blue shield of california gender reassignment surgery

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Insurance Coverage for Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on March 13, 2024.

Navigating insurance coverage for gender affirmation surgery can be complex, but many insurance providers now recognize these forms of healthcare for transgender individuals as medically necessary and thereby deserving of coverage. This guide aims to simplify the process of finding and applying for insurance coverage for gender-affirmative surgery, also known as gender confirmation surgery.

The GCC’s list of insurance providers that cover gender-affirming surgeries

Below you can find a list of insurance providers for which our team has successfully obtained approval for top surgery procedures from here. If you don’t see your insurance listed here or are unsure, you can schedule a free, virtual consultation so our team can verify this information for you. Unfortunately, Medicare does not cover any of our procedures at this time.

*  This list does not guarantee insurance coverage for top surgery and successful approvals may vary on a number of factors, such as the type of plan for each insurance company.

How to Get Coverage: An Overview

The following information is meant to give you an overview of all the components you will need to take into consideration in finding an insurance plan that will cover your gender-affirming surgery.

• Contact your insurance provider directly to inquire about coverage for gender reassignment surgery. You can start by calling the phone number on your insurance card.
• Review your insurance policy or member handbook carefully for any exclusions or limitations related to transgender healthcare.
• Consult the Transgender Legal Defense & Education Fund (TLDEF) for a list of insurance companies known to offer coverage for gender affirmation procedures.
• Get enrollment help from Out2Enroll once you are ready to sign up for health coverage to understand your options.
• Coverage Exclusions: Federal and state laws prohibit discrimination against transgender individuals by most public and private insurance health plans. This means insurance companies must cover transition-related care that’s medically necessary and it is illegal for them to deny coverage, in most cases. Some plans may still have exclusions in their policies, but you can ask for an exception or request the removal of the exclusion.
• Medical Necessity: Virtually all major insurance companies now recognize that gender-affirming medical care for transgender patients is medically necessary. However, the specifics of what procedures or treatments are covered will depend on each insurance plan. Most of them will require letters from healthcare providers to support medical necessity. You can find a list of therapists that can provide support letters for insurance coverage through GALAP .
• Referral Letters: To secure insurance coverage, patients will need 1-2 letters from healthcare providers. Besides a therapist support letter, if GCC surgeons are not in-network providers, you will need a referral letter from your Primary Care Physician.
• Financial Options: If your insurance provider does not cover gender-affirming surgery, other options include paying out-of-pocket, taking out a personal loan, or seeking financial help from charities and organizations.

Identifying Insurance Providers That Cover Gender Affirming Surgery

If you live in the United States, here’s a list of resources to help you identify insurance providers offering coverage for gender-affirming surgery:

• Transgender Legal Defense & Education Fund (TLDEF) provides a list of insurance companies that have coverage for gender-affirming care.
• Campus Pride provides a list of colleges and universities by state that cover gender-affirming surgery or hormone therapy under student health insurance.
• Our Insurance Advocacy Team here at the Gender Confirmation Center has successfully secured coverage for surgery from the insurance companies mentioned above.

Navigating Insurance Policies for Gender Affirming Surgery

The National Center for Transgender Equality created a guide to help navigate getting your insurance to cover gender-affirming care. This process can be summarized in 3 steps below:

• Learn what your insurance plan covers for gender-affirming care by calling your insurance company and ask what medical policies on gender dysphoria treatment are applicable to your plan. You may also find this information in the Member Handbook provided by your insurance.
• Determine the type of insurance you have (self-funded vs fully insured) to see if there are exclusions or limitations on healthcare coverage for transition-related care. Self-funded plans (e.g. insurance through work, school, or government employment) typically have exclusions or limitations to coverage that may be exempt from state protection laws. You may need to request your employer or school to remove the exclusion before insurance can cover surgery.
• Gather necessary documentation , such as letters from healthcare providers (i.e. mental health provider). Most insurance companies require at least 2 letters to cover bottom surgery procedures. In this case, a t least one should come from a licensed mental health professional. The second can come from a mental health or a healthcare provider: for example, an endocrinologist or primary care provider who has been involved in your hormone therapy.  We recognize that the two-letter insurance requirement can be an extra barrier for patients to access medically necessary, gender-affirming care. For this reason, once you have requested a surgical consultation , we can help you through securing this and any other documentation.
• Submit a pre-authorization request to your insurance provider by writing a letter to explain why the procedure is necessary and why refusing to provide coverage may be illegal.
• Follow up with your insurance to ensure the request is being processed or check on its status. Your insurance will send you a notification if your request has been approved or denied.

