,,ii  #aah? ,,congress  #a/ ,session    
,s4 #aeie  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,may #ae1 #bjbc,mr4    
,m>%all 7= himself1 ,mrs4 ,blackburn1   
,mr4 ,braun1 ,mr4 ,cram]1 ,mr4 ,da9es1  
,mrs4 ,hyde-,smi?1 ,mr4 ,lee1 ,mr4      
,mull91 ,mr4 ,ris*1 ,mr4 ,rubio1 ,mr4   
,wick]1 & ,mr4 ,hawley7 introduc$ !     
foll[+ bill2 :i* 0 read twice & ref]r$  
to ! ,committee on ,f9ance  ,a ,,bill   
,to prohibit taxpay]-fund$ g5d]         
transition proc$ures1 & = o!r purposes4 
#a4 ,%ort title2 table ( cont5ts  7a7   
,%ort title ,?is ,act may be cit$ z !   
,end ,taxpay] ,fund+ ( ,g5d]            
,exp]im5tation ,act ( #bjbc 4  7b7      
,table ( cont5ts ,! table ( cont5ts (   
?is ,act is z foll[s3 ,sec4 #a4 ,%ort   
title2 table ( cont5ts4,,title          
,i--,prohibit+ f$]ally fund$ g5d]       
transition procedures,sec4 #aja4        
,prohibit+ taxpay]-fund$ g5d] transition
 proc$ures4,sec4 #ajb4 ,am5dm5t to table
 ( *apt]s4,,title ,,ii--,application "u 
! ,af=dable ,c>e ,act,sec4 #bja4        

,cl>ify+ application ( prohibition to   
premium cr$its & co/-%>+ r$uctions "u   
,,aca4  ,i ,prohibit+ f$]ally fund$ g5d]
 transition proc$ures  #aja4 ,prohibit+ 
taxpay]-fund$ g5d] transition proc$ures 
,title #a1 ,unit$ ,/ates ,code1 is am5d$
 by add+ at ! end ! foll[+ new *apt]3   
#d ,prohibit+ taxpay]-fund$ g5d]        
transition proc$ures  ,sec4 #cja4       
,prohibition on fund+ = g5d] transition 
proc$ures4 #cjb4 ,prohibition on fund+ =
 heal? b5efits plans t cov] g5d]        
transition proc$ures4 #cjc4 ,limitation 
on ,f$]al facilities & employees4 #cjd4 
,con/ruction relat+ to sep>ate cov]age4 
#cje4 ,con/ruction relat+ to ! use (    
non-,f$]al funds = heal? cov]age4 #cjf4 
,con/ruction relat+ to complications    
aris+ f g5d] transition proc$ures4 #cjg4
 ,def9itions4  #cja4 ,prohibition on    
fund+ = g5d] transition proc$ures ,no   
funds au?oriz$ or appropriat$ by ,f$]al 
law1 & none ( ! funds 9 any tru/ fund to
 :i* funds are au?oriz$ or appropriat$  
by ,f$]al law1 %all be exp5d$ = any g5d]

 transition proc$ures4  #cjb4           
,prohibition on fund+ = heal? b5efits   
plans t cov] g5d] transition proc$ures  
,no funds au?oriz$ or appropriat$ by    
,f$]al law1 & none ( ! funds 9 any tru/ 
fund to :i* funds are au?oriz$ or       
appropriat$ by ,f$]al law1 %all be      
exp5d$ = heal? b5efits cov]age t        
includes cov]age ( g5d] transition      
proc$ures4  #cjc4 ,limitation on ,f$]al 
facilities & employees ,no heal? c>e    
s]vice furni%$-- 7#a7 by or 9 a heal?   
c>e facility own$ or op]at$ by ! ,f$]al 
,gov]nm5t2 or  7#b7 by any physician or 
o!r individual employ$ by ! ,f$]al      
,gov]nm5t to provide heal? c>e s]vices  
)9 ! scope ( ! physician's or           
individual's employm5t1  may include    
g5d] transition proc$ures4  #cjd4       
,con/ruction relat+ to sep>ate cov]age  
,no?+ 9 ?is *apt] %all be con/ru$ z     
prohibit+ any individual1 entity1 or    
,/ate or locality f pur*as+ sep>ate     
cov]age = g5d] transition proc$ures or  
heal? b5efits cov]age t includes g5d]   

