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News

Department of Employee Trust Funds
Revised February 2, 2017

Gender Reassignment Exclusion Reinstated

Effective February 1, 2017, the following exclusion is reinstated for participants of the State of Wisconsin Group Health Insurance Program and the Wisconsin Public Employers Group Health Insurance Program.

Section IV. Exclusions and Limitations of the 2017 Uniform Benefits:

  1. Surgical Services
    1. Procedures, services, and supplies related to surgery and sex hormones associated with gender reassignment.

What does this mean for members?
While the exclusion was originally removed for plan year 2017, Group Insurance Board action requires the exclusion go back into effect today. Therefore, state group health insurance only covered services related to this exclusion from January 1 through January 31, 2017. ETF will provide updated benefits materials to participating health insurance program employers.

Frequently Asked Questions

  • I incurred a claim related to this benefit and it was already paid. Will my claim be reprocessed? Will I owe any additional money?

    Answer:
    No, claims for any medically necessary benefits or services incurred from January 1 through January 31, 2017 will be covered based on the cost sharing structure of your enrolled plan.
  • I incurred a claim in January 2017 related to this benefit that has not been paid by my health plan. Will my health plan pay my claim?

    Answer: Yes, as long as the claim was considered medically necessary by your health plan.

Background
Last July, the GIB approved removing the exclusion based on an interpretation of a newly finalized federal requirement under the Affordable Care Act, with an effective date of January 1, 2017. In 2016, the State of Wisconsin became a participant in a federal lawsuit challenging this requirement. On December 30, 2016, the GIB took action to reinstate the exclusion if and when four contingencies were met; the contingencies have been met:

Contingency How Contingency Was Met

A court ruling or an administrative action that enjoins, rescinds or invalidates the rules set by the federal Department of Health and Human Services (HHS);

A federal judge in Texas issued a preliminary injunction halting enforcement of this regulation on December 31, 2016.

Compliance with state law, Section 40.03 (6)(c);

 

This statute provides parameters for modifications to benefits. Modifications must be either required by law, or maintain or reduce premium costs for the state or its employees in the current or any future year.

Health plans did not itemize an increase associated with removing the exclusion for their 2017 premium negotiations. Therefore, there was no increase in health plan premiums due to this coverage and there will be no premium reduction due to the reinstatement of the exclusion.

Renegotiation of contracts that maintain or reduce premium costs for the state;

A contract amendment for contracted health plans was issued on January 31, 2017.

A final opinion of the Wisconsin Department of Justice that the action taken does not constitute a breach of the Board’s fiduciary duties.

The DOJ issued a final opinion that the action does not constitute a breach of the Board’s fiduciary duties.

For More Information

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