I surveyed existing options in Massachusetts and Rhode Island, and then examined those states which have mandates or guidance on transgender health insurance coverage and provisions to gather a collection of that guidance. 22 states and DC currently have guidance.
I'm working from the standpoint of facial feminization surgery, because it's commonly considered cosmetic; It's a convenient basis for comparing coverage.
What I learned is that the Deval Patrick guidance did not specify a list of services, and a number of (small) providers in Massachusetts have a less expansive coverage offering; The difference seems to be that MassHealth's coverage includes the more expansive list of surgical interventions. The comparable Rhode Island program is less extensive, and it may well be that the difference stems from that.
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There are only four providers who issue health insurance in Rhode Island. Rhode Island health insurer gender dysphoria provisions:
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Blue Cross and Blue Shield of Rhode Island considers facial feminization surgery to be cosmetic [https://www.bcbsri.com/providers/sites/providers/files/policies/2019/12/2019%20Gender%20Reassignment%20Surgery.pdf]
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Neighborhood Health Plan excludes facial feminiation surgeries Excluded procedures include but are not limited to the following: Cosmetic Surgeries and Procedures (Refer to CMP Plastic Surgery), [...] Osteoplasty - facial bone reduction, Otoplasty, Rhinoplasty [https://www.nhpri.org/wp-content/uploads/2019/04/CMP-069-GenderDysphoriaTreatment.pdf]
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Tufts excludes facial surgery for RITogether (Medicaid) plans and does not sell direct to individuals in Rhode Island [https://tuftshealthplan.com/documents/providers/guidelines/medical-necessity-guidelines/transgender-surgery]
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United Healthcare considers facial surgery to be cosmetic [https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/gender-dysphoria-treatment-cs.pdf]
Massachusetts has more providers, but these were easy enough to find information for and include the 3 which are easily largest, have much more expansive coverage.
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AllWays Health Partners, facial procedures covered [https://resources.allwayshealthpartners.org/medicalpolicy/GenderAffirmingProcedures.pdf]
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Blue Cross of Massachusetts, facial procedures covered [https://www.bluecrossma.com/common/en_US/medical_policies/189%20Gender%20Affirming%20Services%20(Transgender%20Services)%20prn.pdf]
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Harvard Pilgrim, facial procedures covered [https://www.harvardpilgrim.org/pls/portal/docs/PAGE/PROVIDERS/MEDMGMT/MEDICAL_CLINICALPOLICIES/TRANSGENDERSERVICES_01JUL20_VER.%20D_P.PDF]
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Tufts, facial feminization covered [https://tuftshealthplan.com/documents/providers/guidelines/medical-necessity-guidelines/transgender-surgery]
And Medicaid:
MassHealth's includes this coverage [https://www.mass.gov/doc/gender-affirming-surgery/download]
Comparable Rhode Island program coverage statement [http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/MA%20Providers/MA%20Reference%20Guides/Physician/gender_dysphoria.pdf]
In general, affirmation by states of ACA section 1557 prohibits discrimination based on sex, which effectively means that covered services for non-transgender clients must also be covered for transgender clients. However, transgender folks have needs that are not typically covered for others as they are not procedures which non-transgender folks need, so it's not sufficient.
A common guideline is that for gender dysphoria as defined as a mental health disorder in the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Health Disorders" (DSM), which is currently in it's 5th edition.