Navigating this process can be challenging but our Insurance Advocacy team works directly with your insurance for each step of this process until the insurance company reaches a decision for the preauthorization request. This service is provided free of charge for our patients to ensure the best chance of success in getting their surgery covered.

Overcoming Challenges in Insurance Coverage for Gender Affirming Surgery

• Denial of preauthorization request or claim for reimbursement: Understanding the reason for denial can help determine your options for appealing this decision. Seeking legal assistance from a lawyer may help facilitate this process.
• Dealing with out-of-network coverage: Insurance companies usually have a list of “in-network” healthcare providers that are covered by a particular plan. While some patients are restricted to these in-network providers (i.e. HMO plans), others may have the option to see out-of-network providers if the in-network options are not qualified (i.e., PPO plans). For example, your insurance may restrict you to seek care from a surgeon who can perform mastectomies but may not have training in gender-affirming techniques. In such cases, you have the right to seek out an out-of-network provider who is qualified in gender-affirming surgery, as the in-network provider cannot fulfill your specific needs. It’s essential to understand that the insurance may initially refuse coverage for out-of-network surgeons or facilities, but this decision can be challenged through the appeals process.
• Consider an independent review for denials : If the insurance company continues to deny coverage, you may have the option to request an independent review by a third-party organization. This review can provide an unbiased evaluation of your case and potentially overturn the denial.

Exploring Financial Aid Options for Gender Affirming Surgery

• Surgery Grants: Organizations and programs may offer grants or financial aid to help cover the costs of surgery. The GCC works with various organizations to help with costs of surgery. Learn more about them here.
• CareCredit: GCC has partnered with CareCredit to help patients finance the costs of surgery. Patients can apply for this credit card to see if they qualify and figure out what payment plan options are available.

Advocating for Comprehensive Insurance Coverage

The Affordable Care Act prohibits discrimination based on gender identity, which can be leveraged when seeking coverage for gender-affirming surgery. Despite this, many still face challenges with access or coverage of medically necessary transition related care. Recently, these states have limited protections for transgender youth after passing laws banning their access to gender-affirming care.

Navigating insurance coverage for gender-affirming surgery can be challenging, but our Insurance Advocacy team is dedicated to ensuring access to care for our patients. The National Center for Transgender Equality and Transgender Legal Defense and Education Fund also provides a comprehensive list of resources to help patients find and get insurance coverage for gender-affirming care.

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OHSU's Vaginoplasty Booklet This in-depth guide covers a lot of ground! In addition to a detailed description of Vaginoplasty, you'll also find a recovery plan worksheet, hair removal guide, preparing for surgery checklist, supplies list, dilation guide, scar massage info and much more. Download PDF here »

Gender Reassignment Surgery in Thailand In this introduction to Gender Reassignment Surgery in Thailand you'll find out why Thailand continues to top the list of surgery destinations for trans women year after year. Read more »

Orchiectomy For Transsexuals Personal account of Orchiectomy with an excellent Q&A section. Recommended for any trans woman considering Orchiectomy. Read more »

Medications to Avoid Before Gender-Affirming Surgery Medications contained on the following list are anti-coagulant agents; they may contribute to excessive bleeding during and after surgery. View the list »

Financing Surgery

Get Help Finding Insurance This guide from Forward Together can help you find an insurance plan that covers gender-affirming care. It includes a list of questions to ask insurance companies when choosing a plan. Get the PDF here »

Health Insurance Medical Policies Virtually all major insurance companies recognize that transgender-related medical care is medically necessary and have a written policy describing their criteria for when plans they administer will cover it. The Transgender Legal Defense & Education Fund maintains a list of these policies. View it here »

California Insurance: Blue Shield Gender Reassignment Surgery Criteria Solid information is hard to come by when it relates to what health insurance plans will cover for gender reassignment surgery in California. For a variety of reasons the health insurance companies don't make their policies readily available to the general public. Here are two detailed outlines issued by Blue Shield of California relating to gender reassignment surgery. Read more »

Colleges and Universities that Cover Transition-Related Medical Expenses Under Student Health Insurance 87 colleges and universities in the U.S. cover hormones and gender-affirming surgeries for students. Check out the list »

Paying Out-of-Pocket For Gender Affirming Surgery Wondering how you're going to finance surgery? Find out how others have paid the piper and the piper's anesthesiologist and the piper's surgical nurses... Read more »

Last updated: 03/30/21

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Understanding Insurance Requirements for Gender Affirmation Surgery

• Type of Surgeries
• Barriers to Access
• WPATH Standards

Restrictions to Coverage

Getting started, what you can do.

