Where to Start, What to Ask

We’ve created this guide to help you evaluate your healthcare needs, navigate your new insurance options, and choose the best plan for you and your family.

At Strong Families we support the Affordable Care Act (ACA) – because we know the new healthcare law is a critical step to ensuring that all of our families have the healthcare they need. For too long, LGBT people have been unable to find coverage that treats our families fairly, covers the care that we need, and doesn’t break the bank. Access to affordable health insurance helps us protect ourselves and our families, and it’s vital to making sure that we can get the care we need to stay healthy.

Key Dates and Facts About the New Healthcare Plans

Since January 2014, almost everyone in the United States has to have health insurance coverage for themselves and their families. If you don’t have coverage or want to get new coverage, you can shop online, over the phone, or in person in your state’s health insurance marketplace (sometimes called an “exchange”) for a plan that fits your needs. If it’s hard for you to afford insurance, you might be able to get financial help to purchase coverage.

In most states, the marketplace is run by the fed­eral government through www.HealthCare.gov and will be open for enrollment from November 1, 2017 to December 15, 2017. If you miss this period, you may be able to get coverage during other times of the year but only because of major life changes (like getting married, having a child, losing a job, or having another major life event). About 11 states* and the District of Columbia operate their own marketplaces. In these states, the marketplace may have a different name, such as Covered California, Kynect, Washington Healthplanfinder, or New York State of Health, and be open for different dates. For instance, Covered California will be open until January 31, 2018. It is best to check with your state’s market­place for additional information.

Three key dates you’ll want to mark on your calendar:

November 1, 2017: Marketplaces open for enrollment for coverage to start on January 1, 2018.

December 15, 2017: Open enrollment ends. This is the last day to enroll to avoid a penalty for not having health insurance.

January 1, 2018: New coverage begins.

Health reform includes extensive new nondiscrimination protections for LGBT people. Nobody who works with the marketplaces, including employees, insurance companies, and people helping you look for coverage, can discriminate based on sexual orientation or gender identity. Insurers can’t offer plans with benefits that discriminate based on sexual orientation, gender identity, sex, or health condition. No one can be denied coverage or charged more because of a pre-existing health condition. And if you’re legally married to someone of the same sex, you have the right to the same family coverage options through the marketplace as any other married couple, regardless of what state you live in.

Every insurance plan sold through the marketplaces will have to cover a core set of basic benefits called “essential health benefits.” These benefits include a variety of services and medical procedures such as doctor visits, hospital stays, preventive screenings, prescription drugs, laboratory services, maternal and newborn health care, and mental and behavioral health services.

To help you compare them, all health plans in the marketplace have a metal level: bronze, silver, gold, or platinum. These levels describe the level of coverage in each plan. If you buy a bronze plan, your plan will cover about 60 percent of your healthcare costs, and you will have to pay about 40 percent of your healthcare costs yourself in charges such as deductibles, co-pays, and co-insurance. If you buy a silver, gold, or platinum plan, the percentage that you have to pay for your healthcare costs decreases. Different insurers in your state’s marketplace offer a variety of plans in different metal levels. Picking the right metal level of insurance for you and your family is a critical first step in comparing plans.

* The 11 states with state- run insurance marketplaces are: CA, CO, CT, ID, MD, MA, MN, NY, RI, VT, and WA

Where Can I Get Help?

In every state, you can get free help with enrollment from individuals called “navigators,” “assisters,” and “certified application counselors.” In some states, insurance agents and brokers can also provide help with coverage options. In this guide, we call all of these assistance personnel “assisters.” To find in-person help from an assister in your area, use this tool. Check to see if your local community health center, AIDS service organization, hospital, or LGBT community organizations are available to help. You can also get help through HealthCare.gov online or by phone at 1-800-318-2596. Help through HealthCare.gov is available 24/7 in many different languages.

Healthcare reform includes extensive new nondiscrimination protections for LGBT people. Nobody who works with the marketplaces,including employees, insurance companies, and people helping you look for coverage, can discriminate based on sexual orientation or gender identity. Insurers can’t offer plans with benefits that discriminate based on sexual orientation, gender identity, sex, or health condition. No one can be denied coverage or charged more because of a pre-existing health condition. And you, your spouse, and your children have the right to the same family coverage options through the marketplace as any other married couple.

