Stroke Victims: Getting Health Insurance Coverage After The Fact

The financial impact of a stroke can be unpredictable and overwhelming. The road to recovery can be long and expensive, with hospital bills, therapy, medication, and other costs adding up. Health insurance is key to getting the care you need and recovering faster. If you don't have insurance, there are ways to get it, and no one can be turned down because of a pre-existing condition like a stroke. Understanding insurance and taking advantage of the right options can help you get the coverage and services you need. This includes exploring private insurance options, such as through an employer, or government insurance programs like Medicaid or Medicare. Additionally, disability benefits are important to consider, as they provide financial support until you or your loved one is able to work again.

The financial impact of a stroke

Healthcare Costs

The cost of stroke care can be substantial and varies depending on the type of stroke, treatment required, and long-term rehabilitation needs. The lifetime cost of ischemic stroke, for example, has been estimated at $140,048 in the US, including inpatient care, rehabilitation, and follow-up care. In Europe, the average cost per person for stroke care can range from €5,798.15 to €140,048, with intracerebral hemorrhage being the most expensive type of stroke.

Loss of Income

A stroke can result in a loss of income for the individual and their family. If the person is unable to work due to their disability, they may qualify for Social Security disability benefits or similar schemes in other countries. Additionally, caregivers may need to reduce their working hours to provide care, resulting in further financial strain.

Additional Living Costs

Following a stroke, individuals may face increased living costs. These can include higher expenses for heating, transportation, specialist equipment, and home adaptations. These additional costs can place a significant burden on stroke survivors and their families.

Insurance Coverage

Having health insurance is crucial for stroke survivors. It can ensure access to necessary care and improve recovery outcomes. Types of insurance vary and can include private insurance through an employer or government insurance programs such as Medicaid or Medicare in the US. Understanding insurance coverage and exploring additional benefits can provide financial support during recovery.

Disability Benefits

Disability benefits are an important source of financial assistance for stroke survivors and their families. These benefits provide financial support until the individual is able to return to work. It is essential to explore disability options as soon as possible, as they can also help protect the individual's job. Government disability benefits, such as those provided by the Social Security Administration in the US, may also be available.

In conclusion, the financial impact of a stroke can be significant and encompass various aspects of an individual's life. Navigating insurance coverage, understanding disability benefits, and seeking financial assistance can help mitigate the financial burden and ensure access to necessary care and support during the recovery process.

Types of insurance available

Private Insurance

Private insurance is usually obtained through an employer. This type of insurance can help cover the costs of inpatient care, rehabilitation, and follow-up care after a stroke. It is important to note that the specific coverage and benefits offered may vary depending on the insurance plan and the individual's circumstances. Therefore, it is crucial to contact your insurance provider to understand the extent of your coverage.

Government Insurance

Government insurance programs, such as Medicaid and Medicare, can provide coverage for stroke patients. These programs often have specific eligibility requirements, such as income thresholds, and may be available to those who meet certain disability criteria. In the United States, the Affordable Care Act (ACA) has expanded access to health insurance, particularly through the expansion of Medicaid eligibility and the establishment of health insurance exchanges.

Disability Insurance

Disability insurance is crucial for stroke survivors as it provides financial support during the recovery process. Short-term disability insurance pays benefits directly to the insured if they are unable to work due to illness or injury, helping with deductibles, physical rehabilitation, and lost income. Long-term disability insurance is designed for individuals with more severe impairments or permanent disabilities, providing benefits after an initial waiting period.

Supplemental Benefits

In addition to disability insurance, there are supplemental benefits that can assist with the financial burden of recovering from a stroke. Critical illness insurance, for example, typically covers stroke as one of the conditions and provides benefits to help with medical bills and other associated costs. Hospital indemnity insurance is also beneficial in the case of lengthy hospital stays, as it covers expenses related to admission and confinement.

Social Security Disability Benefits

If a stroke survivor is unable to work for at least 12 months following their stroke, they may be eligible for Social Security disability benefits. To qualify, individuals must provide proof of their stroke and meet certain criteria, such as having difficulty with motor skills, speech, or self-care. The Social Security Administration (SSA) will assess the individual's limitations, work history, and skills to determine their eligibility for benefits.

Qualifying for disability benefits

The road to recovery after a stroke can be long, unpredictable, and expensive. Hospital bills, ongoing therapy, nursing facilities, medication, and other costs can add up quickly. Disability benefits can provide financial support until you or your loved one is able to work again.

Social Security Disability Benefits

The Social Security Administration (SSA) offers disability benefits to stroke survivors. To qualify, you must meet the SSA's definition of a disability and the listing for a stroke in the SSA's Blue Book. The SSA defines a disability as the inability to engage in any substantial gainful activity due to a medical impairment that is expected to last for at least 12 months or result in death.

The Blue Book lists strokes within the category of neurological conditions in Section 11.04, also known as vascular insults to the brain. To qualify for disability benefits, you must provide proof of your stroke as described in the Neurological Impairment section of the Blue Book. This includes medical evidence such as diagnostic test results, hospital records, surgical notes, physical exam notes, therapy session records, and prescription medications.

