Maryland Expands Access to Gender-Affirming Care

On January 1, 2024, Maryland’s Trans Health Equity Act (THEA) went into effect, requiring the state’s Medicaid program to cover all medically necessary gender-affirming services, including services that were not previously covered. As a result of the new law, the Maryland Medicaid Assistance Program (Maryland’s Medicaid) released new guidance for Medicaid-participating providers and health plans, making Maryland one of the first states to integrate into its coverage policies the latest World Professional Association for Transgender Health (WPATH) standards of care.

To develop the guidance, Maryland Medicaid worked with a range of stakeholders, including Trans Maryland, a leading trans-led nonprofit that brought expertise and insights from lived experience to discussions about how to make the guidance as effective as possible.¹

THEA and the new guidance help to position Maryland as a leading state to watch among those seeking to provide equitable access to care for trans individuals.

Maryland’s Steps to Eliminate Barriers to Care

Trans individuals have long faced unique challenges in accessing health care, including stigma, discriminatory treatment and paperwork barriers to receiving medically necessary care. For example, trans individuals seeking gender-affirming surgery often must obtain written letters from two different qualified providers (e.g., mental health professionals) attesting that they require such care, a requirement that exceeds what is needed for any other surgery, even surgeries that are far more complex and costly (e.g., organ transplants). Maryland’s new guidance, consistent with the latest WPATH standards of care (WPATH SOC  8.0), begins to unravel some of these key stigma-based barriers to care and to treat gender-affirming services like other medically-necessary services—provided the services are medically necessary and clinically-appropriate as determined by a qualified professional and in accordance with a patient’s individual circumstances.

Specifically, Maryland has taken the following notable steps in its new clinical guidance:

• Simplifies the process for securing medically necessary care. Previously, trans patients in Maryland had to receive a gender dysphoria diagnosis and obtain up to two letters/referrals from qualified mental health professionals to secure gender-affirming surgery.² In the new guidance, Maryland aligns with the latest recommendations from WPATH by eliminating the requirement for two letters and, instead, allowing clinicians to document the basis for gender-affirming surgery as they would for any other service (e.g., they can document the determination in a patient’s electronic health record). The new guidance also expands the list of providers who can work with trans adults to determine the medical necessity of gender-affirming care by including primary care providers as well as mental health professionals.^3,4 For adolescents, the determination of medical necessity for gender-affirming care must be made by a multidisciplinary team that includes both a somatic health professional/primary care provider and mental health professional, but documentation of the decision can be provided by either the somatic health or mental health professional on the team.
• Defines clearly a full array of gender-affirming care services. As required by THEA, the clinical guidance outlines a comprehensive list of services that are covered in Medicaid. These include services such as hormone therapy, gender-affirming surgeries and therapies, reversal and revision procedures, facial feminization and masculinization surgery, hair removal and fertility preservation services.
• Creates a pathway for “non-traditional providers” who deliver gender-affirming care to participate in the Medicaid program. Some of the newly covered services may best be provided by non-traditional providers. For example, hair removal is a critical service long recommended by WPATH that can help to eliminate distressing secondary sex characteristics or be necessary to prepare for gender-affirming surgery. Just as when a hair graft may be covered by a health plan for someone who experiences hair loss from a serious burn, Maryland now covers gender-affirming hair alteration. Similarly, just as when a nipple reconstruction tattoo may be covered by a health plan when someone undergoes a mastectomy as part of breast cancer treatment, Maryland now covers gender-affirming tattoos (e.g., a nipple tattoo for a trans individual who undergoes “top surgery” to remove breast tissue). Recognizing that hair removal/alterations and tattooing may best be done by “non-traditional providers,” the state is setting up pathways for electrologists and tattoo artists to enroll as “atypical providers” for purposes of participating in the Medicaid program.⁵
• Reflects an updated understanding of the nature of trans experiences when establishing medical necessity criteria for gender-affirming care. Historically, before obtaining gender-affirming care individuals had to obtain a diagnosis of “gender-dysphoria,” which can be viewed as unnecessarily stigmatizing.⁶ In addition to gender dysphoria, Maryland has aligned with WPATH SOC 8.0 to recognize persistent and marked gender incongruence as meeting medical necessity for gender-affirming care.⁷
• Recognizes the diversity of care that trans individuals require. In earlier versions of WPATH, it was assumed that trans individuals in need of gender-affirming surgery would take the same care path (i.e., hormone therapy and then surgery). In keeping with the latest WPATH standards, however, Maryland’s new clinical guidance recognizes that hormone therapy may not be appropriate or required prior to gender-affirming surgery if it is inconsistent with the individual’s desires, goals or expressions of their individual gender identity and/or if their provider determines hormones are not clinically indicated or medically contraindicated.

Moving Forward

To meet the goal of the THEA—to provide equitable access to medical care for trans individuals in Maryland enrolled in Medicaid—it will require continued engagement with trans individuals with lived experience, support for plans and providers to adjust how they approach gender-affirming care and conduct monitoring and oversight to ensure access and fidelity to THEA’s requirements. While more work needs to be done in the state and nationally, Maryland’s new clinical guidance is an important step, offering key improvements for Maryland’s trans residents enrolled in Medicaid and a potential source of information and ideas for other states seeking to improve gender-affirming care.

_{¹ Manatt provides Trans Maryland with pro bono services to support its work on implementation of THEA, including in conversations with Maryland Medicaid.} 

_{² WPATH SOC 7.0 recommended one letter for breast/chest surgery and two for genital surgery; see https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf. Maryland required two separate letters for any surgery, or one letter signed by two providers, if both providers are in the same practices or clinics. See, Maryland’s previous guidance https://health.maryland.gov/mmcp/mcoupdates/documents/pt_37_16.pdf}

_{³ For adolescents, documentation of the medical necessity for GAC needs to be from a multidisciplinary team that includes both somatic and mental health professionals.}

_{⁴ Prior to rendering care, providers who do not meet the criteria to appropriately assess and recommend patients for gender-affirming care must obtain the documentation of a patient’s medical necessity for gender-affirming care.}

_{⁵ Per CMS State Medicaid Director Letter SMDL #06-020, “atypical providers are providers that do not provide health care, as defined under HIPAA in Federal regulations at 45 CFR section 160.103. Taxi services, home and vehicle modifications and respite services are examples of atypical providers reimbursed by the Medicaid program. Even if these atypical providers submit HIPAA transactions, they still do not meet the HIPAA definition of health care and, therefore, cannot receive an NPI.”}

_{⁶ See the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR), of the American Psychiatric Association.}

_{⁷ Gender incongruence is defined by the marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’ in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. See the International Classification of Diseases and Related Health Problems, 11th Version of the World Health Organization (ICD-11).}