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RALEIGH, N.C. (AP) — The North Carolina state employee health plan will resume coverage of gender affirming treatments for transgender employees, the state treasurer said Wednesday, complying with a recent federal court ruling that declared the refusal of coverage unconstitutional.

State Treasurer Dale Folwell and the State Health Plan Board of Trustees agreed to reinstate coverage of “medically necessary services” -– including hormone replacement therapy and surgeries -– which the health plan had provided for a single year in 2017.

Folwell, calling the federal court ruling “legally incorrect,” said he is filing an appeal with the U.S. Court of Appeals for the Fourth Circuit. He said he would carry out the judge’s orders in the meantime.

“We obviously disagree with the judge’s order that is, in essence, assuming responsibility for determining plan benefits for sex transition operations,” Folwell said.

U.S. District Judge Loretta Biggs ruled in June that the state health plan unlawfully discriminates against transgender people, violating both the equal protection clause of the Constitution and Title VII of the Civil Rights Act on the basis of sex.

Overseen by Folwell’s office, the health plan provides medical coverage for more than 750,000 teachers, state employees, retirees, lawmakers and their dependents.

Several current and former state employees and their dependents had sued Folwell, the plan’s executive administrator, state universities and other government entities in 2019 for dropping coverage of medically necessary procedures once provided by the state.

Former State Treasurer Janet Cowell and the health plan board had voted in December 2016 not to enforce the plan’s exclusion of surgical and hormonal treatments for gender dysphoria for a single year. They estimated the annual cost for such coverage would be several hundred thousand dollars, according to the order. The coverage exclusion resumed under Folwell, a Republican, who took office in 2017.

Biggs wrote in her ruling that doctors, medical associations and the health plan’s third-party administrators agreed gender affirming procedures “can be medically necessary to treat gender dysphoria” in some cases.

“I’ve always said that if the legislature or the courts tell me we have to provide for sex transition operations and treatments, I would,” Folwell said, adding that he was disappointed the court did not bring the case before a jury.


Schoenbaum is a corps member for the Associated Press/Report for America Statehouse News Initiative. Report for America is a nonprofit national service program that places journalists in local newsrooms to report on undercovered issues. Follow her on Twitter at