Transgender people often require a great deal of medical care. Mental health counseling, hormone therapy, speech language therapy, mastectomy, facial feminization, sperm retrieval or egg freezing — just to name a few — can cost thousands, or even hundreds of thousands of dollars.

But if an insurance provider classifies a procedure as "cosmetic" rather than "medically necessary," trans people are forced to pay out-of-pocket. Or risk going without care that can be vital to their health.

Even when insurers won't cover certain procedures, some employers will step in and offer coverage. In the last decade, hundreds of companies have revised their healthcare plans to financially assist employees in gender transition and gender affirmation surgery. In 2009, when the Human Rights Campaign first began asking companies about transgender-inclusive benefits as part of their company rankings , only 49 major US employers offered them. In 2018, HRC says a record 759 companies now offer transgender-inclusive healthcare coverage.

"To get to that point, at HRC, we had to do a lot of educating not only of the companies and the benefits managers about what it means, but also of insurance companies, what it means to be able to offer it and fulfill it," says Beck Bailey, deputy director of HRC's workplace equality program.

The realities of care

Not all transgender people want or need medical assistance as they transition. But for those who do, the process can be time consuming and extremely expensive.

Many insurers will deem hormone therapy or other procedures as "medically necessary" for the treatment of gender dysphoria, the distress a person experiences when confronted by the difference between their current body and their gender identity. But a slew of other procedures, like speech therapy or further surgery, can also be considered elective.

As a Master's student and former staff assistant at the University of Michigan, Vidhya Aravind says she paid out-of-pocket for procedures that were vital to her health. She says explaining that to cisgender people is taxing.

"I think that even well-meaning cis people who consider themselves allies don't know what trans people go through to get medical care," she says. "For 99% of things, our healthcare is great. But for trans things, it's completely a disaster."

Throughout the last year, she has been working with other graduate students to make medical care more accessible for her transgender colleagues.

Aravind and her fellow student Monica Lewis both received coverage from University of Michigan's GradCare, the insurance plan provided to unionized graduate student employees.

Aravind and Lewis say it's not uncommon for transgender peers to travel out of the state for surgery, looking for a provider they trust. Both trans women have paid out-of-pocket for procedures, even canceling some because of financial strain.

"The end result is I was making less than my [cisgender] colleagues, because I was paying out-of-pocket for some of these procedures that I don't believe I could've done without," Lewis says.

Companies expanding care

Some well-known American companies, like Starbucks and Pinterest, for example, offer coverage for trans people.

"We believe everyone should have the opportunity to create a life they love and feel welcome at work," Candice Morgan, head of inclusion and diversity at Pinterest, said in a statement to CNN. "That's why we offer a range of benefits to help our employees across their lives, including gender affirmation and fertility treatments, and continue to foster an inclusive culture that embraces diversity."

For 99% of things, our healthcare is great. But for trans things, it's completely a disaster Vidhya Aravind

Companies like Starbucks have pioneered trans-inclusive coverage. Since 2012 , employees at the coffee chain have been able to rely on Starbucks coverage for gender affirmation surgery. Starbucks also comps some procedures other employers consider too "cosmetic" to cover, like hair transplants, electrolysis, facial feminization or masculinization.

When putting together the pieces of its trans-inclusive healthcare benefit, Starbucks first asked its employees — they call them "partners" — what they considered necessary as part of their healthcare package. From there, the company decided to extend the benefit to all partners who work 20 hours or more a week, says Reggie Borges, senior manager of global communications at Starbucks. That means even if you're balancing a Starbucks job part time, you're eligible to receive that care.

"It was something our VP of Benefits was really passionate about," Borges says. "We understood, 'If we're going to do this, we need to do this the right way, for partners who want to go through this transition."