First, is this your page?
Is your plan self-funded through a PRIVATE employer or a union?
Then this page is not yours. Private self-funded plans are governed by ERISA, which changes who enforces your rights and gives you a document request the plans on this page do not have.
Go to self-funded private employer plansWhat to do
Work out which kind of non-ERISA plan you are on
State, county, city, school district, or public university: a non-Federal governmental plan. A church or church-affiliated employer: a church plan, which is outside ERISA unless it has elected in. A federal employee: FEHB, governed by its own law and by OPM.
Stop looking for the Department of Labor
DOL enforces ERISA. It has no authority over a governmental plan, a church plan, or FEHB. Sending your complaint there costs you the time it takes to be told so.
Government plan: ask whether the plan has filed an opt-out election
A self-funded non-Federal governmental plan may exempt itself from certain federal requirements. The election is filed with CMS and must name each requirement. Ask the plan administrator for a copy.
Ask specifically about mental-health parity
Parity was one of the requirements a government plan could opt out of. Since 29 December 2022 no sponsor may newly elect out, but an election made before then can still be running.
Check whether the plan buys stop-loss regulated as insurance
If the stop-loss or excess-risk coverage is regulated as group health insurance under state law, the plan counts as fully insured and cannot use the opt-out at all. That is worth asking about.
Ask for the enrollee notice
An opt-out election has to be accompanied by a notice to enrollees. If you were never given one, that is a question worth putting in writing.
Route the complaint to the right place
Government plan: CMS, and your state if it also regulates public-employee benefits. Church plan: usually the plan's own process, then state law where it reaches. FEHB: the carrier, then the Office of Personnel Management.
Why this page exists
Almost everything written about self-funded plans assumes ERISA, because most self-funded plans are ERISA plans. If you work for a city, a school district, a public university, a hospital system run by a church, or the federal government, that advice sends you to a regulator with no authority over your plan — the same wrong-regulator failure this whole site is built around, one level deeper.
What a government plan can and cannot opt out of
The requirements a self-funded non-Federal governmental plan may currently elect out of are: benefits for mothers and newborns, mental-health and substance-use parity, reconstructive surgery following mastectomy, and coverage of dependent students on a medically necessary leave of absence.
Parity is the one that matters most here, because parity arguments are one of the routes into a gender-affirming care denial. A new opt-out from parity has not been available since December 2022, but an existing one can persist — so the question is not whether they could opt out today, it is whether they already did.
- The election is filed with CMS, not with your employer's HR.
- It must specify each requirement the plan is exempting itself from.
- It must be accompanied by a notice to enrollees.
- It cannot be used retroactively against a claim incurred before the election took effect.
- If the plan's stop-loss is regulated as insurance under state law, the plan is treated as fully insured and cannot opt out.
Church plans, briefly
A church plan is exempt from ERISA unless it has affirmatively elected to be covered. That removes the ERISA appeal machinery and the DOL, and leaves you with the plan's own process plus whatever state law reaches. This is an area where getting advice early is worth it.
If you are a federal civilian employee: FEHB and PSHB changed for 2026
This section is only about the federal civilian plans. If you work for a city, a county, a state, a school district or a church, none of it applies to you and the rest of this page does.
OPM Carrier Letter 2025-01b, dated 15 August 2025, tells carriers that for Plan Year 2026 chemical and surgical modification of a person's sex traits, including what it calls gender transition services, will no longer be covered under the FEHB or PSHB Programs — and, in its own words, that this "applies regardless of age". That is a broadening. The January 2025 letter it replaces reached only people under 19; for anyone 19 or over it had said carriers "may propose to cover, but are not required to cover".
Three things in that letter are worth more to you than the headline, and most summaries leave all three out.
- There is a MANDATORY exceptions process — FOR PLAN YEAR 2026, AND IT IS BEING TAKEN AWAY. OPM tells carriers they "must establish an exceptions process for coverage of excluded services for enrollees who are mid-treatment within a surgical and/or hormonal regimen for diagnosed gender dysphoria", decided case by case, with details in their brochures. But Carrier Letter 2026-07 of 31 March 2026 instructs that "Beginning in the 2027 Plan Year, Carriers must remove any exceptions process". So 2026 is the last year it exists. If you are mid-regimen, ask for it by name now, and get the answer in writing.
