San Francisco Transgender Benefit: Actual Cost & Utilization (2001-2006)

In 2001, the City and County of San Francisco ("San Francisco") became the first major U.S. employer to publicly remove discriminatory transgender access exclusions in its health insurance plans for employees, retirees and their dependents in order to explicitly cover medically necessary treatment for transgender transition. See our complete set of resources on San Francisco's Transgender Benefit.

The cost of covering transgender employees' health needs proved relatively inexpensive compared to other health needs of the City and County of San Francisco's employees. Transgender people had not flocked to work for the city, and there had been no adverse selection as critics had warned. San Francisco had not been bankrupted as some predicted. In 2006 and 2007, San Francisco's Human Rights Commission released a statement along these lines.

Employers seeking to offer transgender-inclusive coverage want to accurately predict costs and determine the impact on the overall plan. Initial actuarial estimates were based on a worst-case 35 claimants per year from an assumed employee base of just over 37,000 and a total enrollee base of 80,000 this gave predicted rates of 0.946 claimants per thousand employees per year or 0.438 claimants per thousand enrollees per year. Although actuaries and advocates alike knew this was an overestimation, only actual utilization data could show by how much.

The actuarial cost and utilization data available from the first five years of San Francisco's coverage are charted here. These can used to make a rough ballpark estimate, but since employers of different sizes will experience different utilization, we discuss necessary adjustments including a rate relative to the total number of employees each year.

Actual Utilization for City and County of San Francisco

The chart below gives available claims and utilization data, showing cost of the benefit over the five years. While the total dollar costs and number of claims paid for this period are known, the number of claimants (people) and total number of employees, retirees and dependents for each year are not known. Since a given surgical procedure for one individual is typically billed as a series of claims, the number of claims usually greatly exceeds the number of claimants.

San Francisco Transgender Surgical Benefit
Available Claims and Claimant Data By Year 2001-6
Year Claims New Claimants Min New Claimants Max $ Claims Paid Plans Available
(3 years)
7 4 [1] 7 $156,000 1 (PPO only)
(1 year)
11 1 [2] 11 $183,000

4 (PPO & HMO)

(1 year)



6 [4] $044,117

4 (PPO & HMO)

(5 year cumulative)
37 6 24 $383,117  
Per Year Average



4.8 $76,623.60  

Dollar amount of claims

Far from the initial projections of $1.75 million per year, total claims averaged less than $77,000 per year. While the overall claims costs experienced by the San Francisco's health plans each year is not available for comparison, it is certain that $77,000 represents a tiny fraction of total claims (whether for surgical services or for all services combined).

Number of claimants

The actual total number of claimants for the five year period is at least 6 and at most 24. On average, the number of claimants per year was at least 1.2 (6 claimants / 5 years) and at most 4.8 (24 claimants / 5 years) per year. Reports of the total employees each year for this period vary from about 25,000 to 37,000. San Francisco experienced a rate of at least 0.0324 and at most 0.192 claimants per thousand employees per year.[5]

The total number of possible enrollees has been variously reported at 80,000 to 100,000. However, the amount of surcharges collected from employee, retirees and dependent plans in the first three years indicates that about 70,260 enrollees paid into the City Plan.[6] Assuming a max of 100,000 enrollees, and a minimum of 70,260 enrollees, San Francisco experienced a rate of at least 0.012 and at most 0.0683 claimants per thousand enrollees.[7]


San Francisco's Predicted Utilization Rate and Actual Rate Range 2001-2006
Claimants Predicted Actual Min Actual
per thousand employees per year




per thousand enrollees per year




Dollars per claimant

Although we have total dollar cost data, we do not have the total number of claimants nor do we have data on the affirmed sexes of the individuals – thus we can only estimate that the average dollars per claimant ranged between $15,963[8] and $63,853[9]. If we assume that 15 different people (the median of our lower and upper bounds of total possible claimants) filed claims over the five year period, total costs averaged $25,542 per claimant.

We can break this down by years:

2001-2004: In the first 3 years, with a cap of $50,000, between 4 and 7 claimants utilized the benefit, averaging between $22,286 and $39,000 each.
2004-2006: In the two year period following the increase in the cap, between 7 and 18 claimants claimed a total of $227,117, or between $12,618 and $32,445 per claimant.


The affirmed sexes of the claimants and the precise nature of services are also not known. Thus it is not possible to assess the accuracy of the projected dollar amounts for services. Similarly, it is not possible to say whether any individual claimant reached the maximum dollar limit on services.


[1] Lifetime cap on services of $50,000 in this period, claims totaled just over $150,000, the minimum number of claimants is 4.

[2] Lifetime cap on services increased to $75,000. If no one from previous years has claims, then minimum number of new claimants would be 3 for this year. However, we might assume that some or all of the 4 from previous years returned to access benefits under the new lifetime cap. The total number of possible claimants for the entire period 2001-2005 is 5 ($339,000 /$75,000 = 4.52). Thus the minimum possible number of new claimants this year is 1 (total five minus the four counted above).

[3] Lifetime cap on services is $75,000, a minimum of 5 people account for costs in the previous years but have not necessarily reached their cap ($375,000 - $339,000 = $36,000). The additional claims costs in this year mean that at least one more person had to have accessed services.

[4] This is the figure actually reported by the SF HRC.

[5] 1.2 claimants per year / 37,000 employees x 1,000 = 0.0324 minimum; 4.8 claimants per year/ 25,000 employees x 1,000 = 0.192 maximum.

[6] We have calculated based on the three-year period when the surcharge rate was uniform and the benefit available to just one plan. However, for the subsequent two years, the benefit was available to all employees, retirees and dependents in all plans. The 70,261 figure does not represent all retirees, employees, and dependents of the City, just those enrolled in the City's self-insured plan. There were certainly other retirees, employees and dependents enrolled in other plans.

[7] 1.2 claimants per year / 100,000 enrollees x1,000 = 0.012 minimum; 4.8 claimants per year / 70,260 enrollees x 1,000 = 0.0683 maximum. Note that 1.2 claimants per year / 70,260 enrollees x1,000 = 0.0171.

[8] Assuming as many as 24 separate individuals filed claims in the 5 years.

[9] Assuming only 6 individuals filed claims over the 5 years. It is likely that higher number filed claims.