How to Find Health Insurance that Covers Gender-Affirming Care: (Health Insurance for LGBTQ Folks Ep. 5)
- Ben Panico (he/they)
- Aug 5, 2025
- 11 min read
In the fifth episode of our Health Insurance for LGBTQ People series, we dive into different plan contracts searching for coverage of gender-affirming care, understanding prior authorization requirements, and noting plan exclusions. We go through the important things to look for and walk through several examples so you can learn how to figure out if a plan will cover the care you need.
Time stamps:
1:18: What is a policy contract?
4:40: Preventive care is always covered regardless of sex assigned at birth, gender identity, or gender marker
6:16: Aetna medical policy on gender-affirming surgery
7:43: Moda of Texas
12:03: Prior authorization is often required for gender-affirming care
13:30: Oscar of Georgia
14:15: Recap of how to find gender affirming coverage in plan documents
Transcript:
Introduction
Welcome back to another episode in our series on health insurance for LGBTQ folks. In the last episode, we talked about a lot of the reasons why you might choose one health plan over another, including network size, cost, a preferred doctor, and some of the covered benefits.
In this episode, we're going to cover one specific benefit: gender-affirming care. We're going to look at how to figure out if a plan covers gender-affirming care. Unfortunately, not all plans in the U.S. cover gender-affirming care, and if they do, they probably don't cover all types of gender-affirming care. So we're going to go over some example plans and figure out how you can find a plan that covers the care that you need.
Where to Look for Coverage Details
A couple of episodes ago, we looked at some sample summaries of benefits and coverage, which are the maybe five-to-six-page documents that have all the information about how much you might pay for a certain procedure, either in-network or out-of-network. At the bottom of that, remember, we looked at some of the “not covered” benefits.
Unfortunately, gender-affirming care isn't going to show up here. In order to figure out if a plan covers gender-affirming care and look more specifically at the procedures that are covered, we need to dive into the policy contract itself. This is more like a 100-page document that is an actually legally binding contract between you and the insurance carrier. This is a document that you'll be given once you sign up for a certain plan. However, they are supposed to also be publicly available on their website and hopefully linked through the summary of benefits and coverage.
Before We Get Started
So I've got a couple queued up here. We're going to go through and look at the policy contracts and figure out how you can decide if a plan covers gender-affirming care or not. I also am going to show you how to find these in case they're not linked properly.
Before I get started, I just want to say that these are the plans for 2025 — so the current plan year. If you are watching this and looking for a health plan for next year, please know that these policies are not going to be made available until either open enrollment starts, or in the past couple of years, we've had something called “window shopping,” which is maybe a couple weeks before open enrollment starts. It gives you a chance to preview the plans.
So you'll have to check back again in November to see what plans for 2026 are going to include. And you can always head to our website here, where we'll have trans guides made available so that you can have a starting place to look at which plans we think might include gender-affirming care.
How to Read a Policy Contract (An Aetna CVS Health Plan example)
The first plan we're going to look at here is an Aetna CVS Health plan. This is out of Florida, and again, this is from 2025. When you open up the summary of benefits and coverage here, you always want to make sure first that the year is the correct year, and whatever state you're in is correct as well, because these documents all kind of look the same — so you never know if it's exactly right.
You can see here: “For more information about your coverage or to get a complete copy of the terms of coverage, visit this website.” And this is what we're looking for — we're looking at the complete terms of coverage. Sometimes it's called “policy contract.” It might be called “evidence of coverage,” or “coverage booklet,” or “benefits booklet.” So there are a lot of different terms. Either way, this is where we're going to go to read the entire document and know if gender-affirming care is covered.
Evaluating Covered Benefits
All right, so here is the document that Aetna downloaded for us — the 2025 Florida Silver 10 Advanced HMO Plan. The way that we're going to look at this is a couple of things. We want to look for:
The surgical benefits.
If there’s a gender-affirming care section — that’s excellent; a lot of plans don’t have that.
Cosmetic exclusions.
The policy exclusions section.
So let's scroll down here and see if gender-affirming care is covered. We do have a section in here, in the covered benefits, on gender-affirming treatment. We’ll visit this link in a second, but I want to go through the rest of the document and see if it says anything else.
Preventive Care Requirements
I do want to take a second here to look at this preventive care section. It is important to know that the Affordable Care Act requires preventive coverage regardless of your sex assigned at birth, your gender identity, or your gender marker on legal documentation. So this means that if you need to get a cervical screening, a prostate exam, a breast cancer screening — it’s going to be covered regardless of your gender identity or the sex on your documents. If you have the anatomy, you need to get the cancer screenings done — and it should be covered under preventive care, so free.
Policy Exclusions to Look Out For
Coming here to the general policy exclusions is a really important place to look. These are things that are not going to be covered for basically any reason. These are explicit exclusions in the plan. We want to look at sections like this — so “cosmetic services” are often overly broad exclusions here that may make it difficult to get access to care like facial feminization procedures.
So when it says, “Any treatment to alter, improve, or enhance the shape or appearance of the body,” that makes me nervous that you might not be able to get certain care like a facial feminization procedure. Now, it does say, “Except where described in the coverage and exclusion sections.” So that’s going to bring us back to the gender-affirming care section, which leads us to their medical policy on gender-affirming care.
What Is and Isn't Covered In a Medical Policy
Let’s turn to that now. We can see here that they're listing certain requirements for medical necessity of different gender-affirming procedures. These are mostly surgical procedures.
Then there is a section down here — “Not medically necessary.” Unfortunately, you can see here that they're saying that hair removal is not medically necessary unless it's part of a surgical procedure.
That is something that is really common in these health policies. I don't personally agree with them, but they are listed in here. So this is important to know — this plan isn't going to cover facial hair removal, for example, if you're a trans woman needing that procedure done.
These are some other procedures that this policy doesn't cover. Now again, I don't agree with this. However, this is what's in the policy. So if you are a trans woman, for example, looking to have vocal cord surgery so that your voice could be higher, then this is important to know that this is not going to be covered under this Aetna plan. You can scroll down here and see that they do have a different policy for voice therapy.
So we come here, and we scroll down, and we see here that they say that voice therapy is considered not medically necessary and cosmetic. Again, I don't agree with that. This can be extremely necessary for certain individuals so that they can pass better in public, which is a matter of safety. So you might want to look elsewhere for health insurance.
Looking at a Moda Plan
Let’s look now at a different plan. This is a Moda plan out of Texas, and you can see here that the URL for this is not comprehensive — this is just a generic URL. And I do want to go through this so that you can try to figure out how to sleuth and find these policies on your own.
So, if we come to this page — this is the member page for Texas — we're going to scroll down. It might be in forms and documents. It might be under here, under "Resources" and "Individual Medical Plans and Policies." I actually think that's it — forms and documents.
They do have something on gender-confirming care, so we'll see what that says. And then we also can see that the medical plans and policies are what we were looking for. So we'll come back here in a second. I'm curious what this document says. "We support gender-confirming care. We offer mental health, hormone therapy, certain procedures." And this is treatment that meets medical necessity.
I wouldn't expect a document like this to list things that they don't cover. However, you can see here that they do cover facial surgery, which is generally something that not everyone covers — so that seems good. And we can look more in the specific policy document for any exclusions.
Finding the Policy Contract
So let's come here. We're looking at Moda Select Texas Standard Silver. So we’ll come down here, and we’ll see — Standard Silver is right here. These are the different cost-sharing reductions that we discussed in the latest episode. And this is American Indian/Alaska Native coverage — so that’s specific to folks who are part of a tribal community. So we just want to click on the standard one. That'll bring us to this policy.
And now we can scroll down here and see that gender-affirming care is listed. It brings us down to this section: "Expenses for gender-affirming care are covered when the following conditions are met." And then you can see here that this is listed — basically just what was in that other document we just saw. So, no extra information provided there.
Hair Removal Policy
Let’s search and see if we can find something else — for hair removal. So we can see down here in the general exclusions — we came to that — hair removal is listed as a cosmetic procedure, which is not surprising; it often is. However, it's not for trans folks. It does say that exceptions are provided for reconstructive surgery. However, obviously, facial hair removal would not be part of a surgical procedure. So I'm not exactly certain if it's going to be covered or not.
