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Quick action averts surgery denial in Arizona

 
James Kaliko
 

In our last email, we mentioned a mom who contacted us on Facebook. Melinda Fernandez works as a nurse at Yavapai Regional Medical Center (YRMC) in Arizona. Her son James Kaliko is on her employer-based health plan. He had surgery scheduled on May 9th and learned just a few weeks beforehand that the health plan excluded all treatments for gender dysphoria.

As a nurse who works at a hospital, it was deeply frustrating for Melinda to not have coverage for her son’s surgery. Because YRMC is a hospital that receives federal funding, its employee health plan is covered by Section 1557 of the Affordable Care Act, which prohibits discrimination on the basis of sex, disability, age and race in health care.

Melinda knew that and sprang into action. She contacted human resources and filed a charge of discrimination with the federal Department of Health of Human Services’ Office of Civil Rights.

To keep the surgery date, Melinda needed to pay $8,300 out-of-pocket, on top of the $2,500 deposit she had paid to get the surgery date. But the arrangements were all in place—the hotel, the time off, plus James had been waiting for surgery for years. She nervously made the payment, knowing she had to get reimbursed by insurance.

Then human resources got back to her saying that Section 1557 did not apply because of a federal court in Texas that had issued a nationwide injunction preventing its enforcement.

Had Melinda not already contacted us, she might have believed them.

We reassured her that the Texas court injunction was limited in scope, and, what’s more, that the injunction didn’t apply at all to Section 1557, which is a statute that remains fully in force. Sometimes employers misunderstand the law, and it’s our job to give them the facts.

We wrote to the employer, laying out the case. The very next day, the surgeon’s office called James to say that the insurance company had reversed its denial. We then received a letter from the employer saying that the exclusion had been removed.

Not only was James able to have surgery as scheduled, but now all other YRMC employees and dependents can now get trans-related health care as well. James had to travel for surgery because there were no qualified providers in the YRMC system. Hopefully, insurance coverage is the first step toward changing that as well.

And the pink hair? James is passionate about coloring hair. He started cosmetology school in the fall of 2017. He loves when someone walks into a salon and they sometimes want to change everything about their life—starting with their hair. He is thrilled when people look elated with their new appearance. He hopes someday to open a salon for LGBT people, and with surgery behind him, he’s now one step closer to realizing that dream.

 

Equal coverage for 12,000 Tennessee workers

 
Bentley Garner
 

It was December when we first asked Bentley Garner’s health plan to remove its “transsexual surgery” exclusion so that he could get top surgery.

Bentley works at a Kroger grocery store in Tennessee, and his health plan is a fund jointly run by Kroger and the United Food and Commercial Workers (UFCW) Local 1995 union.

Bentley had first run up against the exclusion in 2016 when the plan denied coverage for testosterone. He’d gone through the appeals process on his own to no avail. Bentley was particularly disappointed since Kroger is proud of its coverage of transgender health care for its non-union employees.

At Transcend Legal, we take a non-adversarial approach at first. We believe that employers want to do the right thing, and if provided with the facts about our clients’ needs and their liability under the law, they will take action. While litigation can seem like a faster option, it’s usually the opposite, so we do our best to avoid it. Sometimes this means having patience.

We continued to follow up with the health plan and, at the same time, made sure Bentley had a consultation and got a surgery date scheduled so that preauthorization could be submitted. Bentley picked up a second job to try to save up in case he had to pay out of pocket.

Just as we were preparing to send another letter, Bentley received a letter from the Fund saying that, after careful consideration, the Board of Trustees of the Fund decided to eliminate the trans exclusion, effective March 9, 2018.

Because Bentley decided to stand up for himself and not just pay out-of-pocket on his own, he won equal coverage not just for himself, but also for the other 12,000 Kroger workers in middle and east Tennessee, north Alabama, and south Kentucky!

 

Long Island TGNCNB Resource Expo

 
Long Island TGNCNB Resource Expo flyer
 

Join us and Pride for Youth at the 2nd Annual TGNCNB (Transgender, Gender Non-Conforming & Non-Binary) Resource Expo on Long Island. This event is open to individuals of all gender identities and ages from Nassau, Suffolk or Queens Counties and will take place at the SYJCC on June 2, 2018, from 12:00 p.m. - 3:00 p.m. We'll be hosting a clinic to answer your trans-related legal questions. If you need help with a name change, please fill out our Adult or Minor intake form as soon as possible to ensure a spot.

 

Name change trainings on Long Island

 

Transcend Legal will be holding attorney trainings with both the Nassau County Bar Association and Suffolk County Bar Association in June. Attendees will learn how to obtain name change orders for transgender New Yorkers and work with transgender clients.

  • Suffolk County Bar Association Name Change Training & LGBT Law Update, Suffolk Bar Association in Hauppauge, Wednesday, June 6, 6:00 p.m. - 9:00 p.m. Add it to your calendar and check back for registration info soon!
  • Nassau County Bar Association Name Change Training, Nassau County Bar Association in Mineola, Thursday, June 14, 1:00 p.m. - 2:00 p.m. Register now!
 

See you in Philly in August!

 
Philadelphia Trans Wellness Conference logo