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Fact check: Can individuals purchase ACA plans that cover gender reassignment surgery through the healthcare marketplace?
Executive Summary
The short answer: yes, but with important limits and growing uncertainty. Marketplace plans historically could cover gender-affirming services when those services were included in a state’s essential health benefits (EHB) benchmark or when insurers chose to include them, but a final federal rule issued in 2025 excludes “sex-trait modification” from EHBs beginning in plan year 2026, which will meaningfully change how and whether ACA Marketplace plans cover gender reassignment surgery for many consumers [1] [2]. This shift creates a patchwork where coverage depends on insurer policies, state decisions, and legal challenges now underway [3] [1].
1. Why this matters now: a federal rule that redraws the coverage map
The federal government finalized a Marketplace rule in mid-2025 that removes treatment for gender dysphoria from required essential health benefits for plans sold on ACA Marketplaces starting in plan year 2026. The final rule characterizes excluded services as “sex-trait modification procedures,” which means insurers are no longer compelled at the federal EHB level to include gender-affirming surgeries in benchmark plans [1] [2]. That change shifts authority and cost pressures to states and to private insurers: states that want these services treated as essential would need to incorporate them into their EHB benchmark or otherwise require coverage, while insurers may decide individually whether to offer them, often subject to state mandates or market considerations [1].
2. What consumers currently face: a fractured, state-by-state reality
Before the 2025 rule, many consumers in certain states could obtain Marketplace plans that covered gender-affirming surgery because either the EHB benchmark included such services or insurers voluntarily covered them. After the rule, access will increasingly hinge on state policy decisions and insurer coverage choices, creating a fragmented national landscape where someone’s access can differ dramatically by ZIP code [3] [4]. Medicaid and employer-sponsored plans add more complexity: some large employers and many state Medicaid programs already cover gender-affirming care, while others exclude it or have ambiguous policies, so Marketplace enrollees cannot rely on a single nationwide standard [5] [3].
3. Money and legal fights: who pays if EHBs no longer require coverage?
Removing gender-affirming procedures from EHBs carries immediate fiscal implications. States that keep covering these services in their benchmark must assume budgetary responsibility or find ways to offset costs, and insurers that retain coverage may shift costs via premiums or network limits. The regulatory change has provoked litigation: at least twenty-one states sued to block the rule, arguing federal nondiscrimination protections and ERISA/ACA obligations could be violated by excluding care for gender dysphoria [1] [2]. Those court battles will influence whether and how the rule is implemented, so coverage availability could change further depending on legal outcomes and potential injunctions.
4. Insurers and employers: private policy choices matter more than ever
With the federal EHB backstop weakened for gender-affirming care, private payers and employer-sponsored coverage become decisive. Some insurers and large employers explicitly cover gender-affirming hormone therapy and surgery under medical necessity criteria; others limit or exclude those services based on plan design or state requirements. For Marketplace shoppers, that means plan-by-plan scrutiny is essential: network provider availability, medical necessity criteria, and explicit policy language can determine whether surgery is covered and what prior authorization or clinical documentation is required [3] [5]. Consumers should review insurer medical policies and state insurance mandates ahead of enrollment.
5. The big picture: a patchwork now and uncertain future ahead
Taken together, the evidence shows that the right to buy a Marketplace plan that covers gender reassignment surgery still exists in places, but federal rule changes have eroded nationwide consistency and raised costs and legal uncertainty [1]. States, courts, insurers, and employers will shape access going forward; public advocacy and legislation at state levels may restore or expand coverage in some jurisdictions, while others will narrow it. For individuals seeking gender-affirming surgery on the Marketplace, the practical takeaway is to check current plan documents and state rules for 2026 plans, monitor pending litigation, and consider alternatives such as employer plans or state Medicaid where coverage may be more stable [4] [1].