FAQ on Oregon Health Plan coverage for Gender Dysphoria

| August 14, 2014 | Comments (0)

Download this as a PDF:
 FAQ on Oregon Health Plan coverage for Gender Dysphoria

UPDATE: If you are looking for information on what is covered under Oregon Health Plan or are a provider looking for CPT codes, please see the end of this document.

What’s happened today?
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 healthcare 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

  1. relieving gender dysphoria
  2. reducing depression and anxiety
  3. reducing rates of suicide/suicide attempts


What did the HERC vote on today?
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 1st, 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 healthcare 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 healthcare is medically appropriate. The process to receive approval for transition related healthcare services will be similar to other healthcare.  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 healthcare 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 healthcare 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 healthcare 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 healthcare 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 healthcare 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 twelve 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 healthcare 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 healthcare 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 healthcare.  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 http://www.resourcespdx.org/ 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.​  https://apps.state.or.us/Forms/Served/he3001.pdf


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 1 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.

What is going to be covered and how should my doctor code my treatments?

Below is a list of covered procedures and the corresponding CPT codes that a provider may use to ensure that procedures are approved.


CPT code Code description Current placement
19301-19304 Mastectomy 195 CANCER OF BREAST
53430 Urethroplasty, reconstruction of female urethra 91 CONGENITAL ANOMALIES OF GENITOURINARY SYSTEM


54125 Amputation of penis; complete 262 CANCER OF PENIS AND OTHER MALE GENITAL ORGANS
54400-54417 Insertion/repair/removal of penile prosthesis 529 SEXUAL DYSFUNCTION


54520 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach 98,116,211,249,262,331,333,474
54660 Insertion of testicular prosthesis (separate procedure) 98 UNDESCENDED TESTICLE


54690 Laparoscopy, surgical; orchiectomy 98,116,428,474
55175-55180 Scrotoplasty 91, 262, 438 HYPOSPADIAS AND EPISPADIAS
55970 Intersex surgery; male to female Excluded
55980 Intersex surgery; female to male Excluded
56625 Vulvectomy simple; complete 291 CANCER OF VAGINA, VULVA, AND OTHER FEMALE GENITAL ORGANS
56800 Plastic repair of introitus 125,211,356,428
56805 Clitoroplasty for intersex state 428 ADRENOGENITAL DISORDERS,638 BENIGN CERVICAL CONDITIONS
56810 Perineoplasty, repair of perineum, nonobstetrical 125 ABUSE AND NEGLECT,428, 471 UTERINE PROLAPSE; CYSTOCELE
57106-57107 Vaginectomy, partial removal of vaginal wall; 291,471
57110-57111 Vaginectomy, complete removal of vaginal wall 291
57291-57292 Construction of artificial vagina 356 STRUCTURAL CAUSES OF AMENORRHEA
57335 Vaginoplasty for intersex state 428
58150, 58180, 58260-58262, 58275-58291, 58541-58544, 58550-58554, 58570-58573 Hysterectomy Multiple lines, with several guidelines
58661 Laparoscopy, surgical; with removal of adnexal structures Multiple lines
58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral Multiple lines


If you have question about specific benefits that are covered, please contact the Oregon Health Plan as they will have a final list of approved services.



Download this as a PDF: FAQ on Oregon Health Plan coverage for Gender Dysphoria

Category: Resources, Resources: Transgender Justice

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