The U.S. Court of Appeals for the 4th Circuit (Court) has handed down a decision which reinstates the State Health Plan’s (Plan) longstanding exclusion of transition-related treatments from coverage. This stems from the Kadel v. Folwell case, which has now been sent back to the district court for further consideration.
The exclusion dates back to the 1990s, and while litigation has been ongoing it has continued to appear in the annual list of exclusions for Plan members, even though it was inactive. The Court’s decision to vacate the district court’s earlier ruling means the exclusion becomes active again. The Plan communicated this anticipated action in June.
Generally, the exclusion does not prevent the treatment of any infection, injury, disease, disorder or complication that has been caused by or exacerbated by the performance of gender transition medical or pharmaceutical procedures. Additionally, in 2021, the Plan’s Board of Trustees affirmed continued coverage for psychological assessment and psychotherapy treatment in conjunction with a diagnosis of or connected to gender dysphoria. The reimplemented benefit exclusion does not exclude psychological assessment and psychotherapy treatment in these cases.
Plan staff is now working with our third-party administrator and health care providers to make sure this decision is fully communicated to all members affected by the reinstatement.
Under S.L. 2023-111 § 5, the Plan is also now required to comply with the prohibition in N.C. Gen. Stat. § 143C-6-5.6.