What about insurance?

Great Falls Optimist Club

What is the money needed for???

By Mike & Elisa Cafferky

Since Nick’s accident on August 12th, several different people have contacted us regarding trying to raise funds on Nick’s behalf to help offset the enormous costs associated with this tragic injury. Although we never sought this help and felt a little uncomfortable initially at the idea of soliciting support, we have come to realize that we cannot do everything ourselves and we should welcome any assistance that is offered. For that reason, we wanted to help people to understand the financial implications of an injury such as this and what any money donated would be used for.

Let us start by saying that we are early in our journey of understanding the costs and what resources are available to defer some of these costs. As we move Nick to rehab and begin working with the center on a plan to transition Nick to an outpatient status, we will be learning a lot more about the specific equipment needed and costs, as well as what is covered by insurance. However, Kennedy Krieger Institute (KKI) has already told us to expect that out of pocket costs could easily exceed $100,000 in the first year to equip him with what he needs to transition to a home-based rehab program.

Insurance

The first logical question when it comes to the costs of an illness or injury is What about insurance? Every plan is different and like the vast majority of people, we had no idea how our plan compared to others with regard to this type of injury. Within the first couple weeks here at Christiana, we had identified KKI as the appropriate place for Nick’s rehab and began working through insurance issues with reps from the hospital, KKI, and our insurance provider Kaiser Permanente. The initial assessment we got from KKI is that our family plan (through Mike’s work at Fannie Mae) was better than most plans in terms of what is covered. The costs can be broken out into a few categories:

1. Hospital costs – Nick spent 37 days in intensive care and will possibly spend many more in the respiratory step down unit before he moves to rehab. Our understanding is that insurance will pay for almost all of this with only minimal costs paid by us.

2. In-Patient rehab costs – Nick’s injury has left him paralyzed with only some movement in his arms. He has been confined to bed for many weeks which has caused all his muscles (even the ones he has control of) to atrophy and lose mass. Rehab is required to begin building up the muscles he can control and maximize his abilities given his condition. But beyond that, there are medical challenges that must be overcome before he can return home. For example, without control over nerves/muscles in his legs, blood does not easily flow back up from his legs when they are lowered causing it to pool and dropping his blood pressure. His body needs to get used to transitioning into a sitting position. In-patient rehab will begin to build his strength back and prepare him and us to manage his needs outside the facility. Kaiser has indicated that they will pay for up to 60 days of in-patient rehab and this limitation is clearly spelled out in the Evidence of Coverage contract. KKI has indicated that for Nick’s condition, this is not adequate and that he will likely need closer to 3 months before he is able to transition to an outpatient status. We believe the costs for inpatient care beyond the 60 days is approximately $1500 per day (this is a rough estimate). The actual number of days he needs to be in there is a complete mystery to us at this point but the insurance restrictions are not.

3. Out-patient rehab - Insurance will cover up to 90 consecutive days of rehab per incident. Much of this rehab is strengthening and flexibility work on the muscles he can control, as well as conditioning work on the muscles he cannot control. Our goal is to acquire the necessary equipment in our home to be able to transition him to a home-based program when the 60 days is over. Rehab costs for out-patient care is $1000 - $1200 per session, we have been told.

4. Medical Equipment - Insurance typically covers some portion of this. Kaiser will cover a large portion of what they consider to be essential equipment needed to live outside the facility. This will likely include a wheelchair and bed of their choosing. It may not be what is best for him but what Kaiser deems to be adequate. Having spoken at length with someone in Nick’s condition with similar capabilities, this is where some of the largest expenses lie. Realistically, he will need a power chair and a more portable chair. Given his size, he will need a lift system to move him to and from the bed. He will not likely possess enough arm strength to transfer himself without movement in his triceps. In addition, beyond what Kaiser deems necessary, restorative therapy equipment is critical to Nick in keeping his body healthy. This equipment will allow Nick to continue to exercise the muscles below his level of injury through activities such as walking (in a standing frame ) and riding a bike through electrical stimulation. According to KKI and the large body of research available, “Advanced restoration therapies use methods like functional electric stimulation to help patients with paralysis “exercise” muscles through activities such as riding a specially equipped functional electrical stimulation (FES) bicycle. Research has proven that such activity helps improve patients’ quality of life by promoting overall physical integrity: improving cardiovascular health, preventing skin breakdown, reducing the incidence of osteoporosis, scoliosis and other skeletal disorders. A recent cohort study in individuals with chronic spinal cord injury provides evidence that these therapies may also be effective in helping individuals recovery neurological function such as sensation and movement.” The FES bike alone costs over $15,000. The equipment and lifts system needed to support Nick’s rehab from home will cost well over $50,000, none of which is covered by insurance.

5. Adaptive Equipment – The challenges Nick will face in everyday life are so many and there are many devices available that will enable him to do things such as work on a computer, control the television, turn on/off lights, and even play video games. This equipment can be expensive and although it is not covered by insurance, we have been told there are often funds available through social programs and grants, to help people pay for some of these things. We have people working on our behalf to understand what may be available and what Nick may qualify for.

6. Transportation – We will need to get a vehicle equipped to transport Nick in his wheelchair. This must include a lift or ramp and have enough space to accommodate his six foot three inch frame. We have not yet looked into the costs, but we will need to have a vehicle to allow him to leave the KKI facility.

7. Nursing – Nick ‘s level of injury will require ongoing custodial care. This does not necessarily need to be a trained nurse, but someone who can be taught to administer to his needs. This is not covered by insurance.

8. Home accommodations – The costs of modifying a home to accommodate a person such as Nick are unknown but depend largely upon the home.

As you can see, even with insurance, the costs of an accident such as this can be daunting. We will happily make whatever sacrifices are necessary for Nick as we plan our new life. Our home in Great Falls is our largest asset and largely impractical for a handicapped boy such as Nick. Therefore, we will likely put the house on the market in the Spring and look to purchase a more modest home that can be more easily handicap equipped, or buy a lot and build the right home for our family. We would very much like to remain in Great Falls where we have so many dear friends and have gotten such an amazing outpouring of support. We are very humbled by this and so grateful that Nick and our family feel so loved and are not alone in this fight.