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Insurance Coverage for Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on March 13, 2024.

Navigating insurance coverage for gender affirmation surgery can be complex, but many insurance providers now recognize these forms of healthcare for transgender individuals as medically necessary and thereby deserving of coverage. This guide aims to simplify the process of finding and applying for insurance coverage for gender-affirmative surgery, also known as gender confirmation surgery.

The GCC’s list of insurance providers that cover gender-affirming surgeries

Below you can find a list of insurance providers for which our team has successfully obtained approval for top surgery procedures from here. If you don’t see your insurance listed here or are unsure, you can schedule a free, virtual consultation so our team can verify this information for you. Unfortunately, Medicare does not cover any of our procedures at this time.

*  This list does not guarantee insurance coverage for top surgery and successful approvals may vary on a number of factors, such as the type of plan for each insurance company.

How to Get Coverage: An Overview

The following information is meant to give you an overview of all the components you will need to take into consideration in finding an insurance plan that will cover your gender-affirming surgery.

• Contact your insurance provider directly to inquire about coverage for gender reassignment surgery. You can start by calling the phone number on your insurance card.
• Review your insurance policy or member handbook carefully for any exclusions or limitations related to transgender healthcare.
• Consult the Transgender Legal Defense & Education Fund (TLDEF) for a list of insurance companies known to offer coverage for gender affirmation procedures.
• Get enrollment help from Out2Enroll once you are ready to sign up for health coverage to understand your options.
• Coverage Exclusions: Federal and state laws prohibit discrimination against transgender individuals by most public and private insurance health plans. This means insurance companies must cover transition-related care that’s medically necessary and it is illegal for them to deny coverage, in most cases. Some plans may still have exclusions in their policies, but you can ask for an exception or request the removal of the exclusion.
• Medical Necessity: Virtually all major insurance companies now recognize that gender-affirming medical care for transgender patients is medically necessary. However, the specifics of what procedures or treatments are covered will depend on each insurance plan. Most of them will require letters from healthcare providers to support medical necessity. You can find a list of therapists that can provide support letters for insurance coverage through GALAP .
• Referral Letters: To secure insurance coverage, patients will need 1-2 letters from healthcare providers. Besides a therapist support letter, if GCC surgeons are not in-network providers, you will need a referral letter from your Primary Care Physician.
• Financial Options: If your insurance provider does not cover gender-affirming surgery, other options include paying out-of-pocket, taking out a personal loan, or seeking financial help from charities and organizations.

Identifying Insurance Providers That Cover Gender Affirming Surgery

If you live in the United States, here’s a list of resources to help you identify insurance providers offering coverage for gender-affirming surgery:

• Transgender Legal Defense & Education Fund (TLDEF) provides a list of insurance companies that have coverage for gender-affirming care.
• Campus Pride provides a list of colleges and universities by state that cover gender-affirming surgery or hormone therapy under student health insurance.
• Our Insurance Advocacy Team here at the Gender Confirmation Center has successfully secured coverage for surgery from the insurance companies mentioned above.

Navigating Insurance Policies for Gender Affirming Surgery

The National Center for Transgender Equality created a guide to help navigate getting your insurance to cover gender-affirming care. This process can be summarized in 3 steps below:

• Learn what your insurance plan covers for gender-affirming care by calling your insurance company and ask what medical policies on gender dysphoria treatment are applicable to your plan. You may also find this information in the Member Handbook provided by your insurance.
• Determine the type of insurance you have (self-funded vs fully insured) to see if there are exclusions or limitations on healthcare coverage for transition-related care. Self-funded plans (e.g. insurance through work, school, or government employment) typically have exclusions or limitations to coverage that may be exempt from state protection laws. You may need to request your employer or school to remove the exclusion before insurance can cover surgery.
• Gather necessary documentation , such as letters from healthcare providers (i.e. mental health provider). Most insurance companies require at least 2 letters to cover bottom surgery procedures. In this case, a t least one should come from a licensed mental health professional. The second can come from a mental health or a healthcare provider: for example, an endocrinologist or primary care provider who has been involved in your hormone therapy.  We recognize that the two-letter insurance requirement can be an extra barrier for patients to access medically necessary, gender-affirming care. For this reason, once you have requested a surgical consultation , we can help you through securing this and any other documentation.
• Submit a pre-authorization request to your insurance provider by writing a letter to explain why the procedure is necessary and why refusing to provide coverage may be illegal.
• Follow up with your insurance to ensure the request is being processed or check on its status. Your insurance will send you a notification if your request has been approved or denied.

Navigating this process can be challenging but our Insurance Advocacy team works directly with your insurance for each step of this process until the insurance company reaches a decision for the preauthorization request. This service is provided free of charge for our patients to ensure the best chance of success in getting their surgery covered.

Overcoming Challenges in Insurance Coverage for Gender Affirming Surgery

• Denial of preauthorization request or claim for reimbursement: Understanding the reason for denial can help determine your options for appealing this decision. Seeking legal assistance from a lawyer may help facilitate this process.
• Dealing with out-of-network coverage: Insurance companies usually have a list of “in-network” healthcare providers that are covered by a particular plan. While some patients are restricted to these in-network providers (i.e. HMO plans), others may have the option to see out-of-network providers if the in-network options are not qualified (i.e., PPO plans). For example, your insurance may restrict you to seek care from a surgeon who can perform mastectomies but may not have training in gender-affirming techniques. In such cases, you have the right to seek out an out-of-network provider who is qualified in gender-affirming surgery, as the in-network provider cannot fulfill your specific needs. It’s essential to understand that the insurance may initially refuse coverage for out-of-network surgeons or facilities, but this decision can be challenged through the appeals process.
• Consider an independent review for denials : If the insurance company continues to deny coverage, you may have the option to request an independent review by a third-party organization. This review can provide an unbiased evaluation of your case and potentially overturn the denial.

Exploring Financial Aid Options for Gender Affirming Surgery

• Surgery Grants: Organizations and programs may offer grants or financial aid to help cover the costs of surgery. The GCC works with various organizations to help with costs of surgery. Learn more about them here.
• CareCredit: GCC has partnered with CareCredit to help patients finance the costs of surgery. Patients can apply for this credit card to see if they qualify and figure out what payment plan options are available.

Advocating for Comprehensive Insurance Coverage

The Affordable Care Act prohibits discrimination based on gender identity, which can be leveraged when seeking coverage for gender-affirming surgery. Despite this, many still face challenges with access or coverage of medically necessary transition related care. Recently, these states have limited protections for transgender youth after passing laws banning their access to gender-affirming care.

Navigating insurance coverage for gender-affirming surgery can be challenging, but our Insurance Advocacy team is dedicated to ensuring access to care for our patients. The National Center for Transgender Equality and Transgender Legal Defense and Education Fund also provides a comprehensive list of resources to help patients find and get insurance coverage for gender-affirming care.

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In many cases, health insurance in the U.S. covers gender-affirming care. However, whether or not your insurance plan will cover a specific gender-affirming treatment can depend on your state, your employer, and your plan's benefits.

Key Takeaways

• Health insurance generally covers gender-affirming care.
• Not all plans cover all procedures, however, and the process can be murky and require preauthorization.
• Gender-affirming care can cost tens of thousands of dollars without insurance coverage.

Major insurance companies today generally recognize transgender-related care as being medically necessary . However, at least 24 states have passed new laws or enacted new policies limiting coverage of gender-affirming care for people up to age 18. And some transgender people may still be denied coverage for certain procedures by their insurers.

1.6 million

The estimated number of Americans age 13 or older who identify as transgender, according to a 2022 study.

Health insurers generally cover an array of medically necessary services that affirm gender or treat gender dysphoria, according to the American Medical Association, which reaffirmed its advocacy for such care in 2023. Gender dysphoria is a condition that occurs when someone feels a conflict between the sex they were assigned at birth and the one they now identify with.

Gender-affirming care is the phrase used by most medical groups for dysphoria treatment. This care can include hormones, surgery, or counseling. The care aligns a person's gender identity with gender expression in appearance, anatomy, and voice.

In 2010, the federal Affordable Care Act (ACA) banned health insurance discrimination based on sexual orientation and gender identity. Before the law's passage, medically necessary gender-affirming surgeries and hormones often weren't covered by insurers.

A 2024 rule from the Department of Health and Human Services stated that covered entities (a term that includes both insurance plans and providers such as doctors) could not "deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for specific health services related to gender transition or other gender-affirming care if such denial, limitation, or restriction results in discrimination on the basis of sex."

However, insurance is also regulated at the state level and rules can vary based on whether it is an ACA, public, or employer plan, so they don't apply evenly to all insurers.

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Policyholders and plan members can generally find out what's available to them in their member booklet. This should have been given to you when you got the policy or, if it's an employee plan, when you joined the company. It may be called a certificate of coverage, a benefit plan, a summary plan description, a certificate of insurance, or something similar.

This document should describe the insurer's clinical evidence criteria to qualify for claim coverage. For example, to begin hormone therapy, the requirements might include a diagnosis of gender dysphoria from a licensed mental health professional.

Some plans may list exclusions for certain procedures. Even if an exclusion exists in the documentation, it can still be worthwhile to apply for pre-authorization or pre-approval for the procedure to obtain an official decision. For one thing, as the Transgender Legal Defense & Education Fund, notes, "the plan booklet may simply be out of date."

Even if you're turned down, that is not necessarily the final word. If a preauthorization request or a claim is denied, an attorney, healthcare advocate, or your human resources department may be able to help with filing an appeal. Appeals should include individualized, extensive documentation of a service's medical necessity and appropriateness.

Here, we list four types of health insurance and how they might cover gender-affirming care.

Employer-Provided Insurance

Altogether, 24 states and the District of Columbia prohibit transgender exclusions in private health insurance coverage, according to the nonprofit LGBTQ+ advocacy organization Movement Advance Project, leaving half the states without such protections.

However, health coverage benefits that a private employer provides can vary based on whether the employer buys its coverage from an insurance company or is funding the plan itself. If the employer's plan is self-funded, it is governed by the federal law ERISA, the Employee Retirement Income Security Act , which overrides any state nondiscrimination law. The employer can decide what health care is or is not covered.

In the Human Rights Campaign's 2023-2024 Corporate Equality Index, a record 94% of the companies it evaluated offered at least one transgender-inclusive plan option.

Employer-based plans are governed in the state where the plan was issued, not where you live.

Affordable Care Act Plan Coverage

Individuals can buy their own health insurance policies, often with the help of federal subsidies, through the Healthcare.gov Marketplace. Most insurers have eliminated transgender-specific exclusions, which ACA regulations explicitly ban.

Still, policies vary by state and in what they cover. As the Healthcare.gov website notes, "Many health plans are still using exclusions such as 'services related to sex change' or 'sex reassignment surgery' to deny coverage to transgender people for certain health care services."

It suggests that before enrolling in a plan, consumers should carefully review its terms: "Plans might use different language to describe these kinds of exclusions. Look for language like 'All procedures related to being transgender are not covered.' Other terms to look for include 'gender change,' 'transsexualism,' 'gender identity disorder,' and 'gender identity dysphoria.'"

Fortunately, according to Out2Enroll, an organization connecting the LGBT+ community with healthcare coverage, when it recently reviewed silver Marketplace options in 32 states it found that "the vast majority of insurers did not use transgender-specific exclusions" and that "40% of plans had language indicating that all or some medically necessary gender-affirming care would be covered by the plan." (ACA coverage is broken down into bronze, silver, gold, and platinum plans, with silver being a moderately priced level.)

Out2Enroll also has state-specific Transgender Health Insurance Guides on its website for help in choosing a plan.

