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
and providers.
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 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 a healthcare provider 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, individual, exchange and state 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. You can check if your patient is covered under this new mandate by signing in and using our eligibility and benefits tool.
More information?
Here are additional details about our benefits and medical policies related to transgender health:
Medical Policy - 7.01.557
LGBTQ Care Essentials