Eligibility Criteria

All members, including non-binary members, are eligible for Gender reassignment surgery when criteria (aside from desire to be the opposite sex) is met. Members should not be denied coverage for Gender Dysphoria services, based solely on identifying as non-binary, if otherwise eligible for coverage. Gender reassignment surgery (GRS) is considered medically necessary when all of the following criteria are met:

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1. The individual has been diagnosed with Gender Dysphoria, Gender Identity Disorder (GID), or Transsexualism, including all of the following:
   
   a. 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
   
   b. The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and/or
   
   c. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
    

2. For those individuals without a medical contraindication, the individual has undergone continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
    

3. The individual has completed a minimum of 12 months of successful continuous full time real-life experience in their desired gender, with no returning to their original gender, including one or more of the following:
   
   a. Maintain part- or full-time employment; or
   b. Function as a student in an academic setting; or
   c. Function in a community-based volunteer activity; and
    

4. Demonstrable knowledge of the required length of hospitalizations, likely complications, and post-surgical rehabilitation requirements of various surgical approaches; and
    

5. Demonstrable progress in consolidating one's gender identity, including demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance); and
    

6. Two referrals from qualified mental health professionals who have independently assessed the individual are needed for genital surgery; one referral from a qualified mental health professional is needed for breast/chest surgery. The referrals should document the following:
   
   a. The individuals general identifying characteristics;
   
   b. Results of the individual’s psychosocial assessment, including and diagnoses;
   
   c. The duration of their professional relationship with the individual including the type of evaluation
   
   d. An explanation that the criteria for surgery have been met, and a brief description of the clinical rational supporting the individual’s request for surgery;
   
   e. A statement about the fact that informed consent has been obtained from the individual;
   
   f. A statement that the mental health professional is available for coordination of care
    

7. The treatment plan must conform to identifiable external sources including the World Professional Association. Transgender Health (WPATH) standards, and/or evidence based professional society guidance