Florida Medicaid enacts ban on coverage for gender-affirming care

A rule banning Medicaid coverage for gender-affirming care went into effect this week, despite the Agency for Healthcare Administration (AHCA) receiving “1000s and 1000s of comments” urging the agency not to adopt the rule.

The rule prohibits all Florida Medicaid recipients from receiving coverage for 3 services that treat gender dysphoria: puberty blockers, hormones and hormone antagonists, and gender-affirming surgery, described in the rule as “sex reassignment surgery.” The rule also denies coverage for “any other procedures that alter primary or secondary sexual characteristics.”

 

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Prior to the rule, Florida Medicaid did not have a policy for covering gender-affirming care. On April 20th, the Florida Department of Health released guidelines that recommended against providing treatment of gender dysphoria for children and adolescents, citing “a trend of low-quality evidence, small sample sizes, and medium to high risk of bias.” The guidelines are in line with federal CMS age requirements for surgical and non-surgical treatments. 

AHCA Secretary Simone Marstiller then requested the Florida Medicaid program to determine if treatments are in line with “widely accepted professional medical standards.” AHCA released its report on June 2nd.

“Following a robust review of available medical evidence and the assessment of 5 medical experts, including health care researchers who studied the quality of the evidence relied upon for “gender affirming” care, the Agency has determined that several services for the treatment of gender dysphoria – i.e., sex reassignment surgery, cross-sex hormones, and puberty blockers – are not consistent with generally accepted professional medical standards and are experimental and investigational with the potential for harmful long term affects,” AHCA announced in a press release. 

Earlier this year, a JAMA Network study titled, “Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care” studied a cohort of 104 transgender and nonbinary individuals aged 13-20 years who receive gender-affirming care. The study found that treatment was  associated with better mental health outcomes, including 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over 12 months. 

AHCA held a public hearing for the rule on July 8, where over 100 people came to either support or oppose the ban on coverage, according to WFSU. Despite statements from several individuals opposing the ban, including medical professionals, the rule went into effect on Sunday.

“Medicaid programs can only cover those services deemed medically necessary,” Katy DeBriere, litigation director at the Florida Health Justice Project (FHJP), told State of Reform. “The state has some discretion in defining what medical necessity is, although the federal Medicaid act puts up guardrails and limits to a certain extent how that definition can be formed. To that extent, what AHCA has done is taken a somewhat unprecedented step in carving out treatment of gender dysphoria.”

Florida is a non-expansion state, meaning those who are on Medicaid must fall into specific  eligibility categories, including having very low incomes. According to DeBriere, the ruling severely hinders an individual on Medicaid’s ability to afford and access gender-affirming care.

“If Medicaid does not cover their care, there would be very little options if they can’t find free care to continue coverage,” DeBriere said. “That’s why we see some significant urgency to push back on the impact of this rule because it forecloses the opportunity for individuals on Florida Medicaid to access medically necessary life saving care.”

On Aug. 11th FHJP released a joint statement with Lambda Legal, Southern Legal Counsel, and National Health Law Program denouncing the ruling. DeBriere says FHJP is “exploring all options” to oppose the ruling.  On Aug. 17th, Politico reported that a coalition of transgender-rights groups, including Southern Legal Counsel, is preparing to sue Florida over the ruling.