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Objective: We sought to describe the current Medicaid coverage landscape for gender-affirming surgery across the U.S. at the procedure level and identify factors associated with coverage. Summary Background Data: Medicaid coverage for gender-affirming surgery differs by state, despite a federal ban on gender identity-based discrimination in health insurance. States that cover gender-affirming surgery also differ in which procedures are included in Medicaid coverage, leading to confusion among patients and clinicians. Methods: State Medicaid policies in 2021 for gender-affirming surgery were queried for each of the 50 states, and District of Columbia (D.C.). State partisanship, state-level Medicaid protections, and coverage of gender-affirming procedures in 2021 were recorded. Linear correlation between electorate partisanship and total procedures covered was assessed. Pairwise t-tests were used to compare coverage based on state partisanship and presence of absence of state-level Medicaid protections. Results: Medicaid coverage for gender-affirming surgery was covered in 30 states and Washington D.C. The most commonly covered procedures were genital surgeries and mastectomy (n=31), followed by breast augmentation (n=21), facial feminization (n=12), and voice modification surgery (n=4). More procedures were covered in Democrat-controlled or leaning states, as well as in states with explicit protections for gender-affirming care in Medicaid coverage. Conclusion: Medicaid coverage for gender-affirming surgery is patchwork across the United States and is especially poor for facial and voice surgeries. Our study provides a convenient reference for patients and surgeons detailing which gender-affirming surgical procedures are covered by Medicaid within each state.

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