You can find additional national and state-specific resources by clicking here.

How To Use This Guide

Start by thinking about your healthcare needs. Ask yourself questions like: How is your health and the health of individuals you want to find coverage for? This might affect whether you want basic or comprehensive coverage. Do you need family coverage for a spouse, partner, or child? Are you transgender and looking for a plan that covers transition-related care? Do you want to continue seeing specific providers with whom you have pre-existing relationships? Does the plan include the doctor, clinic, or hospital that you currently use? What kind of budget do you have for healthcare? The greater clarity you have about your healthcare needs and budget, the easier talking to an assister will be.

Once you have clarity on your needs, the questions in this guide help you understand more about what a specific plan offers. Start by reading through the sections. We suggest that everyone seeking healthcare consider asking assisters questions from the Cost and Coverage, Reproductive Healthcare, and Mental Health sections. The other areas – Definition of Family, LGBT youth, Transgender Healthcare, and HIV/AIDS – may only apply to you if you are seeking coverage for a same-sex partner or children in your care, or if you have specific healthcare needs in these areas. To see all the questions, download the PDF here.

Throughout the guide, in red you will find targeted questions about the ability of providers to understand LGBT issues. Assisters may not be able to answer these questions because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider. For a list of LGBT-knowledgeable healthcare providers, check out GLMA: Healthcare Professionals Advancing LGBT Equality. They keep a list of self-identified providers with experience working with the LGBT community. Once you identify a provider on the GLMA list, you can ask which plans work with that provider. You may also want to check out RAD Remedy, which has resources on affirming health care providers specifically for transgender, gender nonconforming, intersex, and queer people.

Finding a healthcare plan can require you to be a strong advocate for yourself and your family. You may need to call an assister more than once as you consider the full range of options. Assisters may refer you to specific community organizations that are more knowledgeable about LGBT-specific healthcare needs or suggest you talk to an insurance broker or representative in order to understand specific details about a plan. You can also use this same list of questions when talking to specific insurance company representatives or community partners.

If you are a member of a federally recognized tribe or currently receive health services through the Indian Health Service (IHS), the health reform law may give you new options. If you choose to enroll in a health plan through a marketplace, you may qualify for special benefits and protections offered to American Indians and Alaskan Natives. You can visit the IHS website to get more information. If you are a veteran, the Veteran’s Administration has information about how the ACA impacts healthcare for veterans and their families. Where to Start, What to Ask may still have valuable questions for your current healthcare providers and/or as you evaluate options in the new health insurance marketplaces.

Essential Information For Everyone

Cost and Coverage

The questions below can help you figure out what is included in a healthcare plan, what the copays and other out-of-pocket expenses are, and what the network of healthcare providers is like. Many of these questions would apply to someone of any sexual orientation or gender identity evaluating a plan, but we have also included targeted questions about the cultural competency of the providers and plan network in serving LGBT individuals and their families.