Medicare and Medicaid Coverage

About 6% of transgender adults receive their health coverage from Medicare, the federal insurance program primarily for Americans over age 65. Under these plans, medically necessary care—including some gender-affirming procedures—is covered. Private Medicare Advantage plans should abide by the same rules as traditional Medicare, but patients on such plans should try to get preauthorization before accessing transition-related services, the National Center for Transgender Equality advises.

Some 21% of transgender adults receive Medicaid, the joint federal and state health insurance plan for low-income Americans. On a state-by-state basis, Medicaid coverage is uneven. Medicaid programs explicitly cover transgender-related care in 26 states and the District of Columbia. Meanwhile, programs in 10 states bar coverage of transgender-related care for people of all ages, and programs in three states prohibit coverage of transgender-related care for minors.

Military and Veteran Coverage  

Active military members can access some types of gender-affirming care. TRICARE, the health benefits provider for military members, says it "covers hormone therapy and psychological counseling for gender dysphoria. TRICARE generally doesn't cover surgery for the treatment of gender dysphoria. However, active duty service members may request a waiver for medically necessary, gender affirming surgery."

The Veterans Health Administration offers gender-affirming healthcare, including hormones and prosthetics, mental health care, and other healthcare. Coverage for gender-affirming surgery has traditionally been denied but is currently undergoing a review.

How Much Does Gender-Affirming Surgery Cost?

The cost of gender-affirming care might range from $25,000 to $75,000, according to an estimate from the Human Rights Campaign.

Gender-affirming surgeries may include top surgery (breast removal or augmentation), bottom surgery, vocal surgery, and face and body surgeries such as browlifts, jawline contouring, Adam's apple removal, and forehead reduction.

Bottom surgery may include:

• Phalloplasty : Creation of penis 
• Metoidioplasty : Phallus created from existing genital region tissue. 
• Hysterectomy : Uterus and cervix removal  
• Nullification surgery : Creating a gender-neutral look in the groin
• Oophorectomy : Removal of one or both ovaries
• Vaginoplasty and vulvoplasty : Creation of vagina and vulva 
• Orchiectomy : Testicle removal 

Research published in 2022 by JAMA Surgery found that while gender-affirming surgery can be costly, insurance (for patients who have it) will often cover most of the cost. Looking at phalloplasty and vaginoplasty procedures specifically, it reported:

However, not all transgender people desire surgery. According to 2019 research statistics, only 28% of transgender women get any type of surgery, and only 4% to 13% receive genital surgery. Surgery is more common among transgender men, with 42% to 54% getting some type of surgery; up to 50% get genital surgery.

How Much Does Gender-Affirming Medication Cost?

Gender-affirming medication is far more common than surgery. As many as 65% of transgender people received gender-affirming hormone therapy in 2019, up from 17% in 2011, according to the Journal of Law, Medicine & Ethics .

The costs of gender-affirming medications can vary widely. While they are often at least partially covered by insurance, they also come with out-of-pocket costs, which may continue through the patient's lifetime.

For example, a study in the Journal of General Internal Medicine reported that, "in 2019, median prices for feminizing and masculinizing hormone therapy ranged from $6.76 to $91.15 and $31.82 to $398.99, respectively." At the same time, patients' "median out-of-pocket costs ranged from $5.00 to $10.71 and $10.00 to $12.86 for feminizing and masculinizing hormone therapy, respectively." Those prices refer to a 30-day supply.

Other costs can be involved as well. For example, patients who are taking hormones may need periodic blood tests to monitor their health.

A 2020 study in Annals of Family Medicine found that among insured respondents taking gender-affirming hormones, almost 21% reported that their claims were denied. This group (and those who are uninsured) were more likely to take nonprescription hormones from unlicensed sources, which may not be monitored for quality and potentially carry serious health risks.

Aside from health insurance, how can you pay for gender-affirming care or surgery? Here are some options.

Payment Plans 

Some healthcare providers offer payment plans directly or through lenders that let you pay off medical bills over time.

You might take out a personal loan or even a type of personal loan called a medical loan to cover expenses related to gender-affirming care or surgery. A medical loan is just a personal loan used to pay for medical expenses.

Credit Cards 

Credit cards cab be another avenue for covering the costs of gender-affirming care or surgery, although they tend to have very high interest rates if you run a balance.

Even with health insurance, hormone therapy may be less expensive if you comparison shop and use pharmacy programs, such as GoodRx.

Surgery Grants

Several organizations, such as the Jim Collins Foundation, offer grants for people seeking gender-affirming care or surgery.

Health Accounts 

If you have a flexible spending account (FSA) or health savings account (HSA) , consider allocating some account money for gendering-affirming care or surgery if you are anticipating it.

Health Reimbursement Agreement 

A health reimbursement agreement (HRA) is an employer-funded group health plan that reimburses employees for qualified medical expenses, which might include gender-affirming care or surgery.

Home Equity Loan or Line of Credit (HELOC) 

You could take out a home equity loan or line of credit to cover the costs of gender-affirming care or surgery. With these types of loans, you can typically borrow up to a certain percentage of your home's equity. Interest rates are generally lower than those on a personal loan, because your home serves as collateral. Just realize that if you can't repay the loan, your could lose your home. 

Friends and Family Loans 

If you've got supportive friends or relatives, they might be willing to chip in money to pay for your gender-affirming care or surgery. To avoid misunderstandings, it's usually best to have a written agreement and repayment plan.

Crowdfunding

You might consider setting up a crowdfunding campaign on a platform like GoFundMe to raise money from friends, relatives, colleagues, or even strangers.

When you're financing gender-affirming care or surgery, you may be able to save some money if you follow these tips.

Shop Around 

A number of online tools such as Hospital Cost Compare and Healthcare Bluebook allow you to compare costs for the same procedures and treatments offered by different healthcare providers. Doing this homework could save you a lot of money.

Check the Interest Rate Before You Borrow 

Be sure to investigate how much you'll pay to borrow money if you decide to go the credit card or loan route. 

Try Negotiating or Set up a Payment Plan

You can sometimes negotiate with a healthcare provider to lower the costs of gender-affirming care or surgery. For instance, a healthcare provider might discount your services if you agree to pay off your medical bills quickly. If a healthcare provider isn't willing to provide a discount, they might let you make interest-free payments as part of a payment plan.

Ask About Financial Assistance

Some nonprofit healthcare providers offer financial assistance programs that will cover all or some of your medical expenses.

What Are the Different Types of Gender-Affirming Care?

Various types of gender-affirming care include puberty-blocking medication, hormone therapy, top surgery, bottom surgery, nullification surgery, laser hair removal, facial feminization surgery, speech therapy, and mental health services.

How Much Does Gender-Affirming Care Cost in the U.S.?

The cost of gendering-affirming care varies widely, depending on the type of procedure or treatment involved. A common range is anywhere from $25,000 to $75,000, according to the Human Rights Campaign. Health insurance may cover these costs to varying degrees.

Does Insurance Cover Puberty Blockers?

According to one 2019 study, about 31% of the plans it looked at online claimed to cover puberty blockers. That makes it all the more important for patients and their families to shop around for insurance.

The campaign for transgender rights in the U.S. has experienced victories and setbacks in recent years—in some cases affecting coverage of gender-affirming care. Even amid progress, some people still encounter problems obtaining health insurance to cover such care or paying the out-of-pocket costs involved. People who expect to need gender-affirming care will want to read their insurance plan's coverage details carefully and ask questions if they're unsure about what's covered.

Human Rights Campaign. " Map: Attacks on Gender-Affirming Care by State ."

KFF. " Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions ."

The Williams Institute at UCLA. " How Many Adults and Youth Identify as Transgender in the United States? "

UCSF Transgender Care. " Initiating Hormone Therapy ."

American Medical Association. " Transgender Coverage Issue Brief ."

U.S. Department of Health and Human Services. " Section 1557 of the Patient Protection and Affordable Care Act ."

Transgender Legal Defense & Education Fund. " Health Insurance – Understanding Your Plan ."

Federal Register. " Vol. 89, No. 88 / Monday, May 6, 2024 / Rules and Regulations ," Page 37701.

Movement Advance Protect. " Healthcare Laws and Policies ."

Transgender Legal Defense & Education Fund. " Health Insurance – Understanding Your Plan: Differences Between Self-Funded and Insured Plans. "

Human Rights Campaign. " Corporate Equality Index 2023-2024 ."

HealthCare.gov. " Transgender Health Care ."  

Out2Enroll. " Plan Information for 2024 ."

Healthcare.gov. " How to Pick a Health Insurance Plan ."

KFF. " Trans People in the U.S.: Identities, Demographics, Wellbeing. "

Movement Advancement Project. " Medicaid Coverage of Transgender-Related Health Care ."

TRICARE. " Gender Dysphoria Services ."

U.S. Department of Veterans Affairs. "VHA LGBTQ+ Health Program. "

Annals of Family Medicine, November 2020. " Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey ," See Abstract: Results.

Translational Andrology and Urology. " Demographic and Temporal Trends in Transgender Identities and Gender Confirming Surgery ."

JAMA Surgery. " Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the U.S. "

The Journal of Law, Medicine, and Ethics. " Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population ."

Journal of General Internal Medicine. " Gender Affirming Hormone Therapy Spending and Use in the USA, 2013-2019 ."

Transgender Health. April 11, 2019. " Health Care Insurance of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information ," See Table 1.

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Does Health Insurance Cover Transgender Health Care?

For transgender Americans, access to necessary health care can be fraught with challenges. Section 1557 of the Affordable Care Act (ACA) prohibits discrimination on a wide variety of grounds for any "health program or activity" that receives any sort of federal financial assistance.  

But the specifics of how that section is interpreted and enforced are left up to the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR). Not surprisingly, the Obama and Trump administrations took very different approaches to ACA Section 1557. But the Biden administration has reverted to the Obama-era rules.

In 2020, the Trump administration finalized new rules that rolled back the Obama administration's rules. This came just days before the Supreme Court ruled that employers could not discriminate against employees based on sexual orientation or gender identity. The Trump administration's rule was subsequently challenged in various court cases.

And in May 2021, the Biden administration issued a notice clarifying that the Office of Civil Rights would once again prohibit discrimination by health care entities based on sexual orientation or gender identity.

The Biden administration subsequently issued a proposed rule in 2022 to update the implementation of Section 1557 and strengthen nondiscrimination rules for health care. The proposed rule " restores and strengthens civil rights protections for patients and consumers in certain federally funded health programs and HHS programs after the 2020 version of the rule limited its scope and power to cover fewer programs and services. "

Section 1557 of the ACA

ACA Section 1557 has been in effect since 2010, but it's only a couple of paragraphs long and very general in nature. It prohibits discrimination in health care based on existing guidelines—the Civil Rights Act, Title IX, the Age Act, and Section 504 of the Rehabilitation Act—that were already very familiar to most Americans (i.e., age, disability, race, color, national origin, and sex).

Section 1557 of the ACA applies those same non-discrimination rules to health plans and activities that receive federal funding.

Section 1557 applies to any organization that provides healthcare services or health insurance (including organizations that have self-insured health plans for their employees) if they receive any sort of federal financial assistance for the health insurance or health activities.

That includes hospitals and other medical facilities, Medicaid , Medicare (with the exception of Medicare Part B ), student health plans, Children's Health Insurance Program, and private insurers that receive federal funding.

For private insurers, federal funding includes subsidies for their individual market enrollees who purchase coverage in the exchange (marketplace). In that case, all of the insurer's plans must be compliant with Section 1557, not just their individual exchange plans.

(Note that self-insured employer-sponsored plans are not subject to Section 1557 unless they receive some type of federal funding related to health care activities. The majority of people with employer-sponsored health coverage are enrolled in self-insured plans.)

