The following FAQ is from Oregon’s Q Center.
The Health Evidence Review Commission (HERC)—which is charged with overseeing the prioritized list of services in Oregon’s Medicaid program—the Oregon Health Plan, voted Friday to approve the coverage of medically necessary health care for Transgender people.
Transgender Oregonians on the Oregon Health Plan should be able to receive hormonal and surgical healthcare prescribed by their physician, starting in 2015.
The Health Evidence Review Commission (HERC) – which is charged with overseeing the prioritized list of services in Oregon’s Medicaid program – The Oregon Health Plan voted to approve the coverage of hormonal and surgical health care for Transgender people. Since April, the HERC underwent a process of reviewing the evidence of effectiveness for treatments of gender dysphoria (formerly known as gender identity disorder), a condition in which a person knows their gender to be different than the one they were born with.
Why did the HERC undertake this process?
HERC needed to evaluate the emerging research that had developed since they last looked at this topic in 1999 and reviewed current research and standards of care to ensure that all Oregonians who receive health coverage through the Oregon Health Plan receive the most medically appropriate care for this condition.
The history of coverage of treatment for gender dysphoria by OHP
- Gender dysphoria has not been a covered condition to date.
- Until recently, the evidence on the treatment of this condition had not been considered since 1999.
- Gender reassignment surgery is specifically excluded as a service by the Department of Medical Assistance Programs (DMAP) rules (a rule change proposal is currently under review by DMAP)
What has been done so far?
1) Updating Oregon’s policy and bringing it into line with current treatment guidelines, HERC has voted to move gender dysphoria into the covered portion of the Prioritized List of covered services with the publication of the next biennial review List. Services already approved for this new, covered line for both Healthy Kids and Oregon Health Plan were voted on in 2013 include psychotherapy, medical visits, and medications to suppress puberty in transgender youth.
2) More recently the Value-based Benefits Subcommittee (VbBS) heard extensive testimony from experts and reviewed relevant literature regarding the effectiveness of cross-sex hormone therapy and gender reassignment surgery for
- relieving gender dysphoria
- reducing depression and anxiety
- reducing rates of suicide/suicide attempts
What did the HERC vote on?
1) The VBBS recommended to the full HERC that coverage be added for cross-sex hormone therapy and gender reassignment surgery to the new gender dysphoria line that was approved in 2013.
2) A guideline is recommended which restricts treatments to appropriate patients as determined by major international guidelines.
3) The full HERC voted to include cross-sex hormone therapy and gender reassignment surgeries to the gender dysphoria line, joining psychotherapy, which was approved in 2013.
Is there an estimate of how many people will be affected by the change?
HERC staff estimate a utilization rate (of all treatments for gender dysphoria) in OHP of 175 persons in any 12-month period.
How much will it cost?
HERC staff estimates that the total cost of adding all treatments for OHP will be less than $150,000 per year out of a bi-annual budget of 9.7 Billion.
What happens now?
1) Starting October 1, 2014, consumers on Oregon Health Plan will be eligible to receive coverage for psychotherapy, medical visits, and puberty suppression medication.
2) Changes to the Prioritized List affecting OHP coverage of cross-sex hormone therapy and gender reassignment surgery will go into effect sometime between October 1, 2014 and April 1, 2015.
3) Transgender Oregonians on the Oregon Health Plan should be able to receive hormonal and surgical healthcare as approved in 2015.
What does this mean for Transgender Oregonians?
For the first time in the history of Oregon Health Plan, a comprehensive continuum of health care will be available for the treatment of Gender Dysphoria. These treatments will include psychotherapy, puberty suppression (for youth), medical visits, hormones, androgen blockers, and gender reassignment surgery.
If I am Transgender and on Oregon Health Plan, how do I access care?
Transgender Oregonians who are insured through the Oregon Health Plan should work closely with their primary care doctor to identify what gender transition health care is medically appropriate. The process to receive approval for transition related health care services will be similar to other health care. Some services will require prior approval from Oregon Health Plan and will only be provided if the primary care doctor and patient can demonstrate medical necessity. Making yourself familiar with the WPATH Standards of Care version 7 can help you prepare to access transition related health care as these guidelines were the basis for the guidelines adopted by Oregon Health Plan. Your care should be coordinated by a primary care provider and will need to involve an evaluation by a licensed mental health care provider before starting hormones. For any surgical services patients will need to secure letters from two independent qualified mental health providers.
What will be the requirement for accessing hormonal health care benefits?
Cross-sex hormone therapy is included for treatment of adolescents and adults with gender dysphoria who meet appropriate eligibility and readiness criteria.
What will be the requirement for accessing hormonal health care benefits?
