California Transgender Bill SB-923: Training, Directory, and Penalties

California Senate Bill 923, known as the TGI Inclusive Care Act, requires health plans and insurers in the state to train their patient-facing staff in culturally competent care for transgender, gender diverse, and intersex people, and to identify gender-affirming providers in their directories. Signed on September 29, 2022, the law took full effect for plans on March 1, 2025.¹ It does not create a new coverage mandate; California already bars insurers from denying coverage based on gender identity under a separate regulation. SB-923 targets what happens after coverage exists on paper.

What the Law Actually Does

SB-923 adds two obligations for covered plans. First, staff who interact with enrollees in care delivery or patient services must complete evidence-based cultural competency training in trans-inclusive care. Second, plans must update their provider directories, and their call centers, to identify in-network providers who have affirmed they offer and have provided gender-affirming services.²

A common misreading: the law does not require plans to cover hormone therapy, surgery, or any other specific gender-affirming treatment. Coverage protections come from a separate California insurance regulation discussed below. SB-923 addresses the human layer, whether the person answering the phone, processing the referral, or explaining a benefit treats a TGI enrollee with competence and respect.

Which Plans Have to Comply

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

Health care service plans, including HMOs and other managed care products, regulated by the Department of Managed Health Care (DMHC). Grandfathered plans are included; dental-only and vision-only plans are not.³
Health insurers, including PPO-style products, regulated by the California Department of Insurance (CDI).
Medi-Cal managed care plans and PACE organizations serving elderly participants, regulated by the Department of Health Care Services (DHCS).²

When a plan delegates functions to a contracted medical group or independent practice association, that entity has to comply as well. Self-insured employer plans governed by ERISA fall under federal, not state, insurance regulation and sit outside SB-923’s direct reach.

What the Training Covers and When It Was Due

Every covered entity had to ensure its patient-facing staff completed evidence-based cultural competency training by March 1, 2025.³ The law defines “trans-inclusive health care” as comprehensive care consistent with recognized standards for TGI individuals that honors bodily autonomy, avoids assumptions about gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion and respect.⁴

Curricula must address health inequities within the TGI community, cover people who identify as queer, questioning, asexual, or gender diverse, and include processes specific to those seeking gender-affirming services.¹ Any curriculum used has to be approved by the relevant regulator (DMHC, CDI, or DHCS).

Formal regulations implementing the training requirement are due from each department by July 1, 2027.³ Until then, plans are expected to comply based on departmental guidance already in place. The March 2025 deadline has passed, so plans that have not trained their staff are already exposed to enforcement.

How the Provider Directory Should Work

By the same March 1, 2025 deadline, plans had to update their provider directories to flag in-network providers who have affirmed they offer and have provided gender-affirming services, and that information has to be available through the plan’s call center as well.² Provider participation is voluntary, so the directory reflects providers who opted in.

Accuracy safeguards are built in. Plans must update listings within 30 days when a provider asks to be added or removed. Plans must also investigate complaints about listed providers who fail to actually deliver TGI-inclusive care, and correct any inaccurate or misleading entries within 30 days of finishing the investigation.²

How to File a Complaint

If a plan staff member fails to provide trans-inclusive care, you can file a grievance with the plan and with the state department that regulates it. Plans must have policies to track those complaints, and they must inform enrollees of the right to file. Start with the plan directly, then escalate to the DMHC (for HMOs and similar managed care), the CDI (for health insurance products), or DHCS (for Medi-Cal managed care).

When a grievance is substantiated, the staff member named must complete a refresher training within 30 days, and departments can require more frequent training if they see fit. Plans submit quarterly grievance reports covering both substantiated and unsubstantiated complaints, plus verification that any required refresher training was completed, and an annual summary detailing grievance counts, staff identified, and actions taken.² The reporting structure lets regulators see patterns across plans and individual staff members.

Penalties Plans Face

Enforcement authority sits with each of the three regulators. For health insurers, the Insurance Commissioner can impose a civil penalty of up to $5,000 per violation, or up to $10,000 per violation if the violation was willful.¹ For health care service plans, the DMHC director can act under existing Knox-Keene Act penalty provisions.³ For Medi-Cal managed care plans, DHCS uses its existing managed care sanctioning authority.

How SB-923 Fits With Existing Coverage Rules

California insurance regulations already prohibit an admitted insurer from denying, canceling, limiting, or refusing coverage based on actual or perceived gender identity. Insurers cannot charge higher premiums for transgender enrollees or treat gender identity as a preexisting condition. The regulation also bars denying coverage for services related to gender transition when the same services are covered for other purposes: if a plan covers hormone therapy or mastectomy for non-transition reasons, it cannot categorically exclude those procedures for a transgender enrollee.⁵ Medical necessity determinations still happen case by case.

SB-923 sits on top of that coverage rule. A plan can technically cover gender-affirming services and still employ staff who lack the knowledge, or the willingness, to help enrollees access them. The training and directory requirements address that gap.

Why State Law Matters More Now

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

For Californians in state-regulated plans, SB-923 and the existing insurance regulation now do the heavy lifting. Enrollees in self-insured employer plans governed by ERISA may have fewer protections, since those plans are regulated at the federal level where the enforcement posture has changed. If you are not sure whether your coverage is state-regulated or ERISA-governed, your plan documents or HR benefits contact can tell you.

1
California Legislative Information. California Senate Bill 923 – Gender-Affirming Care
2
DHCS. PL 24-03 SB 923 Gender Affirming Care Policy Letter
3
California Legislative Information. California Health and Safety Code 1367.043
4
DMHC. Transgender, Gender Diverse, or Intersex (TGI) Care
5
Legal Information Institute. California Code of Regulations Title 10 2561.2 – Discrimination on the Basis of Gender Identity
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