Important Considerations for Transgender Individuals in the Marketplace

Applying for Marketplace Coverage

When applying for Marketplace coverage as a transgender individual, it’s important to use the first, middle, and last name that appear on your Social Security card. If you receive a notice stating that additional action is needed because your name doesn’t match what’s on file with the Social Security Administration (SSA), you can update your name in your application.

On your application, it’s recommended to select the sex that appears on most of your legal documents, such as your driver’s license or Social Security card. While the Marketplace doesn’t verify your sex against other government records, some state Medicaid agencies might. The sex you indicate (“Female” or “Male”) will be shared with your health insurance company. However, optional questions about your sexual orientation, gender identity, and sex assigned at birth will not be shared.

If you change your name and/or sex after enrolling in a plan, you should be able to update this information online. If you encounter difficulties, contact the Marketplace Call Center for assistance.

Sex-Specific Preventive Services

Marketplace health plans are required to cover certain preventive services—like vaccinations and screening tests—at no cost to you, as long as you use a provider within your plan’s network. Your health insurance company cannot deny you sex-specific 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 is entitled to receive a mammogram or pap smear if medically appropriate.

If your doctor recommends a preventive service and you meet the criteria for coverage, your plan must cover the service without charging you a copayment or coinsurance, even if you haven’t met your deductible.

Plans with Transgender Exclusions

Some health plans still have exclusions like “services related to sex change” or “sex reassignment surgery,” which can be used to deny coverage for transgender-related care. Coverage varies by state, so it’s crucial to review the full terms of coverage in the “Evidence of Coverage,” “Certificate of Coverage,” or insurance contract before enrolling in a plan. Look for language such as “All procedures related to being transgender are not covered,” as well as terms like “gender change,” “transsexualism,” “gender identity disorder,” and “gender identity dysphoria.”

You can find this information in a plan’s Summary of Benefits and Coverage. If you’re uncertain about how specific services will be covered, contact the health plan directly for clarification.

These exclusions may constitute unlawful sex discrimination. The healthcare law prohibits discrimination based on sex in certain health programs and activities. If you believe a plan is unlawfully discriminating, you can file a complaint with your state’s Department of Insurance or report the issue to the Centers for Medicare & Medicaid Services.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.

Appeals and Rights

Once enrolled in a plan, if your health insurance company refuses to pay a claim or ends your coverage, you have the right to appeal the decision and request a review by an independent third party.