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HB710
HOUSE OF REPRESENTATIVES
H.B. NO.
710
THIRTY-THIRD LEGISLATURE, 2025
STATE OF HAWAII
A BILL FOR AN ACT
relating
to insurance
.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
����
SECTION 1.
�
The
legislature finds that since the enactment of Act 39, Session Laws in Hawaii
2022, known and cited as the Gender Affirming Treatment Act, health insurance
companies, health maintenance organizations, and mutual benefit societies
(collectively referred to as "insurance carriers") have been
continuing to deny transgender persons' coverage for gender transition-related
medical care, according to reports of patient and providers in the State.
����
The legislature further finds
that the gender transition-related medical care being denied by insurance
carriers is often known to be medically necessary, classified as the standard of
care according to the World Professional Association for Transgender Health ("WPATH")
Standards of Care, and supported by scientific evidence.
�
Moreover, these denials are routinely being
overturned through the external review process.
����
The legislature also finds
that since the enactment of the Gender Affirming Treatment Act, WPATH has
released Version 8 of its Standards of Care for the Health of Transgender and
Gender Diverse People ("SOC8") and these updated guidelines have
generally been adopted by insurance carriers across the continental United
States.
�
However, insurance carriers in
Hawai
ʻ
i have taken varying approaches with adopting SOC8, with some
insurance carriers having reached near full adoption and others continuing to
lag.
�
This has resulted in transgender
persons in Hawai
ʻ
i experiencing different coverage standards for gender affirming
care.
�
����
The legislature additionally
finds that despite the enactment of the Gender Affirming Treatment Act and its
transparency requirements, insurance carriers, when denying gender affirming care
on the basis of medical necessity, are not consistently providing transparent and
thorough information clearly explaining the reason the requested care was
deemed not medically necessary.
����
As well, the legislature
finds that the transgender community faces numerous health disparities, among
which include an alarmingly increased risk for suicide and suicidal ideation.
Research has found that transgender youth are about 4.6 times more likely to
attempt suicide and about 13.4 times more likely to have seriously considered
suicide recently than cisgender youth.
�
Transgender
adults have been found to be about 4.4 times more likely to attempt suicide and
about twelve times more likely to have seriously considered suicide recently
than cisgender adults.
�
Denials of gender
transition-related medical coverage and care contribute to the likelihood of
suicide and suicidal ideations.
�
A 2023
federal directive from the Office of Personnel Management underscores the
importance of aligning health coverage policies with updated standards of care,
including WPATH's latest guidelines.
����
The legislature therefore
finds that the intent of this Act is to better implement the 2022 Gender Affirming
Treatment Act.
�
Because this Act does not
establish new health insurance requirements, it is not subject to the section
23-51, Hawaii Revised Statutes, review.
����
Accordingly, the purpose
of this Act is to:
����
(1)
�
Prohibit
health insurers, mutual benefit societies, and health maintenance organizations
from arbitrarily denying coverage requests for gender affirming care services
when the requested care is known to be considered a standard of care for which
scientific evidence exists;
����
(2)
�
Improve
transparency of medical necessity reviews by health insurers, mutual benefit
societies, and health maintenance organizations and the relevant requirements;
and
����
(3)
�
Codify
reasonable standards, protections, and best practices to ensure that the
State's transgender and gender diverse population are afforded access to the
health care coverage that they need to live and thrive.
����
SECTION
2
.
�
Section 431:10A-118.3, Hawaii Revised
Statutes, is amended to read as follows:
����
"
�431:10A-118.3
�
Nondiscrimination
on the basis of actual gender identity or perceived gender identity; coverage
for services.
�
(a)
�
No
individual or group accident and health or sickness policy, contract, plan, or
agreement that provides health care coverage shall discriminate with respect to
participation and coverage under the policy, contract, plan, or agreement
against any person on the basis of actual gender identity or perceived gender
identity.
