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PA Bulletin, Doc. No. 16-1364


Medical Assistance Coverage of Services Related to Gender Transition

[46 Pa.B. 4896]
[Saturday, August 6, 2016]

 The Department of Human Services (Department) is announcing that it intends to amend the Medical Assistance (MA) regulations to remove language that prohibits payment for certain services related to sex reassignment and that medically necessary services related to gender transition that are within the scope of covered benefits will be compensable under the MA Program.


 On May 13, 2016, the United States Department of Health and Human Services' Office of Civil Rights issued the final rule entitled ''Nondiscrimination in Health Programs and Activities,'' implementing section 1557 of the Affordable Care Act (42 U.S.C.A. § 18116), which prohibits discrimination in health programs and activities on the grounds of race, color, national origin, sex, age or disability. The Federal final rule is effective July 18, 2016. See 81 FR 31376 (May 18, 2016).

 In part, this Federal final rule prohibits the State Medicaid Program from having or implementing any categorical coverage exclusion or limitation for health services related to gender transition. The State Medicaid Program is not, however, restricted from determining whether any particular service meets medical necessity requirements or otherwise meets applicable coverage requirements in a particular case. 45 CFR 92.207 (relating to nondiscrimination in health-related insurance and other health-related coverage).

 The Commonwealth's current MA regulations include several explicit categorical coverage exclusions that prohibit MA payment for surgical procedures and medical care related to sex reassignment: 55 Pa. Code §§ 1121.54(10), 1126.54(a)(7), 1141.59(11), 1163.59(a)(1) and 1221.59(7). These categorical payment prohibitions in the Commonwealth's current MA regulations are inconsistent with the Federal final rule and will no longer be applied. The Department has issued an MA Bulletin to providers enrolled in the MA Program relating to the coverage of services related to gender transition.

 The Department intends to remove the explicit categorical coverage exclusions previously indicated from MA regulations. In addition, the Department intends to amend the nondiscrimination statement in 55 Pa. Code § 1101.51(b) (relating to ongoing responsibilities of providers) to include ''age'' and ''sex.''

 The Department intends to publish these regulatory changes as a final-omitted rulemaking by November 12, 2016.

Fiscal Impact

 The estimated cost for Fiscal Year (FY) 2016-2017 is $9.112 million ($4.394 million in State funds). The estimated cost for FY 2017-2018 is $9.112 million ($4.386 million in State funds).


Fiscal Note: 14-NOT-1051. (1) General Fund; (2) Implementing Year 2016-17 is $4,394,000; (3) 1st Succeeding Year 2017-18 is $4,386,000; 2nd Succeeding Year 2018-19 is $4,357,000; 3rd Succeeding Year 2019-20 is $4,357,000; 4th Succeeding Year 2020-21 is $13,486,000; 5th Succeeding Year 2021-22 is $13,486,000; (4) 2015-16 Program—$3,828,000,000; 2014-15 Program—$3,823,000,000; 2013-14 Program—$3,995,000,000; (7) MA—Capitation; (8) recommends adoption. Funds have been included in the budget to cover this increase.

[Pa.B. Doc. No. 16-1364. Filed for public inspection August 5, 2016, 9:00 a.m.]

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