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Gender Transformation Coverage Update

July 25, 2016

Section 1557 is the civil rights provision of the Affordable Care Act of 2010 which prohibits discrimination on the grounds of race, color, national origin, sex, age, or disability in certain health programs and activities. 

These protections against sex discrimination include:

  • Individuals cannot be denied health care or health coverage based on their sex, including their gender identity and sex stereotyping.
  • Women must be treated equally with men in the health care they receive and the insurance they obtain.
  • Categorical coverage exclusions or limitations for all health care services related to gender transition are discriminatory.
  • Individuals must be treated consistent with their gender identity. Treatment may not be denied or limited for any health services that are ordinarily or exclusively available to individuals of one gender based on the fact that a person seeking such services identifies as belonging to another gender. 

While the recent guidance prohibits broad categorical exclusion of gender transformation it does not mandate coverage of specific medical services; however, when any benefits are covered, they may not be administered in a discriminatory manner. 

Fully Insured Customers
For fully insured plans, UnitedHealthcare 2017 certificate of coverage (COC) will include the following benefits and exclusions/limitations. Standard benefits for the treatment of Gender Dysphoria are limited to the following services when clinical criteria for eligibility are met:

  • Psychotherapy and mental health services for Gender Dysphoria and associated co-morbid psychiatric diagnoses.
  • Certain drug therapies, including cross-sex hormone therapy, administered by a medical provider during an office visit or dispensed from a pharmacy when the group purchases a drug rider.
  • Laboratory testing to monitor the safety of continuous cross-sex hormone therapy.
  • Identified surgeries for the treatment of Gender Dysphoria, including female-to-male and male-to-female.  

Specific documentation and written psychological assessments from one or more qualified behavioral health providers experienced in treating Gender Dysphoria are required prior to approval for a bilateral mastectomy, breast reduction surgery, or genital surgery. 

Exclusions and limitations include surgeries and/or related services that are considered cosmetic, unproven, and not medically necessary. 

Self-funded Customers
It is up to the plan sponsor to consult with their legal department to determine whether or not they are a covered entity under Section 1557 and to review their plan for any changes that may be necessary.  UnitedHealthcare will provide standard Summary Plan Description (SPD) language for self-funded customers wishing to adopt our standard benefit coverage.  We can also support custom programs for the self-funded customer.  

Our Approach
We are in the process of filing COC benefit riders for fully insured customers beginning on or after Jan. 1, 2017. Self-funded customers may use our SPD language or customize the language based on their own decision. 

Look for additional information in upcoming Connection newsletters. For more information, please contact your UnitedHealthcare representative.   

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