Date: January 8, 2020
To: All Medical Assistance Program Providers
Re: Gender-affirming Services
This notice seeks to inform providers of the Department’s adoption of amendments to 89 Ill. Adm. Code Sections 140.412; 140.413; and 140.440 regarding the provision of gender-affirming services to medical assistance program participants. 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.
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.
· Non-genital gender-affirming surgery requires the submission of one (1) letter from either the participant’s primary care physician or the physician managing the individual’s gender-related healthcare who 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 participant’s primary care physician or the physician managing the individual’s gender-related healthcare who 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. Code Section 140.453(b)(3)(A-D, F), who has assessed the individual and is referring the individual for gender-affirming services including surgery.
Prior Authorization Process
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 download and complete the HFS Gender-affirming Services Prior Authorization Form, found on the HFS website. The Gender-affirming Services Prior Authorization Form adheres to the requirements of the newly adopted administrative rules and seeks to assist providers in streamlining the submission of prior authorization requests. The Gender-affirming Services Prior Authorization Form includes instructions for the completion and submission of the document to HFS for review. Providers must also include supporting documentation such as the practitioner letters, detailed above, and other medical documentation as detailed on the Gender-affirming Services Prior Authorization Form.
The following outlines the prior approval process:
· Providers are responsible for notifying the Department a minimum of 30 calendar days prior to the planned procedure to request prior authorization review. The prior authorization is a requirement for gender affirming surgical procedures.
· Providers (hospitals, physicians, and other members of the treatment team) must coordinate the completion and submission of the Gender-affirming Services Prior Authorization Form to HFS.GAemail@example.com.
· The participant and submitting provider will receive correspondence from the Department detailing approval or denial. Correspondence pertaining to adverse decisions will include details regarding the participant’s right to appeal.
· Providers must receive approval prior to performing the procedure in order to be eligible to receive reimbursement from the Department. Providers will not be reimbursed without an approved principal procedure on file with the Department.
· Approved requests shall be valid for a 180-day period from the date of the Department’s approval letter. If the surgery cannot be completed within the 180-day timeframe; there is a change in provider; or the planned principal procedure code changes, the hospital must submit a new request for prior authorization to the Department.
· In the event that the Department determines a Gender-affirming Services Prior Authorization request is incomplete, providers will be notified of the incomplete status and be provided five business days to forward additional information. If additional information is not received within the five business day window, the Department will deny the incomplete request.
Additionally, if the gender-affirming services being sought will result in therapeutic sterilization of the participant, then the treating provider must adhere to the HFS policies regarding sterilization and the HFS 2189, Sterilization Consent Form, must also be completed by all parties and submitted as an attachment to the Gender-affirming Services Prior Authorization Form.
Failure to submit all required materials, including necessary attachments, may result in a prolonged review process and requests for the submission of additional documentation or denial of the prior authorization request.
Billing of Gender-affirming Services Directly to HFS
Providers seeking reimbursement for general inpatient procedures from HFS for dates of service on or after January 1, 2020, must submit a paper claim. The paper claim submission must include documentation of the gender-affirming prior authorization outcome, noting approval, to the following address:
Illinois Department of Healthcare and Family Services
Bureau of Hospital and Provider Services
201 South Grand Avenue, East
Springfield, IL 62763
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 follow the directions provided by the applicable managed care entity.