Health Coverage Information for Transgender New Yorkers

Plans Covered by New York Protections

Individual Coverage You Buy In New York. If you buy individual coverage through the New York State of Health Marketplace or from a broker or an insurer in New York.
Group Coverage Your Employer Buys in New York. If your employer buys a group insurance policy from an insurer in New York.

Plans NOT covered by New York Protections

Individual Coverage You Buy Outside New York. If you buy individual coverage in another state, the rules of that other state will apply.
Group Coverage Your Employer Buys Outside New York. If your employer buys a group insurance policy in another state (for example, your employer’s main office is in another state), the policy may cover employees in New York, but New York protections don’t apply.
Self-Funded Group Coverage. If your employer self-funds the coverage, as many large employers do, an insurer may still process the claims, but New York protections don’t apply.

Medicaid, Essential Plan, or Child Health Plus

If you have Medicaid, Child Health Plus, or the Essential Plan, New York protections apply, but there are different rules. Check with the NYS Department of Health (DOH) at (800) 541-2831 for Medicaid, (800) 206-8125 for Medicaid Managed Care and Child Health Plus, and (855) 355-5777 for Essential Plan coverage.

Medicare

If you have Medicare, different rules apply. Check with Centers for Medicare & Medicaid Services (CMS) at (800) MEDICARE, the Medicare Rights Center at (800) 333-4114, or https://www.medicarerights.org/

Treatment Your Insurer is Required to Cover

Medically Necessary Treatment. Your insurer must cover medically necessary treatment for “gender dysphoria.”

The benefits must otherwise be covered under your health insurance policy (for example, surgery, hospital stays, mental health care, and office visits). If your employer has more than 100 employees, some benefits, like prescription drugs, are not required to be covered.
Your health insurance policy can’t exclude medically necessary gender-affirming treatment as a category of treatment.
Check your health insurance policy. You can request a copy by calling the Member Services number on your health insurance ID card or asking your employer.
Your doctor may recommend treatment, but your insurer might not agree it is medically necessary.

Cost-sharing for Treatment. You may have a deductible, copayment, or coinsurance.

A deductible is the dollar amount that you need to pay before services will be covered. If your deductible is $1,000, your health insurance policy won’t pay anything (except for preventive care) until you’ve paid $1,000 for covered services.
You may also have a copayment (set dollar amount) or coinsurance (a percentage of the costs) that you will need to pay for treatment.
Your insurer can’t apply annual limits or lifetime limits on most treatment.
Check your health insurance policy, because the deductibles, copayments, or coinsurance may be different depending on the services you are getting.

Out-of-Network Services. If your health insurance policy has an out-of-network benefit (usually called PPO or POS coverage) you can get care from providers who aren’t in your insurer’s network. Your cost-sharing will usually be higher for out-of-network services, and you will have to pay the difference between the allowed amount (what your insurer pays for the service) and the provider’s actual bill.

Discrimination. Your insurer can’t discriminate against you because of your sexual orientation, gender identity or expression, or transgender status.

Your insurer can’t refuse to cover you, terminate your coverage, or charge you higher premiums.
Your insurer can’t deny your infertility treatment that would otherwise be covered.
Your insurer should request additional information before denying a claim if your gender or sex is not the same as the gender or sex that typically obtains the service.

Denials and Appeals

Services May be Denied for Different Reasons and You Have Appeal Rights for These Denials.

Medical Necessity. Insurers may deny services as not medically necessary (including cosmetic or experimental or investigational services) through their utilization review process. Insurers use clinical review criteria (medical guidelines) which may not be the same among insurers, to make these determinations. Insurers must submit their clinical review criteria for the treatment of gender dysphoria to the State for review and approval, and the criteria must be evidence-based, peer reviewed, and age-appropriate.

Out-of-Network Provider. You may ask for your care to be provided by an out-of-network provider because there is no in-network provider with the training and experience to meet your health care needs (“referral-denial”) or because your insurer can’t cover the treatment you requested in-network but will cover a similar treatment (“service denial”). These denials will start out in your insurer’s grievance process.

