Washington Apple Health Transgender Health Coverage

Washington Apple Health

Transgender Health Coverage

Frequently Asked Questions for people with Apple Health Insurance

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 2

Washington Apple Health - Transgender Health Program

Frequently Asked Questions for people with Apple Health Insurance

Author:

Danni Askini, MSW, Executive Director, Gender Justice League

Editing & Fact Checking by:

Tobi Hill-Mayer, Jessica Littenberg, Elayne Wylie, David Ward, Lisa Brodoff, and Jenni

Wong

Many thanks to:

Pride Foundation, Legal Voice, The Seattle Univeresity School of Law, Ingersoll Gender

Center, Equal Rights Washington, Basic Rights Oregon, GSBA, Gay City Health Project,

Transgender Law Center, National Center for Trans Equality, Center for American Progress,

and the Coalition for Inclusive Healthcare.

Contents Copywrite:

Danni Askini & Gender Justice League, 1433 12th Avenue 1A, Seattle, WA 98122

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 3

PREFACE

Background

Up until 2014, most health insurance plans in Washington would not pay for transition-related

health care services for transgender people due to rules known as trans health exclusions. Due to

the efforts of committed organizations and activists, these exclusions are now mostly gone in

Washington State. Additionally, as of August 31

, 2015, the Washington Apple Health program

(Washington’s version of Medicaid) is required to pay for all medically necessary transgender

health care services. This means that you can now work with your primary health care providers

to get many transgender health care treatments and transition-related care paid for by

Washington’s Apple Health Program.

About this Frequently Asked Question’s Document:

This FAQ is not intended as legal advice, merely as a tool to help explain what we know

about the current policy as outlined by the Washington Healthcare Authority.

This document only contains information that is also available through various public documents.

Legal Advice may be available from some of the following organizations:

The Northwest Justice Project’s CLEAR Hotline (Statewide)

https://www.nwjustice.org/get-legal-help

1-888-201-1014 (M-F 9:15 am to 12:15 pm)

Q-Law Foundation’s Legal Clinic (King County Only)

http://www.q-law.org/LegalClinic

(206) 235-7235 - Call anytime, leave a detailed message – they will call back to schedule you for a 30 minute

appointment. The clinic is held on the 3rd Thursday of each month from 7:00 p.m. to 9:00 p.m.

About Gender Justice League’s Role:

Gender Justice League is a trans activist collecitve! We engage in community building,

education, advocacy, and leadership development within and on behalf of trans and gender non-

conforming communities. We may be able to connect you to supportive attorney’s or other

organizations who take on cases that represent a significant public interest (i.e. high impact cases

that will expand access for all trans people).

Sadly, like many advocacy organization, Gender Justice League do not have the capacity to

take on individual cases or appeals. We also do not offer legal advice and do not have

lawyers on staff.

We can however refer you to assistance, connect you to other legal services, advocate on your

behalf with state agencies, or help you locate and learn more about the Apple Health’s policies that

are already publically available if sometimes difficult to understand.

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 4

Our work ahead to assure good implimentation of this Apple Health victory:

Gender Justice League is profoundly excited and happy to have achieved a Washington Apple

Health policy that is inclusive of transgender health care as a member of the Coalition for Inclusive

Healthcare. The new health care policy makes it possible for trans people to get medically

necessary trans health care treatments covered starting August 31st, 2015, but we want to

caution that there will likely be challenges with ensuring that this policy is fully

implemented during the first year this policy is in place.

In particular, the number of surgeons who are willing to take the reimbursement offered

by Washington Apple Health is going to be limited – this may result in waiting lists, difficulty

finding local providers, or having very limited choice in what provider you see. Gender Justice

League is working on long term projects to educate and recruit more surgeons, primary care

providers, PhD level mental health providers, and specialists to help address this, but this work is

a long term project.

Potential implementation challenges with the new policy:

It is important to remember that we are significantly changing an enormous healthcare system

that has had little exposure to the needs of transgender communities. Additionally, it is an

unfortunate reality that there are very few doctors trained and ready to offer the care trans people

need in Washington and in the United States.

When trying to access transition-related care, you may come across the following challenges:

 Finding an Apple Health provider in Washington that offer transition-related surgical care

 Finding doctors that have experience and competency working with transgender patients

 Finding PhD level mental health providers who accept Apple Health (while some surgeons

may require that pre-surgical evaluations be completed by PhD level mental health

providers, Apple Health does not require pre-surgical evaluations to be completed by PhD’s

– we will be working with surgeons and WPATH to amend the PhD level requirement).

