10 CCR 2505-10-8.735 - GENDER-AFFIRMING CARE

8.735.1 Definitions

Gender-Affirming Hormone Therapy means a course of hormone replacement therapy intended to induce or change secondary sex characteristics.

Gender-Affirming Surgery means a surgery to change primary or secondary sex characteristics to affirm a person's gender identity. Also known as gender confirmation surgery or sex reassignment surgery.

Gender Dysphoria means either: gender dysphoria, as defined in the Diagnostic Statistical Manual of Mental Disorders, 5th Edition (DSM-5), codes 302.85 or 302.6; or gender identity disorder, as defined in the International Classification of Disease, 10th Edition (ICD-10), codes F64. 1-9, or Z87.890.

Gonadotropin-Releasing Hormone Therapy means a course of reversible pubertal or gonadal suppression therapy used to block the development of secondary sex characteristics in adolescents.

8.735.2 Client Eligibility

8.735.2.A. Clients with a clinical diagnosis of Gender Dysphoria are eligible for the gender-affirming care benefit, subject to the service-specific criteria and restrictions detailed in Section 8.735.4.

8.735.3 Provider Eligibility

8.735.3.A. Enrolled providers are eligible to provide gender-affirming care if:

1. Licensed by the Colorado Department of Regulatory Agencies or the licensing agency of the state in which the provider practices;

2. Services are within the scope of the provider's practice; and

3. Knowledgeable about gender diverse identities and expressions, and the assessment and treatment of Gender Dysphoria.

8.735.4 Covered Services

8.735.4.A. The following requirements apply to all covered gender-affirming care:

1. Client has a clinical diagnosis of Gender Dysphoria;

2. Requested service is medically necessary, as defined in Section 8.076.1.8.;

3. Any co-existing physical and behavioral health conditions do not interfere with diagnostic clarity or capacity to consent, and associated risks and benefits have been discussed;

4. Client has given informed consent for the service; and

5. Subject to the exceptions in § 13-22-103, C.R.S., if client is under 18 years of age, client's parent(s) or legal guardian has given informed consent for the service.

8.735.4.B. Requests for services for clients under 21 years of age are evaluated in accordance with the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program criteria detailed in Section 8.280.

8.735.4.C. Behavioral health services are covered in accordance with Section 8.212.

8.735.4.D. Hormone Therapy

1. Covered hormone therapy services are limited to the following:

a. Gonadotropin-Releasing Hormone (GnRH) Therapy

i) GnRH therapy is a covered service for a client who:

1) Meets the criteria at Section 8.735.4.A.;

2) Meets the applicable pharmacy criteria at Section 8.800; and

3) Has reached Tanner Stage 2.

b. Gender-Affirming Hormone Therapy

i) Gender-Affirming Hormone Therapy is a covered service for a client who:

1) Meets the criteria at Section 8.735.4.A.;

2) Meets the applicable pharmacy criteria at Section 8.800;

3) Has been informed of the possible reproductive effects of hormone therapy, including the potential loss of fertility, and the available options to preserve fertility;

4) Has reached Tanner Stage 2; and

5) If under 18 years of age, demonstrates the emotional and cognitive maturity required to understand the potential impacts of the treatment.

ii) Other Gender-Affirming Hormone Therapy requirements

1) Prior to beginning Gender-Affirming Hormone Therapy, a licensed health care professional who has competencies in the assessment of transgender and gender diverse people must determine that any behavioral health conditions that could negatively impact the outcome of treatment have been assessed and the risks and benefits have been discussed with the client; and

2) For the first twelve (12) months of Gender-Affirming Hormone Therapy, client must receive medical assessments at a frequency determined to be clinically appropriate by the prescribing provider.

8.735.4.E. Permanent Hair Removal

1. Permanent hair removal is a covered service when:

a. Client meets the criteria at Section 8.735.4.A.; and

b. Used to treat a surgical site.

8.735.4.F. Surgical Procedures

1. Gender-Affirming Surgery is a covered service for a client who:

a. Meets the criteria at Section 8.735.4.A.1.-4;

b. Is 18 years of age or older;

c. Has completed six (6) continuous months of hormone therapy, unless hormone therapy is not clinically indicated or is inconsistent with the client's desires, goals, or expressions of individual gender identity;

i) This requirement does not apply to mastectomy surgeries;

ii) Twelve (12) continuous months of hormone therapy are required for mammoplasty, unless hormone therapy is not clinically indicated or is inconsistent with the client's desires, goals, or expressions of gender identity;

d. Understands the potential effect of the Gender-Affirming Surgery on fertility.

2. Requests for surgery for clients under 18 years of age will be reviewed by the Department and considered based on medical circumstances and clinical appropriateness of the request;

3. Rendering surgical providers must retain the following documentation for each client:

a. A signed statement from a licensed health care professional who has competencies in the assessment of transgender and gender diverse people, demonstrating that:

i) Criteria in Section 8.735.4.F.1.a.-d. have been met; and

ii) A post-operative care plan is in place.

4. Covered Gender-Affirming Surgeries include:

a. Genital surgery;

b. Breast/chest surgery; and

c. Facial and neck surgery.

5. Requests for other medically necessary Gender-Affirming Surgeries will be reviewed by the Department and considered based on medical circumstances and clinical appropriateness of the request.

6. Pre- and post-operative services are covered when:

a. Related to a surgical procedure covered under Section 8.735.4.F; and

b. Medically necessary, as defined in Section 8.076.1.8.

8.735.5 Prior Authorization

8.735.5.A. Prior authorization is required for hormone therapy services listed in Section 8.735.4.D . in accordance with pharmacy benefit prior authorization criteria at Section 8.800.7.

8.735.5.B. Surgical services may require prior authorization.

8.735.5.C. All prior authorization requests must provide documentation demonstrating that the applicable requirements in Section 8.735.4 have been met.

8.735.6 Non-Covered Services

8.735.6.A. The following services are not covered under the gender-affirming care benefit:

1. Any items or services excluded from coverage under Section 8.011.1.

2. Reversal of surgical procedures covered under Section 8.735.4.F.

Notes

10 CCR 2505-10-8.735

46 CR 15, August 10, 2023, effective 8/30/2023