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Insurance and Financial Assistance for Survivors of Stroke

CDC stroke facts and statistics state that more than 795,000 people in the United States have a stroke annually. Nearly one in four of those have had a stroke before. Strokes are the leading cause of long-term disability with direct costs that total $35 billion annually in the United States.

The incremental direct costs of stroke per single patient in the U.S. is $4,317 with $1,920 related to inpatient costs.

Additionally, studies show that the average cost for hospitalization for stroke patients is $20,396, increased by $14,499 for hemorrhagic strokes, and $9,836 higher for those with a primary diagnosis of ischemic stroke with a secondary diagnosis of ischemic heart disease.

The American Heart Association forecasted in the study of costs for hospitalization for stroke patients that direct medical costs of stroke could increase 238% from 2010 to 2030.

This does not include indirect costs and variables such as wage differences, underemployment, unemployment, and disability-related costs that survivors of stroke experience after the stroke occurs and increases the difficulty of financial recovery from medical bills.

In general, stroke survivors miss 4.2 more days of work compared to people without strokes, and the risk of unemployment is 60% higher than it is for patients who haven’t had a stroke.

About 66.5% of all American bankruptcies are tied to or stem from medical issues. Costs for uninsured stroke patients can be catastrophic and may lead to medical bankruptcy. This article will discuss the ins and outs of stroke treatment, insurance, and other financial, medical, and supportive assistance for survivors of stroke.

Diagnosis, Treatment, and Living With a Stroke

A stroke requires immediate medical attention, treatment, and lifestyle changes to decrease the risk of recurrence, all of which impact the financial cost of having a stroke.

Diagnosis

Diagnosis of a stroke may include one or more of the following:

  • A computerized tomography (CT) scan of the brain to look for bleeding or damage.
  • A brain magnetic resonance imaging (MRI) scan to discover small changes in brain tissue.
  • Computerized tomography angiography (CTA) of blood vessels.
  • Magnetic resonance angiography (MRA) to check blood flow through arteries.
  • Doppler sonography to test carotid arteries.
  • Electrocardiogram tests for irregular heart rhythms.
  • Echocardiography to analyze the heart.

Diagnostics may vary on a patient-to-patient basis.

Emergency Treatment

Emergency treatment for a stroke may include:

  • Thrombolytics or fibrinolytic clot-busting machines.
  • Intravenous medicine and/or therapy to reduce or control brain swelling.
  • Neuroprotective medicines that protect the brain from damage and lack of oxygen.
  • Life support measures that may be necessary and include:
  • Ventilators to assist breathing
  • Intravenous fluids for medication and hydration.
  • Various methods for nutrition.
  • Controlling blood pressure.
  • Craniotomy brain surgery to remove clots, relieve pressure, or repair bleeding in the brain.

Emergency treatments may vary on a patient-to-patient basis.

Stroke Treatment and Care Plans

Stroke treatments and care plans are generally crafted per patient by their healthcare provider.

Treatment circumstances may depend on:

  • The patient’s age, health, and medical history.
  • The type of stroke the patient had.
  • How severe the stroke was.
  • The location of the stroke in the brain.
  • The cause of the stroke.
  • The patient’s reaction to medications, treatments, or therapies.
  • The patient’s opinion or preference.

Some treatments may include:

  • Medicines and prescriptions such as:
  • Blood-thinning medications.
  • Antiplatelet medications.
  • Blood-pressure medications.
  • Cholesterol-lowering medications.
  • Various heart medications.
  • Diabetes medications.
  • Different types of surgery may include:
  • Carotid endarterectomy surgery.
  • Carotid stenting surgery.
  • Surgery to repair aneurysms and arteriovenous malformations.
  • Patent foramen ovale closure surgery.
  • Lifestyle changes that may include:
  • Quitting smoking.
  • Nutrition and dietary changes.
  • Weight management.
  • Physical activity.
  • Limited alcohol use.

Treatments and care plans may be curated to meet the individual needs of a patient.

Effects of a stroke may include:

  • Paralysis on a certain side of the body.
  • Difficulty swallowing.
  • Feelings of tiredness or exhaustion.
  • Neurological complications can make thinking or doing simple math such as adding, subtracting, or balancing a checkbook difficult.
  • Speech and language problems.
  • Loss of speech.
  • Vision impairment.
  • Emotional changes such as feelings of irritability, forgetfulness, carelessness, confusion, anger, anxiety, or depression.
  • Behavioral changes.
  • Memory loss.
  • “Locked-in” state where the patient is unable to speak or achieve movement below the neck.
  • Pain and central pain syndrome.
  • Difficulty performing daily activities such as dressing, showering, or toileting.
  • Additional complications that are unique to the individual.
  • Death.

