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Transgender Inclusive Healthcare Coverage CEI Resources
Transgender-Inclusive Benefits
The following questions (in bold) appear on the 2020 CEI survey in the section on Transgender-Inclusive Benefits. This page lays out guidance and resources for questions as they appear on the 2020 CEI survey. If you still have questions, contact us at cei@hrc.org for assistance.
Transgender people access health care for all the same reasons anyone else does, but sometimes their transgender status is regarded by insurance carriers (and some care providers) as a barrier to care, even when that care is not related to a transition (i.e., reconstruction and alignment of gender characteristics from male to female, or from female to male, through the use of hormones and/or surgical interventions). When a transition is in process, it may involve one or more types of medically necessary treatments. Most of these types of treatments are typically covered for other medical diagnoses, but many health insurance policies specifically exclude gender affirmation/reassignment-related treatments. The effective scope of those exclusions can vary significantly from one insurance plan to another. See Benefits for Transgender Employees and Dependents.
Does your business have at least one health insurance plan available to all employees that explicitly affirms coverage for the medically necessary health care services that transgender people need, including transition-related treatment such as genital surgeries, hormone therapy and mental health counseling?
- Finding the right answer: This question requires a benefits manager experienced with the plan's exclusions and limitations to coverage for specific treatments and services, or an affirmative answer from your insurance administrator in response to the following question:
"It is our understanding that our health plan will now cover the healthcare needs of transgender individuals without exclusion as for any other individual, including routine, emergent or urgent care as well as services related to gender affirmation or reassignment. More specifically, that we have no explicit exclusions in our insurance plan contract that specifically preclude such treatment or that any exclusion we do have is no longer applicable. Is this the case?" - Examining your plan's exclusions: You must find the insurance policy contract and examine the list of coverage exclusions or limitations for transgender-specific language. A complete list of exclusions will be found in the insurance contract, and partial lists are usually found in summary plan documents. See Transgender-Inclusive Benefits: Questions Employers Should Ask for example exclusionary language.
- Confirming with your plan administrator. Having no explicit contractual exclusion does not guarantee that transition-related services will be considered medically necessary and covered. Further, contractual exclusions may not reflect current, actual implementation if the insurance administrator or relevant laws and regulations have changed to consider transition-related services as medically necessary and covered.
- Understanding "medically necessary": Many insurance administrators maintain clinical guidelines or medical policy that indicate what treatments the plan considers medically necessary (e.g., reconstructive and not cosmetic) and conditions under which treatment will be covered. An insurance administrator's clinical guidelines will generally not apply if your plan has transgender exclusions. If you have determined that exclusions do not apply to your plan, this survey will ask for applicable guidelines and whether they are consistent with the World Professional Association for Transgender Health (WPATH, formerly known as Harry Benjamin International Gender Dysphoria Association or HBIGDA) Standards of Care. The WPATH SOC reflect the current medical consensus regarding effective treatment and medically indicated or necessary care for treatment of gender dysphoria.
Please attach summary plan documentation (or summary material modification documentation) readily available to all employees both prior to selecting and after enrolled in the plan that explicitly indicates that coverage is available. You can also attach applicable selections from your summary plan description (Submissions lacking appropriate documentation will be ineligible for credit).
- Summary language: Does not need to discuss the benefit in exhaustive detail, but should signal to an employee that coverage is available and how to find out more information without disclosing confidential medical information directly to the employer. See Communicating Availability of the Benefit for sample Summary Plan Description language.
Please attach a copy of any applicable medical policy or clinical guidelines.
- A common mistake is to assume that clinical guidelines specific to gender reassignment posted on the insurance company/third party administrator's website automatically apply to a particular health insurance plan administered by the same insurance company. If you have already determined that your health insurance plan covers medically necessary transgender-related treatment such as breast/chest, genital and other reconstructive surgeries (Q1), and you understand that the clinical guidelines apply to the administration of the same health insurance plan, please submit them here.
Documentation must include some indication that the insurance carrier or administrator has agreed to implement this policy. Thus, copies of the WPATH SOC or WPATH Clarification letter alone will not be considered sufficient documentation, unless accompanied by an affirmative statement from the carrier or administrator that this policy will be implemented.
Is the plan implemented (e.g., prior authorization, utilization management, etc.) in a manner consistent with the World Professional for Transgender Health Standards of Care (WPATH SOC) with respect to diagnosis, assessment and appropriate treatment plans?
- Finding the right answer: This question requires examination of applicable clinical guidelines utilized by your insurance administrator, or an affirmative answer from your insurance administrator in response to the following question:
"It is our understanding that our health plan covers the full range of medical procedures related to the process of gender affirmation or reassignment that are considered medically necessary by the current World Professional Association for Transgender Health Standards of Care (WPATH SOC v.7 2012), when such treatment is medically indicated for the individual and is consistent with the WPATH SOC. Is this the case?" - Covered services and treatments should include those in the WPATH Standards of Care v.7 of 2012. About WPATH
Mental Health Counseling
Example 1: If your employee benefits include a mental health benefit (outside of an EAP), and that mental health benefit is not subject to a transgender exclusion (e.g., the mental health benefit can be utilized with regard to “gender identity disorders,” “gender dysphoria” or “transsexualism” diagnoses), select Yes, benefit offered, transgender treatment covered.
Example 2: If your employee benefits include a mental health benefit (outside of an EAP), but that mental health benefit is subject to a transgender exclusion (e.g., the mental health benefit cannot be utilized with regard to “gender identity disorders,” “gender dysphoria” or “transsexualism” diagnoses), select No, benefit offered, but transgender treatment excluded.
Example 3: If your employee benefits do not include a mental health benefit, or only provides some counseling through an EAP, select No, benefit not offered.
Problem Area: An employee assistance program (EAP) is insufficient for the purposes of this benefit, which speaks to ongoing mental health treatment from providers experienced with transgender issues.
Pharmacy Benefit
Example 1: If your employee benefits include a pharmacy benefit, and that pharmacy benefit is not subject to a transgender exclusion (e.g., the pharmacy benefit covers hormone replacement therapy for the purposes of gender affirmation or reassignment), select Yes, benefit offered, transgender treatment covered.
Example 2: If your employee benefits include a pharmacy benefit, but that pharmacy benefit is subject to a transgender exclusion (e.g., the pharmacy benefit does not cover hormone replacement therapy for the purposes of gender affirmation or reassignment), select No, benefit offered, but transgender treatment excluded.
Example 3: If your employee benefits do not include a pharmacy benefit, select No, benefit not offered. Note: most health insurance plans offer a pharmacy benefit.
Medical visits and lab procedures
Example 1: If your health/medical benefits cover medical visits and lab procedures, and these visits and procedures are not subject to a transgender exclusion (e.g., the medical benefit covers medical visits to monitor the effects of hormone therapy and associated lab procedures, or visits to assess the patient prior to treatment for the purposes of gender affirmation or reassignment), select Yes, benefit offered, transgender treatment covered.
Example 2: If your health/medical benefits cover medical visits and lab procedures, but these visits and procedures are subject to a transgender exclusion (e.g., the medical benefit does not cover medical visits to monitor the effects of hormone therapy and associated lab procedures, nor visits to assess the patient prior to treatment for the purposes of gender affirmation or reassignment), select No, benefit offered, but transgender treatment excluded.
Example 3: If your health/medical benefits do not cover medical visits and lab procedures, select No, benefit not offered. Note: most health/medical benefits cover medical visits and lab procedures.
Surgical procedures
Example 1: If your health/medical benefit covers surgical procedures (e.g., hysterectomy), and these surgical procedures are not subject to a transgender exclusion (e.g., the medical benefit covers hysterectomy for the purposes of gender affirmation or reassignment), select Yes, benefit offered, transgender treatment covered.
Example 2: If your health/medical benefit covers surgical procedures (e.g., hysterectomy), but these surgical procedures are subject to a transgender exclusion (e.g., the medical benefit does not cover hysterectomy for the purposes of gender affirmation or reassignment), select No, benefit offered, but transgender treatment excluded.
Example 3: If your health/medical benefit does not cover surgical procedures, select No, benefit not offered. Note: most health/medical benefits cover surgical procedures.
Paid short-term leave
Example 1: If your employee benefits include a paid short-term leave benefit, and that benefit is not subject to a transgender exclusion (e.g., the paid short-term leave benefit can be utilized with regard to“gender identity disorders,” “gender dysphoria” or “transsexualism” diagnoses or for treatment related to gender affirmation or reassignment), select Yes, benefit offered, transgender treatment covered.
Example 2: If your employee benefits include a paid short-term leave benefit, but that benefit is subject to a transgender exclusion (e.g., the paid short-term leave benefit cannot be utilized with regard to “gender identity disorders,” “gender dysphoria” or “transsexualism” diagnoses or for treatment related to gender affirmation or reassignment), select No, benefit offered, but transgender treatment excluded.
Example 3: If your employee benefits do not include a paid short-term leave benefit, select No, benefit not offered. Note: most employers have a paid short-term leave benefit.
