gender reassignment policy

The independent source for health policy research, polling, and news.

Youth Access to Gender Affirming Care: The Federal and State Policy Landscape

Lindsey Dawson , Jennifer Kates , and MaryBeth Musumeci Published: Jun 01, 2022

This analysis reflects the policy environment as of June 2020. Our newer tracker , provides a regularly updated overview of state policy restrictions on youth access to gender affirming care.

Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.

What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?

Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.

• Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14 th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14 th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11 th Circuit.
• Arkansas . In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14 th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14 th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1 st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ  argued that the Arkansas law  violates the Equal Protection Clause of the 14 th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8 th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal. 1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs. 2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
• Texas . In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation , a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
• Arizona . In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.

In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:

• criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
• penalize parents aiding in youth accessing gender-affirming care
• permit individuals to file for damages against providers who violate such laws
• limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services

Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.

What states have introduced protections related to sexual orientation and gender identity in health care?

Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:

• prohibitions on health insurance discrimination based on sexual orientation and/or
• requirements that state Medicaid programs explicitly cover health services related to gender transition

What is federal policy regarding gender-affirming services?

The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:

• On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
• On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the  Bostock  ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.

In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:

• Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
• Statement from Dept. of Health and Human Services (HHS) Sec. Becerra : Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
• Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
• Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
• The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
• It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.

OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.

What do major medical societies say about gender affirming services?

Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association , American Academy of Pediatrics , the Endocrine Society , American Psychological Association , American Psychiatric Association , and the World Professional Association for Transgender Health , among others , which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.

Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines , as does the World Professional Association for Transgender Health’s standards of care . Together these guidelines form the standard of care for treatment of gender dysphoria.

What are the implications of access restrictions?

State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:

LGBTQ+ youth : LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy , has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.

In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.

Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.

Parents : In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.

Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.

Teachers and others : In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.

Looking forward

The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.

These states include Alabama, Alaska, Arizona, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Tennessee, Texas, Utah, and West Virginia.

← Return to text

These states include California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, and Washington.

Also of Interest

• LGBT+ People’s Health and Experiences Accessing Care
• The Health System Appears To Be Selling LGBT+ People Short
• The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health

Mobile Menu Overlay

The White House 1600 Pennsylvania Ave NW Washington, DC 20500

FACT SHEET: Biden- ⁠ Harris Administration Advances Equality and Visibility for Transgender Americans

Today, the Biden-Harris Administration recognizes Transgender Day of Visibility, an annual celebration of the resilience, achievements, and joy of transgender people in the United States and around the world. Every American deserves the freedom to be themselves. But far too many transgender Americans still face systemic barriers, discrimination, and acts of violence. Today, the Administration once again condemns the proliferation of dangerous anti-transgender legislative attacks that have been introduced and passed in state legislatures around the country. The evidence is clear that these types of bills stigmatize and worsen the well-being and mental health of transgender kids, and they put loving and supportive families across the country at risk of discrimination and harassment. As the President has said, these bills are government overreach at its worst, they are un-American, and they must stop. Transgender people are some of the bravest people in our nation. But nobody should have to be brave just to be themselves. Today, the Biden Administration announced new actions to support the mental health of transgender children, remove barriers that transgender people face accessing critical government services, and improve the visibility of transgender people in our nation’s data.

Reinforcing federal protections for transgender kids. The Justice Department announced today that it has issued a letter to all state attorneys general reminding them of federal constitutional and statutory provisions that protect transgender youth against discrimination, including when those youth seek gender-affirming care. Advancing dignity, respect, and self-determination for transgender people by improving the traveler experience. For far too long, transgender, non-binary, and gender non-conforming Americans have faced significant barriers to travelling safely and many have not had their gender identity respected as they travel within the United States and around the world. To create a safer and more dignified travel experience, the Biden Administration is announcing the following changes.

• The Department of State is announcing that beginning on April 11, 2022, all U.S. citizens will be able select an “X” as their gender marker on their U.S. passport application. This is a major step in delivering on the President’s commitment to expand access to accurate identification documents for transgender and non-binary Americans. Information on how to apply will be available at travel.state.gov/gender .
• Implementing enhanced screening technology. The Transportation Security Administration (TSA) will soon begin updating its Advanced Imaging Technology (AIT) body scanners with new technology that will increase security and efficiency by reducing false alarm rates and pat-downs for the traveling public. By replacing the current, gender-based system with this more accurate technology, TSA will improve the customer experience of transgender travelers who have previously been required to undergo additional screening due to alarms in sensitive areas.  This new technology will help to improve the experience of travelers, particularly those who are transgender and non-binary travelers. TSA will begin deploying this new technology in airports throughout the country later this year.
• Expanding airline partnerships to enhance the overall travel experience.  TSA is working closely with air carriers across the nation to promote the use and acceptance of the “X” gender marker to ensure more efficient and accurate passenger processing. As of March 31st, two major domestic air carriers already offer a third gender marker option in their travel-reservation systems, with a third air carrier planning to offer this option in the Fall of 2022.
• Streamlining identity validation. TSA has updated its Standard Operating Procedures to remove gender considerations when validating a traveler’s identification at airport security checkpoints. This ensures that TSOs can accurately and efficiently validate each traveler’s identity while avoiding unnecessary delays.
• Updating TSA PreCheck and CBP Trusted Traveler Programs enrollment to include “X” gender markers. The Department of Homeland Security is beginning the process of adding “X” gender markers options in Trusted Traveler programs and the TSA PreCheck program to enhance access for transgender, non-binary, and gender non-conforming travelers to these programs.

Providing resources for transgender kids and their families. Transgender children are put at higher risk of attempted suicide or mental health challenges when they face bullying, rejection, or denial of health care. The Biden Administration is releasing several new resources to help transgender children and their parents thrive:

• Providing mental health resources for transgender youth.  In recent months, multiple states have removed critical information about mental health resources for LGBTQI+ youth from official state websites. Transgender youth often face significant barriers in accessing supportive resources, and are at greater risk of attempted suicide. In response, the Department of Health and Human Services released a new website that offers resources for transgender and LGBTQI+ youth, their parents, and providers. These resources include best practices for affirming an LGBTQI+ child, and information about suicide prevention services.
• Expanding trainings to support transgender and nonbinary students in schools. The Office of Safe and Supportive Schools in the Department of Education will offer new training for schools with experts and school leaders who will discuss the challenges faced by many transgender and nonbinary students and strategies and actions for providing support.
• Confirming the positive impact of gender affirming care on youth mental health. The Substance Abuse and Mental Health Services Administration (SAMHSA) has posted LGBTQI+ Youth – Like All Americans, They Deserve Evidence-Based Care , in which Miriam Delphin-Rittmon, Ph.D., HHS Assistant Secretary for Mental Health and Substance Use and the leader of SAMHSA, shares how to engage LGBTQI+ youth, the evidence behind the positive effects of gender affirming care, and available resources for LGBTQI+ youth, their families, providers, community organizations, and government agencies.
• Confirming that gender-affirming care is trauma-informed care. The National Child Traumatic Stress Network (NCTSN), which is administered by the Substance Abuse and Mental Health Services Administration, is releasing new information for providers confirming that providing gender-affirming care is neither child maltreatment nor malpractice.
• Providing resources on the importance of gender affirming care for children and adolescents. The Office of the Assistant Secretary for Health has developed a resource to inform parents and guardians, educators, and other persons supporting children and adolescents with information on what is gender-affirming care and why it is important to transgender, nonbinary, and other gender expansive young people’s well-being.

Improving access to federal services and benefits for transgender Americans.  With support and coordination from the U.S. Digital Service, federal agencies are removing barriers to access government services by improving the customer experience of transgender, non-binary, and gender non-conforming Americans:

• Accessing retirement savings. The Social Security Administration is announcing that it is removing the requirement that transgender people show proof of identity such as doctor’s notes in order to update their gender information in their social security record by the fall of 2022. This will significantly improve transgender individuals’ experience in accessing their retirement benefits, obtaining health care, and applying for jobs.
• Filing an employment discrimination complaint . The U.S. Equal Employment Opportunity Commission (EEOC) is announcing that it will promote greater equity and inclusion for members of the transgender community by giving individuals the option to select an “X” gender marker during the voluntary self-identification questions that are part of the intake process for filing a charge of discrimination.
• Applying for federal student aid. The Department of Education plans to propose next month that the 2023-24 FAFSA (Free Application for Federal Student Aid) will include an opportunity for applicants to indicate their gender identity as well as their race/ethnicity when applying for federal financial aid. The questions, which will be posted for public comment, will be in a survey that accompanies the application. This privacy-protected information would help to inform the Department about possible barriers students, including transgender and nonbinary students, face in the financial aid process.
• Visiting the White House.  The White House Office of Management and Administration is announcing that it is beginning the process of implementing updates that will improve the White House campus entry process for transgender, gender non-conforming, and non-binary visitors by adding an “X” gender marker option to the White House Worker and Visitor Entry System (WAVES) system. This change will ensure that transgender, non-binary, and gender nonconforming people can visit the People’s House in a manner that respects and affirms their gender identity.

Advancing inclusion and visibility in federal data. In too many critical federal surveys and data systems, transgender, non-binary, and gender non-conforming people are not fully reflected. To improve visibility for transgender Americans, agencies are announcing new actions to expand the collection and use of sexual orientation and gender identity (SOGI) data.

• The White House announced that the President’s proposed Fiscal Year 23 budget includes $10 million in funding for additional critical research on how to best add questions about sexual orientation and gender identity to the Census Bureau’s American Community Survey, one of our nation’s largest and most important surveys of American households. This data collection will help the federal government better serve the LGBTQI+ community by providing valuable information on their jobs, educational attainment, home ownership, and more.
• The Department of Health and Human Services has released the findings of the federal government’s first-ever user research testing conducted with transgender Americans on how they want to see themselves reflected on Federal IDs. This groundbreaking user research by the Collaborating Center for Question Design and Evaluation Research (CCQDER) at the National Center for Health Statistics (NCHS) directly informed the State Department’s adopted definition of the “X” gender marker.
• The Department of Health and Human Services  has released a comprehensive new consensus study on Measuring Sex, Gender Identity, and Sexual Orientation. This work, commissioned by the National Institutes of Health and carried out by the National Academies of Sciences, Engineering, and Medicine, will inform additional data collections and future research in how to best serve LGBTQI+ Americans.

These announcements build on the Biden-Harris Administration’s historic work to advance equality for transgender Americans since taking office, including: Combatting legislative attacks on transgender kids at the state level.

• Condemning anti-transgender bills. The President has consistently made clear that legislative attacks against transgender youth are un-American, and are bullying disguised as legislation. In his March, 2022 State of the Union Address, the President said, “The onslaught of state laws targeting transgender Americans and their families is wrong. As I said last year, especially to our younger transgender Americans, I will always have your back as your President, so you can be yourself and reach your God-given potential.” The White House has also hosted listening sessions with transgender youth and advocates in states across the country that are impacted by anti-transgender legislative attacks.
• Reaffirming that transgender children have the right to access gender-affirming health care. In March, following state actions that aim to target parents and doctors who provide gender-affirming care to transgender children with child abuse investigations, the Department of Health and Human Services took multiple actions to support transgender children in receiving the care they need and promised to use every tool available to protect LGTBQI+ children and support their families.
• Department of Justice statements of interest and amicus briefs. The Department of Justice’s Civil Rights Division has filed Statements of Interest and amicus briefs in several matters to protect the constitutional rights of transgender individuals, including in Brandt v. Rutledge , a lawsuit challenging legislation restricting access to gender-affirming care for transgender youth; B.P.J. v. West Virginia State Board of Education , a lawsuit challenging legislation restricting participation of transgender students in school sports; Corbitt v. Taylor , a lawsuit challenging legislation restricting the ability to change gender markers on state driver’s licenses; and Adams v. School Board of St. John’s County , which involves the right of a transgender boy to use the boys’ restroom at his school.

Advancing civil rights protections for transgender Americans

• Fighting for passage of the Equality Act.  President Biden  continues to call  on the Senate to pass the Equality Act, legislation which will provide long overdue federal civil rights protections to transgender and LGBTQI+ Americans and their families. As the White House has  said , passing the Equality Act is key to addressing the epidemic levels of violence and discrimination that transgender people face. The Administration’s first Statement of Administration Policy was in support of the Equality Act, and the White House has convened national leaders to discuss the importance of the legislation.
• Signing one of the most comprehensive Executive Orders on LGBTQI+ rights in history.  Within hours of taking office, President Biden signed an  Executive Order  which established that it is the official policy of the Biden-Harris Administration to prevent and combat discrimination against LGBTQI+ individuals, and to fully enforce civil rights laws to prevent discrimination on the basis of gender identity or sexual orientation. This Executive Order is one of the most consequential policies for LGBTQI+ Americans ever signed by a U.S. President. As a result of that Order, the Departments of Health and Human Services , Housing and Urban Development , Education , Consumer Financial Protection Bureau , and Justice have announced that they are expanding non-discrimination protections for transgender people in health care, housing, education, credit and lending services, and community safety programs.

Supporting transgender service members and veterans

• Reversing the discriminatory ban on transgender servicemembers.  In his first week in office, President Biden  signed  an Executive Order reversing the ban on openly transgender servicemembers serving in the Armed Forces, enabling all qualified Americans to serve their country in uniform. President Biden believes that an inclusive military strengthens our national security As a result of his Executive Order, the Department of Defense issued new  policies  which prohibit discrimination against transgender servicemembers, provide a path for transgender servicemembers to access gender-affirming medical care, and require that all transgender servicemembers are treated with dignity and respect.
• Supporting transgender veterans. To ensure that transgender veterans are treated with dignity and respect, the Department of Veterans Affairs (VA) launched an  agency-wide review  of its policies and practices to ensure that transgender veterans and employees do not face discrimination on the basis of gender identity or expression. In June, VA also announced that it is beginning the regulatory process to remove restrictions that prevent transgender veterans from accessing the gender-affirming care they need and deserve.

Responding to the crisis of anti-transgender violence and advancing safety

• Establishing a White House-led interagency working group on anti-transgender violence. To address the crisis of anti-transgender stigma and violence, during Pride Month in 2021 the White House established the first Interagency Working Group on Safety, Opportunity, and Inclusion for Transgender and Gender Diverse Individuals. The Working Group is co-led by the White House Domestic Policy Council and Gender Policy Council. To inform the priorities of the Working Group, throughout the fall of 2021 the White House convened 15 historic listening sessions with transgender and gender diverse people, advocates, and civil rights leaders from across the country and around the world, including a White House roundtable with transgender women of color .
• Releasing a White House report uplifting the voices of transgender people on gender-based violence and discrimination. On Transgender Day of Remembrance, the White House released a  report  sharing the perspectives from White House listening sessions, uplifting the voices and advocacy of transgender people throughout the country, and highlighting over 45 key, early actions the Biden-Harris Administration is taking to address the root causes of anti-transgender violence, discrimination, and denial of economic opportunity.
• Department of Justice civil rights enforcement actions. On September 14, 2021, the Department of Justice announced that it was launching a statewide civil investigation into Georgia’s prisons, which includes a focus on sexual abuse of transgender prisoners by other prisoners and staff. The Department of Justice’s Civil Rights Division and U.S. Attorney’s Office for the District of Puerto Rico also obtained a federal indictment charging three men with hate crimes for assaulting a transgender woman because of her gender identity.
• Ensuring non-discrimination protections in community safety programs. The Department of Justice issued a Memorandum from the Assistant Attorney General for Civil Rights regarding the application of Bostock v. Clayton County to the nondiscrimination provisions of the Safe Streets Act, the Juvenile Justice and Delinquency Prevention Act, the Victims of Crime Act, and the Violence Against Women Act to strengthen non-discrimination protections for transgender and LGBTQI+ individuals in key community safety programs.
• Strengthening protections for transgender individuals who are incarcerated. In January 2022 the Bureau of Prisons revised its manual on serving transgender offenders , improving access to gender-affirming care and access to facility placements that align with an inmate’s gender identity.
• Honoring those lost to violence.  The White House and the Second Gentleman of the United States hosted a first of its kind vigil in the Diplomatic Room of the White House to honor the lives of transgender and gender diverse people killed in 2021, and the countless transgender and gender diverse people who face brutal violence, harassment, and discrimination in the United States and around the world. The President also released a statement honoring the transgender people who lost their lives to violence.
• Advancing safety and justice for transgender and Two-Spirit Indigenous people. LGBTQI+ Native Americans and people who identify as transgender or “Two-Spirit” are often the targets of violent crimes. On November 15, 2021, President Biden signed an Executive Order on Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People. The Executive Order directs federal agencies to work hand in hand with Tribal Nations and Tribal partners to build safe and healthy Tribal communities to address the crisis of Missing and Murdered Indigenous People, including LGBTQI+ and “Two-Spirit” Native Americans.

Advancing health equity and expanding access to gender-affirming health care to support transgender patients

• Protecting transgender patients from health care discrimination. The Department of Health and Human Services (HHS) announced that it would interpret and enforce section 1557 of the Affordable Care Act’s prohibition on discrimination on the basis of sex in certain health programs to prohibit discrimination on the basis of gender identity and sexual orientation.
• Advancing gender-affirming care as an essential health benefit.  In 2021, the Centers for Medicare and Medicaid Services (CMS) approved the first ever application from a state to add additional gender-affirming care benefits to a state’s essential health benefit benchmark plan.
• Advancing health equity research on gender-affirming care.  The National Institutes of Health (NIH) announced that it will increase funding for research on gender-affirming procedures to further develop the evidence base for improved standards of care. Research priorities include a more thorough investigation and characterization of the short- and long-term outcomes on physical and mental health associated with gender-affirming care.
• Ending the HIV crisis among transgender and gender diverse communities.  In December, 2021, in recognition of World AIDS Day, the White House Office of National AIDS Policy released a revised National HIV/AIDS Strategy which now identifies transgender and gender diverse communities as a priority population in the federal government’s strategy to end the HIV epidemic.
• Advancing access to gender-affirming care through Ryan White HIV/AIDS Program. The Health Resources and Services Administration announced that it has released a letter encouraging Ryan White HIV/AIDS Program service providers to provide access to gender affirming care and treatment services to transgender and gender diverse individuals with HIV. The letter reaffirms the importance of providing culturally-affirming health care and social services as a key component to improving the lives of transgender people with HIV.
• Ensuring transgender patients can access birth control. In 2021 HHS issued a final rule to strengthen the Title X family planning program, fulfilling the Biden-Harris Administration’s commitment to restore access to equitable, affordable, client-centered, quality family planning services. The rule requires family planning projects to provide inclusive care to LGBTQI+ persons. Additionally, the rule prohibits discrimination against any client based on sex, sexual orientation, gender identity, sex characteristics, or marital status.

Supporting transgender students and their families

• Ensuring educational environments are free from sex discrimination and protecting LGBTQI+ students from sexual harassment.  President Biden signed an  Executive Order  recommitting the Federal Government to guarantee educational environments free from sex discrimination, including discrimination on the basis of sexual orientation or gender identity. The Executive Order charged the Department of Education with reviewing the significant rates at which students who identify as LGBTQ+ are subject to sexual harassment, including sexual violence. The Department of Education has announced that it intends to propose amendments to its Title IX regulations this year.
• Protecting the rights of transgender and gender diverse students. The Department of Education has affirmed that federal civil rights laws protect all students, including transgender and other LGBTQI+ students, from discrimination. The Department published a notice in the Federal Register announcing that it interprets Title IX’s statutory prohibition on sex discrimination as encompassing discrimination based on sexual orientation and gender identity.
• Department of Justice memorandum on Title IX. The Department of Justice issued a memorandum regarding the application of Bostock to Title IX.
• Speaking directly to transgender students. The Department of Justice, Department of Education, and Department of Health and Human Services issued a joint back to school message for transgender youth.
• Outreach and education to transgender and gender diverse students and their families. The Department of Education has published fact sheets and other resources showing the federal government’s support for transgender students, highlighting the ways schools can support students, reminding schools of their duty to investigate and address harassment based on sexual orientation or gender identity, and informing students how they can assert their rights and file complaints.
• Advancing research to address the harms of so-called conversion therapy.  The Substance Abuse and Mental Health Services Administration (SAMHSA) announced that it will update its 2015 publication  Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth  to reflect the latest research and state of the field. 

Promoting fair housing and ending homelessness for transgender Americans

• Advancing fair housing protections on the basis of gender identity. In February 2021 the Department of Housing and Urban Development (HUD) announced that it would administer and enforce the Fair Housing Act to prohibit discrimination on the basis of gender identity and sexual orientation.
• Ensuring safety and access to services for transgender people experiencing homelessness. In April, HUD withdrew the previous administration’s proposed “Shelter Rule,” which would have allowed for federally funded discrimination against transgender people who seek shelter housing. By withdrawing the previous administration’s proposed rule, the agency has restored protections for transgender people to access shelter in line with their gender identity. HUD has also released new tools for recipients to ensure compliance with these requirements in shelters and other facility settings.

Advancing economic opportunity and protections for transgender workers

• Ensuring nondiscrimination protections for transgender and gender diverse workers. In November 2021, the Department of Labor’s Office of Federal Contract Compliance Programs proposed to rescind the agency’s 2020 rule “Implementing Legal Requirements Regarding the Equal Opportunity Clause’s Religious Exemption,” an important step toward protecting workers from discrimination while safeguarding principles of religious freedom.
• Ensuring equal access to the workforce development system. The Department of Labor is enforcing discrimination prohibitions in workforce development programs funded by the Workforce Innovation and Opportunity Act, protecting workers from discrimination based on their gender identity or transgender status.

Advancing gender equity and transgender equality at home and around the world

• Advancing transgender equality in U.S. foreign policy and foreign assistance. In line with the Presidential Memorandum on Advancing the Human Rights of LGBTQI+ Persons Around the World , the United States is making significant investments to uphold dignity, equality and respect for transgender persons globally.  For example, USAID supports the Global Barometer for Transgender Rights and the LGBT Global Acceptance Index which track progress and setbacks to protecting transgender lives around the world.  The Department of Health and Human Services through the United States President’s Emergency Plan for AIDS Relief supports inclusive health care services for transgender individuals, enabling health clinics to provide care to the transgender community. And through the Department of State’s Global Equality Fund , local transgender rights organizations receive support to document human rights violations and provide critical legal assistance to community members.  
• Establishing the White House Gender Policy Council to Advance Gender Equity and Equality.  President Biden signed an  Executive Order  establishing the White House Gender Policy Council to advance gender equity and equality across the whole of the government, including by addressing barriers faced by LGBTQ+ people, in particular transgender women and girls, across our country.  

Supporting transgender leaders and public servants

• Making the Federal government a model employer for transgender public servants. President Biden signed an  Executive Order  which takes historic new steps to ensure the Federal government is a model employer for all employees – including transgender, gender non-conforming, and non-binary employees. The Executive Order charges agencies with building inclusive cultures for transgender employees by: expanding the availability of gender-neutral facilities in Federal buildings; ensuring that employee services support transgender employees who wish to legally, medically or socially transition; advancing the use of non-binary gender markers and pronouns in Federal employment processes; and expanding access to gender-affirming care and inclusive health benefits.
• Appointing historic transgender leaders. The Biden-Harris Administration includes barrier-breaking LGBTQI+ leaders, including Assistant Secretary for Health Dr. Rachel Levine, who is the first openly transgender person ever confirmed by the U.S. Senate. In October, she was also named a four-star admiral in the U.S. Public Health Service Commissioned Corps, becoming the first openly transgender person to hold that rank in any of the country’s uniformed services. Over 14 percent of Biden-Harris Administration appointees identify as LGBTQI+.

Advancing visibility for transgender Americans

• Issuing the First White House Proclamation for Transgender Day of Visibility.  On March 31, 2021 President Biden became the first U.S. President to issue a  proclamation  commemorating Transgender Day of Visibility.  
• Hosting a White House Virtual Convening on Transgender Equality.  In June, White House Press Secretary Jen Psaki hosted a first-of-its-kind  national conversation  on equality for transgender, gender non-conforming, and non-binary Americans.
• Releasing a toolkit on equality and inclusion for transgender Americans.  The White House released a new  toolkit  with best practices for advancing inclusion, opportunity, and safety for transgender Americans.
• Establishing a National Pulse Memorial. On June 25, 2021, President Biden signed H.R. 49 into law to designate the National Pulse Memorial. As the President acknowledged in his statement on the fifth anniversary of the Pulse nightclub shooting, we must acknowledge gun violence’s particular impact on LGBTQ+ communities across our nation, and we must drive out hate and inequities that contribute to the epidemic of violence and murder against transgender women – especially transgender women of color. As the President has said, Pulse Nightclub is hallowed ground.

Stay Connected

We'll be in touch with the latest information on how President Biden and his administration are working for the American people, as well as ways you can get involved and help our country build back better.

Opt in to send and receive text messages from President Biden.

Disclaimer » Advertising

• HealthyChildren.org
• Facebook Icon
• Twitter Icon
• LinkedIn Icon

AAP reaffirms gender-affirming care policy, authorizes systematic review of evidence to guide update

The AAP Board of Directors voted to reaffirm the 2018 AAP policy statement on gender-affirming care and authorized development of an expanded set of guidance for pediatricians based on a systematic review of the evidence.

An updated policy statement, plus companion clinical and technical reports, will reflect data and research on gender-affirming care since the original policy was released and offer updated guidance. The board recognized  the value of additional detail with five more years of experience since the 2018 policy statement was issued.

The decision to authorize a systematic review reflects the board’s concerns about restrictions to access to health care with bans on gender-affirming care in more than 20 states.

AAP CEO/Executive Vice President Mark Del Monte, J.D., is speaking today at the AAP Leadership Conference in Itasca, Ill.

He emphasizes that policy authors and AAP leadership are confident the principles presented in the original policy, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents , remain in the best interest of children.

As part of its mission, the AAP will continue to “ensure young people get the reproductive and gender-affirming care they need and are seen, heard and valued as they are,” Del Monte said.

The board reviews evidence and considers policy renewal on a regular schedule as authorizations expire. Based on the continuing review, the board reaffirmed the current guidance on transgender care until there is an updated version.

To ensure the policy update process is transparent and inclusive, the AAP will invite members and other stakeholders to share input.

The AAP and other major medical organizations — including the American Medical Association, the American College of Obstetricians and Gynecologists and the World Health Organization — support giving transgender adolescents access to the health care they need.

The AAP opposes any laws or regulations that discriminate against transgender and gender-diverse individuals, or that interfere in the doctor-patient relationship. Additional Leadership Conference coverage

• Leadership Conference: AAP pledges to address payment issues, support pediatrician wellness
• Leadership Conference: Top resolution calls for federal protections of gender-affirming care for patients, doctors
• Reform humanitarian system for migrant children: Leadership Conference speaker

Copyright © 2023 American Academy of Pediatrics

Advertising Disclaimer »

Email alerts

1. FDA approves new antibiotic for children, adults with community-acquired bacterial pneumonia

2. New resources available as measles cases continue to rise

3. Child-centered care needed at U.S. border facilities, AAP leaders say

April issue digital edition

Subscribe to AAP News

Column collections

Topic collections

Affiliations

Advertising.

• Submit a story
• American Academy of Pediatrics
• Online ISSN 1556-3332
• Print ISSN 1073-0397
• Pediatrics Open Science
• Hospital Pediatrics
• Pediatrics in Review
• AAP Grand Rounds
• Latest News
• Pediatric Care Online
• Red Book Online
• Pediatric Patient Education
• AAP Toolkits
• AAP Pediatric Coding Newsletter

First 1,000 Days Knowledge Center

Institutions/librarians, group practices, licensing/permissions, integrations.

• Privacy Statement | Accessibility Statement | Terms of Use | Support Center | Contact Us
• © Copyright American Academy of Pediatrics

This Feature Is Available To Subscribers Only

Sign In or Create an Account

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Am J Public Health
• v.104(3); Mar 2014

The State of Transgender Health Care: Policy, Law, and Medical Frameworks

I review the current status of transgender people’s access to health care in the United States and analyze federal policies regarding health care services for transgender people and the limitations thereof. I suggest a preliminary outline to enhance health care services and recommend the formulation of explicit federal policies regarding the provision of health care services to transgender people in accordance with recently issued medical care guidelines, allocation of research funding, education of health care workers, and implementation of existing nondiscrimination policies. Current policies denying medical coverage for sex reassignment surgery contradict standards of medical care and must be amended.

The term transgender is an adjective that has been widely adopted to describe people whose gender identity, gender expression, or behavior does not conform to what is socioculturally accepted as, and typically associated with, the legal and medical sex to which they were assigned at birth. 1 Gender nonconformity, or a desire to express gender in ways that differ from gender-cultural norms linked to sex assigned at birth, was until very recently considered a mental pathology by the psychiatric community. 2 Although recognition and classification of gender nonconformity appeared in Western medicine in the 1920s, gender identity disorder (GID) first appeared as a distinct diagnosis in the American Psychiatric Association’s (APA’s) third edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM ) in 1980 2 and remained a category until the newest edition of the DSM (the DSM-5 ). 3 Over the past few decades, after professional as well as public debates, the APA has moved toward differentiating gender nonconformity from mental illness. On December 1, 2012, the board of the APA approved changing the diagnosis of GID to that of gender dysphoria in the DSM-5, 3 a significant move toward depathologizing gender variance. Psychiatrists increasingly agree that being transgender is not an illness to be cured or overcome (nor, for that matter, a state that can be altered). However, those who suffer because of the misalignment of their physical characteristics with their gender identity may benefit from treatment. 4

Current estimates have suggested that 0.3% of US adults, or close to 1 million people, identify as transgender. 5 (Other estimates have varied widely from a high prevalence of 1:500 or more 6 to 1:11 900–1:45 000 for male-to-female individuals and 1:30 400–1:200 000 for female-to-male individuals. 7–10 ) Demographic studies to date have been limited 7 because national surveys have not included questions recognizing gender identity. Furthermore, important methodological debates remain unresolved, including those about conflation of terms (e.g., differentiation among gender, gender identity, and sex ) and appropriate ways to accurately describe the transgender population (e.g., according to self-identification, gender expression, gender identity, or wish for medical treatment). 8 One way of estimating the proportion of transgender people in the population is through data on medical care, specifically medical assistance in the process of adapting gender presentation to align with identity, a process known as transitioning. However, this approach does not identify transgender people who have not opted for or who have faced insurmountable obstacles in accessing such care. Even using the conservative estimate of 0.3%, the number of people living in the United States who identify as transgender is nearly 1 million. Health care for this population has historically been, and continues to be, overlooked by governmental, health care, and academic establishments.

Transgender people have a unique set of mental and physical health needs. These needs are compounded by prejudices against transgender people within both the medical system and society at large. These prejudices create barriers to accessing timely, culturally competent, medically appropriate, and respectful care. 9,11,12 These societal and medical barriers are associated with increased risk of violence, suicide, and sexually transmitted infections. 11 Additionally, transgender people may have health needs related to gender transition, including hormonal therapy and surgery, that can create an undesired and unavoidable dependency on the medical system for basic identity expression. This combination of high medical needs and barriers to accessing appropriate care may give rise to a self-perpetuating cycle of risk exposure, stigmatization, prejudice, and eventually poor health outcomes.

Transition-related medical care, otherwise referred to as gender-confirming therapy , is designed to assist an individual with the adjustment of primary and secondary sexual characteristics to align with gender identity. 9,13 Such therapy may include hormonal therapy, surgical therapy, or both depending on individual needs and wishes, as well as ability to access such services. Procedures for gender confirmation may include breast or chest surgery, hysterectomy, genital reconstruction, facial hair removal, and plastic reconstruction, as appropriate to the particular person. 14

Denial of, or severely limited access to, medical care for transgender people, whether explicitly by refusal of coverage or implicitly by prejudice and lack of knowledge among health care workers, may have detrimental effects on both short- and longer term health and well-being of transgender people. Moreover, the failure to comprehensively address the medical needs of transgender people stands in contradiction to the medical profession’s prized values of equity and respect. 15 As such, I argue that a new approach is urgently needed: one that not only recognizes the unique health care needs of this group of people, but does so in an ethical, principled, and timely manner.

TRENDS IN DATA COLLECTION

Over the past few decades, a growing body of research has been published regarding lesbian, gay, bisexual, and transgender (LGBT) health. 16,17 However, most of the literature and published data have involved sexual minorities (i.e., lesbians, gays, and bisexuals) or the LGBT community as a whole, leaving unaddressed specific needs, issues, and barriers faced by transgender and gender-nonconforming people. Although a growing body of literature has addressed the overall health and health indicators of transgender people, 12,18,19 the evidence-based work on gender-confirming treatment (medical and surgical transition care) is still limited. For example, few high-quality systematic studies have been conducted 20 ; of those conducted, many are observational in nature. 4,11,21 (Because of the relative availability of funding for HIV/AIDS-related research and high HIV prevalence among transgender people, 11 much of the research to date regarding transgender health policy has focused on HIV/AIDS; see also Brennan et al. 21 ) Further compounding the lack of rigorous research and data, the limited body of published work includes examples of research that may be construed as objectifying and may lead to misunderstanding or prejudice by readers (including authors’ use of assigned rather than chosen gender pronouns 22 ), which brings with it the risk of perpetuating or deepening misconceptions and unconscious prejudices among health care professionals.

In the past few years, several key public health bodies have recognized the lack of robust data on health indicators and on what constitutes medically appropriate care and the negative effect it has had on the quality of care provided to sexual and gender minorities; attempts to address these knowledge gaps have resulted in recent reports on LGBT health, for example, by the Institute of Medicine 17 and Healthy People 2020. 23

In a recently published response to the Institute of Medicine report on LGBT health, the National Institute of Health’s LGBT Research Coordinating Committee found that most LGBT health research

is focused in the areas of Behavioral and Social Sciences, HIV (human immunodeficiency virus)/AIDS, Mental Health, and Substance Abuse. Relatively little research has been done in several key health areas for LGBT populations including the impact of smoking on health, depression, suicide, cancer, aging, obesity, and alcoholism. 24 (p8)

In this same report, the LGBT Research Coordinating Committee called for increased research on transgender-specific health needs, including those associated with transitioning and the safety and efficacy of surgical sex reassignment procedures, as well as mental health and routine clinical care.

On June 29, 2011, US Department of Health and Human Services Secretary Kathleen Sibelius announced that the department would begin collecting data in its population health surveys that would facilitate identification of health issues and reduction of health disparities among LGBT populations. 25 These data will be collected by integrating questions regarding sexual orientation and gender identity into the National Health Interview Survey and, as an initial step toward the creation of a governmental standard for LGBT health data collection, under Section 4302 (nondiscrimination) of the Patient Protection and Affordable Care Act (ACA). 26 Starting in January 2013, the National Health Interview Survey has included a sexual-orientation specific question. HHS is currently testing survey questions on gender identity with the express purpose of capturing data about transgender people. 27

MEDICAL NEEDS

Transgender people, particularly low-income transgender people and transgender people of color, have reported even higher rates of discrimination in accessing competent and comprehensive care than other sexual minorities. 28 In 2008, the National Center for Transgender Equality and the National Gay and Lesbian Task Force partnered to conduct the first large-scale, national survey of transgender people, funded by the Network for LGBT Health Equity (formerly the Network for LGBT Tobacco Control). The study’s overarching objective was to map out the needs of and the issues faced by transgender people. 11 The 70-question survey was developed by an interdisciplinary team of social and health science researchers, grassroots and national transgender rights advocates, expert lawyers, statisticians, and LGBT movement leaders. The survey was completed online or in paper form and returned by more than 7500 respondents recruited through community organizations and community e-mail distribution lists, with direct outreach through organizations serving hard-to-reach populations, such as rural, homeless, and low-income transgender and gender-nonconforming people. The responses of 6456 people were included in the analysis, with a geographical distribution representative of the US population.

The landmark survey confirmed and expanded existing knowledge regarding areas of increased risk and specific difficulties that transgender people face in navigating the health care system. 11 It found that 19% of respondents reported having been denied health care by a provider because of their gender identity, and 28% reported verbal harassment in a medical setting. More than a quarter (28%) of respondents postponed care because of discrimination and disrespect, and a third (33%) postponed preventive care. Nineteen percent of respondents reported that they lacked insurance coverage (compared with 15% of the general population at that time 29 ), and a lower proportion of insured people received employment-based insurance than in the general population, which is likely attributable to high rates of job loss resulting from bias (as reported in the survey). 11

Looking at specific vulnerabilities, the survey reported that transgender people have a particularly high likelihood of being HIV-positive and using drugs, alcohol, or smoking as a mechanism to cope with discrimination compared with the general population. The lifetime suicide attempt rate was 41% of the respondent population (compared with 1.6% in the general population). 11 Each of these vulnerabilities was enhanced among racial minorities and among those participating in sex work, drug use and sales, or both. The survey reported that 75% of transgender women (i.e., female-identified or male-to-female transgender people) and more than 90% of transgender men (i.e., male-identified or female-to-male transgender people) either had or wanted to have surgical treatment, and 85% of transgender people either had or hoped to have hormonal treatment. 11

A modest but growing body of research has examined the efficiency of medical treatment. Gender-confirming surgery, often referred to as sex reassignment surgery (SRS), 1 has been shown to be beneficial in alleviating gender dysphoria (the distress associated with the difference between an individual’s expressed or experienced gender and socially assigned gender). 4,30,31 A 1992 study reported that hormone therapy improves quality of life as assessed by the Short Form-36 (SF-36) Health Survey, a 36-question validated survey assessing measures of health and well-being. 32 Increasingly, the overall consensus among those providing medical care to transgender people is that

sex reassignment generally, and SRS specifically, is associated with a high degree of patient satisfaction, a low prevalence of regrets, significant relief of gender dysphoria, and aggregate psychosocial outcomes that are usually no worse and are often substantially better than before sex reassignment. 33 (pp423–424)

Medical professional associations are increasingly publicly supporting inclusion of health care for transgender people and opposing the commonly held but slowly changing notion that such care is frivolous, cosmetic, experimental, or unnecessary. Since the early 1980s, the World Professional Association for Transgender Health (WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association) has been publishing standards of care (SOC). 9 Both SRS and hormonal therapy are endorsed by the SOC as necessary care for gender dysphoria, being both effective and often life saving. 9 Other professional societies, including the American College of Obstetricians and Gynecologists, 34 the Endocrine Society, 35 the American Medical Association, 36,37 and the American Psychological Association, 38 have endorsed these recommendations. They have each published statements encouraging care for transgender patients and urging public and private health insurance coverage for treatment of gender dysphoria.

