This page is part of a set of resources for employers to implement transgender-inclusive health insurance coverage. See "Transgender-Inclusive Benefits for Employees and Dependents" for the complete set of resources.
Insurance contracts are typically not readily available or accessible to employees. As a result, employers that have modified their insurance contract to remove discriminatory insurance exclusions against transgender people from their health insurance plans need to communicate to employees (and their dependents) that transgender-inclusive coverage is available – both when the benefit first becomes available and on a regular basis.
In addition to utilizing LGBTQ employee groups and intranets for targeted messaging, more general language needs to be included in documentation readily available to all employees, even after the coverage has been in place for multiple years. This is most easily accomplished in the Summary Plan Description.
For employers just implementing the benefit for the first time, the change may need to be listed as part of communications that indicate any "Changes to the Benefits" (e.g., the Summary of Material Modifications, if utilized) prior to the annual open enrollment period.
Because of the complexity of coverage, general plan communications to all employees will likely need to refer individuals to a plan administration hotline and/or e-mail address. Administration specialists need to be prepared to answer questions about the benefit.
Sample language and questions administrators should be prepared to answer are included below.
Sample Summary Plan Description language
Section: What’s Covered, Other Services (affirmatively covering transgender-related services, as with other services)
[Sub-Heading] Sex Reassignment
[PLAN NAME] covers the following sex reassignment services when ordered by a health professional. The treatment plan must conform to World Professional Association for Transgender Health’s standards.
- Psychotherapy -- See "Mental Health and Substance Abuse Benefit" section for coverage details.
- Pre- and post-surgical hormone therapy -- See "Pharmacy Benefit" section for coverage details.
- Sex reassignment surgery/ies. Surgery must be performed by a qualified provider. You or your physician must pre-certify the surgery with [ADMINISTRATOR]. If you do not, the surgery will not be covered.
Contact [ADMINISTRATOR] for more information.
[PLAN NAME] pays:
- In-network: [XX]% of negotiated charges
- Out-of-network: [XX]% of reasonable and customary charges
Section: Exclusions (if exclusion language persists, it must be qualified to indicate coverage is available)
Note: Sex reassignment services may be covered (for XXX and YYY plans only) when ordered by a health professional following a treatment plan conforming to the World Professional Association for Transgender Health’s standards. Pre-authorization for covered services is required. Contact [ADMINISTRATOR] for more information.
Educate Insurance Claims Administrators
Insurance plan administrators should be prepared to answer or correctly guide employees through the following questions.
- Does my plan offer transgender benefits? (does my plan cover sex reassignment?)
- What is covered under the transgender benefit?
- Do I have to pay a deductible or coinsurance to utilize the transgender benefit?
- Do I have to use an in-network provider? What if one isn’t available?
- What documentation do I need to change my/my dependent’s sex in insurance policy records?