Off-Formulary Prescription Drugs. You may request coverage of a prescription drug that is not on your insurer’s formulary (list of covered drugs), and your insurer must have an appeal process for these denials.

Timeframe for Insurers to Make Medical Necessity and Out-of-Network Provider Decisions

	Medical Necessity Decisions – Utilization Review –	Out-of-Network Provider Decisions – Grievance–
Urgent	72 hours of receipt of your request for treatment.	72 hours of receipt of your request for treatment.
Pre-Service – for care you have not received yet	3 business days of receipt of necessary information or 60 days if no information is received. Your insurer must ask for any information within 3 business days of receiving your preauthorization request, and you and your provider have 45 days to send the information.	15 days of receipt of necessary information or 60 days if no is information received. Your insurer must ask for any information within 15 days of receiving your request, and you and your provider have 45 days to send the information.
Concurrent – for an ongoing course of treatment	1 business day of receipt of necessary information or 60 days if no information is received. Your insurer must ask for any necessary information within 1 business day, and you and your provider have 45 days to send the information.
Post-Service – for care you received	30 days of receipt of necessary information or 60 days if no information is received. Your insurer must ask for any information within 30 days, and you and your provider have 45 days to send the information.	30 days of receipt of necessary information or 60 days if no is information received. Your insurer must ask for any information within 30 days, and you and your provider have 45 days to send the information.

Appealing Your Medical Necessity or Out-of-Network Provider Denial

Denial notice. If your treatment is denied, your insurer must notify you in writing, and by telephone for urgent cases, unless you request electronic notification. If you don’t get a notice, file a complaint with DFS.

Timeframes. You have 180 days to appeal with your insurer.

Clinical Review Criteria. You have a right to get a copy of the clinical review criteria (medical guidelines) your insurer used to make its decision from your insurer at any time.

Out-of-Network Provider Appeal (referral denial). Your doctor must (1) send a written statement to your insurer that the in-network providers recommended by your insurer do not have the training and experience to meet your health care needs; and (2) recommend an out-of-network provider with the training and experience to meet your health care needs who is able to provide the service.

Out-of-Network Provider Appeal (service denial). Your doctor must (1) send a written statement to your insurer that the out-of-network service is materially different from the health service the insurer approved; and (2) provide two documents of medical evidence that: (i) the out-of-network service is likely to be more clinically beneficial than the in-network service your insurer recommended; and (ii) the risk would not be increased over the in-network health service.

Timeframes for Insurers’ Medical Necessity and Out-of-Network Provider Appeal Decisions

Urgent	The earlier of 72 hours or two business days of receipt of necessary information.
Pre-Service – for care you have not received yet	30 days if your insurer has one level of internal appeal or 15 days if your insurer has two levels of internal appeal.
Post-Service – for care you received	60 days if your insurer has one level of internal appeal (or 30 days of receipt of necessary information, if earlier, beginning in 2021) or 30 days if your insurer has two levels of internal appeal.

Urgent

The earlier of 72 hours or two business days of receipt of necessary information.

Pre-Service – for care you have not received yet

30 days if your insurer has one level of internal appeal or

15 days if your insurer has two levels of internal appeal.

Post-Service – for care you received

60 days if your insurer has one level of internal appeal (or 30 days of receipt of necessary information, if earlier, beginning in 2021) or

30 days if your insurer has two levels of internal appeal.

Formulary Exception Process for Prescription Drugs

Timeframes	Standard. 72 hours for insurer decision.	Expedited. 24 hours for insurer decision when your health, life, or ability to regain maximum function is in danger, or if you are currently being treated with a non-formulary prescription drug.

Final Denial. If your insurer denies your formulary exception request, it’s a final adverse determination. You do not have to appeal with your insurer. You can request an external appeal with DFS.

Applicability. Individual & small group coverage and, beginning on renewal in 2020, large group coverage.