In terms of costs, the American Medical Association has estimated provision of health care to transgender people to be nearly cost saving (incremental cost-effectiveness estimate = $500). 37 In 2001, San Francisco, California, became the first US city and county to remove transgender access exclusions from its employee health plan; in 2006, employee surcharges to cover these benefits were dropped because costs of reimbursement proved to be significantly lower than previously estimated. 39

Beyond insurance coverage, access to care is limited by the dearth of physicians who focus on, or are comfortable with, providing care for transgender people. A stark example is the paucity of surgeons performing genital reconstructive surgery: As of 2012, only 6 identified surgeons in the United States performed genital reconstructive surgery (Eric Plemons, PhD, written communication, January 3, 2013), thus limiting options for people seeking this surgery.

Other issues that transgender people often encounter in their interaction with the health care system include lack of respect and acceptance of chosen gender by health care staff, privacy and safety, 1 cultural appropriateness and understanding, and adequate knowledge of some of their specific medical needs. 11,12,40 (For example, while breach of confidentiality is always a serious matter, it can have particularly far-reaching consequences for the safety of transgender people when it leads to involuntary “outing,” or exposure of transgender identity.) Given the widespread lack of knowledge about transgender populations, and the absence of transgender health issues from most medical school curricula, 41 much remains to be done to shape a medical workforce that is well informed regarding the needs of this population and capable of providing appropriate care. Therefore, educating health practitioners about these issues is crucial. Of utmost importance is education of primary care providers, along with specialists in fields of particular relevance (including endocrinology, urology, obstetrics and gynecology, and plastic and reconstructive surgery, as well as emergency medicine). However, because physicians from all specialties treat transgender people, the basics of transgender health care should be addressed in medical, physician assistant, and nursing schools on a national scale.

US REGULATORY AND POLICY LANDSCAPE

Among issues of access to care that must be addressed nationally, that of insurance coverage and affordability of care has primary importance.

Federal Agencies and Regulations

As the US population ages, an increasing proportion of the population, including the transgender population, will become dependent on Medicare for access to care. Although Medicare covers both routine care (through parts B and 1) and hormonal treatment (part D), SRS is not covered. The specific language used by the Center for Medicare and Medicaid Services in explaining this lack of coverage is telling:

Transsexual surgery, also known as sex reassignment surgery or intersex surgery, is the culmination of a series of procedures designed to change the anatomy of transsexuals to conform to their gender identity. Transsexuals are persons with an overwhelming desire to change anatomic sex because of their fixed conviction that they are members of the opposite sex. For the male-to-female, transsexual surgery entails castration, penectomy and vulva-vaginal construction. Surgery for the female-to-male transsexual consists of bilateral mammectomy, hysterectomy and salpingo-oophorectomy, which may be followed by phalloplasty and the insertion of testicular prostheses. Transsexual surgery for sex reassignment of transsexuals is controversial. Because of the lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism, the treatment is considered experimental. Moreover, there is a high rate of serious complications for these surgical procedures. For these reasons, transsexual surgery is not covered by Medicare. 42 (sect140.3)

Several issues arise from this language. First, SRS is neither controversial nor experimental; rather, it is a well-recognized therapy advocated for by leading medical associations. This claim cannot serve as a basis for denying coverage for necessary treatment. The terminology and definitions in this statement are inaccurate, outdated, and inconsistent with current APA guidelines. The statement conflates intersexuality with being transgender and fails to acknowledge the wide range of possible gender expressions. Neither does it address the high rate of serious sequelae of failing to treat transgender people who have a need for gender-confirming surgery. Risk of complication is not sufficient grounds for rejecting treatment. As with any other procedure, one must evaluate the potential risk of complication in the context of the condition being treated and the risks of failure to treat.

In June 2011, in an effort to standardize care for transgender veterans, the Veterans Health Administration in the US Department of Veterans Affairs (VA) published directives regarding provision of care to transgender (and intersex) veterans (Patrick Paschall, JD, policy counsel, National Gay and Lesbian Task Force, oral communication, January 8, 2013). The directives state that

medically necessary care is provided to enrolled or otherwise eligible intersex and transgender Veterans including hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery. 43 (p2)

This policy clarifies the obligation of VA medical providers to extend comprehensive care to transgender veterans. The directives, however, deny coverage of SRS on the basis of a VA regulation excluding gender alterations from the medical benefits package, 44 despite the recognition of such alterations as part of care. Furthermore, these directives also contradict VA policy to provide “care and treatment to Veterans that is compatible with generally accepted standards of medical practice.” 34,35,37,43 (p2) However, an increasing commitment to LGBT inclusion in the VA, particularly through the recently founded Office for Diversity and Inclusion, has led to significant progress in health care delivery for transgender people. In June 2011, the Veterans Health Administration added protections based on gender identity to Equal Employment Opportunity Commission protections for employees, 45 and it is currently providing training for health care providers in services for transgender veterans. 46

High rates of unemployment in the transgender population are also a major barrier to maintaining health and appropriate health care. 2 Accordingly, employment of transgender people in the health care workforce is recommended because it offers an important avenue to address some of the challenges and barriers this population faces in the health care system. Although the burden of educating medical professionals should not rest on transgender people, increasing participation of transgender people in the health care workforce can facilitate and catalyze education and increase the understanding of issues faced by transgender people. This, in turn, has the potential to create safer and welcoming spaces for transgender people who seek medical care. Regarding employment more generally, in April 2012 the Equal Employment Opportunity Commission ruled that the Civil Rights Act’s prohibition against sex employment discrimination (title VII) applies to transgender people. See Macy v Holder. 47

In July 2012, in response to a letter from LGBT organizations, the US Department of Health and Human Services issued a statement clarifying that the ban on sex discrimination in section 1557 (nondiscrimination) of the ACA includes discrimination on the basis of gender identity. 48 This federal policy statement, the 1st of its kind, has wide implications, including for Medicare and Medicaid. This statement, along with the Equal Employment Opportunity Commission ruling, should not only increase access of transgender people to appropriate health care but also help alleviate concerns about discrimination and promote active participation in the health care system.

Some additional protections for transgender people are expected with implementation of the ACA. Standards for qualified health providers (QHPs) participating in the exchange programs ban discrimination in any of their activities, including on the basis of sexual orientation or gender identity:

Non-discrimination. A QHP issuer must not, with respect to its QHP, discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. 49 (p916)

Additionally, coverage denial based on being transgender as a preexisting condition will be banned under the ACA starting in 2014. To what extent and how promptly these protections will be implemented, and whether they will lead to higher rates of coverage for mental health services, cross-sex hormone therapy, or gender affirmation surgery, remains to be seen. These advances do not, however, provide an explicit and directed protection of transgender people within the health care system, nor do they address coverage of specific treatments that transgender people may need.

The Ending LGBT Health Disparities Act, a federal bill introduced in 2009, proposed the addition of a sexual orientation and gender identity nondiscrimination clause to all Medicaid, Medicare, and Children’s Health Insurance programs, with gender identity meaning

the gender-related identity, appearance, or mannerisms, or other gender-related characteristics of an individual, with or without regard to the individual's designated sex at birth. 50

The bill included federal grants to improve access and health promotion to gender and sexual minorities, in part through dedicated LGBT health centers, research related to gender and sexual minorities’ health disparities, and a requirement that sexual orientation and gender identity be included in federally funded health surveys. It also aimed to amend the Public Health Services Act by setting national standards for cultural competency of health care service to include sexual and gender minority cultural competency. Also important, the bill included a prohibition against discrimination on the basis of sexual orientation or gender identity under the health benefits program for federal employees and in the provision of health care and other benefits for members of the armed forces and veterans. This bill, though it did not directly relate to treatment coverage, would not only have increased access to care for all those directly affected by it, but may also have helped create a positive and inclusive climate for transgender people as full members of the population whose health is of concern. The bill was not passed, however, and so developments in enabling access to care for transgender people remain dependent on incremental advances within the current legal frameworks.

Court Decisions and Treatment Coverage

Given prisoners’ restriction of liberties, it is perhaps not surprising that some of the most serious limitations on transgender people’s access to health care have been in the US prison system. In most states, either incarcerated transgender people are housed according to their external genitals or no specific policy exists regarding their treatment and housing. 51,52 More surprising, perhaps, is that these abuses coexist alongside some of the most important advancements in protection of these rights. In several instances, federal courts have upheld the rights of transgender prisoners to receive both hormonal and surgical treatment. These decisions were based on the WPATH standards of care and on expert opinions that transition care (both hormonal and surgical) is medically necessary. The courts reasoned that the denial of transition care amounts to cruel and unusual punishment, a violation of the Eighth Amendment.

A landmark case is Fields v Smith. 53 In 2005, Wisconsin passed the Inmate Sex-Change Prevention Act, prohibiting funding of transition therapy (both hormonal and surgical) for transgender prisoners. 54 Several transgender women whose care was abruptly cut off filed against this law, claiming unconstitutionality on the basis of both the Eighth Amendment (cruel and unusual punishment) and the Equal Protection Clause. A federal district court found that the law constituted deliberate indifference to the plaintiffs’ medical needs in violation of the Eighth Amendment and violated the plaintiffs’ right to equal protection. The Seventh Circuit court affirmed the district court’s order.

In Adams v Federal Bureau of Prisons 55 in 2010, a federal district court judge denied a motion to dismiss the complaint of Vanessa Adams, who was denied hormonal treatment. Though Adams was by that time receiving care, the Federal Bureau of Prisons had not changed its policy of refusing hormone therapy for transgender people. The case resulted in a reversal of policy that denied inmates initiation of treatment of GID. In Kosilek v Spencer 52 in 2012, the District of Massachusetts Court ruled in favor of Michelle Kosilek, requiring the Massachusetts Department of Corrections to provide SRS for Kosilek. The court based its ruling on doctors’ expert opinions stating that in severe cases SRS is medically necessary; in this case, Justice Wolf, citing the WPATH Standards of Care, upheld previous rulings that GID is a severe medical condition requiring treatment. Justice Wolf also underscored that treatment cannot be denied on the basis of cost, because prisoners routinely receive care that is perceived as expensive. As Levi 56 pointed out, more than asserting the right or need for treatment of GID or limits to treatment within the prison system, the Kosilek ruling relates to what she called transgender exceptionalism, or the fear of controversy as a guiding principle for decisions made by government officials. In O’Donnabhain v Commissioner in 2010, the US Tax Court ruled in a manner similar to the rulings regarding prisoners’ right to transition care. 57 The court found that SRS and hormonal therapy are tax deductible under the Internal Revenue Code because they constitute necessary medical treatment.

Given these affirmations by the judicial system of the medical necessity for transition care, I argue that the federal Medicaid program should require participating states to cover gender-confirming treatment. 58 Although according to the statute governing the Medicaid programs (Title XIX of the Social Security Act, 42 USC § 1396), states “may place appropriate limits on a service based on such criteria as medical necessity,” 59 (p273) they may also not arbitrarily deny benefits solely on the basis of “diagnosis, type of illness, or condition.” 59 (p273) In fact, as early as 1980, the US Court of Appeals (Eighth Circuit) found that denial of coverage for SRS is an

arbitrary denial of benefits based solely on the diagnosis, type of illness, or condition where physician and hospital care are mandatory services and such surgery is “the only successful treatment known to medical science.” 60

A previously used measure for the reasonableness of the legislature’s standards has been general acceptability by the professional medical community as an “effective and proven treatment.” 61 Thus, although coverage of treatment must ultimately depend on particular need, as prescribed by the treating physician, it seems clear that as a category of treatment, gender-confirming care should be covered by individual states’ Medicaid programs, as by other publicly funded programs.

Many states currently have laws that explicitly deny Medicaid coverage of gender-confirming therapies, either specifically (e.g., Iowa, 62 Massachusetts 63 ) or because it is included in the category of cosmetic and experimental surgery (e.g., Missouri 64 and Illinois 65 ). 58 Legal challenges to the legislation have been successful in those states that did not have a statute or regulation explicitly excluding transition treatment from being covered; existing treatment exclusions have consistently been upheld. 58 After such challenges, Iowa and Minnesota added provisions excluding SRS from Medicaid coverage; currently, only California covers SRS under Medi-Cal. 58 However, True 58 suggested that the O’Donnabhain ruling may affect Medicaid coverage of SRS because upheld exclusions were based on the premise of lack of medical necessity for SRS. As medical opinion confirms that SRS is necessary, effective, nonexperimental, and without a comparable substitute; this opinion becomes even more widely echoed in the medical literature and court decisions; and the WPATH standards of care gain recognition as the professionally accepted guidelines for treatment of gender dysphoria, the provisions and statutes excluding coverage of gender-confirming surgery are likely to become increasingly harder to defend. I would contend that the argument for such provisions to be found invalid by the courts under the Federal Medicaid Act will be increasingly strong because they appear to be based on invalid rationales, put unreasonable restrictions on medically necessary treatment, and discriminate on the basis of diagnosis, which is in violation of the Federal Medicaid Act. Successful challenges to the legality of Medicaid coverage denial may also affect denial under Medicare and in the VA.

DIAGNOSES AND THEIR EFFECT ON CARE

In the United States, the medical establishment follows the APA definition as set out in the DSM for diagnosis and care of transgender people. In the fourth edition, text revision, of the DSM ( DSM-IV-TR ), diagnostic criteria for GID included strong and persistent cross-gender identification, persistent discomfort with the current sex, or sense of inappropriateness in the gender role of that sex. 66 More importantly, the discomfort must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the DSM-5, GID has been replaced with the term gender dysphoria. 3 The new classification emphasizes gender incongruence rather than cross-gender identification in an effort to reflect the individual’s felt sense of incongruence with natal gender, as opposed to pathologizing gender-atypical behavior. (Despite the APA’s stated intention, the new criteria seem to retain diagnosis based on gender nonconformity and fail to differentiate between distress caused by societal prejudice and that caused by a mental disorder.) Additionally, gender dysphoria is now separated from the chapters on sexual dysfunctions and paraphilias. In contrast to the dichotomized DSM - IV-TR GID diagnosis, the type and severity of gender dysphoria can be inferred from the number and type of indicators and from the severity measures.

At the outset, I must state that the inclusion of gender identity and transgender-related matters in the DSM reflects an inherent problem. Although diagnostic coding is necessary to facilitate access to medical and surgical transition care, the pathologizing and stigmatizing suggested by its designation as a mental disorder is not. Such designation gives rise to an inherent contradiction in terms: what is presented as a mental condition has recognized medical and surgical treatment:

Gender Dysphoria is a unique condition in that it is a diagnosis made by mental health care providers, although a large proportion of the treatment is endocrinological and surgical. 3 (p14)

These treatments are aimed not at affecting or changing mental state but rather at addressing the physical components that lead to the dysphoria. Such logic makes GID or gender dysphoria a unique case of surgically treatable mental illness, which is an oxymoron.

When the category of gender dysphoria was proposed, several LGBT and transgender organizations, including Lambda Legal, urged the APA to prioritize coverage of transitional treatment of transgender people as a medical necessity for a recognized condition over demedicalizing and depathologizing transgender people. 67 The current changes reflect an effort to strike a balance between stigmatization and the need to maintain access to care. 68

Future deliberations as to how to enable coverage of transgender-related care without designating a mental condition might consider an approach similar to that taken toward pregnancy and preventive care. Pregnancy is a condition that is recognized clinically and coded under the World Health Organization’s International Classification of Diseases. 69 It is treated, billed, and covered accordingly (with various policy options related to coverage of what is medically deemed necessary) without being pathologized. Similarly, preventive care is offered and routinely covered and is often considered necessary, independent of any diagnosis. So, too, I would suggest, can need for SRS be covered for transgender people without necessitating a DSM diagnosis.

RECOMMENDATIONS

Given the widespread acknowledgment of the health care needs of transgender people, action must be taken to ensure timely access to appropriate care. Such action includes, first and foremost, a requirement that all governmentally funded programs, including the VA, Medicaid and Medicare, Children’s Health Insurance Program, and Indian Health Services, include coverage of transition care and a requirement to ensure safe, appropriate, and sensitive care in federally funded health centers.

Private insurance may ultimately follow adoption of full coverage by federally funded programs, but until it does, federal guidelines protecting transgender people from discrimination by private insurance companies is warranted, including a ban on the practice of denying medical care coverage by linking the care to transition (which is not covered under most policies). To what extent the inclusion of gender identity in the ACA nondiscrimination clause will lessen this type of denial remains to be seen. Continued monitoring is necessary. More importantly, because a relatively high proportion of transgender people are uninsured, the expansion of Medicaid after implementation of the ACA significantly increases transgender people’s access to medical care (beyond transition care and SRS).

As work to enhance access to medical care progresses, the need for appropriate care will also increase. Models of care for marginalized minority populations with particular health needs can be based on existing general health care systems or implemented through specialized clinics and health care centers. Spurred by the AIDS epidemic and its toll on the gay community, dedicated LGBT health centers have been active in the United States since the 1980s. Although only a handful of centers are, at present, dedicated explicitly and exclusively to transgender patients, LGBT community health centers have provided care and often been active participants in and drivers of knowledge accumulation and dissemination regarding transgender health and treatment. These centers include the Fenway Center in Boston, Massachusetts; the Callen Lorde Community Health Clinic in New York City; and the Lyon-Martin Health Services in San Francisco. Achieving widespread access to acceptable, competent, appropriate, and affordable care, while promoting centers of clinical and research excellence in transgender health care, will require a combination of creating and strengthening dedicated centers as well as addressing transgender people’s health needs within the general health system.

Bias against transgender people takes an enormous toll on their health through direct harm, lack of appropriate care, and a hostile environment and through transgender people’s avoidance of the medical system as a result of discrimination and lack of respect. The medical establishment has a duty, and an ability, to protect transgender patients from such harms. Transgender-sensitive care must be incorporated into medical, nursing, and paramedical curricula, as has been done with other cultural competencies. Clear guidelines for all federally funded health centers, in line with the WPATH standards of care, need to be drafted and adopted by leading medical societies, including guidelines related to appropriate language, adoption of gender-neutral bathrooms, health records respectful of names and gender pronouns, and other safe environment measures.

Federal grants should be offered for programs teaching postgraduate-level care of transgender patients, including SRS. The ACA has taken a first positive step in that direction by providing funding for LGBT cultural competency trainings, which have already been implemented in big-city health departments, with training underway for staff of the National Health Service Corps.

Such measures are not only essential for the creation of an equitable health system, but will also likely result in improved health outcomes for the transgender population as barriers to access are removed and knowledge is enhanced. Incorporation of questions regarding gender identity into health surveys will also enable monitoring of progress and effects of these measures.

National surveys and health-related data sets must start to gather information about populations of transgender people by including questions pertaining to gender identity and sexual orientation. Several approaches are possible (including self-identification and identification of gender expression), and although none are perfect and all raise potential issues related to disclosure and the tension between identity and behavior, inclusion of such questions is a necessary step toward building a foundation of knowledge regarding the health and needs of transgender people. Though the National Transgender Discrimination Survey is an immense step forward in gathering data on health needs as transgender people perceive them, a need remains for data collection on outcomes, both through incorporating gender-identity identifiers into existing national surveys and through directed research. Last, it is essential that those who are caring for transgender patients collect and publish their data, in order to improve care for transgender people. It goes without saying that all such research must be conducted with sensitivity and respect toward participants.

Acknowledgments

I thank Diana Bowman, LLB, PhD, for her encouragement, guidance, and help. I also thank Alicia Cohen, MD, for her incisive and insightful comments. Last, I am grateful to Rachel Neis for her support, careful readings, and thoughtful discussions and comments.

Human Participant Protection

Human participant protection was not required because this study involved no participants.

• High contrast
• Press Centre

Search UNICEF

Unicef gender policy 2021-2030, a bolder and more ambitious vision for gender equality and the empowerment of all children, adolescents, and women.

Reducing inequality strengthens economies and builds stable, resilient societies that give all individuals – including boys and men – the opportunity to fulfil their potential. 

UNICEF builds partnerships across the global community to accelerate gender equality. In all areas of our work, we integrate strategies that address gender-specific discrimination and disadvantages.  

UNICEF’s  Gender Policy 2021-2030  ( English , Arabic , French ) and accompanying Action Plan 2022-2025  articulate UNICEF’s commitments to promoting gender equality across programmes, workplaces and practices around the world.  

This means partnering with national health sectors to expand quality maternal care and support the professionalization of the mostly female front-line community health workforce. It means promoting the role of women in the design and delivery of water, sanitation and hygiene (WASH) ecosystems and supporting everyone’s right to clean, quality water and sanitation. And it means working with the education sector to ensure girls and boys of all ages thrive in their learning and find pathways to meaningful employment. 

Recognizing that adolescent girls are consistently disadvantaged, especially in situations of crisis and conflict, UNICEF invests in five interlinked programmatic areas :

• adolescent health and nutrition;
• skills building to further their economic empowerment – as entrepreneurs, innovators and leaders;
• protection from violence and child marriage;
• quality menstrual health and hygiene services and disrupting taboos about menstrual health and
• social protection.

Through the monitoring framework , UNICEF will track progress on programmatic and institutional gender results.  

In everything we do, we strive to create opportunities for girls’ voice, power and agency.  

Files available for download

Related topics, more to explore, global deployment of rapid diagnostic tests to boost fight against cholera, six grave violations against children in times of war.

How children have become frontline targets in armed conflicts

Millions at risk from cholera due to lack of clean water, soap and toilets, and shortage of cholera vaccine

Water and the climate crisis: 10 things you should know.

The world needs to get water smart. Everyone has a role to play, and we cannot afford to wait

Official websites use .gov

Secure .gov websites use HTTPS

5 Things to Know About DOD's New Policy on Military Service by Transgender Persons and Persons With Gender Dysphoria

You have accessed part of a historical collection on defense.gov. Some of the information contained within may be outdated and links may not function. Please contact the DOD Webmaster with any questions.

Here are five things you should know about the new DOD policy:

View the Policy View the Policy:  https://go.usa.gov/xEsEH

Subscribe to Defense.gov Products

Choose which Defense.gov products you want delivered to your inbox.

Related Stories

Defense.gov, helpful links.

• Live Events
• Today in DOD
• For the Media
• DOD Resources
• DOD Social Media Policy
• Help Center
• DOD / Military Websites
• Agency Financial Report
• Value of Service
• Taking Care of Our People
• FY 2025 Defense Budget
• National Defense Strategy

The Department of Defense provides the military forces needed to deter war and ensure our nation's security.

The page could not be loaded. The CMS.gov Web site currently does not fully support browsers with "JavaScript" disabled. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with "JavaScript" disabled. Instructions for enabling "JavaScript" can be found here. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available.

An official website of the United States government

Here's how you know

The .gov means it's official.

Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.

The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Billing and Coding: Gender Reassignment Services for Gender Dysphoria

Document note, note history, contractor information, article information, general information.

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023 , the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA) §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim

Article Guidance

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5™ as a condition characterized by the "distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender" also known as “natal gender”, which is the individual’s sex determined at birth. Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning. GD is characterized by the desire to have the anatomy of the other sex, and the desire to be regarded by others as a member of the other sex. Individuals with GD may develop social isolation, emotional distress, poor self-image, depression and anxiety. The diagnosis of GD is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia. Gender Reassignment Therapy GD cannot be treated by psychotherapy or through medical intervention alone. Integrated therapeutic approaches are used to treat GD, including psychological interventions and gender reassignment therapy. Gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics. Initially, the individual may go through the real-life experience in the desired role, followed by cross-sex hormone therapy and gender reassignment surgery to change the genitalia and other sex characteristics. The difference between cross-sex hormone therapy and gender reassignment surgery is that the surgery is considered an irreversible physical intervention. Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post-surgery. Additionally, certain surgeries may improve gender- appropriate appearance but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered. NON-SURGICAL TREATMENT Initiation of cross-sex hormone therapy may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional. The criteria for cross sex hormone therapy are as follows:

• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Member must be at least 18 years of age;
• If significant medical or mental health concerns are present, they must be reasonably well controlled.

The presence of co-existing mental health concerns does not necessarily preclude access to cross-sex hormones. These concerns should be managed prior to or concurrent with treatment of gender dysphoria. Cross-sex hormonal interventions are not without risk for complications, including irreversible physical changes. Medical records should indicate that an extensive evaluation was completed to explore psychological, family and social issues prior to and post treatment. Providers should also document that all information has been provided and understood regarding all aspects associated with the use of cross-sex hormone therapy, including both benefits and risks. READINESS FOR THE TREATMENT OF GENDER DYSPHORIA Readiness criteria for gender reassignment surgery includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for gender reassignment surgery, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GD. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of cross-sex hormones during the months before the gender reassignment surgery. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes. TRANS-SPECIFIC CANCER SCREENINGS Professional organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists and the US Preventive Services Task Force provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender specific based on assumptions about the genitalia for a particular gender. There is little data on cancer risk specifically in transsexual individuals. There is difficulty in recommending sex/gender specific screenings (e.g., breast, cervix, ovaries, penis, prostate, testicles and uterus) for transsexual individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy have the same risks for breast cancer as natal women. In transwomen, the prostate typically is not removed as part of genital surgery, so individuals who do not take feminizing hormones may be at the same risk for prostate cancer as natal men. Therefore, cancer screenings (e.g., mammograms, prostate screenings) may be indicated based on the individual's original gender. Gender specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

• Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.
• Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.

Claims for gender reassignment surgery will be reviewed on a case-by-case basis. Surgical treatment of gender reassignment surgery for gender dysphoria may be eligible when medical necessity and documentation requirements outlined within this article are met. Surgical treatment for gender dysphoria may be considered medically necessary when ALL of the following criteria are met:

• The individual is at least 18 years of age.
• A gender reassignment treatment plan is created specific to an individual beneficiary
• The individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5 ™ diagnosis of GD:

 A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics.
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender.
• A strong desire for the primary and/or secondary sex characteristics of the other gender.
• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

 B. The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.

• That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.
• That the patient has had persistent and chronic gender dysphoria.
• That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender.
• The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.
• Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider).
• The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.

 SURGICAL TREATMENTS FOR GENDER REASSIGNMENT When all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female):

• Orchiectomy - removal of testicles
• Penectomy - removal of penis
• Vaginoplasty - creation of vagina
• Clitoroplasty - creation of clitoris
• Labiaplasty - creation of labia
• Mammaplasty - breast augmentation
• Prostatectomy -removal of prostate
• Urethroplasty - creation of urethra

When all of the above criteria are met for gender reassignment surgery, the following genital/breast surgeries may be considered for transmen (female to male):

• Breast reconstruction (e.g., mastectomy) - removal of breast
• Hysterectomy - removal of uterus
• Salpingo-oophorectomy - removal of fallopian tubes and ovaries
• Vaginectomy - removal of vagina
• Vulvectomy - removal of vulva
• Metoidioplasty - creation of micro-penis, using clitoris
• Phalloplasty - creation of penis, with or without urethra
• Urethroplasty - creation of urethra within the penis
• Scrotoplasty - creation of scrotum
• Testicular prostheses - implantation of artificial testes

Services or procedures may not be covered when the criteria and documentation requirements outlined within this article are not met.

The determination of whether to cover gender reassignment surgery and related care for a particular individual is based on whether the item or service is reasonable and necessary to treat the beneficiary’s medical condition after considering the individual’s specific circumstances. These decisions are made after the individual has obtained the medical service and a claim has been submitted by the Medicare provider.   The individual's medical record must be submitted along with the claim and support the services billed. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports. When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included:

• The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
• The urethral opening is moved to a position similar to that of a female.
• A vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split- thickness grafts.
• Labia are created out of skin from the scrotum and adjacent tissue.
• A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.

When reporting CPT ® code 55980 (Intersex surgery; female to male), the following staged procedures to form a penis and scrotum using pedicle flap grafts and free skin grafts are included:

• Portions of the clitoris are used, as well as the adjacent skin.
• Prostheses are often placed in the penis to create a sexually functional organ.
• Prosthetic testicles are implanted in the scrotum.
• The vagina is closed or removed.

Response To Comments

Coding information, bill type codes, revenue codes, cpt/hcpcs codes.

Transwoman procedures (male to female) *NOTE: For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services. The following CPT ® codes will be considered when applicable criteria have been met:

Transman procedures (female to male) *NOTE: For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services. The following CPT ® codes will be considered when applicable criteria have been met:

All unlisted procedure codes will suspend for medical review. The following CPT ® codes are considered cosmetic. When billed with any Covered ICD-10 Codes listed below, the service will not be covered (list may not be all-inclusive):

CPT/HCPCS Modifiers

Icd-10-cm codes that support medical necessity.

The following diagnosis codes are considered covered when applicable criteria have been met:

ICD-10-CM Codes that DO NOT Support Medical Necessity

All other diagnosis codes will be denied as non-covered.

ICD-10-PCS Codes

Additional icd-10 information.

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Other Coding Information

Coding table information, revision history information, associated documents.

• Gender Reassignment
• Gender Dysphoria

Read the Article Disclaimer

Email this document to yourself or someone else

An asterisk ( * ) indicates a required field. This email will be sent from you to the recipient email address(es) you enter. Please do not use this feature to contact CMS. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom of every MCD page.

Contractor Detail

Article disclaimer, lcd reference article.

Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).

Articles identified as “Not an LCD Reference Article” are articles that do not directly support a Local Coverage Determination (LCD). They do not include a citation of an LCD. An example would include, but is not limited to, the Self-Administered Drug (SAD) Exclusion List Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article.

Articles which directly support an LCD are known as “LCD Reference Articles” . The referenced LCD may be cited in the Article Text field and may also be linked to in the Related Documents field. Examples may include but are not limited to Response to Comments and some Billing and Coding Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article.

License Agreements

Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes.

LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT")

End User Point and Click Amendment: CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

You, your employees and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt .

Applicable FARS\DFARS Restrictions Apply to Government Use.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept".

LICENSE FOR USE OF CURRENT DENTAL TERMINOLOGY (CDT TM )

End User License Agreement: These materials contain Current Dental Terminology (CDT TM ), copyright© 2023 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement.

If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen.

If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting.

• Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
• Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org .
• Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use.  U.S. Government Rights Provisions.
• Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license.
• ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for software, including any CDT and other content contained therein, is with CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.
• CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CDT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material covered by this license. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I Accept". If you do not agree to the terms and conditions, you may not access or use software. Instead you must click below on the button labeled "I Do Not Accept" and exit from this computer screen.

LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)

American hospital association disclaimer.

The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Page Help for Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)

Introduction.

This page displays your requested Article. The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections. Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).

Finding a specific code

Some articles contain a large number of codes. If you are looking for a specific code, use your browser's Find function (Ctrl-F) to quickly locate the code in the article. Sometimes, a large group can make scrolling thru a document unwieldy. You can collapse such groups by clicking on the group header to make navigation easier. However, please note that once a group is collapsed, the browser Find function will not find codes in that group.

More information

• Billing and Coding articles provide guidance for the related Local Coverage Determination (LCD) and assist providers in submitting correct claims for payment. Billing and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered.
• Response to Comment (RTC) articles list issues raised by external stakeholders during the Proposed LCD comment period.
• Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. The Medicare program provides limited benefits for outpatient prescription drugs. The program covers drugs that are furnished "incident-to" a physician's service provided that the drugs are not "usually self-administered" by the patient. CMS has defined "not usually self-administered" according to how the Medicare population as a whole uses the drug, not how an individual patient or physician may choose to use a particular drug. For purpose of this exclusion, "the term 'usually' means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage" and the MAC will make no payment for the drug.
• Draft articles are articles written in support of a Proposed LCD. A Draft article will eventually be replaced by a Billing and Coding article once the Proposed LCD is released to a final LCD.

Articles are often related to an LCD, and the relationship can be seen in the “Associated Documents” section of the Article or the LCD. Article document IDs begin with the letter “A” (e.g., A12345). Draft articles have document IDs that begin with “DA” (e.g., DA12345).

Printing a Document to PDF

Frequently Asked Questions (FAQs)

Are you a provider and have a question about billing or coding.

Please contact your Medicare Administrative Contractor (MAC). MACs can be found in the MAC Contacts Report .

Do you have questions related to the content of a specific Local Coverage Determination (LCD) or an Article?

Are you a beneficiary and have questions about your coverage, are you looking for codes (e.g., cpt/hcpcs, icd-10), local coverage.

For the most part, codes are no longer included in the LCD (policy). You will find them in the Billing & Coding Articles. Try using the MCD Search to find what you're looking for. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. The list of results will include documents which contain the code you entered.

Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. All other Codes (ICD-10, Bill Type, and Revenue) have moved to Articles for DME MACs, as they have for the other Local Coverage MAC types.

National Coverage

NCDs do not contain claims processing information like diagnosis or procedure codes nor do they give instructions to the provider on how to bill Medicare for the service or item. For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM).

In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy.

How do I find out if a specific CPT code is covered in my state?

Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. (You may have to accept the AMA License Agreement.) Look for a Billing and Coding Article in the results and open it. (Or, for DME MACs only, look for an LCD.) Review the article, in particular the Coding Information section.

If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. The contractor information can be found at the top of the document in the Contractor Information section (expand the section to see the details).

If you don’t find the Article you are looking for, contact your MAC .

Did you receive a Medicare coverage denial?

Was your Medicare claim denied? Here are some hints to help you find more information:

1) Check out the Beneficiary card on the MCD Search page.

2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. Your information could include a keyword or topic you're interested in; a Local Coverage Determination (LCD) policy or Article ID; or a CPT/HCPCS procedure/billing code or an ICD-10-CM diagnosis code. Try entering any of this type of information provided in your denial letter.

3) Contact your MAC .

4) Visit Medicare.gov or call 1-800-Medicare.

It is Thursday and the weekly MCD data isn’t refreshed?

Are you having technical issues with the medicare coverage database (mcd), mcd session expiration warning.

Your MCD session is currently set to expire in 5 minutes due to inactivity. If your session expires, you will lose all items in your basket and any active searches. If you would like to extend your session, you may select the Continue Button.

Reset MCD Search Data

If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues.

Advertisement

Supported by

States Passed a Record Number of Transgender Laws. Here’s What They Say.

Many of the bills denied certain medical care to transgender people, while others targeted bathroom use and preferred personal pronouns.

• Share full article

By Adeel Hassan

Adeel Hassan read through dozens of state laws and spoke with law professors about the implications of the new legislation.

Statehouses around the country this year have been consumed by fights over laws governing transgender people.

Seventeen states during their most recent legislative sessions passed restrictions on medical care for transgender people, joining just three other states that passed similar bans in the last two years. A series of other laws passed regulate which bathrooms transgender people can use and whether schools can affirm transgender children’s identities.

Already many of these laws are being challenged in court, and judges are scrutinizing their precise wording. A federal judge in Arkansas last week struck down that state’s law forbidding medical treatments for children and teenagers seeking gender transitions. Earlier this month, a Florida judge sided with families seeking to block the state’s law banning gender transition care for minors, saying that the ban is likely to be found to be unconstitutional.

Amid the fighting, it’s easy to overlook the text of the laws themselves, which can get clinical very quickly.

So what’s actually in these bills? Here is a closer look at the language.

Many states have banned medical treatments and various surgical procedures for minors.

Laws banning gender-transition care for minors have been enacted in 20 states; Alabama, Arkansas, Tennessee and Arizona enacted bans before 2023, though Arkansas’s was recently struck down. Arizona’s law focuses on surgical procedures, but the rest extend the ban to other treatments, including puberty blockers and hormones.

Out of an estimated 1.6 million Americans who are transgender, about 300,000 are under 18. A small number get surgery as part of their transition, but it is much more common for children to transition socially — changing their name, clothing, haircut or other parts of their appearance and identity — and through the use of puberty-delaying medications or hormones.

Often these laws lay out a broad list of procedures. Indiana’s law, for example, includes mastectomies but also mentions procedures like liposuction and hair reconstruction. The legislation specifies that these procedures are banned for minors only if they are for the specific purpose of gender transition.

Sec. 8. As used in this chapter, “non genital gender reassignment surgery” means medical procedures knowingly performed for the purpose of assisting an individual with a gender transition , including the following: (1) Surgical procedures for a male sex patient, including augmentation mammoplasty, facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation, hair reconstruction, or associated aesthetic procedures. (2) Surgical procedures for a female sex patient, including subcutaneous mastectomy, voice surgery, liposuction, lipofilling, pectoral implants, or associated aesthetic procedures.

Indiana SEA 480

Genital surgery for minors is extremely rare. Top surgery — breast augmentation or removal — for minors is performed more often but is still very uncommon.

Proponents of the bans argue that these operations can be harmful and that children are not mature enough to make decisions about such procedures.

Leading medical organizations oppose bans on transition care, citing extensive evidence that such treatment leads to better mental health outcomes, and associating a lack of treatment with higher rates depression.

A few states passed laws that will also affect adults.

While most of these laws focus on treatments for minors, some states included provisions that will also create obstacles for transgender adults seeking transition treatments.

Florida’s law includes several restrictions, including requiring that medication like puberty blockers be prescribed in person by a physician. Many transgender people receive their prescriptions via telehealth and from nurse practitioners.

(3) Sex-reassignment prescriptions or procedures may not be prescribed, administered, or performed except by a physician . For the purposes of this section, the term “physician” is defined as a physician licensed under chapter 458 or chapter 459 or a physician practicing medicine or osteopathic medicine in the employment of the Federal Government.

Florida SB 254

Laws in both Florida and Missouri prevent Medicaid from covering transition care, which could make it harder for transgender adults to afford treatments and surgeries.

Some states have created strict penalties for providers who break the law.

Many states have defined the act of providing surgeries and medical care to transgender minors as “unprofessional conduct,” which could jeopardize a doctor’s ability to practice medicine.

Some states added potential penalties for people beyond doctors. For example, Indiana and Mississippi outline legal consequences for doctors and others who “aid or abet” in administering care. This language is similar to abortion bans that include legal penalties for providers or others who “aid or abet” someone receiving an abortion.

