Medicare and Medicaid gender-affirming care coverage in 2025 sits on shifting ground. Adult Medicare beneficiaries can still pursue hormone therapy, mental health care, and surgical procedures, but approval runs through regional contractors on a case-by-case basis rather than a national coverage rule. Medicaid coverage for minors faces a proposed federal restriction that would strip federal funding for most gender-affirming procedures for people under 18. And federal non-discrimination enforcement has pulled back from covering gender identity, even though some regulations still name it explicitly.
What Adult Medicare Beneficiaries Can Access
Medicare has no National Coverage Determination that either approves or excludes gender-affirming surgery. The old blanket exclusion for “transsexual surgery” under NCD 140.3 was struck down by the HHS Departmental Appeals Board in May 2014, and CMS decided in 2016 not to issue a replacement.1Centers for Medicare & Medicaid Services. NCD – Gender Dysphoria and Gender Reassignment Surgery (140.9) Coverage decisions instead sit with local Medicare Administrative Contractors (MACs), who evaluate whether a specific service is “reasonable and necessary” for treating gender dysphoria.
In practice, this means facial procedures, chest reconstruction, genital surgery, and other services all get judged the same way: the MAC decides. Some MACs publish Local Coverage Determinations with specific clinical criteria. Others handle each request individually. A procedure approved in one jurisdiction may be denied in another.
What a MAC typically wants to see is a diagnosis of gender dysphoria from a qualified mental health professional and clinical records showing the requested treatment fits the patient’s situation. Many MACs have historically referenced the World Professional Association for Transgender Health (WPATH) Standards of Care Version 8, which simplified referral requirements to a single provider letter for most surgeries. A January 2025 executive order directs agencies to rescind policies relying on WPATH guidance, so whether MACs continue accepting WPATH-based documentation is an open question.2The White House. Protecting Children From Chemical and Surgical Mutilation Before scheduling a procedure, ask your provider what clinical criteria your regional MAC currently applies.
Hormone Therapy Through Medicare Part D
Estrogen, testosterone, and anti-androgens are covered through Medicare Part D. Each plan sets its own formulary, so a specific product your doctor prescribes may or may not be listed. If it is, you fill it like any other prescription, though it may be subject to prior authorization or step therapy.
If your medication is not on the formulary, your prescribing doctor can request a formulary exception with a supporting statement explaining that formulary alternatives would be less effective or cause adverse effects. The plan must respond within 72 hours for a standard request or 24 hours for an expedited one.3Centers for Medicare & Medicaid Services. Exceptions A denial can be appealed through the Part D appeals process.
Medicaid and CHIP Coverage for Minors
Medicaid coverage for gender-affirming care has always varied by state. A December 2025 proposed CMS rule would override that state-by-state variation by prohibiting the use of federal Medicaid funding for what it calls “sex-rejecting procedures” for people under 18, and federal CHIP funding for the same procedures for people under 19.4Federal Register. Medicaid Program – Prohibition on Federal Medicaid and Childrens Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children
The proposed rule carves out three categories that would still receive federal funding:
- Mental health treatment, including psychotherapy and counseling for gender dysphoria.
- Procedures treating medically verifiable disorders of sexual development.
- Treatment for infections, injuries, or disorders caused by earlier gender-affirming procedures.
The public comment period closed February 17, 2026, and the rule is not yet final. If it becomes final, states covering gender-affirming medical interventions for minors would lose federal matching funds for those services. A state could keep coverage using only state dollars, but few Medicaid programs are structured to absorb that cost.
Federal Non-Discrimination Protections in 2025
Section 1557 of the Affordable Care Act prohibits discrimination on the basis of sex in health programs that receive HHS funding, which covers hospitals accepting Medicare, providers who bill Medicaid, and plans on the Marketplaces.5Department of Health and Human Services. Section 1557 – Protecting Individuals Against Sex Discrimination The statute has not changed. The federal interpretation of “sex” has.
