Health plan coverage of gender-affirming treatment under ORS 743A.325 and OAR 836-053-0441
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Guidance for health benefit plans and carriers in Oregon on coverage, network adequacy, cost-sharing, and reviewer training requirements for medically necessary gender-affirming treatment under ORS 743A.325 and OAR 836-053-0441.
This bulletin supersedes Bulletin DFR 2024-2, which is withdrawn as of the effective date of OAR 836-053-0441 (January 1, 2025).
OAR 836-053-0441 adopts WPATH-8 as the minimum standard of care that carriers must follow when determining coverage for gender-affirming treatments.
Carriers must ensure reviewers completing adverse benefit determinations complete the WPATH SOC-8 Health Plan Providers training program or an equivalent by September 1, 2025 (with enforcement discretion).
Carriers may not apply categorical cosmetic or blanket exclusions to medically necessary gender-affirming treatment and must cover treatments prescribed according to accepted standards of care.
If in-network gender-affirming services are unavailable or subject to unreasonable delay, carriers must allow out-of-network access with cost-sharing no greater than in-network amounts.
Coverage Criteria for Gender-Affirming Treatment
Medically Necessary Gender-Affirming Treatment
Covered when ALL of the following are met
Medical necessity determinations are made by treating providers; DCBS does not adjudicate clinical appropriateness.
Carriers may implement utilization review for out-of-network authorizations consistent with Oregon law.
The bulletin establishes WPATH-8 as the minimum standard of care that carriers must use when determining coverage for gender-affirming treatments. This means carriers may not deny coverage for a service that is recommended by WPATH-8 when it is appropriately prescribed by a physical or behavioral health care provider. At the same time, carriers should continue to consult all relevant clinical guidelines and evidence and may cover treatments recommended by other accepted standards of care when those treatments are medically necessary.
The bulletin notes that a small number of items referenced in WPATH-8 are not described as clinical best practices and may be considered experimental or investigational in current practice. An example given is uterine transplantation, which appears in WPATH-8 but is not recommended as a standard of care. For such items carriers should evaluate medical necessity against the latest clinical evidence and may treat coverage on a case-by-case basis.
Provider Requirements, Network, and Authorization Rules
Ensure network adequacy or authorize out‑of‑network with in‑network cost‑sharing
Carriers must ensure enrollees can access gender-affirming treatment either by maintaining an adequate in-network provider network or by authorizing out-of-network services when in-network providers are unavailable or cause unreasonable delay; when out-of-network authorization is required, the enrollee’s cost-sharing must not exceed the in‑network cost‑sharing that would have applied.
- Carriers should contract with sufficient numbers and geographically distributed gender-affirming treatment providers to avoid unreasonable delay.
- If the carrier cannot meet network adequacy for an enrollee, the carrier must allow out-of-network access and ensure cost-sharing parity with in‑network services.
- Carriers may use utilization review to authorize out‑of‑network services consistent with OAR 836-053-0441 and other Oregon law.
Do not apply step therapy to block WPATH‑8‑recommended services
The bulletin does not permit step therapy requirements that would prevent coverage of services recommended by WPATH‑8 when those services are appropriately prescribed by a physical or behavioral health care provider.
- Carriers may consult other clinical guidelines but may not deny coverage for a service recommended by WPATH‑8 if prescribed appropriately.
- No step-therapy sequencing in this bulletin may be applied to block WPATH‑8‑recommended care.
Treating provider must determine medical necessity per accepted standards
Medical necessity determinations for gender-affirming treatment must be made by the physical or behavioral health care provider who prescribes the treatment and must be prescribed in accordance with accepted standards of care (minimum WPATH‑8); carriers may not apply categorical cosmetic or blanket exclusions to medically necessary treatments.
- Treating providers — physical or behavioral health care providers who prescribe the treatment — make medical necessity determinations.
- Accepted standards of care include WPATH‑8 as the minimum; carriers should cover treatments prescribed according to other accepted standards when medically necessary.
- Categorical cosmetic or blanket exclusions (e.g., tracheal shave, facial feminization) may not be used to deny medically necessary gender‑affirming care.
Require experienced provider review before issuing denials or limitations
Carriers may not issue adverse benefit determinations denying or limiting access to medically necessary gender‑affirming treatment unless a physical or behavioral health care provider with experience prescribing or delivering gender‑affirming treatment in accordance with accepted standards of care first reviews and approves the denial or limitation.
- Reviewer pre‑approval by an experienced prescribing/delivering provider is required before any denial or limitation is issued.
- This requirement applies to any adverse benefit determination that would deny or limit access to gender‑affirming treatment.
Key Definitions
Background and Legal Context
ORS 743A.325 and OAR 836-053-0441 require carriers to cover medically necessary gender-affirming treatments as determined by the treating provider and prescribed according to accepted standards of care, with WPATH-8 adopted as the baseline minimum standard. The rule is intended to ensure consistent and equitable coverage across the market while allowing carriers to consider other accepted standards and evolving evidence when assessing medical necessity.
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