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San Francisco HSS adopts standardized gender‑dysphoria benefits, removes $75,000 lifetime cap in one plan
Summary
The San Francisco Health Service System board voted unanimously to adopt a policy harmonizing gender‑dysphoria benefits across its plans for 2018, removing a $75,000 lifetime cap in one Medicare Advantage plan and directing plans to review previously excluded services under medical‑necessity criteria.
The San Francisco Health Service System board voted unanimously March 9 to adopt a standardized Gender Dysphoria Policy Statement for 2018 and to eliminate a $75,000 lifetime cap that applied to gender‑dysphoria benefits in the fully insured UnitedHealthcare Medicare Advantage plan.
Acting Director Mitchell Griggs told the board HSS used its all‑payers claims database to estimate utilization and cost and provided counts of members seeking gender‑dysphoria‑related care: 26 claimants in 2014, 46 in 2015 and 55 in 2016. Griggs said staff recommended three measures: adopt the San Francisco policy statement, remove the lifetime cap for MAPD, and require all plans to review formerly excluded services for medical necessity rather than exclude them outright.
The change followed presentations from insurer and provider representatives. Dr. Anthony J. Van Gore, Senior Medical Director for Policy and Technology Assessment at Blue Shield of California, described Blue Shield’s approach to medical‑necessity review, explaining that the plan’s process uses a medical‑director review, independent expert review when needed, and an overarching commitment to consider medical evidence. "Blue Shield policy is to on the side of making sure the procedure is done," he said when describing adjudications in equivocal cases. Teresa Sparks, senior advisor on transgender initiatives to the mayor, urged the board to treat transgender care the same way the city has long treated other medically necessary reconstructive procedures and noted earlier local experience that costs were lower than expected when comparable services were covered.
Kaiser Permanente’s physician advisor, Bill Plouts, said Kaiser applies reconstructive standards consistent with the California Reconstructive Surgery Act where clinically appropriate and that Kaiser has structured programs and clinics to provide comprehensive care for transgender patients.
The board’s motion to adopt the staff recommendations was moved by Commissioner Lim and seconded by another member; following public comment the board voted to approve the recommendations unanimously. Staff said HSS will work closely with contracted plans to align implementation and expects to return with progress on operational readiness and timing for plan preparations.
Next steps include staff follow‑up with health plans to confirm specific implementation dates, criteria harmonization and a timeline for reviewing how the changes operate in practice; Griggs suggested updates on plan preparedness at the May meeting.
