Gender Affirming Care

Updated: April 2026

Purpose

ND Medicaid covers medically necessary gender affirming care and services provided to members age 18 and older with a qualifying diagnosis. Medicaid will continue to cover hormone therapy for members under age 18 for a period of 6 months from the effective date of the final rule (April 13, 2027) if hormone therapy was started on or before October 13, 2026. 

Applicability 

Eligible Providers 

To receive payment from ND Medicaid, the eligible servicing and billing providers must be enrolled with ND Medicaid on the date of service, and their National Provider Identifiers (NPIs) must be active in their Medicaid enrollment records. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid, and services they provide must be billed with their NPI. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements. 

Gender affirming care services can be provided by the following enrolled providers as allowed by their scope of their licensure: 

  • Physicians 
  • Nurse Practitioners (NPs) 
  • Physicians Assistants (PAs) 
  • Clinical Nurse Specialists (CNSs) 
  • Licensed Psychologists 
  • Licensed Clinical Social Workers (LCSWs) 
  • Licensed Professional Clinical Counselors (LPCCs) 
  • Licensed Professional Counselors (LPCs) 
  • Licensed Marriage and Family Therapists (LMFTs) 

Eligible Members 

Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the Automated Voice Response System by dialing 1.877.328.7098. 

Refer to the Member Eligibility Manual for additional information regarding eligibility including information regarding limited coverage categories. 

Covered Services and Limits 

General Provider Policies 

The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include: 

  • The provider must be enrolled in ND Medicaid; 
  • Services must be medically necessary; 
  • The member must be eligible on the date of service; and 
  • If applicable, the service has an approved service authorization. 

The Procedure Code Look-up Tool can be used to identify if a procedure code is covered by ND Medicaid along with code specific details such as ORP requirements, Service Authorization requirements, and current rates.

A prerequisite for gender affirming care and services is for contraindicated medical and behavioral health conditions to be addressed and well-controlled. Members must also have:

  • A clinical diagnosis of gender dysphoria; and
  • Provided informed consent which indicates understanding of procedure/process, risks and outcomes expected.

 

Cross-Sex Hormone Therapy

Cross Sex-Hormone Therapy is a course of hormone replacement therapy intended to induce or change secondary sex characteristics.

  • Behavioral health counseling is required for the first twelve (12) months at a frequency determined to be clinically appropriate by the licensed behavioral health provider.
  • Individual must receive medical assessments at a frequency determined to be clinically appropriate by the prescribing provider.

 

Surgical Procedures

Gender Confirmation Surgery (also known as gender affirmation surgery or sex reassignment surgery) means a surgery to change primary or secondary sex characteristics to affirm a person’s gender identity. To be considered for gender confirmation surgery, a member must:

  • Have lived in the desired gender role for twelve (12) continuous months;
  • Be evaluated by a licensed behavioral health provider within the past sixty (60) days; and
  • Have completed twelve (12) continuous months of hormone therapy, unless medically contraindicated.

Medical records must be retained and include a signed statement from a licensed behavioral health provider with whom the member has an established and ongoing relationship.

Prior to surgery, a post-operative plan of care must be in place which includes behavioral health counseling, appropriate physical care, and hormone replacement therapy.

Covered Surgical Procedures

  • Clitoroplasty
  • Erectile prosthesis (one per lifetime)
  • Hysterectomy
  • Labiaplasty
  • Mammoplasty – after twenty-four (24) continuous months of hormone therapy
  • Mastectomy
  • Ochiectomy
  • Ovariectomy/oophorectomy
  • Penectomy
  • Permanent hair removal to treat surgical tissue donor sites only
  • Phalloplasty
  • Prostatectomy
  • Salpingo-oophorectomy
  • Scrotoplasty
  • Testicular prostheses
  • Urethroplasty
  • Vaginectomy
  • Vaginoplasty
  • Vulvectomy
  • Vulvoplasty

Revisions to surgeries for the treatment of gender dysphoria are only covered in cases where the revision is required to address complications of the surgery (wound dehiscence, fistula, chronic pain directly related to the surgery, etc.). 

Service Authorization Requirements 

Surgical services for gender affirmation require prior authorization before services are rendered. For more information, please visit the Acentra website. 

Noncovered Services 

General Noncovered Services 

The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid. 

Additional noncovered services include: 

  • Reversal of any surgical procedure listed in this policy;
  • Revisions for cosmetic issues (e.g. laser hair removal from sites other than surgical grafting sites, chondrolaryngoplasty, and facial feminization, liposuction, gluteal implants, hydrogel and silicone injections);
  • Services to reverse effects of hormone induced changes; and
  • Maintenance of fertility, cryopreservation of ova or sperm, infertility treatment.

Documentation Requirements 

General Requirements 

Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Records must be retained for at least 7 years after the last date the claim was paid or denied. Providers must follow the documentation requirements in the Provider Requirements Policy. 

Reimbursement Methodology and Claim Instructions 

Timely Filing 

ND Medicaid must receive an original Medicaid primary claim within one hundred eighty (180) days from the date of service. The time limit may be waived or extended by ND Medicaid in certain circumstances. The Timely Filing Policy contains additional information. 

Third-Party Liability 

Medicaid members may have one or more additional sources of coverage for health services. ND Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources. The Third Party Liability Policy contains additional information. 

Client Share (Recipient Liability) 

Client share (recipient liability) is the monthly amount a member must pay toward the cost of medical services before the Medicaid program will pay for services received. The Client Share Policy contains additional information. 

Reimbursement 

A claim for services must be submitted at the provider’s usual and customary charge. Payment for services is limited to the lesser of the provider’s usual and customary charge or the ND Medicaid calculated reimbursement. 

Claim Form 

Professional Gender-Affirming Care must be billed using the CMS-1500 claim form or 837p electronic transaction. Facility Gender Affirming-Care Services must be billed on a UB-04 or 837I transaction. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage. 

Claim Requirements 

The Federal Consent for Sterilization or the Physician Certification for Medically Necessary Hysterectomy and Member Acknowledgement of Sterility (SFN 614) must be attached to the claim or received within 14 days, or the claim will be denied. Charges related to a sterilization procedure during hospitalization must be entered in the Notes/Remarks section on the Web Portal or the billing notes section for EDI transactions. 

Two forms can be used for submission of claims attachments: the MMIS Cover Page (SFN 177) or the MMIS Web Portal confirmation page. One of these documents needs to accompany the claims attachments. Review our Claims Attachments policy for further information. 

References 

Contact

Medical Services
600 East Boulevard Ave 
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov

Policy Updates

October 2025

  • Policy updated to new format.

April 2026

  • Formatting changes made throughout the policy.

July 2026

  • ADA updates made throughout the policy.

October 2026

  • Policy updated to align with 42 CFR Parts 441 and 457.