THE SENATE S.B. NO. 1224 THIRTY-THIRD LEGISLATURE, 2025 STATE OF HAWAII A BILL FOR AN ACT relating to insurance. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
THE SENATE S.B. NO. 1224
THIRTY-THIRD LEGISLATURE, 2025
STATE OF HAWAII
THE SENATE
S.B. NO.
1224
THIRTY-THIRD LEGISLATURE, 2025
STATE OF HAWAII
A BILL FOR AN ACT
relating to insurance.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
SECTION 1. The legislature finds that since the enactment of Act 39, Session Laws in Hawaii 2022, known and cited as the Gender Affirming Treatment Act, health insurance companies, health maintenance organizations, and mutual benefit societies (collectively referred to as "insurance carriers") have been continuing to deny transgender persons' coverage for gender transition-related medical care, according to reports of patient and providers in the State. The legislature further finds that the gender transition-related medical care being denied by insurance carriers is often known to be medically necessary, classified as the standard of care according to the World Professional Association for Transgender Health ("WPATH") Standards of Care, and supported by scientific evidence. Moreover, these denials are routinely being overturned through the external review process. The legislature also finds that since the enactment of the Gender Affirming Treatment Act, WPATH has released Version 8 of its Standards of Care for the Health of Transgender and Gender Diverse People ("SOC8") and these updated guidelines have generally been adopted by insurance carriers across the continental United States. However, insurance carriers in Hawaiʻi have taken varying approaches with adopting SOC8, with some insurance carriers having reached near full adoption and others continuing to lag. This has resulted in transgender persons in Hawaiʻi experiencing different coverage standards for gender affirming care. The legislature additionally finds that despite the enactment of the Gender Affirming Treatment Act and its transparency requirements, insurance carriers, when denying gender affirming care on the basis of medical necessity, are not consistently providing transparent and thorough information clearly explaining the reason the requested care was deemed not medically necessary. As well, the legislature finds that the transgender community faces numerous health disparities, among which include an alarmingly increased risk for suicide and suicidal ideation. Research has found that transgender youth are about 4.6 times more likely to attempt suicide and about 13.4 times more likely to have seriously considered suicide recently than cisgender youth. Transgender adults have been found to be about 4.4 times more likely to attempt suicide and about twelve times more likely to have seriously considered suicide recently than cisgender adults. Denials of gender transition-related medical coverage and care contribute to the likelihood of suicide and suicidal ideations. A 2023 federal directive from the Office of Personnel Management underscores the importance of aligning health coverage policies with updated standards of care, including WPATH's latest guidelines. The legislature therefore finds that the intent of this Act is to better implement the 2022 Gender Affirming Treatment Act. Because this Act does not establish new health insurance requirements, it is not subject to the section 23-51, Hawaii Revised Statutes, review. Accordingly, the purpose of this Act is to: (1) Prohibit health insurers, mutual benefit societies, and health maintenance organizations from arbitrarily denying coverage requests for gender affirming care services when the requested care is known to be considered a standard of care for which scientific evidence exists; (2) Improve transparency of medical necessity reviews by health insurers, mutual benefit societies, and health maintenance organizations and the relevant requirements; and (3) Codify reasonable standards, protections, and best practices to ensure that the State's transgender and gender diverse population are afforded access to the health care coverage that they need to live and thrive. SECTION 2. Section 431:10A-118.3, Hawaii Revised Statutes, is amended to read as follows: "§431:10A-118.3 Nondiscrimination on the basis of actual gender identity or perceived gender identity; coverage for services. (a) No individual or group accident and health or sickness policy, contract, plan, or agreement that provides health care coverage shall discriminate with respect to participation and coverage under the policy, contract, plan, or agreement against any person on the basis of actual gender identity or perceived gender identity. (b) Discrimination under this section includes the following: (1) Denying, canceling, limiting, non-renewing or otherwise refusing to issue or renew an insurance policy, contract, plan, or agreement on the basis of a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity; (2) Demanding or requiring a payment or premium that is based on a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity; (3) Designating a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity as a preexisting condition to deny, cancel, non-renew or otherwise limit coverage; and (4) Denying, canceling, or limiting coverage for services on the basis of actual gender identity or perceived gender identity, including but not limited to the following: (A) Health care services related to gender transition; provided that there is coverage under the policy, contract, plan, or agreement for the services when the services are not related to gender transition; provided further that it shall not be required that a health care service covered for gender transition be routinely available and covered for services not related to gender transition; and (B) Health care services that are ordinarily or exclusively available to individuals of any sex[.] or of any gender assigned at birth. (c) The medical necessity of any [treatment] health care service for a transgender person, or any person, on the basis of actual gender identity or perceived gender identity shall be determined pursuant to the insurance policy, contract, plan, or agreement and shall [be defined in accordance with] take into account the recommendations in the most recent edition of the Standards of Care for the Health of Transgender and Gender Diverse People, issued by the World Professional Association for Transgender Health, and other applicable law. No health care service shall be deemed not medically