Do Insurance Companies and Medicaid Cover Gender-Affirming Care?
By Laura Temme, Esq. | Legally reviewed by Balrina Ahluwalia, Esq. | Last reviewed April 04, 2025
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Insurance companies and Medicaid coverage for gender-affirming care vary significantly by state. While some states mandate coverage under Medicaid and private insurance, others may not offer any coverage. Federal policies, such as Section 1557 of the Affordable Care Act, aim to prevent discrimination based on gender identity in healthcare. Medicare covers medically necessary gender-affirming surgeries on a case-by-case basis and hormone therapy under Part D with prior authorization. As policies continue to evolve, it's crucial for individuals to verify their eligibility and understand their state's specific regulations regarding 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 "medically necessary" gender confirmation surgery on a case-by-case basis. The memo did not address a nationwide approach to hormone treatments.
Hormone therapy is typically covered under Medicare Part D, with prior authorization.
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. Healthcare providers could deny coverage or care based on someone's gender identity. Insurers that use federal funding could as well. That is, unless state law said otherwise.
In 2022, the Centers for Medicare and Medicaid Services announced a new proposed rule that would reinstate protections for gender identity and sexual orientation.
In May 2024, the Biden administration finalized this rule, reinstating protections for gender identity and sexual orientation under Section 1557 of the Affordable Care Act. However, it's unclear whether this rule will remain in place.
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 covers 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.
In 2023, the state legislature introduced a bill that would prohibit discrimination against LGBTQ+ people in healthcare and other aspects of life. If passed, the bill's ban on LGBTQ+ discrimination would extend to private insurers.
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 in real life? Let's say a Hawaii resident's health insurance typically covers a mastectomy. Under this law, an insurer cannot deny coverage for a mastectomy done for the purpose of gender affirmation or transition. It applies to both private insurers and Medicaid, requiring coverage for gender-affirming treatments.
Iowa
Iowa's Civil Rights Act did prohibit discrimination based on gender identity. It required the state's Medicaid program, as well as private insurers, to provide coverage for medically necessary 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.
Although the Iowa Supreme Court upheld the decision in 2023, the state legislature removed gender identity as a protected class under the Act in early 2025. So, effective July, 2025, insurers may limit or deny coverage for gender-affirming care.
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.
Virginia
Since 2021, Virginia's Medicaid program explicitly covers all medically necessary gender-affirming care, including surgeries and hormone therapies.
The state has removed previous exclusions for specific procedures like body contouring and facial surgeries, aligning with federal non-discrimination mandates.
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.
State |
Gender-affirming care covered by Medicaid? |
Private insurance coverage for gender-affirming care |
Alabama |
No |
|
Alaska |
Yes |
|
Arizona |
|
|
Arkansas |
|
|
California |
Yes |
|
Colorado |
Yes |
|
Connecticut |
Yes |
|
Delaware |
Yes |
|
District of Columbia |
Yes |
|
Florida |
No |
|
Georgia |
Yes, following the 2022 settlement in Thomas v. Georgia Department of Community Health |
|
Hawaii |
Yes |
|
Idaho |
No |
|
Illinois |
Yes |
|
Indiana |
|
|
Iowa |
Yes |
|
Kansas |
|
|
Kentucky |
No |
|
Louisiana |
|
|
Maine |
Yes |
State law protects against gender identity discrimination by private insurers. |
Maryland |
Yes |
|
Massachusetts |
Yes |
|
Michigan |
Yes |
State law protects against gender identity discrimination by private insurers. |
Minnesota |
Yes |
|
Mississippi |
|
|
Missouri |
No |
|
Montana |
Yes (though an enjoined ban on coverage for minors is in litigation) |
|
Nebraska |
|
|
Nevada |
Yes |
State law mandates private insurance coverage for gender-affirming treatments and protects against gender identity discrimination by private insurers. |
New Hampshire |
Yes |
State law protects against gender identity discrimination by private insurers. |
New Jersey |
Yes |
|
New Mexico |
Yes |
|
New York |
Yes |
|
North Carolina |
Yes |
|
North Dakota |
Yes |
|
Ohio |
Yes (though an enjoined ban on coverage for minors is in litigation) |
|
Oklahoma |
No |
|
Oregon |
Yes |
|
Pennsylvania |
Yes |
State protections against gender identity discrimination by private insurers |
Rhode Island |
Yes |
State protections against gender identity discrimination by private insurers. |
South Carolina |
No |
|
South Dakota |
No |
|
Tennessee |
|
|
Texas |
No |
|
Utah |
No |
|
Vermont |
Yes |
|
Virginia |
Yes |
State law mandates private insurance coverage for gender-affirming treatments and protects against gender identity discrimination by private insurers. |
Washington |
Yes |
|
West Virginia |
Yes, excluding gender-affirming surgery (though this exclusion is in litigation) |
|
Wisconsin |
Yes |
State protections against gender identity discrimination by private insurers |
Wyoming |
|
|
What to Do If You Are Denied Coverage
Individuals denied coverage for gender-affirming care under Medicaid can appeal through a standardized federal process, ensuring consistency across states. This process involves submitting an appeal to your state's Medicaid agency, followed by a hearing if necessary. 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:
They can help you determine your best options for receiving care or file a claim if you have been wrongfully denied coverage.
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