Survivors of a stroke may have unique combinations of effects that will differ from patient to patient.

Insurance and Stroke Care

The lifetime cost of an ischemic stroke, including inpatient care, rehabilitation, and follow-up care, is estimated at $140,481.

The financial impact of having a stroke can be overwhelming and difficult to manage, especially if the individual is experiencing mental and physical side effects after their stroke.

Utilizing your health insurance to its fullest to cover costs for medical services and medication is an essential step in managing medical debt.

A few things to be aware of when navigating the necessary care for stroke with insurance:

  • Every insurance service and type is unique in what they will cover for emergency services, rehabilitation and therapy, long-term care, and medication.
  • Your coverage may also depend on your medical situation and recovery process.
  • You need to be specific with your insurance and medical services provider and ask directly what is covered and for how long.
  • Symptoms, effects, and physical changes due to stroke may qualify you for additional coverage and benefits.
  • If you feel that your insurance is not accurately covering your medical expenses and recovery services you do have options to appeal.
  • Dealing with insurance after a stroke and while you are healing can be overwhelming and difficult. You can seek out resources from an advocate or case manager.

If you do not currently have insurance, you can still seek insurance benefits and cannot be turned down because you had a stroke. The following sections will discuss eligibility requirements and associated coverage for different insurance types.

Government-Funded Insurance Programs

Government-funded health insurance programs are publicly funded healthcare options available to those who qualify financially, through a disability, or after the age of 65.

Medicaid

Medicaid is funded both federally and by state governments. Eligibility for Medicaid will depend on a state-by-state basis, though generally people or families with low income, disability, or pregnancy will qualify. Some people who do not qualify for Medicaid due to income may still be eligible for a medically needy program.

Mandatory Medicaid benefits regardless of the state include:

  • Inpatient hospital services.
  • Outpatient hospital services.
  • Early and periodic screening, diagnostic, and treatment services.
  • Nursing facility and home health services.
  • Physician services.
  • Rural health clinic services.
  • Federally qualified health center services.
  • Laboratory and X-ray services.
  • Transportation to medical care.

Some states may include the following optional benefits:

  • Prescription drugs.
  • Clinic services.
  • Physical therapy.
  • Occupational therapy.
  • Speech, hearing, and language disorder services.
  • Additional diagnostic, screening, and rehabilitation services.
  • Respiratory care services.
  • Case management.
  • Private duty nursing services.
  • Personal care.
  • Hospice.
  • Self-directed personal assistance services.

It is important to check for state-specific benefits that are required or offered in your state.

Medicare

Medicare is a federally funded health insurance program that may include additional premiums that the individual is responsible for.

Medicare offers eligibility for people who meet the age requirement of 65 years or older. Some may be eligible for Medicare if they are under 65 and meet disability or illness requirements. There are different parts of Medicare that cover specific services. These include:

  • Medicare Part A is typically considered hospital insurance and covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  • Medicare Part B is typically considered medical insurance and covers certain types of doctor services, outpatient care, medical supplies, preventative services, and physical and occupational therapy.
  • Medicare Part C,the Medicare Advantage Plan, is additional coverage offered by private companies approved by Medicare. These extra coverages typically include vision, hearing, dental, and other types of health and wellness programs.
  • Medicare Part D provides prescription drug coverage and may help to cover the cost of medication and some recommended shots or vaccinations.

Your medicare coverage will depend on what you are enrolled for and what your plan offers.

Social Security Disability Insurance and Supplemental Security Income

There are two forms of disability benefits available for people who have had a stroke, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Though each will differ in technical qualifications, the medical qualifications will be the same.

The Social Security Administration (SSA) considers a stroke to be disabling under certain circumstances; the stroke must cause lasting impairments and/or your stroke-related limitations must have been present or expected to last a minimum of 12 months.

In general, the SSA will require the following:

  • Results and proof of the tests that diagnosed your stroke.
  • Hospital stay records that include any emergency room or inpatient records.
  • Surgical notes from any related operations.
  • Physical exams, progress notes, and detailed reporting from your primary care doctor or neurologist.
  • Records from therapy sessions such as physical, occupational, or speech therapy.
  • Records of prescriptions.