A 2024 final rule read “sex” to include gender identity, but courts enjoined the gender identity provisions, and a ruling in Tennessee v. Kennedy vacated those portions nationwide. On February 20, 2025, the HHS Office for Civil Rights formally rescinded its March 2022 guidance on gender-affirming care, civil rights, and patient privacy, stating it “no longer represents the views or policies of HHS OCR.”6Department of Health and Human Services. Rescission of HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy The practical effect: the federal government is not currently enforcing Section 1557 as protection against gender identity discrimination in health care.
One federal protection that still names gender identity explicitly is the hospital patient rights regulation at 42 CFR ยง 482.13. It prohibits hospitals participating in Medicare from restricting visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability, and it gives patients the right to designate their own visitors.7eCFR. 42 CFR 482.13 – Condition of Participation – Patients Rights This regulation remains in the Code of Federal Regulations.
Sex Markers, Name Changes, and Billing Codes
Medicare records draw the sex designation from Social Security Administration records, and that designation can trigger automatic claim denials when a procedure code doesn’t match. A cervical cancer screening billed for someone whose SSA record shows male, or a prostate exam billed for someone whose record shows female, will bounce out of the system before a human reviews it.
Between October 2022 and January 2025, the SSA allowed self-attested changes to the sex designation without medical documentation or a court order. That ended January 31, 2025, when SSA issued guidance prohibiting changes to the sex field. Beneficiaries who updated their marker before the policy changed should still see the updated designation. For everyone else, the administrative pathway is closed.
Legal name changes are a separate process and remain available. You submit Form SS-5 with proof of identity and legal evidence of the name change, such as a court order. Once SSA processes the update, it flows to your Medicare records.8Social Security Administration. How Do I Change or Correct My Name on My Social Security Number Card
Because sex marker changes are now blocked, the billing tools that prevent gender-procedure mismatch denials matter more than ever. All three remain in effect:
- ICD-10 code Z87.890, “personal history of sex reassignment,” signals to claims systems that a gender-procedure mismatch is expected.9Centers for Medicare & Medicaid Services. Billing and Coding – Sex Reassignment Services for Sexual Identity Dysphoria
- Condition Code 45 flags the same conflict on institutional claims submitted on a UB-04 form.
- The KX modifier does the same on professional claims, indicating that a gender-specific procedure code is clinically appropriate despite the recorded sex marker.
Providers who regularly serve transgender patients should know these codes. If yours doesn’t, raise it directly. A denial based on a gender mismatch pushes the beneficiary into appeals for what is really a coding problem.
If Your Claim Is Denied
Medicare appeals move through five levels. A gender-procedure mismatch usually resolves at the first or second level once the correct billing codes are submitted. Medical necessity disputes tend to run longer.
You start with a redetermination from the MAC, filed by the deadline on your Medicare Summary Notice. If that fails, you have 180 days to request a reconsideration from an independent Qualified Independent Contractor. From there, appeals move to an Administrative Law Judge hearing (60 days to file, $200 minimum amount in dispute for 2026), then the Medicare Appeals Council, and finally federal district court ($1,960 minimum for 2026).10Medicare.gov. Appeals in Original Medicare Strong clinical documentation at the outset helps at every stage.
You can also file a civil rights complaint with the HHS Office for Civil Rights within 180 days of a discriminatory act, either online through the OCR Complaint Portal, by mail, or by email.11Department of Health and Human Services. How to File a Civil Rights Complaint Whether OCR will investigate gender identity claims under current policy is uncertain, but filing creates an official record.
Practical Steps
Confirm your MAC’s current coverage criteria before scheduling any gender-affirming procedure, and ask specifically what clinical documentation the contractor requires now that WPATH-based standards are under executive order review. Make sure your provider bills gender-specific screenings and procedures with Z87.890 and the appropriate condition code or KX modifier. Keep copies of every claim, notice, and piece of correspondence with your plan and providers. If a claim is denied, file the redetermination promptly, because the appeals clock starts running the day the notice is issued.