For fully insured
groups.Self-funded
groups are not required to implement these changes but may opt into the mandate
if they wish.
Starting January 1,
2022, the Washington state Gender-Affirming Treatment Act imposes several
requirements on coverage for health plans for gender-affirming treatment
related to gender expression or identity. Here’s how this law will impact
Premera members.
What’s covered?
The Washington state
Gender-Affirming Treatment Act does the following:
- Prohibits
health plans from denying or limiting coverage for gender-affirming treatment
when that care is prescribed to an individual based on a protected gender
expression or identity, is medically necessary, and is prescribed under
accepted standards of care.
- Stops
insurers from excluding the most commonly prescribed gender-affirming
treatments by classifying such procedures as cosmetic.
- Ensures that private health plans, the Health Care Authority (HCA), managed care plans, and
providers through Medicaid programs do not deny or limit coverage for
gender-affirming treatment that is prescribed relating to the person’s gender
expression or identity, is medically necessary, and is prescribed per accepted
standards of care.
- Forbids
insurers from applying categorical cosmetic or blanket exclusions to
gender-affirming treatment and excluding as cosmetic-specified examples of
medically necessary gender-affirming treatment.
- Requires
that healthcare providers with experience prescribing or delivering
gender-affirming treatment must review and confirm the appropriateness of an
adverse benefit determination denying or limiting access to gender-affirming
services.
- Allows
medically necessary gender-affirming treatment including, but not limited to:
- Breast
augmentation
- Chemical
peel
- Dermabrasion
- Facial
feminization surgeries
- Face
lift
- Facial
masculinization surgeries
- Forehead
brow lift
- Genital
modification
- Hair
line modification
- Hair
removal by electrolysis or laser
- Hysterectomy
- Lip
enhancement
- Reduction
thyroid chondroplasty (chondrolaryngoplasty or tracheal shave)
- Rhinoplasty
- Skin
resurfacing
- Liposuction
- Mastectomy
- Penile
implant
- Voice
modification
- Any
combination of gender-affirming procedures, including revisions to prior
treatment
- Defines gender-affirming
treatment as a service or product that a health care provider prescribes to
treat any condition related to gender identity in accordance with generally
accepted standards of care.
- Clarifies
that gender-affirming treatment can be prescribed for “two-spirit, transgender,
nonbinary, intersex, and other gender-diverse individuals.”
- Doesn’t
mandate coverage of a service that isn’t medically necessary. Health plans are
not barred from using reasonable medical management techniques (such as prior
authorization, clinical review, or maintenance of medical policies).
Who’s covered?
This legislation
applies to all Washington fully insured plans effective January 1, 2022.
Premera has added the extended coverage under this new legislation to our
existing medical policy, which is effective January 1. Self-funded groups are
not required to implement these changes but may opt into the mandate if they
wish.
More information?
Here are additional
details about our benefits and medical policies related to transgender health:
Medical Policy - 7.01.557
Transgender FAQ
LGBTQ Care Essentials