Differences In Medicaid Coverage for Gender-Affirming Care and Their Impacts on Administrative Burden Among Transgender and Gender Diverse Adults

Background & Purpose: Transgender and gender diverse (TGD) individuals experience significant health disparities, particularly mental health disparities, including higher rates of depression, anxiety, and suicidal ideation. Gender-affirming care (GAC) is an effective treatment for gender dysphoria and is known to improve health outcomes among TGD adults. Currently, there is no federal requirement for Medicaid to cover gender-affirming care which has left individual state policies to determine gender-affirming care benefits, leading some states to mandate coverage, others to explicitly exclude coverage, and still others have no specific policy.

TGD individuals experience administrative burden when interacting with government agencies and service providers in the form of learning costs, compliance costs, and psychological costs. Encountering administrative burden is known to negatively impact engagement with services, affecting care-seeking, decision-making, and coping. Drawing on Administrative Burden Theory, the present study assesses how differences in Medicaid coverage for gender-affirming care generates administrative burden, and thus ability to access to care, for transgender and gender diverse adults

Methods: The study employed a cross-sectional secondary data analysis within a policy analysis framework to compare differences in coverage scope and coverage rules for gender-affirming care under Medicaid both across and within states and provide evidence of the administrative burden experienced by individuals seeking to use public insurance for gender-affirming care.

Data was obtained from the Centers for Medicare and Medicaid Services’ Health Insurance Exchange Public Use Files (PUF) to determine essential benefits, state-required benefits, and exclusions for the 50 states and the District of Columbia. Health Plan Benefits Reports from each state’s Medicaid Managed Care Organizations provided data on plan-specific coverage rules for plan year 2026. Using indices of coverage rules for each Medicaid managed care plan, administrative burden was measured by assigning the cost(s) associated with each coverage rule for each gender-affirming care service.

Results: Medicaid coverage for all WPATH recommended care varies widely both across states and within states. Many states that mandate coverage for GAC under Medicaid fail to specify what services are classified as gender-affirming care and must be covered, leading to within-state differences in coverage across Medicaid managed care plans. The diversity in and lack of clarity around coverage generates significant administrative burden across all types of cost.

Conclusions & Implications: Differences in Medicaid policies for GAC across states and managed care plans produce administrative burden that affect individual experiences of seeking care, which may subsequently impact ability to engage with and access services. Policy thus functions as a mechanism of structural inequality that influences lived access to care. Failure to address the ways in which policies and practices reinforce systems of oppression will only contribute to the further structural exclusion of the transgender and gender diverse community and worsen health disparities in this vulnerable population. This study can provide needed evidence to inform and direct changes in policies and practices to improve the health outcomes and quality of life for transgender and gender diverse individuals.