necessary on the basis that the person's actual or perceived gender identity may be classified as a behavioral health condition. (d) No health care service shall be denied coverage on the basis that it is cosmetic or not medically necessary unless a health care provider or mental health professional with current experience in prescribing or delivering gender affirming care services first reviews and confirms the appropriateness of the adverse benefit determination. In the event of a denial of coverage on the basis that a service is cosmetic or not medically necessary, unless otherwise prohibited by law, the denial shall, without requiring a separate request, include the following: (1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and (2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage. (e) In the event of an appeal of a claim denied on the basis of medical necessity of the [treatment, such] service, the appeal shall be [decided in a manner consistent with applicable law and] reviewed for medical necessity in consultation with a health care provider or mental health professional with current experience in prescribing or delivering gender affirming [treatment who shall provide input on the appropriateness of the denial of the claim.] care services. In the event an appeal upholds a denial on the basis of medical necessity, unless otherwise prohibited by law, the appeal determination shall, without requiring a separate request, include the following: (1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and (2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage. [(d)] (f) An insurer shall not apply categorical cosmetic or blanket exclusions to gender affirming [treatments] care services or procedures, or any combination of services or procedures or revisions to prior [treatments, when determined to be medically necessary pursuant to applicable law, only] services or procedures, if the policy, contract, plan, or agreement also provides coverage for those services or procedures when the services or procedures are offered for purposes other than gender transition. It shall not be required that a health care service or procedure covered for gender transition also be routinely available and covered for services or procedures not related to gender transition. These services and procedures may include but are not limited to: (1) Hormone therapies; (2) Hysterectomies; (3) Mastectomies; (4) Vocal training; (5) Feminizing vaginoplasties; (6) Masculinizing phalloplasties; (7) Metaoidioplasties; (8) [Breast] Feminizing breast surgeries, including augmentations; (9) Masculinizing chest surgeries; (10) [Facial feminization] Gender affirming facial surgeries[;], including feminizing and masculinizing surgeries; (11) Reduction thyroid chondroplasties; (12) Voice surgeries and therapies; and (13) Electrolysis [or] and laser hair removal[.], not to be limited to pre-surgical hair removal. [(e)] (g) Each individual or group accident and health or sickness policy, contract, plan, or agreement shall provide applicants and policyholders with clear information about the coverage of gender transition services and the requirements for determining medically necessary [treatments related to these] services, including the process for appealing a claim denied on the basis of medical necessity. The information required by this subsection shall also be made available on a publicly accessible website. [(f)] (h) Any coverage provided shall be subject to copayment, deductible, and coinsurance provisions of an individual or group accident and health or sickness policy, contract, plan, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the policy, contract, plan, or agreement. [(g)] (i) Nothing in this section shall be construed to mandate coverage of a service that is determined to be not medically necessary[.]; provided that the determination has been made in accordance with this section. [(h)] (j) As used in this section unless the context requires otherwise: "Actual gender identity" means a person's internal sense of being male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female. "Gender transition" means the process of a person changing the person's outward appearance or sex characteristics to accord with the person's actual gender identity. "Perceived gender identity" means an observer's impression of another person's actual gender identity or the observer's own impression that the person is male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female. "Transgender person" means a person who has gender dysphoria, has received health care services related to gender transition, or otherwise identifies as a gender different from the gender assigned to that person at birth." SECTION 3. Section 432:1-607.3, Hawaii Revised Statutes, is amended to read as follows: "§432:1-607.3 Nondiscrimination on the basis of actual gender identity or perceived gender identity; coverage for services. (a) No individual or group hospital or medical service policy, contract, plan, or agreement that provides health care coverage shall discriminate with respect to participation and coverage under the policy, contract, plan, or agreement against any person on the basis of actual gender identity or perceived gender identity. (b) Discrimination under this section includes the following: (1) Denying, canceling, limiting, non-renewing or otherwise refusing to issue or renew an insurance policy, contract, plan, or agreement on the basis of a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity; (2) Demanding or requiring a payment or premium that is based on a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity; (3) Designating a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity as a preexisting condition to deny, cancel, non-renew or otherwise limit coverage; and (4) Denying, canceling, or limiting coverage for services on the basis of actual gender identity or perceived gender identity, including but not limited to the following: (A) Health care services related to gender transition; provided that there is coverage under the policy, contract, plan, or agreement for the services when the services are not related to gender transition; provided further that it shall not be required that a health care service covered for gender transition be routinely available and covered for services not related to gender transition; and (B) Health care services that are ordinarily or exclusively available to individuals of any sex[.] or of any gender assigned at birth. (c) The