As Part of Settlement, EmblemHealth Changes Coverage Criteria, Will Pay Full Restitution to Members Plus Penalties to State
Attorney General Barbara D. Underwood announced a settlement with EmblemHealth, requiring the health insurance company to cover gender reassignment surgery for its members. An investigation by the Attorney General revealed that EmblemHealth’s process of updating criteria for gender reassignment surgery was deficient; that the criteria included in the 2014-2017 Guidelines were outdated and not medically accurate or evidence-based during the time they remained in effect; and that EmblemHealth’s review of member requests, including coverage for mammoplasty as part of gender reassignment surgery, was deficient.
As part of the settlement, EmblemHealth has updated its Gender Reassignment Surgery Guidelines and will maintain the changes and continue to update its criteria in accordance with formal reviews. EmblemHealth will also provide restitution to members who were improperly denied coverage for gender reassignment surgery, and pay $250,000 in civil penalties to New York State.
“Health plans have a basic obligation to cover medically necessary health care for their transgender members,” said Attorney General Underwood. “My office will continue to protect the rights of transgender New Yorkers and ensure they’re treated with the fairness and dignity they deserve.”
The Attorney General’s office initiated an investigation after receiving a complaint that EmblemHealth improperly denied coverage of gender reassignment surgery to a member based on failure to meet EmblemHealth’s unlawful criteria.
The Attorney General’s investigation revealed that between January 2014 and July 2017, EmblemHealth received 79 requests for pre-authorization of gender reassignment surgical procedures and that EmblemHealth denied 22 of those requests. The investigation found that EmblemHealth provided misleading and deceptive information to plan members indicating that its 2014-2017 Gender Reassignment Surgery Guidelines were based on current clinical information and standard medical guidelines when they were not – constituting repeated violations of Executive Law § 63 (12) and General Business Law § 349.
As part of the agreement, EmblemHealth will provide full restitution to members who paid out-of-pocket for gender reassignment surgical procedures after denial of coverage by EmblemHealth.
New Yorkers with complaints regarding denial of coverage for gender reassignment surgical procedures or other health-care related issues may contact the Attorney General’s Health Care Helpline at 1-800-428-9071.