- Participating Physician Groups (PPG)
Medically necessary transgender services for treatment of gender identity disorder (GID) are covered benefits for Medi-Cal beneficiaries, as defined in the Medi-Cal Provider Manual, Part 2, Department of Health Services, All Plan Letter (APL) 20-018, and any superseding letter. Medi-Cal's criteria for medical necessity of transgender services is based on the most current "Standards of Care for Health of Transsexual, Transgender, and Gender Nonconforming People" (SOC) published by the World Professional Association for Transgender Health (WPATH). Additional clinical information is located on the Health Net provider portal under Working with Health Net > Clinical > Medical Policies > Gender Reassignment Surgery.
Transgender services refer to the treatment of GID, which may include the following:
- consultation with transgender service providers
- transgender services work-up and preparation
- continuous hormonal therapy
- laboratory testing to monitor hormone therapy
- gender reassignment surgery that is not cosmetic in nature
Treatment for GID is a covered Medi-Cal benefit for members, who have the capacity for fully informed consent, and when medical necessity has been demonstrated. Covered benefits include mastectomy, orchiectomy, hysterectomy, salpingo-oophorectomy, ovariectomy, and genital surgery, including placement of testicular prostheses when indicated, as well as other medically necessary reconstructive surgery.
Medically Necessary/Reconstructive Surgery
No categorical exclusions or limitations apply to coverage for the treatment of GID. Each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon.
- Breast augmentation
- Facial bone reduction
- Facial feminization
- Hair removal
- Hair transplantation
- Reduction thyroid chondroplasty
- Subcutaneous mastectomy
- Voice modification surgery
Reconstructive surgery is "surgery performed to correct or repair abnormal structures of the body... to create a normal appearance to the extent possible." (Health and Safety Code, Section 1367.63(c)(1)(B)). In the case of transgender patients, "normal appearance" is to be determined by referencing the gender with which the patient identifies. Cosmetic surgery is "surgery that is performed to alter or reshape normal structures of the body in order to improve appearance." (Health and Safety Code, Section 1367.63(d)).
This section clarifies how Health Net administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.
For example, with respect to hair removal through electrolysis, laser treatment, or waxing, the WPATH "Statement of Medical Necessity for Electrolysis" (July 15, 2016) clarifies that patients with the same condition do not always respond to, or thrive, following the application of identical treatments. Treatment must be individualized, such as with electrolysis, and medical necessity should be determined according to the judgment of a qualified mental health professional and referring physician. The documentation to support the medical necessity for hair removal should include three essential elements:
- A properly trained (in behavioral health) and competent (in assessment of gender dysphoria) professional has diagnosed the member with gender dysphoria or GID.
- The individual is under feminizing hormonal therapy.
- The medical necessity for electrolysis has been determined according to the judgment of a qualified mental health professional and the referring physician.
If any element remains to be satisfied before medical necessity can be determined, the individual should be directed to an appropriate network participating provider for consultation or treatment.
Prior authorization is required for transgender services. Providers must submit clinically relevant information for medical necessity review with the prior authorization request.
Members may select available specialists in the diagnosis and treatment of GID from Health Net's network. When network specialists are not available, arrangements must be made to refer members to appropriate out-of-network specialists. To find out which specialist providers contract with Health Net or accept Health Net members and who perform transgender services, contact the PPG or Health Net Provider Services Department.
Direct Network Providers
Direct Network providers must request prior authorization by completing and faxing the Inpatient California Medi-Cal Prior Authorization Form (PDF) or the Outpatient California Medi-Cal Prior Authorization Form (PDF).
Providers Participating through PPGs
Providers participating through PPGs must contact their PPGs, follow the PPGs' prior authorization process and use the PPGs' forms. PPGs are responsible for authorizing GID services.