Victory! Apple Health (medicaid) Announces Final Trans Health Coverage – furthest state so far!

AppleHealthFAQCover
Gender Justice League is excited to announce our Frequently Asked Questions document on the Washington Apple Health Plan’s Transgender Health Coverage.

The Washington Healthcare Authority announced on Friday July 31st that it has issued it’s final rules for expanding coverage for gender transition related health care. The new rules go further than any other state so far, covering additional medically necessary procedures and providing parity of coverage with other medical and mental health conditions.  The new rules also provide a clear and concise policy for appeals of currently “non-covered services” that may be medically necessary on a case by case basis for individual transgender people.

Gender Justice League extends our thanks and congratulations to our many colleagues in the Coalition for Inclusive Healthcare in this victory – with special thanks to Lisa Brodoff of Seattle Unviersity School of Law (whose lawsuit on behalf of a client initiated this process nearly 6 years ago!), Marsha Botzer of Ingersoll Gender Center, David Ward of Legal Voice, Kris Hermans of Pride Foundation, Jenni Wong of the ACLU of Washington, Monisha Harrell of Equal Rights Washington, Tobi Hill-Mayer of Gender Justice League, Gunner Scott of Pride Foundation, Seth Kirby of Oasis Youth Center, Petra Wilson, the many other Coalition members, as well as the dozens of trans people, advocates, medical and mental health providers, parents, and supporters who provided public testimony to the Healthcare Authority.

“This is an astounding victory that took nearly 5 years to achieve,” said Danni Askini Gender Justice League’s Executive Director “We are so greatful to have been a part of this collaborative advocacy effort and look forward to ensuring a smooth implementation of this new policy.  While we know not all surgical services will be immediately available in Washington State, we are working closely with the Health Care Authority to identify and contract with surgical providers.  This is a huge step forward but we have a great deal of work to do to ensure that all trans and gender non-conforming Washingtonians get the medical and mental health care they need”

The new policy goes into effect August 31st and will cover all medically necessary mental health, medical, and surgical services listed bellow.

Please see our very detailed Frequently Asked Questions document to understand the details of this new and exciting policy.

Additionally you can read the source documentation from the Health Care Authority of Washington (who issues rules on Apple Health) including, The HCAs Answers to Our Testimony, Their Guidance to Physicians, and of course The Final Rule Document.

Bellow are the list of covered services:

Covered Treatments
(if deemed medically necessary for you by Apple Health)

Please note this list is not exhaustive. The following list is a treatments that may be considered medically necessary for some people. It also notes the availability of these treatments in Washington to the best of our knowledge.

Treatment Description or example Is it available in Washington?
Hormone therapy Prescription testosterones, estrogens, progesterone, etc. Yes. You just need a prescription and to go to a pharmacy that takes your health insurance. You will also need to get a diagnosis of gender dysphoria from a licensed mental health provider and a prescription from your primary care doctor or a specialist.
Puberty blockers Suppressants that act as a “pause button” on the body’s release of hormones typically begins at puberty
Hormone blockers Aromatase inhibitors or gonadotropin-releasing hormone (GnRH) analogues used to suppress hormone release (ex. Anti-androgen, androgen blocker)
Mental health treatment Counseling, psychotherapy, substance abuse treatment, family or couples counseling, and crisis intervention treatment. Yes. You just need to find a therapist,
substance abuse treatment center, or crisis intervention center who takes Apple Health. Contact your Managed Care Organization for more details
Preventive screenings Pap tests, prostate exams, mammograms, breast exams Yes. You need to go to a provider who takes Apple Health. Please know they no longer can deny you care that does not correspond with your gender marker in your file.
Laboratory tests Blood tests to assess
hormone levels, electrolytes, cholesterol levels, liver or kidney
function
Yes, as long as your labs are ordered by a doctor who takes your insurance and sends you to a lab that is covered by your insurance.
Hysterectomy; Salpingo-oophorectomy Removal of the uterus,
cervix, fallopian tubes and ovaries
Many doctors are experienced at these surgeries for non-transgender people but may not have treated trans patients. They should be readily available in Washington, however be careful in selecting your surgeon.
Orchiectomy Removal of testicles Yes, there are providers at University of Washington Urology Department who have performed these surgeries. You will want to verify they are taking your Managed Care Organization.
Mastectomy /
Chest Reconstruction
Removal of the chest or breast tissue for transgender men – Chest Reconstruction or top surgery Chest surgery is available in Washington State – we are working to identify surgeons who will take Apple Health. It is important to note that while currently chest surgery for trans people is labeled under mastectomy, it is a different procedure than a standard mastectomy received for breast cancer and should be done by a surgeon that is familiar with chest reconstruction for trans people.
Breast Reconstruction /
Breast Augmentation
Adding a saline or silicone filled medical device to your chest to reconstruct your chest or breasts to be larger. Breast Reconstruction is readily available in Washington State – we are working to identify providers who are willing to take Apple Health. Several surgical providers such as the Poly Clinic, Swedish Medical Center, and University of Washington Medical Center may be good places to inquire about these services as they generally take Apple Health. These providers will have to sign up with Apple Health first as a COE provider.
Laryngoplasty We believe this means vocal chord surgery – or voice modification surgery We are unsure if this service is available in Washington State – please contact Apple Health’s Transgender Health program for more information.
Abdominoplasty Removing excess skin or fat from the abdomen which may be needed for other surgical procedures such as bottom surgery. Abdominoplasty is readily available in Washington State, however – this procedure is likely only covered when done in combination with another medical procedure. You should check with the surgeon you are working with for bottom surgery to find out more.  Some surgeons may want to do the surgery themselves, and having a separate surgeon in Washington do this surgery may not be helpful.
Belpharoplasty Surgical treatment of the eyelid This surgical procedure is available in Washington State and may be medically necessary as a component of facial feminization surgery. Please consult with your primary care doctor, mental health team, and a surgeon to determine medical necessity.
Colpecotmy; Vaginectomy Surgical removal of the vagina This procedure is typically done in conjunction with other bottom surgeries. It may be available in Washington, we are currently unsure. However, if you plan to have other bottom surgeries you should consult the bottom surgeon first before doing this procedure locally.
Urethroplasty/Urethral
reconstruction
Reconstruction and/or
rerouting of the urethra
We aren’t sure when these surgeries will be available in Washington. Right now we do not know of any local doctors who provide these and accept insurance. However, you should contact the Healthcare Authority – covered services should be made available to all patient, Apple Health can coordinate this care.
Phalloplasty Construction or
reconstruction of the penis
Scrotoplasty; Placement of testicular prosthesis The creation of the scrotum; implantation of testicular implants/prosthesis. This procedure is not likely available in Washington State.
Genital electrolysis Electrolysis done in preparation for Vaginoplasty. Most surgeons require patients to undergo genital electrolysis prior to vaginoplasty. This is considered a medically necessary service when done in conjunction with preparation for vaginoplasty – it is important to note that this must be done in a physician’s office to be covered by Apple Health.  This procedure is available in Washington State.
Vaginoplasty, Penectomy, Cliteroplasty, Colovaginoplasty, Labiaplasty ,Genital surgery. Construction or
reconstruction of the vagina, removal of the penis, creation of the labia, and creation of the clitoris.
We aren’t sure when these surgeries will be available in Washington. Right now we do not know of any local doctors who provide these and accept insurance. However, you should contact Apple Health who is working to identify a contract surgeon out of state.

 

Non-covered Treatments
(only considered on a case-by-case basis under Exception To The Rule)

Please note this list is not exhaustive. The following list is a treatments that may be considered medically necessary for some people but only on a case by case basis through the “Exception to the Rule process”  Please read our FAQ for more information on this process.  Please remember: these are not generally covered – and you must first BE DENIED these services, and then file an appeal including the documentation outlined in the FAQ justifying the medical necessity of these procedures. It also notes the availability of these treatments in Washington to the best of our knowledge.

Treatment Description or example Is it available in Washington?
Brow lift A surgical procedure to shorten the length of the forehead / brow. Yes
Calf implants Prosthetic implants to increase the size/definition of the calf muscle. Possibly, we are unsure.
Cheek/Mylar implants A surgical procedure to place a prosthetic that  increases the size or prominence of the cheeks. Yes.
Chin/nose implants A surgical procedure to place a prosthetic that  increases the size or prominence of the chin or nose. Yes.
Collagen injections Injections of the face to increase prominence or feminize the face. Yes.
Drugs for hair loss or growth Drugs that are specifically used for hair growth. Yes, despite this – we believe that these medications may be covered under testosterone suppression/hormone blockade. Check with your primary care provider.
Facial or trunk electrolysis Removal of body or facial hair by electrolysis. Yes, this is widely available in Washington.
Facial feminization Surgical procedures to feminize the face Yes, there are several Washington plastic surgeons who perform surgeries to feminize the face
Face lift A surgical procedure to ”rejuvenate” the face or reduce the appearance of age Yes, this is widely available in Washington.
Forehead lift A reduction of the forehead to shorten it and bring the hairline downward. Yes, we believe this is available in Washington State.
Hair transplantation Transfer of hair follicles from one part of the scalp to another part. Yes, this is widely available.
Jaw shortening A procedure to shorten the length of the jaw. Yes, there are Maxilliofacial surgeons in Washington performing this procedure.
Lip reduction A surgical procedure to reduce the size or prominence of the lips or reduce the size the surrounding skin. Yes, this procedure is available.
Liposuction The surgical removal of fat by a suction assisted device. This is widely available in Washington
Mastopexy; Also called a ”breast lift” this procedure raises the areola and breast tissue on the chest. Yes, this procedure is widely available in Washington
Neck tightening A surgical procedure to tighten the skin of the neck. Yes, this is available in Washington.
Pectoral implants; The implantation of devices intended to increase the prominence of the pectorals muscles. This procedure is available in Washington
Reduction thyroid chondroplasty; Trachea shave Surgical procedures to reduce the prominence of the Adams Apple / Trachea protrusion. Yes, this procedure is available in Washington
Removal of redundant skin Surgical procedures to reduce excess skin. These surgeries may be available in Washington.
Suction-assisted lipoplasty of the waist A form of Liposuction of the waste Yes, this is available in Washington
Voice modification surgery; Voice Therapy Surgical procedures to change the pitch, tone, or resonance of the voice. We are unsure, these surgeries may be available. Note: Larygoplasty is a covered service – we are currently unclear about this contradiction.

“The agency evaluates a request for any non-covered service listed in (e) of this subsection as an exception to rule under the provisions of WAC 182-501-0160. The justification included in the surgical plan for any of the procedures listed in (e) of this subsection may be recognized by the agency as meeting the documentation requirements of WAC 182-501-0160”