Kalani Bright already has had to pay more than $34,000 out of pocket for sex reassignment procedures after losing a three-year battle to get her health insurance to cover them.

Now, the 42-year-old transgender woman is due for another round of voice surgery, but her insurance will still not cover the costs because it’s considered cosmetic rather than medically necessary.

“It’s really frustrating, and it puts you in a mental state where you’re seeing what your problems are,” Bright said. “Because you’re spending years talking about it, it makes you feel like you’re not getting anywhere.”

She’s one of many transgender people who may benefit from a bill that was passed by the Legislature and is awaiting Gov. David Ige’s approval.

Kalani Bright is a transgender woman who had to pay for her procedures.
Kalani Bright is a transgender woman who had to pay for her procedures. Courtesy: Kalani Bright

Hawaii adopted a law in 2016 that prohibited insurance companies from discriminating against transgender people. However, advocates say insurers are still denying coverage of gender confirmation procedures by claiming they’re cosmetic and not medically necessary.

House Bill 2405 would close the gap by barring health insurance providers from applying “categorical cosmetic or blanket exclusions” to prescribed gender confirmation treatments or procedures.

The measure lists examples including hormone therapies, hysterectomies, mastectomies, vocal training, feminizing vaginoplasty, masculinization phalloplasties, metoidioplasties, breast augmentations, masculinizing chest surgeries, facial surgeries, reduction thyroid chondroplasties, voice surgeries and therapies, and electrolysis or laser hair removal.

Waikiki Ala Moana area HMSA building at left. 17 april 2017
A legislative measure specifically prevents insurers from applying categorical cosmetic or blanket exclusions to gender-affirming treatments. Cory Lum/Civil Beat/2017

The bill also would identify the process for appealing a claim denied on the basis of medical necessity. It also requires health insurers, mutual benefit societies and health maintenance organizations to provide applicants with clear information about the coverage.

Two of Hawaii’s major insurers, Kaiser Permanente and the Hawaii Medical Service Association, said they supported the intent of the bill but asked for technical amendments due to concerns that the new law could potentially raise the cost of insurance and premiums.

In previous written testimony, HMSA’s then-assistant vice president, Matthew Sasaki, said the additional procedures would cost the insurance provider $7.7 million.

HMSA didn’t respond to a request seeking comment on its stance after the Legislature passed the bill. Kaiser said it supports the final version.

“We are proud to offer gender-affirming services that ensure respectful, equitable, and inclusive care to all our transgender and gender diverse patients and members everywhere that we deliver care,” the insurer said in an emailed statement.

Rep. Aaron Ling Johanson, who sponsored the bill, said it was an important step toward equity in care.

Opening Day Legislature 2022.. Rep Aaron Ling Johanson speaks to media during a press conference held at the Capitol.
Rep. Aaron Ling Johanson sponsored House Bill 2405. Cory Lum/Civil Beat/2022

“It’s important to ensure that in gender affirming care that insurers not be able to either inadvertently or consciously discriminate,” he said, calling the procedures “an important and critical part of gender care and a person’s successful transition.”

Ige has until June 27 to announce an intention to veto.

Jen Jenkins, a transgender rights advocate who helped write the measure, said “the whole point is to stop insurers from describing things as cosmetic.”

However, Jenkins is worried that insurers could find more loopholes such as adding administrative burdens that could discourage transgender people from seeking care. That means either more paperwork or steps that could delay the procedures.

“The fight for trans health and health care in general is probably going to be never ending under capitalism, but this (bill) is a great way to bring folks together and signal that Hawaii is different and moving in a different direction than other states,” Jenkins said.

A Constant Fight

The bill comes as the transgender community suffers setbacks in fights for rights in other states such as Alabama and South Carolina.

Hawaii is considered an LGBTQ-friendly state compared to many others. But D. Ojeda, the senior national organizer for the National Center for Transgender Equality, said it’s still common for transgender people to have to fight to get their procedures covered.

Ojeda cited “misinformation and misunderstanding to what these health care services mean to trans people.”

Ojeda said health coverage for these gender-affirming procedures is vital for mental health among the transgender community.

“Surgical care not only improves mental health, it improves your own body and it also improves the quality of our lives,” Ojeda said. “When we don’t have access to gender affirming care, it can lead to fatal situations like suicide and also violence. If people know that we’re trans, there’s a level of violence that comes with it, so surgical care in particular is key to our livelihood.”

Breanna Zoey.
Breanna Zoey Connors is currently working on getting a facial procedure covered by her insurance. Cory Lum/Civil Beat/2022

Last year, Breanna Zoey Connors said she considered suicide after being denied coverage of various gender-affirming services, such as breast augmentation, tracheal shave and other facial produces. The 38-year-old noted that her provider said her surgeries were not medically necessary.

“It was just horrible at one point, yeah, I didn’t want to live anymore,” said Connors, who has taken on a second job as an Uber driver to help cover costs.

After months of pushing back, Connors said she was able to get HMSA to cover the costs of her breast augmentation and some facial procedures late last year, and she’s now working on getting her insurance to cover her facial electrolysis procedure.

She also said that many transgender people may feel too intimidated to push back against insurance companies.

Connors acknowledged that the new bill isn’t perfect.

“It won’t solve all the problems with insurance companies,” she said. “There’s a big wait and see, but the intention is to get trans people the coverage they need (and) to end these nonsensical denials.”

Civil Beat’s health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and Papa Ola Lokahi.

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