,i  #aai? ,,congress  #b;d ,session  ,h4
 ,r4 #igdc  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,july #af1 #bjbf,mrs4 
,h>%b>g] 7= h]self1 ,mr4 ,c>t] (        
,georgia1 ,mr4 ,mc,guire1 ,mr4 ,k5n$y ( 
,utah1 ,mr4 ,c>t] ( ,texas1 ,mr4 ,full]1
 ,mr4 ,van ,epps1 ,mrs4 ,biggs ( ,s\?   
,c>ol9a1 ,mr4 ,bab91 ,mrs4 ,mill] (     
,ill9ois1 ,mr4 ,/utzman1 ,mr4 ,hamadeh (
 ,arizona1 & ,mr4 ,ciscomani7 introduc$ 
! foll[+ bill2 :i* 0 ref]r$ to !        
,committee on ,en]gy & ,comm]ce1 & 9    
addition to ! ,committees on ,education 
& ,work=ce1 & ,ways & ,means1 = a p]iod 
to be subsequ5tly det]m9$ by ! ,speak]1 
9 ea* case = consid]ation ( su*         
provisions z fall )9 ! jurisdiction ( ! 
committee conc]n$  ,a ,,bill  ,to am5d  
title ,,xxvii ( ! ,public ,heal? ,s]vice
 ,act1 ! ,employee ,retirem5t ,income   
,security ,act ( #aigd1 & ! ,int]nal    
,rev5ue ,code ( #aihf to require gr\p   
heal? plans & heal? insurance issu]s    
(f]+ gr\p or individual heal? insurance 
cov]age t provide b5efits = sex-reject+ 

proc$ures to provide b5efits = items &  
s]vices to address ! h>ms caus$ by      
sex-reject+ proc$ures & to re/ore heal?y
 human =m & function+1 to ! greate/     
ext5t practicable4  #a4 ,%ort title ,?is
 ,act may be cit$ z ! ,treatm5t &       
,re/oration ,uni=mity & ,transp>5cy 9   
,heal? ,cov]age ,act ( #bjbf or ! ,,tru?
 9 ,cov]age ,act ( #bjbf4  #b4 ,requir+ 
gr\p heal? plans & heal? insurance      
issu]s (f]+ gr\p or individual heal?    
insurance cov]age t provide b5efits =   
sex-reject+ proc$ures to provide b5efits
 = items & s]vices to address ! h>ms (  
su* proc$ures  7a7 ,,phsa ,"p ,d ( title
 ,,xxvii ( ! ,public ,heal? ,s]vice ,act
 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq47 is
 am5d$ by add+ at ! end ! foll[+ new    
section3  #bgii;,a-#ab4 ,requir$ cov]age
 ( items & s]vices to address ! h>ms (  
sex-reject+ proc$ures  7a7 ,9 g5]al ,a  
gr\p heal? plan & a heal? insurance     
issu] (f]+ gr\p or individual heal?     
insurance cov]age %all1 9 ! case su*    
plan or cov]age provides b5efits )      

respect to any sex-reject+ proc$ure1    
also provide b5efits = items & s]vices  
furni%$ to an individual :o has receiv$ 
any su* proc$ure to address ! h>ms ( su*
 proc$ure 7includ+ re/orative c>e71     
reg>dless ( :e!r-- 7#a7 su* individual  
receiv$ b5efits ) respect to !          
sex-reject+ proc$ure "u ! individual's  
plan or cov]age2 or  7#b7 su* plan or   
issu] provides b5efits "u ! individual's
 plan or cov]age = ! sex-reject+        
proc$ure4  7b7 ,application ( f9ancial  
requirem5ts & treatm5t limitations ,a   
gr\p heal? plan & a heal? insurance     
issu] (f]+ gr\p or individual heal?     
insurance cov]age %all ensure t1 )      
respect to items & s]vices = :i* b5efits
 to address ! h>ms ( sex-reject+        
proc$ures are requir$ to be provid$ "u  
su* plan or cov]age "u subsection 7a7-- 
7#a7 ! f9ancial requirem5ts applicable  
to su* items & s]vices are no m         
re/rictive ?an ! pr$om9ant f9ancial     
requirem5ts appli$ to sub/antially all  
m$ical & surgical b5efits cov]$ by !    

plan or cov]age & !re are no sep>ate    
co/-%>+ requirem5ts t are applicable    
only ) respect to su* items & s]vices2 &
  7#b7 ! treatm5t limitations applicable
 to su* items & s]vices are no m        
re/rictive ?an ! pr$om9ant treatm5t     
limitations appli$ to sub/antially all  
m$ical & surgical b5efits cov]$ by !    
plan or cov]age & !re are no sep>ate    
treatm5t limitations t are applicable   
only ) respect to su* items & s]vices4  
7c7 ,def9itions ,9 ?is section3 7#a7    
,female ,ref]r+ to a natural p]son1 !   
t]m female means an individual *>act]iz$
 by a reproductive sy/em naturally      
organiz$ to produce 7at maturity1 abs5t 
disruption or cong5ital anomaly7 l>ge   
gametes 7ova74  7#b7 ,f9ancial          
requirem5t2 pr$om9ant2 treatm5t         
limitation ,! t]ms f9ancial requirem5t1 
pr$om9ant1 & treatm5t limitation h !    
mean+ giv5 su* t]ms 9 clauses 7i7 ?r\gh 
7iii71 respectively1 ( section          
#bgbf7;a77#c77;,b71 except t ! t]m      
f9ancial requirem5t %all include        

