Health Insurers Cannot Deny Claims for Medical Services Because the Insured Does Not Present as the Gender to Whom the Service Is Typically Provided
Circular Letter Available Here
Governor Andrew M. Cuomo today announced health insurers cannot discriminate or deny coverage based on gender identity. This action will ensure that transgender or gender nonconforming individuals receive coverage regardless of whether they present as the gender to whom the service is typically or exclusively provided. A Department of Financial Services circular letter issued today instructs health insurers to take reasonable steps, including requesting additional information, to determine whether the insured is eligible for the services prior to denying a claim. This announcement builds upon Governor Cuomo’s comprehensive actions to support health insurance access for all New Yorkers, including previous guidance instructing insurers that they may not deny medically necessary treatment for gender dysphoria.
“In New York, we believe that health care is a right, and we are committed to protecting that right for all New Yorkers, regardless of income, age, race, sexuality or gender identity,” Governor Cuomo said. “Now, more than ever, we are leading the nation in furthering protections to all New Yorkers that those in Washington seek to eliminate, and we will continue to work to combat discrimination in all forms and ensure equal treatment for all.”
Financial Services Superintendent Maria T. Vullo said, “Transgender persons should not be discriminated against and denied health insurance coverage because of their transgender status nor denied treatment simply due to insurance coding issues. DFS will ensure that all New Yorkers, regardless of gender identity, receive the health insurance coverage they need.”
The circular letter follows reports received by DFS that some health insurance companies may be denying claims of transgender individuals because the gender with which the individual identifies does not match the gender of someone to whom those services are typically provided. For example, a person who was assigned female at birth but presents as male may be denied a claim for cervical cytology screening because the health insurer’s information indicates that the insured is male. Similarly, a person who was assigned male at birth but presents as female may be denied a claim for prostate cancer screening because the health insurer’s information indicates that the insured is anatomically a female.
The DFS guidance reminds health insurers that, although a health insurer may request additional information regarding a specific medical service, a health insurer cannot deny a claim because it does not have sufficient information to pay the claim. A health insurer who receives a claim from an insured of one gender or sex for a service that is typically or exclusively provided to an individual of another gender or sex should take reasonable steps, including requesting additional information, to determine whether the insured is eligible for the services prior to denying the claim.
Additionally, when processing claims for health services provided to transgender or gender nonconforming individuals, health insurers may not deny or limit health services that are ordinarily or exclusively available to individuals of one sex, to a transgender individual based on the fact that the individual’s sex assigned at birth, gender identity, or gender is different from the one to which such health services are ordinarily or exclusively available.
This action complements a series of actions by Governor Cuomo to protect health insurance coverage for all New Yorkers regardless of federal actions. In June, Governor Cuomo directed DFS to promulgate new emergency regulations mandating health insurance providers do not discriminate against New Yorkers with preexisting conditions or based on age or gender, in addition to safeguarding the 10 categories of essential health benefits guaranteed by the ACA.
