111 S1595 IS: End Taxpayer Funding of Gender Experimentation Act of 2023
U.S. Senate
2023-05-15
text/xml
EN
Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
1.Short title; table of contents(a)This Act may be cited as the End Taxpayer Funding of Gender Experimentation Act of 2023
.(b)The table of contents of this Act is as follows:Sec. 1. Short title; table of contents.TITLE I—Prohibiting federally funded gender transition proceduresSec. 101. Prohibiting taxpayer-funded gender transition procedures.Sec. 102. Amendment to table of chapters.TITLE II—Application under the Affordable Care ActSec. 201. Clarifying application of prohibition to premium credits and cost-sharing reductions under ACA.<enum>I</enum><header>Prohibiting federally funded gender transition procedures</header><section id="H52B7D4371E114F0EAFE91E16D7BCD160"><enum>101.</enum><header>Prohibiting taxpayer-funded gender transition procedures</header><text display-inline="no-display-inline">Title 1, United States Code, is amended by adding at the end the following new chapter:</text><quoted-block display-inline="no-display-inline" id="HCD7D56C57E844E7EAA171A2CA40CCFDC" style="USC"><chapter id="H2D6D7BC1808F4DD2AE75FFE3A6E27517"><enum>4</enum><header>Prohibiting taxpayer-funded gender transition procedures</header><toc><toc-entry level="section">Sec. </toc-entry><toc-entry level="section" idref="HA07074918092475091E3EAF2AC1C39B6">301. Prohibition on funding for gender transition procedures. </toc-entry><toc-entry level="section" idref="H195BC353E3E443E1A77779D73C740F8A">302. Prohibition on funding for health benefits plans that cover gender transition procedures. </toc-entry><toc-entry level="section" idref="H39127A4AA4324232A427209B0CF20A59">303. Limitation on Federal facilities and employees. </toc-entry><toc-entry level="section" idref="HB672573A8BDB4BDEA74C40B6554FCB7B">304. Construction relating to separate coverage. </toc-entry><toc-entry level="section" idref="H6CB9520898244D3B8531BF311FC34376">305. Construction relating to the use of non-Federal funds for health coverage. </toc-entry><toc-entry level="section" idref="HA5B2E8930C7F475A8D139ECABC2A3F9F">306. Construction relating to complications arising from gender transition procedures. </toc-entry><toc-entry level="section" idref="HB118F4BA1FCC43C19DDEC48968FD9D39">307. Definitions. </toc-entry></toc><section id="HA07074918092475091E3EAF2AC1C39B6"><enum>301.</enum><header>Prohibition on funding for gender transition procedures</header><text display-inline="no-display-inline">No funds authorized or appropriated by Federal law, and none of the funds in any trust fund to which funds are authorized or appropriated by Federal law, shall be expended for any gender transition procedures.</text></section><section id="H195BC353E3E443E1A77779D73C740F8A"><enum>302.</enum><header>Prohibition on funding for health benefits plans that cover gender transition procedures</header><text display-inline="no-display-inline">No funds authorized or appropriated by Federal law, and none of the funds in any trust fund to which funds are authorized or appropriated by Federal law, shall be expended for health benefits coverage that includes coverage of gender transition procedures.</text></section><section id="H39127A4AA4324232A427209B0CF20A59"><enum>303.</enum><header>Limitation on Federal facilities and employees</header><text display-inline="no-display-inline">No health care service furnished—</text><paragraph id="H5A4B7A956E344E84802395D62EE12BDA"><enum>(1)</enum><text>by or in a health care facility owned or operated by the Federal Government; or</text></paragraph><paragraph id="H851FA455E9BC4334B645098FF8477DBA"><enum>(2)</enum><text>by any physician or other individual employed by the Federal Government to provide health care services within the scope of the physician’s or individual’s employment,</text></paragraph><continuation-text continuation-text-level="section">may include gender transition procedures. </continuation-text></section><section id="HB672573A8BDB4BDEA74C40B6554FCB7B"><enum>304.</enum><header>Construction relating to separate coverage</header><text display-inline="no-display-inline">Nothing in this chapter shall be construed as prohibiting any individual, entity, or State or locality from purchasing separate coverage for gender transition procedures or health benefits coverage that includes gender transition procedures so long as such coverage is paid for entirely using only funds not authorized or appropriated by Federal law and such coverage shall not be purchased using matching funds required for a federally subsidized program, including a State’s or locality’s contribution of Medicaid matching funds.</text></section><section id="H6CB9520898244D3B8531BF311FC34376"><enum>305.