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Gender Transformation Coverage Update

Aug 03, 2016

Section 1557 is the civil rights provision of the Affordable Care Act of 2010 which prohibits discrimination on the grounds of race, color, national origin, sex, age, or disability in certain health programs and activities. 

These protections against sex discrimination include:

While the recent guidance prohibits broad categorical exclusion of gender transformation it does not mandate coverage of specific medical services; however, when any benefits are covered, they may not be administered in a discriminatory manner. 

Fully Insured Customers
For fully insured plans, UnitedHealthcare 2017 certificate of coverage (COC) will include the following benefits and exclusions/limitations. Standard benefits for the treatment of Gender Dysphoria are limited to the following services when clinical criteria for eligibility are met:

Specific documentation and written psychological assessments from one or more qualified behavioral health providers experienced in treating Gender Dysphoria are required prior to approval for a bilateral mastectomy, breast reduction surgery, or genital surgery. 

Exclusions and limitations include surgeries and/or related services that are considered cosmetic, unproven, and not medically necessary. 

Self-funded Customers
It is up to the plan sponsor to consult with their legal department to determine whether or not they are a covered entity under Section 1557 and to review their plan for any changes that may be necessary.  UnitedHealthcare will provide standard Summary Plan Description (SPD) language for self-funded customers wishing to adopt their standard benefit coverage. UHC can also support custom programs for the self-funded customer.  

UnitedHealthcare's Approach
UHC is in the process of filing COC benefit riders for fully insured customers beginning on or after January 1, 2017. Self-funded customers may use UHC's SPD language or customize the language based on their own decision. 

For questions, please ​contact a member of your b&p Sales Team - 888.722.3373.

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