MedicaidPrior AuthMedium impact
Gender Reassignment/Gender Affirming Surgery and Treatments for Medicaid Managed Care Plan (MMCP) and Health and Recovery Plan (HARP) Members 7.01.105
Excellus BlueCross BlueShield·NY · Plastic Surgery, Urology, OB-GYN +3 more·Miscellaneous
Effective date
Jan 22, 2026
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield has established comprehensive coverage criteria for gender reassignment/gender affirming surgeries and treatments for Medicaid Managed Care Plan (MMCP) and Health and Recovery Plan (HARP) members, requiring specific documentation including letters from two qualified NYS licensed health professionals and meeting detailed medical necessity criteria.
Action Required
By January 22, 2026: Billing team must establish prior authorization procedures for all gender reassignment surgeries and treatments for Excellus MMCP and HARP members. Require two referral letters from qualified NYS licensed health professionals before submitting claims. Update system to flag these procedures for prior approval review by Health Plan Behavioral Health Medical Director. Train staff on new documentation requirements including hormone therapy duration, mental health counseling records, and medical necessity criteria. Claims without proper documentation and prior approval will be denied.