To clarify the nondiscrimination requirements, the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR) published a 362-page final rule for implementation of Section 1557 in May 2016.

At that point, HHS and OCR clarified that gender identity "may be male, female, neither, or a combination of male and female." The rule explicitly prohibited health plans and activities receiving federal funding from discrimination against individuals based on gender identity or sex stereotypes.

But the rule was subject to ongoing litigation, and the nondiscrimination protections for transgender people were vacated by a federal judge in late 2019.

And in 2020, the Trump administration finalized new rules which reversed much of the Obama administration's rule. The new rule was issued in June 2020, and took effect in August 2020. It eliminated the ban on discrimination based on gender identity, sexual orientation, and sex stereotyping, and reverted to a binary definition of sex as being either male or female.

Just a few days later, however, the Supreme Court ruled that it was illegal for a workplace to discriminate based on a person's gender identity or sexual orientation. The case hinged on the court's interpretation of what it means to discriminate on the basis of sex, which has long been prohibited under US law. The majority of the justices agreed that "it is impossible to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex."

The Biden administration announced in May 2020 that Section 1557's ban on sex discrimination by health care entities would once again include discrimination based on gender identity and sexual orientation.

And in 2022, the Biden administration published a new proposed rule for the implementation of Section 1557, rolling back the Trump-era rule changes and including a new focus on gender-affirming care (as opposed to just gender transition care).

Are Health Plans Required to Cover Gender Affirming Care?

Even before the Obama administration's rule was blocked by a judge and then rolled back by the Trump administration, it did not require health insurance policies to " cover any particular procedure or treatment for transition-related care ."

The rule also did not prevent a covered entity from " applying neutral standards that govern the circumstances in which it will offer coverage to all its enrollees in a nondiscriminatory manner ." In other words, medical and surgical procedures had to be offered in a non-discriminatory manner, but there was no specific requirement that insurers cover any specific transgender-related healthcare procedures, even when they're considered medically necessary.

Under the Obama administration's rule, OCR explained that if a covered entity performed or paid for a particular procedure for some of its members, it could not use gender identity or sex stereotyping to avoid providing that procedure to a transgender individual. So for example, if an insurer covers hysterectomies to prevent or treat cancer in cisgender women, it would have to use neutral, non-discriminatory criteria to determine whether it would cover hysterectomies to treat gender dysphoria.

And gender identity could not be used to deny medically necessary procedures, regardless of whether it affirmed the individual's gender. For example, a transgender man could not be denied treatment for ovarian cancer based on the fact that he identifies as a man.

But the issue remained complicated, and it's still complicated even with the Biden administration's proposed rule to strengthen Section 1557's nondiscrimination rules.

Under the 2016 rule, covered entities in every state were prohibited from using blanket exclusions to deny care for gender dysphoria and had to utilize non-discriminatory methods when determining whether a procedure will be covered. But that was vacated by a federal judge in 2019.

However, the new rules proposed in 2022 by the Biden administration " prohibit a covered entity from having or implementing a categorical coverage exclusion or limitation for all health services related to gender transition or other gender-affirming care. "

As of 2023, HealthCare.gov's page about transgender health care still states that " many health plans are still using exclusions such as “services related to sex change” or “sex reassignment surgery” to deny coverage to transgender people for certain health care services. Coverage varies by state. "

The page goes on to note that " transgender health insurance exclusions may be unlawful sex discrimination. The healthcare law prohibits discrimination on the basis of sex, among other bases, in certain health programs and activities ."

The page advises that " if you believe a plan unlawfully discriminates, you can file complaints of discrimination with your state’s Department of Insurance, or report the issue to the Centers for Medicare & Medicaid Services by email to  [email protected] ." (note that this language existed on that page in 2020 as well.)

State Rules for Health Coverage of Gender Affirming Care

Prior to the 2016 guidance issued in the Section 1557 final rule, there were 17 states that specifically prevented state-regulated health insurers from including blanket exclusions for transgender-specific care and 10 states that prevented such blanket exclusions in their Medicaid programs. And as of 2023, the list of states that ban specific transgender exclusions in state-regulated private health plans has grown to 24, plus the District of Columbia.

Starting in 2023, Colorado became the first state to explicitly include gender-affirming care in its benchmark plan (used to define essential health benefits ), ensuring that all individual and small-group health plans in the state must provide that coverage.

While Section 1557 was initially a big step towards equality in health care for transgender Americans, it does not explicitly require coverage for sex reassignment surgery and related medical care. And the implementation of Section 1557 has been a convoluted process with various changes along the way. Most recently, the Biden administration has restored nondiscrimination protections based on gender identity.

Do Health Insurance Plans Cover Sex Reassignment?

It depends on the health insurance plan. This description from Aetna  and this one from Blue Cross Blue Shield of Tennessee are good examples of how private health insurers might cover some—but not all—aspects of the gender transition process, and how medical necessity is considered in the context of gender-affirming care.

Since 2014,  Medicare has covered medically necessary sex reassignment surgery , with coverage decisions made on a case-by-case basis depending on medical need. And the Department of Veterans Affairs (VA) has announced in June 2021 that it has eliminated its long-standing ban on paying for sex reassignment surgery for America's veterans.

But Medicaid programs differ from one state to another, and there are pending lawsuits over some states' refusals to cover gender transition services for Medicaid enrollees.

Over the last several years, many health plans and self-insured employers have opted to expand their coverage in order to cover sex reassignment surgery and other gender-affirming care. But although health coverage for transgender-specific services has become more available, it is still far from universal.

This issue is likely to face protracted legal debate over the coming years, and coverage will likely continue to vary from one state to another and from one employer or private health plan to another.

Many health plans in the U.S. are subject to ACA Section 1557, which prohibits discrimination based on gender. But this section is implemented via HHS rules, which have changed over time: The Obama administration issued rules to protect people from gender-related discrimination in health care, the Trump administration relaxed those rules, and the Biden administration has proposed changes to strengthen them once again.

A Word from Verywell

If you're in need of gender-affirming medical care, you'll want to carefully consider the specifics of the health policy you have or any that you may be considering. If you think that you're experiencing discrimination based on your gender identity, you can file a complaint with the Office of Civil Rights . But you may find that a different health plan simply covers your needs more comprehensively.

US Department of Health and Human Services. Section 1557 of the Patient Protection and Affordable Care Act .

Keith, Katie. Health Affairs. HHS Will Enforce Section 1557 To Protect LGBTQ People From Discrimination . May 11, 2021.

U.S. Department of Health and Human Services. HHS Announces Proposed Rule to Strengthen Nondiscrimination in Health Care . July 25, 2022.

United States DoJ. Overview of Title IX of the education amendments of 1972 . Updated August, 2015.

DHS.  Nondiscrimination in health programs and activities . Effective July 18, 2016.

Keith, Katie. Health Affairs. Court Vacates Parts Of ACA Nondiscrimination Rule . October 16, 2019.

Department of Health and Human Services. Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority . June 12, 2020.

SCOTUS Blog. R.G. & G.R. Harris Funeral Homes Inc. v. Equal Employment Opportunity Commission . Argued October 2019; Decision issued June 15, 2020.

U.S. Department of Health and Human Services. HHS Announces Prohibition on Sex Discrimination Includes Discrimination on the Basis of Sexual Orientation and Gender Identity . May 10, 2021.

National Center for Transgender Equality. Know your rights: medicare .

HealthCare.gov. Transgender Health Care .

Health Affairs. LGBT protections in affordable care act section 1557 . June 2016.

LGBT Map. Health Care Laws and Policies .

U.S. Department of Health and Human Services. Biden-Harris Administration Greenlights Coverage of LGBTQ+ Care as an Essential Health Benefit in Colorado . October 12, 2021.

Military Times. VA to Offer Gender Surgery to Transgender Vets for the First Time . June 19, 2021.

Fleig, Shelby. Des Moines Register. ACLU of Iowa Renews Effort to Overturn Law Restricting Public Funds for Trans Iowans' Transition-Related Care . April 22, 2021.

By Louise Norris Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

Personal Loans

How to afford transgender surgery expenses.

Updated: Nov 11, 2022, 2:00pm

Transgender surgeries—also called gender affirmation or gender confirmation surgeries—are medical procedures you can undergo to affirm your gender identity.

The cost of these kinds of surgeries are often steep, and health insurance coverage for them can vary by policy. “Even if a procedure is covered by insurance, there are still deductibles and out-of-pocket maximums,” said Wynne Nowland, CEO of Bradley & Parker, who transitioned at 56. Surgeries that are solely cosmetic might not be covered by insurance at all.

The good news is that several financing options are available to help you pay for procedures. Some organizations even offer grants and scholarships that can help you afford surgery costs.

How Much Does Transgender Surgery Cost?

The cost of transgender surgery can vary by provider and the type of surgery you choose to get. For a female-to-male transition, masculinization chest surgery (also known as top surgery) might cost $3,000 to $10,000 while chest surgery for a male-to-female transition could cost $5,000 to $10,000, according to Longwood Plastic Surgery.

Bottom surgeries, such as vaginoplasty or phalloplasty, can cost $25,600 and $24,900, respectively, according to estimates from The Philadelphia Center for Transgender Surgery. Additional procedures can increase the transition expenses from there. Aside from the actual surgery cost, other hidden expenses can arise as well.

For example, you could need help at home while in recovery if you don’t have a good support system, according to Nowland. There may also be travel and hotel expenses, which are typically not covered by insurance. Nowland says the best way to prepare for surgery is to reach out to insurance to discuss coverage and plan on saving the funds you’ll need to proceed.

If you’re considering borrowing money to pay for surgery and recovery costs, here are four options to consider.

Related: Does Being Transgender Affect Life Insurance?

4 Ways to Finance Transgender Surgery Costs

Personal loans, credit cards, medical credit cards and home equity loans are products you could use to pay for transgender surgery costs over time. Here’s what you need to know about each:

Personal loans are typically unsecured installment loans that provide a lump sum you can use for almost any legal personal expense, including medical bills. Lenders may offer loans of $1,000 to $100,000. However, your credit and income can affect how much you can borrow and your interest rate.

The average annual percentage rate (APR) for a five-year personal loan is 15.93% as of Sept. 19, 2022, but rates can go up to 36% APR. The good news is that many lenders let you prequalify for personal loans online without a hard credit check , allowing you to shop around for rates and compare costs before borrowing.

Credit Cards

Credit cards give you access to a credit line you can use to cover medical bills. You’ll then pay off the balance over time. While certain credit cards have annual fees, many don’t. Some credit cards even offer an introductory 0% APR for a number of months when you open a new account.

Standard interest applies after the interest-free period, but charging and paying off procedures during the interest-free period could be an affordable way to finance bills. That said, credit cards are usually best for expenses you can repay relatively quickly since interest rates can be higher than personal loans, so maintaining a high balance over several years can get costly.

Medical Credit Cards

Medical credit cards are designed specifically for medical bills and could be a financing option recommended by your doctor’s office.

CareCredit is a popular medical credit card that offers no-interest financing plans of six, 12, 18 or 24 months on transactions over $200. There’s a catch, though: If you don’t pay off the balance during the financing period, interest is charged retroactively from the time of your purchase.

For purchases of at least $1,000, CareCredit offers extended financing terms of 24, 36, 48 or 60 months. The APR for payment plans is fixed and ranges from 14.90% to 17.90%, depending on how much you borrow and the loan term you choose.

Home Equity Loans or Lines of Credit

If you own a house, home equity loans and home equity lines of credit (HELOCs) are ways to borrow from the equity you’ve built up. Here’s how both of these options work:

• Home equity loans: A home equity loan is an installment loan that lets you borrow money in a lump sum, which you could use to cover transgender surgery costs. Homeowners are typically able to borrow up to 85% of home equity, and loan terms can range from five to 30 years.
• HELOCs: These are lines of credit you can draw from and pay down with a variable interest rate. A HELOC could be a better alternative to a home equity loan if you have ongoing costs as it will give you the flexibility to borrow only what you need and pay it back as you go.

