Insurance coverage for trans people has always been tricky. In some cases so many hurdles and coverage exclusions existed that it was common for those in the community to expect almost everything they wanted or needed in way of health care would be covered only via private pay arrangements. This meant, as a practical matter, many waited years to raise the funds needed for hormone replacement therapy, other medicines, surgery, counseling, and so on. Far from idea. One even sees “Go Fund Me” pages being set up by people to get the medical attention or coverage for which they have been denied, or for which the co pays and deductibles are real hurdles.
Most insurance companies around the country, including health insurance companies, need to play by the rules set up by the state insurance commissioner or insurance oversight group in any state in which they hope to sell and market insurance. Efforts have been made on a state-by-state basis with the insurance commissioners to help assure that the barriers to insured coverage are minimal. It’s been a slog, but an example of what just happened in Wisconsin can be found here: https://www.susans.org/2018/08/23/a-big-win-for-wisconsin-but-the-work-does-not-end-here/
At the federal level a part of the Affordable Care Act (Section 1557) has also been viewed as somewhat helpful in increasing coverage, as it outlaws gender discrimination and not just discrimination based on the more common categories. See: https://www.hrc.org/blog/section-1557-of-the-affordable-care-act-and-what-it-means .
With a change in administrations, some see the current discussions about Section 1557, as a bit troubling–if the feds will not mandate that trans related care coverages exist in marketplace policies, what protections will there be for the community if they have an insurance company that prefers to say “no” rather than “yes” when treatment is sought?
Thus the value of individual state insurance commissioners taking on this issue. It is worth keeping up to date with your own state insurance commision office (or whatever it may be called in your state) as decisions there can affect you.
Two more possible articles of interest surrounding this topic and issue incude https://www.cnn.com/2018/05/31/health/transgender-surgery-insurance/index.html and this piece from the TransEquallity group and their article on your healthcare rights: https://transequality.org/know-your-rights/healthcare
People who have followed court cases and regulatory actions and policy developments in ANY area of law, understand there is often a sort of uneven path that is carved out, often case-by-case, until an area of the law is considered “settled.”
And all of us understand that even “settled” areas of the law are subject to change at times, whether because of slightly different facts, new legislation, tweaks in a constitution, and development over the decades in case law and politics, to a lesser degree. (Remember slaveholding was “ok” according to our courts at one time, now, with changes, slaveholding is not “ok.” Pollution and spewing industrial wastes and toxins in the air or land or water, once almost seemed to be a sort of property and business right according to some court decisions, without a lot of enforcement or control over the activities–now many such activities are regulated or prohibited in full or in part.)
In several courts around the country, both federal and state, judicial opinions have supported the notion that discrimination on sexual orientation and gender identity is, in essence, a form of sex discrimination, and so if laws and rules about sex discrimination apply to the situation, so too might discrimination because of one’s orientation and identity. This is good news for many in the LGBT community.
In the vastest oversimplification around, my own, and not other thinkers on the topic, it’s the concept of “you don’t fit in” or “we don’t do that here.” When woman first started working in the trades, or as cops or firemen–there was a lot of pushback, just as there was when women in college wanted to have competitive sports teams and opportunities to play. The law and policy worked their way around the issues–and while it might still be a bit unusual to find a female construction worker on the job–she’s probably gonna find her employment rights protected provided she can do the job . When men started to go to school for nursing and enter the work force as nurses in greater and greater numbers, they too faced pushback–they didn’t “fit in.”
In some ways, just as we might have thought it wasn’t smart or “right” for a woman to do this, or a man to do that, the law has shifted, and the more prominent notion is “can you do the job?” And doing the job usually has little or nothing to do with your race or religion or sex or age (nor frankly for a good number of jobs is your size a factor–Michigan has protections for weight and size–if folks are discriminated on those factors, they might be able to bring a legal complaint about such discrimination too).
And, in what should be good news of sorts for members of the lgbt community–doing the job, or renting an apartment, and so on, should not be hampered merely because you are in the lgbt community. An article from the Detroit Free Press about some of the developments can be found here: https://www.freep.com/story/news/local/michigan/2018/05/21/civil-rights-lgbt-discrimination/630297002/
The arguments about sex discrimination and sexual orientation and gender identity having a common genesis, and arguments that both forms of discrimination should be illegal in most instances, is not a brand new one–I made such an argument as early as 1985 on behalf of an individual substitute teacher fired by the Gobles School system (in Van Buren County) and you can find a synopsis of sort from 1994 and 1995 here: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2248257
Mind you, there is still some debate about the issue, not all circuits quite agree, and nods one way or the other by the executive branch of the US can change as well….but in the process (and it IS a process) of puzzling out what is legal or fair and just, changes can and do occur. This last article may give you more info to chew on: https://www.natlawreview.com/article/second-circuit-rules-anti-gay-discrimination-sex-discrimination
Sometimes people joke around with others about getting older or dying, or losing our capacity, and the joking around goes something like this: “I don’t mind dying, it’s the getting there that bothers me,” or “I want to die peacefully in my sleep at 95 like grandpa, and not screaming like the passengers in the car with him just before the accident” and so on and so forth.
Many of us do die suddenly, often peacefully, and with most of our abilities somewhat intact. But if we have a long glidepath towards death, and happen to have some form of dementia, or Alzheimer’s, it is possible we will be unable to communicate very well, if at all.
