In the United States, health insurance is essential to access healthcare for most people. For the transgender, nonbinary, and gender diverse community, access to gender-affirming health care is necessary and life-saving. Gender-affirming care can include gender-affirming hormone therapy (GAHT, sometimes called HRT) like estrogen, testosterone, and hormone blockers. It may also include gender-affirming surgeries, such as top surgery, bottom surgery, and facial feminization surgery (FFS). Gender-affirming healthcare can also include mental health services, culturally competent healthcare, and reproductive healthcare as well.
Being able to afford adequate health care to stay healthy and happy on your gender journey can be daunting. This blog post provides tools that will help you find, pay for, and understand the basics of accessing trans-friendly health insurance.
What is the Affordable Care Act?
The Affordable Care Act (ACA) is a comprehensive health care reform law enacted by President Barack Obama in March 2010. It is sometimes called Obamacare. The goal of the law is to lower the costs of healthcare for everyone and improve healthcare access. Among other things, the ACA expands the Medicaid program to cover all adults whose income is below 138 percent of the federal poverty level (FPL). The FPL is based on a household’s income and family size. You can use this subsidy calculator to learn what types of insurance are available to you and what you might pay.
While most people still get private health insurance from their employer, the Affordable Care Act created an exchange for people to buy health insurance individually or for their family. If you want health insurance but you’re unemployed, freelancing, or low-income, check out your options at the Healthcare Marketplace.
Understanding health insurance words and terms
Here are some terms you might see when you’re looking for insurance:
Premium
Your premium is a monthly fee that you pay for your insurance. The premium is often lowest on plans that have higher costs elsewhere (such as higher cost sharing – copays and deductibles) . When you choose which policy and premium to pay, think about your total healthcare costs throughout the year—your co-pays, prescription medications, and deductibles—so you can decide where and how to save the most money on care.
Network
Most insurance plans limit which doctors or providers they cover. (Some doctors are “in-network” and others are not. This is also known as “out-of-network.”) For example, with an HMO-type plan, you often need to see a primary care physician first to get referrals to see other specialists, receive treatments, or get a prescription for GAHT, if the primary care provider isn’t familiar with GAHT. Some of the lowest cost insurance plans have a “narrow network” that works with a limited number of “in-network” providers in a specific area, and it can sometimes be challenging to find the type of provider you need (particularly someone with experience in gender-affirming care).
Copays & Out-of-Pocket Costs
Medical costs can include your co-pay for visits with a primary care physician or a specialist, such as an endocrinologist. In-network medical costs tend to be lower with insurance, but always check your plan to make sure you understand what you’ll pay for each visit, lab work or diagnostic test, or prescription.
As an FYI, when you select Plume as your gender-affirming care provider, you won’t have to worry about paying a copay or provider availability. Your membership fee is the same every month. You’ll work with a Plume Care Team of folks who specialize in transgender healthcare. And you’ll be able to make an appointment most anytime you need one.
Pharmacy
Although we think of a brick-and-mortar drugstore when we hear the word “pharmacy,” it means something a little different when we talk about insurance. Pharmacy benefit means the cost of medications commonly associated with gender-affirming hormone therapy. This can include estrogen, testosterone, spironolactone, finasteride, acne medications, erectile and sexual function medications, hair growth medications, and mental health medications for anxiety and depression.
If you are interested in GAHT and want to find a way to make your prescription more affordable, look at the pharmacy costs of each healthcare plan. Some plans will have co-insurance or co-pay coverage for prescription drugs. Other plans have a pharmacy benefits manager, with a standardized preauthorization process. That means that your primary care provider (PCP) will need to refer you to any specialists and prescribe your medications in order to get the medication covered at a lower cost.
Surgery
Surgery isn’t part of everyone’s gender transition, but for those of us who want to have surgery, it is a life-changing event. Surgery costs can include payments for common procedures or gender-affirming surgeries. When you are choosing an insurance plan with surgery in mind, make sure you look at the maximum out-of-pocket costs for an individual or family. This number represents a cap on what you will pay for your surgery, and related services.
Want to learn more, or found a word that doesn’t make sense? You can also check out this glossary of terms at Healthcare.gov.
Can insurers discriminate against transgender people?
The ACA prohibits discrimination by qualified health providers, including physicians, hospitals, and clinics, on the basis of gender or gender identification. That protection extends to insurance as well. Starting in 2014, the ACA prohibited insurers from denying coverage to individuals on the basis of their gender identity. Also in 2014, the US Department of Health and Human Services lifted a ban on Medicare coverage for gender-affirming surgery, which had been in place since 1989.
While some types of health insurance are more trans-friendly than others, no health insurance company and no health insurance provider can legally discriminate against transgender, nonbinary, or gender non-conforming patients. While this type of discrimination isn’t automatically eradicated by law, it gives transgender patients equal protection in the clinic. With only a few exceptions, it is illegal for you to be denied health insurance based on your gender identity. You can learn more about your healthcare rights at the National Center for Transgender Equality (NCTE).
Does Plume accept health insurance?
We will soon be in-network in Texas with Aetna of Texas and United of Texas for 2023, and in California with Aetna of California with expansion to more states and insurance providers to come. You can learn more about using health insurance to cover your gender-affirming care at Plume by checking out our FAQ.
So you know, using GAHT or moving forward with surgery is a personal decision; you are valid in your identity whether you make some or are all of these changes. At Plume, we offer the resources you need to make this important decision for yourself. With or without insurance, you are welcome at Plume. We are so grateful to be part of your journey and a trusted resource on your path toward your most authentic self.
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