Supplemental Security Income is federally funded and provides financial assistance to meet the basic needs of nutrition, clothing, and shelter.

Social Security Disability Insurance is federally funded and provides monthly benefits and assistance to you and certain members of your family if you worked long enough and paid Social Security taxes.

Private Health Insurance

Private health insurance is available either from an employer or by seeking health insurance services in the health insurance marketplace.

To apply through the health insurance marketplace, you will need to sign up for insurance during the open enrollment period. If you miss the open enrollment period, you may be able to qualify under a special enrollment period that is offered specifically for a qualifying life change.

The type of coverage you receive will depend on your chosen health insurance plan, which may include a high-deductible health savings account (HSA) or a preferred provider organization (PPO).

While an HSA will allow you to make tax-free deposits to your account, a more traditional insurance program will require you to pay monthly insurance premiums that are typically indicative of the medical coverage you will receive.

Health insurance providers generally provide tiers of coverage that range in premiums and what type of coverage they will provide. The five general categories are:

  • Bronze: Usually includes a lower monthly premium and less coverage.
  • Silver: A slightly higher premium than bronze coverage, but with lower deductibles.
  • Gold: High monthly premiums but with lower costs to cover medical expenses.
  • Platinum:Typically the highest monthly premiums, but the lowest deductibles and out-of-pocket expenses for care.
  • Catastrophic: This plan is typically the lowest cost but the highest out-of-pocket deductible.

If you already have a private health insurance plan it is essential to speak with a case manager or medical advocate who can help you navigate your coverage. If you do not qualify for Medicaid or Medicare and are choosing a private health insurance plan, you should consider the following to choose the best plan for you;

  • Your budget, expenses, and what level of coverage you can best afford.
  • Your typical out-of-pocket expenses for medical care, treatment, and medication.
  • The providers your health insurance will work with.
  • The specific coverage of the plan including, but not limited to:
  • Emergency services.
  • Hospitalization.
  • Laboratory testing.
  • Mental health services.
  • Outpatient care.
  • Pediatric, vision, and dental services.
  • Prescription and medication assistance.
  • Preventative services.
  • Management of chronic diseases.
  • Rehabilitation services.

Considering your medical history and needs will help you understand the coverage you should seek when selecting a health insurance plan.

Insurance Related Assistance, Advocation, and Processes

Insurance does not automatically approve medical care, treatment, or medication. Each insurance company operates differently, but in general you and/or your medical provider will need to provide information to the insurance company for authorization.

This may include making a call to the insurance company, providing specific information, details, or reports, and filling out a special form.

In many cases, having a medical advocate or a trained professional medical case manager can help you overcome obstacles and understand the ins and outs of navigating healthcare costs, approval, and insurance.

Prior Authorization

Your insurance may require prior authorization for some medical services, treatments, or medications. Prior authorization is also commonly called prior approval, precertification, or pre-authorization.

Prior authorization is not required for emergencies and is also not a commitment or promise from your health insurance that your health insurance plan will cover the cost.

The process of prior authorization should start as early as possible, especially if you are going to need a complex treatment or specific prescription. You should ask your doctor if prior authorization will be necessary and if they can start the process immediately.

To get prior authorization, your doctor will communicate with your insurance provider. Your insurance provider will then review your case and doctor’s recommendation. Your prior authorization will typically be approved or denied within five to 10 business days.

If your prior authorization is rejected by your insurance company, you and your doctor can ask for a review or appeal of the decision, and/or your doctor may recommend an alternative treatment that is equally effective and covered by your plan.

Insurance Appeals

Your insurance may not pay for certain treatments or medications. This may be the case if:

  • Your prescription is not covered.
  • There are lower-cost medications available.
  • The insurance provider has not decided or committed to pay for a new drug or treatment.
  • Your medical records do not match your illness.
  • You are prescribed a different dosage of medication than your insurance provider allows or covers.

If your insurance denies a benefit or refuses payment and you don’t agree with their decision, you have the right to file an appeal and have it reviewed by a third party. There are two ways to appeal: internally, and externally.

When you file an internal appeal you are asking your insurance to conduct a full and fair review of its decision on refusal or denial. If your case is urgent, your insurance provider is required to respond on time.

If you file for an external review, you take your appeal to a third party for review, and the insurance provider is no longer provided the opportunity to make the final decision.

