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

November 2015

Medicare Advantage Stride (HMO) Gender Reassignment Services

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. As is the case with our commercial products, Harvard Pilgrim’s Medicare Advantage StrideSM (HMO) products cover gender reassignment services recommended by qualified practitioners for eligible members with a diagnosis of gender dysphoria. This includes medically necessary clinician visits, gender reassignment surgeries, behavioral health services, etc. Harvard Pilgrim’s Medicare Advantage Stride (HMO) products also cover routine preventive care (including mammograms, pelvic and prostate exams) for all eligible persons, regardless of gender markers.

Gender reassignment support
Harvard Pilgrim works closely with our Medicare Advantage Stride (HMO) members throughout the gender reassignment process. Our Care Management and Medicare Advantage Customer Service departments are often the key points of contact for such members considering gender reassignment services. Medicare Advantage Customer Service 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
Medicare Advantage Stride (HMO) members seeking coverage for gender reassignment surgeries must meet specific clinical guidelines and receive prior authorization. As with other doctor or hospital services, coverage decisions for gender reassignment surgeries are made individually on the basis of medical need and applicable standards of care. Providers can submit a prior authorization request for gender reassignment surgery through our Medicare Advantage Provider Service Center at 888-609-0692 (TTY: 711) or by FAX at 866-874-0857.
Please refer to our Medicare Advantage Stride (HMO) Medical Review Criteria for Gender Reassignment Services for more information. For any questions your patients may have about Harvard Pilgrim’s Medicare Advantage Stride (HMO) gender reassignment benefits or prior authorization processes, you can direct them to Medicare Advantage Customer Service at 888-609-0692 (TTY: 711).

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