Additionally, you must meet certain functional criteria. You may qualify for disability benefits if you are unable to:

• Speak or write effectively due to expressive or sensory aphasia.
• Control the movement of at least two extremities (e.g., an arm and a leg, two arms, or two legs), despite at least three months of treatment.
• Overcome marked physical problems along with limitations in thinking, interacting with others, finishing tasks, or regulating emotions and controlling behavior.

If you have vision loss or other physical impairments as a result of a stroke, you may also qualify for disability benefits under those listings.

Medical Vocational Allowance

If you don't meet the specific listings in the Blue Book but are still unable to work due to medical problems related to your stroke, you may be eligible for benefits through a Medical Vocational Allowance. For this, your doctor must describe your limitations on a Residual Functional Capacity evaluation form. The SSA will examine your evaluation form, work history, and skills to determine if you are able to work. If they cannot find suitable work for you, you will be eligible for benefits.

Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI)

If you haven't worked much or at all and have low income and few assets, you may qualify for SSI, which includes health insurance through Medicaid. On the other hand, if you have worked and paid taxes for years, you may be eligible for SSDI, which includes health insurance through Medicare. SSDI is typically for individuals who could work at some point but can no longer do so due to a disability.

Family and Medical Leave Act (FMLA)

If your employer is covered by the FMLA, you should apply for FMLA benefits as soon as possible. This can protect your job while you explore other short- and long-term disability options.

Supplemental benefits

The financial impact of a stroke can be significant, with inpatient care, rehabilitation, and follow-up care all contributing to the overall cost. Here are some supplemental benefits that can help ease the financial burden:

• Short-term Disability Insurance: Short-term disability insurance provides financial support to individuals who are unable to work due to illness or injury, including stroke. These plans typically offer coverage for three to six months, providing funds to help with deductibles, physical rehabilitation, and lost income.
• Long-term Disability Insurance: For individuals with more severe impairments or permanent disabilities, long-term disability insurance can provide financial support. It begins paying benefits after an initial waiting period, usually three to six months, and can help cover medical bills, everyday expenses, and lost income for an extended period.
• Critical Illness Insurance: Critical illness insurance is a type of supplemental coverage that provides benefits to help with medical bills and other costs associated with serious illnesses, including stroke.
• Hospital Indemnity Insurance: In the event of an extended hospital stay due to stroke, hospital indemnity insurance can provide benefits related to admission and confinement costs.
• Social Security Disability Benefits: If you are unable to work for at least 12 months after your stroke, you may be eligible for Social Security disability benefits. To qualify, you must provide proof of your stroke and meet certain criteria as outlined in the Social Security Administration's Blue Book.
• Wellness Benefits: Some insurance providers offer wellness benefits that encourage employees to get screenings and preventive care. These benefits can help identify risk factors and potentially reduce the impact of a stroke.
• Medicare and Medicaid: For individuals who meet certain income and eligibility requirements, government insurance programs like Medicare and Medicaid can provide coverage for stroke-related expenses.
• Supplemental Security Income (SSI): If you have a low income and limited assets, you may be eligible for SSI, which provides a fixed monthly amount. Receiving SSI can also lead to automatic qualification for Medicaid in most states.
• Social Security Disability Insurance (SSDI): SSDI provides partial income replacement for working-age individuals with disabilities. After a qualifying period, SSDI recipients gain access to Medicare coverage.

How to fight for your rights

Understand your insurance coverage

First, it is important to understand your insurance coverage and what specific stroke rehabilitation services they cover. Call your insurance provider and ask for details about your plan. Your doctor, case manager, or a social worker can also help you understand the specifics of your coverage. Find out how much and how long the insurance will pay for specific rehabilitation services, such as inpatient rehabilitation or outpatient therapy.

Know your rights

Educate yourself about your rights as a patient and an insurance holder. The Patient's Bill of Rights is a great place to start. You also have the right to appeal a decision if you believe you are being denied payment or access to a medical service that you are entitled to.

Seek help from professionals

Dealing with insurance companies can be frustrating and overwhelming. Ask for help from professionals who can guide you through the process and ensure you are getting the coverage you deserve. This can include hospital case managers, social workers, agencies that advocate for the aging population, or your local Social Security Administration Office of Disability. You may also consider hiring a medical billing advocate, a paid professional who can help you interpret your coverage, manage inappropriate insurance claims denials, and navigate insurance issues.

Stay persistent

Don't give up if you feel that your insurance company is not correctly paying for stroke recovery services or therapy. Find out why there is a discrepancy and take the necessary steps to resolve the issue. If services are denied due to a lack of "medical necessity," ask your doctor to get involved and provide additional information or support. Remember, you have the right to appeal any decisions that you believe are unfair or incorrect.

Explore disability benefits

Disability benefits are an important source of financial support if you are unable to work due to the long-term effects of a stroke. Explore your options for short-term and long-term disability benefits, including Social Security disability benefits and coverage through your employer. If you are unable to work for at least 12 months after your stroke, you may be eligible for Social Security disability benefits. Additionally, if you experience changes in physical function, such as motor skills or speech, you may qualify for additional insurance coverage for rehabilitation therapies during your recovery.

Frequently asked questions