  1. Am I eligible for financial assistance to help me afford coverage? Am I eligible for lower premiums? Am I eligible for a reduction in my out-of-pocket costs?
  2. How much is the plan going to cost (beyond the monthly premiums)? What are all my out-of-pocket costs on the plan?
    1. Is there a deductible in this plan before coverage kicks in, and what is the amount of the deductible?
  3. Is there a wide network of providers on the plan?
    1. If you have a healthcare provider you would like to keep, ask if your provider is covered under the plan.
      • If you don’t have a current healthcare provider, but would like to find an LGBT-knowledgeable provider, check out GLMA. They keep a list of self-identified providers with experience working with the LGBT community. Once you identify a provider on the GLMA list, you can ask which plans work for that provider. RAD Remedy is also available as a resource.
    2. Can I choose my primary care provider? Can I select a family practice nurse practitioner, midwife, or other kind of clinician as my primary healthcare provider?
    3. How many healthcare providers belong to this plan?
    4. What’s the referral process within this plan? Do I need to go to my primary care provider to get a referral?
  4. Are there providers who specialize in working with LGBT individuals and families? What about with LGBT people of color?
  5. Does this plan provide any training about LGBT families and LGBT issues to its’ providers? How does this plan ensure providers are culturally competent to serve LGBT individuals and their families?
  6. Immigration status & language access: To be eligible for health coverage in the health insurance marketplace you must be a U.S. citizen or national living in the United States. In order to be eligible for Medicaid, individuals need to satisfy federal and state requirements regarding residency, immigration status, and documentation of U.S. citizenship.
    1. Someone in my family needs language translation to access care. Does the plan provide translators who are both linguistically and culturally competent?
  7. How is urgent and emergency care covered in this plan?
    1. Are there urgent care facilities in this plan? What’s the cost to me for a visit to urgent care?
    2. What’s the cost for a visit to the emergency room in this plan? What about in-network vs. out-of network?
  8. Dental coverage: Dental coverage is not considered an essential health benefit for adults, and insurance plans are not required to offer it as part of plans in the marketplace. However, many companies offer stand-alone dental policies through the marketplace that you can purchase at the same time that you enroll in health insurance. Some Medicaid programs may choose to provide dental benefits and some marketplace health plans may provide dental services as a covered benefit.
    1. Does the plan include dental coverage?
    2. Can I purchase a stand-alone dental policy?
  9. Complementary Alternative Medicine: Does the plan cover complementary alternative medicine like acupuncture, naturopathic medicine, or chiropractic services?
  10. Smoking: Smoking: If you are a smoker or current user of tobacco, you should ask about how this affects the cost of the plan. Generally, an insurer can charge as much as 50% more for a person who uses tobacco products (although CA, MA, NJ, NY, RI, VT, and the District of Columbia have prohibited a tobacco surcharge on health insurance). If you report inaccurate or false information about your tobacco use on an application, an insurer is allowed to retroactively impose the tobacco surcharge to the beginning of the plan year.
    1. I use tobacco products. How does this change the cost of the insurance plan?
    2. I would like to quit using tobacco products. What kinds of services and programs are available?
  11. Does the plan cover medical equipment? If so, which equipment is covered and what limitations are there on equipment coverage?
  12. Does the plan cover personal care services? What about home health services? What is the maximum amount of services allowed?
  13. Does the plan cover skilled nursing facilities? What about hospice? What is the maximum amount of these services allowed?
  14. What kind of rehabilitation services, including physical, speech, and occupational therapy, are covered by the plan? What are the copays and other cost-sharing for these services? Is there a cap on the number of visits that would affect the care I need?
  15. Privacy and billing: If you have concerns about privacy, you might want to know how billing is handled in each plan.
    1. How is billing handled? Which services are explicitly named or billed separately?
  16. What forms of identification are needed for plan enrollment (driver’s license, birth certificate, non-governmental identification)?

Questions in red are ones that assisters may not be able to answer because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider.

Reproductive Healthcare

In addition to providing general healthcare, all marketplace health plans must cover additional reproductive health services. These services include not only contraceptive services and sexually transmitted infection (STI) screening and treatment, but also screening tests for breast, cervical, and colon cancer, screening for intimate partner violence and support for breastfeeding to name a few. These services must be covered regardless of your gender identity, sex assigned at birth, or recorded gender. These plans must also cover preventive services without charging you a copayment or coinsurance, even if you haven’t met your yearly deductible.

Plans are not required to cover contraceptive services for men, like vasectomies, so it is useful to ask specific questions about these services. For a complete list of trans-specific questions, please see the section called Transgender Healthcare.

  1. Contraception: Annual exams and all methods of contraception that have been approved for sale in the United States (in­cluding barrier and hormonal methods, such as rings, pills, patches, and implants, as well as IUDs and sterilization/tubal ligation for women) are now covered without a co-pay, co-insurance, or a deductible when they are prescribed by a clinician and provided by an in-network provider. Even with changes you may have read about under the Trump administration, this continues to be true for marketplace plans and your contracep­tion should be covered. However, your plan might charge a co-pay for some specific brands of contraception if a generic version is available.
    1. I prefer to use X brand of birth control. Is there a co-pay for this brand of contraception?
    2. Is vasectomy covered under this plan as a form of birth control? What kind of pre-approval does a vasectomy need? If vasectomy is not covered, what are the out-of-pocket expenses?
  2. Clinicians: You may prefer to see a nurse midwife, nurse practitioner, family doctor, or other clinician for your reproductive healthcare instead of an OB/GYN.
    1. I would like to keep my current reproductive healthcare provider. Are they covered on this plan?
    2. (OR) I prefer to see a midwife or other clinician for my OB/GYN care. How big is the network of providers?
  3. Fertility Coverage: Does the plan include fertility coverage? If so, what kinds of services (IUI, IVF, surrogacy, medications, and other assisted reproductive technologies) are covered? If the plan includes fertility coverage, be aware that some plans require a waiting period of six to twelve months, depending on the age of the patient, and the following questions may help:
    1. Is there a waiting period before assisted reproductive technology (ART) services are covered?
    2. Do I have to have a condition of infertility to qualify for ART services? Do I have to have attempted to inseminate or get pregnant without success prior to being covered for ART services?
    3. Are ART services provided to single individuals? Are ART services provided to same-sex couples or couples where one or both of us are transgender? Do couples have to be legally married to be covered for ART services?
  4. If the plan I purchase now does not include fertility coverage and I want to purchase coverage for fertility options, how and when may I change plans in the future?
  5. Surrogacy: Maternity and newborn care is considered an essential health benefit that must be covered by any insurance plan offered in state marketplaces. Therefore, pregnancy—regardless of how or why a woman becomes pregnant—should ALWAYS be covered.
    1. If I hire a surrogate, can I cover that surrogate on my health plan?
  6. Birthing: Will the plan cover home birth or birth at an out-of-hospital birth center? Is there a co-pay for out-of-hospital or home birth care?
    1. Does the plan provide coverage for birth assistants or doulas?
  7. Breastfeeding support and coverage: Health insurance plans are required to cover the cost of a breast pump. Plans may offer to cover either a rental or a new one for you to keep. Plans may provide guidance on whether the covered pump is manual or electric, how long the coverage of rented pumps lasts, and when they’ll provide the pump (before or after you have the baby).
    1. What’s the coverage for a breast pump – is it a rental or is it purchased? What’s the co-pay for a pump?
    2. Is hormone or lactation therapy covered if a non-birth parent is trying to induce lactation?
    3. Are there LGBT lactation or trans-friendly lactation consultants available on this plan?
  8. What is included in coverage for post-natal care?
  9. Does this plan cover abortion services?
    1. Is egg harvesting covered in this plan? What is the co-pay for egg harvesting?
    2. Is ongoing storage covered under this plan or is it the individual’s responsibility?
    3. If I am transgender and obtaining transition-related care that will make me infertile, is there coverage for retrieving and storing my eggs/sperm?
    4. To get a hysterectomy, what kind of medical approval or clearance do I need? Will I incur any out-of-pocket expenses?
  10. I might want to preserve my future fertility by storing eggs and/or sperm. Is fertility preservation (egg or sperm capture, storage, freezing, etc.) covered under this plan?
    1. What out-of-pocket expenses would I be responsible for if I choose, or someone covered by the plan chooses, to have an abortion?
    2. Is medication to induce a non-surgical abortion covered on the plan? If not, what is the co-pay?
    3. How is billing handled for abortion services? Is abortion listed on the bill?

Questions in red are ones that assisters may not be able to answer because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider.

Mental Health

The ACA requires marketplace plans to cover mental health and substance use disorder benefits, making them an integral part of healthcare and not an add-on. Health plans are also required to cover preventive services like depression screenings for adults and behavioral assessments for children at no additional cost. And insurance companies cannot deny healthcare coverage to anyone because of a pre-existing mental health condition.

  1. Will I have access to therapists who are experienced treating LGBT individuals, their families, and their children?
    1. To find a list of therapists, counselors, psychologists and other mental health professionals who have self-identified expertise in serving the LGBT community, check out the provider search function at Psychology Today.
  2. How is family defined for the purposes of family therapy?
    1. Is couples therapy covered for same-sex couples?
      1. Do I need to be married to access couples therapy?
  3. How many visits are approved by the plan per year?
  4. Is there a copay for mental health services? How much is the copay for mental health services per visit?
  5. Do mental health services include coverage for suicide prevention, bullying, and harassment in schools?
  6. What kinds of mental health professionals are covered on the plan?
    1. Specifically, are psychologists, psychiatrists, and licensed clinical social workers covered on the plan? What other mental health professionals are covered on the plan?
  7. Do mental health services include addiction treatment?
    1. Do I need a referral to receive addiction treatment? From whom do I need a referral to receive addiction treatment?
    2. What kind of in-patient and out-patient treatment services are covered?
    3. Is nicotine replacement therapy covered for tobacco cessation?
    4. Is direct counseling covered?
  8. What are the mental health benefits for children on the plan?
    1. See the section LGBT Kids/Youth for other specific questions.