 Getting approval for specific transition-related care you may need

 Understanding what steps you need to take to access transition-related care covered by

Apple Health

Some treatments may be easier to access than others. The Washington Apple Health program is

working to enroll primary care providers, surgeons, and mental health providers. However, it may

take time until there are providers in Washington that offer all of the transgender health care

treatments covered by the new Washington Apple Health policy. You will have to work with your

primary care doctors to determine what treatments are right for you and work with them to

access the care you need. Additionally, you can reach out to the Washinton Health Care Authority,

the agency that administers Apple Health to identify surgeons or specialists.

What is Gender Justice League doing to address the implementation challenges ahead.

We are hard at work with the Washington Healthcare Authority and community organizations like

Ingersoll Gender Center, Legal Voice, Pride Foudnation, the ACLU of Washington through the

Coalition for Inclusive Healthcare to ensure that your experience accessing hormones and

surgeries go as smoothly as possible. Additioanlly, Gender Justice League is working with the

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 5

University of Washington School of Medicine to offer a transgender medicine elective class, and

we are working with the University of Washington Medical Center to expand their surgical

programming to include transition related surgeries in the future. Gender Justice League is

committed to working with Apple Health, the Coalition for Inclusive Healthcare, and members of

the transgender community to anticipate and identify issues with implementation as they arise

and act boldly and swiftly to address them together. We have a large task ahead of us, and Gender

Justice League is ready to work with its partners and community to ensure we rise to this

challenge together.

Please understand that nothing in this FAQ should be taken as legal advice. This resource

was produced by Gender Justice League, not the Healthcare Authority. Medicaid (Apple Health)

clients should seek official information on implementation from:

www.hca.wa.gov/medicaid/transhealth/Pages/index.aspx

When will coverage start? Coverage is due to begin August 31

, 2015. Some services and

treatments can be accessed right away such as primary care and mental health care, while others

will take time and prior approval to access, which is discussed in detail in this document.

What is covered under the new guidelines for the Washington Apple Health Plan?

Washington Apple Health insurance will include coverage for puberty suppression, primary care

visits, visits to specialists, mental health care visits, transition related hormones, anti-androgens /

hormone blockers, lab work, and some surgeries. Washington Apple Health will be able to start

paying for these services, but it does not automatically grant access to all of these services.

Individuals will need to work with their doctors to determine what treatments are medically

necessary for them and then follow the guidelines provided by Apple Health to access care. While

there are some surgical procedures that should generally be covered, there is a second set of

surgeries that are only offered with advanced explaination of the medical justification for the

procedure (through a process called an ”exception to the rule”). These procedures may be very

difficult to obtain, as Apple Health may not have a contracted provider, and they may require

extensive documentation to prove medical necessity for these services. This FAQ explains the

exception to the rule process in more detail below.

Original Source documents this FAQ is based on:

Healthcare Authorities Final Rule - CR-103 – Transgender Surgery Services -

http://www.genderjusticeleague.org/wp-content/uploads/2015/08/CR-103P-15-16-084.pdf

The Washington Healthcare Authority’s answers to public testimony:

http://www.genderjusticeleague.org/wp-content/uploads/2015/08/Gender-Dysphoria-

Answers.pdf

Washington Apple Health Physician-Related Services / Health Care Proffessional Services

Provider Guide, August 1st, 2015:

http://www.genderjusticeleague.org/wp-content/uploads/2015/08/HCA_Aug2015_physician-

related_services_mpg.pdf

How the policy works and what you should know

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 6

Managed Care Organizations (MCOs)

In Washignton, the Apple Health Plan is managed by Managed Care Organizations or MCO’s, such

as Molina, Coordinated Care, United Healthcare, Community Health Plan, and many others. A large

majority of patients are assigned to an MCO, and very few have what is called “fee for service.” In

Washington – the MCO is responsible for all medical care including hormone and mental health

services to treat gender dysphoria. Contact your MCO for requirements for those services.

Managed Care Organizations may contract services to a specific provider for some care, such as

mental health care. The Apple Health Transgender Health Program will have a complete list of

doctors who are approved to treat transgender patients – so called ”Centers of Excellence”.

MCOs will not be responsible for handling approval for surgical services.

As a result, contacting the MCO about surgical services might lead to a lot of confusion. The

Health Care Authority will manage surgical benefits directly through ”fee for service”. This

is different from most other types of heatlhcare you receive.

