Health care information for transgender, nonbinary, gender nonconforming, and intersex New Yorkers

Your rights under New York law

Receive the treatment you want – including if you are younger than 18 

In New York, you have the right to receive treatment without discrimination regardless of your sex, gender identity, gender expression, transgender status, diagnosis of gender dysphoria, or intersex status. 

For all health care circumstances, you have the right to receive: 

• any emergency medical care you need 
• the medically acceptable standard of care from your doctor 

A doctor cannot refer to you another doctor for discriminatory reasons. However, a doctor can refer you to another doctor if: 

• They do not have enough experience treating gender dysphoria.
• They want you to have a doctor who is more qualified to treat you. 

Providers and insurers covered by New York law must cover your gender-affirming care for gender dysphoria. If your plan refuses to cover certain services related to gender-affirming care, you may want to consult a lawyer.  

You can receive medical, dental, health, and hospital care even if you are younger than 18. This is true even if you: 

• have left your legal residence without the consent of your parent, legal, guardian, or legal custodian
• do not have a home where supervision and care are available 

Refuse treatment you do not want – for yourself or your child 

For yourself or your child, you have the right to say no to any medical treatment that is not medically necessary. Medically necessary means that the treatment is required to diagnose a disease, injury, or condition or  to prevent a condition from developing or getting worse and it meets the accepted medical standards.  

You have the right to make your own health care decisions with full, informed consent, including if: 

• You or your child are intersex. 
• You are the parent or legal guardian of a child considering treatment. 

If you are a parent or guardian of a child with an intersex variation, sometimes called a difference of sex development, doctors may suggest medically unnecessary surgery in infancy to make your child’s body look more like a typical male or female. You have the right to refuse any procedures like this and to be counseled about all alternatives to this early intervention. Many parents or guardians may not know they can hold off on decisions related to intersex variations until their child is old enough to understand what their options are. As a parent or guardian, you have the right to informed consent.

Be fully informed about any health care treatment 

Before you make any decision about you or your child’s health care, you have the right to be fully informed about any health care treatment and receive all information about: 

• the benefits, risks, and possible side effects of a treatment, procedure, or service
• whether the treatment is medically necessary
• any alternatives you might consider  

Not be discriminated against by providers and insurers 

Health care professionals and insurers cannot discriminate against you because of your sex or gender. You do not have to have a name or gender change ordered by a court or updated identification documents to receive health care.  

In New York, discrimination includes the following types of actions (this is not a complete list):  

• harassing you
• refusing to use the name or pronouns you choose for yourself
• illegally sharing your confidential information, including transgender or intersex status
• calling you inappropriate names or making inappropriate jokes, insulting you, or asking invasive, medically unnecessary questions
• not letting you use the bathroom that is most consistent with your gender 
• assigning you to a room that does not match your gender, or to a worse or separate room because of your gender
• unnecessarily examining any part of your body, including your genitals
• not allowing you to decide whether to let medical interns or students observe your examination 

Have patient privacy  

Under federal HIPAA and New York laws, you have the right to keep your medical records and history private. Health care providers and insurance companies cannot share your personal health information (PHI) with anyone, with certain exceptions. To learn more about privacy protections for physical and mental health care, visit the HIPAA privacy page at the New York State Office of Mental Health, or consult a lawyer.  

For New York not to cooperate with other states’ prosecutions 

If you come to New York state from another state to receive gender-affirming or reproductive care, New York laws protect you. New York law enforcement, insurers, and health care providers are not permitted to cooperate with out-of-state legal action related to legally protected health care activity. New York law enforcement officers are prohibited from arresting or extraditing anyone in connection to protected health care in New York, sharing information, or otherwise participating in the prosecution of such care. You may have addition rights under family law provisions. Learn more here about the shield laws and gender affirming care. 

Report discrimination and get help with health care  

If you face problems with health care in New York, the government agencies and organizations that can take your report depend on the type of complaint you have.  

I have Medicaid or Essential Plan, does that cover my gender affirming care?

Most people have Medicaid managed care, which is managed by plans. Generally under Medicaid, things related to transition should be covered if it is medically necessary and you have a diagnosis of gender dysphoria. This includes puberty blockers, hormone replacement therapy, surgeries, and other procedures related to your care.  

If you don’t have Medicaid managed care, the New York protections are different. This is called fee-for-service or straight Medicaid plans. Learn more about this rare set up by calling DFS at 1-800-541-2831.  

Under Medicaid, things related to transition should be covered if it is medically necessary and you have a diagnosis of gender dysphoria. This includes hormone therapy, surgeries, and other procedures related to your care.  

For youth seeking pubertal suppressants, you must reach the puberty level of Tanner Stage 2, which is determined by your doctor. You need a medical professional to provide documentation that are eligible and ready for the treatment and other requirements, such as proof that you understand the outcomes, risks, and benefits of beginning hormone therapy and that you have the necessary psychological and social support. 