The advantage of home equity products for medical expenses is that interest rates may be lower than unsecured personal loans since the collateral (your home) backing minimizes risk for the lender.

However, since your home secures the transaction, you could lose your house if you can’t keep up with loan payments. If the value of your home decreases, there’s also a chance you could go underwater on the house if you end up owing more on your mortgage and loan than the home is worth.

Can You Get Transgender Surgery Grants?

Several organizations offer grants to help cover transition costs, including gender-affirming surgery, which is money you don’t have to pay back. Requirements for grant funding can vary, but in some cases, you need to show that you’ve saved up some money on your own for the surgery to be awarded money. Here are a few examples of organizations offering grants:

• Jim Collins Foundation : The Jim Collins Foundation offers two grants. General Fund grants can cover all gender-affirming surgery costs while Krysallis Anne Hembrough Legacy Fund grants can cover 50% of surgery costs for recipients who match the grant funds awarded.
• Point of Pride : Point of Pride offers an annual scholarship-like program that provides financial assistance for gender-affirming surgery.
• The Loft LGBTQ+ Community Center : TransMission grant funds through the Loft LGBTQ+ Community Center aren’t enough to cover the full cost of surgery. However, grants may be used to help pay for therapy, hormones and other transition expenses.

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Tips to Pay For Transgender Surgery Expenses

As you come up with a plan and explore ways to pay for surgeries, here are a few tips to consider:

• Double-check your insurance policy. Read policy terms carefully and reach out to your insurer to ask about what surgeries are covered. “Like all covered insurance procedures, expect to deal with some red tape, but your patience in doing so will be worth it,” said Nowland.
• Use a health savings account (HSA) or flexible spending account (FSA). HSAs and FSAs are both tax-advantaged accounts designed to help you stash money for medical expenses, which could include gender-affirming surgeries. You can make pre-tax contributions to both accounts from your salary if you set them up with your employer. If you set up an HSA on your own, you can deduct contributions from your tax return.
• Consider crowdfunding. Crowdfunding is when you set up a campaign to raise funds. If you prefer to keep medical procedures private, creating a campaign and asking for donations may not be the right route to take. But if you feel comfortable sharing your story, setting up a GoFundMe or Fundly fundraising page could be a way to cover the cost of your surgeries. Bonfire is another site you can use to fundraise by selling customized t-shirts.
• Get support from family and peers. If you have friends or family able to gift or loan you money, it can be more affordable than taking out a loan from a bank, online lender or credit union.

How to Save Up for Gender Affirming Surgery

Using a combination of funding sources is a strategy that could help you rely less heavily on loans.

Different surgeons charge different fees, so compare prices to project costs. From there, you can determine how much you’ll need to save and by when. If you don’t use an FSA or HSA to save, consider stashing your savings for surgery in a high-yield savings account so your savings earn more interest than it would in a traditional savings account.

Certain savings tools can make setting aside money easier. For example, banks often have recurring transfer features you can set up to automatically move money from a checking account to your savings on a schedule. Plus, savings apps like Digit exist, which can connect to your bank account, use an algorithm to review your cash flow and put spare money away for you automatically. Your savings can grow over time, so you can pay for treatment and surgery as you go.

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Know Your Rights

Health care.

Read Our Covid-19 Guides

See these resources for more information about your rights during COVID-19:

• A Know Your Rights Guide for Transgender People Navigating COVID-19   (PDF)
• Una guía para que las personas transgénero navegando la COVID-19 conozcan sus derechos   (PDF)

Know Your Rights in Health Care

Federal and state laws - and, in many cases, the U.S. Constitution - prohibit discrimination in health care and insurance because you're transgender. That means that health plans aren’t allowed to exclude transition-related care, and health care providers are required to treat you with respect and according to your gender identity.

Updated October 2021 

What are my rights in insurance coverage?

Federal and state law prohibits most public and private health plans from discriminating against you because you are transgender. This means, with few exceptions, that it is illegal discrimination for your health insurance plan to refuse to cover medically necessary transition-related care.

Here are some examples of illegal discrimination in insurance:

• Health plans can’t have automatic or categorical exclusions of transition-related care . For example, a health plan that says that all care related to gender transition is excluded violates the law.
• Health plans can’t have a categorical exclusion of a specific transition-related procedure. Excluding from coverage specific medically necessary procedures that some transgender people need is discrimination. For example, a health plan should not categorically exclude all coverage for facial feminization surgery or impose arbitrary age limits that contradict medical standards of care.
• An insurance company can’t place limits on coverage for transition-related care if those limits are discriminatory . For example, an insurance company can’t automatically exclude a specific type of procedure if it covers that procedure for non-transgender people. For example, if a plan covers breast reconstruction for cancer treatment, or hormones to treat post-menopause symptoms, it cannot exclude these procedures to treat gender dysphoria.
• Refusing to enroll you in a plan, cancelling your coverage, or charging higher rates because of your transgender status : An insurance company can’t treat you differently, refuse to enroll you, or limit coverage for any services because you are transgender.
• Denying coverage for care typically associated with one gender : It’s illegal for an insurance company to deny you coverage for treatments typically associated with one gender based on the gender listed in the insurance company’s records or the sex you were assigned at birth. For example, if a transgender woman’s health care provider decides she needs a prostate exam, an insurance company can’t deny it because she is listed as female in her records. If her provider recommends gynecological care, coverage can’t be denied simply because she was identified as male at birth.

What should I do to get coverage for transition-related care?

Check out NCTE’s Health Coverage Guide for more information on getting the care that you need covered by your health plan.

If you do not yet have health insurance, you can visit our friends at Out2Enroll to understand your options.

Does private health insurance cover transition-related care?

It is illegal for most private insurance plans to deny coverage for medically necessary transition-related care. Your private insurance plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. 

To understand how to get access to the care that you need under your private insurance plan, check out NCTE’s Health Coverage Guide .

Does Medicaid cover transition-related care?

It is illegal for Medicaid plans to deny coverage for medically necessary transition-related care. Your state Medicaid plan should provide coverage for the care that you need. However, many transgender people continue to face discriminatory denials. Some states have specific guidelines on the steps you have to take to access care. You can check if your state has specific guidelines here .

To understand how to get access to the care that you need under your Medicaid plan, check out NCTE’s Navigating Insurance page.

My plan has an exclusion for transition-related care. What should I do?

There are many reasons why your plan might still have an exclusion for transition-related care in general or for a specific procedure. This does not mean that your plan will not cover your care. Sometimes plan documents are out of date, or you can ask for an exception by showing that this care is medically necessary for you.

If you get insurance through work or school, you can advocate with your employer to have the exclusion removed.

NCTE’s Health Coverage Guide has more information on how to access care and remove exclusions.

Does Medicare cover transition-related care?

It is illegal for Medicare to deny coverage for medically necessary transition-related care.

For many years, Medicare did not cover transition-related surgery due to a decades-old policy that categorized such treatment as "experimental." That exclusion was eliminated in May 2014, and there is now no national exclusion for transition-related health care under Medicare. Some local Medicare contractors have specific policies spelling out their coverage for transition-related care, as do some private Medicare Advantage plans.

To learn more about your rights on Medicare, check out NCTE’s Medicare page.

Does the Veterans Health Administration (VHA) provide transition-related care?

The Veterans Health Administration (VHA) provides coverage for some transition-related care for eligible veterans. However, VHA still has an arbitrary and medically baseless exclusion for coverage of transition-related surgery.  On June 19th, The US Department of Veterans Affairs announced that they will begin the process to expand health care services available to transgender veterans to include gender confirmation surgery. Currently, the Veterans Health Administration (VHA) provides care for thousands of transgender veterans, including some transition-related medical care. We expect the rule will finalize in approximately two years.

For more information FAQs by VHA are found here.

For more information about VHA and transition-related care, check out NCTE’s VAH Veterans Health Care page.

Does TRICARE cover transition-related care?

TRICARE provides coverage for some transition-related care for family members and dependents of military personnel. However, TRICARE still has an exclusion for coverage of transition-related surgery.

What are my rights in receiving health care?

Which health providers are prohibited from discriminating against me?

Under the Affordable Care Act, it is illegal for most health providers and organizations to discriminate against you because you are transgender. The following are examples of places and programs that may be covered by the law:

• Physicians’ offices
• Community health clinics
• Drug rehabilitation programs
• Rape crisis centers
• Nursing homes and assisted living facilities
• Health clinics in schools and universities
• Medical residency programs
• Home health providers
• Veterans health centers
• Health services in prison or detention facilities

What types of discrimination by health care providers are prohibited by law?

Examples of discriminatory treatment prohibited by federal law include (but are not limited to):

• Refusing to admit or treat you because you are transgender
• Forcing you to have intrusive and unnecessary examinations because you are transgender
• Refusing to provide you services that they provide to other patients because you are transgender
• Refuse to treat you according to your gender identity, including by providing you access to restrooms consistent with your gender
• Refusing to respect your gender identity in making room assignments
• Harassing you or refusing to respond to harassment by staff or other patients
• Refusing to provide counseling, medical advocacy or referrals, or other support services because you are transgender
• Isolating you or depriving you of human contact in a residential treatment facility, or limiting your participation in social or recreational activities offered to others
• Requiring you to participate in “conversion therapy” for the purpose of changing your gender identity
• Attempting to harass, coerce, intimidate, or interfere with your ability to exercise your health care rights

What are my rights related to privacy of my health information?

The Health Insurance Portability and Accountability Act (HIPAA) requires most health care providers and health insurance plans to protect your privacy when it comes to certain information about your health or medical history. Information about your transgender status, including your diagnosis, medical history, sex assigned at birth, or anatomy, may be protected health information. Such information should not be disclosed to anyone—including family, friends, and other patients—without your consent. This information should also not be disclosed to medical staff unless there is a medically relevant reason to do so. If this information is shared for purposes of gossip or harassment, it is a violation of HIPAA.

What Can I Do If I Face Discrimination?

Seek preauthorization for care and appeal insurance denials

You shouldn’t be denied the care that you need just because you’re transgender. That's illegal.

To access transition-related care, we recommend applying for preauthorization before any procedures to understand whether your plan will cover it. You should also consider appealing insurance denials that you believe are discriminatory. We recommend you consult an attorney before filing any appeals.

Check our NCTE’s Health Coverage Guide for more information on how to get the care that you need covered.

Contact an attorney or legal organization

If you face discrimination from a health care provider or insurance company, it may be against the law. You can talk to a lawyer or a legal organization to see what your options are. A lawyer might also be able to help you resolve your problem without a lawsuit, for example by contacting your health care provider to make sure they understand their legal obligations or filing a complaint with a professional board.

While NCTE does not take clients or provide legal services or referrals, there are many other groups that may give you referrals or maintain lists of local attorneys. You can try your local legal aid or legal services organization, or national or regional organizations such as the National Center for Lesbian Rights, Lambda Legal, the Transgender Law Center, the ACLU, and others listed  on our   Additional Resources page  and in the  Trans Legal Services Network .

File discrimination complaints with state and federal agencies

Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The U.S. Department of Health and Human Services has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint.  If you face any of ther kind of discrimination or denial of care based on your gender, disability, age, race, or national origin, or if your health care privacy was violated, you can still file a complaint with the   U.S. Department of Health and Human Services, Office for Civil Rights .

