Coverage for Health Services Provided to Transgender Individuals

On Aug. 16, 2017, the New York Department of Financial Services (DFS) published Insurance Circular Letter No. 12 (2017). The new letter relates to coverage for health services provided to transgender individuals. According to the letter, it has come to DFS’s attention that carriers 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 female who identifies as a male may be denied a claim for cervical cytology screening because the carrier’s information indicates that the insured is anatomically a male. As another example, a male who identifies as a female may be denied a claim for prostate cancer screening because the carrier’s information indicates that the insured is anatomically a female.

According to the bulletin, NY law allows carriers to request additional information in order to properly administer, process and pay benefit claims, particularly where the carrier’s obligation to pay the claim is not reasonably clear due to a good faith dispute regarding the eligibility of the insured. The bulletin states that transgender persons should not be discriminated against because of their transgender status nor denied coverage for treatment because of a carrier’s coding issues or practices. Based on that, carriers that receive 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. In doing so, the bulletin reminds carriers that they 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 otherwise recorded is different from the one to which such health services are ordinarily or exclusively available.

The letter contains no new employer compliance obligations. However, employers will want to be aware of the letter to help employees with questions regarding services available under their health plan for transgender individuals.

Insurance Circular Letter No. 12 (2017) »