Background: At Carle Health, we're committed to making diversity, equity and inclusion central to all we do. This includes aligning our Health Plan policies and processes to fit the needs of all individuals who seek care underneath our plans. 

As part of embodying the ideals of DEI, Carle Health does cover various Gender Affirmation Services and Treatments underneath our Health Plan. The parameters around these coverages and treatments are as follows. 

Gender affirmation services and treatment: 

The following gender affirmation services and treatment when ordered by a Provider or Physician:

• Psychotherapy;
• Pre-and-post-surgical hormone therapy; and
• Gender affirmation surgery/ies, subject to Preauthorization by the Utilization Review Manager. The surgery must be performed by a qualified Provider. Gender affirmation surgery(ies) may be considered Medically Necessary when all of the following criteria are met
  • The Covered Person is greater than or equal to age 18 years; and
  • The Covered Person has the capacity to make a fully informed decision and to consent for treatment; and
  • The individual has been diagnosed with the gender dysphoria, including all of the following:

• The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
• The Covered Person’s transgender identity has been present persistently for at least two years; and
• The dysphoria is not a symptom of another mental disorder or a chromosomal abnormality; and
• The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • The Covered Person is an active participant in a recognized gender identity treatment program and demonstrates all of the following conditions:

• The Covered Person has successfully lived and worked within the desired gender role full-time for at least 12 months (real life experience) without returning to the original gender; and

• For breast surgery:
  • Initiation of hormonal therapy (unless medically contraindicated or individual is unable or unwilling to take hormones); and
  • One referral from a qualified mental health professional with written documentation submitted to the Physician performing the breast surgery; and
• For genital surgery:
  • Documentation of at least 12 months of continuous hormonal sex affirmation therapy, (unless medically contraindicated or Covered Person is unable or unwilling to take hormones)(may be simultaneous with real life experience); and

Two referrals from qualified mental health professionals who have independently assessed the Covered Person. If the first referral is from the Covered Person’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) may be sent* (*At least one letter must be a comprehensive report.)

HIV Treatment Coverage and Care Coordination

• Carle Health offers one on one care coordination through Health Alliance on assistance and prevention of HIV. 
• Our Health plan also covers many PrEP(HIV) prescriptions.  

Questions and Care Coordination: 

• If you have further questions regarding the Gender Affirmation Service or would like assistance with care coordination, please reach out to Health Alliance Insurance. You can contact Health Alliance by calling the phone number on the back of your health insurance card. 
• Health Alliance: (800) 322-7451