Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Medical and surgical services, supplies and equipment intended to assist or complete the differentiation of a baby born with undifferentiated or ambiguous genitalia, will be covered.

For children born with ambiguous genitalia, sex assignment and related charges are considered medically necessary and shall be covered as a basic medical service. 

Individualized therapy (mental health, hormones or surgery) provided for gender dysphoria (per DSM V criteria) may be covered according to guidelines in BI531.

Addendum:

Effective 01/01/2017: Limited scope of policy to surgery for congenital ambiguous genitalia or indeterminate sex.  Refer to (new) BI531 for individualized treatment of gender dysphoria.

Unless indicated otherwise, this policy applies to all QCA Health Plans, unless a specific limitation exists.  Consult individual plan sponsor benefit descriptions for self-insured plans.  In the event of a discrepancy between this policy and a self-insured customer’s benefit description, the benefits plan will be followed.  Applicable state mandates will be followed with respect to self-funded non-ERISA plans and fully insured plans.  Federal mandates will apply to all plans.