- Counselling is not excluded. The letter says "counseling services for possible or diagnosed gender dysphoria must still be covered", provided by a licensed mental health provider.
- Whole drug classes are not excluded. OPM tells carriers they "should not exclude coverage for entire classes of pharmaceuticals", naming GnRH agonists prescribed for IVF, endometriosis, fibroids and cancer. A blanket refusal of a drug you take for another indication is not what the letter says.
What that FEHB guidance is, and is not
It is sub-regulatory guidance to carriers about their plan-year proposals. It is not a regulation and it went through no notice-and-comment. That does not make it any less real for the year you are in, but it does mean the thing binding your carrier is a contract term, and your route runs through the carrier and then OPM rather than through a state insurance department.
We have read Carrier Letters 2025-01a and 2025-01b directly. We have not verified how any individual carrier wrote the exclusion or its exceptions process into its own brochure, and that document is what actually governs your claim. Get your plan's brochure for the current year and read what it says about the exceptions process.
Common questions
- I work for a city. Is my plan ERISA?
- No. Governmental plans are excluded from ERISA. If your plan is also self-funded, you are on a self-funded non-Federal governmental plan, which is what most of this page is about.
- How do I find out whether my plan opted out of parity?
- Ask the plan administrator in writing for a copy of the opt-out election filed with CMS, and for the enrollee notice that must accompany it. If neither exists, the plan has not validly opted out.
- I am a federal employee and mid-transition. Is there anything I can ask for?
- Yes, and ask for it by name, and do it this plan year. OPM told carriers they must establish an exceptions process for enrollees who are mid-treatment within a surgical or hormonal regimen for diagnosed gender dysphoria, decided case by case, with the details in their brochures. Then on 31 March 2026 OPM told carriers to remove it beginning in the 2027 plan year — so 2026 is the last year that route exists. Get your plan's brochure for the current year, find that process, use it, and keep the answer in writing. Counselling for gender dysphoria remains covered in 2027, and whole drug classes are not excluded.
- Does my state's coverage mandate apply?
- State insurance mandates reach insurers. A self-funded governmental plan is not insured, so they generally do not — but some states regulate public-employee benefits separately, which is worth asking about.
Better covered elsewhere
- A4TE Trans Health Project — FEHB guidance (PDF)
Federal employees specifically. Dated March 2026 — a PDF, so it downloads rather than opening as a page.
Where to go next
Sources for the legal points on this page
- Self-funded state and local government plans may opt out of some federal requirements
Federal — self-funded non-Federal governmental plans (state, county, city, school district) · effective in force; parity opt-out sunset 2022-12-29
45 CFR 146.180 — (a)(1) requirements subject to exemption, (a)(2) general rule, (a)(3) parity opt-out sunset, (a)(7)(ii) stop-loss regulated as insurance means no opt-out, (b) election must be filed with CMS with an enrollee notice
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06
- Mental-health parity: the 2024 rule is paused, the older duties are not
Federal — group health plans and issuers · effective non-enforcement announced 2025-05-15
29 CFR 2590.712 and 2590.712-1 — current text still carries the 2024 rule (definitions keyed to 22 November 2024), so the rule was not rescinded. The May 2025 non-enforcement policy is sub-regulatory and was NOT located in the Federal Register, so it remains unverified
Status: contested · source-checked 2026-08-06 · primary source verified: 2026-08-06 (partial — regulation text verified, non-enforcement policy not)
- FEHB and PSHB excluded gender-transition care for Plan Year 2026 — with a mandatory exceptions process
Federal — FEHB and PSHB carriers (federal civilian employees, annuitants, Postal Service) · effective Plan Year 2026
OPM FEHB Program Carrier Letter 2025-01b (15 August 2025), Chemical and Surgical Sex-Trait Modification Services for Plan Year 2026 Proposals; Carrier Letter 2025-01a (31 January 2025); Carrier Letter 2026-07 (31 March 2026), which removes the exceptions process beginning Plan Year 2027
Status: settled · source-checked 2026-08-13 · primary source verified: 2026-08-13