Provider Notice Issued 01/03/2020

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Date:    January 3, 2020

To:       All Providers

Re:      Gender-affirming Services

This notice seeks to inform providers of the Department’s adoption of amendments to 89 Ill. Adm. Code 140.412; 140.413; and 140.440 regarding the provision of gender-affirming services to Medicaid assistance recipients. These rulemakings remove transsexual surgery from the list of physician services specifically excluded from coverage and payment, and establish the Department’s requirements for reimbursement for gender affirming services.

Service Effective Date

Effective with dates of service on or after January 1, 2020, the Department will reimburse for gender-affirming surgeries subject to the establishment of medical necessity and prior authorization.

Medical Necessity

Gender-affirming surgeries shall be determined to be medically necessary when provided to individuals: 1) over the age of 21; 2) with a diagnosis of Gender Dysphoria; 3) when supported by sufficient medical documentation, and 4) upon submission of one or more letters from a qualified practitioner. Exceptions to the age provision may be considered on a case-by-case basis.

Letter Requirements

·         Non-genital gender-affirming surgery requires the submission of one (1) letter from either the recipient’s primary care physician or the physician managing the individual’s gender-related healthcare that has assessed the individual and is referring the individual for gender-affirming services.

·         Gender-affirming genital surgery requires the submission of two (2) letters:

o   One letter from either the recipient’s primary care physician or the physician managing the individual’s gender-related healthcare that has assessed the individual and is referring the individual for gender-affirming services, including surgery; and

o   One letter from a Licensed Practitioner of the Healing Arts (LPHA), as defined in 89 Ill. Adm. Code140.453(b)(3)(A-D, F), that has assessed the individual and is referring the individual for gender-affirming services including surgery.

The contents of the practitioner letter(s) must adhere to the requirements found in 89 Ill. Adm. Code140.413(a)(16).

Prior Authorization Process for Medicaid Fee-for-Service Clients

Effective with inpatient general hospital admission dates beginning January 1, 2020, the Department has established a prior authorization review and approval process for requesting gender-affirming services. Providers seeking to deliver gender-affirming surgeries should submit prior authorization requests to HFS.GA-service@illinois.gov.  To assist providers, HFS is also establishing a standardized Gender-affirming Services Prior Authorization Form that will be posted on the HFS website and distributed through a provider notice when it is finalized.

Prior Authorization and Billing of Gender-affirming Services to HFS-contracted MCOs

Prior authorization of gender-affirming services for dates of service on or after January 1, 2020, must be obtained from the member’s managed care health plan. Providers seeking reimbursement for medically necessary and prior authorized services from an HFS-contracted MCO must submit claims directly to the appropriate managed care entity consistent with the direction provided by the managed care entity.

Questions regarding this notice may be directed to HFS.GA-service@illinois.gov.

Doug Elwell

Medicaid Director