Transgender Health Program: Insurance Information

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OHSU clinics accept many kinds of insurance, including the Oregon Health Plan and many Medicare plans. Some services require prior authorization and referrals.

If you have insurance

Many insurance plans cover some transition-related services. Oregon requires health insurers to cover medically necessary treatments related to gender dysphoria if those treatments are covered for other conditions.

Private insurance

Check your member handbook or call the member services number on your insurance card to find out what may be covered.

Terms to look for: Gender dysphoria, gender identity disorder, sexual/gender reassignment or transgender health.

Oregon Health Plan

The Oregon Health Plan covers hormone therapy and some surgical services for transgender and gender-nonbinary patients. Talk to your health care provider and coordinated care organization to find out what services they may provide.

Learn more:

Employer-provided benefits

If you get health insurance through your job, you should have a summary of benefits. Talk with your company’s benefits specialist or human resources manager about what’s covered.

If you don’t have insurance

Choosing a plan

Oregon Health Plan: The Oregon Health Plan is the state’s Medicaid program for low-income people. You can apply online if you haven’t already been denied coverage.

Individual marketplace: HealthCare.gov, run by the federal government, helps you shop for and enroll in affordable health insurance. What you pay is based mostly on your income. You can enroll early November through mid-December or after certain life-changing events, such as losing your previous health insurance.

Medicare: This federal program is for people 65 and older and certain younger people with disabilities. Medicare.gov can help you find a plan.

Senior Health Insurance Benefits Assistance Program: This Oregon network of trained volunteers helps Medicare patients of all ages get coverage.

Seniors and People with Physical Disabilities Offices: This Oregon agency, a branch of the Department of Human Services, can help you find services.

Find an agent or application assistant: Visit the Oregon.gov help page to find someone near you to help you find the right coverage.

Help from health insurance agents and Medicare agents is free, but some insurance agents get a commission for recommending an insurer’s plan. For free unbiased help, look for Medicare volunteers and community partners on the Oregon.gov help page.

Recommended community partners: These organizations have expertise in transgender and gender-nonconforming health:

What to ask

These questions can help you decide on an insurance plan, according to the Strong Families Network:

What is covered? When talking to customer service representatives, ask for the “Evidence of Coverage” or “Certificate of Coverage,” a full list of covered benefits for the plan.

What’s not covered? Pay attention to services or treatments specified as exclusions or limitations.

What’s covered for non-trans patients? If hormone therapy, chest surgery and hysterectomies are covered for anyone on the plan, they should be covered for transgender and gender-nonbinary members. In Oregon, it is illegal for insurers to cover services for some people and deny them to others.

Are there hormone therapy co-pays? If so, how much are they? Is there a limit on hormones or hormone injections? If so, what is it?

Is my health care provider covered by the plan? Check whether your doctor is in the plan’s network.

Is there a network of trans-friendly doctors with training in gender-diverse care? If you want to find a gender-affirming provider, these resources can help. Once you identify someone, ask which plans work with the provider:

Other questions to ask:

  • Are there doctors within 30 miles who can serve trans and gender-nonbinary patients?
  • Are mental health services available for gender-diverse people and their families, and are visits for gender-related needs covered?
  • What kinds of documents are needed to receive services?
  • Do I need to change my legal ID to get coverage as a person who is trans-identified?
  • Are procedures such as facial gender-confirmation surgery covered?

Dealing with claims

These tips can help you navigate the claims process with your insurer:

  • If your insurance is through your employer, contact your company’s benefits specialist or human resources manager.
  • Have an advocate nearby or on call, ready to help you handle the stress.
  • Be prepared to be misgendered. Many insurance companies don’t train their call-center staff on etiquette for transgender and gender-nonbinary patients.
  • Have your group number, plan number and, if you have an online account with your insurer, your username and password.
  • Research your plan and be prepared to explain your benefits package. Know what’s included and excluded. Call-center staffers don’t always distinguish well among the insurer’s various plans.
  • You may need to ask for a supervisor. Be patient and polite, and remember they’re humans on the other end of the line.
  • If you’re told you need a certain form, ask to have a blank copy emailed to you. Use the company’s name for any form, which can help representatives work faster.

These tips can help:

  • Don’t despair. You can appeal.
  • If you get an operator who can’t help, calmly ask for someone else.
  • Don’t accept partial payment. A partial payment can be appealed.
  • If you’re insured through work, ask your human resources manager or benefits specialist for help.
  • If your employer has a policy on nondiscrimination, inclusion and diversity, you can use it to appeal.
  • Find out if your plan has an explicit policy on parity.
  • Some claims are denied more than once, even when a procedure is covered.
  • If your doctor or benefits specialist finds a successful appeal for the same procedure, remove identifying information and include it with your appeal. This can help you avoid multiple denials.

Resources

OHSU resources

Visit our Billing and Insurance page to find:

  • Information about our billing process
  • Hospital costs
  • Numbers to call if you need help
  • Answers to frequent questions
  • Information about financial assistance

Oregon resources

The Oregon Department of Consumer and Business Affairs has information about finding insurance, getting help paying for it, and your rights.

Contact us

Location

Dillehunt Hall, Room 1007
3235 S.W. Pavilion Loop
Portland, OR 97239

Dillehunt Hall can be reached through Sam Jackson Hall.

Refer a patient

Please download our referral form and fax with relevant medical records to 503-346-1501. Learn more on our For Health Care Professionals page.