����
(b)
�
Discrimination under this section includes
the following:
����
(1)
�
Denying, canceling, limiting,
non-renewing
or
otherwise
refusing to issue or renew an insurance policy, contract,
plan, or agreement on the basis of a transgender person's or a person's
transgender family member's actual gender identity or perceived gender
identity;
����
(2)
�
Demanding or requiring a payment or
premium that is based on a transgender person's or a person's transgender
family member's actual gender identity or perceived gender identity;
����
(3)
�
Designating a transgender person's or a
person's transgender family member's actual gender identity or perceived gender
identity as a preexisting condition to deny, cancel,
non-renew
or
otherwise
limit coverage; and
����
(4)
�
Denying, canceling, or limiting
coverage for services on the basis of actual gender identity or perceived
gender identity, including but not limited to the following:
���������
(A)
�
Health care services related to gender
transition; provided that there is coverage under the policy, contract, plan,
or agreement for the services when the services are not related to gender
transition;
provided further that it shall not be required that a health care
service covered for gender transition be routinely available and covered for
services not related to gender transition;
and
���������
(B)
�
Health care services that are
ordinarily or exclusively available to individuals of any sex[
.
]
or of any
gender assigned at birth
.
����
(c)
�
The medical necessity of any
[
treatment
]
health care service
for a transgender person, or any person, on
the basis of actual gender identity or perceived gender identity shall be
determined pursuant to the insurance policy, contract, plan, or agreement and
shall [
be defined in accordance with
]
take into account
the
recommendations in the most recent edition of the Standards of Care for the
Health of Transgender and Gender Diverse People, issued by the World
Professional Association for Transgender Health, and other
applicable
law.
�
No health care
service shall be deemed not medically necessary on the basis that the person's
actual or perceived gender identity may be classified as a behavioral health
condition.
����
(d)
�
No health care service shall be denied coverage
on the basis that it is cosmetic or not medically necessary unless a health
care provider or mental health professional with current experience in
prescribing or delivering gender affirming care services first reviews and
confirms the appropriateness of the adverse benefit determination.
�
In the event of a denial of coverage on the
basis that a service is cosmetic or not medically necessary, unless otherwise
prohibited by law, the denial shall, without requiring a separate request,
include the following:
����
(1)
�
The
training and expertise held by the individuals who determined the service to be
cosmetic or not medically necessary; and
����
(2)
�
A
statement, in plain language, explaining the reason the service was determined
to be cosmetic or not medically necessary that is specific to the person
requesting the coverage.
����
(e)
�
In the event of an appeal of a claim denied on the basis of medical
necessity of the [
treatment, such
]
service, the
appeal shall be
[
decided in
a manner consistent with applicable law and
]
reviewed for medical
necessity
in consultation with a health care provider
or mental
health professional
with
current
experience in prescribing or
delivering gender affirming [
treatment who shall provide input on the
appropriateness of the denial of the claim.
]
care services.
�
In the event an appeal upholds a denial on
the basis of medical necessity, unless otherwise prohibited by law, the appeal
determination shall, without requiring a separate request, include the
following:
����
(1)
�
The
training and expertise held by the individuals who determined the service to be
cosmetic or not medically necessary; and
����
(2)
�
A
statement, in plain language, explaining the reason the service was determined
to be cosmetic or not medically necessary that is specific to the person
requesting the coverage.
����
[
(d)
]
(f)
�
An insurer shall not apply
categorical cosmetic or blanket exclusions to gender affirming [
treatments
]
care services
or procedures, or any combination of services or
procedures or revisions to prior [
treatments, when determined to be
medically necessary pursuant to applicable law, only
]
services or
procedures,
if the policy, contract, plan, or agreement also provides
coverage for those services
or procedures
when the services
or
procedures
are offered for purposes other than gender transition.
�
It shall not be required that a health care service or procedure
covered for gender transition also be routinely available and covered for services
or procedures not related to gender transition.
�
These services
and procedures
may
include but are not limited to:
����
(1)
�
Hormone therapies;
����
(2)
�
Hysterectomies;
����
(3)
�
Mastectomies;
����
(4)
�
Vocal training;
����
(5)
�
Feminizing vaginoplasties;
����
(6)
�
Masculinizing phalloplasties;
����
(7)
�
Metaoidioplasties;
����
(8)
�
[
Breast
]
Feminizing breast
surgeries, including
augmentations;
����
(9)
�
Masculinizing chest surgeries;
���
(10)
�
[
Facial feminization
]
Gender affirming
facial
surgeries[
;
]
, including feminizing and masculinizing
surgeries;
���
(11)
�
Reduction thyroid chondroplasties;
���
(12)
�
Voice surgeries and therapies; and
���
(13)
�
Electrolysis [
or
]
and
laser hair removal[
.
