Payment Options for the Traumatically Brain Injured - Part II

As we discussed last time, once the acute care period is over and the patient is stabilized, the resources available to the patient can substantially impact treatment and recovery. In a perfect world, every patient would have unlimited access to the best resources available to meet their needs. Ours unfortunately is not a perfect world.

The consequences of a traumatic brain injury are far reaching. Not only are there treatment costs associated with the recovery from the acute injuries, but there are the costs of long term care and supervision, the lost support to the family unit that the injured party previously contributed, the increased physical demands placed upon the caregivers and family of the survivor to meet the needs of their injured loved ones, and the family having to step into the breach of the role that the injured person previously contributed to the family.

This analysis will focus on governmental sources of funding for treatment and assistance to the traumatically brain injured.

B. Medicaid Medicaid is health insurance that helps people who cannot afford medical care pay for some or all of their medical bills. Medicaid is available based on income, and applies only to low income individuals and families who fit into the eligibility group recognized by Federal and State law. Medicaid is administered on a state-by-state basis. Medicaid pays money directly to the health care providers.

1. Medicaid Liens. Like private health professionals, Medicaid may assert a lien on any recovery for the monies which it has paid. However, to the extent that there are not enough monies in the recovery to pay every provider in full, Medicaid must share “pro-rata” with any unpaid medical providers pursuant to the requirements of N.C.G.S. 108A-57.

2. Medicaid waiver North Carolina has instituted certain waiver services allowed by statute. These are commonly known as Medicaid Waivers. The Waivers tend to be aimed at different target populations.
a) NC-Community Alternatives Programs. This provides case management, respite, adult day health, in home aids, delivered meals, waiver supplies and home mobility aids to AIDs diagnoses for persons thirteen and older, HIV seroposivity and CDC classification of category A, B, or C for children aged 2 to 12 and HIV seropositivity for children up to age 2.
b) NC-CAP Choice. This waiver provides adult day health, respite, personal assistant, telephone alert, home delivered meals, in-home health aids, home mobility aids, waiver supplies, consumer designated goods and services, care advice, and financial management services to individuals elderly and disabled.
c) NC-Managed Behavioral Health Care Waiver This Medicaid waiver provides managed behavioral health care to the piedmont region.
d) NC Community Alternatives Program for Children The program provides case management, personal care services, respite care, nursing services, home mobility aids and waiver supplies for disabled children aged 18 years or younger.
e) NC-Community Alternatives Program for Disabled Adults. Provides case management, respite (in home and institutional), adult day care, day health care, home modifications, PERS, attendant care, waiver supplies and home delivered meals.
f) NCMR/DD This Medicaid waiver provides case management, personal care, respite habilitation (day and in-patient), environmental modifications, transportation, specialized medical equipment and supplies, PERS, family training, in home aid, vehicle adaptations, crisis stabilization, developmental day care, therapeutic case consultation, supported living, augmentative communication, live-in caregiver and interpreter services to individuals with MR/DD.

3. North Carolina Division of Aging and Adult Services The North Carolina Division of Aging and Adult Services has many programs to assist older adults and persons with disabilities. The benefits extend to the patient and their families through community-based systems of opportunities, services, benefits and protections. Many of these services extend to brain injured individuals who also meet the definition of “persons with disabilities”.

4. Short Term/Long Term Disability Insurance If the injured person was employed at the time they acquired the brain injury, they may also be eligible for short term or long term disability coverage through their employer. It is not unusual for employers to offer group disability coverage to their employees. While this benefit may not directly pay for medical services, employees typically are eligible to receive a percentage of their base pay as their disability benefit. A typical plan has short term coverage for a period of three (3) months where the employee is paid roughly 80% of their base pay and after that period if they are still unable to work and they apply for long term disability, the employee is then paid a lower rate – often 60% -- of the base pay for an extended period of time.
1. Many people also purchase disability coverage’s on mortgages and other financial obligations. Caregivers should consider inquiring with any lending institution to which the brain injured is obligated for the possibility of such coverage. These benefits range from a suspension in the repayment obligation during the period of disability to a complete payoff of the loan.

5. Supplemental Security Income (SSI) Supplemental Security Income (SSI) is Federal income supplement program funded by general tax revenues (not Social Security taxes) that is designed to help aged, blind and disabled people who have little or no income. SSI benefits are intended to meet basis needs of food, clothing and shelter. The standards of disability differ between whether the person is over or under 18 years of age.
1. If the person is under 18 years of age, “disabled” means a medically determinable physical or mental impairment which results in marked and severe functional limitations; and can be expected to result in death; or has lasted or can be expected to last for a continuous period of not less than 12 months.
2. If an individual is over 18 years of age, “disabled” means he or she had a medically determinable physical or mental impairment which results in the inability to engage in any substantial gainful activity; and can be expected to result in death; or has lasted or can be expected to last for a continuous period of not less than 12 months.

6. Social Security Disability In addition to SSI, Social Security Disability insurance pays benefits to the injured person and certain members of that injured persons family if they are “insured” (meaning that they have worked long enough and paid Social Security taxes). To qualify for benefits, a patient must have first worked in jobs covered by Social Security then have a medical condition that meets Social Security’s definition of disability. The definition of “disability” is consistent with the definition of SSI disability stated above. Social Security Disability is not based on income but the benefits can phase-out based on the earned income which the disabled individual receives. Disability payments from private sources, such as private pension or insurance benefits typically do not affect Social Security Disability benefits. However, Workers’ Compensation and other public disability benefits may reduce the Social Security Disability benefits.

For more information visit www.perryfisherlaw.com