Cross-sex hormone therapy is included on this line for treatment of adolescents and adults with gender dysphoria who meet appropriate eligibility and readiness criteria. To qualify for cross-sex hormone therapy, the patient must:
1) Have persistent, well-documented gender dysphoria
2) Have the capacity to make a fully informed decision and to give consent for treatment
3) Have any significant medical or mental health concerns reasonably well controlled
4) Have a thorough psychosocial assessment by a qualified mental health professional with experience in working with patients with gender dysphoria
What will be the requirement for accessing surgical health care benefits?
Sex reassignment surgery is included for patients who are sufficiently physically fit and meet eligibility criteria. To qualify for surgery, the patient must:
1) Have persistent, well documented gender dysphoria
2) Have completed twelve months of continuous hormone therapy as appropriate to the member’s gender goals unless hormones are not clinically indicated for the individual
3) Have completed 12 months of living in a gender role that is congruent with their gender identity unless a medical and a mental health professional both determine that this requirement is not safe for the patient
4) Have the capacity to make a fully informed decision and to give consent for treatment
5) Have any significant medical or mental health concerns reasonably well controlled
6) Have two referrals from qualified mental health professionals with experience in working with patients with gender dysphoria who have independently assessed the patient. Such an assessment should include the clinical rationale supporting the patient’s request for surgery, as well as the rationale of the procedure(s)
Who can provide transition related health care services?
Any provider in the state of Oregon who is licensed to practice medical or mental health care should be able to provide transition related health care if they accept insurance by your Oregon Health Plan Coordinated Care Organization. You will also want to make sure that you are receiving care from providers who are culturally competent and knowledgeable in transition related health care. Basic Rights Oregon will be working with Q Center, CAP, TransActive Gender Center, and other community organizations to identify providers who take OHP throughout Oregon. Q-Center will be maintaining this data, you can check out Resources PDX or contact them by phone (503) 234-7837. If you currently have a supportive provider you would like to recommend, please contact the Q Center to let them know!
What do I do if I am denied payment for specific care?
You have a right to appeal any decision to refuse to pay for a service.The following information is from the Oregon Health Plan website.
How do I send in a complaint about OHP or my plan?
OHP Complaint Form – Use this form to submit complaints to OHP Client Services or your plan.
If DMAP or the plan denies coverage of a service that has already been delivered, can an OHP member appeal the denial?
All OHP members can file a request for hearing if they disagree with a payment decision. Members of OHP health or dental plans who disagree with the plan’s denial of payment can also appeal the decision with their plan. The OHP member is only responsible for payment if he or she signed a waiver agreeing to be responsible for payment of the non-covered service.
How can OHP members request a hearing?
The OHP member must complete the Request for Administrative Hearing (MSC 443) within 45 calendar days of date on the Notice of Action.
Can a provider represent an OHP member in an appeal regarding the denial of payment for services?
The OHP member can designate anyone as his or her representative in an appeal or hearing. The member must provide written consent.
What if I experience discrimination when receiving care covered by Oregon Health Plan:
If you feel that a healthcare provider has unfairly discriminated against you, there are several options for filing a complaint.
You can file a complaint with the Oregon Medical Board (who governs the laws related to medical providers). Their information on filing a complaint is here.
Am I required to have one year of “real life experience” before applying for surgery?
No. There is a waiver in the current rules if a referring physician and qualified mental health care provider agree that a real life experience may pose a safety risk for you. You are still required to have one year of hormone therapy before surgery unless it is medically dangerous. This may be the case if you have another condition that prevents taking hormones – such as a history of hormone responsive cancers, etc. The waiver for the ‘real life experience’ must be noted in your doctor and therapists referral letters.
Do I need to see a psychiatrist to be referred to surgery?
This is unclear: The current language is two letters from qualified mental health providers with experience in working with patients with gender dysphoria who have assessed the patient independently. This might mean two letters from master’s level therapists may be acceptable to the Department of Medical Assistance Programs. We will work with DMAP to clarify this requirement more closely.
How do I document “Persistent, well documented Gender Dysphoria.”
This requirement likely means you should see a therapist for a period of time, discuss your history of gender dysphoria (discomfort with your gender) and ensure that this is noted in the letter for prior approval to DMAP from both your therapist and primary care doctor.
Is there an age limit?
Not specifically. This means that Oregon State Law or the state law where the surgery will take place dictates surgical requirements. In Oregon the medical age of consent is 15. All other requirements listed for surgery must be met before approval.
What about if I have another medical or mental health condition?
You should ensure that your doctor and therapists who are treating your other conditions make sure to note that these conditions are well controlled (and by what measures, medication, therapy, treatments, etc.) in their referral letters. No other conditions should preclude treatment for Gender Dysphoria if they are being well controlled.