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The purpose of this bulletin is to inform providers that the Department of Medical Assistance Services (DMAS) affirms coverage of services related to gender dysphoria for fee-for-service (FFS) and managed care organization (MCO) Medicaid members.

Background

Gender Dysphoria (GD) is a condition characterized by distress or impairment resulting from incongruence between ones experienced or expressed gender and sex assigned at birth. The poor medical and behavioral health outcomes experienced by this population, outsized impact on pediatric and adolescent populations, paucity of research meeting traditional objectivity standards for some treatment modalities, and stigma experienced by this population make treatment and access to treatment particularly important and complex.

Transgender and gender-diverse persons may experience GD and seek a wide range of treatment options. Medical therapy includes pharmacologic treatment for puberty suppression, as well as subsequent gender-affirming pharmacologic treatment. Surgical treatment traditionally includes chest as well as genital surgeries aligning primary and secondary sex characteristics with individuals’ gender identity. Additional services include those for behavioral health, speech and other therapies, and other procedures, including those for facial and voice modification. There is consensus among clinicians, payers, and stakeholders supporting the medical necessity of many treatments for GD.

DMAS’ GD policy is based on myriad sources of information. These include: professional guidelines and policies such as the most recent World Professional Association for Transgender Health Clinical Guidelines [WPATH-7], the Endocrine Society Treatment of Gender-Dysphoric/Gender-Incongruent Persons Clinical Practice Guideline, and the American Academy of Pediatrics’ 2018 Policy Statement; clinical coverage policies used in other states and other payers; and input from national and Virginia-based clinical experts who care for people living with gender dysphoria and whose expertise include the fields of family medicine, gynecology, endocrinology, pediatrics, pediatric endocrinology, plastic surgery, psychiatry, ENT, speech therapy and dermatology; and community stakeholders, including national and Virginia-based patient advocate groups.

Coverage of Gender Dysphoria Services

Detailed coverage guidance is provided in Chapter IV and the Gender Dysphoria Supplement of the DMAS Physician-Practitioner manual, as well as Appendix D of the DMAS Hospital manual. Updated billing guidance will go into effect for covered services with dates of service on and after 2/1/2022. Gender dysphoria surgical services and facial feminization or masculinization services with dates of service on and after 2/1/2022 for members enrolled in fee-for-service must receive authorization from the DMAS Medical Support Unit, as per the Gender Dysphoria Supplement of the Physician-Practitioner Manual. This includes a requirement to complete and submit the Gender Dysphoria Service Authorization Form (DMAS-P264) and all specified clinical documentation, and specify an F64 ICD-10 diagnosis code. Contact information for the DMAS Medical Support Unit is: Fax: 804-452-5450, Phone: 804-786-8056.

Managed Care Organizations (MCOs) contracted with Virginia DMAS will adopt the coverage standards outlined in the manuals and Supplement referenced above. They will not create or enforce additional coverage criteria. This includes, but is not limited to, any member requirements related to a legal name change. Please contact managed care organizations at the contacts listed below for MCO-specific billing guidance for managed care members.

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