My insurer removed coverage for gender-affirming care. What now?

Countless trans people around the country are asking this question. As hostile federal and state governments continue to target our community, we are seeing insurance companies revoke coverage for gender-affirming care. From Medicaid to the Health Insurance Marketplaces, denials of claims for the care we need are unfortunately becoming more common. Here's what you need to know and what you can do.

Is this legal?

No, not really. Your insurance plan likely lasts through the calendar year, January 1st to December 31st. Your plan contract is exactly that: a legally binding contract between you and the insurance carrier. It is not legal for the insurance company to change the terms of this contract mid-year, and denying claims for the transgender health care services outlined in the contract is exactly that.

However, some insurance carriers are using legal loopholes and other sneaky tricks to make it more difficult for trans folks to get the care they need. For example, the insurance carrier Ambetter (which is owned by the Centene Corporation and sells plans on the Marketplaces in more than two dozen states) avoided changing their contracts by changing their underlying clinical necessity guidelines instead. The new guidelines falsely claim that gender-affirming care is “not medically necessary.”

How can they do this?

Unfortunately, the attacks that the federal government and many states are leveling against trans people are creating circumstances where insurance companies feel like they can do whatever they want. The federal government is actively working to discriminate against trans people in health insurance and health care—as well as in many other areas of everyday life—and it is also intentionally creating an environment where it’s increasingly difficult for trans people to know what our rights are and to find ways of enforcing those rights.

What can I do about it?

The good news is that many states do still have health insurance non-discrimination laws that protect LGBTQ people. The states are the main regulators of health insurance in the U.S., which means that the reach of the federal government is limited—no matter what the president claims. Health insurance companies have to listen to state regulators, and they also have to provide opportunities for appeals when care is denied.

Every insurance company has a process for appealing denials, and that’s the best place to start. You can work with your health care provider to document the medical necessity of the care and file an appeal with the plan. This might allow you to get coverage approved on a case-by-case basis. While individual circumstances vary, a significant number of denials are overturned on appeal. Make sure that your provider carefully outlines why the care is necessary for you and cites the peer-reviewed literature (such as the World Professional Association for Transgender Health Standards of Care or the Endocrine Society Clinical Practice Guidelines) in support of your case. Also make sure to keep a close eye on what other information is required for an appeal by your insurer and follow the plan’s deadlines, as outlined in the plan’s certificate of coverage. 

If your appeal is denied, you can request an external review, which is conducted by an independent review board through your state's Insurance Commissioner. You can also file a complaint with your state's Insurance Commissioner, who can help fight your insurance company on your behalf. 

If all else fails and you have to pay for care out of pocket, we recommend searching for a fund like Point of Pride where you can get a scholarship to pay for care. You can also use the LGBTQ Healthcare Directory to search for providers who accept payment on a sliding scale.

Can I change my insurance plan?

Unfortunately, it is unlikely that you will be able to change your insurance provider mid-year. If you are on a Marketplace plan, losing coverage of gender-affirming care is not enough to qualify for a Special Enrollment Period in order to switch to a different insurance carrier.

If you are on Medicaid, you may be able to switch to a Marketplace plan. Unfortunately, you would need to pay full price for the Marketplace plan if you do so, which is likely cost-prohibitive for most people. When you enroll in a Marketplace plan, you can choose to waive the eligibility check for Medicaid. However, doing so also means that you will not be considered for cost-sharing reductions or Advanced Premium Tax Credits. Without these reductions, national averages for deductibles are more than $600 monthly and vary by state and age.

How do I choose a health insurance plan for next year?

Open enrollment (the time when you choose your health plan for 2027) starts November 1st in most states. You can check out our Consumer Training series to learn how to research plans  and find one that will cover the care you need. You can also reference our Trans Health Insurance Guides, which are a good starting point for seeing which plans are more likely to cover transgender care. Keep in mind that a plan categorized as "Some Exclusions" may still be okay for you if the exclusions are not relevant for your particular care needs.

I need help. Who can I talk to?

We provide training for enrollment assisters so they can help you find a plan that covers transgender care. You can meet with an assister—FOR FREE!—virtually or in person. Find an assister near you using our handy Assister Locator Tool. And remember: keep calm and get covered!