For Insurers

FAQ about coverage of transgender enrollees

On June 25, 2014, Insurance Commissioner Mike Kreidler sent a letter to all health insurers (PDF, 291KB) to notify them that health plan exclusions and denials of coverage on the basis of gender identity are against the Washington Law Against Discrimination (WLAD) Chapter 49.60 RCW (leg.wa.gov) and the federal Affordable Care Act (ACA) Section 1557 (www.hhs.gov).

Broadly stated, if a health insurer covers medically necessary services for its enrollees, it cannot exclude or deny those services for a transgender person solely on the basis of a person’s gender identity status. We’ve received questions regarding what this means for 2014 and 2015 plan filings.

Are insurers required to review claims received prior to the date of the commissioner’s letter to ensure that all claims have been paid in compliance with these laws?

No. The Office of the Insurance Commissioner (OIC) is not requiring insurers to review prior claims. However, if we receive consumer complaints that services were excluded or claims were denied after March 23, 2010 -- the first date the WLAD and the ACA were effective -- we will contact the company to ensure that the claims were processed in compliance with these laws.

 

Are insurers whose 2014 plans contain language that limits or excludes services for gender dysphoria or on the basis of a person’s gender status required to re-file these plans with compliant language?

No. Insurers are not required to re-file 2014 plans to correct corresponding language. However, insurers are required to administer their plans in compliance with the law, regardless of the language included in the plans. For example, if a plan states it excludes all transgender services, the insurer may not deny services solely on that basis. The insurer must provide access to medically necessary covered services for transgender individuals to the same extent that those services are covered for non-transgender individuals enrolled in the same plan.

 

The OIC’s news release explicitly notes that “Washington state insurance law doesn’t require insurance companies to cover sexual reassignment surgery.” May a plan exclude sexual reassignment surgery?

Washington state law does not mandate coverage of sexual reassignment surgery. However, gender dysphoria as defined in the DSM-V is the only condition for which sexual reassignment surgery is prescribed. Therefore, it is OIC’s position that a specific exclusion for this surgery would be an impermissible discriminatory exclusion based upon an enrollee’s identification as transgendered, in violation of WLAD and the ACA. It would also constitute an unreasonable restriction on treatment, in violation of RCW 48.46.030(3)(d) and RCW 48.44.020(2)(d) (leg.wa.gov). Insurers may require that the surgery be designated medically necessary before coverage will be provided.