A child with a Doctor Doing a Dyslexia Test

Health Insurance Coverage for Dyslexia

Dyslexia and Health Insurance Coverage for Neurological Exams

Coverage Requirements

The “Dyslexia Diagnosis Access Act” requires fully insured health insurance policies issued in New York to cover comprehensive neuropsychological examinations for dyslexia upon the referral of a physician when performed by a health care professional acting within their scope of practice beginning January 1, 2025, upon policy issuance or renewal.

What You Need to Know Before Scheduling a Comprehensive Neurological Exam

  • Referral. You may need to get a referral from a physician before your health insurer will cover the service. While schools may conduct a screening evaluation, a referral from a school does not meet this requirement.
  • Provider Network. You may need to get the services from a provider in your health insurer’s network. If there is not an in-network provider who can treat you, then you have the right to ask your insurer to approve a referral to an out-of-network provider.
  • Medical Necessity. Your health insurer may review the services for medical necessity. Your insurer may do this through a preauthorization review before you receive the services or through a retrospective review after the services have been provided.

Check your health insurance policy for information about covered services, any required referrals, medical necessity reviews, and if you must go to an in-network provider.

Cost-Sharing Requirements

You may have cost-sharing for these services that includes a deductible and either a copayment or coinsurance.

  • Deductible. A deductible is the amount of money that you must pay before your health insurance policy will cover the services.
  • Copayment. A copayment is a set dollar amount that you must pay to your health care provider, typically when you receive services.
  • Coinsurance. Coinsurance is a percentage of the costs that you will need to pay your health care provider. Typically, your health care provider will send you a bill for any coinsurance.

Check your health insurance policy because the deductibles, copayments, or coinsurance may be different depending on the services you are getting.

If your Health Insurer Denies Coverage

If your health insurer denies the services as not medically necessary or denies your request to see an out-of-network provider, you have the right to an appeal with your insurer and an external appeal with independent medical experts.

• File an Internal Appeal. You or your designee can submit an internal appeal to your health insurer within 180 days of a denial. Be sure to follow the instructions in the denial letter.

• Request an External Appeal. If your internal appeal is denied, your health insurer must send you a Final Adverse Determination (FAD). You have the right to request an external appeal through the New York State Department of Financial Services within 4 months of the date of the FAD.

Do These Protections Apply to You?

These protections apply to policy holders with:

  • Individual Coverage. Individual health insurance coverage that you bought in New York, including through the New York State of Health Marketplace.
  • Fully Insured Group Coverage. Group health insurance coverage that your employer bought in New York, including through the New York State of Health Marketplace.
  • NYSHIP. The New York State Health Insurance Program for New York State or local government employees.

Similar protections apply to Medicaid, Essential Plan, and Child Health Plus coverage that is regulated by the New York State Department of Health. Visit the New York State Department of Health at www.health.ny.gov to learn more.

These protections do not apply to you if you have:

  • Out-of-State Coverage. If you or your employer buys a health insurance policy in another state, the rules of that other state will apply. For example, if your employer has offices in several states and buys a health insurance policy in a state other than New York, then New York requirements won’t apply even if the policy covers people in New York.
  • Self-Funded Coverage. If your employer self-funds coverage and your employer (and not an insurer) pays the claims under your policy, New York requirements won’t apply. Many large employers provide this type of coverage.
  • Medicare. If you have Medicare, call (800) MEDICARE, or the Medicare Rights Center at (800) 333-4114, or visit www.medicare.gov. Check your health insurance ID card to see if your coverage is fully insured or self-funded or check with your employer.

Questions or Complaints?

The Department of Financial Services (DFS) ensures that health insurers meet their legal obligations to cover comprehensive neuropsychological examinations for dyslexia. Always check your health insurance policy for information about covered services, any required referrals, medical necessity requirements, and to see if you must go to an in-network provider. If you have questions, contact the DFS Consumer Hotline at (800) 342-3736.