aggregate lifetime limits & annual      
limits4  7#c7 ,male ,ref]r+ to a natural
 p]son1 ! t]m male means an individual  
*>act]iz$ by a reproductive sy/em       
naturally organiz$ to produce 7at       
maturity1 abs5t disruption or cong5ital 
anomaly7 small gametes 7sp]m74  7#d7    
,re/orative c>e ,! t]m re/orative c>e   
means items & s]vices furni%$ to an     
individual :o has receiv$ any           
sex-reject+ proc$ure at any po9t dur+ ! 
individual's lifetime to address1       
mitigate1 monitor1 treat1 or rev]se !   
h>ms1 complications1 & adv]se effects ( 
su* proc$ure1 includ+ int]v5tions int5d$
 to re/ore1 to ! greate/ ext5t          
practicable1 heal?y human =m &          
function+4 ,su* c>e includes items &    
s]vices furni%$ to address-- 7,a7       
impair$ reproductive capacity1 dim9i%$  
ov>ian res]ve1 impair$ sp]matog5esis1 or
 o!r reproductive-sy/em injury2  7,b7   
endocr9e dysfunction1 hormonal          
imbalance1 hypogonadism1 dep5d5ce on    
exog5\s hormones1 or o!r disruption (   

heal?y endocr9e function2  7,c7 impair$ 
sexual function1 includ+ loss ( sexual  
s5sation1 anorgasmia1 erectile          
dysfunction1 g5ital pa91 vag9al /5osis1 
dim9i%$ libido1 or o!r sexual           
dysfunction2  7,d7 ur9>y dysfunction1   
includ+ ur9>y incont95ce1 ur9>y         
ret5tion1 ure?ral complications1        
recurr5t ur9>y tract infections1 or o!r 
g5it\r9>y injury2  7,e7 resultant vocal 
cord damage1 p]man5t voice *anges1 vocal
 dysfunction1 or impair$ spee*2  7,f7   
female hirsutism1 male-patt]n baldness1 
brea/ atrophy1 brea/ developm5t1 or o!r 
second>y-sex-*>act]i/ic *anges caus$ by 
cross-sex hormones2  7,g7 o/eoporosis1  
o/eop5ia1 impair$ bone developm5t1      
fractures1 r$uc$ bone d5sity1 or o!r    
skeletal disord]s associat$ ) pub]ty    
suppression or cross-sex hormone use2   
7,h7 c>diovascul> disease1 ?romboembolic
 disease1 hyp]t5sion1 /roke1 myoc>dial  
inf>ction1 metabolic syndrome1 diabetes1
 or o!r c>diovascul> or metabolic       
complications associat$ ) su* proc$ures2

  7,i7 surgical complications1 includ+  
infection1 fi/ula =mation1 /5osis1      
tissue necrosis1 *ronic pa91 n]ve       
damage1 graft failure1 implant          
complications1 w\nd complications1 or ! 
ne$ = revision surg]y2  7,j7 loss1      
removal1 alt]ation1 or impairm5t (      
heal?y reproductive organs1 brea/s1     
g5ital /ructures1 or o!r heal?y tissues2
  7,k7 recon/ructive1 reg5]ative1       
pro/hetic1 pla/ic1 or o!r surgical      
int]v5tions int5d$ to re/ore heal?y     
anatomy1 appe>ance1 or physiological    
function2  7,l7 rehabilitation s]vices1 
includ+ spee* !rapy1 physical !rapy1    
occupational !rapy1 pelvic floor !rapy1 
sexual heal? c\nsel+1 & o!r !rapies     
int5d$ to re/ore heal?y function+2  7,m7
 psy*iatric or psy*ological conditions  
associat$ ) or exac]bat$ by su*         
proc$ures1 includ+ depression1 anxiety1 
trauma1 suicidality1 grief1 regret1     
id5tity di/ress1 body-image di/urbance1 
or dissociation2  7,n7 diagno/ic te/+1  
speciali/ evaluations1 f]tility         

assessm5ts1 hormone monitor+1 canc]     
scre5+1 & long-t]m m$ical surveillance  
necessitat$ by alt]$ anatomy or prior   
exposure to pub]ty block]s1 cross-sex   
hormones1 or sex-reject+ surg]ies2  7,o7
 f]tility s]vices t seek to coop]ate )1 
or re/ore ! heal?y physiology & anatomy 
(1 ! human reproductive sy/em1 )\t ! use
 ( me?ods t circumv5t natural human     
functions1 su* z any treatm5ts or       
proc$ures t involve ! h&l+ ( a human egg
 or embryo outside ! body2  7,p7 brea/  
canc] 9 m5 on e/rog5 & c]ta9 canc]s 9   
wom5 on te/o/]one2 &  7,q7 any o!r      
physical1 psy*ological1 reproductive1   
endocr9e1 neurologic1 c>diovascul>1     
musculoskeletal1 or metabolic injury1   
impairm5t1 complication1 or condition   
result+ f or associat$ ) a sex-reject+  
proc$ure4  7#e7 ,sex ,! t]m sex1 :5     
ref]r+ to an individual's sex1 means to 
ref] to ei!r male or female1 z          
g5etically det]m9$ at f]tilization4     
7#f7 ,sex-reject+ proc$ure  7,a7 ,9     
g5]al ,! t]m sex-reject+ proc$ure means 

