California Transgender Bill SB-923: Coverage, Complaints, and Penalties

California Senate Bill 923, signed on September 29, 2022 and often called the TGI Inclusive Care Act, requires health plans and insurers operating in California to train patient-facing staff in culturally competent care for transgender, gender diverse, and intersex (TGI) patients, and to flag gender-affirming providers in their directories. The main compliance deadline passed on March 1, 2025, so your plan should already be meeting both requirements.¹

What SB-923 Does Not Do

SB-923 is not a coverage mandate. It does not require insurers to pay for hormone therapy, surgery, or any other specific gender-affirming treatment. California already prohibits insurers from denying, canceling, or limiting coverage based on gender identity under a separate regulation that predates SB-923, and from excluding transition-related services when the same services are covered for other purposes.² SB-923 addresses the next layer: whether the staff and directories you actually interact with reflect that coverage in practice.

Which Plans Are Covered

The law reaches three categories of entities, each overseen by a different state regulator:

Health care service plans, including HMOs and other managed care plans, regulated by the Department of Managed Health Care (DMHC). Dental-only and vision-only plans are excluded.¹
Health insurers, including PPO-style products, regulated by the California Department of Insurance (CDI).
Medi-Cal managed care plans and PACE organizations, regulated by the Department of Health Care Services (DHCS).³

When a plan contracts out duties to a medical group or independent practice association, that entity has to comply too. One important gap: self-insured employer plans governed by ERISA are federal, not state-regulated, so SB-923 does not reach them.

What Your Plan Should Be Doing Now

Two requirements took effect on March 1, 2025.

First, every patient-facing staff member at a covered plan was supposed to have completed evidence-based cultural competency training by that date. The curriculum has to be approved by the plan’s regulator and must cover health inequities within the TGI community, information relevant to people who identify as queer, questioning, asexual, or gender diverse, and the processes involved in seeking gender-affirming care.⁴ The law defines “trans-inclusive health care” as comprehensive care that honors bodily autonomy, avoids assumptions about gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion and respect.⁵

Second, plans had to update their provider directories by the same date to identify which in-network providers have confirmed they offer and have provided gender-affirming services. The same information must be available through the plan’s call center.³

Final regulations from each regulator are not due until July 1, 2027.¹ Until then, plans are expected to comply based on departmental guidance.

Finding an Affirming Provider Through Your Plan

Check your plan’s online directory or call its member services line and ask for a list of in-network providers who have affirmed they offer gender-affirming services. Participation is voluntary for providers, so the list reflects those who have opted in rather than every clinician who might be a good fit.

Plans must add or remove a listing within 30 days of a provider’s request. If a listed provider does not actually deliver TGI-inclusive care, you can complain to the plan. The plan has to investigate and correct any inaccurate or misleading listing within 30 days of finishing its investigation.³

Filing a Complaint if Staff Fail to Provide Trans-Inclusive Care

Plans are required to inform enrollees that they can grieve a failure to receive trans-inclusive care. Start with the plan’s own grievance process. If that does not resolve things, escalate to the regulator that oversees your plan: DMHC for most HMOs and managed care, CDI for PPO health insurance, or DHCS for Medi-Cal managed care and PACE.

When a grievance is substantiated, the staff member named has to complete a refresher training within 30 days, and the regulator can require more frequent training.³ Plans must track complaints and report them to their regulator, which means repeat problems with the same staff member or the same plan can be identified over time.

Penalties for Noncompliance

Each regulator enforces against the entities it oversees. For health insurers under the CDI, the Insurance Commissioner can impose civil penalties of up to $5,000 per violation, or up to $10,000 per violation if the violation was willful.⁴ DMHC can take enforcement action against health care service plans under existing Knox-Keene Act authority, and DHCS can impose sanctions on Medi-Cal managed care plans under its existing managed care enforcement powers.¹

Because the March 1, 2025 compliance deadline has passed, a plan that has not trained its staff or updated its directory is already exposed to enforcement.

How SB-923 Fits With Other Protections

California insurance regulations already bar admitted insurers from denying, canceling, limiting, or refusing coverage based on actual or perceived gender identity, from charging transgender enrollees higher premiums, and from treating gender identity as a preexisting condition.² SB-923 sits on top of that framework and targets the staff and directory layer that the coverage rule could not reach on its own.

At the federal level, the HHS Office for Civil Rights rescinded its 2022 guidance on gender-affirming care, civil rights, and patient privacy in February 2025. That guidance had treated categorical refusals of treatment based on gender identity as a violation of Section 1557 of the Affordable Care Act. HHS also withdrew its position that gender dysphoria could qualify as a disability under Section 504 of the Rehabilitation Act, and retracted related patient privacy guidance. The rescission followed federal court rulings that found extending sex discrimination protections to gender identity exceeded HHS’s statutory authority.⁶

For Californians enrolled in state-regulated plans, SB-923 and the existing nondiscrimination regulation now carry most of the practical weight. If you are covered by a self-insured ERISA plan, those state protections generally do not apply, and the federal posture has shifted.

1
California Legislative Information. California Health and Safety Code 1367.043
2
Legal Information Institute. California Code of Regulations Title 10 2561.2 – Discrimination on the Basis of Gender Identity
3
DHCS. PL 24-03 SB 923 Gender Affirming Care Policy Letter
4
California Legislative Information. California Senate Bill 923 – Gender-Affirming Care
5
DMHC. Transgender, Gender Diverse, or Intersex (TGI) Care
6
U.S. Department of Health and Human Services (HHS). Rescission of HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy