Does Health Insurance Cover Sex Change?

For health insurance plans that are ACA (Obamacare) compliant, your Gender reassignment surgery may be covered.

Covered services for Gender Dysphoria (a disorder characterized by diagnostic criteria) which is classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, can be provided (if approved) and if it has been prior authorized. We recommend calling the insurance company and getting permission usually with the assistance of your physician. You most likely will need to meet certain diagnostic criteria and satisfy any prerequisite requirements that will be required to be approved.

Non ACA (not Obamacare) Health Insurance Plans

In most cases, if your health plan is not ACA (Obamacare), health insurance plans have exclusions for “services related to sex change” or “sex reassignment surgery.” You will have to look at the summary of benefits of the plan you are looking at.

Gender on your Nevada Health Link Marketplace Coverage

When you sign up for a Marketplace plan, (Nevada Health Link) you should use the full name that appears on your social security card. If there is a discrepancy between the name that you provide and the name that the Social Security Administration has on file for you, you will get a letter or email letting you know that you need to go back to your application and update your name. On your health insurance application, it is also important that you select the gender that appears on most of your legal documents, such as your social security card and driver’s license.

What Does Health Insurance Cover for Transgender Individuals?

Marketplace plans must offer the 10 essential benefits outlined in the Affordable Care Act, such as screenings and vaccinations, without charging a copay as long as you get the services from an in-network healthcare provider.

Health insurance companies are not allowed to limit the preventative services they cover based on either your birth gender or your recorded gender. For example, if you are a transgender man with an intact cervix, your health insurance has to pay for a pap smear regardless of the gender they have on file for you. As long as your doctor determines that a preventative service is medically necessary, your plan has to cover it the same as it does for cisgender people.

Gender reassignment surgery in order to be considered medically necessary, certain criteria must be met, such as if a qualified mental healthcare professional provides a referral and medical or mental health concerns are present. Otherwise, health insurance companies may consider surgeries to be cosmetic and deny coverage just as they would for liposuction or a facelift.

Finding the Right Health Insurance Coverage with Nevada Insurance Enrollment

Before signing up for a health insurance plan, it is important to look at its coverage terms in its Summary of Benefits and Coverage. At Nevada Insurance Enrollment, our health insurance agents can help you review available health insurance plans to find one that fits your needs.