To file an appeal:

  • Don’t wait, file immediately. All appeals have a time limit.
  • Ask your doctor, case manager, or medical advocate for assistance.
  • Contact your insurance provider and ask about their appeal process.
  • Follow the steps of the appeal process that your provider instructs you to do.
  • Make copies of all appeal paperwork and keep a copy for yourself on file.
  • Include all pertinent and important information on your appeal. Including your name, address, phone number, and insurance ID number as well as the name and phone number of your doctor.
  • Include the name of the service or prescription you are appealing.
  • Include copies of treatment records from your doctor and a copy of representative authorizations.
  • Provide as much detail for your case as possible.

Contact your doctor, pharmacy, and insurance provider to follow up and ensure that your appeal is being reviewed.

Patient Advocacy

There are many resources available to assist a survivor of stroke with navigating medical treatments and the healthcare system, medications, insurance, and finances. These may include:

  • Hospital case managers.
  • Social workers.
  • Medical billing advocates.
  • Agencies that specifically advocate for your age bracket or medical condition.
  • The local Social Security Administration Office of Disability.

These advocacy services utilize paid professionals to interpret and assist in managing your medical coverage, services, claim denial, and medical billing. Not all patient advocates provide the same services, and not all services are free of charge.

If you are seeking advocacy, you may consider what type of advocacy you need. An example may include seeking a general patient advocate that assists you in receiving care and choosing the best treatment, or, seeking medical billing advocates who focus on assisting clients with understanding their bills, contesting inaccuracies, or lowering costs.

Some patient advocates may be provided by your health insurance provider, while others may include services from the healthcare provider/institution.

When seeking an advocate, first speak with your healthcare provider and your insurance provider. You can also seek counsel with the Patient Advocate Foundation which offers one-on-one personal advocates for patients.

To contact the Patient Advocate Foundation case management services, call: (866) 512-3861.

You can also use the AdvoConnection Directory to find professional healthcare advocates in your area.

Financial Assistance and Recovery for Stroke Survivors

Preparing and planning for the cost of stroke care can aid you in navigating the expenses that stroke survivors may face. To prepare beforehand:

  • Have an up-to-date ID card and insurance card.
  • If you are not yet insured, consider your insurance options and get insured.
  • Prepare and keep personal files of all paperwork. Make sure your family and advocates know where you keep your paperwork.
  • Review the details of your insurance and what they cover.
  • Make any necessary appeals as quickly as possible.
  • Seek out advocates and counselors to navigate the lengthy process of obtaining and receiving care, as well as financial help.
  • Ask your care provider what the estimated costs are early on in the treatment process, and what type of rehabilitation options are available to you.
  • Ask your care provider and insurance provider about financial aid.

Because of the high cost of care for stroke patients, it’s wise to consider seeking out additional financial resources and options.

Rehabilitation

Rehabilitation is an essential aspect of stroke treatment. Different rehabilitation services may include:

  • Physical therapy.
  • Occupational therapy.
  • Speech-language therapy.
  • Audiology.
  • Recreational therapy.
  • Counseling and mental health services.
  • Chaplaincy.
  • Patient and family education.
  • Support groups.

Rehabilitation services may assist you with:

  • Self-care activities and skills such as feeding, toileting, and grooming.
  • Mobility skills such as walking or using a wheelchair.
  • Communication skills for speech and language.
  • Cognitive skills for memory and problem-solving.
  • Social skills for interacting with others.

Rehabilitation programs may be offered:

  • At inpatient facilities.
  • At skilled nursing facilities.
  • At home through a home health agency.
  • Through outpatient care.

Choosing your rehabilitation services may depend on what is available to you through your insurance, or what you can afford if you do not have insurance. Resources for stroke rehabilitation include:

Stroke rehabilitation will be unique to each survivor or stroke. You should consider your unique needs when choosing where to receive your services and when seeking rehabilitation assistance.

Prescription Assistance

Survivors of stroke often rely on prescription medication during their treatment, rehabilitation, and recovery. Medications assist in lowering the odds of a future stroke.

Prescriptions and medications can be expensive and there are financial resources to aid in covering costs or finding alternative low-cost medicines. Many prescription assistance programs will require:

  • Consent from your doctor.
  • Proof of your financial status.
  • Proof that you are not insured, or that your insurance does not offer drug benefit coverage, or cover the specific prescription that you need.

Consider the following to lower prescription costs or to seek financial prescription assistance:

You should speak with your doctor about finding the right PAP that offers the medications you need.