transition proc$ures s long z su*       
cov]age is paid = entirely us+ only     
funds n au?oriz$ or appropriat$ by      
,f$]al law & su* cov]age %all n be      
pur*as$ us+ mat*+ funds requir$ = a     
f$]ally subsidiz$ program1 includ+ a    
,/ate's or locality's contribution (    
,m$icaid mat*+ funds4  #cje4            
,con/ruction relat+ to ! use (          
non-,f$]al funds = heal? cov]age ,no?+ 9
 ?is *apt] %all be con/ru$ z re/rict+ ! 
ability ( any non-,f$]al heal? b5efits  
cov]age provid] f (f]+ cov]age = g5d]   
transition proc$ures1 or ! ability ( a  
,/ate or locality to contract sep>ately 
) su* a provid] = su* cov]age1 s long z 
only funds n au?oriz$ or appropriat$ by 
,f$]al law are us$ & su* cov]age %all n 
be pur*as$ us+ mat*+ funds requir$ = a  
f$]ally subsidiz$ program1 includ+ a    
,/ate's or locality's contribution (    
,m$icaid mat*+ funds4  #cjf4            
,con/ruction relat+ to complications    
aris+ f g5d] transition proc$ures ,no?+ 
9 ?is *apt] %all be con/ru$ to apply to 

! treatm5t ( any infection1 injury1     
disease1 or disord] t has be5 caus$ by  
or exac]bat$ by ! p]=mance ( a g5d]     
transition proc$ure4  #cjg4 ,def9itions 
,= purposes ( ?is *apt]3 7#a7           
,biological sex ,! t]m biological sex   
means ! biological indication ( male or 
female 9 ! context ( reproductive       
pot5tial or capacity1 su* z sex         
*romosomes1 naturally occurr+ sex       
hormones1 gonads1 & non-ambigu\s int]nal
 & ext]nal g5italia pres5t at bir?1 )\t 
reg>d to an individual's psy*ological1  
*os51 or subjective exp]i5ce ( g5d]4    
7#b7 ,cross-sex hormones ,! t]m         
cross-sex hormones means-- 7,a7         
te/o/]one or o!r &rog5s giv5 to         
biological females at doses t are       
pr(\ndly l>g] or m pot5t ?an w\ld       
normally occur naturally 9 heal?y       
biological females2 &  7,b7 e/rog5 giv5 
to biological males at doses t are      
pr(\ndly l>g] or m pot5t ?an w\ld       
normally occur naturally 9 heal?y       
biological males4  7#c7 ,g5d] ,! t]m    

g5d] means ! psy*ological1 behavioral1  
social1 & cultural aspects ( be+ male or
 female4  7#d7 ,g5d] transition ,! t]m  
g5d] transition means ! process 9 :i* an
 individual goes f id5tify+ ) & liv+ z a
 g5d] t corresponds to 8 or h]          
biological sex to id5tify+ ) & liv+ z a 
g5d] diff]5t f 8 or h] biological sex1 &
 may involve social1 legal1 or physical 
*anges4  7#e7 ,g5d] transition proc$ure 
7,a7 ,9 g5]al ,! t]m g5d] transition    
proc$ure means any m$ical or surgical   
s]vice t seeks-- 7i7 to alt] or remove  
physical or anatomical *>act]i/ics or   
features t are typical = ! individual's 
biological sex2 or  7ii7 to in/ill or   
create physiological or anatomical      
*>act]i/ics t resemble a sex diff]5t f !
 individual's bir? sex4  7,b7           
,inclusions ,= purposes ( subp>agraph   
7,a71 ! t]m m$ical or surgical s]vice   
includes-- 7i7 physician's s]vices2     
7ii7 inpati5t & outpati5t hospital      
s]vices2  7iii7 prescrib$ drugs relat+  
to g5d] transition2  7iv7 a m$ical      

s]vice t provides-- 7,i7 pub]ty-block+  
drugs2  7,,ii7 cross-sex hormones2 or   
7,,iii7 o!r me*anisms to promote !      
developm5t ( fem9iz+ or mascul9iz+      
features 79 ! opposite sex72 &  7v7 g5d]
 transition surg]y4  7,c7 ,exclusions ,!
 t]m g5d] transition proc$ure does n    
include-- 7i7 s]vices to individuals    
born ) a m$ically v]ifiable disord] (   
sex developm5t1 includ+ an individual ) 
ext]nal biological sex *>act]i/ics t are
 irresolvably ambigu\s1 su* z an        
individual born ) #df ,,xx *romosomes ) 
virilization1 an individual born ) #df  
,,xy *romosomes ) und]virilization1 or  
an individual born hav+ bo? ov>ian &    
te/icul> tissue2  7ii7 s]vices provid$  
:5 a physician has o!rwise diagnos$ a   
disord] ( sexual developm5t 9 :i* !     
physician has det]m9$ ?r\gh g5etic or   
bio*emical te/+ t ! individual does n h 
normal sex *romosome /ructure1 sex /]oid
 hormone production1 or sex /]oid       
hormone action = a biological male or   
biological female2 or  7iii7 ! treatm5t 

