Navigating Gender Affirmation Coverage
Client: Self-Funded Group Health Plans
Self-funded group health plans, sponsored by various employers and entities, grapple with coverage decisions for gender dysphoria and gender affirmation surgery amid conflicting federal and state laws. Hall Benefits Law (HBL) partners Tim Kennedy, Anne Tyler Hall, and Sam Krause provided proactive education and policy development following key 2025 rulings, including the U.S. Supreme Court’s U.S. v. Skrmetti (June 2025) allowing state bans for minors and the Eleventh Circuit’s Lange v. Houston County (September 9, 2025) upholding non-discriminatory exclusions under Title VII. This guidance enabled clients to adopt age-based restrictions defensible under ACA and Title VII, with ongoing support as of September 2025.
THE CHALLENGE
Plans must balance MHPAEA, ACA, and Title VII anti-discrimination requirements against state laws and evolving precedents. Decisions on covering gender affirmation procedures risk lawsuits for discrimination if based on gender, or non-compliance if overly restrictive, especially with federal rulings suggesting broader protections while states limit minor access.
THE TURNING POINT
Recent court decisions clarified permissible restrictions but highlighted federal discrimination risks, prompting plan sponsors to seek expert ERISA advice. Without tailored policies, clients faced potential fiduciary breaches and litigation, leading to HBL’s engagement for defensible plan designs.
THE SOLUTION
HBL analyzed rulings and statutes, recommending age-based prohibitions (e.g., for minors) rather than gender-based ones to align with Skrmetti and avoid Title VII/ACA violations. They crafted clear plan language ensuring uniform application, providing ongoing education to position clients defensively regardless of coverage stance.
Our Results
Litigation Risks Mitigated
Enabled clients to limit coverage with confidence in defensibility under key precedents like U.S. v. Skrmetti.
Compliance Aligned
Harmonized plans with ACA, Title VII, and state laws, avoiding discrimination claims through non-gender-specific restrictions.
Proactive Education Delivered
Equipped sponsors with updated policies and training, fostering informed decisions amid regulatory shifts.
Ongoing Support
Provided continuous counsel from September 2025, ensuring adaptability to future legal developments.
WHY IT MATTERS
Gender affirmation coverage intersects complex ERISA, civil rights, and state laws, where missteps can invite costly suits. This case demonstrates how proactive, precedent-informed guidance can create robust, non-discriminatory policies, protecting fiduciaries and allowing plans to navigate sensitive issues ethically and legally.
ABOUT HBL
Hall Benefits Law (HBL) is a boutique ERISA and employee benefits law firm helping employers design and defend retirement and health plans. With offices nationwide, HBL advises on M&A benefits, ESOPs, executive compensation, and compliance, and drives savings and transparency through TPA and PBM negotiations. Firm clients have realized over $400MM+ in penalty abatements and multimillion-dollar annual plan savings.