
- Colorado - What Coloradans Need to Know About the Division of Insurance Recent Bulletin on Health Insurance (March 2013)
- Vermont - Vermont Orders Insurance Companies to End Transgender Exclusions (April 2013)
- Connecticut - Connecticut Becomes Fifth State to Require Transgender Medical Coverage (Dec 2013)
- Washington D.C. - Mayor Gray Announces Steps to Protect GLBT Community from Discrimination in Health Care (Feb 2014)
- Massachusetts - Trans Residents Celebrate Monumental Health Care Ruling in Mass. (June 2014)
- Washington - Progress: Washington's Health Insurance Policies Cannot Discriminate! (June 2014)
- Illinois - Illinois advocates hail great first step to end discrimination against transgender individuals in health insurance coverage (July 2014)
- New York - Insurers in New York Must Cover Gender Reassignment Surgery, Cuomo Says (Dec 2014)
If you live in a state where surgery coverage is not mandated by law, you still might be able to get your top surgery covered via student health insurance. (See More American Universities Including SRS Coverage in Health Insurance Plans.)
Am I Covered?
Keep in mind that coverage varies between health insurance companies, states, and plans. Don't assume that one company, state or plan is consistent with their level of coverage. Read your policy completely—not just the summary—and look for the exclusions and limitations section. Next, call your insurance company's member services department, or contact a benefits representative where you work, and ask:
- Is my selected surgeon a provider with my specific plan? (Make sure that you provide the representative with your surgeon's NPI number.)
- If my surgeon is NOT a provider, does my plan have out of network benefits?
- Does my plan cover gender confirmation Top Surgery?
- How much is my deductible?
How to Find Insurance
To get Top Surgery covered by insurance there are a number of requirements. Some of the hoops you may need to go through include:
- Meeting the insurance company's basic criteria: legal adult status, Gender Dysphoria diagnosis, support letters from qualified mental health practitioners, your primary care provider and your surgeon.
- Having to pay out-of-pocket for surgery, then getting a reimbursement from the insurance company.
- Having to be evaluated by a board of in-network doctors.
- Finding in-network surgeons who have Top Surgery experience.
Appealing a Health Insurance Denial
If your insurance company denies to cover your Top Surgery, you have every right to appeal the decision — and you should.
The Affordable Care Act
The Affordable Care Act and The Patient’s Bill of Rights add several important protections in health insurance that affect transgender people:
- Elimination of coverage denials: Anyone can apply for health insurance and receive coverage the care they need, regardless of their gender. (For example, hysterectomy coverage for a trans man.)
- Pre-existing condition acceptance: Insurers are no longer able to deny a person coverage based on having what an insurance company considers a pre-existing condition, which has included being transgender.
- Plan cancellations are now illegal: Cancelling a plan used to be a way for health insurers to cancel coverage when a person’s health needs changed, such as coming out as transgender.
For more information about the ACA, see What the Affordable Care Act Means for Transgender People (Aug 2012).
Last updated: 11/07/16
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