Here are some other places you can file health care complaints:

• Private insurance: File a complaint with your state insurance department. You can find information about your state department here:  https://www.naic.org/state_web_map.htm .
• Hospitals: File a complaint with the Joint Commission, which accredits most hospitals. You can find more information or submit a complaint online at  http://www.jointcommission.org .
• Nursing home, board and care home, or assisted living facility: Contact your local long-term care ombudsman. You can locate an ombudsman here:  http://www.ltcombudsman.org/ombudsman .
• HIPPA violations: file a complaint with the U.S. Department of Health and Human Services (HHS): https://www.hhs.gov/hipaa/filing-a-complaint/index.html
• Federal Health Employee Benefits Program: File a complaint with the Office of Personnel Management ( [email protected] ) or the Equal Employment Opportunity Commission ( https://www.eeoc.gov/federal/fed_employees/complaint_overview.cfm ).
• Veterans Health Administration: File a complaint with the Veterans Administration’s External Discrimination Complaints Program or contact a Patient Advocate at your VA Medical Center. Find out more here:  http://www.va.gov/orm/  and  http://www.va.gov/health/patientadvocate .
• Employee health plan: File a complaint with the Equal Employment Opportunity Commission ( https://www.eeoc.gov/federal/fed_employees/complaint_overview.cfm ).
• TRICARE (military health care): File a complaint with TRICARE ( http://tricare.mil/ContactUs/FileComplaint.aspx ).

Other state and local agencies: If you face discrimination, you may be able to file a complaint with your state’s human rights agency. You can find a list of state human rights agencies here:  http://www.justice.gov/crt/legalinfo/stateandlocal.php .

What Laws Protect Me?

Federal protections

• The Health Care Rights Law, as part of the Affordable Care Act (ACA)  prohibits sex discrimination, including anti-transgender discrimination, by most health providers and insurance companies, as well as discrimination based on race, national origin, age, and disability. Under the ACA, it is illegal for most insurance companies to have exclusions of transition-related care, and it is illegal for most health providers to discriminate against transgender people, like by turning someone away or refusing to treat them according to their gender identity. On May 5th, 2021, the Biden Administration and HHS announced that the Office for Civil Rights will interpret and enforce Section 1557 and Title IX’s prohibitions on discrimination based on sex to include: 
• Discrimination on the basis of sexual orientation.
• Discrimination on the basis of gender identity.

Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in covered health programs or activities.  The update was made in light of the U.S. Supreme Court’s decision in Bostock v. Clayton County and subsequent court decisions. Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The HHS has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint at: https://www.hhs.gov/ocr/complaints

• The Health Insurance Portability and Accountability Act (HIPAA)  protects patients’ privacy when it comes to certain health information, including information related to a person’s transgender status and transition. It also gives patients the right to access, inspect, and copy their protected health information held by hospitals, clinics, and health plans.
• The Americans with Disabilities Act  prohibits discrimination in health care and other settings based on a disability, which may include a diagnosis of gender dyshoria.
• Medicare and Medicaid regulations  protect the right of hospital patients to choose their own visitors and medical decision-makers regardless of their legal relationship to the patient. This means that hospitals cannot discriminate against LGBT people or their families in visitation and in recognizing a patient’s designated decision-maker.
• The Joint Commission hospital accreditation standards  require hospitals to have internal policies prohibiting discrimination based on gender identity and sexual orientation.
• The Nursing Home Reform Act  establishes a set of nursing home residents’ rights that include the right to privacy, including in visits from friends or loved ones; the right to be free from abuse, mistreatment, and neglect; the right to choose your physician; the right to dignity and self-determination; and the right to file grievances without retaliation.

State and local nondiscrimination laws  prohibit health care discrimination against transgender people in many circumstances.

A large number of states also have explicit policies that prohibit anti-transgender discrimination in private insurance and Medicaid, like exclusions of transition-related care.

• California  private insurance ( PPO regulation ,  HMO general guidelines  and  HMO guidelines on surgery coverage ) and  Medicaid
• Colorado   private insurance  and  Medicaid
• Connecticut   private insurance  and  Medicaid
• Delaware   private insurance
• District of Columbia   private insurance  and  Medicaid
• Hawaii   private insurance and Medicaid
• Illinois  private insurance ( regulations and bulletin ) and Medicaid
• Maine  private insurance and  Medicaid
• Maryland   private insurance  and  Medicaid
• Massachusetts   private insurance  and  Medicaid
• Michigan   Medicaid
• Minnesota   private insurance  and  Medicaid
• Montana  private insurance  and  Medicaid
• Nevada  private insurance  and  Medicaid
• New Hampshire  private insurance  and  Medicaid
• New   Jersey  private insurance and Medicaid
• New Mexico  private insurance 
• New York  private insurance ( coverage ,  code mismatches ,  updated policy ) and Medicaid ( general Medicaid policy ,  criteria for authorization of procedures )
• Oregon  private insurance  and Medicaid ( general policy --refer to Guideline Note 127--and  facial feminization policy )
• Pennsylvania  private insurance  and  Medicaid
• Rhode   Island  private insurance  and  Medicaid
• Vermont  private insurance  and  Medicaid
• Virginia   private insurance
• Washington   State  private insurance  and  Medicaid
• Wisconsin   Medicaid
• Puerto Rico   private insurance

Remember: Just because your state isn’t listed here doesn’t mean you’re not protected. Check out NCTE’s Health Coverage Guide for more information about getting coverage for the care that you need. 

How Can I Help?

• Head to NCTE’s Health Action Center to see the latest on health care and how you can help fight for transgender people’s right to get the health care they need
• Share your story. If you are facing discriminatory treatment, consider  sharing your story  with NCTE so we can use it in advocacy efforts to advance public understanding and policy change for transgender people. If you successfully resolved a health care situation, we want to hear about that as well.

Additional Resources

Government agencies.

Department of Health and Human Services Office for Civil Rights: http://www.hhs.gov/ocr/office/index.html

Links to State and Local Human Rights Agencies: http://www.justice.gov/crt/legalinfo/stateandlocal.php

HealthCare.Gov: https://www.healthcare.gov/transgender-health-care/

Partner resources, best practices and standards of care

Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies, Lambda Legal, HRC, & New York Bar: http://www.lambdalegal.org/publications/fs_transgender-affirming-hospital-policies

Healthcare Equality Index, Human Rights Campaign http://www.hrc.org/campaigns/healthcare-equality-index

National Center for LGBT Health Education: http://www.lgbthealtheducation.org/

• National LGBT Health Education Center’s  guide to best practices for front-line health care staff
• National LGBT Health Education Center’s  guide to providing health care to non-binary people
• National LGBT Health Education Center’s  guide to making health care forms LGBT-inclusive

National Resource Center on LGBT Aging: http://www.lgbtagingcenter.org

RAD Remedy’s  guide to providing competent care for trans people

Transgender Law Center’s  guide to organizing community clinics

Clinical standards of care for transgender people

• WPATH Standards of Care
• Endocrine Society Clinical Guideline
• Center for Excellence for Transgender Health

Mental Health Resources

Trans LifeLine

National suicide prevention hotline

US: 877-565-8860Canada: 877-330-6366

https://www.translifeline.org/

National Alliance on Mental Illness (NAMI)

National network of mental health care providers, as well as a provider database

http://www.nami.org/Find­-Support/LGBTQ Help Line   800­-950-­6264

National Council for Behavioral Health

National network of community behavioral health centers, as well as a provider database

http://www.thenationalcouncil.org/

SAMHSA (Substance Abuse and Mental Health Services Administration)

A national database for local professionals and agencies that provide addiction recovery services and mental health care.

https://findtreatment.samhsa.gov/

800-662-HELP (4357)

Health provider resources

National Association of Free and Charitable Clinics (NAFC) Clinics around the United States that offer basic health care for those without insurance or experiencing homelessness. http://www.nafcclinics.org/

RAD Remedy Community­-sourced list of trans-­affirming healthcare providers https://www.radremedy.org/

Insurance resources

Resources to help transgender people select and enroll in insurance 

https://out2enroll.org

TransHealth Health and guidance for healthcare providers, as well as a list of trans­affirming health clinics in Canada, the United States, and England. http://www.trans-­health.com/

Transcend Legal Transcend Legal helps people get transgender-related health care covered under insurance. https://transcendlegal.org/

TransChance Health Helps transgender people navigate health care and insurance to receive respectful, high-quality care, and get transition-related care covered  

https://www.transchancehealth.org/

JustUs Health Leads the work to achieve health equity for diverse gender, sexual, and cultural communities in Minnesota, including the  Trans Aging Project  and a  Trans Health Insurance guide https://www.justushealth.mn

Transition-related financial support

Jim Collins Foundation Financial support for transition-related expenses for people without insurance or who have been excluded by insurance http://jimcollinsfoundation.org/apply/

Point of Pride Annual Transgender Surgery Fund Provides direct financial assistance to trans folks who cannot afford their gender-affirming surgery https://pointofpride.org/annual-transgender-surgery-fund/

Community Kinship Life Surgery Scholarship Provides the trans community with assistance while having a sense of community and kinship http://cklife.org/scholarship/

Transformative Freedom Fund (Colorado) Supports the authentic selves of transgender Coloradans by removing financial barriers to transition related healthcare https://transformativefreedomfund.org/

Kentucky Health Justice Network Trans Health Advocacy Works to help Trans Kentuckians access the healthcare they need, as well as reaffirm our autonomy and community http://www.kentuckyhealthjusticenetwork.org/trans-health.html

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One of the nation’s largest health insurers is agreeing to pay for breast augmentation for some trans women.

By Reed Abelson

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The independent source for health policy research, polling, and news.

Coverage of Sexual and Reproductive Health Services in Medicare

Meredith Freed , Juliette Cubanski , Michelle Long , Nancy Ochieng , and Alina Salganicoff Published: Apr 30, 2024

Key Takeaways

• One million women of reproductive age (20 to 49 years) receive their health insurance coverage from Medicare, qualifying for Medicare coverage because of having a long-term disability. Compared to women with Medicare who are ages 65 and over, women of reproductive age with Medicare are more likely to be Black or Hispanic, have lower incomes, be in worse health, and experience functional and cognitive impairment.
• Medicare coverage of many preventive sexual and reproductive health services, including wellness visits, screenings for sexually transmitted infections and HIV, and cancer screenings, is on par with coverage in Medicaid and private insurance.
• Many contraceptive products are covered under Medicare’s Part D prescription drug benefit, but coverage and cost sharing for specific contraceptive products vary across Medicare Part D plans. In general, Part D coverage of intrauterine devices (IUDs) and contraceptive implants is not widespread in 2024, though most Part D enrollees are in plans that cover contraceptive pills, rings, patches, and injections. While the out-of-pocket cost for some contraceptive products is relatively low, some Part D enrollees could pay up to a $100 copayment or 50% coinsurance for certain higher-cost contraceptive products.
• While Medicare covers many types of contraception, coverage is more limited than Medicaid and private insurance, which generally cover all U.S. Food and Drug Administration ( FDA)-approved, -granted or -cleared contraceptive supplies and services without cost sharing . In contrast to coverage under Medicaid or private insurance, people with Medicare can face out-of-pocket costs for visits to insert or remove long-acting reversible methods such as IUDs and implants.
• Female sterilization (e.g., tubal ligation) for females is covered under Medicare only when it is necessary as part of the treatment of an illness or injury. However, under Medicaid and most private plans, the procedure is covered without cost sharing.
• The Hyde Amendment prohibits federal funds from being used to cover abortions under Medicare except if the pregnancy is the result of rape or incest or when the pregnancy poses a threat to the life of the pregnant person.
• Medicare, unlike Medicaid, requires cost sharing for pregnancy-related services and, unlike private plans, typically requires cost sharing for prenatal visits and related services including breastfeeding support and supplies.
• Nearly 8 in 10 (79%) women of reproductive age with Medicare are also covered by Medicaid, which gives them broader coverage of sexual and reproductive health services relative to having Medicare alone. In addition, most dual-eligible individuals receive assistance with their Medicare Part A and B cost sharing, meaning they do not pay out-of-pocket for Medicare services that require cost sharing, and also receive subsidies that help pay their cost sharing for contraceptive products covered under Part D.

