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2013 CEI Criteria - Health Insurance for Transgender Employees and Dependents

  1. Insurance contract explicitly affirms coverage and contains no blanket exclusions for coverage.
  2. Insurance contract and/or policy documentation explicitly references and is based on the WPATH Standards of Care, (WPATH SOC v.6 2001 and WPATH Clarification on Medical Necessity 2008).  Documentation must be submitted to HRC for review.
  3. Plan documentation must be readily available to employees and must clearly communicate inclusive insurance options to employees and their eligible dependents.
  4. Benefits available to other employees must extend to transgender individuals. The following benefits should all extend to transgender individuals, including for services related to transgender transition (e.g., medically necessary services related to sex reassignment):
    • Short term medical leave
    • Mental health benefits
    • Pharmaceutical coverage (e.g., for hormone replacement therapies) 
    • Coverage for medical visits or laboratory services
    • Coverage for reconstructive surgical procedures related to sex reassignment   
    • Coverage of routine, chronic, or urgent non-transition services (e.g., for a transgender individual based on their sex or gender. For example, prostate exams for women with a transgender history and pelvic/gynaecological exams for men with a transgender history must be covered.)
    • Plan language ensuring “adequacy of network” or access to specialists should extend to transition-related care (including provisions for travel or other expense reimbursements)
    • Dollar maximums on this area of coverage must meet or exceed $75,000. 

Coverage must be demonstrated through sufficient documentation, including:

  • Excerpt of summary plan description (SPD) –or–
    complete summary of material modifications (SMM) indicating coverage is available
  • Medical policy, clinical guidelines or policy bulletins that indicate the range of services covered and the process of determining coverage eligibility

Helpful Resources

Transgender-Inclusive Health Insurance