Update on Medicaid Coverage of Gender-Affirming Health Services
Under Medicaid, states must cover certain mandatory benefits, such as inpatient and outpatient services, home health services, and family planning services. There aren’t specific federal requirements regarding coverage or exclusion of gender-affirming health care services as a category of Medicaid benefits, but there are rules regarding comparability that say “services must be equal in amount, duration, and scope for all beneficiaries within an eligibility group”.
Medicaid benefits are subject to Section 1557 of the Affordable Care Act which prohibits discrimination based on sex. The Biden Administration recently proposed a new rule on Section 1557 that explicitly states that sex-based protections to include sexual orientation and gender identity.
In a survey of states on coverage of sexual and reproductive health services conducted in Summer 2021, KFF and Health Management Associates asked states about coverage of five gender-affirming care services: 1) gender-affirming counseling; 2) hormones; 3) surgery; 4) voice and communication therapy; 5) fertility assistance for transgender enrollees.
Interestingly (given the nature of the previous administration) AHCCCS covers 3 of the 5 gender affirming care services when medically necessary (for adults): Gender affirming hormone therapy, gender affirming voice/communication therapy and mental health services. The two services not covered by AHCCCS are gender affirming surgery and fertility services.
