Commissioner Lara takes proactive step to ensure transgender youth have access to gender-affirming medical care for gender dysphoria

News: 2020 Press Release

LOS ANGELES, Calif. — Today, Insurance Commissioner Ricardo Lara directed the Department of Insurance 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 gender-affirming care for gender dysphoria based solely on a patient’s age.

“For far too long, individuals diagnosed with gender dysphoria have had to battle a host of challenges to get access to gender-affirming care in order to be their true selves,” said Commissioner Lara. “Social stigma, misconceptions about gender dysphoria and its treatment, and outdated medical criteria create barriers to necessary medical care that can lead to tragic results for individuals with gender dysphoria, especially for our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.”

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 independent medical 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 Support Services 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.

“TransFamily Support Services is proud to partner with the California Department of Insurance to remove the age barrier for gender-affirming care,” said Kathie Moehlig, Executive Director at TransFamily Support Services. “This barrier was discriminatory and detrimental to the lives of trans youth. To have to navigate the overwhelming barriers to health care should not be a part of their experience. Transgender youth already face so many challenges from unsupportive families, bullying at school, social stigmas, and even violence.”

Additionally, imposing strict age limits on coverage of male chest reconstruction surgery when it is requested to treat gender dysphoria but not other medical conditions, such as breast cancer or trauma, constitutes discrimination in health coverage based on age, sex, gender identity, gender expression, sexual orientation, and health conditions in violation of state and federal law.

"Today the State of California has put insurance companies on notice that they cannot deny access to medically-necessary care based on outdated rules that are not supported by evidence or scientific consensus,” said Dr. Ward Carpenter, Co-Director of Health Services at the Los Angeles LGBT Center. “In so doing, the state not only expands access to health care but also takes an important step in saving the lives of transgender and non-binary (TGNB) adolescents struggling with gender dysphoria, depression and suicidal thoughts. Decisions about an adolescent’s health must be left to the patient, their families and their care providers, not to insurance companies." 

The World Professional Association for Transgender Health, an international professional association that provides evidence-based standards of care for transgender people, states that male chest reconstruction surgery to treat gender dysphoria could be carried out in individuals under 18 “depending on an adolescent’s specific clinical situation and goals for gender identity expression.” The use of rigid age criteria in determining medical necessity, and thus insurance coverage, for female-to-male chest reconstruction surgery does not allow consideration of each individual’s unique clinical situation, contrary to the generally accepted standards of care for transgender health and the requirements of state and federal law.

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Media note:

General Counsel’s Opinion Letter, Gender Dysphoria Surgery