Do Insurance Companies and Medicaid Cover Gender-Affirming Care?

Gender-affirming care refers to many different types of health care services. These services are used for the treatment of gender dysphoria (previously known as gender identity disorder). A transgender individual or someone who is gender nonconforming might seek out:

• Hormone treatment

• Surgical treatment

• Behavioral health treatment

Like many who seek medical care, nonbinary or transgender people might want to have their care covered by their health insurance. Or, if they qualify, they might seek care under Medicaid/Medicare assistance programs.

In this article, you can learn more about:

• How different states approach health coverage for gender-affirming care

• Federal government policies that can impact coverage of surgical procedures and hormone therapy

• How each state's Medicaid program addresses gender-affirming care

In a separate article, you can learn more about access to gender-affirming care in different states.

Medicare Coverage for Gender-Affirming Care

Medicare is an important federal health insurance program for people over the age of 65. It also provides coverage for people younger than 65 with certain disabilities.

In 2016, the Centers for Medicare and Medicaid Services announced that it would determine coverage for gender confirmation surgery on a case-by-case basis. The memo did not address a nationwide approach to hormone treatments.

It's important to determine Medicare eligibility before pursuing any type of medical treatment under this program.

Federal Policies on Gender-Affirming Coverage, Medicaid, and Insurance

State Medicaid programs must follow federal anti-discrimination laws. Section 1557 of the Affordable Care Act (ACA) prohibits health care discrimination based on:

• Race
• Color

• National origin

• Sex

• Age

• Disability

In 2016, the Obama administration issued a new rule on sex discrimination under the ACA. The rule did two things:

• Expanded protection to include discrimination based on gender identity and sex stereotypes
• Required health care providers to treat transgender patients according to their gender identity

The U.S. Department of Health and Human Services Office for Civil Rights issues these rules.

Then, in June 2020, the OCR under the Trump administration issued a narrower rule. Specifically, it removed gender identity and sex stereotyping from the sex discrimination category. It also eliminated rules protecting transgender patients. Since then, healthcare providers can deny coverage or care based on someone's gender identity. Insurers that use federal funding can as well. That is, unless state law says otherwise.

In 2022, the Biden administration announced a new proposed rule. This rule would reinstate protections for gender identity and sexual orientation. This rule has not been finalized. For now, states can decide whether to include coverage and protections for gender-affirming care.

State Approaches to Gender-Affirming Care, Insurance, and Medicaid

How gender-affirming care fits into insurance coverage and Medicaid depends on where you live.

Some states do not have a Medicaid policy that specifically addresses gender-affirming care. Others exclude gender-affirming care from Medicaid coverage.

Many states prohibit private insurance companies from denying claims related to gender-affirming care. But some do not. Others have no state law addressing this issue or have policies derived from case law.

Consider the examples below:

Alaska

State law in Alaska does not protect LGBTQ+ individuals from discrimination by private health insurers. But it also does not give private health insurers permission to refuse to cover gender-affirming care.

Alaska's Medicaid program does cover gender-affirming care following a federal court decision in Being v. Crum. In settling that case, the state agreed to remove the ban on gender-affirming care in its Medicaid program in 2021.

Coverage of gender-affirming care is also not mentioned under Alaska's state employee benefits. But, in 2020, a federal court ruled in Fletcher v. The State of Alaska that the state's exclusion of gender-affirming surgeries under the state's employee healthcare plan was unlawful discrimination on the basis of sex.

Hawaii

In 2022, Hawaii passed a law that, among other things, defines all gender transition treatments as a medical necessity and “not cosmetic." This includes things like:

• Breast augmentations/reductions

• Voice surgeries

• Electrolysis (laser hair removal)

• Facial gender-confirmation/feminization surgeries

• Mastectomy

• Hysterectomy

So how does this play out? Let's say a Hawaii resident's health insurance typically covers a mastectomy. Under this law, the insurer cannot deny coverage for a mastectomy done for the purpose of gender affirmation or transition.

However, state law does not specify whether Medicaid funds can cover gender-affirming care in Hawaii. In the past, the Hawaii Department of Human Services has denied Medicaid claims for gender-affirming care.

Iowa

Iowa's Medicaid program provides coverage for gender-affirming care following a 2021 district court ruling, Vasquez v. Iowa Department of Human Services. The court found the denial of Medicaid coverage for gender-affirming care to be unconstitutional.

Maryland

Maryland's Medicaid program covers gender-affirming care, regardless of age. In 2023, the state legislature voted to expand coverage for gender-affirming care under the program. The state also bans private insurers from excluding gender-affirming care from coverage.

Virginia

State law in Virginia does not address Medicaid coverage for gender-affirming care or reassignment surgery. In 2021, Virginia's director of the Department of Medical Assistance Services (DMAS) informed Medicaid providers that the program covers gender-affirming care. However, some procedures, such as body contouring and facial surgeries, may be excluded.

A bill introduced in the Virginia legislature in November 2022 will ban gender-affirming care for minors if passed. If this bill becomes law, Medicaid will not cover this type of care for someone under 18.

Virginia prohibits discrimination on the basis of gender identity by private insurance and bans private insurers from excluding coverage of gender-affirming care.

State-by-State Medicaid and Insurance Coverage for Gender-Affirming Care

In the table below, you'll find a summary of state policies on:

• State Medicaid coverage for gender-affirming care and sex reassignment surgery

• State policies on health care discrimination based on sexual orientation/gender identity

• State policies on private insurers excluding gender-affirming care from coverage

Some states have no laws addressing gender-affirming care and private insurance. This generally means that insurance companies can exclude gender-affirming care from coverage.

Keep in mind that these laws are changing quickly. If you need help appealing an insurance claim or have other questions, it's often best to consult a health care attorney in your area.

What to Do If You Are Denied Coverage

All states have a process for appealing a denial of coverage under Medicaid. The process varies slightly from state to state. But it's generally a good idea to request an appeal in writing. A health care attorney can help you with the paperwork and guide you through the hearings that follow.

Denial under private insurance is a bit trickier. However, if you believe the insurance company is unreasonably withholding benefits that are due under your insurance policy, you might have a bad faith insurance claim. Bad faith insurance attorneys are experts at going toe-to-toe with insurance companies.

Other Questions? An Attorney Can Help

The laws surrounding gender-affirming care are changing all the time. So, it's important to know how these laws apply to your specific circumstances and where you live. To learn more about your options, consider consulting with an attorney experienced in one of the following areas:

• Health care
• Civil rights
• LGBTQ+ rights

They can help you determine your best options to receive care or help you file a claim if you have been wrongfully denied coverage.