(1) In general

Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following new section:

727. Required coverage of items and services to address the harms of sex-rejecting procedures

(a) In general

A group health plan and a health insurance issuer offering group health insurance coverage shall, in the case such plan or coverage provides benefits with respect to any sex-rejecting procedure, also provide benefits for items and services furnished to an individual who has received any such procedure to address the harms of such procedure (including restorative care), regardless of whether—

(1)

such individual received benefits with respect to the sex-rejecting procedure under the individual’s plan or coverage; or

(2)

such plan or issuer provides benefits under the individual’s plan or coverage for the sex-rejecting procedure.

(b) Application of financial requirements and treatment limitations

A group health plan and a health insurance issuer offering group health insurance coverage shall ensure that, with respect to items and services for which benefits to address the harms of sex-rejecting procedures are required to be provided under such plan or coverage under subsection (a)—

(1)

the financial requirements applicable to such items and services are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan or coverage and there are no separate cost-sharing requirements that are applicable only with respect to such items and services; and

(2)

the treatment limitations applicable to such items and services are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan or coverage and there are no separate treatment limitations that are applicable only with respect to such items and services.

(c) Definitions

In this section:

(1) Female

Referring to a natural person, the term female means an individual characterized by a reproductive system naturally organized to produce (at maturity, absent disruption or congenital anomaly) large gametes (ova).

(2) Financial requirement; predominant; treatment limitation

The terms financial requirement, predominant, and treatment limitation have the meaning given such terms in clauses (i) through (iii), respectively, of section 712(a)(3)(B), except that the term financial requirement shall include aggregate lifetime limits and annual limits.

(3) Male

Referring to a natural person, the term male means an individual characterized by a reproductive system naturally organized to produce (at maturity, absent disruption or congenital anomaly) small gametes (sperm).

(4) Restorative care

The term restorative care means items and services furnished to an individual who has received any sex-rejecting procedure at any point during the individual’s lifetime to address, mitigate, monitor, treat, or reverse the harms, complications, and adverse effects of such procedure, including interventions intended to restore, to the greatest extent practicable, healthy human form and functioning. Such care includes items and services furnished to address—

(A)

impaired reproductive capacity, diminished ovarian reserve, impaired spermatogenesis, or other reproductive-system injury;

(B)

endocrine dysfunction, hormonal imbalance, hypogonadism, dependence on exogenous hormones, or other disruption of healthy endocrine function;

(C)

impaired sexual function, including loss of sexual sensation, anorgasmia, erectile dysfunction, genital pain, vaginal stenosis, diminished libido, or other sexual dysfunction;

(D)

urinary dysfunction, including urinary incontinence, urinary retention, urethral complications, recurrent urinary tract infections, or other genitourinary injury;

(E)

resultant vocal cord damage, permanent voice changes, vocal dysfunction, or impaired speech;

(F)

female hirsutism, male-pattern baldness, breast atrophy, breast development, or other secondary-sex-characteristic changes caused by cross-sex hormones;

(G)

osteoporosis, osteopenia, impaired bone development, fractures, reduced bone density, or other skeletal disorders associated with puberty suppression or cross-sex hormone use;

(H)

cardiovascular disease, thromboembolic disease, hypertension, stroke, myocardial infarction, metabolic syndrome, diabetes, or other cardiovascular or metabolic complications associated with such procedures;

(I)

surgical complications, including infection, fistula formation, stenosis, tissue necrosis, chronic pain, nerve damage, graft failure, implant complications, wound complications, or the need for revision surgery;

(J)

loss, removal, alteration, or impairment of healthy reproductive organs, breasts, genital structures, or other healthy tissues;

(K)

reconstructive, regenerative, prosthetic, plastic, or other surgical interventions intended to restore healthy anatomy, appearance, or physiological function;

(L)

rehabilitation services, including speech therapy, physical therapy, occupational therapy, pelvic floor therapy, sexual health counseling, and other therapies intended to restore healthy functioning;