For surgical access, your primary care doctor will need to complete a Gender Authorization

Form (HCA 13-835) along with the additional documentation requirements for each

surgery (listed bellow) and fax it to the Health Care Authority – at 1-866-668-1214 .

This form is available here: http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx

Who can provide transgender health services under Washington Apple Health?

Washington’s Apple Health program has decided to create what it is calling ”Centers of Excellence”

(COE) – a ”Center of Excellence” (COE) can be any medical or mental health provider who signs up

with Apple Health to treat transgender people and can demonstrate some type of training,

experience, or expertise in providing transgender healthcare. In order to be a COE, all providers

must complete the applicable agency attestation form stating they have met the following:

 Possess knowledge about current community, advocacy, and public policy issues relevant

to transgender people and their families (sexuality, sexual health concerns, and the

assessment and treatment of sexual disorders is preferred)

 Endorse the Standards of Care for the Health of Transsexual, Transgender, and Gender

Nonconforming People, Version 7 as developed by the World Professional Association for

Transgender Health (WPATH)

 Agree to provide services consistent with WAC 182-531-1675

Providers and Consumers can read more here:

http://www.genderjusticeleague.org/wp-content/uploads/2015/08/HCA_Aug2015_physician-

related_services_mpg.pdf

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 7

HOW TO GET ACCESS TO CARE

How do I begin getting my transgender health care covered by Apple Health?

The transgender health program has four components. Prior authorization is only required

for component four (surgical care). The Managed Care Organization’s case managers and the

Fee For Service staff coordinate care across the programs and are available to help you navigate

this process. The components described below are not intended to be sequential and may run

concurrently to meet the client’s medical needs. All services must be provided by agency-

approved COE providers.

Component 1 – Intake & Treatment Planning

 Conducting an initial assessment which makes or confirms the diagnosis

 Developing an individualized treatment plan

 Managing referrals to other qualified providers as indicated and

 Assisting with navigation of other program requirements

Component one must be provided by a ”Center-of-Excellence (COE) provider” who is a board

certified physician, a psychologist, a board-certified psychiatrist, or a licensed advanced

registered nurse practitioner (ARNP). If you have a primary care provider already – you can ask

that they become registered as a Center of Excellence with the Apple Health Program. Component

one services provided should be consistent with World Professional Association for Transgender

Health (WPATH) Standards of Care. You should work with your provider to determine what

mental health, hormonal, and surgical services you will need, and put those into a treatment plan.

Your primary care provider can then refer you to a mental health provider.

Component 2 – Mental Health Care & Hormonal Health Care

Includes mental health and medical services directly related to the pathway to

gender reassignment surgery.

 Medical treatment may include androgen suppression, puberty suppression, continuous

hormone therapy, and laboratory testing to monitor the safety of hormone therapy.

 Mental health treatment, provided to the client, client’s spouse, parent, guardian, child, or

person with whom the client has a child in common, if the treatment is directly related to

the client’s care, is medically necessary, and is in accordance with the provisions of WAC

182-531-1400.

Component 3 – Pre-Surgical Requirements

 For top surgery: A referral to the surgeon from a Primary Care Provider (PCP) and a

comprehensive evaluation by an agency-approved COE mental health professional.

 For bottom surgery: A referral to the surgeon from a PCP, a comprehensive evaluation

by two agency approved COE mental health professionals and a pre-surgical consultation

by an agency-approved COE surgeon.

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 8

Component 4 – Surgical Services

Includes surgical interventions and requirements.

Client requirements - The client must:

 Be age 18 or older, unless allowed under the Early and Periodic Screening, Diagnosis,

and Treatment (EPSDT) program. People under 18 may apply for an exception to the rule

with their providers for surgical services, however it is unclear what requirements will

change for people under 18.

 Be competent to give consent for treatment and undergo a comprehensive psychosocial

evaluation

 Have received continuous hormonal therapy as required by the treatment plan to meet

treatment objectives

 Have lived in a gender role congruent with the client's gender identity immediately

preceding surgery as required by the treatment plan to meet treatment objectives

Prior authorization is required for Component 4 only.

