In addition to the noted authors, thank you to Manatt Health’s contributors and thought leaders who supported the development of this brief, including Melinda Dutton, Marissa Korn, Cindy Mann, Carlos Martinez-Mejia and Julian Polaris.
The transgender, or trans, community experiences stark health disparities resulting from discrimination, violence, stigma and a lack of culturally competent providers. Compared with the general U.S. population, trans individuals suffer from more chronic health conditions related to substance use, mental illness, sexual and physical violence, and earlier onset of disabilities.1 Health care coverage and access to care for trans individuals are critical to eliminating these disparities and advancing health equity. This includes timely access to gender-affirming care, which has been shown to positively impact health outcomes.2
Medicaid is a critical source of health care coverage for the trans community, covering an estimated 276,000 trans people (likely undercounted due to stigma and a lack of accurate reporting methodologies). Depending on the state where an individual lives, they may have limited or no access to gender-affirming care. As of November 2023, 22 states have enacted laws or policies banning gender-affirming care up to age 18, with several states also considering bans through early adulthood.3 These laws prevent trans individuals from receiving gender-affirming care but may also have a “chilling” effect on their care-seeking behavior for necessary physical and mental health services, due to stigma and fear.
Policymakers, providers and advocates can help mitigate the widening of health disparities for trans individuals by implementing strategies to ensure access to gender-affirming care through a more inclusive delivery system. This article describes the major strategies that states are taking to advance gender-affirming care.
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Box 1: Key Concepts and Terms 4
Gender-affirming care includes a range of social, psychological, behavioral and medical interventions designed to support and affirm an individual’s gender identity when it conflicts with the gender they were assigned at birth. Services include hormone therapy, puberty blockers, surgical procedures, counseling and other forms of treatment. There is broad consensus in the medical community that gender-affirming care is medically necessary and that it improves the physical and mental health of trans and gender-diverse people.
Gender is often defined as a social construct of norms, behaviors and roles that varies across societies and over time. Gender is often categorized as male, female or nonbinary. Sex refers to an individual’s biological status and is typically assigned at birth based on external anatomy. Sex is often categorized as male, female or intersex. For trans people, gender identity differs in varying ways from the sex assigned at birth.
Gender identity is one’s own internal sense of self and their gender, whether that is man, woman, neither or both. Gender identities and/or gender expression can change over time. When one’s gender identity does not align with sex assigned at birth, they may describe themselves as being trans, transgender, gender nonconforming or nonbinary, among other terms (e.g., gender fluid). For the purposes of this article, we use “trans” as an umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth, including nonbinary, intersex, two-spirit and other gender-diverse or expansive individuals.
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Medicaid’s Role in Covering Gender-Affirming Care
The reality on the ground is that the extent to which Medicaid covers trans-affirming care depends on the state. Some states provide comprehensive coverage through their Medicaid programs, while other states have explicit Medicaid policies that exclude gender-affirming care for minors and/or adults.
Under federal law, it is clear that states can cover the full array of gender-affirming services required by trans individuals, and arguably, they are required to do so. As part of operating their Medicaid programs, states must cover certain mandatory categories of benefits for all enrollees, and they have the option to cover other benefit categories.5,6 The Medicaid statute prohibits discrimination based on diagnosis, stating that Medicaid agencies “may not arbitrarily deny or reduce the amount, duration, or scope of a required service … to an otherwise eligible [beneficiary] solely because of the diagnosis, type of illness, or condition.” For example, denying a Medicaid beneficiary a mastectomy to treat gender incongruence while covering it for someone with a breast cancer diagnosis arguably should be considered discrimination and not permissible. Moreover, in August 2023, the Biden-Harris Administration released a proposed rule on Section 1557 of the Affordable Care Act which seeks to require states to cover gender-affirming care.7
However, there is no consensus on what federal law requires at this time. There are several pending legal challenges related to the Section 1557 rules, statewide bans of gender-affirming care, as well as over-specific Medicaid policies related to coverage of gender-affirming services. It likely will be some time before it is clear whether all state Medicaid programs are required to cover gender-affirming care.
