GIS 15 MA/019: New Restriction/Exception Codes for Transgender Individuals

To: Local District Commissioners, Medicaid Directors

From: Judith Arnold, Director
Division of Eligibility and Marketplace Integration

Subject:New Restriction/Exception Codes for Transgender Individuals

Effective Date: Immediately

Contact Person: Local District Support Units
Upstate (518) 474-8887 NYC (212) 417-4500

The purpose of this General Information System (GIS) message is to inform Local Departments of Social Services (LDSS) of two new Restriction/Exception (R/E) codes for transgender individuals.

Effective March 11, 2015, section 505.2(l) of Department regulations (18 NYCRR), was amended to cover certain medically necessary cross-sex hormone therapy and gender reassignment surgery for persons diagnosed with gender dysphoria. Due to gender edits in eMedNY, in order to pay claims for such services (with the exception of pharmacy claims for estradiol, conjugated estrogens, and testosterone cypionate), there currently is a manual process involving changing the gender temporarily to allow billing, in coordination with the provider, and then changing it back to the original gender.

The Department is working on systems modifications to make this manual process unnecessary. Two new R/E codes - "G1 - Transgender Individual - Male to Female", and "G2 - Transgender Individual - Female to Male" are now available for data entry into eMedNY effective September 24, 2015. This is phase one of this project. In phase two, scheduled for March 24, 2016, having one of the two new R/E codes entered into eMedNY will override gender edits that would otherwise prevent billing for certain treatment, services, and supplies.

Effective immediately, LDSSs are instructed to data enter the appropriate R/E code into eMedNY when a consumer provides appropriate documentation of their new gender status. Until March 24, 2016, when the new R/E codes become operative, it will continue to be necessary to use the current manual process to allow billing. Entering the new R/E code in advance of March 24, 2016 will increase efficiency as the new R/E code will already be in place, and allow billing to occur once phase two is completed.

Once phase two is complete, the two new R/E codes will bypass existing eMedNY gender-related edits and allow payment of all appropriate Medicaid covered treatment, services, supplies and pharmacy claims for the individual regardless of gender designation. Both codes can be retroactively authorized back to March 11, 2015, and will have an open ended "To Date" that does not expire and should not be removed. The new codes can be data entered when a Medicaid applicant/recipient (A/R) submits the appropriate documentation at application or at any time during their Medicaid authorization.

Prior to entering the R/E code into eMedNY, the requesting A/R is required to submit a signed and dated statement from a physician, nurse practitioner or physician assistant who has treated, or reviewed and evaluated the gender-related medical history of, the A/R. The statement must include language stating that the A/R has undergone appropriate clinical treatment for a person diagnosed with gender dysphoria. A copy of a Certified Amended Birth Certificate; or a passport; or a New York State Driver's License; or a Non-Driver ID card; or a statement from the Social Security Administration reflecting the change in gender designation may be submitted in lieu of the provider statement. It is no longer necessary for the individual to have undergone gender reassignment surgery (GRS).

Note: Prior to December 2006, when issuing gender-amended birth certificates, the New York City Department of Health and Mental Hygiene omitted reference to any gender for individuals who had undergone GRS. As of December 2006, the amended gender designation has been included on amended birth certificates.

An A/R's gender can also be changed on the Welfare Management System or New York State of Health (NYSoH) by submitting one of the above referenced documents (again, GRS is no longer required). If a Marketplace consumer submits documentation of a gender status change to the LDSS, the LDSS should fax the documentation to NYSoH. Please fax the documentation to 1-855-387-1363 and include a note on the fax cover sheet indicating the purpose of the documentation. This will help NYSoH staff process it accordingly. If the LDSS prefers to mail the documentation to NYSoH, it should be submitted to the following address: PO Box 11726, Albany, New York 12211. Note: Only the gender status change documentation should be submitted to this address.

Please direct any questions to your Local District Support liaisons.