Insurance Issues

Beyond dealing with the life and death issues you may face immediately after an accident, insurance issues can be some of the most trying and stressful challenges you will face. 

The insurance coverage you have can make dramatic differences in the level of care you receive.  At the initial stages of an injury patients are treated without much regard for insurance coverage.  It is after the patient has been stabilized that the type of insurance coverage starts to play a role.

I will stop and here and put in a big disclaimer.  I admit that it will be very difficult for me to be objective when it comes to writing about insurance companies.  I know that I have become jaded and biased against insurance companies as a result of my experiences so keep my biases in mind when reading this section. 

There may be a number of great insurance companies out there, but, unfortunately, we have not had the luck to have one of them.  My apologies in advance to the good insurance companies out there.

Health Insurance Coverage

There are a myriad of coverages and benefits available to people from a number of various companies.  While I can not comment on individual plans below is a list of things to be aware of in your policy. 

A trend that I saw from my previous employer that you may also see was that each year the cost to the employee went up while the benefits were reduced.  Often the coverages that were being reduced were in areas that not everyone typically uses.  However, with a brain injured family member we felt more of the reductions than the average employee.

Lifetime Coverage Limits - Some companies are instituting lifetime limits on their coverages.  Sounds reasonable unitl you understand that one catastrophic injury and you can use that lifetime limit up in a matter of months.  A one million dollar lifetime limit is not uncommon yet I can tell that our daughter's bill was over a million dollars for the six months she was hospitalized.

Subrogation Clauses

Therapy Benefits

Home Care Benefits

Durable Medical Equipment

Custodial Care

I should rephrase that previous sentence because if you get your health insurance as a benefit from you employer you probably will not ever see the actual policy.  as if you 

Appeals

Medical Director

Case Manager

Medicaid -  Medicaid is health insurance that helps many people who can't afford medical care pay for some or all of their medical bills.  Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. 

Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.  It can be used as a secondary insurance as well.

Medicaid Waiver -  Some states have instituted Waiver services, commonly known as "Medicaid waivers". The programs and services they offer differ in each state. Check into your state’s programs as the waivers can be very good programs for people with brain injuries.

In my state they have six different waiver programs aimed at different target populations. The particular program my daughter is on is called the Home Care Waiver. It provides services to people who would otherwise be institutionalized, such as in a skilled nursing home. Some of the services my daughter receives through the waiver program include: Therapies – PT, OT, and speech, Nursing services, Daily living services - aides, Respite care, Adult day health, Environmental accessibility adaptations, Transportation, Personal emergency response system, Adaptive and assistive devices, and Home delivered meals.

Families should contact the agency in their state that administers the waiver for more specific information about eligibility and services.

Medicare