Introduction

Medicare is the federal program that provides health insurance coverage to 66 million people, including over 35 million women . While Medicare primarily covers people ages 65 and older, it also covers people under age 65 with long-term disabilities , including 1 million women of reproductive age (ages 20-49) in 2021. Women with disabilities have unique health needs and experience greater disparities in health outcomes and access to care, such as physical barriers for those with mobility impairments and a shortage of clinicians with expertise in caring for people with a disability. Misperceptions about the sexual health needs and preferences of women with disabilities may also result in patients not getting needed care or their preferred form of contraception. People who are under age 65 covered by Medicare report worse access to care, more cost concerns, and lower satisfaction than people with Medicare ages 65 and older, yet are often overlooked in discussions about Medicare and ways to make the program work better for beneficiaries.

While Medicare covers a broad range of health and medical care services, it was not originally designed to meet the specific health care needs of people under age 65 with long-term disabilities, including sexual and reproductive health care for women of reproductive age, since Medicare eligibility for people under age 65 was added several years after the program’s creation. Addressing this gap may be part of the impetus behind the executive order issued by President Biden in June 2023 directing the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) to take steps to improve Medicare coverage of contraceptives. The Biden Administration has recently updated the formulary review process for coverage of contraception under the Medicare Part D drug benefit, which could increase coverage of additional types of contraception for people with Medicare, specifically intrauterine devices (IUDs) and implants.

This brief describes Medicare coverage of sexual and reproductive health services for women and others capable of becoming pregnant. It also compares Medicare coverage with what is required by federal law under private insurance plans and Medicaid, the federal-state health coverage program for people with low incomes. (KFF recognizes that some individuals who require contraception and other reproductive health care services may not self-identify as women. The language used here attempts to be as inclusive as possible, but some of the analysis is based on survey data that uses specific gender labels for female and male for the data year analyzed for this brief, and may not be inclusive of gender non-binary, transgender, and other gender expansive identities.)

A Profile of Reproductive-Age Women with Medicare

Women of reproductive age (ages 20 to 49) with Medicare are more likely than women ages 65 and older with Medicare to be Black or Hispanic, have lower incomes, be in worse health, and experience functional and cognitive impairment (Figure 1). (These estimates are based on KFF analysis of 2021 data from the CMS Medicare Current Beneficiary Survey.)

Race/Ethnicity . A larger share of women of reproductive age than women 65 and older with Medicare are Black (20% vs 9%, respectively) and Hispanic (14% vs 9%, respectively).

Income . A much larger share of reproductive-age women enrolled in Medicare have low incomes compared to women 65 and older. For example, nearly three-quarters (73%) of women ages 20-49 have incomes of less than $20,000 per year compared to 28% of women ages 65 and older.

Health Status . Because eligibility for Medicare for those under age 65 generally depends on having a long-term disability, a larger share of reproductive-age women has significant health problems or functional limitations compared to women with Medicare ages 65 and older. Slightly less than half of women of reproductive age (44%) rate their health status as fair or poor compared to 16% of older women, 44% have a limitation in activities of daily living compared to 26% of older women, and 57% have a cognitive impairment compared to 14% of older women.

Sources of Coverage . Among the nearly 1 million women of reproductive age enrolled in Medicare Part A and Part B in 2021, close to 6 in 10 (57%) were covered under traditional Medicare and 43% were enrolled in Medicare Advantage plans (Figure 2). A somewhat smaller share of women 65 and older with Medicare are enrolled in traditional Medicare and a somewhat larger share in Medicare Advantage (52% and 48%, respectively).

Nearly 8 in 10 (79%) women of reproductive age with Medicare are also covered by Medicaid, the federal-state health program for people with low incomes, whereas a relatively small share of women 65 and older with Medicare also have Medicaid (16%). This reflects the fact that most women of reproductive age in Medicare have low incomes. Among women of reproductive age with both Medicare and Medicaid (known as dual-eligible individuals ), in 2021, 60% were in traditional Medicare and 40% in Medicare Advantage, whereas among those age 65 and older, the pattern was reversed (37% in traditional Medicare vs. 63% in Medicare Advantage) (data not shown).

Most women of reproductive age who are dual-eligible individuals qualify for full Medicaid benefits, which gives them enhanced coverage of sexual and reproductive health services relative to having Medicare alone, as described in more detail below (see How Does Coverage of Sexual and Reproductive Health Services Compare Between Medicare and Medicaid? ).

Sexual and Reproductive Health Services Covered by Medicare

Medicare covers many sexual and reproductive health services for women, including preventive care and screenings, maternity care, and contraceptive coverage. Medicare Advantage plans, the private alternative to traditional Medicare that provided coverage to 43% of reproductive-age women with Medicare in 2021, are required to cover all benefits covered under traditional Medicare. Most Medicare Advantage plans also cover Part D outpatient prescription drugs , whereas for people with traditional Medicare, prescription drugs are generally covered under stand-alone Part D prescription drug plans (PDPs).

Preventive Care

Evidence-based preventive services can improve health by preventing the onset of certain conditions or by identifying health conditions earlier when they can be managed more effectively. While Medicare has long provided coverage of many preventive services, the Affordable Care Act requires that Medicare cover many of these services without cost sharing if the Secretary of the Department of Health and Human Services (HHS) determines that they are reasonable and necessary for the prevention or early detection of an illness or disability, and appropriate for individuals in traditional Medicare.

Wellness Visits

Medicare Part B covers, without cost sharing, one “Welcome to Medicare” preventive visit within the first 12 months of being enrolled in Medicare, which includes a review of the beneficiaries’ medical and social history related to their health. After their first 12 months in Medicare, beneficiaries are eligible for a free yearly “Wellness” visit to develop or update a personalized plan to help prevent disease or disability, based on current health and risk factors.

Breast Cancer Screenings and Preventive Medications

The U.S. Preventive Services Task Force (USPSTF) recommends routine screening mammograms every two years for women ages 50 to 74 to detect breast cancer, depending on risk factors. Medicare covers one baseline mammogram to screen for breast cancer or women between ages 35 to 39, as well as screening mammograms once every 12 months for women ages 40 and older without cost sharing under Part B. Diagnostic mammograms may be covered more than once a year, if medically necessary, but typically with cost sharing. For diagnostic mammograms, after the Part B deductible is met, 20% coinsurance applies.

Preventive medications such as tamoxifen and raloxifene can reduce the risk of breast cancer for those who are at high risk. These medications are covered under Part D (both stand-alone drug plans for those in traditional Medicare and Medicare Advantage drug plans), with cost-sharing amounts varying by drug and by plan.

Cervical and Vaginal Cancer Screening

The USPSTF recommends routine cervical cancer screenings for women ages 21 to 65. The recommended frequency ranges from every three years to every five years depending on the person’s age and the type of screening test. Medicare covers pelvic exams and Pap tests to check for cervical and vaginal cancers, once every 24 months, including for women over 65. For women at high risk for cervical or vaginal cancer, or for women of child-bearing age who had an abnormal Pap test in the past 36 months, Medicare covers these screening tests once every 12 months. Medicare also covers Human Papillomavirus (HPV) tests (as part of a Pap test) once every 5 years for women ages 30 to 65 without HPV symptoms. These tests and exams for cervical and vaginal cancers are covered under Part B without cost sharing.

HIV and Other Sexually Transmitted Infections and Preventive HIV Medications

Routine screenings for HIV and other sexually transmitted infections (STIs) such as chlamydia and herpes are important for early detection, treatment, and preventing transmission. Screenings for HIV and other sexually transmitted infections and counseling services are covered with no cost sharing under Medicare Part B.

Medicare covers HIV screening once per year for people who meet one of the following conditions:

• Ages 15 to 65.
• Younger than age 15 or older than age 65 and at an increased risk for HIV.
• Pregnant people can get screened up to 3 times during their pregnancy.

Medicare also covers sexually transmitted infection screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B for pregnant people at certain times during their pregnancy and for people at increased risk for a sexually transmitted infection, once every 12 months. Medicare also covers up to 2 face-to-face, high-intensity behavioral counseling sessions for sexually active adults at increased risk for these infections.

For individuals who are at higher risk for HIV , use of pre-exposure prophylaxis medication, or PrEP, is a highly effective option to prevent infection. Medicare has proposed a national coverage determination that would make PrEP a Part B preventive service, which would make it available at no cost for beneficiaries who qualify. Medicare also proposed to cover up to seven counseling visits per year, HIV screenings up to seven times per year, and a screening for hepatitis B. Currently, antiretrovirals (ARVs) used for PrEP are covered under both Medicare Part D for oral medications and Part B for injectable physician-administered medications. The NCD would streamline coverage of these services under Part B.

Contraception

Coverage of contraception under part b.

Most sexually active females ages 18 to 49 use some form of contraception. While most use contraception to prevent pregnancy, some use it to manage a medical condition or in the case of condoms, to prevent the transmission of STIs. With limited exceptions, Medicare Part B generally does not cover contraception for the sole purpose of preventing pregnancy (unlike coverage under Part D; see below for details).

Under Medicare Part B, IUDs may be covered but coverage is limited to some menstrual illnesses , including to treat endometrial hyperplasia . When IUDs are covered under Part B, Medicare would cover the device and costs for insertion and removal by a physician, but cost sharing would still apply.

Female sterilization (e.g., tubal ligation) is a permanent contraceptive method used to prevent pregnancy. Sterilization is not covered by Medicare as an elective procedure, nor if a physician believes that a future pregnancy would endanger the overall health of the woman. When covered, whether the service falls under Part A or Part B depends on whether the procedure was performed on an inpatient or outpatient basis and would be subject to cost sharing.

Coverage of Contraception Under Part D

Since the Medicare Part D prescription drug benefit took effect in 2006, contraceptive products have been covered by stand-alone Part D prescription drug plans and Medicare Advantage prescription drug plans, but not all types of contraception have been covered by all Part D plans. Until recently, not all forms of contraception were listed on the Part D formulary reference file , which is a list of drugs that may be (though are not all required to be) included on Part D formularies. The Biden Administration has recently taken steps to update the formulary review process in Part D for coverage of contraception, based on widely-accepted clinical guidelines , which could increase access to more types of contraception. While the formulary reference file is not a Part D coverage list, plan formularies must include different types of contraceptives that meet widely accepted clinical treatment guidelines and evidence. As of 2024, the Part D formulary reference file includes IUDs and implants, in addition to contraceptive pills, patches, rings, and injections that were already listed on the formulary reference file.

Coverage and cost sharing for specific contraceptives vary across Medicare Part D plans. In general, Part D coverage of IUDs and contraceptive implants is not widespread in 2024, though most Part D enrollees are in plans that cover contraceptive pills, rings, patches, and injections (Figure 3).

When IUDs, implants, patches, rings, and injections are covered, they are typically placed on higher formulary tiers than oral contraceptives – most often on Tier 4 in the Part D plan’s formulary, which usually corresponds to the non-preferred drug tier and requires higher levels of cost sharing than other tiers (Figure 4). In contrast, for a select group of widely used oral contraceptives, around 4 in 10 Part D enrollees are in plans with coverage on Tier 1 or Tier 2, which typically correspond to generic drug tiers that require relatively low cost sharing.