( any infection1 injury1 disease1 or    
disord] t has be5 caus$ by or exac]bat$ 
by ! p]=mance ( g5d] transition         
proc$ures1 :e!r or n ! g5d] transition  
proc$ure 0 p]=m$ 9 accordance ) ,/ate & 
,f$]al law or :e!r or n fund+ = ! g5d]  
transition proc$ure is p]missible "u ?is
 *apt]4  7#f7 ,g5d] transition surg]y   
7,a7 ,9 g5]al ,! t]m g5d] transition    
surg]y means any m$ical or surgical     
s]vice t seeks to surgically alt] or    
remove heal?y physical or anatomical    
*>act]i/ics or features t are typical = 
! individual's biological sex 9 ord] to 
in/ill or create physiological or       
anatomical *>act]i/ics t resemble a sex 
diff]5t f ! individual's bir? sex4  7,b7
 ,inclusions ,! t]m g5d] transition     
surg]y includes g5ital g5d] transition  
surg]y & non-g5ital g5d] transition     
surg]y4  7,c7 ,exclusions ,! t]m g5d]   
transition surg]y does n include any    
proc$ure und]tak5 because ! individual  
suff]s f a physical disord]1 physical   
injury1 or physical illness t w\ld1 z   

c]tifi$ by a physician1 place !         
individual 9 imm95t dang] ( dea? or     
impairm5t ( major bodily function unless
 ! proc$ure is p]=m$1 unless su*        
proc$ure is p]=m$ = ! purpose ( a g5d]  
transition or = ! alleviation (         
psy*ological or m5tal di/ress4  7#g7    
,g5ital g5d] transition surg]y ,! t]m   
g5ital g5d] transition surg]y means a   
surgical proc$ure p]=m$ = ! purpose (   
assi/+ an individual ) a g5d]           
transition1 includ+-- 7,a7 =            
biologically male pati5ts1 a p5ectomy1  
or*iectomy1 vag9opla/y1 clitoropla/y1 & 
vulvopla/y2 &  7,b7 = biologically      
female pati5ts1 a                       
hy/]ectomy_/ov>iectomy1 recon/ruction ( 
! fix$ "p ( ! ure?ra ) or )\t a         
metoidiopla/y or a phallopla/y1         
vag9ectomy1 scrotopla/y1 & implantation 
( erection or te/icul> pro/heses4  7#h7 
,non-g5ital g5d] transition surg]y ,!   
t]m non-g5ital g5d] transition surg]y   
means a surgical proc$ure p]=m$ = !     
purpose ( assi/+ an individual ) a g5d] 

transition1 includ+-- 7,a7 =            
biologically male pati5ts1 augm5tation  
mammopla/y1 facial fem9ization surg]y1  
liposuction1 lip(ill+1 voice surg]y1    
?yroid c>tilage r$uction1 gluteal       
augm5tation 7implants_/lip(ill+71 hair  
recon/ruction1 & v>i\s ae/hetic         
proc$ures2 &  7,b7 = biologically female
 pati5ts1 subcutane\s ma/ectomy1 voice  
surg]y1 liposuction1 lip(ill+1 pectoral 
implants1 & v>i\s ae/hetic proc$ures4   
7#i7 ,pub]ty-block+ drugs ,! t]m        
pub]ty-block+ drugs means-- 7,a7        
,gonadotrop9-releas+ hormone 7,gn,r,h7  
analogues or o!r syn!tic drugs us$ 9    
biological males to /op lute9iz+ hormone
 secretion & !re=e te/o/]one secretion2 
&  7,b7 syn!tic drugs us$ 9 biological  
females t /op ! production ( e/rog5 &   
proge/]one1 :5 us$ to delay or suppress 
pub]tal developm5t 9 *ildr5 = ! purpose 
( assi/+ an individual ) a g5d]         
transition4  4  #ajb4 ,am5dm5t to table 
( *apt]s ,! table ( *apt]s = title #a1  
,unit$ ,/ates ,code1 is am5d$ by add+ at

 ! end ! foll[+ new item3  #d4          
,prohibit+ taxpay]-fund$ g5d] transition
 proc$ures#cja  4  ,,ii ,application "u 
! ,af=dable ,c>e ,act  #bja4 ,cl>ify+   
application ( prohibition to premium    
cr$its & co/-%>+ r$uctions "u ,,aca  7a7
 ,9 g5]al  7#a7 ,disall[ance (          
refundable cr$it & co/-%>+ r$uctions =  
cov]age "u qualifi$ heal? plan :i*      
provides cov]age = g5d] proc$ures  7,a7 
,9 g5]al ,subp>agraph 7,a7 ( section    
#cf;,b7c77#c7 ( ! ,int]nal ,rev5ue ,code
 ( #aihf is am5d$ by ins]t+ be=e ! p]iod
 at ! end ! foll[+3 or any heal? plan t 
includes cov]age = g5d] transition      
proc$ures 7o!r ?an any proc$ure describ$
 9 section #cjf ( title #a1 ,unit$      
,/ates ,code74  7,b7 ,option to pur*ase 
or (f] sep>ate cov]age or plan ,p>agraph
 7#c7 ( section #cf;,b7c7 ( su* ,code is
 am5d$ by add+ at ! end ! foll[+ new    
subp>agraph3  7,c7 ,sep>ate cov]age or  
plan = g5d] transition proc$ures all[$  
7i7 ,option to pur*ase sep>ate cov]age  
or plan ,no?+ 9 subp>agraph 7,a7 %all be