]
, not to be limited to pre-surgical hair
removal.
����
[
(e)
]
(g)
�
Each individual or group
accident and health or sickness policy, contract, plan, or agreement shall
provide applicants and policyholders with clear information about the coverage
of gender transition services and the requirements for determining medically
necessary [
treatments related to these
] services, including the process
for appealing a claim denied on the basis of medical necessity.
�
The information required by this
subsection shall also be made available on a publicly accessible website.
����
[
(f)
]
(h)
�
Any coverage provided shall
be subject to copayment, deductible, and coinsurance provisions of an
individual or group accident and health or sickness policy, contract, plan, or
agreement that are no less favorable than the copayment, deductible, and
coinsurance provisions for substantially all other medical services covered by
the policy, contract, plan, or agreement.
����
[
(g)
]
(i)
�
Nothing in this section shall
be construed to mandate coverage of a service that is
determined to be
not
medically necessary[
.
]
; provided that the determination has been made
in accordance with this section.
����
[
(h)
]
(j)
�
As used in this section
unless the context requires otherwise:
����
"Actual
gender identity" means a person's internal sense of being male, female, a
gender different from the gender assigned at birth, a transgender person, or
neither male nor female.
����
"Gender
transition" means the process of a person changing the person's outward
appearance or sex characteristics to accord with the person's actual gender
identity.
����
"Perceived
gender identity" means an observer's impression of another person's actual
gender identity or the observer's own impression that the person is male,
female, a gender different from the gender assigned at birth, a transgender
person, or neither male nor female.
����
"Transgender
person" means a person who has gender dysphoria, has received health care
services related to gender transition, or otherwise identifies as a gender
different from the gender assigned to that person at birth."
����
SECTION
3
.
�
Section 432:1-607.3, Hawaii Revised Statutes,
is amended to read as follows:
����
"�
432:1-607.3
�
Nondiscrimination on
the basis of actual gender identity or perceived gender identity; coverage for
services.
�
(a)
�
No individual or group
hospital or medical service policy, contract, plan, or agreement that provides
health care coverage shall discriminate with respect to participation and
coverage under the policy, contract, plan, or agreement against any person on the
basis of actual gender identity or perceived gender identity.
����
(b)
�
Discrimination under this section includes
the following:
����
(1)
�
Denying, canceling, limiting,
non-renewing
or
otherwise
refusing to issue or renew an insurance policy, contract, plan, or
agreement on the basis of a transgender person's or a person's transgender
family member's actual gender identity or perceived gender identity;
����
(2)
�
Demanding or requiring a payment or
premium that is based on a transgender person's or a person's transgender
family member's actual gender identity or perceived gender identity;
����
(3)
�
Designating a transgender person's or a
person's transgender family member's actual gender identity or perceived gender
identity as a preexisting condition to deny, cancel,
non-renew
or
otherwise
limit coverage;
and
����
(4)
�
Denying, canceling, or limiting
coverage for services on the basis of actual gender identity or perceived
gender identity, including but not limited to the following:
���������
(A)
�
Health care services related to gender
transition; provided that there is coverage under the policy, contract, plan,
or agreement for the services when the services are not related to gender
transition;
provided further that it shall not be required that a health care
service covered for gender transition be routinely available and covered for
services not related to gender transition;
and
���������
(B)
�
Health care services that are
ordinarily or exclusively available to individuals of any sex[
.
]
or of any
gender assigned at birth
.
����
(c)
�
The medical necessity of any [
treatment
]
health care service
for a transgender person, or any person, on the
basis of actual gender identity or perceived gender identity shall be
determined pursuant to the hospital or medical service policy, contract, plan,
or agreement and shall [
be defined in accordance with
]
take into
account
the recommendations in the most recent edition of the
Standards of Care for the Health of Transgender and Gender Diverse People,
issued by the World Professional Association for Transgender Health, and other
applicable law.
