Coverage of Gender-Affirming Care

Springfield Office 320 W. Washington Street Springfield, Illinois 62767 (217) 782-4515 Chicago Office 122 S. Michigan Ave., 19th Floor Chicago, Illinois 60603 (312) 814-2420 Illinois Department of Insurance JB PRITZKER Governor DANA POPISH SEVERINGHAUS Director TO: All Companies Writing Accident and Health Insurance and Managed Care Plans in Illinois FROM: Dana Popish Severinghaus, Director DATE: January 9, 2024 RE: Company Bulletin 2024-01 Coverage of Gender-Affirming Care The purpose of this Bulletin is to provide guidance to issuers regarding coverage relating to genderaffirming care. The Department reminds issuers that, as described in Company Bulletin 2020-16 and reflected in both the initial and currently effective versions of 50 Ill. Adm. Code 2603.35, categorically excluding coverage for medically necessary services, procedures, or surgical treatments for gender dysphoria is discriminatory conduct and not allowed, including, for example, medically necessary surgical treatments such as facial feminization or masculinization. Use of Clinical Criteria: In determining whether services, procedures, or surgical treatment to treat gender dysphoria are medically necessary for a covered individual, health insurance issuers must apply utilization review criteria based on valid, evidence-based sources reflecting current generally accepted standards of care, including recommendations of nonprofit health care provider professional associations and specialty societies. 215 ILCS 5/370c(h) and (k). Health insurance issuers have a continuing obligation to apply criteria reflecting current generally accepted standards of care and that the insurance policy’s terms of coverage do not conflict with appropriate standards as written or as applied. In no case may an issuer’s utilization review criteria or terms of coverage be used to categorically exclude services, procedures, or surgical treatments relating to gender-affirming care that fall within current generally accepted standards of care. For example, an issuer’s general exclusion in the terms of coverage for plastic or cosmetic surgery cannot apply when a surgical treatment is medically necessary to treat a covered individual’s gender dysphoria under current generally accepted standards of care. Similarly, a treatment cannot be considered experimental or investigational if it falls within current generally accepted standards of care for a covered individual’s gender dysphoria. Covered individuals who are denied services, procedures, or surgical treatments related to gender-affirming care based on a determination that the service, procedure, or surgical treatment is not medically necessary must be afforded appeal rights under the Managed Care Reform and Patient Rights Act and the Health Carrier External Review Act. Issuers retain flexibility in benefit design and individualized medical necessity determinations, but coverage must be provided in a consistent, neutral manner that does not limit or deny services to enrollees in a discriminatory way or contrary to current generally accepted standards of care. Questions about this Bulletin may be directed to DOI.InfoDesk@illinois.gov.