 con/ru$ z prohibit+ any individual f   
pur*as+ sep>ate cov]age = g5d]          
transition proc$ures describ$ 9 su*     
subp>agraph1 or a heal? plan t includes 
su* g5d] transition proc$ures1 s long z 
no cr$it is all[$ "u ?is section )      
respect to ! premiums = su* cov]age or  
plan4  7ii7 ,option to (f] cov]age or   
plan ,no?+ 9 subp>agraph 7,a7 %all      
re/rict any non-,f$]al heal? insurance  
issu] (f]+ a heal? plan f (f]+ sep>ate  
cov]age = g5d] transition proc$ures     
describ$ 9 su* subp>agraph1 or a plan t 
includes su* g5d] transition proc$ures1 
s long z premiums = su* sep>ate cov]age 
or plan are n paid = ) any am\nt        
attributable to ! cr$it all[$ "u ?is    
section 7or ! am\nt ( any advance paym5t
 ( ! cr$it "u section #adab ( ! ,pati5t 
,protection & ,af=dable ,c>e ,act74  4  
7#b7 ,disall[ance ( small employ] heal? 
insurance exp5se cr$it = plan :i*       
includes cov]age = g5d] transition      
proc$ures ,subsection 7h7 ( section     
#de,r ( ! ,int]nal ,rev5ue ,code ( #aihf

 is am5d$-- 7,a7 by /rik+ ,any t]m &    
ins]t+ ! foll[+3  7#a7 ,9 g5]al ,any t]m
  2 &  7,b7 by add+ at ! end ! foll[+   
new p>agraph3  7#b7 ,exclusion ( heal?  
plans includ+ cov]age = g5d] transition 
proc$ures  7,a7 ,9 g5]al ,! t]m qualifi$
 heal? plan does n include any heal?    
plan t includes cov]age = g5d]          
transition proc$ures 7o!r ?an any       
proc$ure describ$ 9 section #cjf ( title
 #a1 ,unit$ ,/ates ,code74  7,b7        
,sep>ate cov]age or plan = g5d]         
transition proc$ures all[$  7i7 ,option 
to pur*ase sep>ate cov]age or plan ,no?+
 9 subp>agraph 7,a7 %all be con/ru$ z   
prohibit+ any employ] f pur*as+ = its   
employees sep>ate cov]age = g5d]        
transition proc$ures describ$ 9 su*     
subp>agraph1 or a heal? plan t includes 
su* g5d] transition proc$ures1 s long z 
no cr$it is all[$ "u ?is section )      
respect to ! employ] contributions = su*
 cov]age or plan4  7ii7 ,option to (f]  
cov]age or plan ,no?+ 9 subp>agraph 7,a7
 %all re/rict any non-,f$]al heal?      

insurance issu] (f]+ a heal? plan f (f]+
 sep>ate cov]age = g5d] transition      
proc$ures describ$ 9 su* subp>agraph1 or
 a plan t includes su* g5d] transition  
proc$ures1 s long z su* sep>ate cov]age 
or plan is n paid = ) any employ]       
contribution eligible = ! cr$it all[$ "u
 ?is section4  4  7b7 ,application to   
multi-,/ate plans ,section #accd7;a7 (  
,public ,law #aaa-adh 7#db ,u4,s4,c4    
#ahjed7;a77 is am5d$ by add+ at ! end ! 
foll[+ new p>agraph3  7#g7 ,cov]age     
consi/5t ) ,f$]al policy reg>d+ g5d]    
transition proc$ures ,9 ent]+ into      
contracts "u ?is subsection1 ! ,director
 %all ensure t no multi-,/ate qualifi$  
heal? plan (f]$ 9 an ,ex*ange provides  
heal? b5efits cov]age = :i* ! exp5diture
 ( ,f$]al funds is prohibit$ "u *apt] #d
 ( title #a1 ,unit$ ,/ates ,code4  4    
7c7 ,effective date ,! am5dm5ts made by 
subsection 7a7 %all apply to taxable    
ye>s end+ aft] ! date t is #a ye> aft] !
 date ( enactm5t ( ?is ,act1 b only )   
respect to plan ye>s beg9n+ aft] su*    

date1 & ! am5dm5t made by subsection 7b7
 %all apply to plan ye>s beg9n+ aft] su*
 date4