Providers must fax a completed General Authorization form (HCA 13-835) along with any

additional documentation required below to the agency at 1-866-668-1214:

For top surgery

The agency requires referral letters from each of the following:

A mental health provider, who will addresses all of the following:

 Confirm the diagnosis of gender dysphoria using current DSM 5 (Diagnostic and

Statistical Manual of Mental Disorders) criteria

 Assure the client is a good candidate

 Assure the surgery is the next reasonable step in the care

 Assure the client has no coexisting behavioral health conditions (substance abuse

problems, or mental health illnesses), which could hinder participation in treatment for

gender dysphoria

 Assure any coexisting behavioral health condition is adequately managed

The provider managing the hormonal therapy:

 Outcome of clients current hormonal therapy

The surgeon performing surgery:

 Written surgical consultation

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 9

Component 4 – Surgical Services (continued)

For bottom surgery

The agency requires referral letters from each of the following:

Two mental health providers, both of whom will address all of the following:

 The psychosocial evaluation

 Confirm the diagnosis of gender dysphoria using current DSM 5 (Diagnostic and

Statistical Manual of Mental Disorders) criteria

 Assure the client is a good candidate

 Assure the surgery is the next reasonable step in the care

 Assure the client has no coexisting behavioral health conditions (substance abuse

problems, or mental health illnesses), which could hinder participation in gender

dysphoria treatment

 Assure any coexisting behavioral health condition is adequately manage

 Description of the relationship between the mental health professional and the client

and treatment to date

The surgeon performing surgery:

 Written surgical consultation

 Clinical justification for surgery

 Confirmation that the client is able to comply with the postoperative requirements

 Assurance that all surgical criteria has been met or medical necessity is established

 Copy of the signed Sterilization Consent form (HCA 13-364) with the clients understanding

of the permanent impact on the reproductive system consistent with the requirements of

WAC 182-531-1550

 The surgical plan description with all planned procedures and timeline listed

Surgeons must indicate in Comments field 30 on the agency’s General Authorization form (HCA

13-835) the procedures being requested..

The provider managing the hormonal therapy:

 A statement regarding the client’s adherence to the medical and mental treatment plan

 Outcome of client’s current hormonal therapy

 Assurance that all the members of the treatment team will be available to coordinate or

provide postoperative care as needed

These guidelines are copied directly from the following guidance to providers from HCA:

http://www.hca.wa.gov/medicaid/billing/Documents/guides/physician-related_services_mpg.pdf

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 10

Questions on how to access these benefits

If you already have a primary care provider who takes Apple Health:

Your primary care provider can work with you to develop a treatment plan and prescribe

hormones or hormone blockers – but they must first register with Apple Health as a Center of

Excellence. They can email [email protected] to register with the Apple Health

Transgender Health Program.

If you do not have a primary care provider yet:

Please contact your managed care organization or the Washington Apple Health Trans Health

Program to identify a primary care provider who is a designated Center of Excellence – their

website is: www.hca.wa.gov/medicaid/transhealth

For mental health care providers:

Contact your Managed Care Organization (the organization on your insurance card) – they are

requierd to connect you to a mental health provider. Frequently managed care organizations have

a directory of providers who accept their insurance, you can call providers on this list to find

someone who can help – or you can reach out to the Health Care Authority’s trans health program

to help locate a provider as they should have a list of ”Center of Excellence” providers.

Can any therapist diagnose me with gender dysphoria? Does my therapist need a PhD to

diagnose me?

The Washington Health Care Authority only require a letter from licensed qualified mental health

providers to diagnose gender dysphoria. Master’s level clinicians (LIASWs, LMFT, etc.) will be

able to write letters diagnosing patients with gender dysphoria for the Washington Apple Health.

However, many Surgeons may have their own requirements and some require a PhD level

providers, make sure to check in with your surgeon about what is acceptable to them as well

for your second letter.

Do I need to get approval to access mental health care?

No, there should be no barriers to accessing mental health care for transgender health services.

Do I need to get approval to access hormone treatments?

No, you will not be require to provide prior approval or letters from a mental health provider for

treatment with puberty blockers, hormones, or anti-androgens. However, you will need a letter

from a therapist diagnosing you with gender dysphoria in order to get most medical providers to

prescribe hormone therapy, puberty suppression, or anti-androgen treatments.

What should be in referral letters for hormone, puberty suppression, or anti-androgen

treatment?

Doctors will likely ask for a letter from your therapist diagnosing you with gender dysphoria in

order to begin hormone treatments. They will also need this in your file to help determine what

transgender health treatments are medically necessary for you, including surgeries at a later date

if you should choose these options. This letter should also include information about your plans

for transition – including if you are seeking any proceedures not on the covered list.

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 11

Questions on how to access surgery benefits

How can I get surgery covered?

It is not currently clear what surgical care will be available immediately in Washignton

State or how people will get approved for out of state surgical care.

