DHCS updated its guidance to managed care plans regarding covered services for transgender beneficiaries. Under the state Insurance Gender Nondiscrimination Act and the federal Affordable Care Act, plans cannot discriminate in its health care benefits against individuals based on gender, including gender identity and expression. Services that are available based on gender should not be denied or limited based on a beneficiary’s gender assigned at birth. Federal regulations also prohibit categorical exclusions or limitations for services related to gender transition.
The DHCS All Plan Letter reminded plans that they must cover medically necessary services (services which are reasonable and necessary to protect life, to prevent significant illess or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury) and reconstructive surgery (surgery performed to correct or repair abnormal structures of the body . . . to create a normal appearance to the extent possible). Plans do not have to cover cosmetic surgery (surgery that is performed to alter or reshape normal structures of the body in order to improve appearance).
The letter prescribes the use of nationally recognized guidelines to review requested services, specifically naming the WPATH Standards of Care for the treatment of gender dysphoria. Identified core services for the treatment of gender dysphoria include behavioral health services, hormone therapy, psychotherapy, and a variety of surgical procedures to conform primary and secondary gender characteristics with a person’s gender identity.
Evaluation of requested services must be made by a qualified and licensed mental health professional and the treating provider in collaboration with a primary care provider. Plans must provide in a timely manner all medically necessary services that are otherwise available to non-transgender beneficiaries. Plan decisions are subject to review through the plan appeal and grievance process, the State Fair Hearing process, and/or the DMHC IMR process.
DHCS APL 16-013 (October 6, 2016).