Insurance coverage for orchiectomy, genitoplasty, and other types of gender-affirmation surgery is largely governed by standards issued by the World Professional Association for Transgender Health (WPATH). Many health insurance providers use these guidelines to direct which procedures are medically necessary. However, not every insurer—or state—does.

Because acceptance of WPATH guidelines can vary, it can sometimes be hard to determine which procedures are covered by your health plan and whether gender affirmation is even affordable.

This article describes the types of surgeries pursued by transgender or gender-nonconforming people as a part of gender affirmation and the barriers they face. It also explains the WPATH standards of care for each type of surgery, how insurance companies use them to determine eligibility, and what restrictions are imposed by providers or states.

Gender-affirmation surgery is the preferred term but gender-confirmation surgery and gender-alignment surgery can also be used. Outdated terms like "sex reassignment" or "sex change" should not be used.

Gender affirmation reflects the process a person goes through when they begin to live as their authentic gender rather than the gender assigned to them a birth.

Medical or surgical procedures are only one facet of gender affirmation.

Types of Gender-Affirmation Surgery

Not all transgender, non-binary , and genderqueer individuals want surgery to align their bodies to their gender identity. Some people are content with social or other medical transition options .

Others want one or more surgeries, including those referred to as " top surgery ” (occurring above the waist) and "bottom surgery" (occurring below the waist).

An extensive national survey of transgender people found that:

• 66% of transgender women either had or wanted  vaginoplasty or labiaplasty .
• 51% of transgender women either had or wanted breast augmentation.
• 50% of transgender women either had or wanted facial feminization (surgery to make a face appear more feminine).
• 37% of transgender women either had or wanted a tracheal shave (removal of the Adam’s apple).
• 58% of transgender women either had or wanted orchiectomy (removal of the testicles).
• 22% of transgender men either had or wanted phalloplasty (the creation of a penis).
• 27% of transgender men either had or wanted metoidioplasty (surgery that uses existing genitalia to create a penis).
• 97% of transgender men either had or wanted chest reconstruction or mastectomy (removal of the breasts).
• 71% of transgender men either had or wanted a hysterectomy (removal of the uterus).

Common Barriers to Gender-Affirmation Surgery

Cost, surgeon availability, and a process referred to "gatekeeping" are three major hurdles commonly faced by people undergoing gender affirmation.

Cost is one of the primary reasons people have limited access to gender-affirmation surgeries. Historically, most public or private insurance companies have not covered these procedures. Fortunately, that is changing.

Some public and private insurance companies cover some or all gender-affirmation surgery options. But that coverage often comes with many hoops that people need to jump through. It is also not available to all people in all states.

Surgeon Availability

Another major factor limiting access to surgery is the small number of surgeons trained to perform them. These surgeons, particularly very experienced ones, are often booked months or years in advance.

In addition, many don’t take insurance. Fortunately, as insurance coverage for gender-affirmation surgeries has increased, so too has physician interest in training. Today, there are many hospitals across the country that routinely perform vaginoplasty and accept insurance to pay for them.

"Gatekeeping"

Another barrier is a process called “gatekeeping" currently endorsed by WPATH. Gatekeeping involves undergoing a significant therapy or psychiatric assessment before they are allowed to transition medically.

It is a process that attracted considerable debate given that this level of scrutiny is not required for other major surgeries. It ultimately places the decision in the hands of a psychiatrist who can determine if a person is mentally "fit" to pursue treatment.

Discrimination and Stigma

In addition to barriers like cost and surgeon availability/competency, there is also a long history of discrimination and stigma limiting transgender patients’ access to care.

Insurance and the WPATH Standards

When determining eligibility for gender-affirming surgery coverage, many insurers turn to the WPATH Standards of Care to inform their eligibility guidelines. These are also known as the WPATH criteria or WPATH requirements.

WPATH updates its guidelines every five to 10 years. These standards of care help define which treatments are medically necessary and under which conditions they should be authorized. The standards have become less restrictive over time, reflecting the growing recognition of gender diversity in society.

