Husky Health Connecticut (Connecticut Medical Assistance Program)

Policy Issued In
Connecticut
Last Update
Breast Reconstruction

Breast Augmentation may be considered medically necessary as part of male to female gender reassignment when breast enlargement, after undergoing hormone treatment for 24 months, is not sufficient for comfort in the social gender role and when all of the following criteria are met:

  1. The individual has capacity to make fully informed decisions and consent for treatment; and
  2. The individual has been diagnosed with gender dysphoria, and exhibits all of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and

    • The transsexual identity has been present persistently for at least two years; and

    • The disorder is not a symptom of another mental disorder; and

    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

  3. If the individual has significant, outstanding medical or mental health conditions present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated
  4. One referral from a qualified mental health professional who has independently assessed the individual.
Facial Reconstruction

Facial feminization procedures (e.g. rhinoplasty, facial bone reconstruction, blepharoplasty, etc., and electrolysis) may be considered medically necessary as part of male to female gender reassignment when all of the following criteria are met:

  1. The individual has capacity to make fully informed decisions and consent for treatment; and
  2. The individual has been diagnosed with gender dysphoria, and exhibits all of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and

    • The transsexual identity has been present persistently for at least two years; and

    • The disorder is not a symptom of another mental disorder; and

    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

  3. If the individual has significant, outstanding medical or mental health conditions present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
  4. One referral from a qualified mental health professional who has independently assessed the individual; and
  5. A letter from a qualified mental health professional certifying that the individual is experiencing significant psychosocial distress due to perceived inability to pass in the community as a member of the self-identified gender; and
  6. Facial photographs (both front and side views) for facial procedures, or of the affected part of the body.
Youth Services

Puberty Suppressing Hormone Therapy:

Puberty-suppressing hormones may be appropriate in adolescents as soon as pubertal changes have begun. In order for adolescents and their parents to make an informed decision about pubertal delay, it is recommended that adolescents experience the onset of puberty to at least Tanner Stage 2. The use of puberty – suppressing hormones:

  • May give adolescents more time to explore their gender nonconformity and other developmental issues; and
  • May facilitate transition by preventing the development of sex characteristics that are difficult or impossible to reverse if adolescents continue on to pursue gender affirmation surgery.

Puberty suppression may continue for a few years, at which time a decision is made to either discontinue all hormone therapy or transition to a feminizing/masculinizing hormone regimen.

Feminizing/Masculinizing Hormone Therapy Feminizing/masculinizing hormone therapy may be appropriate, Ideal treatment would be after evaluation by, or under the supervision of, a clinician with knowledge in bone development, e.g. pediatrician or pediatric endocrinologist. Treatment decisions should involve the adolescent, the family, and the treatment team.

EPSDT Special Provision Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federal Medicaid requirement that requires the Connecticut Medical Assistance Program (CMAP) to cover services, products, or procedures for Medicaid enrollees under 21 years of age where the service or good is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified through a screening examination. The applicable definition of medical necessity is set forth in Conn. Gen. Stat. Section 17b-259b (2011) [ref. CMAP Provider Bulletin PB 2011-36].