Insurance

Connecticut requires insurance to cover us! …Well not quit, there is one glowing exception. I fell in to that gap when I was working; the company was self-insurance under a federal policy called ERISA. Hun?

What is ERISA?

It is the “Employee Retirement Income Security Act of 1974” what it does is allow company to pay directly (they usually hire an insurance company to administer the claims) and the company that I worked for did not cover my medical expenses for my transition. I had to pay for my Cross Hormone Therapy out of my own pockets.

Deemed ineligible for surgery, transgender man files discriminationcomplaint
The Boston Globe
By Alison Kuznitz
June 29, 2019,

A transgender man from Western Massachusetts who says he was repeatedly denied insurance coverage for a gender-affirming surgery filed a complaint last week with the state’s commission against discrimination, according to his lawyer.

Alexander Pangborn, 41, said he had previously been approved for blood work to monitor his testosterone levels. So when Pangborn, a nurse at Ascend Hospice, learned in January that he wasn’t eligible for the gender dysphoria-related surgery, he said, he appealed the decision to the Aetna Life Insurance Co. — twice.

That’s when Pangborn found out Ascend’s parent company, New Jersey-based CareOne Management, lists “sex change” as a general exclusion under its self-funded employee health benefits plan, he said.

According to CareOne’s plan, any treatment that changes “sex or sexual characteristics” — including surgical procedures, hormone therapies, and prosthetic devices — isn’t covered.

Now here is where the monkey wrench is thrown into the mix…

Self-funded plans are customizable across companies, meaning employers can decide which health services to cover and exclude. According to an Aetna clinical policy bulletin dated Jan. 11, 2019, the insurance provider generally does consider “gender reassignment surgery medically necessary,” as long as certain criteria – such as a mental health referral letter and documentation of gender dysphoria – are established.

But when an organization, like CareOne – and a third-party health administrator, like Aetna in this instance – delineates benefits based on sex, the policy is considered discriminatory, said Chris Erchull*, the lawyer who is representing Pangborn.

“It is unlawful to single out transgender employees and to essentially give them a lesser employee benefit package than all other employees,” said Erchull, of GLBTQ Legal Advocates and Defenders.

This is going to be a very hard case to win because the Trump administration is opposed to any coverage for us and my guess is that the Department of Justice will write a legal brief supporting the exclusions. Trump et al have intervened against cases that grant us protections under Title VII and Title IX.

This is a case that needs close watch to see how it goes because I think it will go all the way to the Supreme Court.

*I have known Chris for five months we sit on several committees together including the Department on Aging: Long Term Care Ombudsman Program workgroup for inclusion.