SECTION 3. (1) A person shall not knowingly provide gender transition procedures to any person under eighteen (18) years of age. (2) A person shall not knowingly engage in conduct that aids or abets the performance or inducement of gender transition procedures to any person under eighteen (18) years of age. This subsection may not be construed to impose liability on any speech protected by federal or state law.

Mississippi HB 1125

“In some states, such as Mississippi, the ‘aid or abet’ language is very broad,” said Elana Redfield, the federal policy director of the Williams Institute at the law school of the University of California, Los Angeles, “and could conceivably subject parents or allies to liability.”

And Montana’s ban allows people who receive care to sue their provider for up to 25 years after the procedure if they claim they were harmed by it.

While most of the laws passed this year do not include criminal liability, last month Florida joined at least four other states that make providing such care a felony. Florida’s law penalizes doctors who violate the law with up to five years in prison. It also changes child custody rules to treat transition care as equivalent to child abuse.

“It is wrong to be sexualizing these kids,” Gov. Ron DeSantis said at the signing. “It’s wrong to have gender ideology and telling kids that they may have been born in the wrong body.”

To enforce these laws, states are defining “male” and “female.”

Both as part of the medical bans and sometimes as separate laws, states are strictly defining “male” and “female.” This could prevent transgender people from receiving identification that matches their identity and appearance.

Tennessee’s law defining sex goes into effect on July 1, and would prevent anyone from changing the sex on their birth certificate and driver’s license. This can create challenges for transgender people when they need to, say, vote or apply for a library card.

(c) As used in this code, "sex" means a person's immutable biological sex as determined by anatomy and genetics existing at the time of birth and evidence of a person's biological sex . As used in this subsection (c), "evidence of a person's biological sex" includes, but is not limited to, a government-issued identification document that accurately reflects a person's sex listed on the person's original birth certificate.

Tennessee SB 1440

Research points to other consequences, including higher levels of anxiety and depression for transgender people who have an inconsistency between their documents and their gender identity.

There is some acknowledgment in the laws, though, that sex is not always binary. Most of the bans or restrictions include exceptions for intersex people who need or opt for medical treatments and surgery. Roughly 0.5 to 2 percent of the population has some intersex condition , meaning a person is born with chromosomes, hormones or sexual anatomy that differs from what is considered typical for males and females.

Nearly half of all states enacted laws banning transgender women and girls from playing on female teams.

At least 21 states, including North Dakota, specifically exclude transgender women and girls from participating in sports consistent with their gender identity. Five of those states extend the bans to transgender boys. All of the bans apply to high schools, and most states include colleges in their bans.

2. An athletic team or sport designated for “females”, “women”, or “girls” may not be open to students of the male sex. 3. This section may not be construed to restrict the eligibility of a student to participate in interscholastic or intramural athletic teams or sports designated as “males”, “men”, or “boys” or designated as “coed” or “mixed”.

North Dakota HB 1249

In Ohio last year, early drafts of the state’s athletic ban , which is still being debated by the legislature, included language requiring a physical examination by a doctor when the sex of an athlete is disputed. That language has since been removed. But it’s unclear in many of the laws how schools and organizations should enforce the bans.

Bathroom laws return, with a focus on school facilities.

In 2016, North Carolina became the first state to pass a bill barring transgender people from using public bathrooms consistent with their gender identity. The law drew nationwide outrage, and companies canceled planned expansions in the state, while the N.B.A. and N.C.A.A. moved events elsewhere. It was repealed in 2017.

But so-called bathroom bills have recently made a comeback in state legislatures. Tennessee passed one in 2021, while Alabama and Oklahoma followed in 2022. At least six states this year enacted laws regulating the use of bathrooms.

Idaho’s law, like many of these laws, targets school restrooms. The law says facilities that can be used by multiple people at once must be designated male or female and may be used only by members of that sex. The reason, it says, is to limit the shame and embarrassment students may feel sharing a restroom with someone of the opposite sex.

(2) Every person has a natural right to privacy and safety in restrooms and changing facilities where such person might be in a partial or full state of undress in the presence of others; (3) This natural right especially applies to students using public school restrooms and changing facilities where student privacy and safety is essential to providing a safe learning environment for all students; (4) Requiring students to share restrooms and changing facilities with members of the opposite biological sex generates potential embarrassment, shame, and psychological injury to students, as well as increasing the likelihood of sexual assault, molestation, rape, voyeurism, and exhibitionism;

Idaho SB 1100

Lawmakers who back such bills say that every child must feel safe in the bathroom and that the laws can help prevent abuse. Multiple studies , however, have shown that transgender people are much more likely to be victims of violence than cisgender people.

“We’ve had a natural experiment going in colleges, universities and high schools for some time” with coed bathrooms, said Katherine Franke, a professor at Columbia University Law School. After all these years, she added, “we haven’t seen any incidence of increased risks to personal security.”

Federal appeals courts have so far been split on the issue. At least two courts have upheld transgender students’ rights to use the bathroom corresponding with their gender identity, and in January one court ruled that a transgender boy was not entitled to use the boys’ bathroom in a public high school in Florida.

Some states extended their laws to include school field trips

Since many of the bathroom bans specifically apply to school facilities, they also often include accommodations on school field trips.

Kansas passed a law specifically targeting school overnight trips, stating that students must have overnight lodging that is separated by sex.

Be it enacted by the Legislature of the State of Kansas: New Section 1. (a) The board of education of each school district shall adopt a policy requiring that separate overnight accommodations be provided for students of each biological sex during school district sponsored travel that requires overnight stays by students. Such policy shall be provided to parents prior to a student’s participation in an activity or travel that requires overnight stays by students.

Kansas HB 2138

Republican legislators passed the law off a report that a female student was assigned to share a room with a transgender student during an overnight trip, and overruled a veto by Gov. Laura Kelly, a Democrat.

“Conservatives who were worried about education were always committed to local school control,” Ms. Franke said. Now they’re “relying on state legislatures, which are taking away that discretion from local school boards.”

A handful of laws directed at schools restrict the discussion of personal pronouns.

At least nine states this year have passed laws regarding how pronouns are handled in school. Florida’s law explicitly prohibits teachers and students from discussing their preferred pronouns.

Kentucky has a law saying teachers can’t be required to use pronouns for students that differ from their sex.

(b) The Kentucky Board of Education or the Kentucky Department of Education shall not require or recommend policies or procedures for the use of pronouns that do not conform to a student's biological sex as indicated on the student's original, unedited birth certificate issued at the time of birth pursuant to KRS 156.070(2)(g)2. (c) A local school district shall not require school personnel or students to use pronouns for students that do not conform to that particular student's biological sex as referenced in paragraph (b) of this subsection.

Kentucky SB 150

Other states, like Indiana, outline “parental rights” policies, requiring that parents be notified when their children request to use a different name or want to be called pronouns that don’t match their sex.

Overall, the many new laws governing transgender children and adults have yet to be tested in everyday life. But already, many are facing lawsuits seeking to stop them.

Nearly half of all the medical bans that have passed are already being challenged in court. A Florida judge issued a limited injunction this month, saying that the state’s medical ban would most likely be found unconstitutional. The judge took issue with the state’s prohibiting treatments “even when medically appropriate.” Texas’ law, which was enacted this month , is also expected to face legal challenges before going into effect in September.

Maggie Astor contributed reporting.

Adeel Hassan is a reporter and editor on the National Desk. He is a founding member of Race/Related , and much of his work focuses on identity and discrimination. He started the Morning Briefing for NYT Now and was its inaugural writer. He also served as an editor on the International Desk.  More about Adeel Hassan

Change Healthcare Security Incident

Change Healthcare, a vendor that connects payers, providers and patients within the U.S health care system, is experiencing a cyber security issue that is affecting the business operations of many companies nationwide, including Horizon.

• BACK back to www.horizonblue.com
• COVID-19 Information
• Update: Coverage and Reimbursement for COVID-19 Testing to change Update: Coverage and Reimbursement for COVID-19 Testing to change
• Important Information for New COVID-19 Vaccine Claims Important Information for New COVID-19 Vaccine Claims
• Code Terminations as the PHE Ends Code Terminations as the PHE Ends
• PHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D members PHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D members
• Important Update: Additional Policy Changes as PHE Ends Important Update: Additional Policy Changes as PHE Ends
• Some Benefits Changes as the PHE Ends Some Benefits Changes as the PHE Ends
• Referral Requirements for All Services Referral Requirements for All Services
• Referral Requirements for Services Not Related to COVID-19 Referral Requirements for Services Not Related to COVID-19
• Reminder: Select one method for COVID-19 and Influenza Testing Reminder: Select one method for COVID-19 and Influenza Testing
• Antibody testing: FDA and CDC do not recommend use to determine immunity Antibody testing: FDA and CDC do not recommend use to determine immunity
• COVID-19 vaccine administration reimbursement at UCCs COVID-19 vaccine administration reimbursement at UCCs
• Coverage for antibody infusion therapy Coverage for antibody infusion therapy
• Reminder to use specific codes when evaluating for COVID-19 Reminder to use specific codes when evaluating for COVID-19
• COVID-19 Update: Telemedicine Reimbursement Policy Addenda COVID-19 Update: Telemedicine Reimbursement Policy Addenda
• FIND A DOCTOR
• MEMBER SIGN IN
• SHOP FOR A PLAN
• Our Commitment Our Commitment

Join Our Networks

• Ancillary Providers Ancillary Providers
• Doula Services Practitioners
• Doula Credentialing Application Checklist Doula Credentialing Application Checklist
• Physicians and Other Healthcare Professionals
• Online Enrollment Tool Online Enrollment Tool
• Credentialing Checklist Applications Credentialing Checklist Applications
• Join the Horizon Dental Network Join the Horizon Dental Network
• Our Healthcare Facilities Our Healthcare Facilities
• Products & Programs
• Braven Health℠
• Braven Health Supportive Program Braven Health Supportive Program
• Braven Health℠ Drug Formulary Braven Health℠ Drug Formulary
• Horizon Behavioral Health℠
• Integrated System of Care (ISC) Program Integrated System of Care (ISC) Program
• Peer Support Program Peer Support Program

Horizon Network and Product Information

• BlueCard Program
• BlueCard Claims BlueCard Claims
• BlueCard Medical Policy/Pre-Certification Info BlueCard Medical Policy/Pre-Certification Info
• BlueCard Program FAQs BlueCard Program FAQs
• BlueCard Program Overview BlueCard Program Overview
• BlueCard Program Tutorial BlueCard Program Tutorial
• GeoBlue: International Coverage GeoBlue: International Coverage
• How to Identify BlueCard Members How to Identify BlueCard Members
• Dental Services Dental Services
• Managed Care Plans Managed Care Plans
• PPO and Indemnity Products PPO and Indemnity Products
• OMNIA Health Plans OMNIA Health Plans
• NJ SHBP/SEHBP Benefit Plans NJ SHBP/SEHBP Benefit Plans
• Braven Health℠ Medicare Advantage Plans Braven Health℠ Medicare Advantage Plans
• Our Pledge Our Pledge
• Patient Care Support Patient Care Support
• Medical Injectables Program
• Medical Injectables Program Code Lists
• Injectable Medication Codes Subject to MRxM Claim Review/Editing Injectable Medication Codes Subject to MRxM Claim Review/Editing
• Injectable Medications subject to Medical Necessity and Appropriateness Review Injectable Medications subject to Medical Necessity and Appropriateness Review
• Medical Injectables Program Provider Questions and Answers Medical Injectables Program Provider Questions and Answers
• Pharmacy Programs
• Medicare Part D Medicare Part D
• Pharmacy Guidelines
• Medical Necessity Determination Policy For Prescription Drugs Medical Necessity Determination Policy For Prescription Drugs
• Oral Anticancer Medication Coverage Law Oral Anticancer Medication Coverage Law
• Pharmaceutical Prior Authorization Policy Pharmaceutical Prior Authorization Policy
• Prescription Drug Formulary Exception, Tier Exception, And Multisource Brand Name Criteria Policy Prescription Drug Formulary Exception, Tier Exception, And Multisource Brand Name Criteria Policy
• Preferred Medical Drugs Preferred Medical Drugs
• Site of Administration Program for Infusion/Injectable Medications
• Site of Administration Program Code List Site of Administration Program Code List
• Specialty Pharmaceuticals for Office Administration Specialty Pharmaceuticals for Office Administration

Risk Adjustment Overview

• Commercial Risk Adjustment (CRA) ICD-10-CM Clinical Documentation Improvement for Chronic Conditions Commercial Risk Adjustment (CRA) ICD-10-CM Clinical Documentation Improvement for Chronic Conditions
• How Risk Adjustment Benefits You and Your Patients How Risk Adjustment Benefits You and Your Patients
• Risk Adjustment Documentation & Coding Improvement Reference Information Risk Adjustment Documentation & Coding Improvement Reference Information
• Risk Adjustment In Depth Risk Adjustment In Depth

Utilization Management Programs

• Carelon Medical Benefits Management
• Cardiovascular Program Cardiovascular Program
• Diagnostic Imaging Program Diagnostic Imaging Program
• Musculoskeletal Program Musculoskeletal Program
• Oncology Program
• Oncology Program Code List Oncology Program Code List
• Sleep Disorder Management Program Sleep Disorder Management Program
• Horizon Care@Home
• About Horizon Care@Home About Horizon Care@Home
• Find A Provider Find A Provider
• Home Infusion Therapy Home Infusion Therapy
• Prior Authorization/Pre-Service Registration Prior Authorization/Pre-Service Registration
• Horizon Supportive Care and Readmission Program Horizon Supportive Care and Readmission Program
• Surgical and Implantable Device Management Program
• About the Surgical and Implantable Device Management Program About the Surgical and Implantable Device Management Program
• Cardiac Services
• Cardiac Services Procedure Codes Cardiac Services Procedure Codes
• Surgical and Implantable Device Management Program for Cardiac Surgeries Frequently Asked Questions Updated: March 25, 2021 Surgical and Implantable Device Management Program for Cardiac Surgeries Frequently Asked Questions Updated: March 25, 2021
• Orthopedic Services
• Orthopedic Services Procedure Codes Orthopedic Services Procedure Codes
• Safety and Quality Award Program Q&A Safety and Quality Award Program Q&A
• Surgical and Implantable Device Management Program Orthopedic Services Frequently Asked Questions Surgical and Implantable Device Management Program Orthopedic Services Frequently Asked Questions
• Spine Services
• Spine Procedure Codes Spine Procedure Codes
• TurningPoint Safety and Quality Award Program TurningPoint Safety and Quality Award Program
• Medical Policy Criteria and Guidelines Medical Policy Criteria and Guidelines
• PA/MND Process PA/MND Process
• Using Out-of-Network Providers in Surgical Services Using Out-of-Network Providers in Surgical Services
• eviCore HealthCare
• Cardiology Imaging Program
• Cardiology Imaging Program Provider Questions and Answers Cardiology Imaging Program Provider Questions and Answers
• Molecular and Genomic Testing Program
• Medical Information Requirements for Programs Administered by eviCore Medical Information Requirements for Programs Administered by eviCore
• Medical Necessity Determination (MND) Review of Molecular and Genomic Diagnostic Testing Services Frequently Asked Questions Medical Necessity Determination (MND) Review of Molecular and Genomic Diagnostic Testing Services Frequently Asked Questions
• Molecular and Genomic Testing Procedure Codes Molecular and Genomic Testing Procedure Codes
• Musculoskeletal Program for Pain Management Services Musculoskeletal Program for Pain Management Services
• Radiation Therapy Program
• Radiation Therapy Program Questions and Answers Radiation Therapy Program Questions and Answers
• Radiology/Imaging Services
• 72 Hour Rule 72 Hour Rule
• Appropriate Use of Modifier 26 Appropriate Use of Modifier 26
• Cardiology & Radiology Imaging Procedure Codes Cardiology & Radiology Imaging Procedure Codes
• Contrast Agents and Radiopharmaceuticals
• Contrast Agents and Radiopharmaceuticals Contrast Agents and Radiopharmaceuticals
• Codes Considered Inclusive to an Imaging Service Codes Considered Inclusive to an Imaging Service
• Codes are Active/Invoice is Required Codes are Active/Invoice is Required
• Maternal Fetal Medicine Evaluation Coding Maternal Fetal Medicine Evaluation Coding
• Radiology/Imaging Guidelines for Emergency Room Preliminary Reads (Wet Reads) Radiology/Imaging Guidelines for Emergency Room Preliminary Reads (Wet Reads)
• Radiology/Imaging Program Guidelines for Use of Modifier 59 Radiology/Imaging Program Guidelines for Use of Modifier 59
• Radiology Imaging Program Q & A Radiology Imaging Program Q & A
• Correct Coding Rules Bank for Radiology, Cardiology and Ultrasound Services
• Correct Coding Rules Bank Correct Coding Rules Bank
• Code Pairs Added to this List Effective January 1, 2023 Code Pairs Added to this List Effective January 1, 2023
• Code Pairs Removed from this List Effective December 31, 2022 Code Pairs Removed from this List Effective December 31, 2022
• Code Description Changes Code Description Changes
• Code Bundling Rules
• Code Bundling Rules for Radiology, Cardiology and Ultrasound Services Code Bundling Rules for Radiology, Cardiology and Ultrasound Services
• Code Bundling Rules for PET/MRI Services Code Bundling Rules for PET/MRI Services

Value-Based Programs

• Quality vs. Fee for Service Quality vs. Fee for Service
• Policies & Procedures

HEDIS Resources

• Behavioral Health HEDIS Webinar Series
• Introduction to Behavioral Health HEDIS Introduction to Behavioral Health HEDIS
• Child Behavioral Health HEDIS Measures Child Behavioral Health HEDIS Measures
• Adult Behavioral Health HEDIS Measures Adult Behavioral Health HEDIS Measures
• Substance Use Disorder HEDIS Measures Substance Use Disorder HEDIS Measures
• Follow-Up Care for Children Prescribed ADHD Medication & Metabolic Monitoring for Children and Adolescents on Antipsychotics HEDIS Measures Follow-Up Care for Children Prescribed ADHD Medication & Metabolic Monitoring for Children and Adolescents on Antipsychotics HEDIS Measures
• Claim Submission & Billing
• Billable Service Exceptions
• Eligible Laboratory Procedures Rendered by a Practice Eligible Laboratory Procedures Rendered by a Practice
• PCP Billable Lists PCP Billable Lists
• Claim Editing Policies Claim Editing Policies
• Claim Overpayments Claim Overpayments
• Claim Reimbursement Claim Reimbursement
• Claim Submission
• Claim Submission Instructions
• Institutional Institutional
• Professional Professional
• Tips for Electronic Claim Submission Tips for Electronic Claim Submission
• Electronic Claim Adjustments Electronic Claim Adjustments
• Explanation of Payment Explanation of Payment
• Pre-payment Correct Coding Reviews
• Advancement of Pre-Payment Integrity Capabilities - Claim Pattern Review (CPR) FAQ Advancement of Pre-Payment Integrity Capabilities - Claim Pattern Review (CPR) FAQ
• Advancement of Pre-Payment Integrity Capabilities – Coding Validation (CV) with Medical Record Review (MRR) FAQ Advancement of Pre-Payment Integrity Capabilities – Coding Validation (CV) with Medical Record Review (MRR) FAQ
• Clinical Auditing and Monitoring Unit (CAMU) Medical Necessity Audit FAQs Clinical Auditing and Monitoring Unit (CAMU) Medical Necessity Audit FAQs
• Provider Guidelines for Submitting Information to Our Clinical Inquiry Team Provider Guidelines for Submitting Information to Our Clinical Inquiry Team
• Prompt Pay Guidelines Prompt Pay Guidelines

