QUESTION

My plan refuses to cover services related to gender transition. Is this allowed?

Post enrollment issues | Individual Health Insurance | Employer-Sponsored Coverage |
ANSWER

Coverage of gender transition services varies by insurer and state. The Affordable Care Act prohibits health plans and providers that receive federal financial assistance from discriminating on the basis of sex, which includes discrimination on the basis of gender and gender identity (the regulation implementing this provision is currently being revised, but the law’s protections are still in effect). This generally means that Marketplace plans cannot categorically refuse to provide you treatment based on your gender identity and must cover medically necessary services as long as those services are covered for other people on your plan. For instance, a Marketplace plan may not deny coverage for preventive screenings (e.g., mammograms, pap smears, and prostate exams), mental health services, or surgical procedures related to gender transition based on a person’s sex assigned at birth. If you believe you are being discriminated against by your health plan when seeking gender-affirming care, you should first seek to appeal any adverse benefit decisions. You can also file a complaint with the U.S. Department of Health & Human Services’ Office of Civil Rights or with your state Department of Insurance. For assistance determining the right course of action for you, there are several legal organizations you can contact. For more information on state-specific requirements with regard to coverage of transgender and transition-related services, see Out2Enroll’s Trans Insurance Guides.

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