A transgender person’s assigned sex at birth doesn’t match their gender identity, expression, or behavior.
Refer to glossary for more details.
have important details to consider in the Marketplace.
Applying for Marketplace coverage
When you apply for Marketplace coverage as a transgender person, you should use the first, middle, and last name that are on your Social Security card. If you get a letter or email stating that you need to take additional action because your name doesn’t match the name on file with the Social Security Administration (SSA), you can go back to your application and update your name.
On your Marketplace application, it’s also recommended that you select the sex that appears on the majority of your other legal documents, such as your driver’s license or Social Security card. While the Marketplace doesn’t check an applicant’s sex against any other government record, including SSA, some state Medicaid agencies may verify your sex against available records.
The response to the application question identifying your sex ("Female" or "Male") will go to your health insurance company. The optional questions about your sexual orientation, gender identity, and sex assigned at birth won't be shared.
If you change your name and/or sex after you enroll in a plan, you should be able to update the information when you log in. If you have trouble updating this information, contact the Marketplace Call Center.
Sex-specific preventive services
Marketplace health plans must cover a set of preventive services — like shots and screening tests — at no cost to you when delivered by a doctor or other provider within your plan’s network.
Your health insurance company can’t limit sex-specific recommended preventive services based on your sex assigned at birth, gender identity, or recorded gender — for example, a transgender man who has residual breast tissue or an intact cervix getting a mammogram or pap smear.
If your doctor determines that the preventive service is medically appropriate for you and you meet the criteria for this recommendation and coverage requirements, your plan must cover the service without charging you a
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Refer to glossary for more details.
or
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
Refer to glossary for more details.
, even if you haven’t met your yearly
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
Refer to glossary for more details.
.
Plans with transgender exclusions
Many health plans are still using exclusions such as “services related to sex change” or “sex reassignment surgery” to deny coverage to transgender people for certain health care services. Coverage varies by state.
Before you enroll in a plan, you should always look at the complete terms of coverage that are included in the “Evidence of Coverage,” “Certificate of Coverage,” or contract of insurance. This contains the full explanation of which procedures and services are covered or excluded under each plan. Plans might use different language to describe these kinds of exclusions. Look for language like “All procedures related to being transgender are not covered.” Other terms to look for include “gender change,” “transsexualism,” “gender identity disorder,” and “gender identity dysphoria.”
You can access the full terms of coverage through a plan’s
An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You'll get the "Summary of Benefits and Coverage" (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.
Refer to glossary for more details.
. If you’re still not sure about how services would be covered or excluded, you should contact your health plan directly by phone.
These transgender health insurance exclusions may be unlawful sex discrimination. The health care law prohibits discrimination on the basis of sex, among other bases, in certain health programs and activities.
If you believe a plan unlawfully discriminates, you can file complaints of discrimination with your state’s Department of Insurance, or report the issue to the Centers for Medicare & Medicaid Services by email to marketconduct@cms.hhs.gov.
You may also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.
Once you’re enrolled in a plan, if your health insurance company refuses to pay a claim or ends your coverage, you also have the right to appeal the decision and have it reviewed by an independent third party.
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