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Transgender Services Benefits

On May 18, 2016, the Office for Civil Rights (OCR) of the Department of Health and Human Services (HHS) published its final regulation implementing Section 1557 of the Affordable Care Act (ACA). Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in health programs or activities that receive federal financial assistance. Under the final rule, sex discrimination includes, but is not limited to, discrimination on the basis of pregnancy, gender identity, and sex stereotyping.

This provision requires plan benefits to be amended by prohibiting any categorical exclusion for gender transition services and any surgical sex transformation exclusion must be removed from group health plans to comply with Section 1557. Also, removal of applicable gender edits within our claims system will be required, including existing pharmacy gender edits. For example, if a transgender male develops ovarian cancer, group health plans must provide covered benefits even though the health plan has enrolled this person as a male.

Our Plan has created coverage guidelines for sex transformation services. The following coverage guidelines related to Transgender Services have been approved and will be effective as of January 1, 2017.

Transgender Services Benefits, effective 01/01/17:
A member must meet ALL the following criteria established under the World Professional Association for Transgender Health (WPATH) (7th version) in order to be eligible:

  1. Diagnosis of Gender Identity Disorder (ICD-10 F64.0, F64.1 or F64.9); and
  2. Age of majority (18 years of age or older); and
  3. Have knowledge of the benefits and risks of surgery as demonstrated by and documented in an evaluationfrom a qualified mental health professional; and
  4. Unless medically contraindicated, completion of twelve (12) months of continuous hormone therapy (EXCEPT for Mastectomy); and
  5. Twelve continuous months of living in a congruent gender role with his/her gender identity (real life experience) prior to the gender reassignment services noted in the medical documentation (start/end dates included); and
  6. If the member has significant medical or mental health issues present, they must be reasonably well controlled and noted in the medical documentation. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy prior to surgery and the effort(s) noted in the medical documentation; and
  7. Two (2) referrals from qualified mental health professionals who have independently assessed the individual. 1 referral should be from a person who has only had an evaluative role with the individual. Both referring providers must submit letters of their evaluation. (At least 1 of the evaluating professionals must have a doctoral degree [PhD, MD, Ed.B, D. Sc, D.S.W. or Psy.D] and be capable of adequately evaluating co-morbid psychiatric conditions.)

If the above criteria are met, the following procedures are eligible for coverage:

A. Non-Surgical

1. HORMONE REPLACEMENT THERAPIES, including androgen blockers and gonadotropin-releasing (GnRh) analogs
2. LABORATORY TESTING, to monitor hormone therapy

B. Surgical

1. Female-to-Male

           a. MASTECTOMY and CHEST WALL RECONSTRUCTION
               *Note that a trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy.

b. GONADECTOMY

i. hysterectomy
ii. salpingo-oophorectomy

c. GENITAL RECONSTRUCTIVE SURGERY

i. vaginectomy
ii. urethroplasty
iii. metoidioplasty
iv. phalloplasty
v. scrotoplasty
vi. placement of a testicular prosthesis and erectile prosthesis

2. Male-to-Female

a. BREAST DEVELOPMENT - female hormones for at least 12 months to achieve adequate breast development without surgery. Any further intervention by surgical means would be reviewed for medical necessity in accordance with medical policy #106 Reconstructive versus Cosmetic Surgery.

b. GONADECTOMY

i. orchiectomy

c. GENITAL RECONSTRUCTIVE SURGERY

i. penectomy
ii. vaginoplasty
iii. labiaplasty, and
iv. clitoroplasty

The following services are considered COSMETIC in accordance with medical policy #106 Reconstructive versus Cosmetic Surgery, including but not limited to:

  • Abdominoplasty
  • Blepharoplasty (see also MP#064)
  • Body contouring
  • Breast augmentation, surgical (implants or autologous tissue flaps)
  • Brow lift
  • Calf implants
  • Cheek/malar implants
  • Chin/nose implants
  • Collagen injections
  • Construction of a clitoral hood
  • Drugs for hair loss or growth
  • Facial bone reduction
  • Face lift/forehead lift
  • Hair removal
  • Hair transplantation
  • Jaw shortening/sculpturing/facial bone reduction
  • Lip reduction/lip enhancement
  • Liposuction (see also MP#056)
  • Mastopexy
  • Neck tightening
  • Pectoral implants
  • Removal of redundant skin
  • Rhinoplasty (see also MP#109)
  • Skin resurfacing
  • Thyroid chrondroplasty/trachea shave
  • Voice modification surgery
  • Voice therapy/voice lessons