</enum><header>Construction relating to the use of non-Federal funds for health coverage</header><text display-inline="no-display-inline">Nothing in this chapter shall be construed as restricting the ability of any non-Federal health benefits coverage provider from offering coverage for gender transition procedures, or the ability of a State or locality to contract separately with such a provider for such coverage, so long as only funds not authorized or appropriated by Federal law are used and such coverage shall not be purchased using matching funds required for a federally subsidized program, including a State’s or locality’s contribution of Medicaid matching funds.</text></section><section id="HA5B2E8930C7F475A8D139ECABC2A3F9F"><enum>306.</enum><header>Construction relating to complications arising from gender transition procedures</header><text display-inline="no-display-inline">Nothing in this chapter shall be construed to apply to the treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of a gender transition procedure. </text></section><section id="HB118F4BA1FCC43C19DDEC48968FD9D39"><enum>307.</enum><header>Definitions</header><text display-inline="no-display-inline">For purposes of this chapter:</text><paragraph commented="no" display-inline="no-display-inline" id="id377a6a66de094eb38eee2261d3a50ed4"><enum>(1)</enum><header>Biological sex</header><text>The term <term>biological sex</term> means the biological indication of male or female in the context of reproductive potential or capacity, such as sex chromosomes, naturally occurring sex hormones, gonads, and non-ambiguous internal and external genitalia present at birth, without regard to an individual’s psychological, chosen, or subjective experience of gender.</text></paragraph><paragraph commented="no" display-inline="no-display-inline" id="idb7282989e09a450797c4157c906e047c"><enum>(2)</enum><header>Cross-sex hormones</header><text display-inline="yes-display-inline">The term <term>cross-sex hormones</term> means—</text><subparagraph commented="no" display-inline="no-display-inline" id="idc0090a5bfc2c47aeb91b653d2c512e95"><enum>(A)</enum><text display-inline="yes-display-inline">testosterone or other androgens given to biological females at doses that are profoundly larger or more potent than would normally occur naturally in healthy biological females; and </text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="ida61bdef05ff04854a2be79458f0f9818"><enum>(B)</enum><text display-inline="yes-display-inline">estrogen given to biological males at doses that are profoundly larger or more potent than would normally occur naturally in healthy biological males.</text></subparagraph></paragraph><paragraph id="ide20499870e974e7196342e7ea7d83793"><enum>(3)</enum><header>Gender</header><text>The term <term>gender</term> means the psychological, behavioral, social, and cultural aspects of being male or female. </text></paragraph><paragraph id="id2d7d8b7e351c41a48b5580e4325bff6d"><enum>(4)</enum><header>Gender transition</header><text>The term <term>gender transition</term> means the process in which an individual goes from identifying with and living as a gender that corresponds to his or her biological sex to identifying with and living as a gender different from his or her biological sex, and may involve social, legal, or physical changes. </text></paragraph><paragraph id="idC4FCCC6104C748629128D297FB89E322"><enum>(5)</enum><header>Gender transition procedure</header><subparagraph id="id840DD45A46164D7FBCF67095424CB3E3"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">The term <term>gender transition procedure</term> means any medical or surgical service that seeks—</text><clause commented="no" display-inline="no-display-inline" id="id013d0bacbbeb42f8bcc1445b376f54ad"><enum>(i)</enum><text display-inline="yes-display-inline">to alter or remove physical or anatomical characteristics or features that are typical for the individual’s biological sex; or</text></clause><clause commented="no" display-inline="no-display-inline" id="id72b41be63f9f4e05a065c726f87683b1"><enum>(ii)</enum><text display-inline="yes-display-inline">to instill or create physiological or anatomical characteristics that resemble a sex different from the individual’s birth sex.</text></clause></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="id3fc6ed3d8e9e409cb0d3fdc1223882fe"><enum>(B)</enum><header>Inclusions</header><text display-inline="yes-display-inline">For purposes of subparagraph (A), the term <term>medical or surgical service</term> includes—</text><clause commented="no" display-inline="no-display-inline" id="id5d0f6ade17b6413d9dfa3a5ada95a972"><enum>(i)</enum><text display-inline="yes-display-inline">physician’s services;</text></clause><clause commented="no" display-inline="no-display-inline" id="id679372e0ce98439d9ec3fedda6c7ec12"><enum>(ii)</enum><text display-inline="yes-display-inline">inpatient and outpatient hospital services;</text></clause><clause commented="no" display-inline="no-display-inline" id="id5b2a573620324cada88a1a0704763160"><enum>(iii)</enum><text display-inline="yes-display-inline">prescribed drugs relating to gender transition;</text></clause><clause commented="no" display-inline="no-display-inline" id="id06240db220b44a1884f68ebeb6314311"><enum>(iv)</enum><text display-inline="yes-display-inline">a