West Virginia Medicaid Can Exclude Gender-Affirming Surgeries

AG: West Virginia News

Filed March 10th, 2026

Detected March 20th, 2026

Summary

The Fourth Circuit Court of Appeals reversed a lower court ruling, upholding West Virginia's authority to exclude gender-affirming surgeries from Medicaid coverage. The court found the state's policy does not violate the Equal Protection Clause, the Affordable Care Act, or the Medicaid Act, prioritizing taxpayer funds for essential medical care.

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What changed

The Fourth Circuit Court of Appeals has ruled in favor of West Virginia Attorney General JB McCuskey in Anderson v. Crouch, reversing a lower court decision. The appellate court held that West Virginia Medicaid is permitted to exclude coverage for gender-affirming surgeries, determining that the state's policy does not violate the Equal Protection Clause, the Affordable Care Act, or the Medicaid Act. This decision allows the state to prioritize taxpayer funds for what it deems proven, essential medical care, citing concerns about cost, medical efficacy, and safety of the excluded procedures.

This ruling has significant implications for states seeking to control Medicaid expenditures and define covered medical services. Regulated entities, particularly healthcare providers and patients within West Virginia's Medicaid program, should be aware that coverage for gender-affirming surgeries remains excluded. The decision reinforces the state's authority in making such coverage determinations based on medical criteria and cost-benefit analyses, rather than solely on patient identity or diagnosis.

What to do next

Review West Virginia Medicaid policy regarding coverage for gender-affirming surgeries.
Ensure billing and claims processing align with the court's decision on excluded procedures.
Communicate policy changes to relevant clinical and administrative staff.

Source document (simplified)

Attorney General McCuskey wins court battle to protect Medicaid dollars, preserve coverage for essential services

March 10, 2026

Court upholds state's authority to prioritize taxpayer funds for proven, essential medical care

West Virginia Attorney General JB McCuskey announced today that the Fourth Circuit Court of Appeals reversed a lower court ruling and held that West Virginia Medicaid may exclude coverage for gender-affirming surgeries and that the state’s policy does not violate the Equal Protection Clause, the Affordable Care Act, or the Medicaid Act. This decision is a major win for the state and its Medicaid program.

This case, Anderson v. Crouch, is part of a years-long national legal fight over whether states can exclude gender-affirming care from Medicaid and insurance coverage.

“This is a big win for West Virginia taxpayers who pay the bill for Medicaid—a much needed and utilized program. As good stewards of taxpayer dollars, the state should not be footing the bill for unproven, non-essential medical procedures,” Attorney General McCuskey said. “Simply put, the Constitution does not compel states to fund sex reassignment surgeries. Every dollar spent on these unproven procedures takes away funding that could be used to treat cancer, heart disease, and diabetes. I’m pleased the Fourth Circuit finally agrees that our policy does not discriminate and provides the best service for all the state’s Medicaid participants.”

The case arose from a challenge to West Virginia’s decision not to reimburse Medicaid beneficiaries for surgical procedures to treat gender dysphoria. The plaintiffs alleged the exclusion violated the Equal Protection Clause of the U.S. Constitution, the Affordable Care Act, and the Medicaid Act. A district court had sided with the plaintiffs and enjoined the state from enforcing its policy. The Fourth Circuit Court of Appeals initially affirmed that ruling, but the U.S. Supreme Court vacated the decision and remanded the case back for reconsideration after its ruling in United States v. Skrmetti, which upheld states’ authority to make policy decisions about medical interventions.

On remand from the Supreme Court, the Fourth Circuit decided the case differently. The court held that West Virginia’s policy excluding coverage for “sex change” surgeries does not facially classify individuals based on sex or transgender status, and thus does not violate the Equal Protection Clause. Instead, the exclusion classifies based on medical diagnosis and applies evenhandedly to all Medicaid recipients. The court also confirmed that West Virginia Medicaid had legitimate reasons for the exclusion, including concerns about cost, medical efficacy, and the safety of the procedures.

The Fourth Circuit also held that West Virginia’s Medicaid policy does not violate the Affordable Care Act. The Court confirmed that West Virginia Medicaid’s coverage decisions are based on medical criteria, not a patient’s gender identity. The Court further said the plaintiffs could not enforce the Medicaid Act through litigation.

Deputy Solicitor General and Special Counsel for the State of West Virginia Caleb David presented oral argument before the Fourth Circuit Court of Appeals in December.

Read the decision here.

Contact Name Kallie Cart