External Appeals

Right to an External Appeal. If your insurer makes a determination (usually on appeal) that your treatment is not medically necessary (including cosmetic denials, an experimental or investigational treatment, an out-of-network service, an out-of-network referral, or a non-formulary prescription drug) you have a right to an external appeal with medical experts that are independent from your insurer.

Timeframe to Request an External Appeal. You must send your external appeal request to DFS four months from the date of:

The final adverse determination from the first level of appeal with your insurer;
Notice that your insurer said you didn’t need to go through internal appeal process; or
The first denial of your formulary exception request.
If your insurer offers a second-level internal appeal, you do not have to file one, but if you do, you must still send an external appeal to DFS within four months of the first appeal decision.

Timeframe for the External Appeal Agent to Make a Determination.

Standard. 30 days (or 72 hours for a formulary exception).
Expedited. 72 hours (or 24 hours for a formulary exception), even if all your medical information has not yet been sent to the external appeal agent.

Request an External Appeal. Complete the New York State External Appeal Application. There may be a $25 fee. Your fees won’t be more than $75 in a year if you request more than one external appeal. There is no fee if you are covered under Medicaid, Child Health Plus, Essential Plan, or if the fee is a hardship. The fee will be returned to you if the external appeal agent overturns the denial. You can also ask for help from Community Health Advocates, NY State’s insurance consumer advocacy group at (888) 614-5400 and/or www.communityhealthadvocates.org.

Information on Surprise Bills

A surprise bill happens when:

Hospital or Surgical Center. You receive services from an out-of-network doctor at an in-network hospital or surgical center and (1) an in-network doctor was not available; or (2) you did not know the doctor was out-of-network; or (3) an unexpected medical situation happened when your health care services were provided. It is not a surprise bill if you chose to receive services from an out-of-network doctor instead of from an available in-network doctor.
Referral. You are referred by your in-network doctor to an out-of-network provider and you did not sign a paper saying that you knew the services would be out-of-network and would result in costs not covered by your insurer. A referral to an out-of-network provider happens if (1) during a visit with your in-network doctor, an out-of-network provider treats you; (2) your in-network doctor takes a specimen from you in the office (for example, blood) and sends it to an out-of-network laboratory or pathologist; or (3) for any other health care services when referrals are required by your insurer.

You will be protected from a surprise bill and will only be responsible for your in-network copayment, coinsurance, or deductible if you sign the assignment of benefits form and return it to your insurer and out-of-network provider.

Find the assignment of benefits form and get more information about Independent Dispute Resolution

When You or Your Provider Submit a Claim to Your Insurer

Your insurer is required to send you an “explanation of benefits” form when it does not pay your claim in full. The explanation of benefits must include the following information.

Provider name.

Date of service and description of service.

Provider’s charge.

Amount your insurer will pay after deductible, copayments, or coinsurance.

Explanation of any denial or reason for not paying the full amount.

Insurer’s telephone number and information on how to appeal any denial of benefits.

Questions and Complaints

Questions. If you have questions, call DFS at (800) 342-3736 (available Monday through Friday, 8:30 AM to 4:30 PM). Local calls can be made to (212) 480-6400 or (518) 474-6600.

Complaints. You can file a complaint with DFS or DOH depending on the type of coverage you have.

If you are covered by an insurer or HMO. File a complaint with DFS. DFS will investigate your complaint and may share a copy of your complaint with your insurer or refer it to another state agency, if applicable.
If you have HMO, Medicaid, Essential Plan, or Child Health Plus coverage. File a complaint with DOH. You may call the NYS Department of Health at (800) 541-2831 for Medicaid, (800) 206-8125 for Medicaid Managed Care and Child Health Plus, and (855) 355-5777 for Essential Plan coverage.
You can also ask for help from Community Health Advocates, NY State’s insurance consumer advocacy group at (888) 614-5400 and/or http://www.communityhealthadvocates.org/.