medical service that provides—</text><subclause commented="no" display-inline="no-display-inline" id="ida38b28ae15ed42728ec0585ef876b48e"><enum>(I)</enum><text display-inline="yes-display-inline">puberty-blocking drugs;</text></subclause><subclause commented="no" display-inline="no-display-inline" id="id1399137b806e4b09ac01c86a7e487550"><enum>(II)</enum><text display-inline="yes-display-inline">cross-sex hormones; or </text></subclause><subclause commented="no" display-inline="no-display-inline" id="idc1638359a6834b92a2888a9a04a78532"><enum>(III)</enum><text display-inline="yes-display-inline">other mechanisms to promote the development of feminizing or masculinizing features (in the opposite sex); and</text></subclause></clause><clause commented="no" display-inline="no-display-inline" id="idb4f1948304e241b581322b52baa25740"><enum>(v)</enum><text display-inline="yes-display-inline">gender transition surgery.</text></clause></subparagraph><subparagraph id="id6281e9b926f648788760bc8d6d72556a"><enum>(C)</enum><header>Exclusions</header><text>The term <term>gender transition procedure</term> does not include—</text><clause id="id24ca7f72c726494d9835a04f0b8aedc9"><enum>(i)</enum><text>services to individuals born with a medically verifiable disorder of sex development, including an individual with external biological sex characteristics that are irresolvably ambiguous, such as an individual born with 46 XX chromosomes with virilization, an individual born with 46 XY chromosomes with undervirilization, or an individual born having both ovarian and testicular tissue; </text></clause><clause commented="no" display-inline="no-display-inline" id="id931dfaddf7c2470fa7866ac7db9d67da"><enum>(ii)</enum><text display-inline="yes-display-inline">services provided when a physician has otherwise diagnosed a disorder of sexual development in which the physician has determined through genetic or biochemical testing that the individual does not have normal sex chromosome structure, sex steroid hormone production, or sex steroid hormone action for a biological male or biological female; or</text></clause><clause id="ide071a357941c4b9daaf1ed996596936a"><enum>(iii)</enum><text>the treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of gender transition procedures, whether or not the gender transition procedure was performed in accordance with State and Federal law or whether or not funding for the gender transition procedure is permissible under this chapter.</text></clause></subparagraph></paragraph><paragraph id="idc0613d0451bb46a284259661f5b71771"><enum>(6)</enum><header>Gender transition surgery</header><subparagraph commented="no" display-inline="no-display-inline" id="id5e5e333d91d744c089aab1b2ee375add"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">The term <term>gender transition surgery</term> means any medical or surgical service that seeks to surgically alter or remove healthy physical or anatomical characteristics or features that are typical for the individual’s biological sex in order to instill or create physiological or anatomical characteristics that resemble a sex different from the individual’s birth sex.</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="idb88c89f0eb9d4bc88b87fe1a6716fbc0"><enum>(B)</enum><header>Inclusions</header><text display-inline="yes-display-inline">The term <term>gender transition surgery</term> includes genital gender transition surgery and non-genital gender transition surgery.</text></subparagraph><subparagraph id="id85a04f7c899448f78ae33136b24b9491"><enum>(C)</enum><header>Exclusions</header><text>The term <term>gender transition surgery</term> does not include any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in imminent danger of death or impairment of major bodily function unless the procedure is performed, unless such procedure is performed for the purpose of a gender transition or for the alleviation of psychological or mental distress.</text></subparagraph></paragraph><paragraph id="id09f09618fa7e4396a2f1eca015c73294"><enum>(7)</enum><header>Genital gender transition surgery</header><text>The term <term>genital gender transition surgery</term> means a surgical procedure performed for the purpose of assisting an individual with a gender transition, including—</text><subparagraph commented="no" display-inline="no-display-inline" id="id96a1f84a68fe4df69a9cf9200f8333f8"><enum>(A)</enum><text display-inline="yes-display-inline">for biologically male patients, a penectomy, orchiectomy, vaginoplasty, clitoroplasty, and vulvoplasty; and</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="ide4e48f57fd5c47f8bb7add6950124cbd"><enum>(B)</enum><text display-inline="yes-display-inline">for biologically female patients, a hysterectomy/ovariectomy, reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty, vaginectomy, scrotoplasty, and implantation of erection or testicular prostheses.