Questions in red are ones that assisters may not be able to answer because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider.

Specific Information You May Need

Definition of Family

There is no universal definition of “family” within the Affordable Care Act. Therefore, family gets defined at various levels:

  • Marketplace plans that offer family coverage to different-sex married couples must offer the same coverage to same-sex married couples.
  • You and your spouse can apply for financial assistance together, as long as you are legally married and file your federal taxes jointly. Married couples must file joint federal income tax returns to be jointly eligible for financial assistance.
  • Following the Obergefell decision at the US Supreme Court, state Medicaid and Children’s Health Insurance Programs must consider married same-sex couples a family when determining eligibility for these programs.

Below are questions to help you figure out how different plans and your state define family. These questions will also help you to understand what documentation you might need in your state to purchase a plan that covers your entire family.

  1. Does this plan offer coverage for married couples?
  2. Can I cover my same-sex partner on this health plan?
    1. Can I cover my partner if we are not legally married or in a legally recognized union (like a civil union or a domestic partnership)?
      1. If we’re not legally married or in a recognized union, will this plan cover me, and my same-sex partner/spouse, and all of our children? What kind of documentation is accepted by the plan as proof of our relationship?
      2. If we choose not to be married or in a recognized union in a state that recognizes marriage/unions between same-sex couples, are we still able to buy insurance coverage as one family?
    2. Given my family composition (spouse/domestic partner/unmarried partner/children/etc.), is my family eligible for either federal or state subsidies to assist with the cost of purchasing insurance through the marketplace?
      1. If so, do we have to be legally married? What documents are needed?
      2. If my partner/spouse is a foreign national, are we eligible for a subsidy?
      3. Are there tax ramifications for having my same-sex spouse/partner on this plan?
  3. What’s the definition of family under my state’s applicable laws? Which families qualify?
    1. Can I cover our children, even if I am not a biological parent and have not adopted?
    2. Am I considered a step-parent under my state’s laws?
      • Can I cover my partner/spouse’s children if I am a stepparent?
    3. If my family cannot be covered under one comprehensive family plan, how do I apply for a tax credit to cover the cost of having to purchase multiple plans?
    4. Other than children, can I include other family members or members of our household (such as my or my partner/spouse’s parent)?
  4. What kind of documentation do I need to apply for coverage for members of my family(marriage certificate, domestic partner registry, birth certificate, etc.)?

Questions in red are ones that assisters may not be able to answer because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider.

LGBT Kids and Youth

If you are seeking coverage for a child or person under 26 years old on your health plan, the ques­tions in the Definition of Family section will be important to ask. And if a plan covers children, they can be added or kept on that health insur­ance policy until they turn 26 years old. If you are a person under the age of 18 seeking healthcare for yourself, at least 34 states allow minors to apply for health insurance without parental con­sent. The ACA also ensures that young adults who have aged out of the foster care system can stay on Medicaid coverage until they turn age 26.

Children for whom you are seeking health cov­erage may qualify for Medicaid or the Children’s Health Insurance Program (CHIP), both of which provide free or low-cost health coverage for children. Each state program has its own rules about who qualifies for Medicaid or CHIP. If your children qualify for either of these pro­grams, you won’t need to buy a Marketplace plan to cover them.

  1. Eligibility for CHIP:If your family meets certain income requirements, children you are trying to cover may qualify for the Children’s Health Insurance Program.
    1. Do my children qualify for coverage under Medicaid or Children’s Health Insurance Program?
  2. Do you have pediatricians and family practitioners who know how to work with LGBT families and youth?
  3. Are there doctors in this plan experienced working with gender non-conforming (GNC) or gender variant youth?
  4. What kinds of medication or hormone therapy can young people access? Can this therapy be accessed with or without parental involvement?
    1. What kind of mental health “requirements” are necessary to access hormone blockers?
    2. What kind of dermatology drugs/regimens are covered for youth?
  5. Are there any providers experienced in working with intersex youth?
  6. Dental Coverage:While dental coverage is considered an essential benefit for children (not adults), it does not need to be included in the health insurance plans offered in the new state health insurance marketplaces. However, many companies offer stand-alone dental policies through the marketplace that you can purchase at the same time that you enroll in health insurance.
    1. Is pediatric dental part of this health plan? If not, how would pediatric coverage cost on this plan?
    2. Can I purchase a stand-alone dental policy?
  7. What counseling and support options are available to parents with LGBT children?
  8. What mental health services are available for LGBT youth?
    1. Are mental health services available for trans youth or GNC/gender variant youth?
    2. What suicide prevention counseling is in place?
  9. What confidentiality is in place for LGBT youth if they are covered on their parent’s plan?
    1. Will I be notified if a minor on this health plan seeks certain services—like birth control, mental health counseling, abortion, or hormone-related therapy?
    2. How does billing happen? What services are outlined on bills?

Questions in red are ones that your navigators, assistance counselors, or insurance brokers may not be able to answer because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider.

HIV/Aids

New health insurance plans created since 2014 cannot refuse to cover you or charge you more just because you have a pre-existing health condition, including HIV/AIDS. Once you have insurance, these plans cannot refuse to cover treatment for pre-existing conditions. The only exception is for an older plan that you bought yourself before 2014 – these plans, which are called “grandfathered” plans – do not have to cover pre-existing conditions. If you have a grandfathered plan, you can switch to a marketplace plan during open enrollment (November 1, 2017 to December 15, 2017) and get coverage that includes any pre-existing condition.

A note on limits: Under the ACA, insurance companies cannot set a lifetime or annual limit on what they spend on essential health benefits for your care during the entire time you are enrolled in that plan.

For a list of providers who specialize in care for individuals with HIV or AIDS, contact your local Ryan White HIV/AIDS program. The Ryan White HIV/AIDS program can help you get medical care and other services. And, depending on your state, you may qualify for additional financial help to pay your premiums or other out-of-pocket medical costs.

  1. Does the plan cover PrEP (Pre-Exposure Prophylaxis) drugs for HIV-negative individuals?
    1. Does the plan cover PEP (Post Exposure Prophylaxis) drugs for newly HIV infected individuals?
    2. What are the costs (such as co-insurance and co-pays) associated with PrEP? What drug “tier” is PrEP covered under?
  2. HIV/AIDS medication coverage: Coverage of specific medications is regulated state by state, and you should ask about the specific drugs covered in your state by brand name to assess if there will be a co-pay.
    1. Which HIV/AIDS drugs are/are not covered? How do I access my prescription drug formulary? What drug “tier” are my HIV/AIDS drugs covered under?
    2. What are the costs (such as coinsurance and copays) associated with the HIV/AIDS drugs that I need?
  3. What kind of testing is covered?
    1. Is blood testing, oral rapid testing, or an in-home rapid testing kit covered?
    2. What’s the confidentiality of testing for young people on their parent’s plan?
  4. What kind of long-term care coverage is part of the plan for people living with HIV or AIDS?

 

Transgender Healthcare

Health insurance companies can no longer use pre-existing conditions as a reason to deny you coverage or charge you more. For transgender people, this means that having a diagnosis of “gender identity disorder” in your health record or having previously gotten healthcare related to gender transition can no longer be used as a reason to refuse to sell you a health insurance plan or to charge you more for coverage.

With that barrier removed, there are still ongoing questions about what transition-related and gender-specific care you can expect your insurance plan to cover. The ACA prohibits discrimination based on gender identity, so we expect that health plans offered through the state marketplaces will cover some transition-related care, as long as those kinds of services are covered for other people on that plan. If your plan denies you coverage for a service or procedure that is covered for other people on your plan, you have experienced discrimination. You can appeal the denial with the insurance company, and if the company denies the appeal, you have the right to ask for an external review of the plan’s decision. You can also file a complaint with your state’s insurance commissioner or with the Office for Civil Rights at the U.S. Department of Health and Human Services – click here for more information about filing a complaint. You can also share your experiences and concerns via the HealthCare.gov help hotline at 1-800-318-2596.

