Planning for Gender-Affirming Care: Part 1 – Surgery

This piece was shaped by the generous input of transgender and gender diverse friends who’ve navigated this firsthand. Thank you for trusting me with your stories.

In California and many other coastal states, health insurance plans regulated at the state level are required to cover medically necessary gender-affirming care. However, “medically necessary” is defined by the insurance companies themselves, and not all procedures that patients or providers consider essential are approved.

A few tips when navigating insurance:

• Request a copy of your Summary of Benefits and Coverage (SBC) to see what’s explicitly included or excluded. For CalPERS and CalSTRS members, state law requires gender-affirming care in state employee health benefits.

• Preauthorization is often required: Most insurers will require documentation, such as a letter from a medical provider diagnosing gender dysphoria and stating the surgery is medically necessary. Requirements vary significantly by insurer and procedure type (e.g., top surgery vs bottom surgery often have different documentation requirements). Surgeon’s offices can assist with preauthorization and appeals, as they will usually have staff who know how to navigate insurance processes and requirements.

• You can appeal if denied coverage: If you’re denied coverage, request a written explanation and consider filing an internal appeal or seeking support from a healthcare advocate or legal aid organization. Keep thorough records of all communications and paperwork. Appeals can take weeks to months, and persistence often makes a difference.

• Ask your HR or benefits administrator if your health plan is fully insured or self-funded.

  • Fully insured health plans are when an employer buys health insurance from a commercial insurance company, paying a fixed premium; the insurance company pays employees’ medical claims, and employees are responsible for deductibles and copays.

  • Self-funded/self-insured health plans are where the employer pays employee medical claims directly from the company’s own funds, usually with the help of a third-party administrator. Even if your insurance membership card says a specific insurance company’s name, your employer may be making actual coverage decisions.

  • This distinction is important because state-level protections (like California’s gender-affirming care mandates) apply only to fully insured plans, not self-funded plans.

Expenses to Plan For

Even when surgery is covered, you’ll likely face some or all of the following out-of-pocket costs:

• Deductibles and coinsurance

• Travel and lodging if the nearest affirming provider is far away

• Lost wages from recovery time

• Post-surgery supplies and garments (e.g., scar care cream, donut or wedge pillows, medication, compression vests after top surgery, dilation kits for vaginoplasty)

If you have access, setting aside money in a tax-advantaged Health Savings Account (HSA) or Flex Spending Account (FSA) in advance might help you cover some of the costs associated with medical care, although you will want to confirm what expenses are eligible with your plan’s administrator.

Eligible expenses typically include copays, deductibles, and certain post-op supplies if deemed medically necessary. However, travel and lodging are generally not reimbursable under IRS rules unless tied directly to medical care and with a physician's letter.

If you work for someone else, coordinating paid time off (PTO), state short-term disability benefits, or even part-time return-to-work transitions can also help make your recovery smoother and more financially stable.

Resources Beyond Insurance

If insurance isn’t an option, or doesn’t go far enough, there are some other possibilities:

• Nonprofits and mutual aid networks: Many organize around specific surgeries or states. The national nonprofit Genderbands offers microgrants for gender-affirming care every October.

• GoFundMe and direct community support: Crowdfunding is common, and success often depends on storytelling and reach.

Final Thoughts

No one should be priced out of their own bodily autonomy. If gender-affirming surgery is part of your path, planning ahead and knowing what is and isn’t covered can help make this a smoother process.

Part 2 of this series, covering gender-affirming care outside of the operating room, will be coming soon!

Disclaimer: This information is for educational purposes only and doesn't constitute financial advice. Consider consulting with a fee-only financial planner for personalized guidance.