(M)

psychiatric or psychological conditions associated with or exacerbated by such procedures, including depression, anxiety, trauma, suicidality, grief, regret, identity distress, body-image disturbance, or dissociation;

(N)

diagnostic testing, specialist evaluations, fertility assessments, hormone monitoring, cancer screening, and long-term medical surveillance necessitated by altered anatomy or prior exposure to puberty blockers, cross-sex hormones, or sex-rejecting surgeries;

(O)

fertility services that seek to cooperate with, or restore the healthy physiology and anatomy of, the human reproductive system, without the use of methods that circumvent natural human functions, such as any treatments or procedures that involve the handling of a human egg or embryo outside the body;

(P)

breast cancer in men on estrogen and certain cancers in women on testosterone; and

(Q)

any other physical, psychological, reproductive, endocrine, neurologic, cardiovascular, musculoskeletal, or metabolic injury, impairment, complication, or condition resulting from or associated with a sex-rejecting procedure.

(5) Sex

The term sex, when referring to an individual’s sex, means to refer to either male or female, as genetically determined at fertilization.

(6) Sex-rejecting procedure

(A) In general

The term sex-rejecting procedure means any medical or surgical intervention for the purpose of attempting to align an individual’s physical appearance or body with an asserted identity that differs from the individual’s sex, including—

(i)

gonadotropin-releasing hormone (GnRH) agonists or any other puberty-blocking or suppressing drugs to stop or delay normal puberty;

(ii)

testosterone, dihydrotestosterone (DHT), or other androgens, estrogen, progesterone, to an individual at doses that are supraphysiologic to what would be produced endogenously in a healthy individual of the same age and sex, as well as anti-androgen medications;

(iii)

castration;

(iv)

orchiectomy;

(v)

scrotoplasty;

(vi)

implantation of erection or testicular prostheses;

(vii)

vasectomy;

(viii)

hysterectomy;

(ix)

oophorectomy;

(x)

ovariectomy;

(xi)

reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty;

(xii)

metoidioplasty;

(xiii)

penectomy;

(xiv)

phalloplasty;

(xv)

vaginoplasty;

(xvi)

clitoroplasty;

(xvii)

vaginectomy;

(xviii)

vulvoplasty;

(xix)

reduction thyrochondroplasty;

(xx)

chondrolaryngoplasty;

(xxi)

mastectomy;

(xxii)

tubal ligation;

(xxiii)

sterilization;

(xxiv)

any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual;

(xxv)

any placement of chest implants to create feminine breasts;

(xxvi)

any placement of fat or artificial implants in the gluteal region;

(xxvii)

augmentation mammoplasty;

(xxviii)

liposuction;

(xxix)

lipofilling;

(xxx)

voice surgery;

(xxxi)

hair reconstruction;

(xxxii)

pectoral implants; and

(xxxiii)

the removal of any otherwise healthy or non-diseased body part or tissue.

(B) Exceptions

The term sex-rejecting procedure does not include the following when furnished by a health care professional with the consent of such individual or, if applicable, such individual’s parents or legal guardian:

(i)

Services to individuals born with a medically verifiable disorder of sex development, including an individual with external sex characteristics that are irresolvably ambiguous, such as an individual born with 46,XX chromosomes with virilization, an individual born with 46,XY chromosomes with undervirilization, or an individual born having both ovarian and testicular tissue.

(ii)

Services provided when a physician has otherwise diagnosed a disorder of sex development in which the physician has determined through genetic or biochemical testing that the individual does not have healthy sex chromosome structure, sex steroid hormone production, or sex steroid hormone action for a healthy individual of the same sex and age.

(iii)

The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of sex-rejecting procedures, whether or not the sex-rejecting procedure was performed in accordance with State and Federal law and whether or not funding for the procedure is permissible under this section.

(iv)

Any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness (but not claimed mental distress) that would, as certified by a physician, place the individual in imminent danger of death or impairment of major bodily function, unless the procedure is performed.

(v)

Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty.

(vi)

Male circumcision.

(2) Clerical amendment

The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 note) is amended by inserting after the item relating to section 726 the following new item:

(1) In general

Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:

9827. Required coverage of items and services to address the harms of sex-rejecting procedures

(a) In general

A group health plan shall, in the case such plan provides benefits with respect to any sex-rejecting procedure, also provide benefits for items and services furnished to an individual who has received any such procedure to address the harms of such procedure (including restorative care), regardless of whether—

(1)

such individual received benefits with respect to the sex-rejecting procedure under the individual’s plan; or

(2)

such plan provides benefits under the individual’s plan for the sex-rejecting procedure.

(b) Application of financial requirements and treatment limitations

A group health plan shall ensure that, with respect to items and services for which benefits to address the harms of sex-rejecting procedures are required to be provided under such plan under subsection (a)—

(1)

the financial requirements applicable to such items and services are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan and there are no separate cost-sharing requirements that are applicable only with respect to such items and services; and

(2)

the treatment limitations applicable to such items and services are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan and there are no separate treatment limitations that are applicable only with respect to such items and services.

(c) Definitions

In this section:

(1) Female

Referring to a natural person, the term female means an individual characterized by a reproductive system naturally organized to produce (at maturity, absent disruption or congenital anomaly) large gametes (ova).

(2) Financial requirement; predominant; treatment limitation

The terms financial requirement, predominant, and treatment limitation have the meaning given such terms in clauses (i) through (iii), respectively, of section 9812(a)(3)(B), except that the term financial requirement shall include aggregate lifetime limits and annual limits.

(3) Male

Referring to a natural person, the term male means an individual characterized by a reproductive system naturally organized to produce (at maturity, absent disruption or congenital anomaly) small gametes (sperm).

(4) Restorative care

The term restorative care means items and services furnished to an individual who has received any sex-rejecting procedure at any point during the individual’s lifetime to address, mitigate, monitor, treat, or reverse the harms, complications, and adverse effects of such procedure, including interventions intended to restore, to the greatest extent practicable, healthy human form and functioning. Such care includes items and services furnished to address—

(A)

impaired reproductive capacity, diminished ovarian reserve, impaired spermatogenesis, or other reproductive-system injury;

(B)

endocrine dysfunction, hormonal imbalance, hypogonadism, dependence on exogenous hormones, or other disruption of healthy endocrine function;

(C)

impaired sexual function, including loss of sexual sensation, anorgasmia, erectile dysfunction, genital pain, vaginal stenosis, diminished libido, or other sexual dysfunction;

(D)

urinary dysfunction, including urinary incontinence, urinary retention, urethral complications, recurrent urinary tract infections, or other genitourinary injury;

(E)

resultant vocal cord damage, permanent voice changes, vocal dysfunction, or impaired speech;

(F)

female hirsutism, male-pattern baldness, breast atrophy, breast development, or other secondary-sex-characteristic changes caused by cross-sex hormones;

(G)

osteoporosis, osteopenia, impaired bone development, fractures, reduced bone density, or other skeletal disorders associated with puberty suppression or cross-sex hormone use;

(H)

cardiovascular disease, thromboembolic disease, hypertension, stroke, myocardial infarction, metabolic syndrome, diabetes, or other cardiovascular or metabolic complications associated with such procedures;

(I)

surgical complications, including infection, fistula formation, stenosis, tissue necrosis, chronic pain, nerve damage, graft failure, implant complications, wound complications, or the need for revision surgery;

(J)

loss, removal, alteration, or impairment of healthy reproductive organs, breasts, genital structures, or other healthy tissues;

(K)

reconstructive, regenerative, prosthetic, plastic, or other surgical interventions intended to restore healthy anatomy, appearance, or physiological function;

(L)

rehabilitation services, including speech therapy, physical therapy, occupational therapy, pelvic floor therapy, sexual health counseling, and other therapies intended to restore healthy functioning;