any m$ical or surgical int]v5tion = !   
purpose ( attempt+ to align an          
individual's physical appe>ance or body 
) an ass]t$ id5tity t diff]s f !        
individual's sex1 includ+-- 7i7         
gonadotrop9-releas+ hormone 7,gn,r,h7   
agoni/s or any o!r pub]ty-block+ or     
suppress+ drugs to /op or delay normal  
pub]ty2  7ii7 te/o/]one1                
dihydrote/o/]one 7,,dht71 or o!r &rog5s1
 e/rog51 proge/]one1 to an individual at
 doses t are supraphysiologic to :at    
w\ld normally be produc$ endog5\sly 9 a 
heal?y individual ( ! same age & sex1 z 
well z anti-&rog5 m$ications2  7iii7    
ca/ration2  7iv7 or*iectomy2  7v7       
scrotopla/y2  7vi7 implantation (       
erection or te/icul> pro/heses2  7vii7  
vasectomy2  7viii7 hy/]ectomy2  7ix7    
oophorectomy2  7x7 ov>iectomy2  7xi7    
recon/ruction ( ! fix$ "p ( ! ure?ra )  
or )\t a metoidiopla/y or a phallopla/y2
  7xii7 metoidiopla/y2  7xiii7 p5ectomy2
  7xiv7 phallopla/y2  7xv7 vag9opla/y2  
7xvi7 clitoropla/y2  7xvii7 vag9ectomy2 

7xviii7 vulvopla/y2  7xix7 r$uction     
?yro*ondropla/y2  7xx7                  
*ondrol>yngopla/y2  7xxi7 ma/ectomy2    
7xxii7 tubal ligation2  7xxiii7         
/]ilization2  7xxiv7 any pla/ic1        
cosmetic1 or ae/hetic surg]y t fem9izes 
or mascul9izes ! facial or o!r          
physiological features ( an individual2 
7xxv7 any placem5t ( *e/ implants to    
create fem99e brea/s2  7xxvi7 any       
placem5t ( fat or artificial implants 9 
! gluteal region2  7xxvii7 augm5tation  
mammopla/y2  7xxviii7 liposuction2      
7xxix7 lip(ill+2  7xxx7 voice surg]y2   
7xxxi7 hair recon/ruction2  7xxxii7     
pectoral implants2 &  7xxxiii7 ! removal
 ( any o!rwise heal?y or non-diseas$    
body "p or tissue4  7,b7 ,exceptions ,! 
t]m sex-reject+ proc$ure does n include 
! foll[+ :5 furni%$ by a heal? c>e      
pr(essional ) ! cons5t ( su* individual 
or1 if applicable1 su* individual's     
p>5ts or legal gu>dian3 7i7 ,s]vices to 
individuals born ) a m$ically v]ifiable 
disord] ( sex developm5t1 includ+ an    

individual ) ext]nal sex *>act]i/ics t  
are irresolvably ambigu\s1 su* z an     
individual born ) #df1,,xx *romosomes ) 
virilization1 an individual born )      
#df1,,xy *romosomes ) und]virilization1 
or an individual born hav+ bo? ov>ian & 
te/icul> tissue4  7ii7 ,s]vices provid$ 
:5 a physician has o!rwise diagnos$ a   
disord] ( sex developm5t 9 :i* !        
physician has det]m9$ ?r\gh g5etic or   
bio*emical te/+ t ! individual does n h 
heal?y sex *romosome /ructure1 sex /]oid
 hormone production1 or sex /]oid       
hormone action = a heal?y individual ( !
 same sex & age4  7iii7 ,! treatm5t (   
any infection1 injury1 disease1 or      
disord] t has be5 caus$ by or exac]bat$ 
by ! p]=mance ( sex-reject+ proc$ures1  
:e!r or n ! sex-reject+ proc$ure 0 p]=m$
 9 accordance ) ,/ate & ,f$]al law &    
:e!r or n fund+ = ! proc$ure is         
p]missible "u ?is section4  7iv7 ,any   
proc$ure und]tak5 because ! individual  
suff]s f a physical disord]1 physical   
injury1 or physical illness 7b n claim$ 

m5tal di/ress7 t w\ld1 z c]tifi$ by a   
physician1 place ! individual 9 imm95t  
dang] ( dea? or impairm5t ( major bodily
 function1 unless ! proc$ure is p]=m$4  
7v7 ,pub]ty suppression or block+       
prescription drugs = ! purpose (        
normaliz+ pub]ty = a m9or exp]i5c+      
precoci\s pub]ty4  7vi7 ,male           
circumcision4  4  7b7 ,,erisa  7#a7 ,9  
g5]al ,subp>t ,b ( "p #g ( subtitle ,b (
 title ,i ( ! ,employee ,retirem5t      
,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #aahe et seq47 is am5d$ by    
add+ at ! end ! foll[+ new section3     
#gbg4 ,requir$ cov]age ( items & s]vices
 to address ! h>ms ( sex-reject+        
proc$ures  7a7 ,9 g5]al ,a gr\p heal?   
plan & a heal? insurance issu] (f]+ gr\p
 heal? insurance cov]age %all1 9 ! case 
su* plan or cov]age provides b5efits )  
respect to any sex-reject+ proc$ure1    
also provide b5efits = items & s]vices  
furni%$ to an individual :o has receiv$ 
any su* proc$ure to address ! h>ms ( su*
 proc$ure 7includ+ re/orative c>e71     