�
No health care
service shall be deemed not medically necessary on the basis that the person's
actual or perceived gender identity may be classified as a behavioral health
condition.
�
����
(d)
�
No health care service shall be denied coverage
on the basis that it is cosmetic or not medically necessary unless a health
care provider or mental health professional with current experience in
prescribing or delivering gender affirming care services first reviews and
confirms the appropriateness of the adverse benefit determination.
�
In the event of a denial of coverage on the
basis that a service is cosmetic or not medically necessary, unless otherwise
prohibited by law, the denial shall, without requiring a separate request,
include the following:
����
(1)
�
The
training and expertise held by the individuals who determined the service to be
cosmetic or not medically necessary; and
����
(2)
�
A
statement, in plain language, explaining the reason the service was determined
to be cosmetic or not medically necessary that is specific to the person
requesting the coverage.
����
(e)
�
In the event of an appeal of a claim denied on the basis of medical
necessity of the [
treatment, such
]
service, the
appeal shall be [
decided
in a manner consistent with applicable law and
]
reviewed for medical
necessity
in consultation with a health care provider
or mental health
professional
with
current
experience in prescribing or delivering
gender affirming [
treatment who shall provide input on the appropriateness
of the denial of the claim.
]
care services.
�
In the event an appeal upholds a denial on
the basis of medical necessity, unless otherwise prohibited by law, the appeal
determination shall, without requiring a separate request, include the
following:
����
(1)
�
The
training and expertise held by the individuals who determined the service to be
cosmetic or not medically necessary; and
����
(2)
�
A
statement, in plain language, explaining the reason the service was determined
to be cosmetic or not medically necessary that is specific to the person
requesting the coverage.
����
[
(d)
]
(f)
�
A mutual benefit society
shall not apply categorical cosmetic or blanket exclusions to gender affirming [
treatments
]
care services
or procedures, or any combination of services or
procedures or revisions to prior [
treatments, when determined to be
medically necessary pursuant to applicable law, only
]
services or
procedures,
if the policy, contract, plan, or agreement also provides
coverage for those services
or procedures
when the services
or
procedures
are offered for purposes other than gender transition.
�
Is shall not be required that a health
care service or procedure covered for gender transition also be routinely
available and covered for services or procedures not related to gender
transition.
�
These services
and
procedures
may include but are not limited to:
����
(1)
�
Hormone therapies;
����
(2)
�
Hysterectomies;
����
(3)
�
Mastectomies;
����
(4)
�
Vocal training;
����
(5)
�
Feminizing vaginoplasties;
����
(6)
�
Masculinizing phalloplasties;
����
(7)
�
Metaoidioplasties;
����
(8)
�
[
Breast
]
Feminizing breast
surgeries, including
augmentations;
����
(9)
�
Masculinizing chest surgeries;
���
(10)
�
[
Facial feminization
]
Gender affirming
facial
surgeries[
;
]
, including feminizing and masculinizing
surgeries;
���
(11)
�
Reduction thyroid chondroplasties;
���
(12)
�
Voice surgeries and therapies; and
���
(13)
�
Electrolysis [
or
]
and
laser hair removal[
.
]
, not to be limited to pre-surgical hair
removal.
����
[
(e)
]
(g)
�
Each individual or group
hospital or medical service policy, contract, plan, or agreement shall provide
applicants and members with clear information about the coverage of gender
transition services and the requirements for determining medically necessary [
treatments
related to these
] services, including the process for appealing a claim
denied on the basis of medical necessity.
�
The information required by this subsection shall also be made
available on a publicly accessible website.
����
[
(f)
]
(h)
�
Any coverage provided shall
be subject to copayment, deductible, and coinsurance provisions of an
individual or group hospital or medical service policy, contract, plan, or
agreement that are no less favorable than the copayment, deductible, and
coinsurance provisions for substantially all other medical services covered by
the policy, contract, plan, or agreement.
����
[
(g)
]
(i)
�
Nothing in this section shall
be construed to mandate coverage of a service that is
determined to be
not
medically necessary[
.
]
; provided that the determination has been made
in accordance with this section.