medical necessity of any [treatment] health care service for a transgender person, or any person, on the basis of actual gender identity or perceived gender identity shall be determined pursuant to the hospital or medical service policy, contract, plan, or agreement and shall [be defined in accordance with] take into account the recommendations in the most recent edition of the Standards of Care for the Health of Transgender and Gender Diverse People, issued by the World Professional Association for Transgender Health, and other applicable law. No health care service shall be deemed not medically necessary on the basis that the person's actual or perceived gender identity may be classified as a behavioral health condition. (d) No health care service shall be denied coverage on the basis that it is cosmetic or not medically necessary unless a health care provider or mental health professional with current experience in prescribing or delivering gender affirming care services first reviews and confirms the appropriateness of the adverse benefit determination. In the event of a denial of coverage on the basis that a service is cosmetic or not medically necessary, unless otherwise prohibited by law, the denial shall, without requiring a separate request, include the following: (1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and (2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage. (e) In the event of an appeal of a claim denied on the basis of medical necessity of the [treatment, such] service, the appeal shall be [decided in a manner consistent with applicable law and] reviewed for medical necessity in consultation with a health care provider or mental health professional with current experience in prescribing or delivering gender affirming [treatment who shall provide input on the appropriateness of the denial of the claim.] care services. In the event an appeal upholds a denial on the basis of medical necessity, unless otherwise prohibited by law, the appeal determination shall, without requiring a separate request, include the following: (1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and (2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage. [(d)] (f) A mutual benefit society shall not apply categorical cosmetic or blanket exclusions to gender affirming [treatments] care services or procedures, or any combination of services or procedures or revisions to prior [treatments, when determined to be medically necessary pursuant to applicable law, only] services or procedures, if the policy, contract, plan, or agreement also provides coverage for those services or procedures when the services or procedures are offered for purposes other than gender transition. Is shall not be required that a health care service or procedure covered for gender transition also be routinely available and covered for services or procedures not related to gender transition. These services and procedures may include but are not limited to: (1) Hormone therapies; (2) Hysterectomies; (3) Mastectomies; (4) Vocal training; (5) Feminizing vaginoplasties; (6) Masculinizing phalloplasties; (7) Metaoidioplasties; (8) [Breast] Feminizing breast surgeries, including augmentations; (9) Masculinizing chest surgeries; (10) [Facial feminization] Gender affirming facial surgeries[;], including feminizing and masculinizing surgeries; (11) Reduction thyroid chondroplasties; (12) Voice surgeries and therapies; and (13) Electrolysis [or] and laser hair removal[.], not to be limited to pre-surgical hair removal. [(e)] (g) Each individual or group hospital or medical service policy, contract, plan, or agreement shall provide applicants and members with clear information about the coverage of gender transition services and the requirements for determining medically necessary [treatments related to these] services, including the process for appealing a claim denied on the basis of medical necessity. The information required by this subsection shall also be made available on a publicly accessible website. [(f)] (h) Any coverage provided shall be subject to copayment, deductible, and coinsurance provisions of an individual or group hospital or medical service policy, contract, plan, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the policy, contract, plan, or agreement. [(g)] (i) Nothing in this section shall be construed to mandate coverage of a service that is determined to be not medically necessary[.]; provided that the determination has been made in accordance with this section. [(h)] (j) As used in this section unless the context requires otherwise: "Actual gender identity" means a person's internal sense of being male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female. "Gender transition" means the process of a person changing the person's outward appearance or sex characteristics to accord with the person's actual gender identity. "Perceived gender identity" means an observer's impression of another person's actual gender identity or the observer's own impression that the person is male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female. "Transgender person" means a person who has gender dysphoria, has received health care services related to gender transition, or otherwise identifies as a gender different from the gender assigned to that person at birth." SECTION 4. Section 432D-26.3, Hawaii Revised Statutes, is amended to read as follows: "§432D-26.3 Nondiscrimination on the basis of actual gender identity or perceived gender identity; coverage for services. (a) No health maintenance organization policy, contract, plan, or agreement shall discriminate with respect to participation and coverage under the policy, contract, plan, or agreement against any person on the basis of actual gender identity or perceived gender identity. (b) Discrimination under this section includes the following: (1) Denying, canceling, limiting, non-renewing or otherwise refusing to issue or renew an insurance policy, contract, plan, or agreement on the basis of a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity; (2) Demanding or requiring a payment or premium that is based on a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity; (3) Designating a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity as a preexisting condition to deny, cancel, non-renew or otherwise limit coverage; and (4) Denying, canceling, or limiting coverage for services on the basis of actual gender identity or perceived gender identity, including but not limited to the