The following examples illustrate the variation in potential cost sharing for selected contraceptive products faced by Medicare Part D enrollees who do not receive Part D low-income subsidies (LIS) , which helps cover premiums and cost sharing for low-income enrollees:

• For the less than 1% of Part D enrollees with coverage of the Mirena IUD in 2024, over 90% are in plans where the drug is covered on Tier 4, which would translate to a copayment of $100 for most of these enrollees. (These costs do not include cost sharing for the physician visit required for insertion of the device). The Mirena IUD typically lasts for 8 years.
• For the 67% of enrollees who have coverage of the Xulane patch, nearly 90% are in plans where the drug is covered on Tier 4. Around half of these enrollees would face Tier 4 copayments of $100 for a month’s supply, while the others would face coinsurance of 50% for Tier 4 drugs, which translates to around $45 to $50 for Xulane depending on the retail price.
• For a selected group of contraceptive pills, which are covered nearly all Part D enrollees, around 4 in 10 enrollees are in plans where these drugs are covered on Tier 2, and most of these enrollees would face Tier 2 cost sharing of $10 for a month’s supply. However, if the retail cost of the drug is less than the copayment, enrollees would pay the lower cost. For example, the retail cost of Junel FE 1/20 is between $5 and $6 per one-month supply, so an enrollee would pay that lower amount rather than a $10 copayment.

As noted, these examples of cost sharing do not apply to Medicare Part D enrollees who receive Part D Low-Income Subsidies (LIS), which offers financial assistance with Part D plan premiums and cost sharing for beneficiaries with low incomes and assets. LIS enrollees face only modest copayments for prescriptions covered under Part D regardless of tier placement. Of note, dual-eligible individuals – a majority of all women of reproductive age with Medicare – automatically receive LIS. These subsidies are a valuable benefit to those who qualify. In 2024, Part D enrollees receiving LIS pay no more than $4.50 for generic and $11.20 for brand-name covered contraceptive products, regardless of which formulary tier the drugs are placed on by their plans, while non-LIS enrollees would face higher cost sharing depending on the specific product and tier placement, as explained above.

It is not yet clear whether or how coverage will be provided for the insertion and/or removal of IUDs, implants, and other forms of longer-acting contraception when the device itself is covered under Part D for birth control.

For nearly 50 years, since 1976, the Hyde Amendment has blocked federal funds from being used to cover abortions under all federal programs including Medicare except : 1) if the pregnancy is the result of rape or incest or (2) in the case where a woman suffers from a physical injury, including a life-endangering physical condition arising from the pregnancy itself, that could cause her death unless an abortion is performed. When covered, whether the service falls under Medicare Part A or Part B depends on whether the procedure was performed as inpatient (Part A) or outpatient (Part B).

In June 2022, the Supreme Court overturned Roe v. Wade , allowing states to prohibit or severely restrict abortion. In states where abortion is now banned , individuals covered by Medicare wanting or needing an abortion have few options: they can travel out of state or seek medication abortion pills via telehealth or from an online platform if it is still early in the pregnancy. In states that prohibit abortion, even exceptions for life endangerment of the pregnant person can be legally unclear . Doctors in these states may be hesitant to perform an abortion even for life endangerment due to concerns about legal risk.

Fertility Services

Treatments for infertility include fertility medications, artificial insemination, surgery, and in-vitro fertilization. According to the Medicare Benefit Policy Manual , “reasonable and necessary services associated with treatment for infertility are covered under Medicare [Part B].” However, specific covered services are not listed, and the definition of “reasonable and necessary” in this specific context is not defined. The  2003 law  that established the Medicare Part D prescription drug benefit explicitly prohibits Part D plans from covering fertility drugs , along with some other types of drugs, including those prescribed to treat sexual or erectile dysfunction.

Pregnancy-Related Care

A wide range of services are recommended to support the health of pregnant and postpartum individuals. Medicare covers “reasonable and necessary” services associated with pregnancy, including prenatal care, labor and delivery, and necessary postnatal care . Medicare Part A hospital insurance covers all pregnancy-related care when admitted to the hospital. Medicare Part B covers doctors’ visits and other outpatient services and tests related to pregnancy. All these services are subject to Medicare cost-sharing requirements.

Gender-Affirming Care

Gender-affirming care includes a spectrum of “social, psychological, behavioral or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.”

While federal Medicare policy does not cover gender reassignment surgery for beneficiaries with gender dysphoria, local Medicare Administrative Contractors (MACs) may determine coverage of gender reassignment surgery on a case-by-case basis. Coverage may also include hormonal therapies such as estrogens and anti-androgens for male to female transitions and androgens and progestins for female to male transitions; such therapies would be covered under Part D, subject to each plan’s formulary coverage and cost-sharing requirements.

How Does Coverage of Sexual and Reproductive Health Services Compare Between Medicare and Medicaid?

About 8 in 10 reproductive-age women (79%) with Medicare also have Medicaid coverage to help with the out-of-pocket costs of Medicare. Most of these women qualify for full Medicaid benefits, which gives them broader coverage of sexual and reproductive health services relative to having Medicare alone, as described below. In addition, most dual-eligible individuals receive assistance with their Medicare Part A and Part B cost sharing, meaning they do not pay out-of-pocket for Medicare services that require cost sharing, whether they receive their Medicare coverage through traditional Medicare or a Medicare Advantage plan. As noted earlier, dual-eligible individuals also receive Medicare Part D Low-Income Subsidies, which offer financial assistance with Part D plan premiums and cost sharing.

Federal Medicaid rules allow states some flexibility to design their own benefit packages beyond meeting mandatory federal requirements , which include coverage for physician, family planning, and pregnancy-related services. Furthermore, individuals who qualify for Medicaid under the Affordable Care Act (ACA) Medicaid expansion option (now offered by 40 states and DC) requires coverage of “essential health benefits” including several specific services for women (for a discussion of Medicaid and women, see Medicaid Coverage for Women ). While this coverage requirement typically only applies to ACA Medicaid expansion populations (generally, single individuals or married couples without children), most states have aligned the benefits to also include those who qualify for Medicaid under other coverage pathways.

In terms of coverage of sexual and reproductive health services, traditional Medicaid programs must cover family planning services broadly and states are permitted to define those services within that broad category, but cost sharing is prohibited for family planning services, including contraception. All state expansion programs must cover FDA-approved, -granted or -cleared contraceptives with a prescription, including long-acting contraception such as IUDs, implants, and sterilizations without cost sharing.

As under Medicare, the Hyde Amendment also limits Medicaid coverage of abortions to cases of rape, incest, or life endangerment of the pregnant person. However, 17 states use their own funds to pay for abortions for Medicaid enrollees in other (non-Hyde) circumstances.

Medicaid also covers pregnancy-related services , but unlike Medicare, federal law prohibits cost sharing for these services. Medicaid pays for over 4 in 10 births in the U.S. Beyond inpatient and outpatient hospital care, which must be covered, states can define the specific maternity services covered by Medicaid. Nearly all states provide comprehensive pregnancy-related benefits, including prenatal vitamins, ultrasounds, and postpartum visits. Breast pumps and lactation counseling are required benefits for individuals who qualify for the Medicaid expansion under the ACA, and most people who qualify for Medicaid through other eligibility pathways typically receive this benefit without cost sharing, which is not the case in the Medicare program.

While most reproductive-age women with Medicare are also enrolled in Medicaid, which should protect them from cost sharing relative to those who have Medicare alone, navigating coverage under these two different health care programs can be challenging , with varying levels of coordination across states and payors. Recognizing these challenges, federal and state governments are engaged in efforts to improve coordination of benefits between Medicare and Medicaid, but few dual-eligible individuals are enrolled in fully integrated plans and there are reports of difficulties in accessing coverage for contraceptives among dual-eligible individuals. A recent study of contraceptive use among women with disabilities found that those with Medicare alone had the lowest use of contraceptive care and while utilization was higher among dual-eligible individuals, utilization was highest among those with Medicaid alone.

How Does Coverage of Sexual and Reproductive Health Services Compare Between Medicare and Private Insurance?

Under a requirement of the ACA, individual and fully-insured small group health insurance plans must cover ten categories of “essential health benefits” such as prescription drug coverage, doctors’ services, maternity care, and hospital care. In addition, nearly all health insurance plans (including self-funded plans and large group plans) must also cover, without cost sharing, certain recommended preventive health services.

Like Medicare, private plans are required to cover certain preventive services for women such as annual check-ups and routine cancer screenings like mammograms and Pap tests without cost sharing. Coverage for maternity care is required to be covered in the individual and fully-insured small group markets as an essential health benefit but may be subject to cost sharing. The Pregnancy Discrimination Act effectively requires the health plans of employers with a minimum of 15 workers to cover pregnancy-related services, including maternity care. Nearly all private plans must also cover, without cost sharing, prenatal care visits (considered to be a type of well-women care) and preventive screenings recommended by the U.S. Preventive Services Task Force for pregnancy-related care and by the Health Resources and Services Administration (HRSA). In addition, plans must also cover without cost sharing pre-pregnancy, postpartum, and interpregnancy visits (defined as well woman care), and breastfeeding support services and supplies.

The preventive services coverage requirements also mandate that most private plans cover risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women ages 35 years and older who are at increased risk for breast cancer and at low risk for adverse medication effects. These medications are required to be covered for high-risk women without cost sharing. Under Medicare, these drugs are typically covered under Part D plans, but cost sharing can apply. Similarly, private plans must cover PrEP for individuals at high risk of acquiring HIV. Insurers must also cover at no cost baseline and monitoring services including HIV testing, Hepatitis B and C testing, creatinine testing and calculated estimated creatine clearance or glomerular filtration rate, pregnancy testing, STI screening and counseling, adherence counseling, as well as office visits associated with these services.

As discussed earlier, Medicare offers coverage for contraception, but the scope of coverage is not as comprehensive as that which is required in most private plans (with the exception of the plans of employers with religious objections to contraception and grandfathered plans). Under the ACA, most plans are required to include coverage of the full range of FDA-approved, -granted, or -cleared contraceptives, as well as effective family planning practices, and sterilization procedures, and they must be covered without cost sharing. This also includes coverage of counseling and device insertion and removal, without cost sharing, which is not the case under Medicare Part B or Part D.

In contrast to Medicare, which is subject to federal laws, state regulated private health insurance plans (individual plans and the fully-insured group markets) are subject to state insurance laws, in addition to the federal requirements. Although federal law does not require private plans to cover abortion, 10 states require this coverage for their state-regulated plans. Likewise, some states also require coverage of other sexual and reproductive health services not required by federal law such as certain infertility services, over-the-counter contraceptive methods without a prescription, and one state explicitly requires coverage of specific gender-affirming care services in its state-regulated plans.

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• Preventive Services Covered by Private Health Plans under the Affordable Care Act

Federal judge temporarily blocks Indiana law banning gender-transition care

A federal judge has temporarily blocked an Indiana law that would have prevented doctors from providing gender transition care to minors. 

The law was set to take effect July 1 but on Friday, U.S. District Judge for the Southern District of Indiana James Patrick Hanlon issued a preliminary injunction in a lawsuit brought by four transgender youth, their parents, and a medical provider who said it violated the U.S. Constitution.  

“Today’s victory is a testament to the trans youth of Indiana, their families, and their allies, who never gave up the fight to protect access to gender-affirming care and who will continue to defend the right of all trans people to be their authentic selves, free from discrimination,” Ken Falk of the ACLU of Indiana, which represented the plaintiffs, said in a prepared statement.  

The Indianapolis Star, a member of the USA TODAY Network, has requested comment from Indiana Attorney General Todd Rokita’s office, which represents the state in court and is one of the defendants.

