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    v1.0.31
    OpenPayerPolicy UpdatesClinical/Medical PolicyBeacon MD Gender-Affirming Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedBeacon-Health-OptionsPolicy N/A

    Expanded Medicaid Coverage of Gender-Affirming Treatment

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    This policy governs Maryland Medicaid coverage and preauthorization requirements for medically necessary gender-affirming treatments prescribed by licensed healthcare providers. It applies to participating managed care organizations and healthcare professionals serving Maryland Medical Assistance Program members.

    Policy Summary
    PayerBeacon-Health-Options
    PolicyExpanded Medicaid Coverage of Gender-Affirming Treatment
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJan 1, 2024
    Next Review DateN/A
    Key ActionBefore authorization, submit the required assessment documentation: at least one qualified letter for adults or an assessment letter from a multidisciplinary team for adolescents.
    SourceLink
    POLICY UPDATE CHANGES

    The Maryland Medical Assistance Program expanded coverage to include additional gender-affirming treatments, including procedures involving hair, voice, body, face and neck, genitals and gonads, fertility preservation, scar treatment, treatment reversal, and combinations of treatments.

    The policy establishes updated documentation requirements for gender dysphoria or gender incongruence assessments before gender-affirming medical and surgical treatment is authorized.

    11Categories of gender-affirming treatments expressly identified for coverage
    1 letterMinimum adult assessment documentation requirement

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Multidisciplinary teamRequired adolescent assessment source
    FDA-approved and rebate-eligibleMedication eligibility conditions for Medicaid consideration

    Coverage Criteria

    Medical Necessity

    Covered as medically necessary when all of the following are met:

    Medical necessity: Treatment is prescribed by a licensed healthcare provider and is consistent with current clinical standards of care for a condition related to the individual's gender identity.

    Adults

    For adults, all of the following documentation requirements must be met:

    Adult assessment: At least one letter of assessment is provided by either a Mental Healthcare Professional or a Somatic Healthcare Professional/Primary Care Provider with competencies in assessing transgender and gender-diverse people.At least 1 letter

    The letter must recommend gender-affirming medical and surgical treatment.

    Adolescents

    For adolescents, all of the following documentation requirements must be met:

    Adolescent multidisciplinary assessment: At least one letter of assessment is provided by a multidisciplinary team that includes both somatic and mental health professionals.At least 1 letter

    The letter may be submitted by either the Somatic Healthcare Professional or Mental Healthcare Professional member of the team.

    Medications

    Medication coverage is considered when all of the following are met:

    Medication eligibility: The medication is approved by the Food and Drug Administration (FDA) and is subject to the Federal Rebate Program.

    All medications must also satisfy applicable restrictions under COMAR 10.09.03.05 and COMAR 10.67.06.04. Oral, transdermal, and topical medications may not have an associated CPT code.

    Medications that are not FDA-approved or are not subject to the Federal Rebate Program are not considered for Medicaid coverage.

    Authorization and Documentation Requirements

    Prior Authorization

    Required Preauthorization Assessment

    Before gender-affirming medical or surgical treatment is authorized, submit the required assessment documentation in accordance with the applicable clinical guidance and templates.

    Documentation Required

    Gender Dysphoria or Incongruence Assessment Letter

    For adults, submit at least one assessment letter recommending gender-affirming medical and surgical treatment. The letter must be from a Mental Healthcare Professional (MHP) or Somatic Healthcare Professional (SHP)/Primary Care Provider (PCP), as defined by COMAR 10.67.05.05A(5), who has competencies in assessing transgender and gender-diverse people.

    • For adolescents, submit at least one assessment letter from a multidisciplinary team that includes both somatic and mental health professionals; the letter may be provided by either the SHP or MHP team member.

    Policy Background

    Gender-affirming treatments are considered medically necessary when they are consistent with current clinical standards of care and prescribed by a licensed healthcare provider to treat a condition related to an individual’s gender identity.

    Gender-Affirming Treatments

    Gender-affirming treatments
    DefinitionMedically necessary treatments consistent with current clinical standards of care and prescribed by a licensed health care provider for treatment of a condition related to the individual’s gender identity.
    Medical necessity standardTreatment must be consistent with current clinical standards of care.
    Prescriber requirementTreatment must be prescribed by a licensed health care provider.
    Treatment purposeTreatment must address a condition related to the individual’s gender identity.
    Policy Summary
    PayerBeacon-Health-Options
    PolicyExpanded Medicaid Coverage of Gender-Affirming Treatment
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJan 1, 2024
    Next Review DateN/A
    Key ActionBefore authorization, submit the required assessment documentation: at least one qualified letter for adults or an assessment letter from a multidisciplinary team for adolescents.
    SourceLink
    On This Page
    Coverage CriteriaAuthorization and Documentation RequirementsPolicy BackgroundGender-Affirming Treatments
    Documentation Required

    Medication Eligibility Documentation

    For medication requests, verify that the medication is approved by the Food and Drug Administration (FDA), is subject to the Federal Rebate Program, and meets all applicable regulatory requirements before submitting the request.

    • All medications are subject to the restrictions in COMAR 10.09.03.05 and COMAR 10.67.06.04.
    • Oral, transdermal, and topical medications may not have an associated CPT code.

    Unsupported block type: denial_risk

    Denial Risk

    Missing Assessment Documentation

    Treatment may not be authorized when the required qualified assessment documentation is missing or inadequate. Confirm that the applicable assessment letter is submitted before requesting authorization.

    • Adults: at least one letter from a qualified MHP or SHP/PCP with competencies in assessing transgender and gender-diverse people.
    • Adolescents: at least one letter from a multidisciplinary team that includes both somatic and mental health professionals.