FTM Top Surgery Insurance Coverage:
What You Need to Know

The tides are turning: increasingly insurance companies in the United States are accepting the medically necessity of gender-affirming surgeries and covering Top Surgery.

The medical necessity of gender-affirming surgeries has been affirmed by the American Medical Association (pdf), American Psychiatric Association, and World Professional Organization for Transgender Health (pdf), as well as insurance companies such as Aetna.

State Non-Discrimination Laws

There are a number of states that now prohibit discrimination and legally require insurance companies to provide transgender health coverage. These include: Oregon, California, Colorado, Vermont, Connecticut, Massachusetts, Washington, Illinois, New York, Nevada, Delaware, Pennsylvania, Michigan, Minnesota, Montana, Rhode Island, plus Washington D.C.

If you live in a state where surgery coverage is not mandated by law, you still might be able to get your top surgery covered via student health insurance.

Am I Covered?

Coverage varies between health insurance companies, states, and plans. Don't assume that one company, state or plan is consistent with their level of coverage. Read your policy completely—not just the summary—and look for the exclusions and limitations section. Next, call your insurance company's member services department, or contact a benefits representative where you work, and ask:

• Is my selected surgeon a provider with my specific plan? (Provide the representative with your surgeon's NPI number.)
• If my surgeon is NOT a provider, does my plan have out-of-network benefits?
• Does my plan cover gender-affirming surgery?
• How much is my deductible?

Don't miss: Top Tips for Getting Top Surgery Covered by Insurance »

How to Find Insurance

• out2enroll.org - Get free enrollment help.
• Finding Insurance for Transgender-Related Healthcare
• Transgender Health Care: Applying for Marketplace coverage
• How to shop for health insurance as a transgender person
• List of Businesses with Transgender-Inclusive Health Insurance Benefits
• These Insurers Offer Transgender Health Care Coverage
• State-by-state health coverage options in 5 easy steps

Insurance Requirements

To get Top Surgery covered by insurance there are a number of requirements. Some of the hoops you may need to go through include:

1. Meeting the insurance company's basic criteria: legal adult status, Gender Dysphoria diagnosis, support letters from qualified mental health practitioners, your primary care provider and your surgeon.
2. Having to pay out-of-pocket for surgery, then getting a reimbursement from the insurance company.
3. Having to be evaluated by a board of in-network doctors.
4. Finding in-network surgeons who have Top Surgery experience.

Appealing a Health Insurance Denial

If your insurance company denies to cover your Top Surgery, you have every right to appeal the decision — and you should.

• What should I do if I am denied coverage for transition-related health care?
• How to Appeal a Health Insurance Denial
• Your Guide to the Appeals Process

The Affordable Care Act

The Affordable Care Act and The Patient’s Bill of Rights add several important protections in health insurance that affect transgender people:

1. Elimination of coverage denials: Anyone can apply for health insurance and receive coverage the care they need, regardless of their gender. (For example, hysterectomy coverage for a trans man.)
2. Pre-existing condition acceptance: Insurers are no longer able to deny a person coverage based on having what an insurance company considers a pre-existing condition, which has included being transgender.
3. Plan cancellations are now illegal: Cancelling a plan used to be a way for health insurers to cancel coverage when a person’s health needs changed, such as coming out as transgender.

For more information about the ACA, see What the Affordable Care Act Means for Transgender People (Aug 2012).

More Resources:

• How-To Guide: Insurance Coverage for FTM Top Surgery In the United States
• Surgeons Who Accept Insurance for Top Surgery
• Surgeons Who Accept Medicare for Top Surgery
• Surgeons Who Accept Medicaid for Top Surgery
• WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide

Last updated: 09/04/20