Insurance Coverage for Gender Affirming Care
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Navigating insurance can be difficult for anyone—it is made to be inaccessible. Especially for those trying to access gender affirming care, we know things keep changing, and trying to find care and get it covered in a system that was not created with us in mind is exhausting. If you are feeling confused and overwhelmed, you are not alone. We are working hard to make these healthcare systems more accessible and supportive for LGBTQ+ Coloradans. In the meantime, we’ve pulled together some information on finding gender affirming care insurance coverage, knowing your rights, and what to do if you get denied coverage.
For the best advice, always reach out to your insurance provider with specific questions about your plan.
Finding Coverage
Private Insurance Plans
What are they?
Private insurance plans include those offered through your employer or individual plans purchased through Colorado’s insurance marketplace, called Connect for Health Colorado. Examples include Aetna, Anthem, Kaiser, and United Healthcare.
Gender affirming care coverage:
Colorado is the first state in the US to include gender affirming care as an essential health benefit (EHB)! This means Colorado-based (your insurance card will say CO-DOI) individual plans (not from an employer) and small group plans (employers with 2 - 100 employees) have to cover certain services including facial & chest surgeries and hair removal.
Colorado’s Department of Insurance (DOI) created a helpful Gender Affirming Care Coverage Guide showing what services each insurance plan covers. Don’t see your plan here? It may not be an individual or small group plan, but that doesn’t mean they won’t cover gender affirming care. You will just need to reach out to them (best to get it in writing) about what exactly they will cover.
Public insurance plans
1. Medicaid
What is it?
Health First Colorado, our state’s Medicaid program, is an income-based insurance program for individuals and families. It is regulated by Colorado’s Department of Health Care Policy and Financing.
Gender affirming care coverage:
Gender affirming care covered by Medicaid was expanded in 2017 to include coverage for certain gender affirming services. It was expanded again in August 2023 and now aligns closely with WPATH SOC-8, best practices in gender-affirming healthcare. Learn more about the recent policy changes here or here.
2. Medicare
What is it?
Medicare provides health insurance for adults over 65 years old and people with disabilities. It is regulated by the federal government.
Gender affirming care coverage:
Because Medicare is regulated federally, not by Colorado, the gender-affirming care coverage is not as comprehensive as Colorado-based insurances. The National Center for Transgender Equality (NCTE) offers information and resources about the type of care covered based on different types of Medicare plans and more!
What if myself or someone in my family is undocumented?
Check out Omnisalud!
What is it?
Omnisalud is a new program in Colorado that provides insurance coverage options for people in Colorado and does not ask for documentation status. The only info required to apply is name, address, and income.
Gender affirming care coverage:
Gender affirming services are covered as EHBs for Omnisalud. See above for more details.
What if my employer or insurance plan is based in another state?
Even if you live and work in Colorado, if your employer is based in another state, you will have to look at what gender-affirming care policies are in effect in that state to know what your insurance has to cover.
Denials and Appeals
Getting a denial for care you need can be frustrating, but it doesn’t mean the fight is over! The first thing you need to do is understand why the service was denied so you can equip yourself with the tools you need to appeal it. The Trans Health Project has a wonderful resource for understanding denials. Oftentimes, your healthcare provider will be able to support you in this process as well.
Once you understand why you were denied services, you may be able to appeal. There are different types of appeals with different deadlines, so best to start the process as soon as you can after receiving a denial. The Trans Health Project also has an excellent resource on understanding the appeal process.
Know Your Rights
What are my rights?
Colorado Regulation 4-2-62 prohibits discrimination in private health insurance plans based on sexual orientation or gender identity. Private insurance plans sold in Colorado cannot:
- Inquire about an applicant’s or a beneficiary’s sexual orientation or gender identity in an application for coverage;
- Deny, cancel, limit, or refuse to issue or renew a policy because of a person’s sexual orientation or gender identity;
- Deny, exclude, or otherwise limit coverage for medically necessary services, in accordance with generally accepted professional standards of care, based upon a person’s sexual orientation or gender identity.
What if I need to file a complaint?
I feel I have been discriminated against by my insurance plan:
- You can contact the Division of Insurance to ask a question or file a complaint at 303-894-7490 / 800-930-3745 / DORA_Insurance@state.co.us or here.
I feel I have been discriminated against in a healthcare setting:
