Transgender people have better access to health care today than they did 10 or 15 years ago thanks to years of advocacy. Now health care organizations like the American Medical Association  and the American Academy of Pediatrics  have come out in support of gender-affirming care as medically necessary for transgender people. Sadly, some state lawmakers are now advancing anti-transgender legislation that threatens to restrict access to health care for many people.
“Trans people are in some ways a casualty of the growing cultural divide we’re seeing in the country, and this has been weaponized to rile up a political base, and isn’t grounded in actual medicine and what’s good for people,” says Sasha Buchert, senior attorney and director of Lambda Legal’s Nonbinary and Transgender Rights Project.
Health insurance for transgender people: What are the obstacles?
Transgender people face a mix of laws governing health insurance plans. Section 1557 of the Affordable Care Act prohibits health programs from discrimination based on a number of factors, including sexual orientation and gender identity. But regulations requiring insurers to cover transition-related care were held up in court, then effectively suspended by the Trump administration.
“While the Biden-Harris administration is now at work on new regulations under Section 1557, we are now on year six of [the department of Health and Human Services] failing to enforce Seciton 1557’s protections when it comes to transgender regulations,” says C.P. Hoffman, senior policy counsel for the National Center for Transgender Equality.
The lack of federal progress has given states leeway to make their own rules. States like Alabama,  Florida,  and Ohio  have advanced legislation that would restrict access to health care for transgender people. Like access to abortion, trans access to health insurance coverage is determined to a large extent by the laws in your state. For example, only about half of U.S. states explicitly prohibit health insurance plans from excluding coverage for transgender-related health benefits.  In other states, the laws either don’t explicitly protect coverage of trans-related health care or ban it outright.
Transgender people also face the same obstacles with health insurance that everyone else does: restrictive networks, high deductibles, and navigating a maze of bureaucracy when care is denied. For people with Medicaid, provider networks can be even narrower. And while Medicaid is funded by the federal and state governments, states set the guidelines for what gets covered, as is the case in Florida, where lawmakers are trying to ban Medicaid from covering any transition-related care. On the other hand, some progressive states have made it easier to access transition-related care.
“Not everywhere is perfect,” Hoffman says. “Maryland, for instance, still has a state policy prohibiting Medicaid reimbursement for a list of 31 transition-related procedures. But the trend in ‘blue’ states has been toward greater access to care.”
Even for insurance companies that cover gender-affirming care, many still put up barriers, Hoffman says. Most insurance companies still require transgender people to use hormone replacement therapy for a minimum of 12 months before covering gender-affirming surgery. “But everyone’s transition looks different, so using HRT may not be the right choice for a particular trans individual,” they say. “While there are often ways to have HRT requirements waived for the individual, the process can be burdensome and may require going through the appeals process.”
Many insurance companies also require people to get letters of support from mental health providers before they cover gender-affirming surgery.
“Requiring these letters has the effect of dehumanizing transgender individuals, as we are effectively asked to prove that we are geniunely transgender to cisgender therapists,” Hoffman says.
For many trans people, it can be prohibitively time-consuming to wade through the rules of your health insurance and your medical provider on your own, especially since transgender people often face other financial obstacles. 
How to know if your health insurance covers transgender-related care
Because of the mix of laws governing health insurance coverage, the best source for finding out what your plan covers may be your health insurance company. Look through your policy documents for any mention of transgender-related care to see if your plan explicitly excludes certain procedures. You may want to call your insurance company or health care provider directly to ask about specific procedures.
What to do if you can’t get health insurance coverage
If your health insurance company denies coverage, you should receive a written document confirming this. That letter, and your policy documents, should include instructions on how to file a formal appeal to that decision. You can also file an appeal through your state insurance regulator. There are national and local organizations that can help with this process.
“Lambda Legal and many other organizations have resources on how to challenge an exclusion and present your case if it’s a question about medical necessity,” Buchert says.
Buchert hopes lawmakers and insurance companies lower the barriers for trans people to get access to health coverage, and listen to the medical professionals who have denounced attacks on transgender health care.
“Trans people want the same crappy health care that everybody else gets,” she says. “We’re not asking for special or different treatment.”
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