State Medicaid Actions to Ensure Access to Gender-Affirming Care
Against this backdrop, a number of states are acting to ensure and bolster access to gender-affirming care in their Medicaid programs. Below are major strategies that states are using:
Establish an explicit policy that gender-affirming care is covered by Medicaid and must be provided when clinically appropriate. Some states have issued written Medicaid policies that explicitly cover gender-affirming care, make it clear to providers which services are covered and mitigate obstacles to people’s access to care (e.g., prior authorizations, claim denials). States are establishing new policy through a variety of mechanisms, including laws and regulations (e.g., New Jersey), provider manuals (e.g., Delaware), and guidance and bulletins to health plans and providers (e.g., Massachusetts, Michigan).8
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Box 2: World Professional Association for Transgender Health
WPATH is a 501(c)(3) nonprofit, interdisciplinary professional and educational organization devoted to transgender health. WPATH has established internationally accepted standards of care to promote the health and welfare of trans individuals. The standards are updated and revised as new scientific information becomes available. Version 8 of the WPATH standards was published in 2022 and eliminated unnecessary barriers to care, including by requiring only one letter from a provider instead of two letters in instances where a letter of assessment is required before accessing services.
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Cover the full array of gender-affirming care. Gender-affirming care includes provision of hormones, surgery, hair removal, voice and communication therapy, fertility assistance, and supportive counseling (e.g., to assist individuals with exploring their gender identity). A recent survey of state Medicaid coverage policies for adults over the age of 21 found that fertility and voice and communication therapy were often not covered, while hormones, surgery, and counseling were typically covered by states; Maine and Illinois reported covering all services. Maryland’s Transgender Health Equity Act, signed into law in April 2023, requires the state’s Medicaid agency to provide “any medically necessary treatment consistent with the current clinical standards prescribed by a licensed health care provider for treatment of a condition related to the individual’s gender identity.” When determining which services should be covered, states generally are adopting coverage policies and medical necessity standards that align with established standards of care, including those of the World Professional Association for Transgender Health (WPATH; see Box 2), the Endocrine Society (guidelines for hormone treatment) and the American Academy of Pediatrics.
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Include trans people in codesign of Medicaid policy on gender-affirming care. States can ensure Medicaid policies appropriately meet enrollee needs by including community members in the policy development process. For example, California launched a Trans, Gender Diverse, or Intersex Health Care Quality Standards and Training Curriculum Working Group to allow consumers to share their lived experience and ensure state policies and programs are responsive to the needs of the trans community. Specifically, the work group will develop a quality standard for patient experience to measure cultural competency related to the trans community and recommend a training curriculum to provide trans-inclusive health care.
Update coverage policies and provider guidance to clearly state coverage of and remove barriers to gender-affirming care. Washington has a publicly available billing guide that clearly lays out covered gender-affirming care services, eligibility guidelines, provider requirements for delivering and billing for services, and authorization processes. Colorado updated its policies in 2019 to clarify that permanent hair removal is not subject to surgical authorization requirements, reducing administrative time and effort burdens placed on trans beneficiaries and their providers. In March 2023, Governor Walz of Minnesota signed an executive order to help protect and expand access to gender-affirming care, including through requiring health plans to ensure that their contracted providers are aware they may bill for medically necessary gender-affirming care services and mandating review of the Minnesota Health Care Programs Provider Manual—which covers Medicaid, the Basic Health Program and the Family Planning Program—to ensure there are current standards and criteria for medically necessary gender-affirming care. Recently, Minnesota also underwent a process to update its policies related to gender-affirming care to align with the WPATH guidelines, which resulted in modifying and clarifying authorization requirements and removing restrictions for accessing services.
Establish and monitor provider network requirements. Maryland is requiring that Medicaid managed care plans, beginning December 2024, submit a report on their provider networks and types of gender-affirming treatment provided, for providers that consented to being included. The state will use this data to compile an annual report on geographic access to gender-affirming treatment across the state. California requires health plans to include within their network directories a list of in-network providers who offer gender-affirming services. Oregon has implemented network access standards that require all carriers and coordinated care organizations (Oregon Medicaid’s managed care plans) to ensure gender-affirming services are accessible to all members “without unreasonable delay.” Colorado requires health plans to “actively recruit LGBTQ-friendly specialists that can address the unique needs of members seeking gender transition—such as an endocrinologist to monitor hormone treatment.”
