California Insurance Commissioner Ricardo Lara directed the Department of Insurance this week to issue a General Counsel Opinion Letter clarifying that under existing California law, health insurance companies may not deny coverage for male chest reconstruction surgery for female-to-male patients undergoing care for gender dysphoria based solely on a patient’s age.
Lara says that people diagnosed with gender dysphoria have had to battle a host of challengesto access gender-affirming care.“ Social stigma, misconceptions about gender dysphoria and its treatment, and outdated medical criteria create barriers to necessary medical care that can lead to tragic results for individuals with gender dysphoria, especially for our transgender youth,” says Lara. California law already provides protections meant to reduce these barriers to gender-affirming care for gender dysphoria.
However, due to complaints from young Californians and their parents, some health insurance companies may still use coverage criteria and processes that wrongfully deny coverage, and place the burden on consumers to pursue their legal rights to transgender health services through time-consuming appeals and independentmedical reviews. To be proactive, health insurance companies should evaluate their coverage criteria for gender dysphoria treatment and eliminate any noncompliant practices to avoid needlessly delaying and interfering with medical care recommended by a patient’s doctor.
The Department’s General Counsel Opinion Letter, issued pursuant to Insurance Code section 12921.9, was prepared in response to an inquiry from San Diego’s TransFamily SupportServices regarding several denials of coverage for male chest surgery for patients under 18 years old who are transitioning from female to male. The Department determined that denying coverage for mastectomy and reconstruction of a male chest based solely on age is impermissible under state laws requiring coverage of reconstructive surgery. Health insurance companies must consider a patient’s specific clinical situation in determining medical necessity.