Gender-Affirming Primary Care
An important part of gender-affirming care is finding and working with a primary care provider (PCP) you trust and with whom you feel comfortable. In addition to providing general primary care, your PCP can help connect you to useful resources, answer your questions, and refer you to specialist care if needed.
Gender-Affirming Hormone Therapy and Puberty Blockers
MassHealth covers medically necessary puberty blockers and gender-affirming hormone therapy (GAHT). Both puberty blockers and GAHT are prescribed and managed by a health care provider trained in managing GAHT, like an endocrinologist or a PCP. If you are interested in starting puberty blockers or GAHT, talk with your PCP to learn more.
Behavioral Health Services for Members and Their Families
MassHealth covers a full array of behavioral health services for members of all ages, such as outpatient therapy for individuals and group therapy. There are also behavioral health providers who can help diagnose and support members with gender dysphoria.
As described in greater detail below and in the MNG, MassHealth will cover gender-affirming surgery only if the member seeking such procedure received a diagnosis of gender dysphoria from a licensed qualified behavioral health (BH) provider at least six months before submitting the request for prior authorization (PA) for that surgery. This means that any member seeking gender-affirming surgery will need to start working with a licensed, qualified BH provider at least six months before requesting PA for such treatment. Licensed, qualified BH providers include doctors, such as psychiatrists and other licensed BH providers, like social workers, mental health counselors, family therapists, and psychologists.
MassHealth also covers family and couples therapy, which may help you and your family and caregivers as you navigate the medical, social, and emotional aspects of gender-affirming treatments. Having the support of loved ones can be helpful for promoting overall well-being for transgender and gender-diverse individuals, including children and youth.
In addition, MassHealth covers home- and community-based behavioral health services for members younger than 21 with MassHealth Standard and/or MassHealth CommonHealth, known as Children’s Behavioral Health Initiative (CBHI) services. Certain CBHI services are also available to members younger than 21 with MassHealth Family Assistance. To learn more about these and other behavioral health services available to children and adolescents, and how to access them, you can visit this CBHI Brochures and Companion Guide | Mass.gov.
Consult your health plan handbook, MassHealth Customer Service, or the MassHealth member handbook to learn more about any of these BH services.
Gender-Affirming Surgeries
As described in the GAS MNG, gender-affirming surgery refers to one or more reconstruction procedures that may be part of a multidisciplinary treatment plan involving medical, surgical, and BH interventions available for the treatment of gender dysphoria. GAS may be part of therapeutic treatment to better align physical characteristics to gender identity. MassHealth covers gender-affirming procedures and surgeries on a case-by-case basis when medically necessary for the treatment of gender dysphoria. Examples of such procedures and surgeries include, but are not limited to, those identified in the charts that follow. These charts summarize, at a high level, some, but not all, of the contents of the GAS MNG. Please refer to the GAS MNG for additional requirements. In the event of a conflict between this website, including the charts that follow, and those guidelines, the guidelines take precedence.
If you are enrolled in a managed or integrated care plan, review the Eligibility for Gender-Affirming Care | Mass.gov page for more information on requirements and whom to call with questions.
The following surgeries may be considered medically necessary when all the criteria listed in the GAS MNG are met and documented. All gender-affirming surgeries require PA. The surgeon to perform the procedure must submit the Request for PA for GAS to MassHealth or your managed or integrated care plan (depending on your managed care/integrated care status). Any request for PA for GAS must be accompanied by clinical documentation that supports the medical necessity for the procedure. MassHealth or your health plan will approve the request for PA only if such request demonstrates the medical necessity of the requested procedure.
For more information on the specific criteria that are required for gender-affirming surgeries, please refer to the GAS MNG.
Note: It may be helpful to contact a health care provider or other trusted resource for further guidance or explanation on the technical terms or concepts used in the table.
|
Surgery/Procedure |
General Description of Required Criteria |
|
Chest Reconstruction, including
|
(a) Must have a diagnosis of gender dysphoria from a licensed qualified behavioral health provider. Diagnosis must be present for at least six months. (b) The behavioral health provider referenced in (a) must recommend the specific procedure. (c) Any co-morbid medical or behavioral health conditions must be appropriately managed, reasonably controlled, and not causing symptoms of gender dysphoria. For more details on the requirements for these procedures, visit Section II: Clinical Guidelines under item 1: GAS MNG. |
|
Facial Surgeries For more details on which facial surgeries may be covered, visit Section II. A Clinical Coverage in the GAS MNG. |
Must meet criteria (a)–(c) and
For more details on the requirements for these procedures, visit Section II: Clinical Guidelines under item 5: GAS MNG.
|
|
Breast Augmentation |
Must meet criteria (a)–(d) and
For more details on the requirements for these procedures, visit Section II: Clinical Guidelines under item 3: GAS MNG. |
|
Surgery/Procedure |
General Description of Required Criteria |
|
Genital Surgeries, including, but not limited to
For more details on these and other covered genital surgeries, visit Section II. A Clinical Coverage in the GAS MNG. |
For more details on the requirements for these procedures visit Section II: Clinical Guidelines under item 2: GAS MNG. |
Hair Removal
As described in the Hair Removal MNG, MassHealth covers certain types of hair removal as a treatment for gender dysphoria.
If you are enrolled in a managed or integrated care plan, review the Eligibility for Gender-Affirming Care | Mass.gov page for more information on requirements and whom to call with questions.
The following procedures may be considered medically necessary when all the criteria listed here and in MassHealth’s Guidelines for Medical Necessity Determination for Hair Removal are met and documented. These charts summarize, at a high level, some, but not all, of the contents of the Hair Removal MNG. Please refer to the Hair Removal MNG for additional requirements. In the event of a conflict between the charts that follow and those guidelines, the guidelines take precedence.
For more information about criteria for hair removal, see the MassHealth Guidelines for Medical Necessity for Hair Removal. Hair removal needed for a skin graft site is covered as part of the procedures associated with genital surgery, previously listed.
Note: It may be helpful to contact a health care provider or other trusted resource for further guidance or explanation on the technical terms or concepts used in the table.
|
Procedure |
General Description of Required Criteria |
|
For more details on the requirements for these procedures, visit Section II: Clinical Guidelines: MassHealth Guidelines for Medical Necessity for Hair Removal. |
Speech Therapy
Speech therapy may also be covered as part of a treatment plan for gender dysphoria. Speech therapy is provided by a speech-language pathologist, sometimes called a speech therapist. Before approving coverage of speech therapy, MassHealth requires a prescription from a physician or nurse practitioner, as well as a comprehensive evaluation by the speech-language pathologist, to determine if you could benefit from speech therapy. If you are interested in starting speech therapy, talk with your primary care provider (PCP) to learn more.
MassHealth covers up to 35 visits to a speech-language pathologist within a 12-month period without a PA. Your provider may request approval for additional speech therapy visits after the first 35. MassHealth’s Guidelines for Medical Necessity Determination also detail the requirements for requesting PA for more than 35 speech therapy visits within a 12-month period.
If you are enrolled in a managed or integrated care plan, review the Eligibility for Gender-Affirming Care | Mass.gov page for more information on requirements and whom to call with questions.
For more information about MassHealth’s criteria for speech therapy, visit the MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy | Mass.gov.
Non-Covered Surgeries and Treatments
As explained in MassHealth’s Guidelines for Medical Necessity Determination for Gender Affirming Surgery, MassHealth has determined that certain procedures and surgeries are either not medically necessary or lack sufficient medical evidence to support their use as treatment for gender dysphoria. Examples of such procedures and surgeries include, but are not limited to, the following.
- Chemical peels
- Collagen injections
- Dermabrasion
- Hair transplantation
- Implants: calf, gluteal, or pectoral
- Isolated blepharoplasty (eyelid surgery)
- Lip reduction or enhancement
- Neck lift
- Panniculectomy (removal of hanging skin and fat from the lower abdomen) or abdominoplasty (removal of excess fat and skin and tightening of weakened abdominal muscles)
- Reversal of previous GAS
- Revisions of previous GAS other than for complications (infections or impairment of function)
- Rhytidectomy (face-lift)
- Vocal cord surgery
Prior Authorization for Gender-Affirming Surgeries and Hair Removal
As explained in MassHealth’s Medical Necessity Guidelines for Gender-Affirming Surgery and Hair Removal, MassHealth requires PA for all gender-affirming surgeries and hair removal.
If you are enrolled in a MassHealth managed or integrated care plan, review the Eligibility for Gender-Affirming Care | Mass.gov page for more information on requirements and whom to call with questions.
If you are a provider looking for more information on the PA process, please review the information found in Prior Authorization for MassHealth Providers.
Please note that it is the responsibility of the treating provider to submit any necessary PAs.
For GAS, a PA must be submitted by the surgeon performing the procedure, along with clinical documentation that supports medical necessity. This documentation must include, but is not limited to, the assessment made by the qualified licensed behavioral health professional(s) resulting in a diagnosis of gender dysphoria and the referral(s) for surgery from the qualified licensed health professional(s) performing the procedure(s).
Additional documents must be included with the PA to prove that the medical necessity criteria for the particular surgery being requested have been met. For a full list of these requirements, visit Section III: Submitting Clinical Documentation in the GAS MNG.
For facial and neck hair removal, a PA must be submitted by the provider performing the procedure, along with clinical documentation that supports the medical necessity for the procedure. There are certain documents that must be included with the PA to prove medical necessity. For a full list of these requirements, visit Section III: Submitting Clinical Documentation in the MassHealth Guidelines for Medical Necessity for Hair Removal.
For speech therapy, PA is required for more than 35 treatments within a 12-month period. PA for additional treatments must be submitted by the speech-language pathologist providing treatment, and accompanied by clinical documentation supplied by a licensed physician or licensed nurse practitioner that supports the need for the services being requested. There are certain documents that must be included with the PA to prove medical necessity. For a full list of these requirements, visit Section III: Submitting Clinical Documentation in the MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy.
Nondiscrimination Statement
MassHealth is committed to ensuring that transgender and gender-diverse members have access to all MassHealth-covered benefits without unlawful discrimination. Providers must comply in all respects with 130 CMR 450.202: Nondiscrimination and all other applicable federal and state nondiscrimination laws and regulations. If you feel you have been discriminated against, visit Nondiscrimination Statement | Mass.gov for information on how to file a grievance.
Additionally, MassHealth emphasizes that except as otherwise provided in 130 CMR 450.130: Copayments Required by the MassHealth Agency, providers may not bill a member for any services that are payable under MassHealth. If you believe you have received a bill in error, please contact MassHealth Customer Service.