The ban targeted cross-sex hormone therapy, puberty-blocking drugs and gender reassignment surgery, according to Hanlon's order. The judge specified that under the injunction the state can't prohibit “gender transition procedures for minors except gender reassignment surgery and ... speech that would aid or abet gender transition procedures for minors" while the lawsuit continues to move through the court.

The minors’ request that a judge freeze the ban on gender reassignment surgeries was denied, however, as Hanlon said they “lack standing to challenge that ban because gender reassignment surgeries are not provided to minors in Indiana.” 

Those who back the law say it would protect kids from making life-changing decisions at an age where they’re too young to understand the consequences. Opponents say the care targeted by the law is life-saving, and that the ban would end parents’ rights to make medical decisions on behalf of their children.  

If the law were to take effect, physicians who provide these procedures could face discipline by the state’s medical licensing board. 

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Brazilian Butt Lift Clinics Must Now Carry Liability Insurance Under New Florida Law

Practitioners of Brazilian butt lift surgery, repeatedly in the news after infections and at least two patient deaths in south Florida, must now obtain medical malpractice liability insurance, thanks to a bill signed into law last month.

House Bill 1561 , approved by the Florida Legislature this spring, took effect May 10, when Gov. Ron DeSantis signed it. It now requires most butt-lifting clinics that transfer more than 1,000 cubic centimeters of fat to secure liability coverage of at least $250,000 per claim and an annual aggregate of at least $750,000.

Physician offices must also register with the state Department of Health, regardless of whether the liposuction procedure was considered temporary or permanent transfer of fat. Until this year, some clinics were able to avoid registering and avoid liability coverage due to the wording of the previous Florida statute.

The new law also raises penalties for those that do not register, from $5,000 per day to $5,000 per incident, allowing the Department of Health to fine doctors for multiple offenses in the same day, according to a legislative analysis of the bill. It also requires more inspections and adherence to safety procedures at clinics.

HB 1561 is a “pivotal moment” in the regulation of the troubled butt-lift business in Florida, Harlan Wald, a retired plastic surgeon who is now an injury lawyer, wrote in Law.com. Requiring malpractice insurance will allow victims to obtain damage awards to cover medical expenses and other losses from injuries and deaths caused by botched surgeries, Wald and his daughter, also a plaintiffs’ attorney, noted.

Health authorities in April said that 15 infections from drug-resistant bacteria have been linked to the surgeries at clinics in the Miami area. And in 2017 and in 2022, patients after surgery at a clinic in south Florida. A surgeon was allowed to keep his medical license despite claims that he was unauthorized to perform surgeries. Multiple lawsuits have resulted but in some cases, clinics have closed or moved to new locales, according to news reports.

Photo: A window display advertises low-cost “Brazilian butt lift” cosmetic surgery procedures outside a clinic in Miami on Friday, March 22, 2019. On Thursday, Jan. 25, 2024, the Centers for Disease Control and Prevention said 93 Americans have died after cosmetic surgery in the Dominican Republic since 2009, with many of the recent deaths involving a procedure known as a Brazilian butt lift. (AP Photo/Ellis Rua, File)

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The Unique Burial of a Child of Early Scythian Time at the Cemetery of Saryg-Bulun (Tuva)

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Pages:  379-406

In 1988, the Tuvan Archaeological Expedition (led by M. E. Kilunovskaya and V. A. Semenov) discovered a unique burial of the early Iron Age at Saryg-Bulun in Central Tuva. There are two burial mounds of the Aldy-Bel culture dated by 7th century BC. Within the barrows, which adjoined one another, forming a figure-of-eight, there were discovered 7 burials, from which a representative collection of artifacts was recovered. Burial 5 was the most unique, it was found in a coffin made of a larch trunk, with a tightly closed lid. Due to the preservative properties of larch and lack of air access, the coffin contained a well-preserved mummy of a child with an accompanying set of grave goods. The interred individual retained the skin on his face and had a leather headdress painted with red pigment and a coat, sewn from jerboa fur. The coat was belted with a leather belt with bronze ornaments and buckles. Besides that, a leather quiver with arrows with the shafts decorated with painted ornaments, fully preserved battle pick and a bow were buried in the coffin. Unexpectedly, the full-genomic analysis, showed that the individual was female. This fact opens a new aspect in the study of the social history of the Scythian society and perhaps brings us back to the myth of the Amazons, discussed by Herodotus. Of course, this discovery is unique in its preservation for the Scythian culture of Tuva and requires careful study and conservation.

Keywords: Tuva, Early Iron Age, early Scythian period, Aldy-Bel culture, barrow, burial in the coffin, mummy, full genome sequencing, aDNA

Information about authors: Marina Kilunovskaya (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Vladimir Semenov (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Varvara Busova  (Moscow, Russian Federation).  (Saint Petersburg, Russian Federation). Institute for the History of Material Culture of the Russian Academy of Sciences.  Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail:  [email protected] Kharis Mustafin  (Moscow, Russian Federation). Candidate of Technical Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Irina Alborova  (Moscow, Russian Federation). Candidate of Biological Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Alina Matzvai  (Moscow, Russian Federation). Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected]

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Gagarin Cup Preview: Atlant vs. Salavat Yulaev

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Gagarin cup (khl) finals:  atlant moscow oblast vs. salavat yulaev ufa.

Much like the Elitserien Finals, we have a bit of an offense vs. defense match-up in this league Final.  While Ufa let their star top line of Alexander Radulov, Patrick Thoresen and Igor Grigorenko loose on the KHL's Western Conference, Mytischi played a more conservative style, relying on veterans such as former NHLers Jan Bulis, Oleg Petrov, and Jaroslav Obsut.  Just reaching the Finals is a testament to Atlant's disciplined style of play, as they had to knock off much more high profile teams from Yaroslavl and St. Petersburg to do so.  But while they did finish 8th in the league in points, they haven't seen the likes of Ufa, who finished 2nd. 

This series will be a challenge for the underdog, because unlike some of the other KHL teams, Ufa's top players are generally younger and in their prime.  Only Proshkin amongst regular blueliners is over 30, with the work being shared by Kirill Koltsov (28), Andrei Kuteikin (26), Miroslav Blatak (28), Maxim Kondratiev (28) and Dmitri Kalinin (30).  Oleg Tverdovsky hasn't played a lot in the playoffs to date.  Up front, while led by a fairly young top line (24-27), Ufa does have a lot of veterans in support roles:  Vyacheslav Kozlov , Viktor Kozlov , Vladimir Antipov, Sergei Zinovyev and Petr Schastlivy are all over 30.  In fact, the names of all their forwards are familiar to international and NHL fans:  Robert Nilsson , Alexander Svitov, Oleg Saprykin and Jakub Klepis round out the group, all former NHL players.

For Atlant, their veteran roster, with only one of their top six D under the age of 30 (and no top forwards under 30, either), this might be their one shot at a championship.  The team has never won either a Russian Superleague title or the Gagarin Cup, and for players like former NHLer Oleg Petrov, this is probably the last shot at the KHL's top prize.  The team got three extra days rest by winning their Conference Final in six games, and they probably needed to use it.  Atlant does have younger regulars on their roster, but they generally only play a few shifts per game, if that. 

The low event style of game for Atlant probably suits them well, but I don't know how they can manage to keep up against Ufa's speed, skill, and depth.  There is no advantage to be seen in goal, with Erik Ersberg and Konstantin Barulin posting almost identical numbers, and even in terms of recent playoff experience Ufa has them beat.  Luckily for Atlant, Ufa isn't that far away from the Moscow region, so travel shouldn't play a major role. 

I'm predicting that Ufa, winners of the last Superleague title back in 2008, will become the second team to win the Gagarin Cup, and will prevail in five games.  They have a seriously well built team that would honestly compete in the NHL.  They represent the potential of the league, while Atlant represents closer to the reality, as a team full of players who played themselves out of the NHL. 

• Atlant @ Ufa, Friday Apr 8 (3:00 PM CET/10:00 PM EST)
• Atlant @ Ufa, Sunday Apr 10 (1:00 PM CET/8:00 AM EST)
• Ufa @ Atlant, Tuesday Apr 12 (5:30 PM CET/12:30 PM EST)
• Ufa @ Atlant, Thursday Apr 14 (5:30 PM CET/12:30 PM EST)

Games 5-7 are as yet unscheduled, but every second day is the KHL standard, so expect Game 5 to be on Saturday, like an early start. 

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Savvino-storozhevsky monastery and museum.

Zvenigorod's most famous sight is the Savvino-Storozhevsky Monastery, which was founded in 1398 by the monk Savva from the Troitse-Sergieva Lavra, at the invitation and with the support of Prince Yury Dmitrievich of Zvenigorod. Savva was later canonised as St Sabbas (Savva) of Storozhev. The monastery late flourished under the reign of Tsar Alexis, who chose the monastery as his family church and often went on pilgrimage there and made lots of donations to it. Most of the monastery’s buildings date from this time. The monastery is heavily fortified with thick walls and six towers, the most impressive of which is the Krasny Tower which also serves as the eastern entrance. The monastery was closed in 1918 and only reopened in 1995. In 1998 Patriarch Alexius II took part in a service to return the relics of St Sabbas to the monastery. Today the monastery has the status of a stauropegic monastery, which is second in status to a lavra. In addition to being a working monastery, it also holds the Zvenigorod Historical, Architectural and Art Museum.

Belfry and Neighbouring Churches

Located near the main entrance is the monastery's belfry which is perhaps the calling card of the monastery due to its uniqueness. It was built in the 1650s and the St Sergius of Radonezh’s Church was opened on the middle tier in the mid-17th century, although it was originally dedicated to the Trinity. The belfry's 35-tonne Great Bladgovestny Bell fell in 1941 and was only restored and returned in 2003. Attached to the belfry is a large refectory and the Transfiguration Church, both of which were built on the orders of Tsar Alexis in the 1650s.  

To the left of the belfry is another, smaller, refectory which is attached to the Trinity Gate-Church, which was also constructed in the 1650s on the orders of Tsar Alexis who made it his own family church. The church is elaborately decorated with colourful trims and underneath the archway is a beautiful 19th century fresco.

Nativity of Virgin Mary Cathedral

The Nativity of Virgin Mary Cathedral is the oldest building in the monastery and among the oldest buildings in the Moscow Region. It was built between 1404 and 1405 during the lifetime of St Sabbas and using the funds of Prince Yury of Zvenigorod. The white-stone cathedral is a standard four-pillar design with a single golden dome. After the death of St Sabbas he was interred in the cathedral and a new altar dedicated to him was added.

Under the reign of Tsar Alexis the cathedral was decorated with frescoes by Stepan Ryazanets, some of which remain today. Tsar Alexis also presented the cathedral with a five-tier iconostasis, the top row of icons have been preserved.

Tsaritsa's Chambers

The Nativity of Virgin Mary Cathedral is located between the Tsaritsa's Chambers of the left and the Palace of Tsar Alexis on the right. The Tsaritsa's Chambers were built in the mid-17th century for the wife of Tsar Alexey - Tsaritsa Maria Ilinichna Miloskavskaya. The design of the building is influenced by the ancient Russian architectural style. Is prettier than the Tsar's chambers opposite, being red in colour with elaborately decorated window frames and entrance.

At present the Tsaritsa's Chambers houses the Zvenigorod Historical, Architectural and Art Museum. Among its displays is an accurate recreation of the interior of a noble lady's chambers including furniture, decorations and a decorated tiled oven, and an exhibition on the history of Zvenigorod and the monastery.

Palace of Tsar Alexis

The Palace of Tsar Alexis was built in the 1650s and is now one of the best surviving examples of non-religious architecture of that era. It was built especially for Tsar Alexis who often visited the monastery on religious pilgrimages. Its most striking feature is its pretty row of nine chimney spouts which resemble towers.

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