Transgender Health Care | New Hampshire

The Affordable Care Act (ACA) prohibits discrimination in health coverage on the basis of sex. This applies to health insurance companies, health care providers, Medicaid, Medicare, and marketplace plans, but generally not directly to employer-sponsored health plans.  

In 2020, the Supreme Court ruled in Bostock v. Clayton County that discrimination “on the basis of sex” includes discrimination based on sexual orientation or gender identity. Though the case was not about health insurance specifically, its reasoning extends to health coverage as well. Because discrimination against transgender people is inherently sex discrimination, and sex discrimination is illegal under the ACA, denying or limiting health coverage based on someone’s gender identity violates the ACA.

State nondiscrimination laws require many health insurance plans to cover care fairly. This includes plans you buy on your own, plans from the state marketplace, Medicaid, and most job-based plans where an employer buys insurance from a company.  

But some large employers don’t buy insurance. Instead, they pay their employees’ health costs directly. These are called “self-funded” or “self-insured” plans.  

A federal law called ERISA says these self-funded plans don’t have to follow state insurance rules. That means your state’s insurance nondiscrimination protections do not apply to them. However, state and federal laws that protect workers from employment discrimination still apply.  

If you’re not sure what kind of plan you have, ask your employer’s HR department or check your plan documents (often called a Summary Plan Description).

Medicare  

In 2014, Medicare removed a decades-old rule that had categorically banned coverage of transgender surgery. Since then, coverage for transgender health care under Medicare has been decided on a case-by-case basis by local Medicare administrators, based on medical necessity.  

However, in December 2025, the Trump administration proposed two new rules that would threaten this coverage. These are proposed rules, not final. They are subject to a public comment period and legal challenges, and nearly half of all states have already filed lawsuits challenging the administration’s authority to issue them. This situation is actively evolving.  

Section 1557 of the Affordable Care Act (ACA)  

Section 1557 of the Affordable Care Act (ACA) says that any health care provider or insurance company that gets money from the federal government cannot discriminate against someone because of their sex, race, color, national origin, age, or disability. This applies to doctors, hospitals, and health insurers that receive federal funding, as well as health programs and insurance marketplaces run by Health and Human Services (HHS).  

However, Section 1557 usually does not apply to self-funded employer health plans or short-term health plans, because these plans typically don’t receive federal financial assistance directly and aren’t principally in the business of providing health care.  

Title VII  

Title VII is a federal law that applies to employers with 15 or more employees. It bans discrimination based on race, color, religion, sex, or national origin in all aspects of employment – including hiring, firing, pay, and benefits. This includes employer-provided health insurance. In 2020, the US Supreme Court ruled in Bostock v. Clayton County that discrimination because of sexual orientation or gender identity is a form of sex discrimination under Title VII. That means employers cannot treat LGBTQ+ workers unfairly in jobs or benefits because of who they are.  

There are some limited exceptions for religious organizations. Under what’s known as the “ministerial exception,” religious employers may be exempt from antidiscrimination laws for certain employees. But which roles qualify is an evolving and contested area of law.

Employers generally cannot discriminate against LGBTQ+ workers in employment or benefits, including health insurance. But when the employer is a religious organization, the picture gets more complicated.  

On July 8, 2020, the US Supreme Court decided a case called Our Lady of Guadalupe School v. Morrissey-Berru. In this case, the Court confirmed that religious organizations have a “ministerial exception.” This means that certain employees who perform religious duties, like ministers or religious teachers, cannot bring employment discrimination lawsuits against their religious employers, including for discrimination based on sexual orientation or gender identity.  

However, the ruling raised a question that hasn’t been clearly answered: who qualifies as a minister? So far, courts have been expanding the types of roles that count as “ministerial.” In 2024, a federal appeals court applied the exception to a drama teacher at a Catholic school who was fired after announcing his same-sex marriage, and in 2025, another court applied it to customer service representatives at a Christian nonprofit. What is clear is that the ministerial exception is meant to apply to employees with religious roles. But where the line falls between “religious” and “secular” positions is still being debated in the courts.

1. Check your plan’s coverage. Start by finding out if your health insurance covers the treatment you need. You can do this by getting a copy of your plan’s Summary of Benefits and Coverage. You should also ask your insurer for a copy of their “medical policy” or “clinical criteria” for gender dysphoria – this will tell you exactly what your plan requires in order to approve treatment.  

