Thursday, August 15, 2024
DMHC Fines Blue Cross of California $850,000 for Illegally Limiting Coverage of Gender Dysphoria Services
(Sacramento) – The California Department of Managed Health Care (DMHC) has taken enforcement actions, including a total of $850,000 in fines, against Blue Cross of California Partnership Plan, Inc. and Blue Cross of California (Anthem Blue Cross) for illegally limiting the coverage of services to treat gender dysphoria for health plan members. The plans have agreed to pay the penalties, which include a $400,000 fine for Blue Cross of California Partnership Plan, Inc. and a $450,000 fine for Anthem Blue Cross. In addition, both plans are required to take corrective actions to comply with the law and revise guidelines to remove the barriers to care for health plan members diagnosed with gender dysphoria and seeking treatment.
“California law protects health plan members from gender discrimination and prohibits health plans from refusing to provide health benefits to an individual, or from limiting or excluding benefits, on the basis of the individual’s sex or gender identity,” said DMHC Director Mary Watanabe. “The DMHC found the plans wrongfully denied health plan members’ requests for treatment for gender dysphoria. The plans have agreed to change their policies to comply with the law, and ensure members receive medically necessary care.”
PROTECTIONS IN THE LAW: California law prohibits discrimination in health care per the Insurance Gender Nondiscrimination Act (IGNA). IGNA prohibits health plans from refusing to provide health benefits to an individual, or from limiting or excluding benefits, on the basis of the individual’s sex or gender identity. IGNA requires health plans to provide transgender individuals with the same coverage benefits that are available to non-transgender individuals.
The plans used guidelines that placed limits or exclusions on several procedures related to treatment of gender dysphoria, which did not comply with IGNA. This included exclusions for procedures including facial feminization, laser hair removal/electrolysis, voice modification surgery, and voice therapy.
PLANS TAKE CORRECTIVE ACTION: Blue Cross of California Partnership Plan, Inc. and Anthem Blue Cross have acknowledged their failure to comply with the law and agreed to pay the penalties and complete Corrective Action Plans (CAPs) to settle the issue. The CAPs include revisions to their guidelines to remove categorical limitations for transgender services. Additionally, the plans have completed audits of denials of requests for services related to gender dysphoria and have offered members rereview of previous denials. Also, the plans will retrain clinical review staff and dedicate a full-time case manager to address the needs of health plan members diagnosed with gender dysphoria. Finally, Anthem Blue Cross will implement a program designed to assist LGBTQIA+ members with appropriate and inclusive access to care.
WHAT HEALTH PLAN MEMBERS CAN DO: The DMHC encourages health plan members experiencing issues with their health plan, including denials, delays or modifications of requested health care services, to file a complaint, also called an appeal or grievance, with their health plan. If the member does not agree with their health plan's response or the plan takes more than 30 days to fix the problem for non-urgent issues, the DMHC Help Center can work with the member and health plan to resolve the issue. If a health plan member is experiencing an urgent issue, they should contact the DMHC Help Center immediately.
Health plan members can file a complaint or apply for an Independent Medical Review with the DMHC Help Center at www.DMHC.ca.gov or 1-888-466-2219.
###
About DMHC:
The California Department of Managed Health Care (DMHC) protects the health care rights of 29.8 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted 2.9 million Californians to resolve complaints and issues with their health plan. The DMHC Help Center provides assistance in all languages and all services are free. For more information visit www.DMHC.ca.gov or call 1-888-466-2219.