Relating to required health benefit plan coverage for gender transition adverse effects and reversals.

Contracts

• Carrier/TPA Agreements: Fully insured and non-ERISA self-funded entities must amend plan documents to explicitly include coverage for "reversal," "reconstruction," and "adverse effects."
• Network Agreements: Review provider networks for adequacy regarding reconstructive surgery and endocrinology. If in-network providers cannot perform complex reversals, plans may be contractually forced to execute Single Case Agreements (SCAs) at higher out-of-network rates.

Hiring/Training

• Utilization Review (UR): Train UR staff to decouple biological screenings from gender markers. For example, a claim for a pap smear on a patient with a "Male" gender marker must not be auto-denied if the anatomy is present.
• Claims Adjudication: Claims processors must be retrained to distinguish between "cosmetic" procedures and statutorily mandated "reconstructive" surgeries related to transition reversals.

Reporting & Record-Keeping

• Plan History Audits: You must document historical coverage. The law applies if a plan "has ever provided" transition coverage. You must retain records proving whether transition benefits were offered in prior years to determine current liability.
• 2026 Plan Documents: Summary Plan Descriptions (SPDs) and Evidence of Coverage (EOC) must be updated to list these specific benefits to avoid ambiguity disputes during claims processing.

Fees & Costs

• Premium Adjustments: Carriers will likely adjust premiums for the 2026 plan year to account for the expanded liability tail, particularly for reconstructive surgeries previously categorized as cosmetic.
• Claims Liability: Expect an increase in claims for corrective procedures for patients who transitioned under prior policies, as the mandate attaches to the current insurer.