2. Learn the requirements. Most health plans – public and private – have specific rules you must follow to get coverage. This is especially true for transgender surgeries. Contact your health plan and ask for a list of the requirements for the treatment you’re seeking.  

3. Work with your doctors and therapists. Make sure your therapists and doctors help you meet all the plan’s requirements. Their documentation and letters of support are usually the most important part of getting your treatment approved.  

4. Check if pre-approval is needed. Many treatments, especially surgeries, require pre-approval from your insurance company. Some plans will only pay for surgery if you use a surgeon who is in their network (someone who accepts that insurance).  

5. If your request is denied, find out why. The reason for the denial matters. A denial based on “medical necessity” is handled differently than a denial based on a blanket exclusion of transgender care, and the right strategy depends on which type you’re facing. If you believe you qualify, follow your plan’s appeal process. You usually start with an internal appeal. Under federal law, you generally have 180 days to file one. If that doesn’t work, you may be able to appeal to an outside agency through an external review, which is binding on the insurance company. Always pay attention to deadlines, because external appeal deadlines may be shorter than internal ones, and missing one could end your chance to appeal.  

6. Get help from GLAD Law. If your treatment is denied, let GLAD Law know. We may be able to help you. You can reach GLAD Law Answers by filling out the form on our website, sending an email to [email protected], or by calling 1-800-455-GLAD (4523).  

7. Be patient and persistent. More health plans now cover care for gender dysphoria, but the process – especially for transgender surgery – can still be slow and frustrating. It takes a lot of paperwork, and finding a qualified surgeon your plan will accept can be hard. For a detailed, step-by-step guide to navigating insurance denials for transgender health care, the Trans Health Project’s free tutorial is an excellent resource.  

Don’t give up! Keep pushing and reapply if needed.

More and more surgeons who perform transgender surgeries now accept health insurance. It’s important to take time to research surgeons and find one who’s the right fit for you.  

Start by checking your insurance plan’s list of in-network providers to find out if it includes any surgeons who offer transgender procedures. You can usually search your insurer’s website using their “find a doctor” or provider directory tool. If you don’t see any listed, you can call the surgeon’s office directly to ask if they accept your insurance.  

Most health plans require you to use in-network doctors or surgeons. But if your plan doesn’t include anyone who provides the care you need, you may have the right to see an out-of-network surgeon and have your insurance treat them as in-network. This is because insurers are generally required to maintain an adequate network of providers, and if they can’t offer you a qualified in-network surgeon for the procedure you need, they may be required to cover an out-of-network one. You will likely still need prior authorization (approval ahead of time) from your insurance company before scheduling surgery.

On January 28, 2025, President Trump signed Executive Order 14187, which directed the federal government to take steps to end transgender medical care for adolescents under 18. The order spread dangerous misinformation about transgender health care, in direct contradiction to the positions of every major medical association in the United States – including the American Medical Association, the American Academy of Pediatrics, and the American Psychiatric Association – all of which recognize transgender as safe, effective, and medically necessary.  

Since then, the Trump administration has worked to implement this policy throughout the executive branch. On December 18, 2025, HHS Secretary Robert F. Kennedy Jr. signed a declaration claiming that transgender health care for adolescents under 18 does not meet professional standards of health care – a claim rejected by the mainstream medical community. The declaration threatened to exclude any doctor or hospital that provides transgender health care to adolescents under 18 from participating in Medicare and Medicaid. 

On December 18, 2025, the Centers for Medicare and Medicaid Services (CMS) proposed two federal regulations targeting transgender health care for adolescents under 18. The first would ban any hospital that participates in Medicare or Medicaid from providing transgender health care to adolescents under 18 regardless of who is paying for the care. The second would prohibit federal Medicaid and CHIP funds from covering transgender for adolescents under 18.  

These are proposed rules, not final. They are subject to a public comment period and legal challenges. Nearly half of all states have filed lawsuits challenging the administration’s authority to issue them, and litigation over the related HHS declaration issued the same day has already resulted in HHS agreeing not to issue exclusion notices against providers while the case is being decided. This situation is actively evolving.