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Transgender-Inclusive Benefits
The following questions (in bold) appear on the 2020 CEI survey in the section on Transgender-Inclusive Benefits. This page lays out guidance and resources for questions as they appear on the 2020 CEI survey. If you still have questions, contact us at cei@hrc.org for assistance.
Transgender people access health care for all the same reasons anyone else does, but sometimes their transgender status is regarded by insurance carriers (and some care providers) as a barrier to care, even when that care is not related to a transition (i.e., reconstruction and alignment of sex characteristics from male to female, or from female to male, through the use of hormones and/or surgical interventions). When a transition is in process, it may involve one or more types of medically necessary treatments. Most of these types of treatments are typically covered for other medical diagnoses, but many health insurance policies specifically exclude sex affirmation/reassignment-related treatments. The effective scope of those exclusions can vary significantly from one insurance plan to another. See Benefits for Transgender Employees and Dependents.
Does your business have at least one health insurance plan available to all employees that explicitly affirms coverage for the medically necessary health care services that transgender people need, including transition-related treatment such as genital surgeries, hormone therapy and mental health counseling?
- Finding the right answer: This question requires a benefits manager experienced with the plan's exclusions and limitations to coverage for specific treatments and services, or an affirmative answer from your insurance administrator in response to the following question:
"It is our understanding that our health plan will now cover the healthcare needs of transgender and transsexual individuals without exclusion as for any other individual, including routine, emergent or urgent care as well as services related to sex affirmation or reassignment. More specifically, that we have no explicit exclusions in our insurance plan contract that specifically preclude such treatment or that any exclusion we do have is no longer applicable. Is this the case?" - Examining your plan's exclusions: You must find the insurance policy contract and examine the list of coverage exclusions or limitations for transgender-specific language. A complete list of exclusions will be found in the insurance contract, and partial lists are usually found in summary plan documents. See Transgender-Inclusive Benefits: Questions Employers Should Ask for example exclusionary language.
- Confirming with your plan administrator. Having no explicit contractual exclusion does not guarantee that transition-related services will be considered medically necessary and covered. Further, contractual exclusions may not reflect current, actual implementation if the insurance administrator or relevant laws and regulations have changed to consider transition-related services as medically necessary and covered.
- Understanding "medically necessary": Many insurance administrators maintain clinical guidelines or medical policy that indicate what treatments the plan considers medically necessary (e.g., reconstructive and not cosmetic) and conditions under which treatment will be covered. An insurance administrator's clinical guidelines will generally not apply if your plan has transgender exclusions. If you have determined that exclusions do not apply to your plan, this survey will ask for applicable guidelines and whether they are consistent with the World Professional Association for Transgender Health (WPATH, formerly known as Harry Benjamin International Gender Dysphoria Association or HBIGDA) Standards of Care. The WPATH SOC reflect the current medical consensus regarding effective treatment and medically indicated or necessary care for treatment of gender dysphoria.
Please attach summary plan documentation (or summary material modification documentation) readily available to all employees both prior to selecting and after enrolled in the plan that explicitly indicates that coverage is available. You can also attach applicable selections from your summary plan description (Submissions lacking appropriate documentation will be ineligible for credit).
- Summary language: Does not need to discuss the benefit in exhaustive detail, but should signal to an employee that coverage is available and how to find out more information without disclosing confidential medical information directly to the employer. See Communicating Availability of the Benefit for sample Summary Plan Description language.
Please attach a copy of any applicable medical policy or clinical guidelines.
- A common mistake is to assume that clinical guidelines specific to sex reassignment posted on the insurance company/third party administrator's website automatically apply to a particular health insurance plan administered by the same insurance company. If you have already determined that your health insurance plan covers medically necessary transgender-related treatment such as breast/chest, genital and other reconstructive surgeries (Q1), and you understand that the clinical guidelines apply to the administration of the same health insurance plan, please submit them here.
Documentation must include some indication that the insurance carrier or administrator has agreed to implement this policy. Thus, copies of the WPATH SOC or WPATH Clarification letter alone will not be considered sufficient documentation, unless accompanied by an affirmative statement from the carrier or administrator that this policy will be implemented.
Is the plan implemented (e.g., prior authorization, utilization management, etc.) in a manner consistent with the World Professional for Transgender Health Standards of Care (WPATH SOC) with respect to diagnosis, assessment and appropriate treatment plans?
