Health Insurance – Consumer Rights

Since the beginning of the Foundation in 1988, we have seen insurance cover less and less after a spinal cord injury because of the strong push to contain costs of health care. If you are living with a spinal cord injury it is important to know your health care rights. Choosing the right doctor and ensuring that you have the access to information to make informed decisions about the appropriate health insurance for yourself is primary. Do your homework and know what type of health insurance is available to you including health insurance limitations, exclusions and any necessary treatment, medications or specialists that are or are not covered. By being a wise consumer, you have the power to promote your own health & well-being and reduce potential health complications. Make sure you read information provided to you and review all of your paperwork including the insurance company’s booklet. Create a relationship with your insurance company’s claims department representative or case manager and your health care providers. Sometimes, there are complications with spinal cord injury such as bed sores, spasms, urinary tract infection, breathing problems and falls. Ensuring that your health care provider knows these risks is important to your livelihood.

Forms of Insurance
Health insurance is generally covered by Third Party Payors, Health Maintenance Organization (HMO) or Preferred Provider and Point of Service Organizations. Government funded insurance plans include MedicaidMedicare, and Social Security Disability Insurance.

Government Funded Insurance Plans
Medicare In the United States, Medicare is a national social insurance program, administered by the U.S. federal government since 1966, that guarantees access to health insurance for Americans aged 65 and older who have worked and paid into the system,

Social Security Disability Insurance
Social Security pays disability benefits to you and certain members of your family if you have worked long enough and have a medical condition that has prevented you from working or is expected to prevent you from working for at least 12 months or end in death.  You can find the Social Security Benefits Pamphlet here.

Medicaid is a jointly funded, Federal-State health insurance program for low-income and needy people. It covers children, the aged, blind, and/or disabled and other people who are eligible to receive federally assisted income maintenance payments.

Thirty-two states and the District of Columbia provide Medicaid eligibility to people eligible for Supplemental Security Income (SSI ) benefits. In these States, the SSI application is also the Medicaid application. Medicaid eligibility starts the same months as SSI eligibility. The following jurisdictions use the same rules to decide eligibility for Medicaid as SSA uses for SSI, but require the filing of a separate application: Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon, Utah, Northern Mariana Islands

The following States use their own eligibility rules for Medicaid, which are different from SSA`s SSI rules. In these States a separate application for Medicaid must be filed: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, Virginia.

What happens to Medicaid coverage if a SSI recipient works?
If a recipient’s State provides Medicaid to people on SSI, the recipient will continue to be eligible for Medicaid. Please refer to the general Work Incentives section for more information about SSI work incentives. Medicaid coverage can continue even it a recipient`s earnings along with other income become too high for a SSI cash payment.

How does a recipient qualify?

To qualify a recipient must:

  • Have been eligible for an SSI cash payment for at least one month;
  • Still be disabled;
  • Still meet all other eligibility rules, including the resources test;
  • Need Medicaid in order to work; and
  • Have gross earned income that is insufficient to replace SSI, Medicaid, and any publicly funded attendant care. (Refer to Red Book for the “threshold amount” section.)

The Center for Medicare and Medicaid Services (formerly HCFA) oversees State administration of Medicaid. You may go to that web site at:

Read more on Health Insurance for people with SCI from United Spinal which includes selecting a policy, the insurance maze, what is insured, a consumer health insurance guide, guidance for finding health insurance, ACA/Health Insurance Marketplace website and Call Center, find insurance options, Insure Kids Now and the Patient Advocate Foundation.