The Apple Health Trans Health Program must first locate and contract with surgical providers to

offer the covered services. We have provided Apple Health with a comprehensive list of surgeons

around the country in hopes of increasing access to surgical care. Some surgeries may already be

provided by local surgeons –such as top surgery or some bottom surgeries (hystorectomy or

orchiectomy for example), however other highly specialized surgeries may be difficult to

obtain immediately.

We would encourage you to navigate through components 1 – 3 as they apply and then work

directly with the Health Care Authority to identify a surgeon who can meet your needs.

We definitely understand that winning this policy is the first step in an ongoing process for our

community to access care and will be working hard to expand the number of providers in the

Northwest who will take Apple Health.

What transition-related care is specifically excluded or not covered?

The chart on the following pages lists both covered services and ”non-covered services” that are

only allowed on a case-by-case basis through the ”exception to the rule” process. You must work

closely with your mental health provider, physician, and a surgeon to present a strong case

for medical necessity for this care for generally non-covered services. There is an Exception

to the Rule Process in place which is required for services that are listed in the second list – this

process requires your provider to make a clear case of the medical need. You can reach out to the

Trans Health Program at Apple Health for more information on how to file an exception to the

rule: [email protected] Gender Justice League can also provide you with information,

referral, and limited assistance.

What is the ”Exception to the Rule” Process for ”non-covered services”?

The Health Care Authority has divided surgical care into two categorics ”Covered” services –

which are generally available by following the 4 components listed above, and ”Non-Covered”

services, which are not generally covered but may be allowed on a case by case basis. This may be

confusing, but the Health Care Authority can still pay for ”non-covered” services on a case by case

basis. Advocates worked very hard to create as many possibilities for Trans people to receive all

medically necessary care as deteremined by their health care team.

To get access to ”non-covered” services, you must first apply for coverage for that service by

submitting a Pre-Service Authorization for the requested service. You should follow the guideline

in component 4 for submitting information including 2 letters from mental health provides, and

assessment from a surgeon, and a letter from your primary care provider. All providers should

give specific and detailed unformation about why the service you are requesting is medically

necessary, cost effective (i.e. cheaper than ongoing treatment for gender dysphoria / mental

health treatment), and safe/effective. The most helpful component is to make sure to inform your

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 12

doctors as early in your relationship about how yuor Gender Dysphoria is manifesting, and what

services you believe will remedy the distress you feel.

Important notes:

Providers: Medicaid can only reimburse physicians, hospitals, or other established medical

provdiers. This means for services like Laser hair removal or electrolysis – Medicaid would only

be able to pay a physicians office for those services. Private practitioners will not be covered

unless they go through the process to become an Apple Health Transgender Health Program

”Center of Excellence”. Many ’non-covered’ services are offered by providers who do not generally

take insurance, and this may present a significant barrier to getting coverage.

Appeals & Decisions: The Medical Director for the Health Care Authority will make the final

determination about if Apple Health will pay for the non-covered service. You will not have the

right to appeal this decision, the decision is final. This is very important to note: you get

’one shot’ at getting a non-covered service.

If you are denied a service – we would urge you to contact the CLEAR Hotline for assistance.

What should I include in a referral letter for surgery?

Doctors and therapists should work with patients to obtain prior approval for covered surgeries

from Washington Apple Health . The MCO will require letters from two licensed qualified mental

health providers who have independently assessed the patient. These assessments should

document that the qualifying criteria have been met.

How do I qualify for bottom surgeries?

(Also known as gender reassignment, gender confirmation, sex reassignment surgery, etc.):

How do I find surgeon for trans health services?

Gender Justice League has been told that The Healthcare Authority will be arranging appropriate

coverage for surgeries for transgender patients who meet the above guidelines. Some surgeons in

Washington are performing covered surgeries.. We encourage providers and patients to connect

with the Healthcare Authority and other local surgeons skilled and experienced in providing

transition-related surgeries to see if they will take Apple Health.

Can you recommend doctors who are reliable, safe, and transgender-friendly?

The Washington Healthcare Authority will be creating a list of Center of Excellence (COE)

providers which they intend to make public. Gender Justice League does not maintain a list of

providers. Ingersoll Gender Center does offer a list of providers –though not all take Apple Health.

What if I can’t find a surgeon who takes my insurance?