Require or facilitate provider training. Multiple states require health plans to provide cultural competency and other trainings to providers, employees and contracted staff. As part of their LGBTQ Care Quality Improvement Project, Michigan requires its Medicaid managed care plans to report on training protocols and activities that address discrimination and access to gender-affirming care. In California, Medicaid health plan staff who are in direct contact with enrollees must complete an evidence-based cultural competency training that is developed by a trans-serving organization and focused on providing trans-inclusive health care. California also requires continuing medical education to include an evidence-based culturally competent curriculum to help physicians provide inclusive care for trans individuals.
Establish Medicaid plans with trans individuals as a population of focus. New York has established HIV Special Needs Plans for those eligible for Medicaid who are trans, as well as individuals living with HIV/AIDS or who are experiencing homelessness. The plan covers all the same services as other Medicaid plans and also provides specialized services, such as a primary care provider specializing in HIV, personalized care coordination services for social needs (e.g., legal assistance, housing), and access to providers who are experienced in serving the LGBTQ population and delivering gender-affirming care.9
Additionally, and beyond Medicaid, 14 states and Washington, D.C., have enacted a “shield” or “safe haven” law or executive order to protect trans individuals, their families and their medical providers against civil or criminal charges.10 For example, a recently enacted New York law bars state courts from enforcing the laws of other states that might authorize a child to be taken away if the parents provide gender-affirming medical care, prohibits New York courts from considering transition-related care for minors as child abuse, and bars state and local authorities from cooperating with out-of-state agencies regarding the provision of lawful gender-affirming care in New York.
Looking Ahead
States looking to ensure and enhance access to gender-affirming care can pursue strategies similar to those mentioned here and continue to learn from each other on how to create a more inclusive health care delivery system.
Contact Jocelyn Guyer and Bryant Torres with questions on gender-affirming care and support for LGBTQ+ individuals in Medicaid.
1 For this article, we use “trans” as an umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth, including nonbinary, intersex, two-spirit and other gender-diverse/expansive individuals.
2 In one recent study, trans and nonbinary adolescents and young adults who received gender-affirming care had 60 percent lower odds of moderate or severe depression and 73 percent lower odds of suicidality.
3 For example, Oklahoma, South Carolina and Texas have considered banning care for transgender people up to age 26. Alabama, Arkansas, Florida and Indiana court injunctions are ensuring access to care despite current bans.
4 Human Rights Campaign Foundation. Sexual Orientation and Gender Identity Definitions. Available here. Also see, Wamsley, L. A Guide to Gender Identity Terms. National Public Radio. June 2021. Available here.
5 As part of their Medicaid programs, states are required to cover mandatory benefits, such as inpatient hospital services/surgery, outpatient services and prescribed drugs, and ensure that these mandatory services are sufficient in amount, duration and scope. Available here.
6 For children and youth under age 21, there is an additional requirement that states must cover all appropriate and medically necessary services through Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, regardless of their coverage for adults within a state.
7 The rule seeks to clarify and affirm that it is prohibited for health programs or facilities that receive federal funds to discriminate on the basis of gender identity, and require Medicaid programs to provide gender-affirming services that would otherwise be provided to someone else. However, there are pending legal challenges holding that Section 1557 cannot be interpreted in this way.
8 Some states have taken steps to remove historic exclusions in their Medicaid programs. Minnesota removed its previous exclusion of coverage for gender-confirmation surgery via a state plan amendment in 2016 (see SPA #16-0018). While explicit coverage policies provide a robust avenue for patient access, states without detailed policies may still cover some or all gender-affirming care services as part of standard benefits in their state plan.
9 Association for Community Affiliated Plans. Safety Net Health Plan Initiatives to Improve LGBTQI+ Health Equity. September 2021. Available here.
10 Additionally, three states have an executive order. More information available here.