����
[
(h)
]
(j)
�
As used in this section
unless the context requires otherwise:
����
"Actual
gender identity" means a person's internal sense of being male, female, a
gender different from the gender assigned at birth, a transgender person, or
neither male nor female.
����
"Gender
transition" means the process of a person changing the person's outward
appearance or sex characteristics to accord with the person's actual gender
identity.
����
"Perceived
gender identity" means an observer's impression of another person's actual
gender identity or the observer's own impression that the person is male,
female, a gender different from the gender assigned at birth, a transgender
person, or neither male nor female.
����
"Transgender
person" means a person who has gender dysphoria, has received health care
services related to gender transition, or otherwise identifies as a gender
different from the gender assigned to that person at birth."
����
SECTION
4
.
�
Section 432D-26.3, Hawaii Revised Statutes,
is amended to read as follows:
����
"
�432D-26.3
�
Nondiscrimination on
the basis of actual gender identity or perceived gender identity; coverage for
services.
�
(a)
�
No health maintenance
organization policy, contract, plan, or agreement shall discriminate with
respect to participation and coverage under the policy, contract, plan, or
agreement against any person on the basis of actual gender identity or
perceived gender identity.
����
(b)
�
Discrimination under this section includes the following:
����
(1)
�
Denying,
canceling, limiting,
non-renewing
or
otherwise
refusing to issue
or renew an insurance policy, contract, plan, or agreement on the basis of a
transgender person's or a person's transgender family member's actual gender
identity or perceived gender identity;
����
(2)
�
Demanding
or requiring a payment or premium that is based on a transgender person's or a
person's transgender family member's actual gender identity or perceived gender
identity;
����
(3)
�
Designating
a transgender person's or a person's transgender family member's actual gender
identity or perceived gender identity as a preexisting condition to deny,
cancel,
non-renew
or
otherwise
limit coverage; and
����
(4)
�
Denying,
canceling, or limiting coverage for services on the basis of actual gender
identity or perceived gender identity, including but not limited to the
following:
���������
(A)
�
Health
care services related to gender transition; provided that there is coverage
under the policy, contract, plan, or agreement for the services when the
services are not related to gender transition;
provided further that it shall
not be required that a health care service covered for gender transition be
routinely available and covered for services not related to gender transition;
and
���������
(B)
�
Health
care services that are ordinarily or exclusively available to individuals of
any sex[
.
]
or of any gender assigned at birth.
����
(c)
�
The medical necessity of any [
treatment
]
health care service
for a transgender person, or any person, on the
basis of actual gender identity or perceived gender identity shall [
be
defined in accordance with
]
take into account
the recommendations in the most recent edition of the
Standards of Care for the Health of Transgender and Gender Diverse People,
issued by the World Professional Association for Transgender Health, and other
applicable law.
�
No health care
service shall be deemed not medically necessary on the basis that the person's
actual or perceived gender identity may be classified as a behavioral health
condition.
�
��
����
(d)
�
No health care service shall be denied coverage
on the basis that it is cosmetic or not medically necessary unless a health
care provider or mental health professional with current experience in
prescribing or delivering gender affirming care services first reviews and
confirms the appropriateness of the adverse benefit determination.
�
In the event of a denial of coverage on the
basis that a service is cosmetic or not medically necessary, unless otherwise
prohibited by law, the denial shall, without requiring a separate request,
include the following:
����
(1)
�
The
training and expertise held by the individuals who determined the service to be
cosmetic or not medically necessary; and
����
(2)
�
A
statement, in plain language, explaining the reason the service was determined
to be cosmetic or not medically necessary that is specific to the person
requesting the coverage.
����
(e)
�
In the event of an appeal of a claim denied on the basis of medical
necessity of the [
treatment, such
]
service, the
appeal shall be [
decided
in a manner consistent with applicable law and
]
reviewed for medical necessity
in consultation with a health care provider
or mental health professional
with
current
experience in prescribing or delivering gender affirming [
treatment
who shall provide input on the appropriateness of the denial of the claim.
]
care services.
�
In the event an appeal
upholds a denial on the basis of medical necessity, unless otherwise prohibited
by law, the appeal determination shall, without requiring a separate request,
include the following:
����
(1)
�
The
training and expertise held by the individuals who determined the service to be
cosmetic or not medically necessary; and
����
(2)
�
A
statement, in plain language, explaining the reason the service was determined
to be cosmetic or not medically necessary that is specific to the person
requesting the coverage.