reg>dless ( :e!r-- 7#a7 su* individual  
receiv$ b5efits ) respect to !          
sex-reject+ proc$ure "u ! individual's  
plan or cov]age2 or  7#b7 su* plan or   
issu] provides b5efits "u ! individual's
 plan or cov]age = ! sex-reject+        
proc$ure4  7b7 ,application ( f9ancial  
requirem5ts & treatm5t limitations ,a   
gr\p heal? plan & a heal? insurance     
issu] (f]+ gr\p heal? insurance cov]age 
%all ensure t1 ) respect to items &     
s]vices = :i* b5efits to address ! h>ms 
( sex-reject+ proc$ures are requir$ to  
be provid$ "u su* plan or cov]age "u    
subsection 7a7-- 7#a7 ! f9ancial        
requirem5ts applicable to su* items &   
s]vices are no m re/rictive ?an !       
pr$om9ant f9ancial requirem5ts appli$ to
 sub/antially all m$ical & surgical     
b5efits cov]$ by ! plan or cov]age & !re
 are no sep>ate co/-%>+ requirem5ts t   
are applicable only ) respect to su*    
items & s]vices2 &  7#b7 ! treatm5t     
limitations applicable to su* items &   
s]vices are no m re/rictive ?an !       

pr$om9ant treatm5t limitations appli$ to
 sub/antially all m$ical & surgical     
b5efits cov]$ by ! plan or cov]age & !re
 are no sep>ate treatm5t limitations t  
are applicable only ) respect to su*    
items & s]vices4  7c7 ,def9itions ,9 ?is
 section3 7#a7 ,female ,ref]r+ to a     
natural p]son1 ! t]m female means an    
individual *>act]iz$ by a reproductive  
sy/em naturally organiz$ to produce 7at 
maturity1 abs5t disruption or cong5ital 
anomaly7 l>ge gametes 7ova74  7#b7      
,f9ancial requirem5t2 pr$om9ant2        
treatm5t limitation ,! t]ms f9ancial    
requirem5t1 pr$om9ant1 & treatm5t       
limitation h ! mean+ giv5 su* t]ms 9    
clauses 7i7 ?r\gh 7iii71 respectively1 (
 section #gab7;a77#c77;,b71 except t !  
t]m f9ancial requirem5t %all include    
aggregate lifetime limits & annual      
limits4  7#c7 ,male ,ref]r+ to a natural
 p]son1 ! t]m male means an individual  
*>act]iz$ by a reproductive sy/em       
naturally organiz$ to produce 7at       
maturity1 abs5t disruption or cong5ital 

anomaly7 small gametes 7sp]m74  7#d7    
,re/orative c>e ,! t]m re/orative c>e   
means items & s]vices furni%$ to an     
individual :o has receiv$ any           
sex-reject+ proc$ure at any po9t dur+ ! 
individual's lifetime to address1       
mitigate1 monitor1 treat1 or rev]se !   
h>ms1 complications1 & adv]se effects ( 
su* proc$ure1 includ+ int]v5tions int5d$
 to re/ore1 to ! greate/ ext5t          
practicable1 heal?y human =m &          
function+4 ,su* c>e includes items &    
s]vices furni%$ to address-- 7,a7       
impair$ reproductive capacity1 dim9i%$  
ov>ian res]ve1 impair$ sp]matog5esis1 or
 o!r reproductive-sy/em injury2  7,b7   
endocr9e dysfunction1 hormonal          
imbalance1 hypogonadism1 dep5d5ce on    
exog5\s hormones1 or o!r disruption (   
heal?y endocr9e function2  7,c7 impair$ 
sexual function1 includ+ loss ( sexual  
s5sation1 anorgasmia1 erectile          
dysfunction1 g5ital pa91 vag9al /5osis1 
dim9i%$ libido1 or o!r sexual           
dysfunction2  7,d7 ur9>y dysfunction1   

includ+ ur9>y incont95ce1 ur9>y         
ret5tion1 ure?ral complications1        
recurr5t ur9>y tract infections1 or o!r 
g5it\r9>y injury2  7,e7 resultant vocal 
cord damage1 p]man5t voice *anges1 vocal
 dysfunction1 or impair$ spee*2  7,f7   
female hirsutism1 male-patt]n baldness1 
brea/ atrophy1 brea/ developm5t1 or o!r 
second>y-sex-*>act]i/ic *anges caus$ by 
cross-sex hormones2  7,g7 o/eoporosis1  
o/eop5ia1 impair$ bone developm5t1      
fractures1 r$uc$ bone d5sity1 or o!r    
skeletal disord]s associat$ ) pub]ty    
suppression or cross-sex hormone use2   
7,h7 c>diovascul> disease1 ?romboembolic
 disease1 hyp]t5sion1 /roke1 myoc>dial  
inf>ction1 metabolic syndrome1 diabetes1
 or o!r c>diovascul> or metabolic       
complications associat$ ) su* proc$ures2
  7,i7 surgical complications1 includ+  
infection1 fi/ula =mation1 /5osis1      
tissue necrosis1 *ronic pa91 n]ve       
damage1 graft failure1 implant          
complications1 w\nd complications1 or ! 
ne$ = revision surg]y2  7,j7 loss1      