following: (A) Health care services related to gender transition; provided that there is coverage under the policy, contract, plan, or agreement for the services when the services are not related to gender transition; provided further that it shall not be required that a health care service covered for gender transition be routinely available and covered for services not related to gender transition; and (B) Health care services that are ordinarily or exclusively available to individuals of any sex[.] or of any gender assigned at birth. (c) The medical necessity of any [treatment] health care service for a transgender person, or any person, on the basis of actual gender identity or perceived gender identity shall [be defined in accordance with] take into account the recommendations in the most recent edition of the Standards of Care for the Health of Transgender and Gender Diverse People, issued by the World Professional Association for Transgender Health, and other applicable law. No health care service shall be deemed not medically necessary on the basis that the person's actual or perceived gender identity may be classified as a behavioral health condition. (d) No health care service shall be denied coverage on the basis that it is cosmetic or not medically necessary unless a health care provider or mental health professional with current experience in prescribing or delivering gender affirming care services first reviews and confirms the appropriateness of the adverse benefit determination. In the event of a denial of coverage on the basis that a service is cosmetic or not medically necessary, unless otherwise prohibited by law, the denial shall, without requiring a separate request, include the following: (1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and (2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage. (e) In the event of an appeal of a claim denied on the basis of medical necessity of the [treatment, such] service, the appeal shall be [decided in a manner consistent with applicable law and] reviewed for medical necessity in consultation with a health care provider or mental health professional with current experience in prescribing or delivering gender affirming [treatment who shall provide input on the appropriateness of the denial of the claim.] care services. In the event an appeal upholds a denial on the basis of medical necessity, unless otherwise prohibited by law, the appeal determination shall, without requiring a separate request, include the following: (1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and (2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage. [(d)] (f) A health maintenance organization shall not apply categorical cosmetic or blanket exclusions to gender affirming [treatments] care services or procedures, or any combination of services or procedures or revisions to prior [treatments, when determined to be medically necessary pursuant to applicable law, only] services or procedures, if the policy, contract, plan, or agreement also provides coverage for those services or procedures when the services or procedures are offered for purposes other than gender transition. It shall not be required that a health care service or procedure covered for gender transition also be routinely available and covered for services or procedures not related to gender transition. These services and procedures may include but are not limited to: (1) Hormone therapies; (2) Hysterectomies; (3) Mastectomies; (4) Vocal training; (5) Feminizing vaginoplasties; (6) Masculinizing phalloplasties; (7) Metaoidioplasties; (8) [Breast] Feminizing breast surgeries, including augmentations; (9) Masculinizing chest surgeries; (10) [Facial feminization] Gender affirming facial surgeries[;], including feminizing and masculinizing surgeries; (11) Reduction thyroid chondroplasties; (12) Voice surgeries and therapies; and (13) Electrolysis [or] and laser hair removal[.], not to be limited to pre-surgical hair removal. [(e)] (g) Each health maintenance organization policy, contract, plan, or agreement shall provide applicants and subscribers with clear information about the coverage of gender transition services and the requirements for determining medically necessary [treatments related to these] services, including the process for appealing a claim denied on the basis of medical necessity. The information required by this subsection shall be made available on a publicly accessible website. [(f)] (h) Any coverage provided shall be subject to copayment, deductible, and coinsurance provisions of a health maintenance organization policy, contract, plan, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the policy, contract, plan, or agreement. [(g)] (i) Nothing in this section shall be construed to mandate coverage of a service that is determined to be not medically necessary[.]; provided that the determination has been made in accordance with this section. [(h)] (j) As used in this section unless the context requires otherwise: "Actual gender identity" means a person's internal sense of being male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female. "Gender transition" means the process of a person changing the person's outward appearance or sex characteristics to accord with the person's actual gender identity. "Perceived gender identity" means an observer's impression of another person's actual gender identity or the observer's own impression that the person is male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female. "Transgender person" means a person who has gender dysphoria, has received health care services related to gender transition, or otherwise identifies as a gender different from the gender assigned to that person at birth." SECTION 5. This Act does not affect rights and duties that matured, penalties that were incurred, and proceedings that were begun before its effective date. SECTION 6. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored. SECTION 7. This Act shall take effect upon its approval. INTRODUCED BY: _____________________________
SECTION 1. The legislature finds that since the enactment of Act 39, Session Laws in Hawaii 2022, known and cited as the Gender Affirming Treatment Act, health insurance companies, health maintenance organizations, and mutual benefit societies (collectively referred to as "insurance carriers") have been continuing to deny transgender persons' coverage for gender transition-related medical care, according to reports of patient and providers in the State.
