Insurance Coverage for Transition-Related Healthcare in New York
On December 11, 2014, the New York State Department of Financial Services, which regulates the New York insurance industry, issued an interpretation of the law governing health insurance policies in New York. The Department stated that the law requires health insurance companies to cover transgender health care on the same terms as other care. Most health insurance policies currently exclude coverage for such treatment, regardless of whether or not a doctor determines that it is medically necessary.
The Department’s interpretation took effect immediately. It carries the force of law and renders exclusions related to transgender health care void. It requires that health insurance companies cover transgender health care on the same terms as all other care. This will dramatically improve the lives of transgender people.
Medically Necessary Treatment for Gender Dysphoria Must be Covered
Specifically, the Department announced that insurance policies that include coverage for mental health conditions may not exclude coverage for medically necessary treatment solely because the treatment is for gender dysphoria, the diagnostic term used to refer to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth. This includes coverage for all hospital care and physician services determined to be medically necessary. In short, health insurance must pay for medically necessary treatment for gender dysphoria if it pays for that treatment for other conditions.
Review & Appeal of Individual Claims
Insurance companies are still permitted to review health care treatments related to gender transition for medical necessity, just as they do in connection with treatment for any diagnosed condition. And just like any other claim, a denial of coverage on the basis of medical necessity can be appealed.
Medicaid & Self-Funded Plans Are Not Affected
These changes apply to all policies issued in New York State that include coverage for mental health conditions. These changes do not apply to New York State’s Medicaid program, which is expected to begin covering transgender health care soon. And they do not apply to self-funded plans because those plans are not regulated by the Department of Financial Services.
Basis for New York's Action
The Department based its interpretation on several existing state and federal statutes and regulations. The Department found that the law prohibits health insurance companies from discriminating based on the type of illness, treatment, or medical condition involved. In addition, the Department relied on state and federal laws requiring that health insurance cover the treatment of mental health on the same terms as the treatment of other health issues.
Contact Us for Help
The Department’s interpretation of the law must be followed by your health insurance company. You can read more about New York health insurance coverage for transition-related care in our F.A.Q. If you believe that you have been wrongly denied coverage by your health insurance company, or if you need more information, please contact us.