Learn More

Find out what services your insurer covers and what you can do when your insurer denies services you think should be covered in the HCFANY Fact Sheet Health Coverage for Transgender New Yorkers: Navigating Private Insurance to Get the Care You Need (PDF).

For more information about Medicaid, Essential Plan, or Child Health Plus coverage of gender-affirming care visit the NYS Department of Health website at www.health.ny.gov.

Definitions of Health Insurance Terms

Allowed Amount. The amount your insurer will pay for a health care service.

Annual Limit. A dollar limit on health care services your insurer will cover in a year. Most in-network benefits can’t have annual dollar limits.

Appeal. When you or your provider ask your insurer to review its denial of services or payment (utilization review or grievance decision).

Assignment of Benefits Form for Surprise Bills. The form that you sign to be protected from a surprise bill.

Balance Billing. When an out-of-network provider bills you for the difference between their charge and the allowed amount (what your insurer paid). An in-network provider can’t balance bill you for covered services.

Claim. When you or your provider ask for a benefit or payment from your insurer.

Clinical Review Criteria. Insurers’ medical policies, clinical guidelines, reports published by health care organizations, and peer-reviewed medical articles.

Coinsurance. The percent of the cost that you pay for a covered health care service (for example, 20%).

Copayment. The dollar amount (for example, $15) you pay to a provider when you receive a health care service. The copayment may be different for different health care services.

Cost-Sharing. The amount you pay for covered health care services (sometimes called “out-of-pocket costs”). Examples are deductibles, copayments, and coinsurance.

Deductible. An amount you must pay each year before your insurer will pay for your health care services. If your deductible is $1,000, your health insurance won’t pay anything (except for preventive care) until you’ve paid $1,000 for covered services. You may also have to pay coinsurance or copayments after you’ve paid the deductible. Examples of costs that don’t usually count towards your deductible are premium or costs for health care services not covered by your health insurance policy.

DFS. Department of Financial Services

External Appeal. Independent medical experts decide whether your insurer must cover your treatment.

Final Adverse Determination. Your insurer’s denial (usually first level appeal) for which you can request an external appeal.

Formulary. A list of drugs your insurer covers. Different drugs may have different cost-sharing. For example, a formulary may include generic and brand name drugs and different cost-sharing amounts will apply.

Grievance. A complaint that you send to your insurer.

Health Insurance Policy. The document from your insurer that lists covered health care services.

Lifetime Limit. A dollar limit on health care services while you have coverage with your insurer (can be more than a year). Most in-network benefits can’t have lifetime limits.

Medically Necessary or Medical Necessity. Health care services or supplies needed to prevent, diagnose, or treat your illness, injury, condition, disease, or symptoms that meet accepted standards of medicine.

Network. Health care providers your insurer contracts with to provide health care services to you.

New York State of Health, the Official Health Plan Marketplace. An online market where you can shop for health insurance; apply for help paying premiums and cost-sharing; and enroll in coverage including Medicaid, Child Health Plus, and the Essential Plan (www.nystateofhealth.ny.gov).

Out-of-Network. Providers that aren’t in your insurer’s network. Some insurance policies have an out-of-network benefit (PPO or POS coverage) and you can get care from out-of-network providers.

Plan Year. A 12-month period. It sometimes is a calendar year (January through December).

Preauthorization or Pre-Service. When your insurer reviews a health care service or item before it is provided for medical necessity. Your insurer can’t require preauthorization for emergency services.

Premium. The amount you or your employer pay for your health insurance (monthly, quarterly, or yearly).

Provider. A person or place that provides health care services (including doctors, nurses, and hospitals).

Self-funded or self-insured coverage. When an employer, not an insurer, takes the financial risk and pays for health services. Insurers may help employers with self-funded coverage process claims.

Utilization Review Process. Your insurer’s process for medical necessity decisions. The decision must be made by providers in the same specialty (for substance use disorder and mental health treatment) or similar specialty as your treating provider.