TRICARE Manuals - Display Chap 7 Sect 1.3 (Change 120, Nov 8, 2023)

Medicine

Chapter 7

Section 1.3

Gender Dysphoria (GD) and Gender-Affirming Health Care For Dates of Service On or After July 1, 2022

Issue Date: December 6, 2022

Authority: 32 CFR 199.4(e)(8)(ii)(D), (g)(29), and (g)(30); and Title 10, United States Code (USC) 1079(a)(11)

Revision: C-105, December 6, 2022

1.0 DESCRIPTION

GD is a condition in which a person experiences clinically significant distress, or impairment in social, occupational, or other important area of functioning, of at least six months duration, because of a marked incongruence between the sex assigned, usually at birth (i.e., natal sex) and their experienced/expressed gender identity. The clinical definition is provided in the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition (May, 2013). Diagnosis is to be made using the most current edition of the DSM.

2.0 POLICY

Medically or psychologically necessary and appropriate medical care (as defined in 32 CFR 199.2), including non-surgical treatments for GD, are covered when provided by a TRICARE-authorized provider.

2.1 Mental Health Treatment

2.1.1 Psychotherapy for the treatment of GD and psychotherapy for beneficiaries pursuing transition are covered.

2.1.2 Consistent with mental health treatment for other diagnoses, outpatient, office-based, mental health visits do not require a referral or preauthorization.

2.1.3 Treatment team conferences (Common Procedural Terminology (CPT) 99366, 99367, and 99368) are covered.

Note: Active Duty Service Members (ADSMs) require Military Treatment Facility (MTF) referral/authorization or Specified Authorized Staff (SAS) preauthorization prior to receiving non-emergency health care services (other than primary health care for members enrolled in TRICARE Prime Remote (TPR)) in the private sector. The contractor shall comply with the provisions of the TRICARE Operations Manual (TOM), Chapters 16 and 17 when processing requests for ADSMs.

2.2 Endocrine Treatment

Gender-affirming hormone therapy, also known as cross-sex hormone treatment, is covered for adult or adolescent beneficiaries when all of the following criteria are met:

• The beneficiary meets the eligibility criteria outlined in the most current version of the Endocrine Society Clinical Practice Guidelines for Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons.

• The beneficiary has no contraindications to gender-affirming hormone therapy.

• Note: Endocrine treatment includes pubertal suppression.

3.0 EXCLUSIONS

3.1 Surgical treatment of GD for all beneficiaries (10 USC 1079). All services and supplies related to surgical treatment for GD (i.e., gender-affirming surgical procedures), including, but not limited to, mastectomy, oophorectomy, and orchiectomy. ADSMs may obtain the surgical treatment for GD with a Supplemental Health Care Program (SHCP) waiver approved by the Defense Health Agency (DHA) Director or the delegated authority.

3.2 Cosmetic, reconstructive or plastic surgery procedures. See Chapter 4, Section 2.1.

3.3 Endocrine treatment of prepubertal children prior to Tanner Stage 2.

3.4 All services and supplies to preserve fertility. See Chapter 4, Sections 15.1 and 17.1.

3.5 Voice therapy by a speech language pathologist to transform speech patterns of the affirmed gender. See Chapter 7, Section 7.1.

4.0 EFFECTIVE DATE

July 1, 2022, for non-surgical treatments of GD.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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