The legislature further finds that the gender transition-related medical care being denied by insurance carriers is often known to be medically necessary, classified as the standard of care according to the World Professional Association for Transgender Health ("WPATH") Standards of Care, and supported by scientific evidence. Moreover, these denials are routinely being overturned through the external review process.
The legislature also finds that since the enactment of the Gender Affirming Treatment Act, WPATH has released Version 8 of its Standards of Care for the Health of Transgender and Gender Diverse People ("SOC8") and these updated guidelines have generally been adopted by insurance carriers across the continental United States. However, insurance carriers in Hawaiʻi have taken varying approaches with adopting SOC8, with some insurance carriers having reached near full adoption and others continuing to lag. This has resulted in transgender persons in Hawaiʻi experiencing different coverage standards for gender affirming care.
The legislature additionally finds that despite the enactment of the Gender Affirming Treatment Act and its transparency requirements, insurance carriers, when denying gender affirming care on the basis of medical necessity, are not consistently providing transparent and thorough information clearly explaining the reason the requested care was deemed not medically necessary.
As well, the legislature finds that the transgender community faces numerous health disparities, among which include an alarmingly increased risk for suicide and suicidal ideation. Research has found that transgender youth are about 4.6 times more likely to attempt suicide and about 13.4 times more likely to have seriously considered suicide recently than cisgender youth. Transgender adults have been found to be about 4.4 times more likely to attempt suicide and about twelve times more likely to have seriously considered suicide recently than cisgender adults. Denials of gender transition-related medical coverage and care contribute to the likelihood of suicide and suicidal ideations. A 2023 federal directive from the Office of Personnel Management underscores the importance of aligning health coverage policies with updated standards of care, including WPATH's latest guidelines.
The legislature therefore finds that the intent of this Act is to better implement the 2022 Gender Affirming Treatment Act. Because this Act does not establish new health insurance requirements, it is not subject to the section 23-51, Hawaii Revised Statutes, review.
Accordingly, the purpose of this Act is to:
(1) Prohibit health insurers, mutual benefit societies, and health maintenance organizations from arbitrarily denying coverage requests for gender affirming care services when the requested care is known to be considered a standard of care for which scientific evidence exists;
(2) Improve transparency of medical necessity reviews by health insurers, mutual benefit societies, and health maintenance organizations and the relevant requirements; and
(3) Codify reasonable standards, protections, and best practices to ensure that the State's transgender and gender diverse population are afforded access to the health care coverage that they need to live and thrive.
SECTION 2. Section 431:10A-118.3, Hawaii Revised Statutes, is amended to read as follows:
"§431:10A-118.3 Nondiscrimination on the basis of actual gender identity or perceived gender identity; coverage for services. (a) No individual or group accident and health or sickness policy, contract, plan, or agreement that provides health care coverage shall discriminate with respect to participation and coverage under the policy, contract, plan, or agreement against any person on the basis of actual gender identity or perceived gender identity.
(b) Discrimination under this section includes the following:
(1) Denying, canceling, limiting, non-renewing or otherwise refusing to issue or renew an insurance policy, contract, plan, or agreement on the basis of a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity;
(2) Demanding or requiring a payment or premium that is based on a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity;
(3) Designating a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity as a preexisting condition to deny, cancel, non-renew or otherwise limit coverage; and
(4) Denying, canceling, or limiting coverage for services on the basis of actual gender identity or perceived gender identity, including but not limited to the following:
(A) Health care services related to gender transition; provided that there is coverage under the policy, contract, plan, or agreement for the services when the services are not related to gender transition; provided further that it shall not be required that a health care service covered for gender transition be routinely available and covered for services not related to gender transition; and
(B) Health care services that are ordinarily or exclusively available to individuals of any sex[.] or of any gender assigned at birth.
(c) The medical necessity of any [treatment] health care service for a transgender person, or any person, on the basis of actual gender identity or perceived gender identity shall be determined pursuant to the insurance policy, contract, plan, or agreement and shall [be defined in accordance with] take into account the recommendations in the most recent edition of the Standards of Care for the Health of Transgender and Gender Diverse People, issued by the World Professional Association for Transgender Health, and other applicable law. No health care service shall be deemed not medically necessary on the basis that the person's actual or perceived gender identity may be classified as a behavioral health condition.
(d) No health care service shall be denied coverage on the basis that it is cosmetic or not medically necessary unless a health care provider or mental health professional with current experience in prescribing or delivering gender affirming care services first reviews and confirms the appropriateness of the adverse benefit determination. In the event of a denial of coverage on the basis that a service is cosmetic or not medically necessary, unless otherwise prohibited by law, the denial shall, without requiring a separate request, include the following:
(1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and
(2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage.
