Washington, DC. - The DC Department of Health Care Finance (DHCF) has updated Policy Number 001-17 to clarify coverage for Gender Reassignment Surgery (GRS). The policy supersedes all previous policies and is effective as of September 1, 2016. It applies to all District of Columbia Medicaid providers and managed care organizations. Gender reassignment surgery is not a covered benefit of the DC Health Care Alliance. 
 
All gender reassignment surgery must meet medical necessity criteria. Prior authorization is required for all gender reassignment surgery and is subject to verification of Medicaid eligibility for both the surgical provider and the patient. 
  
DHCF established its policy for coverage of GRS upon review of scientific evidence, the World Professional Association for Transgender Health (WPATH) standards of care and CMS guidance. Gender reassignment surgery describes a number of surgical treatment options for Gender Dysphoria, also known as Gender Identity Disorder (GID). Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth and the associated gender role and/or primary and secondary sex characteristics.
 
GRS is often not a single procedure, but part of a complex process that may involve multiple medical, psychological, and surgical modalities performed in conjunction with each other to help the candidate achieve successful behavioral and medical outcomes. Before undertaking GRS, candidates must undergo medical and psychological evaluations, and may begin medical therapies and behavioral trials to confirm surgery is the most appropriate treatment choice. 

For additional information or for questions regarding this policy, please contact Ms. Cavella Bishop, Program Manager: Clinician, Pharmacy and Acute Provider Services at (202) 724-8936 or [email protected].