Frequently Asked Questions About Private Insurance Coverage For Transgender Health Care In New York State


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CaduceusOn December 11, 2014, the New York State Department of Financial Services, which regulates insurance in New York State, issued an interpretation of the law governing health insurance policies in New York.  The Department stated that the law requires that health insurance policies that include coverage for mental health conditions must 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.  This action will dramatically improve the lives of transgender people.

When does this take effect?

Immediately. 

Is my health insurance affected by this interpretation?

This interpretation applies to all policies in New York State that include coverage for mental health conditions. It does not apply to New York State’s Medicaid program, which is expected to begin covering transgender health care soon. And it does not apply to self-funded insurance plans.  A self-funded health insurance plan is a job-based health insurance plan whose claims are paid by an employer with its own money rather than through a health insurance company.  If you are unsure if your plan is self-funded, you can ask your health insurance administrator or another appropriate person in your workplace.  You can also contact us for help.

Do I have to live or work in New York State for this to affect my health insurance?

No.  But your health insurance is also not necessarily affected simply because you do live or work in New York.  The interpretation applies only to health insurance policies delivered or issued for delivery in New York State.  Even if you live or work in New York, your employer may have its headquarters or offices in another state and your employer group insurance policy may be delivered in that other state.  In that case, your coverage under that policy will not be affected by this interpretation.  The opposite is true, too.  You may live or work outside of New York, but you are covered under an employer group insurance policy delivered in New York (because, for example, your employer has its headquarters or an office in New York).  In that case, your policy will be affected by this interpretation and will now cover transgender health care.  The important thing is where the employer group insurance policy was delivered or issued for delivery, and not where you live or work.

What treatments are covered?

Medically necessary treatment for gender dysphoria must be covered if the insurance company pays for that treatment for other conditions.  This includes coverage for hospital care and physician services, including mental health therapy, hormone therapy, and many surgical procedures.

What is “medically necessary”?

Like other health care, treatment for gender dysphoria is based on an individualized assessment of a particular patient by that patient’s doctor.  Medically necessary care generally refers to health care services that a doctor or health care provider prescribes for the evaluation, diagnosis or treatment of gender dysphoria.  The services must fit within accepted standards of medical practice and be considered effective for the treatment of gender dysphoria. This is a general definition, and most insurance plan documents will include a detailed definition of medical necessity.

Are children and youth covered by this guidance letter?

Yes.  Regardless of age, health insurance must pay for medically necessary treatment for gender dysphoria if it pays for that treatment for other conditions.  This includes coverage for all hospital care and physician services.

Does this interpretation require my health insurance to pay for any doctor I choose? 

No.  Most health insurance companies have limited networks of health care providers with whom they work.  Nothing about the interpretation expands the scope of your provider network.  Some policies may allow you to use out-of-network doctors, but they may not cover the cost of health care services provided by those doctors at the same rate that they cover in-network doctors.  If there is no doctor in your health insurance network who is qualified to provide the medically necessary care you need, you may be entitled to treatment by an out-of-network provider. If you are unsure, please contact us.

What if my insurance company denies my claim?

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.  If you believe that your claim has been wrongly denied, please contact us.