Transgender Health Care

Transgender people have important details to consider in the Health Insurance Marketplace.

Applying for Marketplace coverage

When you apply for Marketplace coverage as a transgender person, you should use the first, middle, and last name that are on your Social Security card. If you get a letter or an email saying there are “inconsistencies” or “data matching issues” in your application because your name doesn’t match the name on file with the Social Security Administration (SSA), you can go back to your application and update your name.

On your Marketplace application, it’s also recommended that you select the sex that appears on the majority of your other legal documents, such as your driver’s license or Social Security card. While the Marketplace doesn’t check an applicant’s sex against any other government record, including SSA, some state Medicaid agencies may verify your sex against available records. Note: The information you put on your Marketplace application will go to your health insurance company.

If you change your name and/or sex after you enroll in a plan, you should be able to update the information when you log in. If you have trouble updating this information, contact the Marketplace Call Center.

Sex-specific preventive services

Marketplace health plans must cover a set of preventive services — like shots and screening tests — at no cost to you when delivered by a doctor or other provider within your plan’s network.

Your health insurance company can’t limit sex-specific recommended preventive services based on your sex assigned at birth, gender identity, or recorded gender — for example, a transgender man who has residual breast tissue or an intact cervix getting a mammogram or pap smear.

If your doctor determines that the preventive service is medically appropriate for you and you meet the criteria for this recommendation and coverage requirements, your plan must cover the service without charging you a copayment or coinsurance, even if you haven’t met your yearly deductible.

Plans with transgender exclusions

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.

Before you enroll in a plan, you should always look at the complete terms of coverage that are included in the “Evidence of Coverage,” “Certificate of Coverage,” or contract of insurance. This contains the full explanation of which procedures and services are covered or excluded under each plan. 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.”

You can access the full terms of coverage through a plan’s Summary of Benefits and Coverage. If you’re still not sure about how services would be covered or excluded, you should contact the plan’s issuer directly by phone.

These transgender health insurance exclusions may be unlawful sex discrimination. The health care law prohibits discrimination on the basis of sex, among other bases, in certain health programs and activities.

If you believe a plan unlawfully discriminates, you can file complaints of discrimination with your state’s Department of Insurance or the U.S. Department of Health & Human Services Office for Civil Rights.

Once you’re enrolled in a plan, if your health insurance company refuses to pay a claim or ends your coverage, you also have the right to appeal the decision and have it reviewed by an independent third party.