removal1 alt]ation1 or impairm5t (      
heal?y reproductive organs1 brea/s1     
g5ital /ructures1 or o!r heal?y tissues2
  7,k7 recon/ructive1 reg5]ative1       
pro/hetic1 pla/ic1 or o!r surgical      
int]v5tions int5d$ to re/ore heal?y     
anatomy1 appe>ance1 or physiological    
function2  7,l7 rehabilitation s]vices1 
includ+ spee* !rapy1 physical !rapy1    
occupational !rapy1 pelvic floor !rapy1 
sexual heal? c\nsel+1 & o!r !rapies     
int5d$ to re/ore heal?y function+2  7,m7
 psy*iatric or psy*ological conditions  
associat$ ) or exac]bat$ by su*         
proc$ures1 includ+ depression1 anxiety1 
trauma1 suicidality1 grief1 regret1     
id5tity di/ress1 body-image di/urbance1 
or dissociation2  7,n7 diagno/ic te/+1  
speciali/ evaluations1 f]tility         
assessm5ts1 hormone monitor+1 canc]     
scre5+1 & long-t]m m$ical surveillance  
necessitat$ by alt]$ anatomy or prior   
exposure to pub]ty block]s1 cross-sex   
hormones1 or sex-reject+ surg]ies2  7,o7
 f]tility s]vices t seek to coop]ate )1 

or re/ore ! heal?y physiology & anatomy 
(1 ! human reproductive sy/em1 )\t ! use
 ( me?ods t circumv5t natural human     
functions1 su* z any treatm5ts or       
proc$ures t involve ! h&l+ ( a human egg
 or embryo outside ! body2  7,p7 brea/  
canc] 9 m5 on e/rog5 & c]ta9 canc]s 9   
wom5 on te/o/]one2 &  7,q7 any o!r      
physical1 psy*ological1 reproductive1   
endocr9e1 neurologic1 c>diovascul>1     
musculoskeletal1 or metabolic injury1   
impairm5t1 complication1 or condition   
result+ f or associat$ ) a sex-reject+  
proc$ure4  7#e7 ,sex ,! t]m sex1 :5     
ref]r+ to an individual's sex1 means to 
ref] to ei!r male or female1 z          
g5etically det]m9$ at f]tilization4     
7#f7 ,sex-reject+ proc$ure  7,a7 ,9     
g5]al ,! t]m sex-reject+ proc$ure means 
any m$ical or surgical int]v5tion = !   
purpose ( attempt+ to align an          
individual's physical appe>ance or body 
) an ass]t$ id5tity t diff]s f !        
individual's sex1 includ+-- 7i7         
gonadotrop9-releas+ hormone 7,gn,r,h7   

agoni/s or any o!r pub]ty-block+ or     
suppress+ drugs to /op or delay normal  
pub]ty2  7ii7 te/o/]one1                
dihydrote/o/]one 7,,dht71 or o!r &rog5s1
 e/rog51 proge/]one1 to an individual at
 doses t are supraphysiologic to :at    
w\ld be produc$ endog5\sly 9 a heal?y   
individual ( ! same age & sex1 z well z 
anti-&rog5 m$ications2  7iii7 ca/ration2
  7iv7 or*iectomy2  7v7 scrotopla/y2    
7vi7 implantation ( erection or te/icul>
 pro/heses2  7vii7 vasectomy2  7viii7   
hy/]ectomy2  7ix7 oophorectomy2  7x7    
ov>iectomy2  7xi7 recon/ruction ( ! fix$
 "p ( ! ure?ra ) or )\t a metoidiopla/y 
or a phallopla/y2  7xii7 metoidiopla/y2 
7xiii7 p5ectomy2  7xiv7 phallopla/y2    
7xv7 vag9opla/y2  7xvi7 clitoropla/y2   
7xvii7 vag9ectomy2  7xviii7 vulvopla/y2 
7xix7 r$uction ?yro*ondropla/y2  7xx7   
*ondrol>yngopla/y2  7xxi7 ma/ectomy2    
7xxii7 tubal ligation2  7xxiii7         
/]ilization2  7xxiv7 any pla/ic1        
cosmetic1 or ae/hetic surg]y t fem9izes 
or mascul9izes ! facial or o!r          

physiological features ( an individual2 
7xxv7 any placem5t ( *e/ implants to    
create fem99e brea/s2  7xxvi7 any       
placem5t ( fat or artificial implants 9 
! gluteal region2  7xxvii7 augm5tation  
mammopla/y2  7xxviii7 liposuction2      
7xxix7 lip(ill+2  7xxx7 voice surg]y2   
7xxxi7 hair recon/ruction2  7xxxii7     
pectoral implants2 &  7xxxiii7 ! removal
 ( any o!rwise heal?y or non-diseas$    
body "p or tissue4  7,b7 ,exceptions ,! 
t]m sex-reject+ proc$ure does n include 
! foll[+ :5 furni%$ by a heal? c>e      
pr(essional ) ! cons5t ( su* individual 
or1 if applicable1 su* individual's     
p>5ts or legal gu>dian3 7i7 ,s]vices to 
individuals born ) a m$ically v]ifiable 
disord] ( sex developm5t1 includ+ an    
individual ) ext]nal sex *>act]i/ics t  
are irresolvably ambigu\s1 su* z an     
individual born ) #df1,,xx *romosomes ) 
virilization1 an individual born )      
#df1,,xy *romosomes ) und]virilization1 
or an individual born hav+ bo? ov>ian & 
te/icul> tissue4  7ii7 ,s]vices provid$ 