Additional Financial Assistance to Cover Medical Costs

The cost of healthcare after a stroke is expensive, and not all costs will be covered by insurance. This section will discuss additional options available to stroke survivors and their families to manage and assist with medical costs.

Clinical Studies

Participation in a clinical study may include sharing your health information and/or volunteering for a trial for new or alternative treatments or medications.

If you are interested in participating in a clinical study, speak with your doctor or primary care provider. You can also check with ClinicalTrials.gov from the U.S. National Library of Medicine to see if there is an available program that you are eligible for.

Nonprofit, Charity, Organization, and Community Programs

There are diverse programs, organizations, charities, or nonprofits may be national or state-led that may be available for medical financial assistance. Each program will have individual qualifications that you may need to consider or discover through the application process. Programs that offer financial assistance may include:

Some programs may be hosted by your medical institution and you can ask your doctor or medical advocate to seek them out for you. This may include preparing and negotiating a debt repayment program.

Grants

Some government, nonprofit, charity, and community programs offer grants that can assist in paying medical bills. Each grant will have unique eligibility requirements, but in general, you will need to qualify through financial and medical needs. Grant opportunities may include:

Grant money is not a loan, and you are not required to pay it back. Most often, government and nonprofit grants are tax-free.

Tax Deductions

Some medical expenses can be deducted from your taxes. In general, you cannot deduct all of your medical expenses, but you can deduct expenses that are higher than 7.5% of your adjusted gross income. These may include:

  • Prescription costs.
  • Transportation and admission expenses.
  • Payments to medical practitioners.
  • Nursing home and hospital care expenses.
  • Medically necessary equipment costs.
  • Transportation charges for expenses to and from medical care facilities.
  • Payments made for mental health services.

While tax deductions may not immediately pay your medical bills, they can help to reduce the economic impact of your medical debt.

Crowdfunding and Medical Fundraising

Crowdfunding and medical fundraising for medical expenses are becoming a popular method to alleviate the financial burden of seeking essential medical care.

Crowdfunding is typically hosted on a platform such as GoFundMe, Transparent Hands, or Fundly, where you can appeal to the general public with your story to receive donations.

Using Credit to Pay Medical Bills

In some instances, you may consider paying your medical bills with a credit card or a bank loan. However, this should be done carefully and with consideration of your budget and future finances so that you can avoid a low credit score.

To pay medical bills with a credit card, you should ensure that when you apply for your card you select a card with a low APR so that you do not accrue too much interest on your balance.

When you have made your regular monthly payments to your account, you can then negotiate for a higher credit limit which may allow you to cover larger medical charges.

However, you mustn’t use credit to pay your medical bills without wisely managing your budget. A credit card can be used in an emergency to ensure you have financial access to obtain the medical treatment you need, but can also harm your credit score and financial health in the long run.

If you already have poor credit from medical expenses, you may consider credit repair, or utilizing credit repair services. These services dispute negative or inaccurate information on your credit report, including inaccurate medical debt.

Consolidating and Paying Medical Debt

While credit repair may negotiate with your creditors and reporting companies, it differs from debt consolidation. Debt consolidation is a service that allows you to combine your various debts into one entity, so you only have to make one monthly payment.

Medical debt consolidation typically offers two options. You can take out a bank loan to pay off your various medical bills, and thus, only owe one debt to your creditor. You can also enroll in a debt management program that reduces your monthly payments or interest rates, which allows you to pay your medical debt off more easily, and oftentimes, with guided support from debt management professionals.

Additional Stroke Assistance and Resources

Additional stroke assistance and resources include:

  • The Social Security Administration’s Ticket to Work Program offers employment services for people with disabilities.
  • This program is available for those aged 18 to 64 and supports people with disabilities in their goal of financial independence.
  • The AARP Foundation Tax-Aide Program provides free tax assistance for those aged 50 or older who have a low or moderate income.
  • United Way provides information about medical assistance and programs in your area.
  • 211.org offers resources and guidance for mental health, medical services, and bill-paying assistance. You can visit their website or call by dialing 221 on the phone.
  • The National Association of Free and Charitable Clinics has free clinics that can help with various medical needs.
  • You can search for a free clinic near you by visiting their website and entering your zip code.
  • Services vary per clinic, but they may also be able to assist in finding discounted prescription medications and mental health services.
  • FAIR Health Consumer is a nonprofit organization that provides information on the customary charges for medical procedures, allowing you the opportunity to search for shoppable services and to find fair medical and hospital costs.