Last week, the US Court of Appeals for the Fourth Circuit issued a decision holding that state health care plans in North Carolina and West Virginia must cover gender-affirming surgeries.

A copy of the decision, Kadel v. Folwell, 4th Cir. en banc, No. 22-1721 (April 29, 2024), can be found here.

The appellate decision resolved two cases, one involving a North Carolina state health plan for teachers and state employees and the other involving West Virginia’s Medicaid Program. Both plans contained treatment exclusions for gender-affirming care. The North Carolina plan excluded “treatment or studies leading to or in connection with sex changes or modifications and related care.” The West Virginia Medicaid Program paid for some gender-affirming care, but the plan excluded coverage for gender-affirming surgery to treat gender dysphoria.

In both cases, transgender individuals were denied coverage for gender-affirming care to treat gender dysphoria. The individuals brought suit in federal district courts, and both district courts ruled in their favor.

Affirming the trial court decisions, the Fourth Circuit held that the coverage exclusions violated the 14^th Amendment’s Equal Protection Clause. The court held that the exclusions facially discriminated on the basis of sex and gender identity and that the exclusions are not substantially related to an important government interest. The court also held that the West Virginia exclusion violates both the Medicaid Act and the Affordable Care Act.

It is expected that the decision will be appealed to the US Supreme Court.

Nicole M. Curtis also contributed to this article.