As more insurance plans cover transition-related care, more and more experienced surgeons are

accepting insurance, both public and private. At this point, we are working to identify surgeons in

Washington that take Apple Health and will work to sign them up, and collaborate with Ingersoll

Gender Center to list them on their directory. If you cannot find a qualified surgeon who takes

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 13

your insurance, you may have to wait. We don’t know whether that will take weeks, months, or

years. You may want to think carefully before going to a surgeon who is not yet fully trained and

experienced with providing specific surgeries for transgender people. Additionally, please also

know that you may not be able to choose your surgeon and one may be provided for you. You

should contact the Healthcare Authority directly to get assistance in identifying a surgeon who is

qualified. In the past when Apple Health previously covered transition related care, some patients

were sent out of state for surgery, we are unsure if this practice will continue.

Should I see a doctor who has never performed gender reassignment surgeries before, but

who is now offering them?

We presume that some doctors who have no experience doing gender reassignment surgeries will

look at the news in Washington and start offering these procedures. We urge you to be careful and

find out about their training and experience before having surgery with them. Though a doctor

may regularly perform a procedure on non-transgender patients, there may be aspects of a

surgery that go better if a doctor has experience and training with transgender patients. Please

select your provider carefully!

What about different kinds of surgeries, are some available now?

Until more surgeons begin taking insurance and Apple Health, some surgeries may be easier to get

than others. For example, hysterectomies and orchiectomies should already be easy to get in-

network or through Apple Health without any problems (see the chart below). It may be easier to

find qualified breast/chest surgeons than for bottom surgeries.

What about traveling out of state for surgery?

Gender Justice League has been told that patients will need to work directly with The Healthcare

Authority of Washington to identify appropriate providers for covered services listed that have

been approved. For services that are not offered in Washington, or are not in network for MCO’s –

The Healthcare Authority & Apple Health will need to work to identify and contract with a

provider, this may mean coverage might be available out of state. It is unclear how this process

will roll out and it may take some time, advocacy, and hard work to make this happen. Some out

of state surgeons may choose to work with Apple Health – though at this time it is unclear.

Can patients choose their own surgeon?

This is currently unclear, patients will have to work directly with their doctor and the Healthcare

Authority to identify an appropriate, approved, and competent surgeon. Your primary care doctor

should contact the Healthcare Authority to identify a surgeon for the medically necessary care you

need. We will work with the Healthcare Authority to identify and publish a list of surgeons willing

to take Apple Health.

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 14

Questions on how Youth can access care

Can youth access care?

Yes, trans youth should have access to all medically necessary care, including mental health care,

puberty suppression, hormones, specialists visits, and primary care visits. We are still exploring

the question of age of consent as detailed below, but with supportive guardians, all care provided

to trans youth should be available. This care is provided through the ”Early and Periodic

Screening Program” – which will evaluate on a case by case basis the need for care. Puberty

blockers are a covered service. Some surgeries may be available through the early and periodic

screening, diagnosis, and treatment program (EPSDT).

What is the age of consent in Washington State?

As a general rule for non-emergecy services, 18. However, mental health care is 13 and

reproductive healthcare is 14. Advocates from the Coalition for Inclusive Healthcare have

advocated for no arbitrary age restrictions in this policy for youth who need to access surgical

benefits. We will continue to fight hard to expand surgical coverage for older teens who are in

need of care.

What are the age requirements for surgeries in this policy?

The Health Care Authority has set the age requirements at 18 for surgical access. They have

however indicated that in certain cases, they will approve surgical services for people under 18

years old under the ”exception to the rule” process as outlined above. Advocates strongly disagree

with this arbitrary age limit, especially when it interfers with the best interest of young trans

people. If you are the parent of a young person who is in need of help accessing care, please reach

out to Gender Justice League, Legal Voice, the ACLU of Washington, or Q-Law Legal Clinic.

Can Young People who are wards of the court (foster youth) or amancipated consent to

medical care?

Washington State Law does include a provision for young people who are under 18 to consent to

medical care – they are required to meet the ”mature minor doctrine” – we believe this is also true

for accessing transition related healthcare. Oregon, our neighboring state has a far lower age of

medical consent; 15 years old. Minors who are able to travel to Oregon may be able to receive

surgical or medical care in Oregon consistent with their state laws. You can read more about these

guidelines here:

https://depts.washington.edu/hcsats/PDF/guidelines/Minors%20Health%20Care%20Rights%20Washington%20State.pdf

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 15

Covered Treatments

(if deemed medically necessary for you)

Please note this list is not exhaustive. The following list is a treatments that may be considered

medically necessary for some people. It also notes the availability of these treatments in

Washington to the best of our knowledge.

