Transinclusive-Related Coverage

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Transinclusive-Related Coverage

The following health plan benefits are available to enrolled faculty and staff experiencing the distress and impairment of Gender Identity disorder, or Gender Dysphoria:

  • Mental health coverage
  • Pharmaceutical coverage (e.g., for hormone replacement therapy)
  • Coverage for medical visits or laboratory services
  • Coverage for reconstructive surgical procedures related to gender reassignment
  • Coverage of routine, chronic, or urgent nontransition services (e.g., for a transgender individual based on their sex or gender. For example, pelvic/gynecological exams for men with a transgender history).

Some Things to Think About

The coverage for transgender-related health care expenses will be covered at the same percentage/basis as for any other diagnosis.  There is no separate annual or lifetime maximum coverage amount and no separate deductible.

Surgical services require Prior Authorization. The required form is located at: https://www.osuhealthplan.com/forms-and-downloads. Coverage for any surgical procedure will be determined in accordance with the OSU Health Plan’s (OSUHP) medical necessity guidelines and with the OSUHP Medical Policy for Gender Reassignment Surgery.  

OSUHP Medical Policy

The OSUHP considers gender reassignment surgery medically necessary when all of the following criteria are met:

  1. Requirements for mastectomy for female-to-male patients:
    1. Single letter of referral from a qualified mental health professional (see Appendix); and
    2. Persistent, well-documented gender dysphoria by a qualified mental health professional (see Appendix); and
    3. Capacity to make a fully informed decision and to consent for treatment; and
    4. Age of majority (18 years of age or older); and
    5. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Note that a trial of hormone therapy is not a prerequisite to qualifying for a mastectomy.

  1. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female):
  • Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); and
  • Persistent, well-documented gender dysphoria by a qualified mental health professional (see Appendix); and
  • Capacity to make a fully informed decision and to consent for treatment; and
  • Age of majority (18 years or older); and
  • If significant medical or mental health concerns are present, they must be reasonably well controlled; and
  • Twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones).

Requirements for genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis in female to male; penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male to female)

  • Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); and
  • Persistent, well-documented gender dysphoria by a qualified mental health professional (see Appendix); and
  • Capacity to make a fully informed decision and to consent for treatment; and
  • Age of majority (age 18 years and older); and
  • If significant medical or mental health concerns are present, they must be reasonably well controlled; and
  • Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and
  • Twelve months of living in a gender role that is congruent with their gender identity (real life experience).

Note On Gender Specific Services for the Transgender Community

Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy.  Examples include:

  • Breast cancer screening may be medically necessary for female to male trans identified persons who have not undergone a mastectomy;
  • Prostate cancer screening may be medically necessary for male to female trans identified persons who have retained their prostate.

OSUHP considers gonadotropin-releasing hormone medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria (see CPB 501: Gonadotropin-Releasing Hormone Analogs and Antagonists).

OSUHP considers the following procedures that may be performed as a component of a gender reassignment as cosmetic. Cosmetic procedures/surgeries are specifically excluded for all OSU health plans.

  • Abdominoplasty
  • Blepharoplasty
  • Brow lift
  • Calf implants
  • Cheek/malar implants
  • Chin/nose implants
  • Collagen injections
  • Construction of a clitoral hood
  • Drugs for hair loss or growth
  • Forehead lift
  • Hair removal
  • Hair transplantation
  • Lip reduction
  • Liposuction
  • Mastopexy
  • Neck tightening
  • Pectoral implants
  • Removal of redundant skin
  • Rhinoplasty
  • Voice therapy/voice lessons
  • Esthetic operations on umbilicus
  • Breast augmentation (breast implants and pectoral implants)
  • Breast lift (mastopexy)
  • Buttock lift or augmentation
  • Cheek implant (malar implant/augmentation)
  • Chin implant (genioplasty, mentoplasty)
  • Correction of diastasis recti abdominis
  • Correction of inverted nipple
  • Ear or body piercing
  • Electrolysis or laser hair removal
  • Excision of excessive skin of thigh (thigh lift, thighplasty), leg, hip, buttock, arm (arm lift, brachioplasty), forearm or hand, submental fat pad, or other areas
  • Mesotherapy (injection of various substances into the tissue beneath the skin to sculpt body contours by lysing subcutaneous fat)
  • Neck Tucks
  • Removal of frown lines
  • Removal of spider angiomata
  • Removal of supernumerary nipples (polymastia)
  • Salabrasion
  • Surgery to correct moon face
  • Surgery to correct tuberous breast deformity
  • Surgical depigmentation (e.g., laser treatment) of nevus of Ito or Ota
  • Treatment with small gel-particle hyaluronic acid (e.g., Restylane) and large gel-particle hyaluronic acid (e.g., Perlane) to improve the skin's contour and/or reduce depressions due to acne, injury, scars, or wrinkles
  • Vaginal rejuvenation procedures (clitoral reduction, designer vaginoplasty, hymenoplasty, re-virgination, G-spot amplification, pubic liposuction or lift, reduction of labia minora, labia majora surgery/reshaping, and vaginal tightening)

 

Appendix

Table 1: DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents

  1. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months duration, as manifested by two or more of the following:
  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
  • A strong desire for the primary and/or secondary sex characteristics of the other gender
  • A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

      B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Table 2. Format for Referral Letters from Qualified Health Professional: (From SOC-7)

  • Client’s general identifying characteristics; and
  • Results of the client’s psychosocial assessment, including any diagnoses; and
  • The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; and
  • An explanation that the WPATH criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery; and
  • A statement about the fact that informed consent has been obtained from the patient; and
  • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

Note:  There is no minimum duration of relationship required with mental health professional.  It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written.  A common period of time is three months, but there is significant variation in both directions.  When two letters are required, the second referral is intended to be an evaluative consultation, not a representation of an ongoing long-term therapeutic relationship, and can be written by a medical practitioner of sufficient experience with gender dysphoria.

Note: Evaluation of candidacy for gender reassignment surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.

Table 3. Characteristics of a Qualified Mental Health Professional: (From SOC-7)

  • Master’s degree or equivalent in a clinical behavioral science field granted by an institution accredited by the appropriate national accrediting board.  The professional should also have documented credentials from the relevant licensing board or equivalent; and
  • Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Disease for diagnostic purposes; and
  • Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; and
  • Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; and
  • Continuing education in the assessment and treatment of gender dysphoria.  This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

 

 

 

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