In an effort to promote equal access to healthcare and coverage, the New Jersey Department of Banking and Insurance has published Bulletin No. 23-05 following Governor Murphy’s issuance of Executive Order 326, “Protecting Gender-Affirming Health Care in New Jersey”. This bulletin serves as a reminder to all insurance companies authorized to issue health benefits plans, hospital service corporations, medical service corporations, health service corporations, and health maintenance organizations about their obligations to provide nondiscriminatory coverage for transgender individuals.
The bulletin outlines specific acts that are prohibited including:
- carriers are prohibited from maintaining broad, blanket, or categorical exclusions, provisions, or definitions that effectively eliminate transition-related care from coverage.
- carriers cannot deny or limit coverage for medically necessary transition-related care while providing coverage for similar services related to other conditions.
- carriers must not deny or limit coverage or deny authorizations and claims for healthcare services that are ordinarily or exclusively available to individuals of one sex solely based on a person’s gender identity or expression or because they are transgender.
- carriers cannot impose extra premiums on transgender individuals seeking transition-related care or seek additional out-of-pocket cost or incur expenses beyond what a covered person who is not transgender would pay.
- carriers are also prohibited from treating a person’s gender identity as a pre-existing condition for which coverage will be denied or limited.
Consumer Information and Network Providers
Carriers are expected to provide consumers with clear information regarding coverage for transition-related care, and clinical criteria guidelines related to medical necessity determinations must be available on the carrier’s website. Carriers may not apply a different medical necessity review process, or impose extra documentation requirements, for transgender individuals relative to other individuals seeking the same or similar services.
Further carriers are required to maintain an adequate network of healthcare providers who will offer all covered services to individuals regardless of their gender identity or expression.
The Department of Banking and Insurance’s Bulletin serves as a reminder to insurance companies of their obligations to provide nondiscriminatory coverage for transgender individuals. Despite guidance, executive orders, and enforcement action for violating Federal and State laws, carriers’ lack of compliance can be the barrier to fair reimbursement for healthcare providers’ administering patient care. This bulletin serves as a reminder for providers to aggressively dispute any delay tactics, denial of authorizations, and/or under-reimbursement of claims post services rendered by the carriers.