:5 a physician has o!rwise diagnos$ a   
disord] ( sex developm5t 9 :i* !        
physician has det]m9$ ?r\gh g5etic or   
bio*emical te/+ t ! individual does n h 
heal?y sex *romosome /ructure1 sex /]oid
 hormone production1 or sex /]oid       
hormone action = a heal?y individual ( !
 same sex & age4  7iii7 ,! treatm5t (   
any infection1 injury1 disease1 or      
disord] t has be5 caus$ by or exac]bat$ 
by ! p]=mance ( sex-reject+ proc$ures1  
:e!r or n ! sex-reject+ proc$ure 0 p]=m$
 9 accordance ) ,/ate & ,f$]al law &    
:e!r or n fund+ = ! proc$ure is         
p]missible "u ?is section4  7iv7 ,any   
proc$ure und]tak5 because ! individual  
suff]s f a physical disord]1 physical   
injury1 or physical illness 7b n claim$ 
m5tal di/ress7 t w\ld1 z c]tifi$ by a   
physician1 place ! individual 9 imm95t  
dang] ( dea? or impairm5t ( major bodily
 function1 unless ! proc$ure is p]=m$4  
7v7 ,pub]ty suppression or block+       
prescription drugs = ! purpose (        
normaliz+ pub]ty = a m9or exp]i5c+      

precoci\s pub]ty4  7vi7 ,male           
circumcision4  4  7#b7 ,cl]ical am5dm5t 
,! table ( cont5ts 9 section #a ( !     
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4 #ajja note7 
is am5d$ by ins]t+ aft] ! item relat+ to
 section #gbf ! foll[+ new item3  ,sec4 
#gbg4 ,requir$ cov]age ( items & s]vices
 to address ! h>ms ( sex-reject+        
proc$ures4  4  7c7 ,,irc  7#a7 ,9 g5]al 
,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal  
,rev5ue ,code ( #aihf is am5d$ by add+  
at ! end ! foll[+ new section3  #ihbg4  
,requir$ cov]age ( items & s]vices to   
address ! h>ms ( sex-reject+ proc$ures  
7a7 ,9 g5]al ,a gr\p heal? plan %all1 9 
! case su* plan provides b5efits )      
respect to any sex-reject+ proc$ure1    
also provide b5efits = items & s]vices  
furni%$ to an individual :o has receiv$ 
any su* proc$ure to address ! h>ms ( su*
 proc$ure 7includ+ re/orative c>e71     
reg>dless ( :e!r-- 7#a7 su* individual  
receiv$ b5efits ) respect to !          
sex-reject+ proc$ure "u ! individual's  

plan2 or  7#b7 su* plan provides b5efits
 "u ! individual's plan = ! sex-reject+ 
proc$ure4  7b7 ,application ( f9ancial  
requirem5ts & treatm5t limitations ,a   
gr\p heal? plan %all ensure t1 ) respect
 to items & s]vices = :i* b5efits to    
address ! h>ms ( sex-reject+ proc$ures  
are requir$ to be provid$ "u su* plan "u
 subsection 7a7-- 7#a7 ! f9ancial       
requirem5ts applicable to su* items &   
s]vices are no m re/rictive ?an !       
pr$om9ant f9ancial requirem5ts appli$ to
 sub/antially all m$ical & surgical     
b5efits cov]$ by ! plan & !re are no    
sep>ate co/-%>+ requirem5ts t are       
applicable only ) respect to su* items &
 s]vices2 &  7#b7 ! treatm5t limitations
 applicable to su* items & s]vices are  
no m re/rictive ?an ! pr$om9ant treatm5t
 limitations appli$ to sub/antially all 
m$ical & surgical b5efits cov]$ by !    
plan & !re are no sep>ate treatm5t      
limitations t are applicable only )     
respect to su* items & s]vices4  7c7    
,def9itions ,9 ?is section3 7#a7 ,female

