Indiana Medicaid and Transgender Healthcare

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We had a number of folks contact us about Indiana Medicaid. Among the things that trans Hoosiers were reporting to us was that they were not getting consistent information from Indiana Medicaid about whether their transition-related health care is covered under their health plans. They were being told:

  • That hormone therapies for trans men and women ARE covered as medically necessary under the diagnosis ICD-9 code 302.85 for gender dysphoria (that’s awesome!)
  • that gender-confirming surgeries were not covered at all.
  • that Indiana Medicaid covered surgery, but couldn’t cover surgeons out of state unless they had a specific contract with Indiana Medicaid.
  • that surgeries like 19303 ( trans male top surgery) were covered under Indiana Medicaid, but they wouldn’t be considered medically necessary under the diagnosis ICD-9 code 302.85 for gender dysphoria.

After calling around to a number of Medicaid offices, I finally tracked down some folks who would give me a definitive answer to my questions about Indiana Medicaid policies for transgender care, which is this:

  • Hormone therapies for trans men and women ARE covered as medically necessary by Indiana Medicaid under the diagnosis ICD-9 code 302.85 for gender dysphoria – 100% (although this isn’t in the official policy manual, but trans men and women are reporting having their hormones covered )
  • gender-confirming surgeries for trans people are not covered at all by Indiana Medicaid because Indiana Medicaid does not consider them medically necessary, even if a trans person has a diagnosis of gender dysphoria.

Office of Medicaid and Policy Planning: Medical Policy Manual – Relevant information is on Pages 750-760. [Note that in this 800+ page document, the words transgender & gender dysphoria appear not once. There is literally no policy noted for trans health care at all for Hoosiers.]

The reason there was some confusion was because some of the gender confirming surgeries for trans men and for trans women ARE covered for other diagnoses – but not for gender dysphoria.

Interestingly, chest reduction and re-sculpting to a male chest (codes 19300 and 19350) *is* covered – for cis men (suffering from “gynecomastia”)- as medically necessary for mental health reasons. But it’s not covered for trans men.

In talking to some activists from other red states, this is not an unusual discrepancy between covering hormone treatments but not gender-confirming surgeries. It’s WRONG, of course. It’s not up to the state or any insurance company to decide what is and is not medically necessary if it contradicts the diagnosis of medical professionals. But it’s not uncommon.

That inconsistency leaves the state of Indiana open for a lawsuit, and this is an area where we should, as a trans community, seek to pursue a case, if we can find an Indiana medicaid client seeking this kind of care that would like to pursue the issue.

The process I went through to extract this info from the state of Indiana

1) I started off by calling Hoosier Care Connect, which is one of three programs under the Indiana Medicaid program. I chose it because it’s the plan that trans folks have reported trying to contact for information about whether trans-related care is covered.

2) They said that they didn’t know the answer, but that I should try calling the Office of Family and Social Services Administration, which oversees Medicaid. I gave them a call, and they sent me back to the Hoosier Care Connect line.

3) I got Hoosier Care Connect back online. They told me that they only determine people’s eligibility for enrollment under Hoosier Care Connect, not what the Medicaid policy is. They suggested I call the Medicaid Hotline Number (1-800-457-4584).

4) I called Medicaid Hotline Number (1-800-457-4584) they told me that they could look up the procedures about what would be covered. I gave them the codes for trans men’s top surgery – 19303 and 19350 and they said they would be covered, but not be considered medically necessary under a diagnosis of gender dysphoria. I asked why hormones were considered medically necessary and people were able to successfully get hormones, and they didn’t know. They suggested I call the Office of Medicaid Policies and Planning (317-233-4455) and ask.

5) I called the Office of Medicaid Policies and Planning (317-233-4455), and got an odd phone tree. I ended up with two numbers – one for the director (Chris??)- 317-232-4966 and one for the communications director Jim Gavin – 317-234-0197. I left messages at both numbers. Eventually I got email from Mr. Gavin responding in a very indirect manner to my inquiry. Throughout all of my conversations I discussed transgender clients, diagnosis of gender dysphoria and used the specific medical codes for trans men and trans women in discussing my questions, so there should have been no confusion about what we were talking about. Nevertheless, the email I received from Mr. Gavin spoke almost completely about intersex conditions and not transgender people:

Indiana Transgender Network,

Indiana Medicaid does have policy language around coverage of intersex surgery. 405 IAC 5-3-13 states we require prior authorization for intersex surgery. The medical policy manual language is included below:

Reconstructive surgery is considered medically necessary for missing, defective, damaged, or misshapen structures of the genitourinary system. Additionally, the IHCP will provide reimbursement if a member has had significant alterations due to disease, trauma, surgery, or congenital anomalies. PA is required for reconstructive surgery.

The IHCP does not provide reimbursement for the following:

· Scar removal or tattoo removal by excision or abrasion
· Penile implants
· Perineoplasty for sexual dysfunction
· Tubal reanastomosis for the purpose of infertility

The IHCP defines intersex surgery as surgical intervention for members having congenital anomalies, resulting in both male and female characteristics. The IHCP considers intersex surgery medically necessary for congenital anomalies resulting in a member having ambiguous genitalia. Documentation in the member’s medical record is required to support medical necessity. All other intersex surgery is not covered. (emphasis ours)

The manual found at the link below outlines all of our covered services. The policy language above is on page 753.
http://provider.indianamedicaid.com/ihcp/manuals/Medical%20Policy%20Manual.pdf

We do cover some other services that individuals transitioning may need, such as psychotherapy for members diagnosed with gender dysphoria.

Finally, Indiana Medicaid reimburses for covered outpatient drugs which are prescribed for FDA-approved or compendia-based indications.

Thank you,

Jim Gavin, APR
Director of Communications and Media
Indiana Family and Social Services Administration

As you can see, Mr. Gavin was bending over backwards to give me the information that our gender-confirming surgery care is not covered under Indiana Medicaid, but in the most round-about way possible without actually saying the word “transgender” in his reply. Follow-up emails with specific questions about diagnosis of gender dysphoria and specific medical codes involved yielded no response.

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