Washington state law prevents insurance discrimination based on gender identity and in 2021 Washington State passed Senate Bill 5313, prohibiting health insurers from denying or limiting coverage for gender affirming treatment when that care is prescribed to an individual on the basis of a protected gender expression or identity, is medically necessary, and is prescribed in accordance with accepted standards of care.
Still, there are often a number of documentation and health-related steps necessary in order to meet the World Professional Association of Transgender Health (WPATH) standards of care and requirements for coverage through insurance. All gender affirming surgeries must meet the above standards of care and have this documented by both a primary care provider and mental health provider(s), regardless of insurance coverage and payment. All gender affirming health providers are required to follow WPATH standards of care that include provider letters, without exception.
Please read the Before making a referral for gender affirming surgical care – What you need to know section below to ensure these steps are completed.
The gender affirming surgical care coverage process is unique and the provider documents required are specific to these services and this population. No additional referring provider letter requirements are necessary for primary care establishment, or the initiation or management of Hormone Replacement Therapy (HRT).
For more information on current gender affirming care services available at UW Medicine. If you are interested in learning about gender affirming care and becoming an allied provider check out the TGNB Allied Provider Resources page and contact us to be added to the group.
Before making a surgical referral – What you need to know
UW Medicine follows the standards of care determined by the WPATH and ask that you ensure your patient meets the below criteria and you provide all required clinical documentation before referring your patient to a surgical provider.
Does your patient meet medical and surgical criteria?
1) All gender affirming healthcare is dependent on a Gender Dysphoria/Gender Identity disorder diagnosis (F64.9), so ensure the patient has been diagnosed with GD/GID before making a surgical referral.
2) All Gender Affirming Surgical Criteria must be met as determined by WPATH, established in WA gender affirming care legislation, and indicated in WA insurance coverage requirements regulated by the Washington state Office of the Insurance Commissioner.
Does your patient have the surgical endorsement letters needed for surgical referral and consult?
All gender affirming surgical referrals must be accompanied with: (letter requirements and sample templates linked below)
- A letter of support from a primary care provider or whomever is prescribing hormones (if applicable).
- (1-2) Mental health assessment letter(s) from a licensed mental health provider, depending on surgery requested. (See Gender Affirming Surgical Criteria). Mental Health letters can be acquired during the consult process, but patients must have an accessible avenue to get these letters before or soon after a referral is made, so as not to delay surgical authorization and scheduling.
*These criteria do not apply to patients who are having these surgical procedures for medical indications other than gender dysphoria, nor post-op repairs. If another medical indication is appropriate and would facilitate care sooner, fine to proceed on that basis.
All gender affirming care is dependent on a Gender Dysphoria/Gender Identity disorder diagnosis (F64.9).
Gender Dysphoria – DSM V (adolescents and adults)
The DSM-5 defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
- A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
- A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
- A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Gender Dysphoria – DSM V (children)
The DSM-5 defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):
- A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
- In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
- A strong preference for cross-gender roles in make-believe play or fantasy play
- A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
- A strong preference for playmates of the other gender
- In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
- A strong dislike of one’s sexual anatomy
- A strong desire for the physical sex characteristics that match one’s experienced gender
As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
UW Medicine’s allied gender affirming Primary Care Providers and allied Endocrinologist can initiate or manage Hormone Replacement Therapy (HRT)
UW Medicine, in accordance with the WPATH standards of care, utilizes an informed consent model when providing hormone replacement therapy (cross-sex hormones) services to our TGNB patients
This model eliminates unnecessary gatekeeping that can delay access to care, improving health outcomes while also proactively responding to the well documented disparities in care access and utilization for the trans and non-binary community.
Looking for guidance on HRT management and/or HRT consent forms? More can be found on the TGNB Allied Provider Resources page
- Informed consent form for estrogen and/or androgen antagonists
- Lab monitoring on estradiol
- Informed consent form for testosterone
- Lab monitoring on testosterone
Informed Consent Smart Phrases:
If you have confirmed your patient has a Gender Dysphoria diagnosis, meets gender affirming surgical criteria, and has access to or all the necessary letters from their primary care and mental health providers in support of surgery, then finding the right provider is the next step and can be explored on the UW Medicine Services and Providers, UW Medicine Surgical providers, and Gender Affirming Surgical Care Overview pages.
*For providers and services not yet offered at UWM, consult the Surgical Providers and Services Outside UWM tab in the section below.
- All Gender Affirming Surgeries require the following WPATH guidelines be met, and for insurance plans to approve coverage of procedures for Gender Dysphoria (this excludes post-operative repairs or emergencies):
- Letter of surgical support from a primary care provider. This is often the provider who diagnosed Gender Dysphoria, and/or prescribes and monitors HRT if present.
- Letter from a licensed mental health provider affirming readiness for surgery.
- Letter from surgeon in support of surgery and affirming readiness for surgery (This will be done after surgical consult with the surgeon).
*Evaluations or qualifying psychotherapy must be performed by, and letters of recommendation written by, professionals who are state licensed to practice independently (without supervision) as master’s degree level mental health clinicians, doctoral level mental health clinicians, psychiatric nurse practitioners, psychiatric physician assistants, or Board-Eligible or Board-Certified psychiatrists.
Hair removal for surgery is now covered by WA state insurance providers. If your patient needs a letter to support covering these services, consult this SFHP guide. It is similar to the surgical endorsement letters needed from PCPs and/or MH providers, but with the added language that hair removal is indicated as necessary for gender affirming surgery. Not all plans will require this, but for those who request it for coverage, this guide can be followed.