New York Attorney General Barbara D. Underwood has reached a settlement with EmblemHealth that requires the health insurance company to cover gender reassignment surgery for its members.
In a statement, the attorney general said that an investigation revealed that EmblemHealth's process of updating criteria for gender reassignment surgery was deficient; that the criteria included in its 2014-2017 guidelines were outdated and not medically accurate or evidence-based during the time they remained in effect; and that EmblemHealth's review of member requests, including coverage for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 updated its gender reassignment surgery guidelines and will maintain the changes and continue to update its criteria in accordance with formal reviews. EmblemHealth also will 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 had improperly denied coverage of gender reassignment surgery to a member based on failure to meet EmblemHealth's criteria.
The attorney general said that its 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 New York Executive Law § 63(12) and General Business Law § 349.
Steven A. Meyerowitz
Steven A. Meyerowitz, a Harvard Law School graduate, is the founder and president of Meyerowitz Communications Inc., a law firm marketing communications consulting company. He may be contacted at [email protected].