When you or someone you love has suffered a spinal cord injury (SCI), there is a mountain of medical costs and bills that frequently results from the injury: Emergency room costs, hospitalizations, surgeries, doctors’ visits, medications, medical scans, physical and occupational therapy, and a variety of other hidden SCI costs.
In the first year alone, the average annual expenses for spinal cord injury survivors with high tetraplegia average $1.1 million, according to the National Spinal Cord Injury Statistical Center (NSCISC). And, the costs average about $191,436 for each year that follows. For someone living with high tetraplegia who is injured in their teens or 20s — these costs total millions of dollars over the span of a lifetime.
Finding the money to help cover those costs, however, presents a challenge. Some people will lean on their insurance from their jobs (while they are still employed); others will lean on their families for support. In the U.S., many will seek out alternative funding through the government such as Medicaid and Supplemental Security Income (SSI).
1. What is Medicaid for Spinal Cord Injuries?
At its core, Medicaid is a joint federal and state program that aids in covering the medical costs of individuals with low incomes and limited resources. Medicaid, the largest source of health coverage in the United States, together with the Children’s Health Insurance Program, provides coverage to more than 72.5 million Americans.
Many people with spinal cord injuries who are eligible for the Social Security Administration’s (SSA) SSI program are also automatically eligible for Medicaid coverage, as the application for applying for SSI also encompasses applying for Medicaid.
Medicaid is the only national program that covers the complete range of services that spinal cord injury survivors and others with disabilities can use to live in their homes and communities. However, in most states, more than 70% of Medicaid coverage spending is put toward nursing homes, limiting the funds that are available for use by SCI survivors who want to live at home.
Some states have additional programs that can help provide funding to meet their needs. In Georgia, for example, there is a program known as Brain and Spinal Injury Trust Fund, which uses a surcharge on drunk driving fines to fund the program that aims to “fill the gaps in the system where there was no one else providing resources.”
2. What Does Medicaid Coverage Cover for SCIs?
We mentioned that Medicaid is a joint federal and state program, which means that the coverage varies from state to state. In Florida, for example, there is a Traumatic Brain Injury and Spinal Cord Injury Waiver program (0342.R04.00) through the Florida Agency for Health Care Administration that provides the financial support for services that can prevent or delay institutionalization. Through the fee-for-service program, which is not offered by Medicaid enrollee health plans, people with TBIs and SCIs can choose to receive services in their homes or in the community.
According to the Agency for Health Care Administration website, the state’s Medicaid coverage reimburses for the following waiver services:
- Assistive Technology
- Attendant Care
- Behavior Programming
- Community Support Coordination
- Companion Care
- Consumable Medical Supplies
- Emergency Alert Response (unit installation, monitoring, and maintenance)
- Environmental Accessibility Adaptations
- Life Skills Training
- Occupational Therapy
- Personal Adjustment Counseling
- Personal Care Services
- Physical Therapy (initial and regular)
- Rehabilitation Engineering Evaluation
- Residential Habilitation
- Transition Case Management
- Transition Environmental Accessibility Adaptations
Similar TBI/SCI Waiver Medicaid coverage programs exist in some other states, including Mississippi, Colorado, and South Carolina. However, it is critical to note that the types of services that are eligible for reimbursement vary by state.
3. Rules and Eligibility Requirements for Medicaid Coverage
Unlike Medicare, which is a federal program that is available to people 65 years or older, or individuals who worked and paid taxes for at least 10 years, Medicaid coverage opportunities require alignment with extensive rules for determining the available resources and income of every applicant.
For Medicaid eligibility, federal law requires states to cover specific groups of people in the program who are eligible to participate. However, building on this:
“States have additional options for coverage and may choose to cover other groups, such as individuals receiving home and community based services and children in foster care who are not otherwise eligible.”
The implementation of The Affordable Care Act in 2010 set forth new income eligibility determinations. The new income requirements are based on Modified Adjusted Gross Income (MAGI), a methodology that “considers taxable income and tax filing relationships to determine financial eligibility.”.
Eligibility for Medicaid coverage also includes:
- Financial Considerations
- Non-Financial Eligibility Considerations
- Medical Necessity
- Appeals
4. Maximum Income Requirements Limit SCI Survivors
The maximum amount of income that people with spinal cord injuries and other disabilities can earn while receiving Medicaid coverage varies by state. However, many full-time workers with disabilities find themselves experiencing a seemingly insurmountable challenge: Having to choose between being able to work and having caregivers. Paying out-of-pocket for caregivers is not possible for most SCI survivors, as the expenses would negate the wages they earn and they may lose money by working.
For individuals with cervical spinal cord injuries, this is particularly challenging because they need caregivers/home health aides/personal care attendants for years — in many cases, for the rest of their lives.
Medicaid may be the safety net that ensures people with spinal cord injuries receive the basic care that they need, however, you can lose your Medicaid coverage if you make more than the income limit in some states, including Florida. Florida’s Medicaid coverage eligibility caps income at $15,000 for a one-person household, $21,307 for two people, $26,813 for three, and so on.
There are other programs available as well that can help or limit people with spinal cord injuries who wish to work.
To learn more about spinal cord injuries, treatments, and legal options, download our free guide by clicking on the link below.