Treatment

Description or example

Is it available in Washington?

Hormone therapy

Prescription testosterones,

estrogens, progesterone, etc.

Yes. You just need a prescription and to go to a

pharmacy that takes your health insurance. You will also

need to get a diagnosis of gender dysphoria from a

licensed mental health provider and a prescription from

your primary care doctor or a specialist.

Puberty blockers

Suppressants that act as a

“pause button” on the body’s

release of hormones typically

begins at puberty

Hormone blockers

Aromatase inhibitors or

gonadotropin-

releasing hormone (GnRH)

analogues used to suppress

hormone release (ex. Anti-

androgen, androgen blocker)

Mental health treatment

Counseling, psychotherapy,

substance abuse treatment,

family or couples counseling,

and crisis intervention

treatment.

Yes. You just need to find a therapist,

substance abuse treatment center, or crisis intervention

center who takes Apple Health. Contact your Managed

Care Organization for more details

Preventive screenings

Pap tests, prostate exams,

mammograms, breast exams

Yes. You need to go to a provider who takes Apple

Health. Please know they no longer can deny you care

that does not correspond with your gender marker in your

file.

Laboratory tests

Blood tests to assess

hormone levels, electrolytes,

cholesterol levels, liver or kidney

function

Yes, as long as your labs are ordered by a doctor who

takes your insurance and sends you to a lab that is

covered by your insurance.

Hysterectomy; Salpingo-

oophorectomy

Removal of the uterus,

cervix, fallopian tubes and

ovaries

Many doctors are experienced at these surgeries for non-

transgender people but may not have treated trans

patients. They should be readily available in Washington,

however be careful in selecting your surgeon.

Orchiectomy

Removal of testicles

Yes, there are providers at University of Washington

Urology Department who have performed these

surgeries. You will want to verify they are taking your

Managed Care Organization.

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 16

Mastectomy /

Chest Reconstruction

Removal of the chest or breast

tissue for transgender men –

Chest Reconstruction or top

surgery

Chest surgery is available in Washington State – we are

working to identify surgeons who will take Apple Health. It

is important to note that while currently chest surgery for

trans people is labeled under mastectomy, it is a different

procedure than a standard mastectomy received for

breast cancer and should be done by a surgeon that is

familiar with chest reconstruction for trans people.

Breast Reconstruction /

Breast Augmentation

Adding a saline or silicone filled

medical device to your chest to

reconstruct your chest or

breasts to be larger.

Breast Reconstruction is readily available in Washington

State – we are working to identify providers who are

willing to take Apple Health. Several surgical providers

such as the Poly Clinic, Swedish Medical Center, and

University of Washington Medical Center may be good

places to inquire about these services as they generally

take Apple Health. These providers will have to sign up

with Apple Health first as a COE provider.

Laryngoplasty

We believe this means vocal

chord surgery – or voice

modification surgery

We are unsure if this service is available in Washington

State – please contact Apple Health’s Transgender

Health program for more information.

Abdominoplasty

Removing excess skin or fat

from the abdomen which may

be needed for other surgical

procedures such as bottom

surgery.

Abdominoplasty is readily available in Washington State,

however – this procedure is likely only covered when

done in combination with another medical procedure. You

should check with the surgeon you are working with for

bottom surgery to find out more. Some surgeons may

want to do the surgery themselves, and having a

separate surgeon in Washington do this surgery may not

be helpful.

Belpharoplasty

Surgical treatment of the eyelid

This surgical procedure is available in Washington State

and may be medically necessary as a component of

facial feminization surgery. Please consult with your

primary care doctor, mental health team, and a surgeon

to determine medical necessity.

Colpecotmy; Vaginectomy

Surgical removal of the vaigna

This procedure is typically done in conjunction with other

bottom surgeries. It may be available in Washington, we

are currently unsure. However, if you plan to have other

bottom surgeries you should consult the bottom surgeon

first before doing this procedure locally.

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 17

Urethroplasty/Urethral

reconstruction

Reconstruction and/or

rerouting of the urethra

We aren’t sure when these surgeries will be available in

Washington. Right now we do not know of any local

doctors who provide these and accept insurance.

However, you should contact the Healthcare Authority –

covered services should be made available to all patient,

Apple Health can coordinate this care.

Phalloplasty

Construction or

reconstruction of the penis

Scrotoplasty; Placement of

testicular prosthesis

The creation of the scrotum;

implantation of testicular

implants/prothesis.

This procedure is not likely available in Washington

State.