The standards of care are broadly described as follows:

Standards for Top Surgery

“Top surgery” refers to gender-affirmation surgery of the breast or chest. For transmasculine people, this surgery is called chest reconstruction. For transfeminine people, it is breast augmentation.

The WPATH criteria for top surgery include:

• Persistent, well-documented gender dysphoria (distress caused by the difference between a person’s gender and the gender they were assigned at birth)
• The ability to make an informed decision and consent to treatment
• Any significant medical or mental health conditions are “reasonably well controlled”

Standards for Hormone Therapy

It is important to note that hormone therapy is not required for these surgeries. However, a year of hormone therapy is recommended  for transgender women because it allows them to get the maximum possible breast growth without surgery, which improves surgical outcomes.

For transgender men, there is no hormone requirement or recommendation. That’s because some transmasculine people are only dysphoric about their chests. Therefore, they do not want or need testosterone treatment.

There are also several physical and psychological reasons people choose to undergo top surgery without hormone use. That said, people who are taking testosterone and are very active may wish to wait a year for surgery because testosterone and exercise can significantly reshape the chest. Therefore, waiting a year may result in a more aesthetic outcome.

Standards for Orchiectomy, Hysterectomy, and Ovariectomy

These surgeries involve the removal of the testicles (orchiectomy), uterus (hysterectomy), or ovaries (ovariectomy).

WPATH criteria for these surgeries include:

• Persistent, well-documented gender dysphoria
• Any significant medical or mental health conditions are “well controlled”
• At least 12 continuous months of appropriate hormone therapy, unless there are reasons someone can’t or won’t take hormones. The purpose of this guideline is so that people can experience reversible hormone changes before they undergo irreversible ones.

Surgeries to remove the gonads (testes, ovaries) and the uterus may be performed independently. They may also be performed alongside other gender-affirmation surgeries.

Removing the gonads alone can lower the amount of cross-sex hormone therapy required to get results. In addition, removing the uterus or cervix eliminates the need to screen those organs. That’s important because those screening exams can cause dysphoria and discomfort in many transgender men.

Standards for Vaginoplasty, Phalloplasty, and Metoidioplasty

This group of surgeries constructs a vagina (vaginoplasty) or penis (phalloplasty, metoidioplasty). These procedures make a person’s genitalia more in line with their gender identity.

• Any significant medical or mental health conditions are “well controlled”
• Appropriate hormone therapy for 12 continuous months, unless there are reasons why someone can’t or won’t take hormones
• Living in a gender role that is consistent with their gender identity for 12 continuous months

The requirement for a year of living in a gender role is because it gives people time to adjust to their desired gender. In addition, doctors widely believe that a year is a sufficient time for that adjustment before undergoing a complicated, expensive, and irreversible surgery.

Aftercare for these surgeries can be emotionally intense and difficult. For example, following vaginoplasty , consistent vaginal dilation is required to maintain depth and girth and avoid complications. These requirements can sometimes be challenging for people with a history of sexual trauma.

Aftercare Recommendations

Due to these surgeries’ physical and emotional intensity, experts recommend that those considering them have regular visits with a mental or medical health professional.

Standards for Facial Feminization Surgery

There are no formal guidelines for facial feminization surgery. In addition, it has historically been tough to get this procedure covered by insurance due to a lack of research on the benefits.

However, some individuals have been able to have it successfully covered by arguing that it is as medically necessary as genital surgery and has equally positive effects on quality of life.

Standards for Children and Adolescents

WPATH guidelines for children and adolescents include criteria for fully reversible interventions ( puberty blockers that pause puberty, for example) or partially reversible ones (hormones, for example). However, they do not recommend irreversible (surgical) interventions until the age of majority in their given country.

One exception is chest surgery for transmasculine adolescents. WPATH criteria suggest this could be carried out before adulthood, after ample time of living in their gender role, and after being on testosterone treatment for one year.

Despite the increasing uptake of WPATH guidelines by insurers, not every organization embraces them or applies them in the same way. Even WPATH notes that “the criteria put forth in this document... are clinical guidelines. Individual health professionals and programs may modify them.” And many times, they do.

Generally speaking, private insurance companies are more likely to offer coverage for some or all procedures than government agencies like Medicaid and Medicare. Even so, eligibility requirements can vary as can copayment and coinsurance costs.