Types of care likely to be covered include mental health counseling, hormone replacement therapy, and organ removal (orchiectomy, hysterectomy/oophorectomy). Gender confirmation surgeries and procedures such as electrolysis may or may not be covered, depending on the plan.

You also have the right to free gender-specific preventive care (such as mammograms, pap smears, and prostate exams) that your provider recommends as medically appropriate. Plans cannot limit these services based on your sex assigned at birth, gender identity, or the gender listed or otherwise recorded by the plan or insurance company. If you encounter any challenges in accessing these services, you can appeal the denial with the insurance company or file a complaint.

Unfortunately, assisters may not know the specifics of which benefits are covered in which plans, but you can ask for help in finding this in­formation. The best way to find out for sure what will and won’t be covered is to look up the plans that you are eligible for and ask the insurer(s) for the “Evidence of Coverage” or “Certificate of Coverage” (the full list of covered benefits) for that plan. If your plan denies you coverage for a service or procedure that is covered for other people on your plan, you have experienced discrimination. You can appeal the denial with the insurance company, and if the company denies the appeal, you have the right to ask for an exter­nal review of the plan’s decision. If you experience any form of discrimination, have a transgender exclusion in your plan, or if your coverage is denied, you should contact a legal organization for help. You can also file a complaint with your state insurance department – visit this page to connect with your state insurance regulators. It can be frustrating to file a complaint, but this is especially important given the lack of clar­ity about what must be covered. You can also share your experiences and concerns via the HealthCare.gov help hotline at 1-800-318-2596.

As you look at the “Certificate of Coverage” or “Evidence of Coverage,” the following ques­tions will be useful to consider in comparing plans and selecting the plan that is best for you. If cov­erage for care related to gender transition is part of what is important for you, keep a close eye out for the “exclusions” and “limitations” on coverage. Exclusions for things like “services related to sex change” or “sex reassignment surgery” should no longer be appearing in plans sold through the marketplaces. If you see this type of exclusion in your policy, please contact a legal organization or file a complaint with your state insurance depart­ment. For more information, visit HealthCare.gov’s page on transgender health.

The enrollment process may include completing forms where gender boxes do not correspond to how you identify. In order to minimize confusion during enrollment, we suggest filling these forms out according to the sex you believe is on file with the Social Security Administration, or according to the sex that’s on the majority of your legal identification documents such as a driver’s license or passport. If you have questions about how to change the sex on file with the Social Security Administration, the National Center for Transgender Equality has created a guide for trans people and the SSA.

  1. Is hormone therapy covered for individuals on this plan? NOTE: If hormone therapy is covered for anyone using the specific plan you are evaluating, it should be covered for transgender individuals. The ACA makes it illegal for plans to discriminate by offering some people services that they deny to others.
    1. Is there a co-pay for hormone therapy? What is the co-pay amount?
    2. Is there a limit on hormones or hormone injections? What is the limit?
  2. Is there a network of trans-friendly doctors and/or doctors who have training working with or currently serve trans clients?
    1. Is my current healthcare provider covered by the plan?
    2. If you don’t have a current healthcare provider, but would like to find a trans-friendly provider, check out GLMA: Healthcare Providers Advancing LGBT Equality. They keep a list of self-identified providers with experience working with the LGBT community. RAD Remedy is also available as a resource. Once you identify a provider on the GLMA or Rad Remedy list, you can ask which plans work with that provider.
    3. Are there local doctors/doctors within 30 miles who can provide services to transgender individuals?
      • If not, will the plan provide travel reimbursements?
  3. Are mental health services available for trans individuals and their family members?
  4. Can I get mental health visits covered specifically for trans-related needs?
  5. What kinds of documents are needed to receive services? Do I need to change my legal ID to receive coverage as a person who is trans-identified?
  6. Are procedures like facial feminization, breast augmentation, or hair removal covered?What is the co-pay for these services?
  7. Are procedures like breast reductions/mastectomies, chest lifts, and hysterectomies included in the plan? What is the co-pay for these services?
  8. Preserving future fertility: If I am transgender and obtaining transition-related care that will make me infertile, is there coverage for retrieving and storing my eggs/sperm?

Questions in red are ones that assisters may not be able to answer because this kind of information is not gathered consistently from healthcare providers. However, we included them because we know that these kinds of questions can make a critical difference in creating a trusted relationship with your healthcare provider.