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California, based on state gender non-discrimination law and by direction of the Department of Insurance and the Department of Managed Care [https://www.dmhc.ca.gov/Portals/0/LawsAndRegulations/DirectorsLettersAndOpinions/dl12k.pdf]
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Colorado, relies on anti-discrimination provisions of state law [https://one-colorado.org/wp-content/uploads/2017/06/B-4.49.pdf]
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Connecticut, based on state law and requiring coverage based on DSM 5's description of gender dysphoria. [https://portal.ct.gov/-/media/CID/BulletinIC37GenderIdentityNondiscriminationRequirementspdf.pdf?la=en] and with an additional ruling by the state commission on Human Rights and Opportunities prohibiting denying coverage of transition treatments [https://www.glad.org/wp-content/uploads/2020/04/Dec-Rule_04152020.pdf]
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Delaware, based on state gender identity nondiscrimination act and calls out blanket surgical exclusion as unacceptable [https://insurance.delaware.gov/wp-content/uploads/sites/15/2016/11/domestic-foreign-insurers-bulletin-no86.pdf]
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District of Columbia, based on DC unfair trade practices act, calls out blanket exclusion language [https://disb.dc.gov/sites/default/files/dc/sites/disb/publication/attachments/Bulletin13-IB-01-30-15.pdf]
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Hawaii, specific law codifying non-discrimination for insurance coverage based on real or perceived gender identity [https://www.capitol.hawaii.gov/session2016/bills/HB2084_SD1_.htm]
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Illinois, based on ACA and a list of state-mandated minimum benefits [https://insurance.illinois.gov/cb/2014/CB2014-10.pdf] and a supplement which calls out as discriminatory provisions that exclude from, limit, charge a higher rate for, or deny a claim for coverage for the surgical treatments for gender dysphoria; [https://insurance.illinois.gov/cb/2020/CB2020-16.pdf]
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Maryland, based on ACA and 45 CFR ss156.200(e): The formerly permissible exclusion which reads “treatment leading to or in connection with transsexualism, or sex changes or modifications, including, but not limited to surgery,” which is found on pages B49 and B50 of the 2017 benchmark plan and originally permitted by COMAR 31.11.06.06B(32), is required to be deleted as federal guidance has determined that this type of exclusion is a discriminatory benefit design prohibited by 45 CFR § 156.200(e).[https://insurance.maryland.gov/Insurer/Documents/bulletins/15-33_2017-ACA-Rate-Form-Filing-Deadlines-and-Substitution-Rules.pdf]
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Massachusetts, based on state gender identity discrimination law and ACA 1557 [https://www.mass.gov/doc/bulletin-2014-03-guidance-regarding-prohibited-discrimination-on-the-basis-of-gender-identity-0/download]
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Michigan, insurers must use 2017 EHB benchmark plan for minimum coverage and blanket exclusions are prohibited. [https://www.michigan.gov/documents/difs/Bulletin_2016-10-INS_516961_7.pdf]
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Minnesota, based on ACA 1557 but specifically calls out that gender confirmation surgery is considered medically necessary: Commerce and Health currently disapprove policy forms filed by insurers if there are exclusions on coverage for medically necessary treatment for gender dysphoria and related health conditions, including gender confirmation surgery (previously known as sex reassignment surgery). [https://mn.gov/commerce-stat/pdfs/bulletin-insurance-2015-5.pdf]
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Montana, based on ACA and state law. Health cares services related to the treatment of gender dysphoria are medically necessary for transgender people and are not "cosmetic." [...] including gender confirmation surgery [http://csimt.gov/wp-content/uploads/2017formfilingmemo.pdf]
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Nevada, based on state statutes [http://doi.nv.gov/uploadedFiles/doinvgov/_public-documents/News-Notices/Bulletins/Bulletin%2015-002.pdf]
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New Hampshire, gender identity law, and Department of Insurance guidance that blanket policy exclusions for health care services related to gender transition of any other form of gender dysphoria treatment [...] discriminate on the basis of gender identity [https://www.nh.gov/insurance/media/bulletins/2020/documents/ins-20-033-ab-gender-identity-discrimination-prohibited.pdf]
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New Jersey, direct legal mandate [https://www.njleg.state.nj.us/2016/Bills/S3500/3017_R1.HTM]
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New Mexico, refers to ACA and New Mexico Human Rights act. [https://www.osi.state.nm.us/wp-content/uploads/2019/06/Bulletin2018-013.pdf]
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New York, refers to the DSM, suggests gender dysphoria treatment can be reviewed for medical necessity but offers specific appeal rights. ,[https://www.dfs.ny.gov/insurance/circltr/2014/cl2014_07.htm]
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Oregon, based on state law on gender identity issues [https://dfr.oregon.gov/laws-rules/Documents/Bulletins/bulletin2012-01.pdf]
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Pennsylvania, based on ACA 1557 [http://www.pacodeandbulletin.gov/Display/pabull?file=/secure/pabulletin/data/vol46/46-18/762.html]
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Rhode Island, based on ACA 1557 and existing laws regarding sex and gender identity discrimination [http://www.ohic.ri.gov/documents/Bulletin-2015-3-Guidance-Regarding-Prohibited-Discrimination.pdf]
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Vermont, relies on state Department of Financial Regulation minimum standards for insurance, includes qualification that plans shall not exclude coverage for medically necessary treatment including gender affirmation surgery for gender dysphoria and related health conditions. In addition, insurers may not deny coverage of gender affirmation surgery as not medically necessary on the basis of age without other clinical factors or circumstances supporting the decision [https://dfr.vermont.gov/reg-bul-ord/guidance-regarding-prohibited-discrimination-basis-gender-identity-including-medically]
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Washington, based on ACA 1557 [https://www.insurance.wa.gov/sites/default/files/documents/gender-identity-discrimination-letter.pdf] and supplemented [https://www.insurance.wa.gov/sites/default/files/documents/final-letter-health-carriers-transgender-protection-non-discrimination.pdf]
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Wisconsin, based on ACA 1557 and Wisconsin statutes [https://oci.wi.gov/Documents/Regulation/Bulletin20200629Nondiscrimination.pdf]