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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

August 2015

Coordination of Care for Transgender Patients

Providing the proper care to transgender men and women requires a highly personalized care management plan, often involving collaboration between health professionals in different specialties. The medical course will be different for every transgender individual — some may choose to have one or multiple surgeries; some opt to identify as their gender of choice without any physical medical procedures; some take hormones but do not feel the need to have surgery; etc. The goal is to help patients with gender dysphoria affirm who they see themselves to be.

What kind of support does Harvard Pilgrim offer?

Harvard Pilgrim works closely with members throughout the gender reassignment process. The overall treatment plan often includes services covered under multiple medical plan benefits (e.g., physician and behavioral health visits, outpatient prescription drugs). As such, collaboration and communication among health care providers involved in the treatment of each individual patient is essential.

Our Care Management and Member Services departments are often the key points of contact for members considering gender reassignment services. Member Services can review the member’s coverage and transgender benefit and connect the patient with a nurse care manager. The nurse care manager works closely with the member every step of the way, answering questions, explaining coverage, identifying providers to administer the necessary services, and helping to manage costs.

Behavioral health services

The individual’s health care team may also include behavioral health providers. These providers can offer support with any issues that may come up for transgender individuals, such as the effect on relationships with family, friends and coworkers, concerns about prejudice or violence, levels of satisfaction with appearance, etc. For complex clinical situations, practitioners can call the Optum/UBH Physicians Consultation Service at 800-292-2922. To refer a patient for behavioral health services and to facilitate the coordination of care, call Optum at 888-777-4742.

Prior authorization for gender reassignment surgeries

All members seeking coverage for gender reassignment surgeries must meet Harvard Pilgrim’s clinical guidelines and receive prior authorization. For example, the member must  be at least 18 years of age, be enrolled in a plan with the gender reassignment surgery benefit, and must be medically cleared by a physician for the procedure(s). Please refer to our Medical Review Criteria for Gender Reassignment Services for more information on our gender reassignment coverage and authorization criteria.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator