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NY fines EmblemHealth over gender reassignment surgery coverage issues

EmblemHealth Inc. will pay $250,000 in civil penalties to New York State as part of a settlement that requires the health insurance company to cover gender reassignment surgery for its members.

An investigation by the New York State Office of the Attorney General found that EmblemHealth had a "deficient" process of updating criteria for gender reassignment surgery. The process included 2014 to 2017 guidelines that were "outdated" and "not medically accurate or evidence-based" during effective period.

The investigation also revealed the insurance company's "deficient" review of member requests, including coverage for mammoplasty as part of gender reassignment surgery. From January 2014 to July 2017, EmblemHealth denied 22 of 79 requests for pre-authorization of gender reassignment surgical procedures.

In accordance with the settlement, EmblemHealth updated its gender reassignment surgery guidelines. The company will also pay full restitution to members who paid out of pocket for the procedures after denial of coverage.