• This page, Eligibility for Gender-Affirming Care , is   offered by
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Eligibility for Gender-Affirming Care

General eligibility information about gender-affirming care for MassHealth members.

Eligibility depends on several factors, including your MassHealth coverage type. If you don’t know what coverage type you are enrolled in or how your coverage works, check your insurance card or call MassHealth Customer Service Center for more information.

Table of Contents

MassHealth Standard, MassHealth CommonHealth, MassHealth CarePlus, and MassHealth Family Assistance

If you have MassHealth Standard, MassHealth CommonHealth, MassHealth CarePlus, or MassHealth Family Assistance, and meet the criteria listed in the medical necessity guidelines (MNG) (see links below), you may be eligible for coverage of medically necessary gender-affirming treatments.

Managed and Integrated Care Plans and MassHealth Fee-for-Service

MassHealth managed or integrated care plans may have their own policies and medical necessity criteria for covered services. Plans must provide covered services in an amount, duration, and scope not less than as provided by MassHealth. Any medical necessity guidelines must not be more restrictive than MassHealth’s Guidelines for Medical Necessity Determination.

If you are enrolled in a MassHealth Accountable Care Partnership Plan (ACPP), Managed Care Organization (MCO), One Care plan, Senior Care Options (SCO) plan, or a Program of All-Inclusive Care for the Elderly (PACE) plan and are looking for more information about these services and your plan’s policies, you should call your plan or visit the plan’s website. Your provider can also help you understand how coverage for certain procedures will work.

If you are enrolled in a Primary Care ACO or the Primary Care Clinician (PCC) Plan, or are a MassHealth fee-for-service member, you should refer to MassHealth’s policies for covered services, or contact the MassHealth Customer Service Center. Members enrolled with the MassHealth Behavioral Health Vendor (the Massachusetts Behavioral Health Partnership, or MBHP), may call MBHP for information about coverage of gender-affirming behavioral health treatments. Your provider can also help you understand how coverage for certain procedures will work.

MassHealth Members with Medicare or Private Insurance

Some MassHealth members have both MassHealth and Medicare or MassHealth and private insurance at the same time. For these members, Medicare or the private health insurance is considered a liable third party, also known as “TPL.” This means that Medicare or the private health insurance is billed as the primary insurer and MassHealth is the secondary coverage. If you have Medicare or private insurance, contact Medicare or that insurer first to determine which gender-affirming services are covered.

For more information about third party liability visit MassHealth and private health insurance also known as Third Party Liability (TPL) | Mass.gov.

Health Safety Net

Gender-affirming treatments may also be paid for by the Health Safety Net (HSN) when they are provided by an HSN provider (either a community health center or an acute hospital). For more information about the Health Safety Net, visit Information For Patients | Mass.gov.

Helpful Links

How to Contact MassHealth

MassHealth Customer Service Center

Phone

(800) 841-2900

Self-service available 24 hrs/day in English and Spanish.

Other services available Monday–Friday, 8 a.m.–5 p.m. Interpreter service available.

TTY: (800) 497-4648

Self-service available 24 hrs/day in English and Spanish.

Other services available Monday–Friday, 8 a.m.–5 p.m. Interpreter service available.

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