</text></subparagraph></paragraph><paragraph id="id34d6a4785f6d46a898d6607eba0051e3"><enum>(8)</enum><header>Non-genital gender transition surgery</header><text>The term <term>non-genital gender transition surgery</term> means a surgical procedure performed for the purpose of assisting an individual with a gender transition, including—</text><subparagraph commented="no" display-inline="no-display-inline" id="id74d29c8591664e7fbaf2050177914f42"><enum>(A)</enum><text display-inline="yes-display-inline">for biologically male patients, augmentation mammoplasty, facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction, and various aesthetic procedures; and</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="id009ef386f10e46e5a49fb07095fb0c18"><enum>(B)</enum><text display-inline="yes-display-inline">for biologically female patients, subcutaneous mastectomy, voice surgery, liposuction, lipofilling, pectoral implants, and various aesthetic procedures.</text></subparagraph></paragraph><paragraph id="id4964ae222b93434eb84d31253293e0bb"><enum>(9)</enum><header>Puberty-blocking drugs</header><text>The term <term>puberty-blocking drugs</term> means—</text><subparagraph commented="no" display-inline="no-display-inline" id="iddec35b7592c640aa9e201cf9f45498a9"><enum>(A)</enum><text display-inline="yes-display-inline">Gonadotropin-releasing hormone (GnRH) analogues or other synthetic drugs used in biological males to stop luteinizing hormone secretion and therefore testosterone secretion; and</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="idf9122f6c120d47ac81434870fbb318de"><enum>(B)</enum><text display-inline="yes-display-inline">synthetic drugs used in biological females that stop the production of estrogen and progesterone, when used to delay or suppress pubertal development in children for the purpose of assisting an individual with a gender transition.</text></subparagraph></paragraph></section></chapter><after-quoted-block>.</after-quoted-block></quoted-block></section><section id="HA95543D479B24850A00F415BE49255DB"><enum>102.</enum><header>Amendment to table of chapters</header><text display-inline="no-display-inline">The table of chapters for title 1, United States Code, is amended by adding at the end the following new item:</text><quoted-block display-inline="no-display-inline" id="HAFEEA1F380AB498D8B0F87E0BDCE21B4" style="USC"><toc regeneration="no-regeneration"><multi-column-toc-entry bold="on" level="section"><toc-enum>4. </toc-enum><level-header bold="on" level="section">Prohibiting taxpayer-funded gender transition procedures</level-header><target>301</target></multi-column-toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></section><enum>II</enum><header>Application under the Affordable Care Act</header><section id="H0DE80340EC61478EA6649B070AEA1BCC"><enum>201.</enum><header>Clarifying application of prohibition to premium credits and cost-sharing reductions under ACA</header><subsection display-inline="no-display-inline" id="H6B42E1EC68394AAAAC74D3FCA14FA996"><enum>(a)</enum><header>In general</header><paragraph id="H37BAEB6C8860482A834A4C1858E3A49F"><enum>(1)</enum><header>Disallowance of refundable credit and cost-sharing reductions for coverage under qualified health plan which provides coverage for gender procedures</header><subparagraph id="H7E28F811940C4447983D28DD80CD1914"><enum>(A)</enum><header>In general</header><text>Subparagraph (A) of <external-xref legal-doc="usc" parsable-cite="usc/26/36B">section 36B(c)(3)</external-xref> of the Internal Revenue Code of 1986 is amended by inserting before the period at the end the following: <quote>or any health plan that includes coverage for gender transition procedures (other than any procedure described in section 306 of title 1, United States Code)</quote>.</text></subparagraph><subparagraph id="H690F5E3CDA9349749F96BB5469F6F0A7"><enum>(B)</enum><header>Option to purchase or offer separate coverage or plan</header><text display-inline="yes-display-inline">Paragraph (3) of section 36B(c) of such Code is amended by adding at the end the following new subparagraph:</text><quoted-block display-inline="no-display-inline" id="HA3726A2D89804EF0A7661BF34298BEA6" style="OLC"><subparagraph id="H1FDD7EE2C3B64D6DBAD610252DE7E1EB"><enum>(C)</enum><header>Separate coverage or plan for gender transition procedures allowed</header><clause id="HE45BAC6CE2A8463DBD06F3933B3E12B1"><enum>(i)</enum><header>Option to purchase separate coverage or plan</header><text display-inline="yes-display-inline">Nothing in subparagraph (A) shall be construed as prohibiting any individual from purchasing separate coverage for gender transition procedures described in such subparagraph, or a health plan that includes such gender transition procedures, so long as no credit is allowed under this section with respect to the premiums for such coverage or plan.