FY2024 NDAA: TRICARE Coverage of Gender-Affirming Care

FY2024 NDAA: TRICARE Coverage of Gender-Affirming Care

INSIGHTi

FY2024 NDAA: TRICARE Coverage of
Gender-Affirming Care
Updated August 28, 2023
Background
The Department of Defense (DOD) administers a statutory health entitlement (under Chapter 55 of Title
10, U.S. Code), through the Military Health System (MHS). The MHS offers health care benefits and
services through its TRICARE program to approximately 9.6 million beneficiaries composed of
servicemembers, military retirees, and dependent family members. Congress often specifies certain
TRICARE coverage parameters (e.g., how health care services may be delivered, and whether
beneficiaries may be subject to cost-sharing requirements) through an annual National Defense
Authorization Act (NDAA).
During ongoing deliberations on a FY2024 NDAA, Congress has expressed interest in TRICARE
coverage policies for gender-affirming care. Defense Health Agency (DHA) Procedural Instruction
6025.21 defines gender-affirming care as “clinical services that support an individual’s physical and
[behavioral health] as they define, explore, and align with their gender identity.” Gender-affirming care
includes non-surgical care (e.g., hormone therapy and psychotherapy) and surgical care (e.g., gender-
affirming surgery).
The TRICARE Policy Manual stipulates that “medically or psychologically necessary and appropriate
medical care (as defined in 32 C.F.R. §199.2), including non-surgical treatments for [gender dysphoria],
are covered [for all beneficiaries] when provided by a TRICARE-authorized provider.” For hormone
therapy, a beneficiary diagnosed with gender dysphoria must also meet the eligibility criteria outlined in
the Endocrine Society’s clinical practice guideline for treatment of gender dysphoria. Under 10 U.S.C.
§1079(a)(11)), TRICARE is explicitly prohibited from covering gender-affirming surgical care for
beneficiaries except to treat individuals with an intersex condition due to congenital malformations or
chromosomal abnormalities.
This statutory prohibition applies only to health care services covered by the TRICARE program for
beneficiaries; DOD may pay for gender-affirming surgical care through the Supplemental Health Care
Program (SHCP) for “active duty members of the uniformed services.” SHCP is authorized under 10
U.S.C. §1074(c), 32 C.F.R. §199.16, Health Affairs Policy 12-002, and the TRICARE Operations
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Manual. The DHA Director may consider requests from the military services to use SHCP funds to
“lawfully cover otherwise non-covered services for Service members in circumstances that will enable
them to return to full duty/worldwide deployable status, or to reach their maximum rehabilitative
potential.” Typically, DHA uses SHCP to pay for non-covered services (e.g., certain emerging medical
therapies and services, fertility services, or unique rehabilitative services).
DHA policy outlines the process for providing gender-affirming surgical care to an active duty
servicemember diagnosed with gender dysphoria, which includes requirements for the servicemember to
obtain endorsements from their respective transgender care team and their chain of command prior to
being authorized care.
Table 1 lists gender-affirming care-related provisions included in the House-passed (H.R. 2670) and
Senate-passed (S. 2226) versions of an FY2024 NDAA.
Table 1. FY2024 NDAA Legislative Proposals
House-passed H.R. 2670
Senate-passed S. 2226
Section 640C would prohibit an Exceptional Family Member
No similar provision.
Program from providing “gender transition procedures” or
providing referrals for “gender transition services” to a
minor dependent child. The provision would also prohibit
the approval of a change of duty station due to a minor
dependent child having a lack of access to gender transition
services.
Section 717 would amend Chapter 55 of Title 10, U.S. Code,
No similar provision.
to prohibit DOD from providing or paying for gender-
affirming surgical care and hormone treatment for all
beneficiaries.
Source: CRS analysis of legislation on Congress.gov.
Discussion
The number of TRICARE beneficiaries who identify as transgender and have sought or received gender-
affirming care is unclear, though some estimates of transgender servicemembers have been reported over
the past several years. In 2016, the RAND Corporation estimated that approximately 1,320 to 6,630 of the
1.3 million active duty servicemembers identified as transgender. The report also estimated the potential
cost to expanding TRICARE coverage to include gender-affirming surgical care for active duty
servicemembers, which ranged between $2.4 million and $8.4 million annually. Between January 1, 2016
and May 14, 2021, DOD reportedly spent approximately $15 million to provide gender-affirming care
(surgical and non-surgical care) to 1,892 servicemembers.
Congress continues to debate whether federal health programs, like TRICARE, should cover gender-
affirming care and related support services. Certain observers argue that federal taxpayer funds should not
be used to pay for gender-affirming care that they perceive as “costly and controversial” and that such
care could impact a servicemember’s ability to be “combat-ready” or “deployable.” Other observers argue
that there is a “growing consensus” among medical experts that gender-affirming care is medically
necessary and that health payers should ensure coverage of these services.
The House-passed bill includes two related provisions. The SASC-reported bill has no similar provisions.
Section 717 of the House-passed bill would amend Chapter 55 of Title 10, U.S. Code, by adding a new
section that prohibits DOD from providing or paying for gender-affirming surgical care and hormone
treatment used to treat gender dysphoria under TRICARE and SHCP.

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In certain instances, a dependent family member diagnosed with a “current and chronic” mental health
condition requiring “inpatient or intensive (i.e., greater than one visit monthly for more than 6 months)
outpatient mental health service” may access additional family support services through the Exceptional
Family Member Program (EFMP). Dependent family members diagnosed with gender dysphoria, as a
mental health condition categorized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-
V), could also be eligible to enroll in EFMP.
DOD policy also allows EFMP-enrolled servicemembers to request a reassignment to another duty station
before meeting the minimum time-on-station requirement, and to be afforded certain housing flexibilities
during their relocation to another duty station. Section 640C of the House-passed bill would prohibit
EFMP from providing or making referrals for a minor dependent child to obtain “gender transition
procedures, including surgery or medication.” The provision would also prohibit the military services
from approving a servicemember’s request for early reassignment to another duty station due to a minor
dependent child having lack of access to gender transition services.

Author Information

Bryce H. P. Mendez

Specialist in Defense Health Care Policy

Disclaimer
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