Reporting Discrimination

If you have encountered any kind of discrimination, harassment, or judgment in exploring healthcare enrollment options or accessing health care, your rights have been violated. The ACA prohibits discrimination based on sexual orientation and gender identity. Every person has a right to expect confidential, safe, and non-judgmental services in trying to navigate these new healthcare options.

If you feel you’ve been treated unfairly, you can make a complaint directly to your state’s mar­ketplace or your state’s insurance department. You can also contact a legal organization for help. If you receive a denial of coverage for services that should be included under your plan, you have the right to appeal the denial by contacting your insur­ance company or your state’s department of insurance.

A number of LGBT groups are tracking barriers and challenges that LGBT individuals and families experience during enrollment in the ACA to inform their legal strategies, organizing, and advocacy work. Please consider sharing your experience with organizations like:

Out2Enroll: info@out2enroll.org
Equality New Mexico: (505) 224-2766
Family Equality Council: (202) 496-1285
Lambda Legal: (866) 542-8336
National Center for Lesbian Rights Helpline: (800) 528-6257
Southwest Women’s Law Center: (505) 244-0502
Transgender Law Center: (415) 865-0176 x 308

Resource List

National Resources

The following list of organizations and websites may be able to offer additional support through the enrollment process.

Healthcare.gov
National Help Center at 1 (800) 318-2596 (available 24/7 in different languages)
Run by the federal government, the National Help Center can connect you, enroll you, help you understand the subsidies available to your family, and direct you to local groups in your state to get additional information.
healthcare.gov

Henry Kaiser Family Foundation
The Kaiser Family Foundation has created a great searchable frequently asked questions page. Just enter your key search words to get more information.
kff.org

Out2Enroll
Out2Enroll is a nationwide initiative that seeks to connect LGBT people with new health insurance coverage options made available by the Affordable Care Act. The Out2Enroll initiative is a collaborative project of the Center for American Progress, the Federal Agencies Project, and the Sellers Dorsey Foundation.
www.Out2Enroll.org

Family Equality Council
Family Equality connects, supports, and represents the three million parents who are lesbian, gay, bisexual, and transgender and their six million children.
(617) 502-8700
www.familyequality.org

Greater Than AIDS
This website includes great information for what the ACA means for someone living with HIV. It also has specific information about how the Ryan White HIV/AID program and the AIDS Drug Assistance Program (ADAP) may change with implementation of the ACA.
greaterthan.org

Intersex Society of North America
Although INSA has closed its doors, the website contains a wealth of facts and links for individuals looking for additional information about being intersex or raising an intersex child.
www.isna.org

National Women’s Health Network (NWHN)
The NWHN’s health information program “Women’s Health Voice” provides clear, well-researched, and independent information on a variety of women’s health topics.
Email: healthquestions@nwhn.org
(202) 682-2646, Tuesday through Friday, 9am–5pm EST
nwhn.org

Lambda Legal
Lambda Legal’s Help Desk provides information and assistance regarding discrimination related to sexual orientation, gender identity and expression, and HIV status.
lambdalegal.org

State Resources

Groups listed in specific states have information about their states, but are not able to answer questions about other states.

California

Transgender Law Center
(415) 865-0176 x 308
www.transgenderlawcenter.org

New Mexico

Equality NM
(505) 224-2766
www.eqnm.org

Southwest Women’s Law Center
(505) 244-0502
www.swwomenslaw.org

Transgender Resource Center of New Mexico
(505) 200-9086
www.tgrcnm.org

Univ. of New Mexico LGBT Resource Center
(505) 200-9086
lgbtqrc.unm.edu

Young Women United
(505) 831-8930
www.youngwomenunited.org

Oregon

Basic Rights Oregon
(503) 222-6151
www.basicrights.org

Cascade AIDS Project
1 (800) 777-AIDS (2437)
cascadeaids.org

PFLAG – Portland Black Chapter
1 (503) 232-7676
http://pflagpdx.org/wordpress/?page_id=429\

Q Center
1 (503) 234-7837
pdxqcenter.org

Sexual & Gender Minority Youth Resource Center
1 (503) 872-9664
smyrc.org

Texas

Lesbian Health Initiative of Houston
(713) 426-3356
www.lhihouston.org