Demographic Updates

• The Importance of Demographic Updates The Importance of Demographic Updates
• Provider Directory Management Policy Provider Directory Management Policy
• CMS Audits to Validate Directory Information CMS Audits to Validate Directory Information
• How to Make Demographic Updates: Participating Ancillary Providers
• Horizon Data Submission Template for Ancillary Providers Horizon Data Submission Template for Ancillary Providers
• Exceptions to Using Horizon Data Submission Template Exceptions to Using Horizon Data Submission Template
• Supporting Documentation for Ancillary Provider Demographic Updates Supporting Documentation for Ancillary Provider Demographic Updates
• How to Make Demographic Updates: Participating Practices
• Provider Data Maintenance Tool Provider Data Maintenance Tool
• Horizon Data Submission Template Horizon Data Submission Template
• Specific Criteria You Should Confirm is Accurate and Up to Date Specific Criteria You Should Confirm is Accurate and Up to Date
• Supporting Documentation Requirements for Practice-level Demographic Updates Supporting Documentation Requirements for Practice-level Demographic Updates
• Supporting Documentation Requirements for Practitioner Demographic Updates Supporting Documentation Requirements for Practitioner Demographic Updates
• Creating and Updating Nonparticipating Provider Files Creating and Updating Nonparticipating Provider Files
• Using CAQH ProView™ Using CAQH ProView™
• Inquiries, Complaints & Appeals
• Inquiries Inquiries
• Complaints Complaints
• Time Limits for Filing Inquiries/Complaints Time Limits for Filing Inquiries/Complaints
• Resolving Inquiries/Complaints Resolving Inquiries/Complaints
• Appeals of Non-Utilization Management Determinations Appeals of Non-Utilization Management Determinations
• Appeals of Utilization Management/Medical Management Determinations Appeals of Utilization Management/Medical Management Determinations
• Appeals of Post Service Medical Necessity Determinations Appeals of Post Service Medical Necessity Determinations
• Medical Policies
• Allied Health Allied Health
• Drugs Drugs
• Introduction Introduction
• Medicine Medicine
• Obstetrics Obstetrics
• Pathology Pathology
• Radiology Radiology
• Surgery Surgery
• Treatment Treatment
• Hosted Medical Policy Content Hosted Medical Policy Content
• ASAM (Substance Use) Criteria ASAM (Substance Use) Criteria
• MCG Health (Clinical) Guidelines MCG Health (Clinical) Guidelines
• Documentation Submission Guidelines Documentation Submission Guidelines
• Administrative Policies
• Allowable Practice Locations for Pathologists Allowable Practice Locations for Pathologists
• Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers
• Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
• Initial Credentialing Initial Credentialing
• Recredentialing Recredentialing
• Standards for Participation Standards for Participation
• Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
• Diagnostic Imaging Privileging by Participating Provider Practice Specialty Diagnostic Imaging Privileging by Participating Provider Practice Specialty
• Digital Member ID Card Policy Digital Member ID Card Policy
• EDI and NaviNet Claims Submission Requirement EDI and NaviNet Claims Submission Requirement
• Electronic Funds Transfer (EFT) Electronic Funds Transfer (EFT)
• Material Adverse Change (MAC) Notification Policy Material Adverse Change (MAC) Notification Policy
• Medical Records Documentation Standards Medical Records Documentation Standards
• Medicare Advantage Readmission Medicare Advantage Readmission
• Medicare Part B Utilization Management in the Absence of NCD or LCD Medicare Part B Utilization Management in the Absence of NCD or LCD
• Never Events Never Events
• Out-of-Network Referral Policy Out-of-Network Referral Policy
• Outlier Audit Programs: Post Payment and Pre-Payment Outlier Audit Programs: Post Payment and Pre-Payment
• Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network
• Pass Through Billing (Modifier 90) Pass Through Billing (Modifier 90)
• Practice Location Reinstatements Practice Location Reinstatements
• Practice Locations Limit Practice Locations Limit
• Practitioner Counseling and Termination Policy - Professional Competency Practitioner Counseling and Termination Policy - Professional Competency
• Practitioner Office Site Quality and Medical/Behavioral Health Record Keeping Standards Practitioner Office Site Quality and Medical/Behavioral Health Record Keeping Standards
• Provider Directory Management Provider Directory Management
• Provider Outlier Program Frequently Asked Questions Provider Outlier Program Frequently Asked Questions
• Retainer Based Medicine Retainer Based Medicine
• SHBP/SEHBP Inpatient Readmission Reimbursement SHBP/SEHBP Inpatient Readmission Reimbursement
• Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities
• Tier Awareness Policy Tier Awareness Policy
• Use of Horizon Hospital Network Performance Data Use of Horizon Hospital Network Performance Data
• Use of Practitioner Performance Data Use of Practitioner Performance Data
• BlueCard Medical Policies BlueCard Medical Policies
• Reimbursement Policies & Guidelines
• Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005) Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
• After-hours and Weekend Care After-hours and Weekend Care
• Allergy Services Allergy Services
• Ambulance Services Ambulance Services
• Ambulatory Electrocardiographic Monitoring Ambulatory Electrocardiographic Monitoring
• Anesthesia Reimbursement Guidelines Anesthesia Reimbursement Guidelines
• ASC Multiple Procedure Methodology ASC Multiple Procedure Methodology
• Assistant at Surgery Assistant at Surgery
• Balloon Sinuplasty Balloon Sinuplasty
• Bariatric Surgery Billed With Hiatal Hernia Repair Bariatric Surgery Billed With Hiatal Hernia Repair
• Behavioral Health Services Rendered by Supervised Practitioners Behavioral Health Services Rendered by Supervised Practitioners
• Bilateral Procedures Bilateral Procedures
• Billing Guidelines for Maternity Services Billing Guidelines for Maternity Services
• Biologics Coding Biologics Coding
• Cardiac Event Detection Cardiac Event Detection
• Cardiovascular Implant Device Monitoring Services Cardiovascular Implant Device Monitoring Services
• Casting, Strapping and Splints Casting, Strapping and Splints
• Chemotherapy Administration Chemotherapy Administration
• Chronic Care Management Services Chronic Care Management Services
• Claims Requiring Additional Documentation Claims Requiring Additional Documentation
• ClaimsXten Editing Rules ClaimsXten Editing Rules
• Clinical Trials Support Program Clinical Trials Support Program
• Co-Surgeon Reimbursement Co-Surgeon Reimbursement
• Collaborative Care Management Services Collaborative Care Management Services
• Colonoscopy with Modifier 59 Colonoscopy with Modifier 59
• Conscious Sedation Conscious Sedation
• Consultation Services Payment Consultation Services Payment
• Consumable Medical Supplies Consumable Medical Supplies
• Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies
• COVID 19 Antibody Testing COVID 19 Antibody Testing
• COVID-19 Testing and Testing Related Services COVID-19 Testing and Testing Related Services
• Daily Management of Epidural or Subarachnoid Continuous Drug Administration Daily Management of Epidural or Subarachnoid Continuous Drug Administration
• Daily Maximum Units for Surgical Pathology and Microscopic Examination Daily Maximum Units for Surgical Pathology and Microscopic Examination
• Determination of Refractive State Determination of Refractive State
• Diabetic Screening Services Diabetic Screening Services
• Diabetic Supplies Diabetic Supplies
• Distinct Procedural Service Modifiers (59, XE, XP, XS, XU) Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
• DME Rent to Purchase DME Rent to Purchase
• Doula Services Doula Services
• Drug and Immunization Pricing Drug and Immunization Pricing
• Duplex Scanning Duplex Scanning
• Drug Wastage – Modifier JW Drug Wastage – Modifier JW
• Duplicate Claim Logic for Independent Laboratory Services Duplicate Claim Logic for Independent Laboratory Services
• Evaluation and Management Services with Chiropractic Manipulative Treatment Evaluation and Management Services with Chiropractic Manipulative Treatment
• Evaluation and Management Services with Osteopathic Manipulative Treatment Evaluation and Management Services with Osteopathic Manipulative Treatment
• Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging
• False Claims False Claims
• Free Flap Breast Reconstruction Free Flap Breast Reconstruction
• Frequency of Care Coordination Services and ESRD Procedures Frequency of Care Coordination Services and ESRD Procedures
• Frequency of G0179 Frequency of G0179
• Hip Arthroscopy Hip Arthroscopy
• Horizon Fee Schedule Updates based on Third Party Sources Horizon Fee Schedule Updates based on Third Party Sources
• Hospital Non-Patient Laboratory Services
• Hospital Non-Patient Laboratory Services Sample Fees Hospital Non-Patient Laboratory Services Sample Fees
• Hot or Cold Pack Therapy Hot or Cold Pack Therapy
• Inpatient Consultations Inpatient Consultations
• Knee Arthroscopy Knee Arthroscopy
• Lab Panel Rebundling Lab Panel Rebundling
• Laboratory Services Billed by Physicians Laboratory Services Billed by Physicians
• Laser Treatment of Psoriasis or Parapsoriasis Laser Treatment of Psoriasis or Parapsoriasis
• Maternity Reimbursement Maternity Reimbursement
• Maximum Units for Anesthesia Maximum Units for Anesthesia
• Medical Nutrition Therapy (MNT) Medical Nutrition Therapy (MNT)
• Medicare Advantage Hospital Sequestration Reimbursement Medicare Advantage Hospital Sequestration Reimbursement
• Microsurgery and Robotic Surgery Microsurgery and Robotic Surgery
• Modifier 25 Modifier 25
• Modifier 50 Bilateral Guidelines Modifier 50 Bilateral Guidelines
• Modifier 52 Modifier 52
• Modifier 53 Modifier 53
• Modifier 54 Modifier 54
• Modifier 55 Modifier 55
• Modifier 56 Modifier 56
• Modifier 57 Modifier 57
• Modifier 76 Modifier 76
• Modifier 77 Modifier 77
• Modifier 78 Modifier 78
• Modifier SU Modifier SU
• Modifiers CQ/CO Modifiers CQ/CO
• Multiple Procedure Reductions Multiple Procedure Reductions
• Mutually and Non-Mutually Exclusive NCCI Supplemental Edits Mutually and Non-Mutually Exclusive NCCI Supplemental Edits
• Non-ESRD ESA Level Reporting Non-ESRD ESA Level Reporting
• Noncovered Related Services Noncovered Related Services
• Outpatient Consultations Outpatient Consultations
• Outpatient Facility Claim Coding Requirements Outpatient Facility Claim Coding Requirements
• Outpatient Facility Code Edits: Bundling and Revenue Codes
• Bundled Services Bundled Services
• Lab codes when billed with other services Lab codes when billed with other services
• Revenue Codes Requiring HCPCS Codes Revenue Codes Requiring HCPCS Codes
• Typically packaged codes Typically packaged codes
• Outpatient Laboratory Claims: Referring Practitioner Required Outpatient Laboratory Claims: Referring Practitioner Required
• Outpatient Services Prior to Admission or Same-Day Surgery Outpatient Services Prior to Admission or Same-Day Surgery
• Outpatient Therapy Daily Maximum Outpatient Therapy Daily Maximum
• Physician Extenders Non-Surgical Services Physician Extenders Non-Surgical Services
• Pre-Payment Coding Reviews Documentation Requests Pre-Payment Coding Reviews Documentation Requests
• Pre-Payment Documentation Requests: Facility Claims Pre-Payment Documentation Requests: Facility Claims
• Post Payment Documentation Requests: Facility Claims Post Payment Documentation Requests: Facility Claims
• Pulmonary Diagnostic Procedures when billed with E&M Codes Pulmonary Diagnostic Procedures when billed with E&M Codes
• Radiology, Preliminary and Double Reads Radiology, Preliminary and Double Reads
• Radiopharmaceuticals Radiopharmaceuticals
• Reimbursement and Billing Guidelines for Anesthesia Claims Reimbursement and Billing Guidelines for Anesthesia Claims
• Removal of Impacted Cerumen Requiring Instrumentation Removal of Impacted Cerumen Requiring Instrumentation
• Screening and Diagnostic Mammography & 3D Tomosynthesis Screening and Diagnostic Mammography & 3D Tomosynthesis
• Site of Service Differential Site of Service Differential
• Smoking Cessation Smoking Cessation
• Status N Codes Status N Codes
• Telemedicine Services
• Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products
• Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage
• Ulcer Debridement and Ulcer Stages Ulcer Debridement and Ulcer Stages
• Urgent Care Center Billing Requirements Urgent Care Center Billing Requirements
• Urinalysis with Evaluation and Management (E&M) Services Urinalysis with Evaluation and Management (E&M) Services
• Urine Drug Screening/Testing Urine Drug Screening/Testing
• Vascular Coding Vascular Coding
• Venipuncture Facility Outpatient Claims Venipuncture Facility Outpatient Claims
• Vitamin D Testing Vitamin D Testing

Utilization Management

• Utilization Management Request Tool Utilization Management Request Tool
• Prior Authorization Procedure Search Tool Prior Authorization Procedure Search Tool
• BlueCard Members BlueCard Members
• FEP Members FEP Members
• UNITE HERE HEALTH UNITE HERE HEALTH
• Patient Quality & Outcome Resources
• Clinical Practice Guidelines Clinical Practice Guidelines
• Consumer Assessment of Healthcare Providers and Systems (CAHPS)
• Focusing on Your Horizon and Braven Health Patients’ Experience: Tools to Help You Focusing on Your Horizon and Braven Health Patients’ Experience: Tools to Help You
• Discussion Checklist for CAHPS and HOS Surveys Discussion Checklist for CAHPS and HOS Surveys
• Cultural Competency Cultural Competency
• HEDIS Measure Guidelines for Behavioral Health Providers
• Follow-Up Care for Children Prescribed ADHD Medication (ADD-E) Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)
• Antidepressant Medication Management (AMM) Antidepressant Medication Management (AMM)
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E) Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)
• Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)
• Follow-Up After Emergency Department Visit for Substance Use (FUA) Follow-Up After Emergency Department Visit for Substance Use (FUA)
• Follow-Up After Hospitalization for Mental Illness (FUH) Follow-Up After Hospitalization for Mental Illness (FUH)
• Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)
• Follow-Up After Emergency Department Visit for Mental Illness (FUM) Follow-Up After Emergency Department Visit for Mental Illness (FUM)
• Initiation and Engagement of Substance Use Disorder Treatment (IET) Initiation and Engagement of Substance Use Disorder Treatment (IET)
• Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
• Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
• Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC) Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC)
• Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD) Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD)
• HEDIS Measurement Year (MY) 2024 Provider Tips for Optimizing HEDIS Results
• Best Practices Overall for Coding Best Practices Overall for Coding
• Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)* Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)*
• Adult Immunization Status (AIS-E) Adult Immunization Status (AIS-E)
• Adults’ Access to Preventive/Ambulatory Health Services (AAP) Adults’ Access to Preventive/Ambulatory Health Services (AAP)
• Advanced Care Planning (ACP) Advanced Care Planning (ACP)
• Antibiotic Utilization for Respiratory Conditions (AXR) Antibiotic Utilization for Respiratory Conditions (AXR)
• Appropriate Testing for Pharyngitis (CWP) Appropriate Testing for Pharyngitis (CWP)
• Appropriate Treatment for Upper Respiratory Infection (URI) Appropriate Treatment for Upper Respiratory Infection (URI)
• Asthma Medication Ratio (AMR) Asthma Medication Ratio (AMR)
• Avoidance of Antibiotic Treatment for Acute Bronchitis/ Bronchiolitis (AAB) Avoidance of Antibiotic Treatment for Acute Bronchitis/ Bronchiolitis (AAB)
• Blood Pressure Control for Patients With Diabetes (BPD) Blood Pressure Control for Patients With Diabetes (BPD)
• Breast Cancer Screening (BCS-E) Breast Cancer Screening (BCS-E)
• Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC) Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
• Care for Older Adults (COA) Care for Older Adults (COA)
• Cervical Cancer Screening (CCS) (CCS-E) Cervical Cancer Screening (CCS) (CCS-E)
• Child and Adolescent Well-Care Visits (WCV) Child and Adolescent Well-Care Visits (WCV)
• Childhood Immunization Status (CIS) (CIS-E) Childhood Immunization Status (CIS) (CIS-E)
• Chlamydia Screening in Women (CHL) Chlamydia Screening in Women (CHL)
• Colorectal Cancer Screening (COL-E) Colorectal Cancer Screening (COL-E)
• Controlling High Blood Pressure (CBP) Controlling High Blood Pressure (CBP)
• Deprescribing of Benzodiazepines in Older Adults (DBO) Deprescribing of Benzodiazepines in Older Adults (DBO)
• Depression Remission or Response for Adolescents and Adults (DRR-E) Depression Remission or Response for Adolescents and Adults (DRR-E)
• Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
• Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD) Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD)
• Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
• Eye Exam for Patients With Diabetes (EED) Eye Exam for Patients With Diabetes (EED)
• Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC) Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC)
• Follow-Up After Emergency Department Visit for Substance Use (FUA)* Follow-Up After Emergency Department Visit for Substance Use (FUA)*
• Glycemic Status Assessment for Patients With Diabetes (GSD) Glycemic Status Assessment for Patients With Diabetes (GSD)
• Immunizations for Adolescents (IMA) (IMA-E) Immunizations for Adolescents (IMA) (IMA-E)
• Kidney Health Evaluation for Patients with Diabetes (KED) Kidney Health Evaluation for Patients with Diabetes (KED)
• Lead Screening in Children (LSC) - EPSDT Lead Screening in Children (LSC) - EPSDT
• Lead Screening in Children (LSC) - NCQA Lead Screening in Children (LSC) - NCQA
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)* Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)*
• Osteoporosis Management in Women Who Had a Fracture (OMW) Osteoporosis Management in Women Who Had a Fracture (OMW)
• Osteoporosis Screening in Older Women (OSW) Osteoporosis Screening in Older Women (OSW)
• Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)
• Pharmacotherapy Management of COPD Exacerbation (PCE) Pharmacotherapy Management of COPD Exacerbation (PCE)
• Postpartum Depression Screening and Follow-Up (PDS-E) Postpartum Depression Screening and Follow-Up (PDS-E)
• Prenatal Depression Screening and Follow-Up (PND-E) Prenatal Depression Screening and Follow-Up (PND-E)
• Prenatal Immunization Status (PRS-E) Prenatal Immunization Status (PRS-E)
• Prenatal and Postpartum Care (PPC) Prenatal and Postpartum Care (PPC)
• Risk of Continued Opioid Use (COU) Risk of Continued Opioid Use (COU)
• Statin Therapy for Patients with Cardiovascular Disease (SPC) Statin Therapy for Patients with Cardiovascular Disease (SPC)
• Statin Therapy for Patients with Diabetes (SPD) Statin Therapy for Patients with Diabetes (SPD)
• Topical Fluoride for Children (TFC) Topical Fluoride for Children (TFC)
• Transitions of Care (TRC) Transitions of Care (TRC)
• Unhealthy Alcohol Use Screening and Follow-Up (ASF-E) Unhealthy Alcohol Use Screening and Follow-Up (ASF-E)
• Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)* Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)*
• Use of Imaging Studies for Low Back Pain (LBP) Use of Imaging Studies for Low Back Pain (LBP)
• Use of Opioids at High Dosage (HDO) Use of Opioids at High Dosage (HDO)
• Use of Opioids from Multiple Providers (UOP) Use of Opioids from Multiple Providers (UOP)
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)
• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
• Well-Child Visits in the First 30 Months of Life (W30) Well-Child Visits in the First 30 Months of Life (W30)
• HorizonDocs
• HorizonDocs 2023 Training HorizonDocs 2023 Training
• Quality Resource Center
• Educational Materials
• Achieving Success in Quality Improvement Achieving Success in Quality Improvement
• Quality Management 2024 Webinars
• R&R Overview R&R Overview
• Adult Measures Adult Measures
• Pediatric Measures Pediatric Measures
• Optimizing Monthly R&R Reports Optimizing Monthly R&R Reports
• Overview of Horizon Docs Overview of Horizon Docs
• Quality Care Gap Closure Quality Care Gap Closure
• Lead Overview Lead Overview
• Asthma Medication Ratio Asthma Medication Ratio
• CWP Overview CWP Overview
• Risk Adjustment Overview Risk Adjustment Overview
• CAHPS Overview CAHPS Overview
• Telehealth Telehealth
• Women’s Health Women’s Health
• What’s the Code? What’s the Code?
• Colorectal Cancer Screening Colorectal Cancer Screening
• Electronic Claim Data System (ECDS) Supplemental Data File Feed 2024 Electronic Claim Data System (ECDS) Supplemental Data File Feed 2024
• Results & Recognition Program
• HEDIS and Quality Management Program Manual HEDIS and Quality Management Program Manual
• Women’s Health Results and Recognition Program Women’s Health Results and Recognition Program
• Provider Guidelines: Non-Standard (Medical Record) Supplemental Data for HEDIS Gap Closure
• Adult HEDIS Measures Adult HEDIS Measures
• Pediatric HEDIS Measures Pediatric HEDIS Measures
• How to Submit Supplemental Data to Horizon How to Submit Supplemental Data to Horizon
• Health Outcomes Survey: How You Can Drive Results Health Outcomes Survey: How You Can Drive Results
• Provider Portal Provider Portal

