Even if the survivor has the best insurance, brain injury is so financially devastating that at some point the well runs dry. Before this happens, learn to navigate the system so that the survivor continually gets the care he or she needs, as well as any special services or equipment.
After the survivor or his or her loved ones have put their finances in order and familiarized themselves with insurance policies and employee benefits, it’s time to learn about Medicare, Medicaid, and Social Security.
If the survivor is over the age of 65, or younger than 65 and has a disability, he or she might qualify for Medicaid. In order to do so, the survivor must be a United States citizen, and he or she or his or her spouse must have worked and paid taxes for at least 10 years.
There are two different “parts” to Medicare. Part A refers to hospital insurance, while Part B refers to medical insurance.
Medicare Part A is automatically given to most people when they turn 65. In addition, anyone who is not yet 65 but has received Social Security Disability benefits for 24 months is also eligible for Medicare Part A. In this case, the brain injury survivor does not have to pay premiums for Part A.
Medicare Part B pays for doctor visits, outpatient care, physical therapy, and any necessary home healthcare. Medical equipment that’s deemed necessary is also covered. It’s important to understand that Medicare doesn’t pay for all services, nor are all services covered in full. Some services that Medicare doesn’t cover include prescription drugs, homemaker services, personal care, and 24-hour care.
Medicaid is often confused with Medicare, but it’s a completely different benefit. Medicaid is a state and federal program that’s designed to help those with limited resources or income with their medical costs. About 80 percent of people who access Medicaid are eligible because they received assistance through the SSI program, while the remaining 20 percent have qualified because of large medical expenses associated with their injury or disability. While the majority of Medicaid funds are spent on nursing homes and other institutional care, Medicaid will pay for any service that allows a person with a disability to live in his or her own home and community.
Medicaid eligibility varies from state to state. In addition, states may expand their Medicaid services via a “buy in,” which allows people with disabilities to continue to work and still receive benefits. The best way to determine state eligibility requirements is to contact your state’s Medicare office by calling 1.877.267.2323 or by logging on to the Medicaid website, http://www.cms.hhs.gov/.
Social Security provides two programs for people with disabilities. These are Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Let’s spend a little time discussing each one of these.
Social Security Disability Insurance (SSDI)
SSDI is for any person who is unable to work due to a disability. The person must fit a specific definition set forth by the American with Disabilities Act. Basically, the survivor is considered disabled if he or she can’t do the work he or she did before the brain injury, nor can he or she take on other work because of the injury. There are two other qualifications that determine whether a person is eligible for SSDI:
- It’s determined that the disability will last at least one year or result in death; and
- The survivor has worked and paid FICA taxes at least five of the ten years preceding the disability.
The fairly stringent qualifications mean that many people who apply for SSDI are turned down. If the survivor is turned down he or she can go through the appeals process. During this process, the person will be asked to provide proof of the disability. To improve the chances of being approved, this proof is required to come from the survivor’s doctor, and not from family members, former employers, or the survivor.
Supplemental Security Income (SSI)
One of the main differences between SSDI and SSI is that benefits aren’t linked to prior work. Instead, SSI is geared toward anyone over the age of 65 or with a disability who has limited resources and income. Benefits vary from state to state, but may include assistance such as food stamps, Medicaid coverage, and paid Medicare premiums.
For more information on SSDI and SSI, or to educate yourself on the appeals process, contact your local Social Security office. You can also visit their website at www.ssa.gov/disability.
If you need help navigating the often confusing world of Social Security benefits, an organization called the National Organization of Social Security Claimants’ Representatives (NOSSCR) specializes in representation and advocacy. They can be reached at 1.800.431.2804, or by visiting their website at www.nosscr.org. It is also advantageous to consult with an attorney who specializes in social security benefits to review the survivor’s options, eligibility, and to get assistance with the appeals process.