Insurance Coverage of Facial Gender Affirmation Surgery: A Review of Medicaid and Commercial Insurance

Objective: To provide a portrait of gender affirmation surgery (GAS) insurance coverage across the United States, with attention to procedures of the head and neck. Study Design: Systematic review. Setting: Policy review of US medical insurance companies. Methods: State policies on transgender care for Medicaid insurance providers were collected for all 50 states. Each state’s policy on GAS and facial gender affirmation surgery (FGAS) was examined. The largest medical insurance companies in the United States were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical insurance companies were examined. Results: Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17%). Thirteen states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy. Ninety-two percent of commercial medical insurance providers had a published policy on GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100% of the commercial policies reviewed. Ninety-three percent discussed coverage of FGAS, but 51% considered these procedures cosmetic. Thyroid chondroplasty (20%) was the most commonly covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13% of the medical policies reviewed. Conclusion: While certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers, potentially limiting patient access. Level of Evidence: Level V.