Policy: Gender Reassignment/Gender Affirming Surgery and Treatments for Medicaid Managed Care Plan (MMCP) and Health and Recovery Plan (HARP) Members
Policy Number: 7.01.105
Last Update: 2021-07-05
Issued in: New York

This policy applies to Medicaid

Breast Reconstruction:

I. Based on our assessment of peer-reviewed literature, hormone therapy, whether or not in preparation for gender reassignment surgery, has shown to be a beneficial and effective intervention for gender dysphoria, and is considered medically appropriate as follows:

A. Treatment with gonadotropin-releasing hormone agents (pubertal suppressants), based upon a determination by a qualified medical professional that an individual is eligible and ready for such treatment, i.e., that the individual:

1. Meets the criteria for a diagnosis of gender dysphoria;

2. Has experienced puberty to at least Tanner stage 2, and pubertal changes have resulted in an increase in gender dysphoria;

3. Does not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment;

4. Has adequate psychological and social support during treatment; and

5. Demonstrates knowledge and understanding of the expected outcomes of treatment with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment.

B. Treatment with cross-sex hormones for patients who are 16 years of age and older, based upon a determination by a qualified medical professional that such treatment is medically necessary.

1. Patients who are under 18 years of age must meet only the applicable criteria stated in Policy Statement I.A.1-5. above.

2. Payment for cross-sex hormones for patients under 16 years of age who otherwise meet the requirements stated in Policy Statement I.A.1-5., shall be made in specific cases if medical necessity is demonstrated by a qualified medical professional and prior approval is received.

3. New York State (NYS) Medicaid reimbursement is only available for conjugated estrogens, estradiol, and testosterone cypionate, and testosterone topical gel 1.62 percent (Androgel).

Youth Services:

Bilateral mastectomy: The patient has reached the age of majority (18 years of age or older), or, if under the age of majority, meets all of the following criteria for early intervention:

1. has consent from parent(s)/guardian(s) for surgery; and
2. has identified as transgender for at least two years; and
3. has been living in the desired gender role for at least one year; and
4. has been receiving testosterone treatment for at least one year; and
5. has received an additional letter of referral from a second qualified mental health professional or physician (refer to Policy Guidelines below); and
6. has compelling reasons impacting their physical and/or psychological well-being, as documented by the patient’s mental health/adolescent medicine provider(s); and
7. any significant medical or mental health concerns that are present are reasonably well controlled.