</text></clause><clause id="H60CB4EC4E2DF414FB2F6EC8685305816"><enum>(ii)</enum><header>Option to offer coverage or plan</header><text display-inline="yes-display-inline">Nothing in subparagraph (A) shall restrict any non-Federal health insurance issuer offering a health plan from offering separate coverage for gender transition procedures described in such subparagraph, or a plan that includes such gender transition procedures, so long as premiums for such separate coverage or plan are not paid for with any amount attributable to the credit allowed under this section (or the amount of any advance payment of the credit under section 1412 of the Patient Protection and Affordable Care Act).</text></clause></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph><paragraph id="H7D9C27C513D3420AB6D3BBC39ADBB5DC"><enum>(2)</enum><header>Disallowance of small employer health insurance expense credit for plan which includes coverage for gender transition procedures</header><text>Subsection (h) of <external-xref legal-doc="usc" parsable-cite="usc/26/45R">section 45R</external-xref> of the Internal Revenue Code of 1986 is amended—</text><subparagraph display-inline="no-display-inline" id="H7F9FC83392FD4064A995D97D0DEB7D3D"><enum>(A)</enum><text>by striking <quote>Any term</quote> and inserting the following:</text><quoted-block display-inline="no-display-inline" id="H830165352A784DEEB5AEF04A322D6312" style="OLC"><paragraph id="H644383919A8D41A1B4314EE826B13B6C"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Any term</text></paragraph><after-quoted-block>; and</after-quoted-block></quoted-block></subparagraph><subparagraph id="H5A051F72AA914D0BA1762210FE487D9D"><enum>(B)</enum><text>by adding at the end the following new paragraph:</text><quoted-block display-inline="no-display-inline" id="H3C913A111B7041DD977B821ABE31033E" style="OLC"><paragraph id="HA82D0E5ED5B64CF08605AF4F0BC5D176"><enum>(2)</enum><header>Exclusion of health plans including coverage for gender transition procedures</header><subparagraph id="HD2F80CFCF6BE416CABBC945287168603"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">The term <term>qualified health plan</term> does not include any health plan that includes coverage for gender transition procedures (other than any procedure described in section 306 of title 1, United States Code).</text></subparagraph><subparagraph id="H633B515D7B4547C3AA9B25F7ABA8C388"><enum>(B)</enum><header>Separate coverage or plan for gender transition procedures allowed</header><clause display-inline="no-display-inline" id="H61A805050D054F258CD39774AF7C2589"><enum>(i)</enum><header>Option to purchase separate coverage or plan</header><text display-inline="yes-display-inline">Nothing in subparagraph (A) shall be construed as prohibiting any employer from purchasing for its employees separate coverage for gender transition procedures described in such subparagraph, or a health plan that includes such gender transition procedures, so long as no credit is allowed under this section with respect to the employer contributions for such coverage or plan.</text></clause><clause id="H53CF98624B674DDD9B0CDB339D68A174"><enum>(ii)</enum><header>Option to offer coverage or plan</header><text display-inline="yes-display-inline">Nothing in subparagraph (A) shall restrict any non-Federal health insurance issuer offering a health plan from offering separate coverage for gender transition procedures described in such subparagraph, or a plan that includes such gender transition procedures, so long as such separate coverage or plan is not paid for with any employer contribution eligible for the credit allowed under this section.</text></clause></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></subsection><subsection id="H2DDB1BAC2ED645D49C86323BB4250033"><enum>(b)</enum><header>Application to multi-State plans</header><text>Section 1334(a) of <external-xref legal-doc="public-law" parsable-cite="pl/111/148">Public Law 111–148</external-xref> (<external-xref legal-doc="usc" parsable-cite="usc/42/18054">42 U.S.C. 18054(a)</external-xref>) is amended by adding at the end the following new paragraph:</text><quoted-block display-inline="no-display-inline" id="HE4D1F5923F6C49D8AF184D18C4D4EDCC" style="OLC"><paragraph id="H1FEE24B6C9D842E69F6B97CDFE494033"><enum>(7)</enum><header>Coverage consistent with Federal policy regarding gender transition procedures</header><text display-inline="yes-display-inline">In entering into contracts under this subsection, the Director shall ensure that no multi-State qualified health plan offered in an Exchange provides health benefits coverage for which the expenditure of Federal funds is prohibited under <external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/1/4">chapter 4</external-xref> of title 1, United States Code.</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></subsection><subsection id="HF9EEEF7612E24689B6BD8DCA764A01BD" commented="no" display-inline="no-display-inline"><enum>(c)</enum><header>Effective date</header><text display-inline="yes-display-inline">The amendments made by subsection (a) shall apply to taxable years ending after the date that is 1 year after the date of enactment of this Act, but only with respect to plan years beginning after such date, and the amendment made by subsection (b) shall apply to plan years beginning after such date. </text></subsection></section>