In these circumstances we might have neighbors or friends or loved ones or a spouse who can speak up on our behalf.
Our care, most argue, is best delivered by those who not only have technical skills in the delivery of care (nursing or otherwise), but who know or understand us.
But what if we have no one around to relay our history, or they are far far away? Or what if no one left really “knows” us? That’s a challenge for caregivers.
As one small step, completing a sort of “values and information” document can help. Such a document isn’t really related to a lot of legal issues, rather it gives a little glimpse into your personality and values.
Armed with such information, caregivers can better help you in the event you are not able to communicate much of anything. And if some respect is given to your thoughts and wishes (even as it becomes harder and harder, or impossible for you to communicate the wishes) many think you will do a bit better until death.
Our firm has a values and information document that is always evolving. Feel free to play with it, or use it, in any manner you wish. It is below. (Also, see the earlier blog post on our page called: I Hate Oatmeal)
If a person is going to be in a nursing home (nh) or needs long term care help for half a year or more, maybe the rest of their lifetime, many will eventually apply for assistance. This is because of the long term care costs involved–on average close to $8100 per month in Michigan.
Medicare typically only covers such costs the first 20 days in full, the next 80 days afterwards with a co-pay, and typically bows out, or stops coverage, after day 100. (If the care level is hospice in nature, Medicare may jump back in with payments for the hospice service costs–but not the room and board portion of hospice.)
Medicare, which most folks 65 or older get, is not really “means tested.” This means that Medicare doesn’t really care about our assets or incomes and doesn’t typically care what our financial situation might be in a coverage analysis.
If it appears that the person is going to need a nursing home for months and months and months, or even years, they might apply for help with such bills via Medicaid, which doesn’t have a 100 day coverage limit. But Medicaid IS ‘means tested” and so a review of exempt versus non exempt assets is made, and sometimes, to qualify, one has to do some planning or spending down of non-exempt assets, or both.
Below are the “numbers” for 2018. Feel free to make an appointment with us if you need to look into Medicaid planning, or need help paying for long term care or preserving the nest egg of the spouse who doesn’t need long term care care.
Equity value of homestead (exempt) $572,000.00
Individual Resource Allowance (yearly) 2,000.00 (0r $3,000 if both spouses in nh)
Monthly Personal Needs Allowance 60.00
Minimum Protected Amount Community Spouse 24,720.00
Maximum ” ” ” ” 123,600.00
Burial Fund/Space Allowance (2 different things) 1,500.00 or more, depending on many factors
Pre-paid Funeral Contracts 12,540 (2017 number subject to adjustments)
Vehicle (one vehicle only) exempt (generally no value limit)
Minimum Monthly Allowance for Community Spouse 2,030.00
Maximum ” ” ” ” ” 3,090.00
There are more figures and numbers that can crop up when a medicaid application is being made–keep in mind DHHS essentially puts the assets into two piles–those assets which are exempt (and don’t count “against” an application, thus also amounts one can readily “protect) and assets which are not exempt. Non exempt assets would likely be used up, spent, on care BEFORE Medicaid could help. But this can really put those left behind at a disadvantage. Sometimes, with prudent planning or review, a couple or individual could shift these numbers a bit, to help preserve important savings or protections for the community spouse. Elder law attorneys help review these issues with the applicant/family. Naturally each situation differs and so what might be prudent or possible for one family, might not work, or may not be needed, for others. But a review is always smart.
DHHS also looks at the income of a Medicaid applicant. Typically, virtually all of the applicant’s income is used to help pay for the nursing home, with Medicaid helping pick up the balance, or shortfall. Thus, if a single person had monthly social security of 1300 dollars, and an 800 dollar pension from one spot and a 125 dollar pension from another spot they would turn over all but 60 dollars a month to the nursing home (this would be their patient pay amount under Medicaid rules), in this instance the single person would pay 2165 dollars every month towards their care–and Medicaid would help with the rest of the monthly bill.
When the nursing home patient (or prospective patient) has a spouse who can stay at home though, the patient pay amount might be adjusted so the community spouse–the one still home–can avoid what the law would call spousal impoverishment. The federal government and states who come together to provide Medicaid, realize that a spouse left behind might suffer if they can’t keep a bare bones budget going.
So in the example above, the nursing home spouse had 2225 of monthly income. What if their (community) spouse had income of 900 a month social security and one pension of 420 a month (as an example) for a total income of 1320 a month? Under the rules, at minimum, the community spouse could keep 2030 from their joint incomes. This means that the nursing home spouse would be able to give the community spouse at least 710 per month (to bring the community spouse up to 2030 in monthly income) and this also means that the “patient pay” amount in our example would change–and would drop to 1455 per month.
Anyway, this stuff can get confusing but as a basic numbers example for 2018, I wanted to get this posted. Most of the numbers above changed with the beginning of 2018, a few of the numbers change in the summer, so check with the Michigan Department of Health and Human Services or call an elder law attorney and make an appointment if you need to explore this more.
As reported in the New York Times the other day, there are some steps one can take if you are single or essentially so, and the quasi- automatic default system of relative care won’t be available. This is good reading. Remember too, a stop with an attorney, a consultation, and perhaps preparation of documents such as a power of attorney or medical power of attorney, or long-term care planning strategies, is smart. https://www.nytimes.com/2018/03/23/business/elder-orphans-care.html