 ,ref]r+ to a natural p]son1 ! t]m      
female means an individual *>act]iz$ by 
a reproductive sy/em naturally organiz$ 
to produce 7at maturity1 abs5t          
disruption or cong5ital anomaly7 l>ge   
gametes 7ova74  7#b7 ,f9ancial          
requirem5t2 pr$om9ant2 treatm5t         
limitation ,! t]ms f9ancial requirem5t1 
pr$om9ant1 & treatm5t limitation h !    
mean+ giv5 su* t]ms 9 clauses 7i7 ?r\gh 
7iii71 respectively1 ( section          
#ihab7;a77#c77;,b71 except t ! t]m      
f9ancial requirem5t %all include        
aggregate lifetime limits & annual      
limits4  7#c7 ,male ,ref]r+ to a natural
 p]son1 ! t]m male means an individual  
*>act]iz$ by a reproductive sy/em       
naturally organiz$ to produce 7at       
maturity1 abs5t disruption or cong5ital 
anomaly7 small gametes 7sp]m74  7#d7    
,re/orative c>e ,! t]m re/orative c>e   
means items & s]vices furni%$ to an     
individual :o has receiv$ any           
sex-reject+ proc$ure at any po9t dur+ ! 
individual's lifetime to address1       

mitigate1 monitor1 treat1 or rev]se !   
h>ms1 complications1 & adv]se effects ( 
su* proc$ure1 includ+ int]v5tions int5d$
 to re/ore1 to ! greate/ ext5t          
practicable1 heal?y human =m &          
function+4 ,su* c>e includes items &    
s]vices furni%$ to address-- 7,a7       
impair$ reproductive capacity1 dim9i%$  
ov>ian res]ve1 impair$ sp]matog5esis1 or
 o!r reproductive-sy/em injury2  7,b7   
endocr9e dysfunction1 hormonal          
imbalance1 hypogonadism1 dep5d5ce on    
exog5\s hormones1 or o!r disruption (   
heal?y endocr9e function2  7,c7 impair$ 
sexual function1 includ+ loss ( sexual  
s5sation1 anorgasmia1 erectile          
dysfunction1 g5ital pa91 vag9al /5osis1 
dim9i%$ libido1 or o!r sexual           
dysfunction2  7,d7 ur9>y dysfunction1   
includ+ ur9>y incont95ce1 ur9>y         
ret5tion1 ure?ral complications1        
recurr5t ur9>y tract infections1 or o!r 
g5it\r9>y injury2  7,e7 resultant vocal 
cord damage1 p]man5t voice *anges1 vocal
 dysfunction1 or impair$ spee*2  7,f7   

female hirsutism1 male-patt]n baldness1 
brea/ atrophy1 brea/ developm5t1 or o!r 
second>y-sex-*>act]i/ic *anges caus$ by 
cross-sex hormones2  7,g7 o/eoporosis1  
o/eop5ia1 impair$ bone developm5t1      
fractures1 r$uc$ bone d5sity1 or o!r    
skeletal disord]s associat$ ) pub]ty    
suppression or cross-sex hormone use2   
7,h7 c>diovascul> disease1 ?romboembolic
 disease1 hyp]t5sion1 /roke1 myoc>dial  
inf>ction1 metabolic syndrome1 diabetes1
 or o!r c>diovascul> or metabolic       
complications associat$ ) su* proc$ures2
  7,i7 surgical complications1 includ+  
infection1 fi/ula =mation1 /5osis1      
tissue necrosis1 *ronic pa91 n]ve       
damage1 graft failure1 implant          
complications1 w\nd complications1 or ! 
ne$ = revision surg]y2  7,j7 loss1      
removal1 alt]ation1 or impairm5t (      
heal?y reproductive organs1 brea/s1     
g5ital /ructures1 or o!r heal?y tissues2
  7,k7 recon/ructive1 reg5]ative1       
pro/hetic1 pla/ic1 or o!r surgical      
int]v5tions int5d$ to re/ore heal?y     

anatomy1 appe>ance1 or physiological    
function2  7,l7 rehabilitation s]vices1 
includ+ spee* !rapy1 physical !rapy1    
occupational !rapy1 pelvic floor !rapy1 
sexual heal? c\nsel+1 & o!r !rapies     
int5d$ to re/ore heal?y function+2  7,m7
 psy*iatric or psy*ological conditions  
associat$ ) or exac]bat$ by su*         
proc$ures1 includ+ depression1 anxiety1 
trauma1 suicidality1 grief1 regret1     
id5tity di/ress1 body-image di/urbance1 
or dissociation2  7,n7 diagno/ic te/+1  
speciali/ evaluations1 f]tility         
assessm5ts1 hormone monitor+1 canc]     
scre5+1 & long-t]m m$ical surveillance  
necessitat$ by alt]$ anatomy or prior   
exposure to pub]ty block]s1 cross-sex   
hormones1 or sex-reject+ surg]ies2  7,o7
 f]tility s]vices t seek to coop]ate )1 
or re/ore ! heal?y physiology & anatomy 
(1 ! human reproductive sy/em1 )\t ! use
 ( me?ods t circumv5t natural human     
functions1 su* z any treatm5ts or       
proc$ures t involve ! h&l+ ( a human egg
 or embryo outside ! body2  7,p7 brea/  

