Transhealth program

Apple Health (Medicaid) Transhealth program

Apple Health covers primary care, behavioral health services, speech therapy (including voice training), hormone therapy (including puberty blockers), and labs. If you are enrolled in a managed care plan, these services will be covered by your plan. Contact your plan to request a list of providers.

You can ask your managed care plan for a case manager to help coordinate your care. The member services phone number can be found on the back of your insurance card.

Other gender-affirming treatments, including surgical procedures and gender affirming hair removal, are covered directly by Apple Health using your ProviderOne services card.

Requirements

Gender-affirming treatments must be provided by Apple Health-enrolled providers. Prior authorization is required for these services. Apple Health only approves and pays for medically necessary services.

General requirements

General requirements include:

• Six continuous months of hormone therapy immediately preceding a request for genital surgery and/or;
• Twelve continuous months of hormone therapy immediately preceding a request for breast augmentation surgery.
• Some exceptions include if:
  • Hormones are not clinically indicated and/or not aligned with your gender health care plan.
  • You have requested a mastectomy or reduction mammoplasty.
  • You have a medical contradiction to hormone therapy.
  • You have a medical necessity for surgery and are currently following gender dysphoria treatment.

Definitions

This webpage covers some terms you may not be familiar with. Refer to to the definitions below for more information.

• Gender dysphoria, or gender incongruence, describes the deep discomfort or distress someone might feel when their gender identity doesn't match the sex they were assigned at birth.
• Informed consent means your provider makes sure you understand your treatment before moving forward. They will explain what the treatment involves, the benefits, risks, and side effects, as well as other options and what might happen if you choose not to proceed. They will also talk about any limits to keeping your information private and how the treatment might affect your ability to have children. You'll need to confirm that you understand everything and agree to the treatment willingly.

Commonly requested procedures (top, bottom, hysterectomy, orchiectomy, and facial feminization surgery)

Required documentation

• A letter from a licensed mental health care provider.
  • Letters and evaluations must be no more than 18 months old, signed and dated by providers and/or licensed health care professionals eligible under WAC 182-531-1400.
  • Each behavioral health assessment must include the following:
    • Confirmation of the diagnosis of gender dysphoria, or gender incongruence, or both, as defined by the Diagnostic Statistical Manual of Mental Disorders.
    • Documentation that you feel your gender identity does not match your body, and this feeling has been strong and persistent. You want to make your body align more with your gender, using treatments like surgery, hormone therapy, or other medical treatments. This mismatch between your gender identity and your body causes significant stress or problems in your daily life, like in work, relationships, or other important areas. You don't have any mental health conditions that would make it hard for you to fully understand and agree to the treatments. If you do have a condition that affects your ability to make decisions, but you still understand the risks, benefits, and other options for treatment, your provider will help you manage that condition to make sure you can give informed consent.
• A letter from the provider who prescribes your hormone therapy.
  • The letter must be no more than 18 months old. The letter must be signed and dated. If you do not take hormones, then a letter of support is required from your primary care provider documenting that hormones are not clinically indicated and/or hormones are not aligned with your gender health care plan.
• Chart notes from the surgeon or provider.
  • Must be no more than one year old and include your provider's or surgeon’s evaluation and the treatment plan for gender affirming care.
  • Must demonstrate medical necessity for surgery and surgical plan.
• The surgeon must provide documentation showing that you have been informed of:
  • The nature of proposed care, treatment, services, medications, and procedures;
  • Potential benefits, risks, or side effects, including potential problems that might occur during recuperation;
  • The likelihood of achieving client treatment goals;
  • Reasonable alternatives;
  • Relevant risks, benefits, and side effects related to alternatives, including the possible results of not receiving care, treatment, and services;
  • Any limitations on the confidentiality of information learned from or about the patient;
  • The effect of gender-affirming treatment on reproduction, and;
  • Reproductive options before having gender-affirming surgeries that have the potential to create iatrogenic infertility.

Genital or donor skin site hair removal in preparation for bottom surgery

Required documentation

• Letter of medical necessity from the treating surgeon.
  • The letter must include the size and location of the area to be treated and expected date of the planned genital surgery.
• Letter of medical necessity from the provider who will perform the hair removal.
  • The letter must include the surgical consult for bottom surgery that addresses the need for hair removal before gender-affirming surgery.

Hair removal from face and body

Required documentation

• Letter from the provider managing the client's gender affirming hormone therapy.
  • The letter must be no more than 18 months old and should be signed and dated.
  • If you are not taking hormones, the letter must explain why hormones are not needed for you, or why they don’t fit with your overall gender health care plan.
  • The letter should describe which hair removal methods you’ve tried and why they didn’t work, for each area of your body.
• Letter from your hair removal provider written within the past 18 months that includes:
  • Size and locations of areas to be treated.
  • The number of treatment sessions and units needed for each area.
  • Photographs of the areas to be treated, only if requested by the agency.

Gender affirming voice surgery

• Completion of speech or voice therapy.
• Otalarynologists consult and evaluation.
• Gender dysphoria/incongruence is marked and sustained.
• Gender affirming hormone therapy is not required for voice feminization.

Required documentation

• Letter of support from speech language pathologist (SLP).
  • Letter should be within the past 12 months and confirm completed speech therapy or voice therapy which includes the outcome.
• History and physical and treatment plan from the otolaryngologist who will perform the procedure.
  • Letter should be within the past 12 months.
• Letter of medical necessity supporting the request for voice modification procedure from the primary care provider.
  • Letter should be within the past 18 months.
• For voice masculinization - letter from the managing provider of hormone therapy.
  • Letter should be within the past 18 months.

How to provide the required documentation

Follow the steps below to provide documentation for your gender-affirming treatments.

1. Prepare your documentation: Gather all necessary documents, such as behavioral health assessments, letters of medical necessity, or any additional documentation specified for your treatment.
2. Contact providers: Reach out to the providers who will be performing your gender-affirming treatments. Call their office to schedule a consultation or ask about their process for submitting documentation.
3. Share your documents: Provide your documentation to the providers during your consultation or as directed. They will include this information when they request prior authorization for your treatments.
4. Get help if needed: For questions about the Transhealth Program or assistance with documentation requirements, you can email the Transhealth Program.

Starting with a consultation helps ensure that your provider has everything needed to support your treatment journey.

Find a provider

You can see any provider enrolled with Apple Health who offers the treatments you need. Call the providers office directly to schedule a consultation. Consultations do not require prior approval. However, the provider will seek prior authorization for treatments.

Need help finding a provider?

Primary care, behavioral health, speech therapy, and hormone therapy

• Contact your managed care plan for a list of providers. The contact information is located on the back of your health plan card.

Gender-affirming surgeries and treatments (including hair removal)

• Email the Transhealth Program to request a list of providers.
• Apple Health-enrolled providers:
  • You can see any provider enrolled with Apple Health who offers the treatments you need.
  • Call the provider directly to schedule a consultation.
  • Consultations do not require prior approval. However, the provider will seek prior authorizations for treatments.

Not sure if a provider accepts Apple Health?

• Use the ProviderOne Find a Provider tool to confirm if a provider accepts Apple Health coverage.

Transportation services

If you need help getting to your health care appointments, you may be eligible for free transportation, as long as the appointment is for services covered by Apple Health.

Here’s how to get started:

• Call 1-800-562-3022 if you need help finding transportation or a doctor in your area.
• Visit the transportation services webpage to find a transportation broker in your county.
• Contact the broker 7 to 14 days before your appointment to schedule your ride.
• Keep in mind that requests made less than two business days before your appointment may not be scheduled.

Make sure to plan ahead to ensure your transportation is arranged in time for your appointment.

Changing your gender marker

• If you applied for health coverage through Washington Healthplanfinder, report this change by either calling Health Care Authority at 1-800-562-3022, emailing AskMAGI, or online at Washington Healthplanfinder. As of May 2020, the Washington Healthplanfinder application asks for your “sex assigned at birth.” If you are seeking pregnancy coverage, you will need to answer “female.” Otherwise, you can continue to use your gender marker.
• If you applied for health coverage through the Department of Social and Health Services or Washington Connection, you must report this change by either calling 1-877-501-2233 or online at Washington Connection.

Any Apple Health client can call and choose a gender. Clients should be aware that other state agencies, such as the Department of Licensing, have different requirements.

The Health Care Authority, Department of Social and Health Services, and the Health Benefit Exchange are working together with other state agencies to incorporate gender identity into their applications and other processes.

Changing your name

Before making a name change, you should first obtain a name change through the Social Security Administration (SSA). If your name in the system does not match the name on file with SSA, an error will be generated and this could affect your coverage.

• If you applied for health coverage through Healthplanfinder, you must report this change by either calling Health Care Authority at 1-800-562-3022 or online at Washington Healthplanfinder.
• If you applied for health coverage through the Department of Social and Health Services or Washington Connection, you must report this change by either calling 1-877-501-2233 or online at Washington Connection.