Medicaid is the U.S. government health coverage program for low-income people, jointly funded by the federal government and states. Of the estimated 1.4 million transgender adults living in the United States, approximately 152,000 have Medicaid coverage, according to the Kaiser Family Foundation.

Many state Medicaid programs cover aspects of gender-affirming health services. But only two states—Maine and Illinois—cover all five WPATH standards of care as of October 2022 (hormone therapy, surgery, fertility assistance, voice and communication therapy, primary care, and behavioral intervention).

Current Medicaid Coverage Status

In terms of gender-affirming surgery, 23 states provide coverage for adults, while nine states (Alabama, Arizona, Florida, Hawaii, Iowa, Kansas, Missouri, Texas, and Wyoming) currently deny coverage. The remaining states either have no policies in place or offer no reporting of coverage.

Medicare is federal health insurance for people 65 or older and some younger people with disabilities. Original Medicare (Part A and Part B) will cover gender-affirmation surgery when it is considered medically necessary. Prior to 2014, no coverage was offered.

The challenge with accessing surgery is that Medicare has no national precedent for approving or denying coverage. As such, approval or denial is based largely on precedents within your state and is conducted on a case-by-case basis.

This suggests that approval may be more difficult in states that deny coverage to Medicaid recipients given that Medicare is administered by a central agency called the Centers for Medicare & Medicaid Services (CMS).

As a general guideline, the CMS states that the following is needed for you to be an eligible candidate for gender-affirmation surgery:

• Have a diagnosis of gender dysphoria
• Provide proof of counseling
• Provide evidence of hormone therapy (for transgender women)

If coverage is denied, there is an appeal process you can undergo to overturn the denial.

Private Insurance

Most private insurance companies in the United States will offer coverage for some—but not necessarily all—gender-affirming surgeries.

According to the Transgender Legal Defense & Education Fund (TLDEF), many of the larger insurers offer coverage for a comprehensive array of surgeries, including providers like:

• Blue Cross/Blue Shield
• UnitedHealthcare

Others have different standards in different states (such as AmeriHealth) or only offer coverage for specific surgeries like facial feminization surgery (Prestige and AmeriHealth New Hampshire).

Though coverage of gender-affirmation surgery is increasing, many private insurers still require you to meet extensive criteria before approval is granted. By way of example, to get approval for breast augmentation, a transgender woman would need to provide a company like Aetna:

• A signed letter from a qualified mental health professional stating their readiness for physical treatment as well as their capacity to consent to a specific treatment
• Documentation of marked and sustained gender dysphoria
• Documentation that other possible causes of gender dysphoria have been excluded
• The completion of six to 12 months of hormone therapy
• A risk assessment of breast cancer screening by a qualified healthcare provider

Even if approval is granted, copayment, coinsurance, and out-of-pocket costs can vary, often considerably.

Out-of-Pocket Costs

According to a 2022 study from Oregon Health & Science University, a transgender person who underwent "bottom" surgery from 2007 to 2019 paid an average of $1,781 out of pocket.

With that said, 50% had to leave their state due to the restriction or unavailability of gender-affirmation surgery and ended up paying an average of $2,645 out of pocket, not including travel or living expenses.

Showing that a person has “persistent, well-documented gender dysphoria” usually requires a letter from a mental health provider. This letter usually states that the person meets the criteria for gender dysphoria, including the length of time that has been true.

This letter often also contains a narrative of the person’s gender history in detail. In addition, the letter should state how long the provider has been working with the person.

Well or Reasonably Controlled

It is important to note that some standards require that medical and mental health problems be well controlled, while others only require them to be reasonably well controlled. Documentation of this is also usually in a letter from the relevant healthcare provider.

This letter should contain information about the history of the condition, how it is controlled, and the length of the clinician’s relationship with the person. Ideally, the phrases “well controlled” or “reasonably well controlled” are used in the letter as appropriate.

Using terminology referenced in the WPTH criteria makes it easier for providers and insurance companies to determine that the conditions of the standards of care have been met.

Of note, mental health conditions are not a contraindication for gender affirmation surgeries. In fact, these procedures can help resolve symptoms in many transgender people and others with gender dysphoria. Symptom relief is true not just for anxiety and depression but for more severe conditions such as psychosis.

Getting insurance coverage for gender confirmation surgery can be a frustrating process. However, it can help to prepare a copy of the WPATH guidelines and any relevant research papers to support your goals. That’s particularly true if they include surgeries other than those listed above.