Provider Self-Service Tools

• Drug Authorizations Tool Drug Authorizations Tool
• Electronic Data Interchange (EDI)
• Braven Health℠ Electronic Data Interchange (EDI) Braven Health℠ Electronic Data Interchange (EDI)
• Horizon BCBSNJ Electronic Data Interchange (EDI) Horizon BCBSNJ Electronic Data Interchange (EDI)
• Eligibility and Benefits Cost Share Estimator Eligibility and Benefits Cost Share Estimator
• Interactive Voice Response System (IVR)
• Referral Process Using the Interactive Voice Response System Referral Process Using the Interactive Voice Response System
• Effective use of the Interactive Voice Response System Effective use of the Interactive Voice Response System
• NaviNet NaviNet
• Working with Us: Information & Education Resources
• Educational Webinars
• Behavioral Health Training Webinars Behavioral Health Training Webinars
• Manuals & User Guides
• Agreements Agreements
• Ancillary Manual
• The BlueCard Program The BlueCard Program
• Claims Submissions and Reimbursement Claims Submissions and Reimbursement
• Coordination of Benefits Coordination of Benefits
• HIPAA HIPAA
• Horizon Behavioral Health Horizon Behavioral Health
• Horizon Hospital Network Horizon Hospital Network
• Identification Identification
• Inquiries, Complaints and Appeals Inquiries, Complaints and Appeals
• Member Rights and Responsibilities Member Rights and Responsibilities
• Patient-Centered Programs Patient-Centered Programs
• Patient Health Support Patient Health Support
• Policies, Procedures and General Guidelines Policies, Procedures and General Guidelines
• Products Products
• Provider Responsibilities Provider Responsibilities
• Quality Management Quality Management
• Quality Recognition Programs Quality Recognition Programs
• Referrals Referrals
• Service Service
• Utilization Management Utilization Management
• Horizon Hospital Network Manual
• Claims Submission and Reimbursement Claims Submission and Reimbursement
• Programs Administered by eviCore healthcare Programs Administered by eviCore healthcare
• Important Resources for Providers Important Resources for Providers
• Participating Physician and Other Health Care Professional Office Manual
• At Your Service At Your Service
• Payment Summaries and Vouchers Payment Summaries and Vouchers
• Special Programs Special Programs
• Welcome Kit Welcome Kit
• Network Specialists
• Medical Network Specialist Assignments Medical Network Specialist Assignments
• Behavioral Health Network Specialist Assignments Behavioral Health Network Specialist Assignments
• Recognition Programs and Partnerships
• Blue Distinction Centers Blue Distinction Centers
• New Jersey Infection Prevention Partnership New Jersey Infection Prevention Partnership
• CMS Training Requirements
• Compliance Training for Providers Compliance Training for Providers
• Health Care Fraud, Waste and Abuse Health Care Fraud, Waste and Abuse
• Prepayment Coding Audit Review Prepayment Coding Audit Review
• Horizon BlueCard Horizon BlueCard
• Horizon EPO Horizon EPO
• Horizon Indemnity/PPO Horizon Indemnity/PPO
• Navinet Navinet
• Online Tools
• Electronic Funds Transfer Electronic Funds Transfer
• Health Risk Assessment Health Risk Assessment
• Radiation Therapy Medical Necessity Determination Radiation Therapy Medical Necessity Determination
• Virtual ID Cards Virtual ID Cards

Forms by Plan Type

• Dental Dental
• Medical Medical
• Pharmacy Pharmacy

Forms by Specialty Type

Forms by type.

• Appeal / Dispute Appeal / Dispute
• Assess / Evaluate / Examine Assess / Evaluate / Examine
• Authorizations Authorizations
• Braven Health Forms Braven Health Forms
• Claim Claim
• Consent Consent
• Credentialing Credentialing
• Enroll / Elect / Apply Enroll / Elect / Apply
• Horizon NJ TotalCare (HMO D-SNP) Forms Horizon NJ TotalCare (HMO D-SNP) Forms
• Inquiry / Request Inquiry / Request
• Prescription Drug Mail Order Prescription Drug Mail Order
• Reimbursement / Payment Reimbursement / Payment
• Frequently Used Forms Frequently Used Forms
• Miscellaneous Miscellaneous
• W9 Form-Dental W9 Form-Dental
• W9 Form-Medical W9 Form-Medical

Blue Review

• Blue Review March 2024 Blue Review March 2024
• Blue Review March 2022 Blue Review March 2022
• Blue Review December 2021 Blue Review December 2021
• Blue Review September 2022 Blue Review September 2022
• Blue Review September 2021 Blue Review September 2021
• Blue Review June 2021 Blue Review June 2021
• Blue Review March 2021 Blue Review March 2021
• Blue Review June 2023 Blue Review June 2023
• Blue Review December 2022 Blue Review December 2022
• Blue Review December 2023 Blue Review December 2023
• Blue Review June 2022 Blue Review June 2022
• Blue Review March 2023 Blue Review March 2023
• Blue Review September 2023 Blue Review September 2023
• Blue Review 2020 Blue Review 2020
• Blue Review 2019 Blue Review 2019

Braven Health Provider News

• 2024 Issue 1 2024 Issue 1

Feature Stories

• As Mental Health Needs Continue To Rise, So Do Innovative Virtual Services As Mental Health Needs Continue To Rise, So Do Innovative Virtual Services
• Treat Knee, Back, and Hip Pain with Orthotic Device that Helps Avoid Invasive Procedures Treat Knee, Back, and Hip Pain with Orthotic Device that Helps Avoid Invasive Procedures
• Bariatric Surgery Value-Based Program Helps Members with Weight Loss Bariatric Surgery Value-Based Program Helps Members with Weight Loss
• Dental Providers Benefit from Dedicated Horizon Liaisons Dental Providers Benefit from Dedicated Horizon Liaisons
• Connecting with parents on the importance of early childhood health screenings and vaccinations Connecting with parents on the importance of early childhood health screenings and vaccinations
• Episodes of Care Program Gives Cancer Patients the Care They Need Episodes of Care Program Gives Cancer Patients the Care They Need
• Home-Delivered Meals Help Braven Health℠ Patients Home-Delivered Meals Help Braven Health℠ Patients
• How a value-based primary care provider helps the New Jersey Vaccination Program How a value-based primary care provider helps the New Jersey Vaccination Program
• Improving Health Equity through Increased Access to Prenatal Care Across New Jersey Improving Health Equity through Increased Access to Prenatal Care Across New Jersey
• Pharmacy Collaboration leads to better patient outcomes and cost savings Pharmacy Collaboration leads to better patient outcomes and cost savings
• Providing Innovative Cancer Care - Expanding Episodes of Care Providing Innovative Cancer Care - Expanding Episodes of Care
• When planning, collaboration and crisis merge - a medical practice's successful response to COVID-19 When planning, collaboration and crisis merge - a medical practice's successful response to COVID-19
• News & Legal Notices News & Legal Notices
• Provider Alerts Provider Alerts

Update: Coverage and Reimbursement for COVID-19 Testing to change

Important information for new covid-19 vaccine claims, code terminations as the phe ends, phe update: prescription limitation change for braven health, hmo d-snp and medicare part d members, important update: additional policy changes as phe ends, some benefits changes as the phe ends, referral requirements for all services, referral requirements for services not related to covid-19, reminder: select one method for covid-19 and influenza testing, antibody testing: fda and cdc do not recommend use to determine immunity, covid-19 vaccine administration reimbursement at uccs, coverage for antibody infusion therapy, reminder to use specific codes when evaluating for covid-19, covid-19 update: telemedicine reimbursement policy addenda, our commitment, our healthcare facilities, braven health℠, horizon behavioral health℠, patient care support, claim submission & billing, inquiries, complaints & appeals, patient quality & outcome resources, provider portal, working with us: information & education resources, frequently used forms, miscellaneous, w9 form-dental, w9 form-medical, news & legal notices, provider alerts, medical policy revision: gender reassignment surgery.

Effective May 1, 2019 , Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy, Gender Reassignment Surgery .

Access our Medical Policy Manual to review this medical policy content.¹

Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO), or Medicare Advantage (MA) plans will be processed as follows.

• Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT® codes 15786 , +15787 , 15824 , 15825 , 15826 , 15828 , 15832 , 15833 , 15834 , 15835 , 15836 , 15837 , 15838 , 15839 , 15876 , 15878 , 15879 or 17380 .  
• Following our review, the services represented by these codes may be denied as cosmetic services.  
• Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 11970 , 11971 , 15871 , 92507 and/or 92508 .  
• Following our review, the services represented by these codes may be denied as not medically necessary or cosmetic services.  
• Based on the submitted diagnosis code(s), CPT codes 92507 or 92508 may be denied as cosmetic services.

Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ commercial or ASO plans will be processed as follows.

• Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT codes 11950 , 11951 , 11952 , 11954 , 15775 , 15776 , 15780 , 15781 , 15782 or 15783 .
• Following our review, the services represented by these codes may be denied as cosmetic services.

Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ MA plans will be processed as follows.

• Based on the submitted diagnosis code(s), CPT codes 11950 , 11951 , 11952 or 11954 may be denied as cosmetic services.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after May 1, 2019.

CPT® is a registered mark of the American Medical Association.

¹ The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

Are you sure you want to leave this website?

You are leaving the Horizon Blue Cross Blue Shield of New Jersey website. Please click Continue to leave this website. Or, if you would like to remain in the current site, click Cancel.

Please note that these forms are to be used by Federal Employee Program Members only

TLDEF's Trans Health Project

Gender affirming surgery.

Policy: Gender Affirming Surgery Policy Number: CG-SURG-27 Last Update: 2021-05-20

Breast Reconstruction:

Gender affirming chest surgery ( augmentation, mastectomy, or reduction ) is considered reconstructive when all of the following criteria have been met: The individual is at least 18 years of age (see Further Considerations section below for individuals under 18 years of age); and The individual has capacity to make fully informed decisions and consent for treatment; and The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and For gender affirming breast augmentation procedures only : for individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician, and insufficient breast development has occurred; and Existing chest appearance demonstrates significant variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

Facial Reconstruction:

Gender affirming facial surgery† is considered reconstructive when all of the following criteria have been met: The individual is at least 18 years of age; and The individual has capacity to make fully informed decisions and consent for treatment; and The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and For individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and Existing facial appearance demonstrates significant variation from normal appearance for the experienced gender; and The procedure directly addresses variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission. †See Discussion section for a list of procedures included in this group of procedures

Permanent Hair Removal:

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Voice Therapy and Surgery:

Gender affirming voice modification surgery is considered reconstructive when all of the following criteria have been met: The individual is at least 18 years of age; and The individual has capacity to make fully informed decisions and consent for treatment; and The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and For gender masculinization only: for individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and Existing vocal presentation demonstrates significant variation from normal for the experienced gender; and One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

Youth Services:

A provider with experience treating adolescents with gender dysphoria may request further consideration of a gender affirming chest procedure case in an individual under 18 years old when they meet all other gender affirming chest procedure criteria above (including prior mental health evaluation) by contacting a Medical Director. (Further information is available in the Discussion/General Information section of this document titled ‘ Gender Affirming Surgery in Individuals Under the Age of 18 ’).

Back to top

Updated on Aug 26, 2021

The Hong Kong government revised on Tuesday the Hong Kong ID cards sex entry policy. After the revision, individuals who have not completed full sex reassignment surgery may apply to change the gender marker on their identity cards.

After the revision, preoperative transgender individuals may still apply for an amendment if the individual has completed surgical treatment such as the removal of breasts or removal of the penis and testes. The individual must also make a statutory declaration to confirm they have gender dysphoria, have lived in the opposite sex throughout the period of at least two years before the application, and will continue to live in the opposite sex for the rest of their lives. In addition, the individual must also have received hormonal treatment for two years before the application is made and must confirm that they will continue to undergo hormonal treatment and submit blood test reports when required by the Director of Immigration.

The government reiterated that the change to the gender marker on Hong Kong ID cards does not represent the holder’s sex as a matter of law. It also does not affect other government policies or the handling of any other gender-related matters under the law.

To apply for an amendment to the gender marker on the Hong Kong ID cards, the government previously required transgender individuals to undergo full sex-reassignment surgery. In February 2023, the Hong Kong Court of Final Appeal ruled that the requirement was unconstitutional. The court held that requiring transgender individuals to undergo the most invasive surgical intervention in the range of treatments for gender dysphoria went to far because it may be medically unnecessary. The court, therefore, required the government to present a more compelling reason to uphold the policy. Consequently, the court also held that a full sex reassignment surgery is not the only workable, objective and verifiable criterion to determine the application to change gender marker.

International human rights experts came up with the Yogyakarta Principles in 2006. Principle 3 provides for the right to recognition before the law. It specifically states, “[E]ach person’s self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom.” Principle 3 also provides that undergoing medical procedures should not be a requirement for legal recognition of people’s gender identity.

Requirements for legal gender recognition vary among different countries. South American countries such as Argentina, Brazil, Uruguay, Colombia and Ecuador have already provided legal gender recognition by self-determination. The revised policy adopted by Hong Kong is similar to the UK Gender Recognition Act 2004 , except with an additional requirement of having completed certain surgical treatments.

Senate approves purchase of Alaska

On April 9, 1867, the U.S. Senate voted to ratify the Treaty with Russia for the Purchase of Alaska and thereby approve the purchase of the territory from Russia for $7.2 million . Initially, the purchase was made to keep Alaska away from the British. It was politically unpopular with many Americans who denounced it is "Seward's Folly", after U.S. Secretary of State William Seward, who had lobbied for the purchase. Seward was later vindicated by the discovery of gold and oil in Alaska. Learn more about the Alaska Purchase from the U.S. State Department.

Last beheading in England

On April 9, 1747, Simon Fraser, Lord Lovat, became the last man to be beheaded in England when he was executed on Tower Hill for his part in the Highland rising of 1745. Learn more about the legal history and practice of beheading .

NAIA All but Bans Transgender Athletes From Women's Sports. NCAA Vows to Ensure 'Fair Competition'

The National Association of Intercollegiate Athletics has announced a policy that all but bans transgender athletes from women’s sports

NAIA All but Bans Transgender Athletes From Women's Sports. NCAA Vows to Ensure 'Fair Competition'

Charlie Riedel

Freed-Hardeman guard Quan Lax wears the championship banner after the NAIA men's national championship college basketball game against Langston, Tuesday, March 26, 2024, in Kansas City, Mo. Freed-Hardeman won 71-67. (AP Photo/Charlie Riedel)

The National Association of Intercollegiate Athletics announced a policy Monday that all but bans transgender athletes from competing in women's sports at its 241 mostly small colleges across the country.

The NAIA Council of Presidents approved the policy in a 20-0 vote at its annual convention in Kansas City, Missouri. The NAIA, which oversees some 83,000 athletes competing in more than 25 sports, is believed to be the first college sports organization to take such a step.

According to the transgender participation policy, which goes into effect in August, all athletes may participate in NAIA-sponsored male sports but only athletes whose biological sex assigned at birth is female and have not begun hormone therapy will be allowed to participate in women’s sports.

A student who has begun hormone therapy may participate in activities such as workouts, practices and team activities, but not in intercollegiate competition.

NAIA programs in competitive cheer and competitive dance are open to all students. The NAIA policy notes every other sport “includes some combination of strength, speed and stamina, providing competitive advantages for male student-athletes.”

NAIA President and CEO Jim Carr said in an interview with The Associated Press he understands the policy will generate controversy but that it was deemed best for member schools for competitive reasons.

Photos You Should See

“We know there are a lot of opinions, and a lot of people have a very emotional reaction to this, and we want to be respectful of all that,” Carr said. “But we feel like our primary responsibility is fairness in competition, so we are following that path. And we've tried as best we could to allow for some participation by all."

The NAIA's 2023-24 policy did not bar transgender and nonbinary athletes from competing in the division of their choice in the regular season. In the postseason, and with some exceptions for those who have had hormone therapy, athletes had to compete in the division of their birth sex.

There is no known number of transgender athletes at the high school and college levels, though it is believed to be small. The topic has become a hot-button issue among conservative groups and others who believe transgender athletes should not be allowed to compete on girls’ and women’s sports teams.

Shiwali Patel, senior counsel at the National Women’s Law Center, said her organization was outraged by the NAIA policy.

“This is unacceptable and blatant discrimination that not only harms trans, nonbinary and intersex individuals, but limits the potential of all athletes,” Patel said in a statement. “It’s important to recognize that these discriminatory policies don’t enhance fairness in competition. Instead, they send a message of exclusion and reinforce dangerous stereotypes that harm all women.”

Last month, more than a dozen current and former college athletes filed a federal lawsuit against the NCAA, accusing the sports governing body for more than 500,000 athletes of violating their rights by allowing transgender women to compete in women’s sports.

Hours after the NAIA announcement, the NCAA released a statement: “College sports are the premier stage for women’s sports in America and the NCAA will continue to promote Title IX, make unprecedented investments in women’s sports and ensure fair competition for all student-athletes in all NCAA championships.”

At least 24 states have laws barring transgender women and girls from competing in certain women’s or girls sports competitions.