(e) In the event of an appeal of a claim denied on the basis of medical necessity of the [treatment, such] service, the appeal shall be [decided in a manner consistent with applicable law and] reviewed for medical necessity in consultation with a health care provider or mental health professional with current experience in prescribing or delivering gender affirming [treatment who shall provide input on the appropriateness of the denial of the claim.] care services. In the event an appeal upholds a denial on the basis of medical necessity, unless otherwise prohibited by law, the appeal determination shall, without requiring a separate request, include the following:
(1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and
(2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage.
[(d)] (f) An insurer shall not apply categorical cosmetic or blanket exclusions to gender affirming [treatments] care services or procedures, or any combination of services or procedures or revisions to prior [treatments, when determined to be medically necessary pursuant to applicable law, only] services or procedures, if the policy, contract, plan, or agreement also provides coverage for those services or procedures when the services or procedures are offered for purposes other than gender transition. It shall not be required that a health care service or procedure covered for gender transition also be routinely available and covered for services or procedures not related to gender transition. These services and procedures may include but are not limited to:
(1) Hormone therapies;
(2) Hysterectomies;
(3) Mastectomies;
(4) Vocal training;
(5) Feminizing vaginoplasties;
(6) Masculinizing phalloplasties;
(7) Metaoidioplasties;
(8) [Breast] Feminizing breast surgeries, including augmentations;
(9) Masculinizing chest surgeries;
(10) [Facial feminization] Gender affirming facial surgeries[;], including feminizing and masculinizing surgeries;
(11) Reduction thyroid chondroplasties;
(12) Voice surgeries and therapies; and
(13) Electrolysis [or] and laser hair removal[.], not to be limited to pre-surgical hair removal.
[(e)] (g) Each individual or group accident and health or sickness policy, contract, plan, or agreement shall provide applicants and policyholders with clear information about the coverage of gender transition services and the requirements for determining medically necessary [treatments related to these] services, including the process for appealing a claim denied on the basis of medical necessity. The information required by this subsection shall also be made available on a publicly accessible website.
[(f)] (h) Any coverage provided shall be subject to copayment, deductible, and coinsurance provisions of an individual or group accident and health or sickness policy, contract, plan, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the policy, contract, plan, or agreement.
[(g)] (i) Nothing in this section shall be construed to mandate coverage of a service that is determined to be not medically necessary[.]; provided that the determination has been made in accordance with this section.
[(h)] (j) As used in this section unless the context requires otherwise:
"Actual gender identity" means a person's internal sense of being male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.
"Gender transition" means the process of a person changing the person's outward appearance or sex characteristics to accord with the person's actual gender identity.
"Perceived gender identity" means an observer's impression of another person's actual gender identity or the observer's own impression that the person is male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.
"Transgender person" means a person who has gender dysphoria, has received health care services related to gender transition, or otherwise identifies as a gender different from the gender assigned to that person at birth."
SECTION 3. Section 432:1-607.3, Hawaii Revised Statutes, is amended to read as follows:
"§432:1-607.3 Nondiscrimination on the basis of actual gender identity or perceived gender identity; coverage for services. (a) No individual or group hospital or medical service policy, contract, plan, or agreement that provides health care coverage shall discriminate with respect to participation and coverage under the policy, contract, plan, or agreement against any person on the basis of actual gender identity or perceived gender identity.
(b) Discrimination under this section includes the following:
(1) Denying, canceling, limiting, non-renewing or otherwise refusing to issue or renew an insurance policy, contract, plan, or agreement on the basis of a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity;
(2) Demanding or requiring a payment or premium that is based on a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity;
(3) Designating a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity as a preexisting condition to deny, cancel, non-renew or otherwise limit coverage; and
(4) Denying, canceling, or limiting coverage for services on the basis of actual gender identity or perceived gender identity, including but not limited to the following:
(A) Health care services related to gender transition; provided that there is coverage under the policy, contract, plan, or agreement for the services when the services are not related to gender transition; provided further that it shall not be required that a health care service covered for gender transition be routinely available and covered for services not related to gender transition; and
(B) Health care services that are ordinarily or exclusively available to individuals of any sex[.] or of any gender assigned at birth.
(c) The medical necessity of any [treatment] health care service for a transgender person, or any person, on the basis of actual gender identity or perceived gender identity shall be determined pursuant to the hospital or medical service policy, contract, plan, or agreement and shall [be defined in accordance with] take into account the recommendations in the most recent edition of the Standards of Care for the Health of Transgender and Gender Diverse People, issued by the World Professional Association for Transgender Health, and other applicable law. No health care service shall be deemed not medically necessary on the basis that the person's actual or perceived gender identity may be classified as a behavioral health condition.