- Finding the right answer: This question requires examination of applicable clinical guidelines utilized by your insurance administrator, or an affirmative answer from your insurance administrator in response to the following question:
"It is our understanding that our health plan covers the full range of medical procedures related to the process of sex affirmation or reassignment that are considered medically necessary by the current World Professional Association for Transgender Health Standards of Care (WPATH SOC v.7 2012), when such treatment is medically indicated for the individual and is consistent with the WPATH SOC. Is this the case?" - Covered services and treatments should include those in the WPATH Standards of Care
- Mental Health Counseling
- Pharmacy Benefit
- Surgical Procedures
- Medical visits and lab procedures
- Paid short-term leave
Mental Health Counseling
Example 1: If your employee benefits include a mental health benefit (outside of an EAP), and that mental health benefit is not subject to a transgender exclusion (e.g., the mental health benefit can be utilized with regard to gender identity disorders, gender dysphoria or transsexualism diagnoses), select Yes, benefit offered, transgender treatment covered.
Example 2: If your employee benefits include a mental health benefit (outside of an EAP), but that mental health benefit is subject to a transgender exclusion (e.g., the mental health benefit cannot be utilized with regard to gender identity disorders, gender dysphoria or transsexualism diagnoses), select No, benefit offered, but transgender treatment excluded.
Example 3: If your employee benefits do not include a mental health benefit, or only provides some counseling through an EAP, select No, benefit not offered.
Problem Area: An employee assistance program (EAP) is insufficient for the purposes of this benefit, which speaks to ongoing mental health treatment from providers experienced with transgender issues.
Example 1: If your employee benefits include a pharmacy benefit, and that pharmacy benefit is not subject to a transgender exclusion (e.g., the pharmacy benefit covers hormone replacement therapy for the purposes of sex affirmation or reassignment), select Yes, benefit offered, transgender treatment covered.
Example 2: If your employee benefits include a pharmacy benefit, but that pharmacy benefit is subject to a transgender exclusion (e.g., the pharmacy benefit does not cover hormone replacement therapy for the purposes of sex affirmation or reassignment), select No, benefit offered, but transgender treatment excluded.
Example 3: If your employee benefits do not include a pharmacy benefit, select No, benefit not offered. Note: most health insurance plans offer a pharmacy benefit.
Medical visits and lab procedures
Example 1: If your health/medical benefits cover medical visits and lab procedures, and these visits and procedures are not subject to a transgender exclusion (e.g., the medical benefit covers medical visits to monitor the effects of hormone therapy and associated lab procedures, or visits to assess the patient prior to treatment for the purposes of sex affirmation or reassignment), select Yes, benefit offered, transgender treatment covered.
Example 2: If your health/medical benefits cover medical visits and lab procedures, but these visits and procedures are subject to a transgender exclusion (e.g., the medical benefit does not cover medical visits to monitor the effects of hormone therapy and associated lab procedures, nor visits to assess the patient prior to treatment for the purposes of sex affirmation or reassignment), select No, benefit offered, but transgender treatment excluded.
Example 3: If your health/medical benefits do not cover medical visits and lab procedures, select No, benefit not offered. Note: most health/medical benefits cover medical visits and lab procedures.
Example 1: If your health/medical benefit covers surgical procedures (e.g., hysterectomy), and these surgical procedures are not subject to a transgender exclusion (e.g., the medical benefit covers hysterectomy for the purposes of sex affirmation or reassignment), select Yes, benefit offered, transgender treatment covered.
Example 2: If your health/medical benefit covers surgical procedures (e.g., hysterectomy), but these surgical procedures are subject to a transgender exclusion (e.g., the medical benefit does not cover hysterectomy for the purposes of sex affirmation or reassignment), select No, benefit offered, but transgender treatment excluded.
Example 3: If your health/medical benefit does not cover surgical procedures, select No, benefit not offered. Note: most health/medical benefits cover surgical procedures.
Example 1: If your employee benefits include a paid short-term leave benefit, and that benefit is not subject to a transgender exclusion (e.g., the paid short-term leave benefit can be utilized with regard to gender identity disorders, gender dysphoria or transsexualism diagnoses or for treatment related to sex affirmation or reassignment), select Yes, benefit offered, transgender treatment covered.
Example 2: If your employee benefits include a paid short-term leave benefit, but that benefit is subject to a transgender exclusion (e.g., the paid short-term leave benefit cannot be utilized with regard to gender identity disorders, gender dysphoria or transsexualism diagnoses or for treatment related to sex affirmation or reassignment), select No, benefit offered, but transgender treatment excluded.
Example 3: If your employee benefits do not include a paid short-term leave benefit, select No, benefit not offered. Note: most employers have a paid short-term leave benefit.
Click here to return to the Corporate Equality Index Resource Center