The North Carolina State Health Plan has announced the reinstatement of its exclusion of coverage for transition-related treatments for patients suffering from gender dysphoria. This followed a September 23 Federal Appeals Court ruling that vacated a 2022 injunction that required the plan to cover these treatments. The treatments no longer covered include the administration of puberty blockers and cross-sex hormones as well as “gender transition” surgeries.
Background on the Case
According to a statement released by State Treasurer Brad Briner’s office, “The exclusion dates back to the 1990s, and while litigation has been ongoing it has continued to appear in the annual list of exclusions for Plan members, even though it was inactive. The Court’s decision to vacate the district court’s earlier ruling means the exclusion becomes active again.”
US District Judge Loretta Biggs issued the 2022 injunction forcing coverage, which was affirmed by the 4th Circuit Court of Appeals in a split 8-6 vote in 2024. However, the US Supreme Court (SCOTUS) vacated that ruling in June 2025 and called on the 4th Circuit to reconsider the case in light of United States v. Skrmetti, which upheld Tennessee’s ban on puberty blockers and hormone therapy for transgender-identifying minors. After this, SCOTUS ordered the 4th Circuit Court to reconsider their decision.
“Kadel v. Folwell has always been about one question. Do the people of North Carolina, through their elected representatives, get to ultimately manage the State Health Plan? Or can plaintiffs dictate what procedures we cover? We are gratified that the Supreme Court has agreed with our strongly held belief in the State Health Plan Board of Trustees’ authority in this matter,” Briner’s office said in a news release responding to SCOTUS’ decision.
Former State Treasurer Dale Folwell stood firm in his conviction that it was inappropriate for the State Health Plan to cover these medications and procedures, and current Treasurer Briner has maintained this position on behalf of the State.
What Remains Covered
The exclusion does not prevent treatment of infections, injuries, diseases, disorders, or complications caused by or exacerbated by gender transition procedures. Additionally, it does offer coverage for psychological assessment and psychotherapy connected to gender dysphoria.