(M)

psychiatric or psychological conditions associated with or exacerbated by such procedures, including depression, anxiety, trauma, suicidality, grief, regret, identity distress, body-image disturbance, or dissociation;

(N)

diagnostic testing, specialist evaluations, fertility assessments, hormone monitoring, cancer screening, and long-term medical surveillance necessitated by altered anatomy or prior exposure to puberty blockers, cross-sex hormones, or sex-rejecting surgeries;

(O)

fertility services that seek to cooperate with, or restore the healthy physiology and anatomy of, the human reproductive system, without the use of methods that circumvent natural human functions, such as any treatments or procedures that involve the handling of a human egg or embryo outside the body;

(P)

breast cancer in men on estrogen and certain cancers in women on testosterone; and

(Q)

any other physical, psychological, reproductive, endocrine, neurologic, cardiovascular, musculoskeletal, or metabolic injury, impairment, complication, or condition resulting from or associated with a sex-rejecting procedure.

(5) Sex

The term sex, when referring to an individual’s sex, means to refer to either male or female, as genetically determined at fertilization.

(6) Sex-rejecting procedure

(A) In general

The term sex-rejecting procedure means any medical or surgical intervention for the purpose of attempting to align an individual’s physical appearance or body with an asserted identity that differs from the individual’s sex, including—

(i)

gonadotropin-releasing hormone (GnRH) agonists or any other puberty-blocking or suppressing drugs to stop or delay normal puberty;

(ii)

testosterone, dihydrotestosterone (DHT), or other androgens, estrogen, progesterone, to an individual at doses that are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex, as well as anti-androgen medications;

(iii)

castration;

(iv)

orchiectomy;

(v)

scrotoplasty;

(vi)

implantation of erection or testicular prostheses;

(vii)

vasectomy;

(viii)

hysterectomy;

(ix)

oophorectomy;

(x)

ovariectomy;

(xi)

reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty;

(xii)

metoidioplasty;

(xiii)

penectomy;

(xiv)

phalloplasty;

(xv)

vaginoplasty;

(xvi)

clitoroplasty;

(xvii)

vaginectomy;

(xviii)

vulvoplasty;

(xix)

reduction thyrochondroplasty;

(xx)

chondrolaryngoplasty;

(xxi)

mastectomy;

(xxii)

tubal ligation;

(xxiii)

sterilization;

(xxiv)

any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual;

(xxv)

any placement of chest implants to create feminine breasts;

(xxvi)

any placement of fat or artificial implants in the gluteal region;

(xxvii)

augmentation mammoplasty;

(xxviii)

liposuction;

(xxix)

lipofilling;

(xxx)

voice surgery;

(xxxi)

hair reconstruction;

(xxxii)

pectoral implants; and

(xxxiii)

the removal of any otherwise healthy or non-diseased body part or tissue.

(B) Exceptions

The term sex-rejecting procedure does not include the following when furnished by a health care professional with the consent of such individual or, if applicable, such individual’s parents or legal guardian:

(i)

Services to individuals born with a medically verifiable disorder of sex development, including an individual with external sex characteristics that are irresolvably ambiguous, such as an individual born with 46,XX chromosomes with virilization, an individual born with 46,XY chromosomes with undervirilization, or an individual born having both ovarian and testicular tissue.

(ii)

Services provided when a physician has otherwise diagnosed a disorder of sex development in which the physician has determined through genetic or biochemical testing that the individual does not have healthy sex chromosome structure, sex steroid hormone production, or sex steroid hormone action for a healthy individual of the same sex and age.

(iii)

The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of sex-rejecting procedures, whether or not the sex-rejecting procedure was performed in accordance with State and Federal law and whether or not funding for the procedure is permissible under this section.

(iv)

Any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness (but not claimed mental distress) that would, as certified by a physician, place the individual in imminent danger of death or impairment of major bodily function, unless the procedure is performed.

(v)

Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty.

(vi)

Male circumcision.

(2) Clerical amendment

The table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new item: