Even for plans that offer coverage, the line between procedures that are “medically necessary” versus cosmetic can blur.

National groups, including the Center for American Progress and the American Civil Liberties Union, are teaming with regional activists on the issue. Transgender individuals are not asking for unique treatment, they say. They simply want insurance companies to pay for procedures deemed medically necessary for other adults. A man becoming a woman should have access to the same hormone therapies as a menopausal woman, advocates maintain. Or a woman becoming a man should have access to the same reconstructive surgery as a man severely wounded below the waist in a car accident.

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Moreover, advocates contend that any costs are cheaper than leaving gender dysphoria untreated. A majority of respondents to the 2011 National Transgender Discrimination Survey said they had been refused medical treatment by a provider because of transgender bias — and 60 percent of respondents reported attempting suicide.

Armed with the research, advocates are pressing forward. Discussions are underway with regulators in Rhode Island and New York, and in late June, they filed a federal lawsuit seeking coverage from the Empire State’s Medicaid program. The negotiations tend to involve uncomfortable conversations with policymakers about what, exactly, a gender dysphoria diagnosis means and the medical rationale for treating it.

“It’s really intense and icky for people, including policymakers, to think about people changing their genitals,” acknowledged Danielle Askini, a founder of the Gender Justice League in Washington state.

Askini was also involved with the successful coverage effort in Oregon, and she credits its transgender community with becoming more visible and sharing personal stories through the YouTube video “Faces of Trans Inclusive Health Care.”

Insurance companies say they are committed to nondiscrimination and ready to offer plans covering surgery when payers request it or regulators require it. Even when a policy includes coverage, however, issues arise over what’s elective versus essential.

In their coverage descriptions, major insurers like Aetna and UnitedHealthcare will pay for changes to private body parts, like vaginoplasty and testicular prosthesis. Mastectomies for female-to-male patients and breast implants for male-to-female patients are usually covered, too. Procedures such as facial feminization or voice modification surgery are generally excluded as cosmetic.

“It’s important that a person undergoing gender-confirming surgery is brought into the wide range of appearance variation for people of the desired gender,” said Patrick Johnston, head of the California Association of Health Plans. But, he continued, “it remains important in controlling health care costs to continue the distinction between medically necessary services and services designed to improve appearance generally, no matter who the person is.”

Other, more fundamental health care barriers remain. In Illinois, for example, Lambda Legal is representing a woman who alleges that her doctor refused to provide any care because of her gender identity. And transgender people are four times more likely to live in poverty than the general population, according to the National Transgender Discrimination Survey. Advocates say ongoing employment discrimination and social ostracism drive that statistic.

Perhaps the surest sign of the “inevitability” Keisling foresees comes from the insurance companies themselves. Four of the five largest insurers cover all medically necessary treatments for their own transgender employees. And independent of regulators, a spokesman said Aetna is at least one company expecting to add coverage for gender reassignment surgery to some private plans in the future.