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Insurance Coverage for Gender Affirmation Surgery

Medically reviewed by Jennifer Richman on October XX, 2024.

Some of the most stressful questions arise when trying to figure out insurance coverage for gender confirming surgery. You’re not alone if you’re looking at your Google search history and see:

• Insurance companies that cover gender confirmation surgery
• Top surgery insurance
• Does insurance cover gender confirming surgery?
• Insurance that covers top surgery
• What’s the cost of top surgery?
• Is gender confirming surgery covered by insurance?
• How to get top surgery covered by insurance
• Top surgery grants
• Breast augmentation insurance
• Transgender surgery insurance coverage
• Best insurance for transgender coverage

We’re here to provide some guidelines to help answer some of these questions. Your first step is to reach out to us for a consultation. We have an insurance concierge who works directly with your insurance provider to see what transgender medical insurance benefits you have.

Our insurance advocacy team will take you through every step of the insurance approval process until either approval is achieved or when it becomes clear that you do not have coverage. Because one of our main goals is to get your gender confirmation surgery covered by insurance, we provide the insurance advocacy work as a free service to all of our patients to give everyone the best chance of success.

Our team has experience securing insurance approvals for our surgeons to work with the following insurance providers:

• Aetna (Student Services only)
• Anthem (National and California)
• Brown & Toland HMO
• Health Net
• Assurant
• Blue Shield
• Aetna National
• Hills Physicians (HMO)
• Excellus (Blue Cross/Blue Shield of New York)
• United Health Care

To help us verify the benefits, we will need the following information from you:

• Full Name
• Date of Birth
• Procedure(s) you are looking to have covered
• A scanned copy of your insurance card (front and back)
• Your contact number (where we can also leave a message)

Once we have your information, we will contact the insurance company and then let you know as soon as we hear from them. When we contact you,we’ll present one of the following scenarios:

Scenario A: Your insurance carrier does not cover the cost of your procedure(s). Some options you will have if this happens:

• Pay out-of-pocket for the procedure
  • Lack of medical insurance for gender confirming procedures is an unfortunately reality for some. Rest assured you are not alone in this process; reach out to your community for support and guidance.
• Finance your procedure(s) with CareCredit
  • It works just like a credit card but is exclusive to healthcare services. You can use it on any healthcare service, including gender confirmation surgeries in San Francisco and beyond. Will it cover your top surgery costs? This is dependent on the amount you’ve been approved for. Visit CareCredit’s website to find out more.
• Finance your surgery with a loan
  • A loan may be best for you if you’re unable to get your gender confirming surgery covered by insurance, if your surgeon of choice doesn’t accept insurance, or if you’re uncomfortable with or unable to sign up for CareCredit.
  • There are several loan types specifically for gender confirming surgery procedures.

If Scenario A happens, our team will help you explore the two options listed above.

California law prohibits insurance companies from denying medical insurance benefits for transgender-related care. However, there are two exceptions:

1. 1. If the policy is a large group that is ‘Self-Funded,’ meaning the employer assumes the direct risk for payment of claims or benefits (not the insurance company), these policies are not required by law to have health insurance benefits that cover gender confirmation surgery.
   2. If the employer’s corporate office is in a state other than California, the health benefit policy falls under the laws of the state where the corporate office is located.

Scenario B: Your health insurance covers gender confirming surgery :

This scenario can be further broken down into two possibilities:

Possibility #1: Your insurance is with Anthem Blue Cross, Blue Shield, or Brown & Toland. Our practice has agreements with these providers so your approval process should be smooth and straightforward.

What we will need from you for authorization approval:

1. 1. • A letter from a mental health provider stating that you meet WPATH guidelines for surgery (for example, confirming your use of hormones if relevant to your insurance requirements)
      • Notes from your consultation with our surgeons which we will have ready 1-2 days after your consultation
      • Referral to our practice from your primary care provider (if you have either an HMO or are getting your insurance through a school)

There may be additional requirements based on individual circumstances.

Once we receive the necessary documents, we’ll start the request for authorization right away! It takes 4-6 weeks to receive a response from the insurance providers with whom we have an agreement.

Possibility #2: You have health insurance that covers gender confirming surgery, but our surgeons do not have an agreement with these providers

There are a couple of ways to have your surgery covered, even if our practice doesn’t have an established agreement with your company:

1. 1. 1. Our office can obtain a single-case LOA (Letter of Agreement) with your provider. This is usually a one-time contract between us and your insurance, for this procedure, just for you.
      2. In the rare cases when an LOA cannot be obtained, you will then pay up front and then we continue to try to get reimbursement for you after surgery. In this case, you would receive reimbursement from your insurance plan later (minus a 6 % administration fee from our billing company. That is the percentage they charge the GCC to file a claim).

Your insurance would treat this case as ‘out-of-network’. It is still beneficial to go through the authorization process because this can greatly reduce your hospital expenses, and usually your insurance will pay for a portion of the surgery.

What are some insurance companies that cover gender confirming surgeries?

It’s important to clear up that there’s not ‘one’ insurance company that is ‘the best’ when it comes to covering transgender healthcare. However, throughout the years of working with different insurance companies that cover gender confirming surgeries, some companies have a higher trend of approvals versus denials. Gender confirming surgery insurance approval is based on a variety of factors that could potentially disqualify a patient for approval, no matter how ‘good’ your insurance is. Remember, you’ll want to find a surgeon who accepts your insurance. These factors include:

First, is the coverage:

1. 1. 1. Patient must have GRS benefits on their plan
      2. Network qualifications: If a patient does not have an out of network benefit and the LOA requested from the office is denied, then the insurance denies the case.

Second, if a patient meets the gender affirming care guideline, most insurances have the same guidelines that they follow with WPATH and this is where the support letter comes in.

Larger companies that we accept and have seen decent insurance approval rates are:

1. 1. • Anthem Blue Cross
      • Blue Shield
      • Aetna
      • Cigna
      • United Health Insurance
      • Anthem Blue Cross Blue Shield Medical

If you have the above health insurance and are looking for gender confirmation surgeons outside of our practice, try searching what surgeons are in network with your health insurance plan. Or, contact your insurance provider directly to see if they have information to guide you.

What if I have insurance that covers gender confirming surgery but they don’t have qualified surgeons in their network?

It can be exciting when you’re enrolled in health insurance that covers gender confirming surgery. After looking at your policy, you might even find that you have the best insurance for transgender healthcare. But when it comes down to it, it could be that they don’t have qualified surgeons in your network.

Your insurance provider is required by law to refer you to a surgeon who can perform the procedure.

Obtaining approval may seem like an overwhelming process. However, with our experienced staff to help, you’ll be able to maximize your insurance benefits without the hassle and stress.

And, just to boil this down to bite-size, here is a summary of most of this information as a flowchart, also downloadable as a PDF here: