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United States of America

Insurance coverage for Transgender/Transsexual (TG/TS) related services

More and more insurance companies are starting to cover TG/TS services, such as but not limited to: Hormone Replacement Therapy (HRT), Behavior Health (therapist), and transition related surgeries.

Here are some people experience getting their health care to cover TG/TS Services:

Understanding your plan

When selecting a plan, there are a few things that are key too look for to see if TG/TS related care will be available. The following sections will attempt to outline the following items:

  • The key terms used when talking about health insurance plans.
  • The differences between HMO and PPO plans.
  • How to identify what TG/TS related services are covered.
  • What steps to take, to get TG/TS related services covered if they are not.

Navigating your current health care plan, or attempting to select a new one can be a very difficult process. This page attempts to explain health insurance in terms of a TG/TS patient. Please feel free to update this page as needed.

Key terms

Case Manager - Usually a doctor or nurse assigned to you by your insurance company to help you understand your plan, as well as advise you in health care decisions.
Co-insurance - Percent of the medical costs you are required to pay.
Copay - Fixed cost of medical services, varies from service to service.
Deductible - Amount one must pay before insurance will start to cover medical services.
Network - Group of healthcare providers who have signed a contract with an insurance company(s).
HMO - Health Maintenance Organizations, a single network based healthcare plan managed by a PCP.
PCP - Primary Care Provider, your primary doctor. Required by most HMO insurance plans.
PPO - Preferred Provider Organizations, a multi-network based healthcare plan.
Provider - Any doctor, or specialist who provides healthcare.
Specialist - Healthcare provider who provides a special service that your normal doctor cannot.

Checking for TG/TS related coverage

The first thing to do when checking a plan for coverage is to check the limitations and exclusions list. This list can be obtained from your current or potential healthcare provider, and can be found on your instance providers website when you log in. If you need an updated copy of it due to a policy change it can be requested as needed. It is recommended that if you get your insurance through your employer, that you get this list from the insurance company itself as the copy they have on file may be out of date.

If you do not find Transgender/Transsexual Services such as sexual reassignment surgery, therapy, or hormone replacement therapy in the limitations and exclusions section of your plan, this means those services are covered. The next step is to read your plan, or call your insurance provider to confirm what services are covered and what the copay/co-insurance cost would be.

If you do find TG/TS services specifically listed in the limitations and exclusions of your plan do not give up! These days an increasing number of plans have the ability so simply add TG/TS services such as SRS/GCS to an existing or new plan for little or no extra cost. If you get your health care though an employer you will have to talk to your Human Resources Department to ask if they can add it to your plan. In general it may only take a single phone call for them to add it to your plan if they are willing to do it.

More About Insurance Plans

Here is a quick summery about different types popular healthcare plans.

HMO - Health Maintenance Organizations

An HMO plan is when your insurance company

In this set up, the following things are usually true:

  • You are required to have a Primary Care Provider (PCP)
  • Limited to a geographical area.
  • The ability to select an out-of-network provider for a higher rate/coinsurance.
  • Your PCP will refer you to a specialist in the HMO's network if required.
  • If a specialist can not be found in your network, you can be referred to an out-of-network provider (this may or may not cost extra).
  • A lower a copay/deductible compared to a PPO plan.
PPO - Preferred Provider Organizations

The following is usually true about PPO plans:

  • You do not need to select a Primary Care Provider (PCP).
  • Larger network than an HMO plan.
  • You can pick your own specialist with out a referral.
  • A higher copay/deductible compared to a HMO plan.

Insurance Requirements

GCS/SRS Coverage

The following is a list of insurance requirements for GCS/SRS:

TG/TS Service Coverage

The following is a list of requirements for transgender related services:

Source(s): - Finding Insurance for Transgender-Related Healthcare


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Page last modified on April 10, 2016, at 12:30 AM