����
[
(d)
]
(f)
�
A health maintenance
organization shall not apply categorical cosmetic or blanket exclusions to
gender affirming [
treatments
]
care services
or procedures, or any
combination of services or procedures or revisions to prior [
treatments,
when determined to be medically necessary pursuant to applicable law, only
]
services or procedures,
if the policy, contract, plan, or agreement also
provides coverage for those services
or procedures
when the services
or procedures
are offered for purposes other than gender
transition.
�
It shall not be required
that a health care service or procedure covered for gender transition also be
routinely available and covered for services or procedures not related to gender
transition.
�
These services
and
procedures
may include but are not limited to:
����
(1)
�
Hormone therapies;
����
(2)
�
Hysterectomies;
����
(3)
�
Mastectomies;
����
(4)
�
Vocal training;
����
(5)
�
Feminizing vaginoplasties;
����
(6)
�
Masculinizing phalloplasties;
����
(7)
�
Metaoidioplasties;
����
(8)
�
[
Breast
]
Feminizing breast
surgeries, including
augmentations;
����
(9)
�
Masculinizing chest surgeries;
���
(10)
�
[
Facial feminization
]
Gender affirming
facial
surgeries[
;
]
, including feminizing and masculinizing
surgeries;
���
(11)
�
Reduction thyroid chondroplasties;
���
(12)
�
Voice surgeries and therapies; and
���
(13)
�
Electrolysis [
or
]
and
laser hair removal[
.
]
, not to be limited to pre-surgical hair removal.
����
[
(e)
]
(g)
�
Each health maintenance
organization policy, contract, plan, or agreement shall provide applicants and
subscribers with clear information about the coverage of gender transition
services and the requirements for determining medically necessary [
treatments
related to these
] services, including the process for appealing a claim
denied on the basis of medical necessity.
�
The information required by this subsection shall be made available
on a publicly accessible website.
����
[
(f)
]
(h)
�
Any coverage provided shall be subject to
copayment, deductible, and coinsurance provisions of a health maintenance
organization policy, contract, plan, or agreement that are no less favorable
than the copayment, deductible, and coinsurance provisions for substantially
all other medical services covered by the policy, contract, plan, or agreement.
����
[
(g)
]
(i)
�
Nothing in this section shall
be construed to mandate coverage of a service that is
determined to be
not medically necessary[
.
]
; provided that the determination has been made
in accordance with this section.
����
[
(h)
]
(j)
�
As used in this section unless the context
requires otherwise:
����
"Actual gender identity" means a
person's internal sense of being male, female, a gender different from the
gender assigned at birth, a transgender person, or neither male nor female.
����
"Gender transition" means the
process of a person changing the person's outward appearance or sex
characteristics to accord with the person's actual gender identity.
����
"Perceived gender identity" means
an observer's impression of another person's actual gender identity or the
observer's own impression that the person is male, female, a gender different
from the gender assigned at birth, a transgender person, or neither male nor
female.
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"Transgender person" means a
person who has gender dysphoria, has received health care services related to
gender transition, or otherwise identifies as a gender different from the
gender assigned to that person at birth."
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SECTION 5.
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This Act does not affect rights and duties that matured, penalties that
were incurred, and proceedings that were begun before its effective date.
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SECTION 6.
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Statutory material to be repealed is bracketed and stricken.
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New statutory material is underscored.
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SECTION 7.
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This Act shall take effect upon its approval.
INTRODUCED BY:
_____________________________
Report Title:
Gender
Affirming Treatment Act; Insurance; Nondiscrimination; Transgender; Gender
Affirming Care Services
Description:
Prohibits health insurers, mutual benefit societies, and
health maintenance organizations from arbitrarily denying coverage requests for
gender affirming health care services when the requested service is known to be
considered a standard of care and for which scientific evidence exists that
supports the service.
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Increases
transparency of insurance carrier medical necessity reviews and requirements
when coverage is denied.
The summary description
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not legislation or evidence of legislative intent.