In addition, it may be a good idea to reach out to your local LGBT health center for assistance. Many health centers are now hiring transgender patient navigators who have extensive experience with the insurance process. They can be a great resource.

Local and national LGBTQ-focused legal organizations often have helplines or access hours where people can seek information.

Gender-affirmation surgery refers to various surgeries that allow people to align their bodies with their gender. WPATH guidelines offer criteria for determining whether someone is a good candidate for gender-affirmation surgery.

Not all insurance offers coverage for gender-affirmation surgery, but some do. First, however, you need to provide the proper documentation to show that you meet specific surgery criteria. This documentation is usually in a letter written by your physician or mental health clinician.

Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al. Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study . Plast Reconstr Surg . 2020;145(6):1499-1509. doi:10.1097/PRS.0000000000006837

National Center for Transgender Equality. The report of the 2015 U.S. transgender survey .

World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version .

Kaiser Family Foundation. Update on Medicaid coverage of gender-affirming health services .

CMS.gov. Gender dysphoria and gender reassignment surgery .

Transgender Legal Defense & Education Fund. Health insurance medical policies: gender dysphoria / gender reassignment .

Aetna. Gender-affirming surgery .

Downing J, Holt SK, Cunetta M, Gore JL, Dy GW. Spending and out-of-pocket costs for genital gender-affirming surgery in the US . JAMA Surg.  2022;157(9):799-806. doi:10.1001/jamasurg.2022.2606

Meijer JH, Eeckhout GM, van Vlerken RH, de Vries AL. Gender dysphoria and co-existing psychosis: review and four case examples of successful gender affirmative treatment . LGBT Health . 2017;4(2):106-114. doi:10.1089/lgbt.2016.0133

By Elizabeth Boskey, PhD Boskey has a doctorate in biophysics and master's degrees in public health and social work, with expertise in transgender and sexual health.

TLDEF's Trans Health Project

Anthem blue cross blue shield, gender affirming surgery.

Policy: Gender Affirming Surgery Policy Number: CG-SURG-27 Last Update: 2021-05-20

Permanent Hair Removal:

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Voice Therapy and Surgery:

Gender affirming voice modification surgery is considered reconstructive when all of the following criteria have been met: The individual is at least 18 years of age; and The individual has capacity to make fully informed decisions and consent for treatment; and The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and For gender masculinization only: for individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and Existing vocal presentation demonstrates significant variation from normal for the experienced gender; and One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission. Cosmetic and Not Medically Necessary: The following procedures, when requested alone or in combination with other procedures, are considered cosmetic and not medically necessary when applicable reconstructive criteria above have not been met, or when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender affirming surgery, including, but not limited to, the following: Abdominoplasty Bilateral mastectomy Blepharoplasty Breast augmentation Brow lift Calf implants Face lift Facial bone reconstruction Facial implants Gluteal augmentation Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met Jaw reduction (jaw contouring) Lip reduction/enhancement Lipofilling/collagen injections Liposuction Nose implants Pectoral implants Rhinoplasty Thyroid cartilage reduction (chondroplasty) Voice modification surgery

Reconstructive Gender affirming chest surgery ( augmentation, mastectomy, or reduction ) is considered reconstructive when all of the following criteria have been met: The individual is at least 18 years of age (see Further Considerations section below for individuals under 18 years of age); and The individual has capacity to make fully informed decisions and consent for treatment; and The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and For gender affirming breast augmentation procedures only : for individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician, and insufficient breast development has occurred; and Existing chest appearance demonstrates significant variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission. Nipple reconstruction, including tattooing, following a gender affirming mastectomy that meets the reconstructive criteria above is considered reconstructive.

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Updated on Nov 11, 2021

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Blue Shield Gender Reassignment Surgery Criteria

March 28, 2014 By Kevin Knauss 22 Comments

Solid information is hard to come by when it relates to what health insurance plans will cover for gender reassignment surgery in California. In response to the Insurance Gender Non-Discrimination Ac t passed by California in 2013, some health plans have created detailed medical policies for transgender health benefits. For a variety of reasons the health insurance companies don’t make their policies readily available to the general public. I was able to locate two detailed outlines issued by Blue Shield of California relating to gender reassignment surgery.