Genital electrolysis

Electrolysis done in preperation

for Vaginoplasty.

Most surgeons require patients to undergo genital

electrolysis prior to vaginoplasty. This is considered a

medically necessary service when done in conjunction

with preparation for vaginoplasty – it is important to note

that this must be done in a physician’s office to be

covered by Apple Health. This procedure is available in

Washington State.

Vaginoplasty, Penectomy,

Cliteroplasty,

Colovaginoplasty,

Labiaplasty ,Genital

surgery.

Construction or

reconstruction of the vagina,

removal of the penis, creation of

the labia, and creation of the

clitoris.

We aren’t sure when these surgeries will be available in

Washington. Right now we do not know of any local

doctors who provide these and accept insurance.

However, you should contact Apple Health who is

working to identify a contract surgeon out of state.

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 18

Non-covered Treatments

(only considered on a case-by-case basis under Exception To The Rule)

Please note this list is not exhaustive. The following list is a treatments that may be considered

medically necessary for some people but only on a case by case basis through the Exception to the

Rule process. Please remember: these are not generally covered – and you must first BE DENIED

these services, and then file an appeal including the documentation outlined in Stage 4 justifying

the medical necessity of these procedures. It also notes the availability of these treatments in

Washington to the best of our knowledge.

Treatment

Description or example

Is it available in Washington?

Brow lift

A surgical procedure to

shorten the length of the

forehead / brow.

Yes

Calf implants

Prosthetic implants to

increase the size/definition

of the calf muscle.

Possibly, we are unsure.

Cheek/Mylar implants

A surgical procedure to place

a prosthetic that increases

the size or prominence of

the cheeks.

Yes.

Chin/nose implants

A surgical procedure to place

a prosthetic that increases

the size or prominence of

the chin or nose.

Yes.

Collagen injections

Injections of the face to

increase prominence or

feminize the face.

Yes.

Drugs for hair loss or

growth

Drugs that are specifically

used for hair growth.

Yes, despite this - we believe that these

medications may be covered under testosterone

suppression/hormone blockade. Check with your

primary care provider.

Facial or trunk electrolysis

Removal of body or facial

hair by electrolysis.

Yes, this is widely available in Washington.

Facial feminization

Surgical procedures to

feminize the face

Yes, there are several Washington plastic surgeons

who perform surgeries to feminize the face

Face lift

A surgical procedure to

”rejuvenate” the face or

Yes, this is widely available in Washington.

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 19

reduce the appearance of

age

Forehead lift

A reduction of the forehead

to shorten it and bring the

hairline downward.

Yes, we believe this is available in Washington

State.

Hair transplantation

Transfer of hair follicles from

one part of the scalp to

another part.

Yes, this is widely available.

Jaw shortening

A procedure to shorten the

length of the jaw.

Yes, there are Maxilliofacial surgeons in

Washington performing this procedure.

Lip reduction

A surgical procedure to

reduce the size or

prominence of the lips or

reduce the size the

surrounding skin.

Yes, this procedure is available.

Liposuction

The surgical removal of fat

by a suction assisted device.

This is widely available in Washington

Mastopexy;

Also called a ”breast lift” this

procedure raises the areola

and breast tissue on the

chest.

Yes, this procedure is widely available in

Washington

Neck tightening

A surgical procedure to

tighten the skin of the neck.

Yes, this is available in Washington.

Pectoral implants;

The implantation of devices

intended to increase the

prominence of the pectorals

muscles.

This procedure is available in Washington

Reduction thyroid

chondroplasty; Trachea

shave

Surgical procedures to

reduce the prominence of

the Adams Apple / Trachea

protrusion.

Yes, this procedure is available in Washington

Removal of redundant skin

Surgical procedures to

reduce excess skin.

These surgeries may be available in Washington.

Suction-assisted lipoplasty

of the waist

A form of Liposuction of the

waste

Yes, this is available in Washington

Gender Justice League

8/11/15

Frequently Asked Questions on Apple Health Transgender Health Program 20

Voice modification surgery;

Voice Therapy

Surgical procedures to

change the pitch, tone, or

resonance of the voice.

We are unsure, these surgeries may be available.

Note: Larygoplasty is a covered service – we are

currently unclear about this contradiction.

“The agency evaluates a request for any non-covered service listed in (e) of this subsection as an

exception to rule under the provisions of WAC 182-501-0160. The justification included in the surgical

plan for any of the procedures listed in (e) of this subsection may be recognized by the agency as

meeting the documentation requirements of WAC 182-501-0160”