Law changes for gender-affirming care
On July 13, 2023, Gov. Tina Kotek signed
House Bill (HB) 2002, which prohibits health insurers from denying claims for medically necessary gender-affirming treatment that is prescribed in accordance with accepted standards of care. The new law improves on protections already in place in Oregon and removes barriers that transgender people may face when accessing gender-affirming care.
Coverage of gender-affirming treatment
Effective Jan. 1, 2024, HB 2002 prohibits an insurance carrier offering a health benefit plan in Oregon from doing any of the following:
- Denying or limiting coverage for gender-affirming treatment that is medically necessary as determined by the prescribing provider, in accordance with accepted standards of care.
- Applying categorical cosmetic or blanket exclusions to medically necessary gender-affirming treatment.
- Excluding medically necessary gender-affirming procedures, such as tracheal shaves, hair electrolysis, and facial feminization surgery, as cosmetic services.
- Denying or limiting access to gender-affirming treatment unless a health care provider with experience in gender-affirming treatment has first reviewed and approved the denial or limitation.
HB 2002 also requires a health benefit plan to include a sufficient number of gender-affirming treatment providers in their networks to ensure geographic access. The Department of Consumer and Business Services, Division of Financial Regulation will conduct targeted market exams of each carrier to evaluate compliance with the bill and will submit a report to the Oregon Legislature on the bill's implementation by Dec. 31, 2026.
HB 2002 applies to comprehensive health insurance plans, including those sold on the Oregon Health Insurance Marketplace and group plans sold to Oregon employers that are issued or renewed on or after Jan. 1, 2024. The law also applies to coverage provided under the Oregon Health Plan.
Appeal a claim denial
If your health plan denies a claim, you have the right to appeal. This means you can ask your health plan to review its decision and perhaps reverse it and pay the claim. Appeals must be submitted within 180 days from when you were notified of the denial. Call your health plan to ask how to submit a request to appeal a claim.
If your health plan denies your claim on appeal, you may have the right to have your case reviewed externally by a third party that is not affiliated with your insurer. You can ask to have your case assigned to an independent review organization that has contracted with the Division of Financial Regulation to perform external reviews, and the independent review organization will determine if the denial meets the requirements for an external review. You must file a written request for an external review within four months after you receive a final determination from your insurer that your claim has been denied.
You can find out more about the internal and external appeals process on the appeals and external review page.
Oregon passed legislation in 2019 protecting individuals enrolled in health benefit plans from discrimination based on race, color, national origin, disability, age, sex, gender identity, or sexual orientation. Additionally, the Affordable Care Act and associated regulations protect transgender people from discrimination by their health insurer and from blanket denials of gender-affirming services.
If you feel you have been discriminated against related to insurance, access to benefits, or any part of the appeals or external review process, contact the Division of Financial Regulation's consumer advocates.