The Biden administration originally planned to release a new federal Title IX rule — the law forbids discrimination based on sex in education — addressing both campus sexual assault and transgender athletes. Earlier this year, the department decided to split them into separate rules, and the athletics rule now remains in limbo.

“It’s similar to the NIL stuff with all these different state laws," said Kasey Havekost, a former Division I athlete who is now a higher education attorney at Bricker Graydon. “The NCAA kind of does something but nothing really happens, and they look to the federal government, and the federal government is slow to put something in place and then we’re left with all these different state laws.”

Havekost expects lawsuits will follow and challenge the NAIA policy on the basis of Title IX laws.

“I feel like at some point, it will have to be addressed," she said. "It’s a really complex issue. It might take a Supreme Court ruling.”

About 190 of the 241 NAIA schools are private, and about 125 of those have religious affiliations of varying degrees, Carr said. Of the 20 presidents who voted, 17 are from schools affiliated with Christian denominations.

“People have certain views of the world, and even though I believe all our Council of Presidents members are trying to think what’s best for the NAIA, they certainly come to these kinds of issues with their own beliefs and the missions of their institutions in mind,” Carr said. “I would think that had some impact.”

Patel said the NAIA ban, along with the state laws, “emphasizes the urgency in having clear Title IX rules that expressly prohibit this type of sex-based discrimination, and ensure the rights of all students, including transgender, nonbinary, and intersex athletes, are safeguarded. Trans athletes deserve a chance to play.”

The NCAA has had a policy for transgender athlete participation in place since 2010, which called for one year of testosterone suppression treatment and documented testosterone levels submitted before championship competitions. In 2022, the NCAA revised its policies on transgender athlete participation in an attempt to align with national sport governing bodies, following the lead of the U.S. Olympic and Paralympic Committee.

The three-phase implementation of the policy included a continuation of the 2010 policy, requiring transgender women to be on hormone replacement therapy for at least one year, plus the submission of a hormone-level test before the start of both the regular season and championship events.

The third phase adds national and international sport governing body standards to the NCAA’s policy and — after a delay — is scheduled to be implemented for the 2024-25 school year on Aug. 1.

There are some 15.3 million public high school students in the United States and a 2019 study by the CDC estimated 1.8% of them — about 275,000 — are transgender. The number of athletes within that group is much smaller; a 2017 survey by Human Rights Campaign suggested fewer than 15% of all transgender boys and transgender girls play sports.

The number of NAIA transgender athletes would be far smaller.

AP Sports Writers Hank Kurz Jr., Mark Long and John Zenor contributed to this report.

AP college sports: https://apnews.com/hub/college-sports

Copyright 2024 The  Associated Press . All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Join the Conversation

Tags: Associated Press , sports

America 2024

Health News Bulletin

Stay informed on the latest news on health and COVID-19 from the editors at U.S. News & World Report.

Sign in to manage your newsletters »

Sign up to receive the latest updates from U.S News & World Report and our trusted partners and sponsors. By clicking submit, you are agreeing to our Terms and Conditions & Privacy Policy .

You May Also Like

The 10 worst presidents.

U.S. News Staff Feb. 23, 2024

Cartoons on President Donald Trump

Feb. 1, 2017, at 1:24 p.m.

Photos: Obama Behind the Scenes

April 8, 2022

Photos: Who Supports Joe Biden?

March 11, 2020

The Week in Cartoons April 8-12

April 8, 2024, at 12:38 p.m.

Trump Abortion Quotes Over the Years

Cecelia Smith-Schoenwalder April 8, 2024

Trump Lays Out Stance on Abortion

Lauren Camera April 8, 2024

EXPLAINER: The Total Solar Eclipse

Inflation Back in the Picture

Tim Smart April 8, 2024

RFK Jr.’s Mixed-Up Messaging on Jan. 6

Susan Milligan April 5, 2024

NAIA bans all transgender women from women’s sports

The National Association of Intercollegiate Athletics voted Monday to ban transgender women from women’s competitions starting next school year , spurring concerns among transgender-rights advocates that the NCAA may follow suit.

At the NAIA’s national convention, the Council of Presidents determined that beginning Aug. 1, only students “whose biological sex is female” may compete in women’s sports. That includes transgender men or nonbinary students who are not receiving masculinizing hormones.

“We are unwavering in our support of fair competition for our student-athletes,” NAIA President and CEO Jim Carr said in a news release. “It is crucial that NAIA member institutions, conferences, and student-athletes participate in an environment that is equitable and respectful. With input from our member institutions and the Transgender Task Force, the NAIA’s Council of Presidents has confirmed our path forward.”

With 241 member schools, most of them private with relatively low enrollments, the NAIA is overshadowed in size and influence by the NCAA, whose teams and events, including Monday night’s men’s basketball title game, are among the most popular in American sports.

NCAA rules allow transgender athletes to compete if they adhere to the guidelines of their international sport governing bodies. The NCAA has generally advocated for inclusion but has resisted pressure to pull championship events from states that prohibit transgender athletes from competing in publicly funded school sports.

“I think that [the NAIA vote] provides a feeling that the NCAA would have the latitude to do the same,” said Anna Baeth, director of research for queer sports advocacy group Athlete Ally. “That feeling of latitude would be incredibly misguided.”

Trans-athlete rights have long been the subject of conservative attacks and scrutiny, including at the K-12, college and Olympic levels. Anti-transgender activists and legislators argue that restricting or banning transgender athletes from competition is a matter of protecting women’s sports under Title IX and keeping cisgender women safe. (The science surrounding any physical advantages transgender women may retain over cisgender women is unsettled , and research is ongoing.)

Since 2020, about half of U.S. states have enacted measures banning transgender girls and women — and sometimes boys and men — from publicly funded scholastic sports in the categories that align with their gender identities. (Some of those bans are being challenged in court.)

Meanwhile, many international sport governing bodies have been grappling with how to institute scientifically sound and equitable rules. World Aquatics and World Athletics are among the groups that have heavily restricted the eligibility of transgender girls and women, barring them from competition if they have experienced testosterone-driven puberty.

“I’m 110 percent disappointed,” said Mack Beggs, a transgender man and former NAIA wrestler for Life University in Marietta, Ga. Competing in college, he said, “meant the world. It not only made me grow as an athlete — it made me grow as a person.”

The NAIA does not track whether any out trans athletes are among the approximately 83,000 participating in its sports, a spokesperson said. The organization’s 2023-24 policy allows trans and nonbinary athletes to compete in any gender category during the regular season.

For postseason events, trans athletes not receiving gender-affirming hormone treatment may compete in coed sports or in single-gender sports in the category associated with their assigned gender at birth. Transgender women who are receiving gender-affirming hormone treatment may compete in the women’s category in the postseason, provided they have already undergone one year of treatment. Transgender men taking medically prescribed, gender-affirming testosterone may not compete on women’s teams but may compete on men’s teams in the postseason.

Marshi Smith, co-founder of the Independent Council on Women’s Sports, which has funded a lawsuit against the NCAA over its policy, called the decision “historic” and urged more groups to “follow the science to preserve the original intent of Title IX.”

“The NCAA needs to look to the NAIA now to do what is just and right,” she said.

Chris Mosier, a trans rights activist and the first out transgender athlete to represent the United States in international competition, referenced recent anti-trans rhetoric as a potential influence on collegiate sports governing bodies’ policies.

“[The] NAIA and NCAA, along with many other sport organizations, teams, and leagues, have been under attack by anti-trans groups and individuals who have made it their life’s work to harm transgender people,” Mosier wrote in an email. “A policy change at this time, without a robust process of engaging experts, athletes, and people with lived experience, is solely based on political pressure.”

About 40 out trans athletes are thought to compete in NCAA sports, Baeth said. In March, 16 cisgender current and former female college athletes filed a lawsuit against the NCAA over its trans-athlete eligibility policy, demanding that the organization prohibit trans women from competing in women’s events and that it redistribute any recognition those athletes have received. The plaintiffs alleged the NCAA violated Title IX by allowing trans athletes such as University of Pennsylvania swimmer Lia Thomas to compete . Thomas won the 500-yard freestyle at the 2022 NCAA Division I championships.

The NCAA most recently updated its transgender eligibility policy in January 2022, in the run-up to the swimming championship meet.

The organization enacted a sport-by-sport approach that requires athletes to adhere to guidelines dictated by their specific sport’s international governing body. That change is still being phased in. The NCAA Board of Governors is next expected to meet April 25.

“College sports are the premier stage for women’s sports in America, and the NCAA will continue to promote Title IX, make unprecedented investments in women’s sports and ensure fair competition for all student-athletes in all NCAA championships,” an NCAA spokesperson said.

During a Final Four news conference Saturday, a reporter from OutKick, a conservative sports website, asked South Carolina women’s basketball coach Dawn Staley about her position on transgender athletes.

“I’m of the opinion that if you’re a woman, you should play,” Staley said. “If you consider yourself a woman and you want to play sports or vice versa, you should be able to play.”

• NCAA women’s title game sets new ratings record, capping historic run April 8, 2024 NCAA women’s title game sets new ratings record, capping historic run April 8, 2024
• NAIA bans all transgender women from women’s sports April 8, 2024 NAIA bans all transgender women from women’s sports April 8, 2024
• Caitlin Clark’s next steps include the WNBA draft and maybe the Olympics April 8, 2024 Caitlin Clark’s next steps include the WNBA draft and maybe the Olympics April 8, 2024

Hong Kong Free Press HKFP

Hong Kong news, breaking updates – 100% Independent, impartial, non-profit

After ‘painful’ wait since landmark ruling, Hong Kong revises policy on changing gender marker on ID card

• Click to share on X (Opens in new window)
• Click to share on Facebook (Opens in new window)
• Click to share on LinkedIn (Opens in new window)
• Click to share on Mastodon (Opens in new window)
• Click to share on WhatsApp (Opens in new window)
• Click to share on Reddit (Opens in new window)
• Click to share on Telegram (Opens in new window)
• Click to print (Opens in new window)

Transgender individuals in Hong Kong who have not completed full sex reassignment surgery may now apply to change the gender marker on their identity card, the government has announced, more than a year after a landmark ruling by the city’s top court .

The government on Wednesday said it had expanded the scope of eligibility for an individual to apply for amending the gender marker on their Hong Kong identity card. The amendment application was previously restricted to people who had undergone full sex reassignment surgery (SRS), but the Court of Final Appeal ruled in February last year that such a requirement was unconstitutional.

According to the revised policy, individuals who have not undergone full SRS may apply to change the gender marker on their ID card if they have completed surgical treatment for the purpose of modifying sexual characteristics. For those changing from female to male, they are required to have completed the removal of breasts, while those transforming from male to female need to have their penis and testes removed to be eligible for the application.

Applicants must also confirm that they have gender dysphoria; have lived as the opposite sex for at least two years and vow to continue living as the opposite sex for the rest of their lives; and that they have been undergoing hormonal treatment continuously for at least two years and will continue to do so.

They may be asked to submit blood test reports at the request of the commissioner of registration – a position held by the immigration chief – for random checking of their hormonal profile, the government said.

“[T]he revision concerns the policy on change of sex entry of Hong Kong identity card only, and that the sex entry on a Hong Kong identity card does not represent the holder’s sex as a matter of law. It does not affect any other policies of the government or the handling of any other gender-related matters under the law in Hong Kong or relevant legal procedures,” the statement read.

The policy revision came two weeks after transgender activist Henry Tse launched a legal challenge against the government’s delay in issuing him an identity card matching his gender, despite securing a win at the top court last year.

According to the bid, Tse said he had applied for the gender marker on his identity card to be amended to male last February. But the authorities had rejected his application, saying it could not be processed until the government had reviewed its policy based on the court ruling.

The government said on Wednesday that the review took into account the objective of the gender marker policy, relevant legal and medical advice, and drew reference from overseas practices.

The Immigration Department will process the received applications that were held up and contact individual applicants for follow-up, the government added.

In a statement released on Wednesday, Tse’s legal representative Wong Hiu-chong said her client and other people in the transgender community had “waited a very long time for such an unconstitutional policy to be revised.” The wait had been “painful,” the lawyer from Patricia Ho & Associates said.

“It remains regrettable that immense time and costs had to be spent before they could see their rights implemented,” the statement read.

Although the government announced the policy revision, it did not explain the delay for reviewing the policy, Wong said. The lawyer also raised concerns over the random blood test requirement.

“We do not see the justifications but the contravention of individuals’ rights by forcing them to take unnecessary medical tests and their right to privacy under Article 14 of the Bill of Rights,” she said.

Support HKFP   |   Policies & Ethics   |   Error/typo?   |   Contact Us   |   Newsletter   |  Transparency & Annual Report | Apps

Help safeguard press freedom & keep HKFP free for all readers by supporting our team

LATEST FROM HKFP

Tiananmen vigil trio turn to Hong Kong’s top court to try and challenge convictions over nat. security request

Hong Kong buys broadcasting rights for Paris Olympics for undisclosed fee, as leader John Lee cites ‘value to society’

Green group hits back after pro-Beijing heavyweight urges Hong Kong to halt or delay waste charging scheme

Hong Kong seizes HK$84m of ‘smuggled’ gold, reshaped into air compressor parts

HKFP has an  impartial stance ,  transparent funding , and  balanced coverage  guided by an  Ethics Code  and  Corrections Policy . 

Support press freedom & help us surpass 1,000 monthly Patrons : 100% independent, governed by an ethics code & not-for-profit.

Support HKFP   |  Code of Ethics   |  Error/typo?   |  Contact Us   |   Newsletter   |  Annual & Transparency Report

Kelly Ho Senior Reporter

Ho Long Sze Kelly is a Hong Kong-based journalist covering politics, criminal justice, human rights, social welfare and education. As a Senior Reporter at Hong Kong Free Press, she has covered the aftermath of the 2019 extradition bill protests and the Covid-19 pandemic extensively, as well as documented the transformation of her home city under the Beijing-imposed national security law.

Kelly has a bachelor's degree in Journalism from the University of Hong Kong, with a second major in Politics and Public Administration. Prior to joining HKFP in 2020, she was on the frontlines covering the 2019 citywide unrest for South China Morning Post’s Young Post. She also covered sports and youth-related issues.

HKFP is a proud member of:

Latest Stories

Activist lobbied for visa routes for Hongkongers, sanctions in wake of security law, Jimmy Lai trial hears

3 minors to face trial in China over alleged murder of classmate

After arrests in 2023, Hong Kong’s Songkran water-splashing festival moved off the streets

US ‘will not accept’ flood of underpriced Chinese goods, treasury chief Janet Yellen says as she wraps China visit

Hong Kong to consider public approval, drivers’ income as industry seeks to raise urban taxi flagfall to HK$32

Hong Kong press group seeks to challenge ‘unreasonable’ limits on journalists’ access to vehicle registry

Something went wrong. Please refresh the page and/or try again.

features & interviews

Hong Kong struggles to win back long-haul tourists amid fewer flights and travel warnings

Goodbye Music Zone: As the mid-sized Hong Kong venue closes its doors, it leaves a hole in local indie scene

Learning their red lines: Hong Kong’s drama groups struggle to set boundaries as performances are axed

In Pictures: Hong Kong book lovers bid farewell to independent store Mount Zero

Views expressed by opinion writers & advertisers are not necessarily shared by HKFP.

Where to find HKFP:

• HKFP Mobile Apps .
• HKFP Newsletter .
• HKFP Podcast .
• HKFP Facebook .
• HKFP Instagram .
• HKFP LinkedIn .
• HKFP Mastodon .
• HKFP Telegram .
• HKFP X/Twitter .
• HKFP YouTube .
• HKFP Apple News .
• HKFP Flipboard .
• HKFP News360 .
• HKFP Pushbullet .
• HKFP Whatsapp .

About HKFP:

• Advertise with HKFP .
• Announcements .
• Contact HKFP .
• Community Guidelines .
• Corrections Policy .
• Corrections Log .
• Documentary on HKFP .
• Freelance Charter .
• Newspaper Registration (periodical) .
• Policies, Ethics & Standards .
• Privacy, T's & C''s .
• Security Law .
• Staff Roster .

HKFP Partnerships:

Most-read stories today

About The Trust Project

The Trust Project is a collaboration among news organizations around the world. Its goal is to create strategies that fulfill journalism’s basic pledge: to serve society with a truthful, intelligent and comprehensive account of ideas and events.

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( A locked padlock ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

• Create Account

USCIS Provides Third Gender Option on Form N-400

We have revised Form N-400, Application for Naturalization, to provide a third gender option, “X,” defined as “Another Gender Identity.” We are also updating guidance in the USCIS Policy Manual accordingly to account for this form revision and other forthcoming form revisions that will add a third gender option; see the  Policy Alert (PDF, 344.77 KB) .

The 04/01/24 edition of Form N-400 will be the first USCIS form to include the X gender option. Applicants filing this edition of Form N-400 on or after April 1, 2024, will have X immediately available as a gender option on their form.

Applicants who have a pending Form N-400 using the edition in effect before April 1, 2024, may request to update their gender on or after April 1, 2024, as well. For all other forms, individuals must wait until USCIS revises those forms to include the X gender option.

Consult the chart below to determine if the X gender option is available to you.

Form N-400 is the only USCIS form that offers the X gender option at this time. Therefore, until we complete additional form revisions that add the X gender option, naturalization certificates are the only USCIS-issued secure identity documents that can reflect the gender X. The X gender option is not yet available on the Form N-565.

If you have other benefit requests pending with USCIS and would like to choose X as your gender, or if you would like to change your existing USCIS-issued secure identity documents to reflect X as your gender, you must wait until we update the relevant forms before you may do so. Once USCIS updates additional forms to offer the X gender option, benefit requestors may follow the instructions on the  Updating or Correcting Your Documents  webpage to select the X gender option. 

Supporting Documentation Not Needed

You do not need to provide supporting documentation to select X as your gender initially or to change your gender selection for Form N-400. The gender you select does not need to match the gender listed on your other immigration documents or on supporting identity documents, such as your birth certificate, passport, or state identification.

Social Security Card

Note that if you select the X gender option on the new Form N-400, you may need to visit a Social Security office for a Social Security card or to update your citizenship status. The Social Security Administration is still developing systems to accept the X gender option.

Historically, USCIS forms and associated documents have only offered two gender options: “Male (M)” and “Female (F).” This has created significant barriers for requestors who do not identify with either of those options. Limiting benefit requestors to two gender options also creates administrative challenges for USCIS when we receive birth certificates or other official government-issued documents with a gender other than M or F. Adding a third gender option helps ensure that secure identity documents and biographical data are accurate and helps both external stakeholders and individuals requesting immigration benefits. It is also consistent with federal and state agencies that have adopted a third gender option, such as the U.S. Department of State’s expanded passport services to offer gender X in their application.

In March 2023, USCIS updated the Policy Manual to allow for the self-selection of gender on USCIS forms. (PDF, 333.48 KB) This policy update allows benefit requestors to select their gender on all USCIS forms without providing supporting documentation (except for Form N-565, which requires a formal form revision to implement this policy). Benefit requestors may also change a prior selection without the need to provide specific supporting documentation, or to match prior documentation provided. This revision is consistent with efforts to break down barriers in the immigration system and reduce undue burdens in accessing immigration benefits, while still maintaining identity verification and fraud prevention procedures.