Traumatic Brain Injuries Delegated as Chronic Condition by Medicare
In a monumental step for Americans living with traumatic brain injury (TBI), the Centers for Medicare and Medicaid (CMS) recently added TBI as a qualifying condition for Medicare Advantage Chronic Special Needs Plans (C-SNP). Chronic special needs plans are crucial for individuals with chronic conditions for a few reasons. Compared to regular Medicare Advantage coverage, they offer forms of coverage and coordination for beneficiaries that account for the additional needs required from patients.
Care management programs under C-SNPs utilize value-based care that incentivizes providers to coordinate while providing efficient, cost-effective care. The increased collaboration provides extra assistance for patients who require multiple specialists in their care team. The plans include low cost-sharing requirements for specialists that strengthen affordability and access for patients. There are even additional benefits like transportation or coverage for over-the-counter items included within the plans. These benefits can lift much of the burden held by beneficiaries with chronic conditions.
The change to include TBI as an eligible C-SNP condition represents a broader achievement within the brain injury community: the first time federal agencies have recognized brain injuries as a chronic condition. There are approximately 5 million Americans living with a brain injury-related disability. Traumatic brain injury patients usually possess long-term care needs like rehabilitation, community-based services, and regular follow up care. Many individuals who experience a TBI remain moderately or severely disabled after 5 years. This has long qualified brain injuries as a chronic condition by many healthcare stakeholders.
Eligibility for Chronic Special Needs Plans (C-SNP) varies for individuals with hydrocephalus. Not all hydrocephalus patients qualify for Medicare. Additionally, not all hydrocephalus patients who qualify for Medicare qualify for the chronic special needs plans (C-SNP) through the new traumatic brain injury qualification avenue. Hydrocephalus itself is not classified as a traumatic brain injury. However, TBI is one cause of hydrocephalus and individuals who developed hydrocephalus as a result of a traumatic brain injury are likely eligible for the plan. Individuals who develop hydrocephalus as a result of a brain bleed, also known as post-hemorrhagic hydrocephalus, may qualify for the plans if already on Medicare.
Beneficiaries will have the option to browse new plans until December 7th during Medicare open enrollment.
To learn more about the new rule, please contact advocacy@hydroassoc.org for more information.