Understanding Private Health Insurance After a Traumatic Brain Injury

The type of health insurance you have will dictate the level of care and treatment you or your loved one will receive. One of the most daunting tasks after a TBI is understanding health insurance, and then trying to secure the required benefits and services from an insurer. Hospitals, rehabilitation and nursing facilities, home health care providers, all require information about insurance coverage because they want to know how much treatment you can afford. It is equally important, if not more so, for you to understand your health insurance and the benefits. You may already have private insurance, or government health insurance, long-term rehabilitation benefits, home-care benefits, short and long term disability policies. People with TBI may also qualify to receive government benefits. You must identify all insurance policies, benefits, and programs. You must study policy exclusions, definitions, limitations, and treatment guidelines. And most important, you need to develop strategies to overcome the potential barriers to receiving necessary treatment.

Health Care Law Post-2010: The Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act, commonly known as the Affordable Care Act (ACA) and often dubbed Obamacare, became the law in 2010 and expanded in 2014. The ACA is based on the principle that all Americans should have access to affordable health care. The goal of the ACA was to extend health coverage to uninsured Americans, which was estimated at about 47 million individuals in 2010.

The ACA significantly improved health care for individuals with disabilities by expanding access to essential services and protections. A key initiative of the ACA was to prohibit insurance companies from denying coverage based on preexisting conditions. The effect of this provision on individuals with disabilities cannot be underestimated; this was a major barrier for individuals with disabilities who needed to obtain health coverage. After the ACA became law, people with disabilities could secure insurance and could also benefit from essential health services without the fear of exorbitant costs or gaps in coverage.

In addition, the ACA established health insurance exchanges, which provide a platform for individuals to obtain coverage that might have previously been unaffordable or inaccessible. Exchanges allow many to enroll in plans that offer comprehensive benefits for managing chronic conditions with disabilities like TBI.

The ACA also had a substantial impact on Medicare and Medicaid by reducing out-of-pocket expenses for medications under Medicare and expanding Medicaid eligibility to a broader population. The ACA encouraged preventive services without co-pays or deductibles, thereby promoting early detection and management of health conditions, and influenced quality of care by incentivizing health care providers to focus on quality improvement initiatives.

Finally, the ACA significantly improved long-term care insurance by requiring insurers to cover a wider range of essential health benefits, including preventive services and rehabilitation, which can benefit individuals with catastrophic TBI that need long-term care. Under the ACA, long-term care recipients are more likely to have better access to treatments and rehabilitative services without incurring overwhelming out-of-pocket costs.

Although there have been many legal challenges, and this will no doubt continue to be part of the national debate about health care for the foreseeable future, the ACA remains the law and has been successful in expanding access to affordable, comprehensive health insurance coverage and reducing the nation’s uninsured rate to the historic low of 7.7 million individuals in 2023.

Private Health Insurance Coverage

If you are at a hospital and know there is private health insurance coverage but do not have the details of the policy, you can confirm coverage by contacting the insurance company directly at its toll-free number. There are also staff members at a hospital who are available to call the insurer on your behalf to confirm coverage. Alternatively, you may obtain this information from the employer or from a group benefit brochure, or by calling the employer’s human relations or benefits department.

That said, our experience is that the coverage information provided is often inaccurate, out of date, incomplete, or misleading. To fully understand a health insurance policy, you must get a copy of the Master Health Insurance Policy. You need to thoroughly review this document. Insurance coverage is limited by the definitions, terms, and exclusions in the Master Health Insurance Policy. An insurance policy is a contract, and the devil is always in the details of that contract. Plan descriptions, telephone calls, and brochures do not provide the details you need to fully understand the policy, or an insurer’s denial of benefits and services. Understanding the policy will guide decisions about care, treatment, and decisions about appealing denials of benefits. The terms of the insurance policy will dictate the care provided. This is critical, because with a TBI, or any catastrophic injury, the level of care received will have an influence on a person’s recovery.

There are many types of private health insurance policies that you can purchase through the ACA marketplace as well as employer-sponsored private health insurance plans, including:

A Health Maintenance Organization (HMO) arranges managed care for health insurance, including self-funded health care benefit plans, on behalf of individuals and others and acts as the liaison between medical providers (doctors and hospitals) on a prepaid basis. These plans typically require members to select a primary care physician and obtain referrals for all specialty care. HMOs are adapting to competition by offering more comprehensive coverage and a wider network of health care providers. The HMO covers care provided by medical professionals, who receive a steady stream of income in exchange for treating patients in accordance with the HMO’s written guidelines. HMOs provide emergency care, regardless of the medical provider’s participation in the plan, but with restrictions.

While the cost of HMOs is lower, the concerns about HMOs include higher out-of-pocket costs; the cost of emergency treatment, which must meet certain conditions to qualify; the requirement that participants use in-network providers to get coverage; and the need for referrals from primary care physicians to see a specialist, who is approved by the HMO.

Preferred Provider Organizations (PPOs) allow patients greater flexibility to choose health care providers within a network because they do not require physician referrals. PPOs also generally provide broader coverage and allow for out-of-network care.

While the PPOs offer more flexibility to choose medical providers, the concerns about PPOs include that PPOs cost more than HMOs; a PPO is more likely to have an annual deductible than an HMO; PPO members pay a higher coinsurance fee than under an HMO for seeing a doctor outside of the network; increased paperwork when patients see out-of-network providers; and patient responsibility for coordinating care because PPO patients choose their own medical providers, unlike HMOs that make the primary care physician responsible for coordinating care.

Exclusive Provider Organizations (EPOs) combine certain features of HMOs and PPOs. EPOs offer a network of preferred providers for covered services. EPO health plans do not typically provide coverage for out-of-network care except in emergencies. EPOs focus on so-called cost-effective strategies and preventive care initiatives to improve health outcomes; this focus may result in barriers to obtaining coverage.

Common concerns about EPOs include additional out-of-pocket expenses; limited full coverage alternatives; the need to find a new primary or specialist doctor; substantial deductibles; lack of coverage outside of the network; and numerous network constraints.

High-Deductible Health Plans (HDHPs) work with Health Savings Accounts (HSAs) to allow individuals to save for medical expenses tax-free. An HSA is a savings account that allows individuals to save for qualified medical expenses. Either you or your employer can make HSA contributions and are limited to a maximum amount every year. These plans feature lower premiums and higher deductibles, making them suitable for those who prefer control over their health care spending and can afford high deductibles. HDHPs with HSAs emphasize wellness programs and telehealth services for preventive care.

HDHPs will reduce monthly premiums over other options, but there are some downsides, including large medical out-of-pocket costs in the event of unforeseen hospitalization. Since people with severe brain injuries may require hospitalization or other long-term treatment, it is important to determine whether you have access to the funds needed to pay the out-of-pocket maximum deductible required when considering a HDHP.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) refers to a federal law that allows individuals and their dependents to continue their employer-sponsored health insurance for a limited time after certain qualifying events, such as job loss or reduction in work hours. One of the primary benefits of COBRA insurance is that it provides a safety net for those who may need temporary health coverage, thereby ensuring access to necessary medical services. A significant limitation of COBRA coverage is that individuals must pay the full premium themselves, which can be a substantial financial burden. COBRA coverage is only available for 18–36 months, after which individuals must secure alternative health insurance.