canc] 9 m5 on e/rog5 & c]ta9 canc]s 9   
wom5 on te/o/]one2 &  7,q7 any o!r      
physical1 psy*ological1 reproductive1   
endocr9e1 neurologic1 c>diovascul>1     
musculoskeletal1 or metabolic injury1   
impairm5t1 complication1 or condition   
result+ f or associat$ ) a sex-reject+  
proc$ure4  7#e7 ,sex ,! t]m sex1 :5     
ref]r+ to an individual's sex1 means to 
ref] to ei!r male or female1 z          
g5etically det]m9$ at f]tilization4     
7#f7 ,sex-reject+ proc$ure  7,a7 ,9     
g5]al ,! t]m sex-reject+ proc$ure means 
any m$ical or surgical int]v5tion = !   
purpose ( attempt+ to align an          
individual's physical appe>ance or body 
) an ass]t$ id5tity t diff]s f !        
individual's sex1 includ+-- 7i7         
gonadotrop9-releas+ hormone 7,gn,r,h7   
agoni/s or any o!r pub]ty-block+ or     
suppress+ drugs to /op or delay normal  
pub]ty2  7ii7 te/o/]one1                
dihydrote/o/]one 7,,dht71 or o!r &rog5s1
 e/rog51 proge/]one1 to an individual at
 doses t are supraphysiologic to :at    

w\ld normally be produc$ endog5\sly 9 a 
heal?y individual ( ! same age & sex1 z 
well z anti-&rog5 m$ications2  7iii7    
ca/ration2  7iv7 or*iectomy2  7v7       
scrotopla/y2  7vi7 implantation (       
erection or te/icul> pro/heses2  7vii7  
vasectomy2  7viii7 hy/]ectomy2  7ix7    
oophorectomy2  7x7 ov>iectomy2  7xi7    
recon/ruction ( ! fix$ "p ( ! ure?ra )  
or )\t a metoidiopla/y or a phallopla/y2
  7xii7 metoidiopla/y2  7xiii7 p5ectomy2
  7xiv7 phallopla/y2  7xv7 vag9opla/y2  
7xvi7 clitoropla/y2  7xvii7 vag9ectomy2 
7xviii7 vulvopla/y2  7xix7 r$uction     
?yro*ondropla/y2  7xx7                  
*ondrol>yngopla/y2  7xxi7 ma/ectomy2    
7xxii7 tubal ligation2  7xxiii7         
/]ilization2  7xxiv7 any pla/ic1        
cosmetic1 or ae/hetic surg]y t fem9izes 
or mascul9izes ! facial or o!r          
physiological features ( an individual2 
7xxv7 any placem5t ( *e/ implants to    
create fem99e brea/s2  7xxvi7 any       
placem5t ( fat or artificial implants 9 
! gluteal region2  7xxvii7 augm5tation  

mammopla/y2  7xxviii7 liposuction2      
7xxix7 lip(ill+2  7xxx7 voice surg]y2   
7xxxi7 hair recon/ruction2  7xxxii7     
pectoral implants2 &  7xxxiii7 ! removal
 ( any o!rwise heal?y or non-diseas$    
body "p or tissue4  7,b7 ,exceptions ,! 
t]m sex-reject+ proc$ure does n include 
! foll[+ :5 furni%$ by a heal? c>e      
pr(essional ) ! cons5t ( su* individual 
or1 if applicable1 su* individual's     
p>5ts or legal gu>dian3 7i7 ,s]vices to 
individuals born ) a m$ically v]ifiable 
disord] ( sex developm5t1 includ+ an    
individual ) ext]nal sex *>act]i/ics t  
are irresolvably ambigu\s1 su* z an     
individual born ) #df1,,xx *romosomes ) 
virilization1 an individual born )      
#df1,,xy *romosomes ) und]virilization1 
or an individual born hav+ bo? ov>ian & 
te/icul> tissue4  7ii7 ,s]vices provid$ 
:5 a physician has o!rwise diagnos$ a   
disord] ( sex developm5t 9 :i* !        
physician has det]m9$ ?r\gh g5etic or   
bio*emical te/+ t ! individual does n h 
heal?y sex *romosome /ructure1 sex /]oid

 hormone production1 or sex /]oid       
hormone action = a heal?y individual ( !
 same sex & age4  7iii7 ,! treatm5t (   
any infection1 injury1 disease1 or      
disord] t has be5 caus$ by or exac]bat$ 
by ! p]=mance ( sex-reject+ proc$ures1  
:e!r or n ! sex-reject+ proc$ure 0 p]=m$
 9 accordance ) ,/ate & ,f$]al law &    
:e!r or n fund+ = ! proc$ure is         
p]missible "u ?is section4  7iv7 ,any   
proc$ure und]tak5 because ! individual  
suff]s f a physical disord]1 physical   
injury1 or physical illness 7b n claim$ 
m5tal di/ress7 t w\ld1 z c]tifi$ by a   
physician1 place ! individual 9 imm95t  
dang] ( dea? or impairm5t ( major bodily
 function1 unless ! proc$ure is p]=m$4  
7v7 ,pub]ty suppression or block+       
prescription drugs = ! purpose (        
normaliz+ pub]ty = a m9or exp]i5c+      
precoci\s pub]ty4  7vi7 ,male           
circumcision4  4  7#b7 ,cl]ical am5dm5t 
,! table ( sections = sub*apt] ,b (     
*apt] #ajj ( ! ,int]nal ,rev5ue ,code ( 
#aihf is am5d$ by add+ at ! end ! foll[+

 new item3  ,sec4 #ihbg4 ,requir$       
cov]age ( items & s]vices to address !  
h>ms ( sex-reject+ proc$ures4  4  7d7   
,effective date ,! am5dm5ts made by ?is 
section %all apply ) respect to plan    
ye>s beg9n+ on or aft] ,janu>y #a1      
#bjbg4