(d) No health care service shall be denied coverage on the basis that it is cosmetic or not medically necessary unless a health care provider or mental health professional with current experience in prescribing or delivering gender affirming care services first reviews and confirms the appropriateness of the adverse benefit determination. In the event of a denial of coverage on the basis that a service is cosmetic or not medically necessary, unless otherwise prohibited by law, the denial shall, without requiring a separate request, include the following:
(1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and
(2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage.
(e) In the event of an appeal of a claim denied on the basis of medical necessity of the [treatment, such] service, the appeal shall be [decided in a manner consistent with applicable law and] reviewed for medical necessity in consultation with a health care provider or mental health professional with current experience in prescribing or delivering gender affirming [treatment who shall provide input on the appropriateness of the denial of the claim.] care services. In the event an appeal upholds a denial on the basis of medical necessity, unless otherwise prohibited by law, the appeal determination shall, without requiring a separate request, include the following:
(1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and
(2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage.
[(d)] (f) A mutual benefit society shall not apply categorical cosmetic or blanket exclusions to gender affirming [treatments] care services or procedures, or any combination of services or procedures or revisions to prior [treatments, when determined to be medically necessary pursuant to applicable law, only] services or procedures, if the policy, contract, plan, or agreement also provides coverage for those services or procedures when the services or procedures are offered for purposes other than gender transition. Is shall not be required that a health care service or procedure covered for gender transition also be routinely available and covered for services or procedures not related to gender transition. These services and procedures may include but are not limited to:
(1) Hormone therapies;
(2) Hysterectomies;
(3) Mastectomies;
(4) Vocal training;
(5) Feminizing vaginoplasties;
(6) Masculinizing phalloplasties;
(7) Metaoidioplasties;
(8) [Breast] Feminizing breast surgeries, including augmentations;
(9) Masculinizing chest surgeries;
(10) [Facial feminization] Gender affirming facial surgeries[;], including feminizing and masculinizing surgeries;
(11) Reduction thyroid chondroplasties;
(12) Voice surgeries and therapies; and
(13) Electrolysis [or] and laser hair removal[.], not to be limited to pre-surgical hair removal.
[(e)] (g) Each individual or group hospital or medical service policy, contract, plan, or agreement shall provide applicants and members with clear information about the coverage of gender transition services and the requirements for determining medically necessary [treatments related to these] services, including the process for appealing a claim denied on the basis of medical necessity. The information required by this subsection shall also be made available on a publicly accessible website.
[(f)] (h) Any coverage provided shall be subject to copayment, deductible, and coinsurance provisions of an individual or group hospital or medical service policy, contract, plan, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the policy, contract, plan, or agreement.
[(g)] (i) Nothing in this section shall be construed to mandate coverage of a service that is determined to be not medically necessary[.]; provided that the determination has been made in accordance with this section.
[(h)] (j) As used in this section unless the context requires otherwise:
"Actual gender identity" means a person's internal sense of being male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.
"Gender transition" means the process of a person changing the person's outward appearance or sex characteristics to accord with the person's actual gender identity.
"Perceived gender identity" means an observer's impression of another person's actual gender identity or the observer's own impression that the person is male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.
"Transgender person" means a person who has gender dysphoria, has received health care services related to gender transition, or otherwise identifies as a gender different from the gender assigned to that person at birth."
SECTION 4. Section 432D-26.3, Hawaii Revised Statutes, is amended to read as follows:
"§432D-26.3 Nondiscrimination on the basis of actual gender identity or perceived gender identity; coverage for services. (a) No health maintenance organization policy, contract, plan, or agreement shall discriminate with respect to participation and coverage under the policy, contract, plan, or agreement against any person on the basis of actual gender identity or perceived gender identity.
(b) Discrimination under this section includes the following:
(1) Denying, canceling, limiting, non-renewing or otherwise refusing to issue or renew an insurance policy, contract, plan, or agreement on the basis of a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity;
(2) Demanding or requiring a payment or premium that is based on a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity;
(3) Designating a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity as a preexisting condition to deny, cancel, non-renew or otherwise limit coverage; and
(4) Denying, canceling, or limiting coverage for services on the basis of actual gender identity or perceived gender identity, including but not limited to the following:
(A) Health care services related to gender transition; provided that there is coverage under the policy, contract, plan, or agreement for the services when the services are not related to gender transition; provided further that it shall not be required that a health care service covered for gender transition be routinely available and covered for services not related to gender transition; and
(B) Health care services that are ordinarily or exclusively available to individuals of any sex[.] or of any gender assigned at birth.
(c) The medical necessity of any [treatment] health care service for a transgender person, or any person, on the basis of actual gender identity or perceived gender identity shall [be defined in accordance with] take into account the recommendations in the most recent edition of the Standards of Care for the Health of Transgender and Gender Diverse People, issued by the World Professional Association for Transgender Health, and other applicable law. No health care service shall be deemed not medically necessary on the basis that the person's actual or perceived gender identity may be classified as a behavioral health condition.