For youth and adults seeking cross sex hormones 

• If you are over 18, you need a medical professional to provide documentation that it is medically necessary.
• If you are 16-17, you need a medical professional to provide documentation that it is medically necessary, that you are eligible and ready for the treatment and other requirements, such as proof you understand the outcomes, risks, and benefits of beginning hormone therapy and that you have the necessary social and psychological support. 
• If you are under 16, a medical professional must provide documentation that it is medically necessary, that you are eligible for the treatment, and that you have fulfilled other requirements, such as proof you understand the outcomes, benefits, and risks of beginning hormone therapy and that you have the necessary psychological and social supports and your health insurance company’s prior approval. 

To receive gender-affirming surgery, you must have two letters of medical necessity for the procedure. Together, the letters must show: 

• You have a persistent and well-documented case of gender dysphoria. 
• The procedure is medically necessary to treat your gender dysphoria.  
• You have lived for at least a year in the gender role that matches your gender identity.  
• You have the ability to fully understand your decision and consent to the treatment.  
• You have received mental health counseling as deemed medically necessary.  
• Any physical or mental health conditions you have are reasonably controlled and do not make the surgery risky. 
• One of the following:  
  • You did not receive hormone therapy because it was not necessary or because you are seeking breast-removal surgery. 
  • For genital surgery, you have been on hormone therapy for at least one year. 
  • For breast augmentation, you have been on hormone therapy for at least two years and have had minimal breast growth (this depends on your body type and situation determined by a doctor). 

These letters must be from professionals licensed by New York state. Each professional must be a physician, psychiatrist, psychologist, psychiatric nurse practitioner, or clinical social worker: 

• One letter must be from a health professional with whom you have an ongoing relationship.  
• One letter must be from a health professional who has evaluated you for the procedure.  

There are some surgeries, services, and procedures related to transitioning that were considered “cosmetic” under previous regulations. Although Medicaid does not cover “cosmetic” services, it does cover medically necessary treatments. Medicaid cannot automatically deny a treatment because it was previously considered cosmetic. Such treatments include genital surgery, top surgery, permanent hair removal, voice-modification surgery, body-sculpting procedures and services, and gender-affirming facial surgery.  

If you are under 18, you may receive coverage for surgery in specific cases if it is medically necessary and you receive prior approval from your health insurance company. You may want to speak to a lawyer to better understand your specific health care rights if you are under 18. 

What to do if your procedure is denied by Medicaid?

Most people have managed-care Medicaid plans.  

Managed-care

Medicaid plans have a different appeals process than fee-for-service or straight Medicaid plans. To determine what kind of plan you have: 

• Call New York State of Health at 1-855-355-5777
• In New York City, call the Human Resources Administration’s Medicaid helpline at 1-888-692-6116
• Visit Legal Aid Society’s page on using Medicaid to get health care 

Medicaid managed-care plan: How to appeal a decision 

Your insurer may deny you a service because it finds the service is not medically necessary. It will send you a notice called an initial adverse determination. You can appeal this decision. If you do not receive a written denial within 21 days, you can request a “fair hearing” as if your claim had been denied. This may also be necessary if your insurer says your claim is denied over the phone but you never receive it in writing, or if you never hear from your insurer. 

The insurer must notify you in writing of its denial in an initial adverse determination. If you do not receive a written notice, file a complaint with DFS.  If your claim is denied, you should receive a decision in writing within three days for managed-care plans. 

You have 60 days to request an internal appeal from your insurer. The instructions on how to file an appeal are in the initial adverse determination.  

The insurer must send you its decision within 30 days of receiving your internal appeal.  

If the insurer denies your internal appeal, it will send you a final adverse determination. You will have the option to appeal this denial through a fair hearing. You may or may not also be to request an external appeal. 

• You must request a fair hearing within 120 days of the date on the final adverse determination.
• In the fair hearing, you can present evidence to an administration law judge.
• You will receive a decision in the mail, usually within a few weeks of the hearing.  

External appeal – you will receive this option only if the insurer determines that the treatment is not medically necessary, is an out-of-network service, is an out-of-network referral, or is a non-formulary prescription drug: 

You must file an external appeal within four months of the date on the final adverse determination.  

The reviewer must provide its decision within 30 days for a standard appeal, or 72 hours for an expedited appeal, where waiting would seriously jeopardize your health or life. 

Ensure that your insurance company has your current mailing address. If you move, notify your plan of any changes immediately. You may want to opt into electronic notifications from your insurer.  

Medicaid fee-for-service or straight Medicaid: How to appeal a decision 

If your Medicaid insurer denies your request for service, the only option you have is to request a fair hearing. They should tell you if the procedure is covered or not with reasonable promptness. 

• You have 60 days from the date on the denial notice to request a fair hearing.
• An administrative law judge will review the decision and evidence. The judge will determine whether you and the provider have proven that you meet the prior-authorization standards for the service.
• A decision by the administrative law judge is final. It overrules any decisions made by your plan.  

To learn more about appeals, visit the DFS page about health coverage for transgender New Yorkers.

What if my procedure is denied by 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.