In a case like this, I would say it's best to call the company directly and tell them that you're searching for health insurance that's going to cover hair removal, and see if that's going to be a covered service.
However, I would say that other than that, this is a pretty good policy. They are covering a number of surgical procedures here, as well as hormone therapy and puberty suppression for adolescents. Of course, that depends on the law in the state that you're in. We know a lot of states right now are making that care illegal, so this would be dependent on the state law. But this is generally a pretty good policy.
Reviewing a Blue Cross Blue Shield Plan from North Carolina
Let's now look at this Blue Cross Blue Shield plan from North Carolina. If we look here, it will direct us to the booklets. We can see there are a bunch of booklets available. I was looking specifically at the Blue Home Silver Preferred plan.
Again, cost-sharing reductions are available depending on your income level. We generally want to look at the standard plan first, and then the cost-sharing reductions probably have the same care, just obviously with lower cost-sharing.
Surgical Benefits and Prior Authorization Requirements
Under the surgical benefits section, let's read over some important notes. Certain procedures, including bariatric surgery, gender affirming surgery, hormone therapy, and others that are potentially cosmetic, require prior review and certification, or the services will not be covered.
This is a really important note: many plans require prior authorization in order to cover gender affirming care. For example, if you go to your doctor, get a referral for a surgeon, have your surgery done, and then try to get reimbursed by your health insurance plan, it’s possible they will not pay you back. Many plans require prior authorization ahead of time before the procedure is done in order to cover it. Make sure you have all your ducks in a row and that you’re doing things in the proper order, getting the documentation the insurer requires.
Covered Gender Affirming Services in the Plan
Coming down here to gender affirming services, you can see that this plan covers hormone therapy, voice lessons, and voice therapy, gender affirming surgery—including chest, facial, and general procedures—and related hair removal.
Note that hair removal might not be facial hair removal; it might just be hair removal related to a surgical procedure. This is an important distinction to ask about. More detailed information is also listed in their specific medical policy for gender affirming care.
Examining an Oscar Plan from Georgia
I want to look at one more plan, which is the Oscar plan out of Georgia. Let’s see what they have for us. If we search for gender affirming services, we can find the definition section. Under covered services, gender affirming services may include hormone therapy, counseling, psychiatric care, and gender affirming surgical services.
There is a brief note stating that if they consider a service to be cosmetic, experimental, or investigational, it is excluded. While this isn't terribly helpful, it does give you a sense that hormones, therapy, and some surgical procedures are generally covered.
Key Sections to Review in Policy Contracts
Just to briefly go over this again, when you’re looking at policy contracts, you want to read through several sections carefully, including:
The mental health section
Surgical benefits section
Cosmetic section
Gender affirming care section (if there is one)
You also want to review the list of exclusions to see if any procedures you want are excluded.
Additionally, look specifically for prior authorization requirements, because prior authorizations are extremely necessary to make sure your coverage will actually apply to any procedure you get done.
Getting Help If You’re Confused or Overwhelmed
Usually, your doctor or surgeon can help you navigate this process. It’s just something that needs to happen before your surgery itself can take place. If this seems like too much or if you can’t find the policy contract you’re looking for, don’t worry—this is super confusing. That’s why there are people who can help you.
You can reach out to an assister using our assister locator tool to find someone who is LGBTQ-affirming and knows how to find this information in plans. They can help you find a plan that fits your budget and provides the benefits you need.
Trans Health Insurance Guides
I also recommend taking a look at our Trans Health Insurance Guides. These come out at the end of November every year and give you a starting point to look at different health insurance plans in your state that may cover gender affirming care. This guide isn’t meant to be the endpoint—it’s just a starting place where you can review insurers based on our criteria and figure out if they are likely to cover the specific benefits you need.
Contacting Your Insurer Directly
Finally, you should feel free to reach out to the insurer directly. You can call them if you have questions about a specific benefit or coverage needs. They should be able to help you—either through member services, claims, or by providing information about specific medical policies.
Conclusion
I hope this tour of policy contracts helps you feel more confident about finding a plan that covers the gender affirming care you need. Now that you know how to find a plan, in the next episode, we’ll go over signing up for a plan, getting gender-affirming care, and appealing denials of care if you experience them.