(d) No health care service shall be denied coverage on the basis that it is cosmetic or not medically necessary unless a health care provider or mental health professional with current experience in prescribing or delivering gender affirming care services first reviews and confirms the appropriateness of the adverse benefit determination. In the event of a denial of coverage on the basis that a service is cosmetic or not medically necessary, unless otherwise prohibited by law, the denial shall, without requiring a separate request, include the following:
(1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and
(2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage.
(e) In the event of an appeal of a claim denied on the basis of medical necessity of the [treatment, such] service, the appeal shall be [decided in a manner consistent with applicable law and] reviewed for medical necessity in consultation with a health care provider or mental health professional with current experience in prescribing or delivering gender affirming [treatment who shall provide input on the appropriateness of the denial of the claim.] care services. In the event an appeal upholds a denial on the basis of medical necessity, unless otherwise prohibited by law, the appeal determination shall, without requiring a separate request, include the following:
(1) The training and expertise held by the individuals who determined the service to be cosmetic or not medically necessary; and
(2) A statement, in plain language, explaining the reason the service was determined to be cosmetic or not medically necessary that is specific to the person requesting the coverage.
[(d)] (f) A health maintenance organization shall not apply categorical cosmetic or blanket exclusions to gender affirming [treatments] care services or procedures, or any combination of services or procedures or revisions to prior [treatments, when determined to be medically necessary pursuant to applicable law, only] services or procedures, if the policy, contract, plan, or agreement also provides coverage for those services or procedures when the services or procedures are offered for purposes other than gender transition. It shall not be required that a health care service or procedure covered for gender transition also be routinely available and covered for services or procedures not related to gender transition. These services and procedures may include but are not limited to:
(1) Hormone therapies;
(2) Hysterectomies;
(3) Mastectomies;
(4) Vocal training;
(5) Feminizing vaginoplasties;
(6) Masculinizing phalloplasties;
(7) Metaoidioplasties;
(8) [Breast] Feminizing breast surgeries, including augmentations;
(9) Masculinizing chest surgeries;
(10) [Facial feminization] Gender affirming facial surgeries[;], including feminizing and masculinizing surgeries;
(11) Reduction thyroid chondroplasties;
(12) Voice surgeries and therapies; and
(13) Electrolysis [or] and laser hair removal[.], not to be limited to pre-surgical hair removal.
[(e)] (g) Each health maintenance organization policy, contract, plan, or agreement shall provide applicants and subscribers with clear information about the coverage of gender transition services and the requirements for determining medically necessary [treatments related to these] services, including the process for appealing a claim denied on the basis of medical necessity. The information required by this subsection shall be made available on a publicly accessible website.
[(f)] (h) Any coverage provided shall be subject to copayment, deductible, and coinsurance provisions of a health maintenance organization policy, contract, plan, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the policy, contract, plan, or agreement.
[(g)] (i) Nothing in this section shall be construed to mandate coverage of a service that is determined to be not medically necessary[.]; provided that the determination has been made in accordance with this section.
[(h)] (j) As used in this section unless the context requires otherwise:
"Actual gender identity" means a person's internal sense of being male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.
"Gender transition" means the process of a person changing the person's outward appearance or sex characteristics to accord with the person's actual gender identity.
"Perceived gender identity" means an observer's impression of another person's actual gender identity or the observer's own impression that the person is male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.
"Transgender person" means a person who has gender dysphoria, has received health care services related to gender transition, or otherwise identifies as a gender different from the gender assigned to that person at birth."
SECTION 5. This Act does not affect rights and duties that matured, penalties that were incurred, and proceedings that were begun before its effective date.
SECTION 6. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.
SECTION 7. This Act shall take effect upon its approval.
INTRODUCED BY: _____________________________
INTRODUCED BY:
_____________________________
Report Title: Gender Affirming Treatment Act; Insurance; Nondiscrimination; Transgender; Gender Affirming Care Services Description: Prohibits health insurers, mutual benefit societies, and health maintenance organizations from arbitrarily denying coverage requests for gender affirming health care services when the requested service is known to be considered a standard of care and for which scientific evidence exists that supports the service. Increases transparency of insurance carrier medical necessity reviews and requirements when coverage is denied. The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.
Report Title:
Gender Affirming Treatment Act; Insurance; Nondiscrimination; Transgender; Gender Affirming Care Services
Description:
Prohibits health insurers, mutual benefit societies, and health maintenance organizations from arbitrarily denying coverage requests for gender affirming health care services when the requested service is known to be considered a standard of care and for which scientific evidence exists that supports the service. Increases transparency of insurance carrier medical necessity reviews and requirements when coverage is denied.
The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.