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    v1.0.31
    OpenPayerPolicy UpdatesClinical/Medical PolicyBeacon Medicaid Gender-Affirming Coverage | OpenPa…
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    CurrentBeacon-Health-OptionsPolicy PT 52-24

    Updated Guidance – Expanded Medicaid Coverage of Gender-Affirming Treatments

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    Maryland Medicaid coverage, preauthorization, medical-necessity documentation, and limitations for gender-affirming treatments provided to Medicaid beneficiaries through managed care organizations and participating providers.

    Policy Summary
    PayerBeacon-Health-Options
    PolicyUpdated Guidance – Expanded Medicaid Coverage of Gender-Affirming Treatments
    Policy CodePolicy N/A
    Change TypeCoverage expansion and documentation revision
    Effective DateJanuary 1, 2024
    Next Review DateN/A
    Key ActionSubmit preauthorization documentation of medical necessity through the applicable adult or adolescent documentation pathway before authorization.
    SourceLink
    POLICY UPDATE CHANGES

    The guidance supersedes prior Maryland guidance on covered gender-transition services and expanded gender-affirming treatment coverage.

    Coverage is expanded to include additional gender-affirming treatments required by House Bill 283, including specified medical, surgical, voice, fertility, revision, reversal, and combination treatments.

    Medical-necessity documentation requirements are updated to permit qualified mental-health or somatic-care documentation for adults and require multidisciplinary-team documentation for adolescents.

    13Covered treatment categories
    1 of 2Adult documentation pathways

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    2Adolescent team disciplines
    FDA-approved and rebate-eligibleMedication eligibility

    Covered Gender-Affirming Treatments

    General coverage requirements

    Covered when all of the following requirements are met:

    General medical-necessity requirements: The treatment is related to the individual's gender identity, is medically necessary, is consistent with current clinical standards of care, and is prescribed by a licensed health care provider.

    Adult documentation criteria

    For adults, documentation must satisfy either one of the following professional pathways:

    Adult documentation pathway

    • Mental-health pathway: A Mental Healthcare Professional recommends the treatment.
    • Somatic-care pathway: A Somatic Healthcare Professional or Primary Care Provider recommends the treatment.

    Adolescent documentation criteria

    For adolescents, documentation must meet all of the following requirements:

    Adolescent documentation pathway: Medical-necessity documentation comes from a multidisciplinary team that includes both somatic and mental-health professionals.

    Documentation may be submitted by either the Somatic Healthcare Professional/Primary Care Provider or the Mental Healthcare Professional member of the team.

    Covered treatment categories

    The following treatment categories are covered when the applicable medical-necessity and documentation requirements are met:

    Covered gender-affirming treatment categories: Hormone therapy; hormone blockers and puberty blockers; hair alteration for secondary sex characteristics and surgical-site preparation; voice therapy and voice-modification surgery; alterations to the abdomen, chest, trunk, or buttocks; alterations to the face and neck; alterations to the genitals and gonads; laser treatment for surgery scars; fertility-preservation procedures as set forth in § 15810.1 of the Insurance Article; revision and reversal of prior treatments; combinations of gender-affirming treatments; and other treatments as prescribed.

    For Medicaid coverage consideration, medications must be FDA-approved and subject to the Federal Rebate Program. Medications that do not meet either condition are not considered for coverage. All medications remain subject to applicable restrictions under COMAR 10.09.03.05 and COMAR 10.67.06.04.

    Authorization and Documentation Requirements

    Prior Authorization

    Preauthorization and Medical Necessity

    Prior authorization is required for covered gender-affirming treatments. Providers must submit documentation supporting medical necessity, consistent with current clinical standards of care and the member’s gender-identity-related condition.

    • Applies to treatments covered under HB 283, including hormone therapy and blockers, voice services, hair alteration, surgical procedures, fertility preservation, revisions or reversals, and combinations of treatments.
    Documentation Required

    Adult Medical-Necessity Documentation

    For adults, medical-necessity documentation must recommend gender-affirming medical or surgical treatment and be provided by either a Mental Healthcare Professional (MHP) or a Somatic Healthcare Professional (SHP)/Primary Care Provider (PCP) with competencies in assessing transgender and gender-diverse people, as defined in COMAR 10.67.05.05A(5).

    • The documenting professional must have the applicable transgender and gender-diverse assessment competencies.

    Clinical Policy Context

    The Program considers gender-affirming treatments medically necessary when they are related to an individual’s gender identity, consistent with current clinical standards of care, and prescribed by a licensed health care provider. Covered care may include hormonal, medical, surgical, voice, fertility-preservation, revision, reversal, and related treatment categories when applicable documentation and authorization requirements are met.

    Key Terms

    Gender-affirming treatments
    Medical necessityTreatment must be medically necessary for a condition related to the individual’s gender identity.
    Clinical standardTreatment must be consistent with current clinical standards of care.
    Prescribing providerTreatment must be prescribed by a licensed health care provider.
    Multidisciplinary team
    Team compositionA multidisciplinary team includes both somatic and mental-health professionals.
    SHP/PCP submissionDocumentation may be submitted by the Somatic Healthcare Professional or Primary Care Provider member of the team.
    Policy Summary
    PayerBeacon-Health-Options
    PolicyUpdated Guidance – Expanded Medicaid Coverage of Gender-Affirming Treatments
    Policy CodePolicy N/A
    Change TypeCoverage expansion and documentation revision
    Effective DateJanuary 1, 2024
    Next Review DateN/A
    Key ActionSubmit preauthorization documentation of medical necessity through the applicable adult or adolescent documentation pathway before authorization.
    SourceLink
    On This Page
    Covered Gender-Affirming TreatmentsAuthorization and Documentation RequirementsClinical Policy ContextKey Terms
    Documentation Required

    Adolescent Multidisciplinary Documentation

    For adolescents, medical-necessity documentation must come from a multidisciplinary team that includes both somatic and mental-health professionals. Documentation may be submitted by either the SHP/PCP or the MHP member of that team.

    • Ensure the record reflects involvement of both required professional disciplines.
    Note

    Program Templates and Clinical Guidance

    Before requesting authorization, providers may use the updated clinical guidance and documentation templates for gender-affirming treatments. The linked materials also include a comprehensive CPT code list and reimbursement rates for newly covered services: https://bit.ly/485Hpti.

    • The Program will review World Professional Association for Transgender Health (WPATH) guidance and update clinical criteria as appropriate.
    • To request Medicaid coverage consideration for new procedure codes, devices, or drugs/biologics, submit a request to the Maryland Medicaid Coverage Determination Committee: https://bit.ly/3q11vDC.
    Billing Rule

    Medication Eligibility and Regulatory Restrictions

    For Medicaid consideration, medications must be approved by the Food and Drug Administration (FDA) and subject to the Federal Rebate Program. All medications remain 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.
    MHP submission
    Documentation may be submitted by the Mental Healthcare Professional member of the team.