Blue Shield gender reassignment surgery

The Blue Shield medical policy for gender reassignment surgery leans heavily on recommendations from the World Professional Association for Transgender Health guidance (WPATH) . Their transgender coverage is at least nominally rooted in established and accepted definitions related to the therapeutic options for transgender individuals to successfully transition to their identified gender. Of the two Blue Shield medical policy excerpts presented, one is directed toward the member seeking services and the other supplies more technical information for the physicians and surgeons.

Criteria for gender reassignment surgery

The guiding principles for the Blue Shield health plans to consider covering sex reassignment surgery is outlined with six points from the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-5).

• Criteria for the diagnosis of gender dysphoria
• A marked incongruence between one’s experienced/expressed gender and/or secondary sex characteristics
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender
• A strong desire for the primary and/or secondary sex characteristics of the other gender
• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
• A strong desire to be treated as the other gender
• A strong conviction that one has the typical feelings and reactions of the other gender

Authorizing medically necessary gender surgery

Before authorizing any medically necessary procedures for the treatment of gender dysphoria and ensuing gender reassignment surgery, Blue Shield lists a number of criteria that must be met. Here are summaries of the criteria. For the comprehensive list and associated notes download the files at the end of this post.

The individual is age 18 or older

Documented DSM-5 diagnosis of gender dysphoria including all of the following

Desire to live and be accepted as member of opposite sex

Transsexual identity has been present for at least 2 years

Disorder is not a symptom of another mental disorder

Disorder causes clinically significant distress or impairment

If significant medical or mental health concerns are present, they must be well controlled

Medical record documentation to support medical necessity of any of the following gender reassignment surgeries and all associated criteria

• Mastectomy – at least one letter of recommendation written from qualified mental health professional
• Hysterectomy, salpingo-oophrectomy, orchiectomy – with 12 months of continuous hormone sex reassignment therapy, recommendations from two qualified mental health professionals.
• Genital reconstructive surgeries
• Vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, urethromeatoplasty, testicular prosthesis, phalloplasty (female to male)
• Vaginoplasty, penectomy, clitoroplasty, vulvulplasty (male to female)

12 months of continuous hormone sex reassignment therapy unless the individual has a medical contraindication to take hormones (may be simultaneous with real-life experience)

Real-life experience of living within desired gender role full-time for 12 months.

Regular participation with a mental/behavioral health provider or other medical professional throughout real-life experience.

Recommendations for sex reassignment surgery by two qualified mental health professionals.

Referral and Recommendations from qualified mental health providers

Blue Shield is explicit that they will only consider referrals and recommendations from mental health professionals with specific credentials. “The minimal credentials for qualified mental health professionals who work with adults presenting with gender dysphoria include a master’s degree or its equivalent or more advanced degree (e.g., Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) in clinical behavioral science field with established competence in the assessment and treatment of gender dysphoria.” Letters of recommendation for gender reassignment surgery must include the following:

• The client’s general identifying characteristics
• Results of the individuals psychosocial assessment, including any diagnoses
• The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy and counseling to date
• An explanation that the WPATH criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery
• A statement that informed consent has been obtained from the patient
• A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this

Real-Life Experience

The Blue Shield medical policy also places importance on documenting that any candidate for sex reassignment surgery has lived full-time in their identified gender role for a minimum of 12 months. “Health professionals should clearly document a patient’s experience in the gender role in the medical chart, including that start date of living full-time for those who are preparing for genital surgery.”

• Communication with individuals who have related to the patient in an identity-congruent gender role
• Request documentation of legal name and/or gender-marker change, if applicable

Transgender transition guide

The Blue Shield medical policy for assessing and granting coverage for sex reassignment surgery is fairly comprehensive in its scope. The documents have a litany of different procedures that could possibly be covered and a list of cosmetic procedures that will not be covered. While the documents are technical in nature and written for medical professionals and internal Blue Shield employees evaluating requests for authorization for gender reassignment surgery, they contain important information for any transgender individual who is on the path to transition to the gender they truly identify with.

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About Kevin Knauss

"Education Before Enrollment" Kevin is an independent agent for health insurance in California and a Certified Insurance Agent for Covered California. CA LIC. 0H12644. Focusing on families, individuals, self employed and small business. Representing several insurance carriers plus Medicare Advantage and Part D Plans. I blog on several topics to provide consumer information for people who have questions about health insurance and the Affordable Care Act. Author: "Hidden History Beneath Folsom Lake", "Benjamin Norton Bugbey, Sacramento's Champagne King", and "Amos Catlin, The Whig Who Put Sacramento On The Map."

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