Understanding Insurance

There is a LOT of change going on in the world of insurance coverage for gender-affirming care—and despite headlines, a lot of it is favorable to transgender and nonbinary people. That doesn’t mean it’s any less complicated!

Many people look at their health insurance card, see an insurance company listed, and assume that the company insures them. Not necessarily! For the millions of Americans who get their coverage through a workplace plan, if the employer is relatively small, the insurance company may indeed be acting as an insurer. But in most large-employer contexts, the company is simply administering the employer’s plan on the employer’s behalf. The first type of plan is generally regulated by the State, and the second by the federal government. And, of course, there are exceptions.

Also, many insurance companies offer a wide array of plans: Medicare, Medical Assistance (also known as MA, or Medicaid), large-group plans, individual/small-group plans, state or federal government employee plans, and more. Each type of plan is often subject to different rules, and to different regulators. What this means is that even though two people have health insurance cards with the same insurance company’s name and logo on them, each might have different experiences getting the same procedure covered.

Most insurance plans have some sort of basic document outlining their general approach to covering gender-affirming care, which is often tied more or less closely to the WPATH Standards of Care, version 8. NOTE: in September 2022, version 8 replaced the previous, seventh version. It may take time for plans to bring their policies into alignment with version 8, potentially creating a period of some confusion, including unwarranted denials, which our team is happy to review.

But sometimes those documents are superseded by other requirements, which may be more or less stringent than those of the insurance company itself. These superseding requirements might be ones set for government-regulated plans; ones set for government-provided plans like MA or Medicare; or be found in the Summary Plan Document provided to the insured individual. And there are still employer plans which claim to cover no gender-affirming care at all.

Examples of the basic coverage policies related to gender-affirming care for some of the major health insurance plans operating in Minnesota include:

  • NOTE: Medicare does not have a specific policy of this sort, but covers gender-affirming care it deems “reasonable and necessary.”

    Finally, depending on the specific type of plan involved, paths toward getting coverage approved may lead one to a variety of destinations, including one’s employer, the Equal Employment Opportunity Commission; the Minnesota Departments of Commerce, Human Services, or Health; or the US Department of Health and Human Services.

    For plans subject to regulation by the Minnesota Departments of Health or Commerce, the State issued guidance in 2023 continuing the existing ban on exclusions of gender-affirming care, in place since 2015.  Perhaps even more important than this specific bulletin, the Departments of Health and Commerce now require that insurers offering State-regulated plans in Minnesota must demonstrate that, in addition to not excluding coverage for gender-affirming care, their plans and medical policies follow the prevailing medical guidelines to cover the full range of relevant procedures.  Rainbow Health takes seriously the State’s reference to “deceptive trade practices” in the bulletin and will be carefully monitoring insurers’ adherence to this guidance.

    Confusing? Of course it is! If you have a question about insurance coverage for gender-affirming care, reach out to our Gender Care Access Project advocacy team at [email protected] and let’s sort it out.