Spinal cord injury is expensive. The initial hospital stay and rehabilitation is just the beginning. Permanent spinal cord injuries can require extensive resources and involve secondary complications that demand extra care. The first-year costs for incomplete injuries is almost $350K, and for high level complete injuries, over 1 million. Obtaining good health insurance is critical to avoid outrageous out-of-pocket cost.
Employer-Sponsored Insurance
Some individuals have employer-sponsored insurance at the time of injury, or they’re listed as a dependent on a family member’s employer plan. These plans typically have limits that fall short of covering the extensive and long-term costs associated with SCI however. Also, an individual’s time under the coverage is limited if they’re unable to keep the job.
If employer-sponsored coverage is lost due to a job loss related to SCI, coverage may continue through the COBRA program for a limited time, but it can be expensive as you eventually become responsible for the full premium.
Government-Sponsored Insurance
Medicare eligibility is primarily based on age or disability, not on income or assets.
Most individuals who sustain spinal cord injuries are not on Medicare at the time but almost 40% use it as their primary insurance later. That’s because they qualify for Medicare after collecting Social Security Disability Insurance (SSDI) for 24 months. (The average processing time for an SSDI claim was over 7.5 months in 2024, so apply as soon as possible.)
Qualifying for State Medicaid is faster than Medicare or SSDI. You’ll need a physician letter to the Social Security Administration stating your disability and the expectation that it will last at least 12 months. You’ll also have to make sure you don’t go over the income and asset limits. These vary from one state to another but typically your countable income must be at or below 100% of the Federal Poverty Guidelines ($1,305 per month in 2025). In most states there are asset limits to qualify for Medicaid too. Your countable assets must be $2,000 or less to qualify.
Many states offer “medically needy” coverage after deducting healthcare expenses for those with higher income or assets, and most states offer buy-in programs so coverage isn’t lost if earned income exceeds the standard limits.
Private Pay
Individuals who sustain SCIs but do not qualify for Medicaid and Medicare and do not have employer-sponsored insurance (or the insurance is expiring) will need to purchase a private health insurance policy. Check the Affordable Care Act Marketplace. The yearly open enrollment period typically runs from November 1 to January 15. If you are outside the open enrollment period, you may qualify for a Special Enrollment Period due to a qualifying life event, such as losing other health coverage.
Indicate your SCI on your application. All Marketplace plans cover rehabilitation services and resources for individuals living with SCI but plans differ in cost-sharing levels. Based on income you may qualify for a plan with cost-sharing reductions which can significantly lower out-of-pocket costs like deductibles and copayments. You may also be eligible for a premium tax credit to help lower your monthly premium, based on your household income and size.
Important Note
Medicare and most standard private health insurance plans, including those obtained through employers or the ACA Marketplace, typically do not cover non-medical personal care services. These include assistance with activities of daily living like bathing and dressing. The out-of-pocket cost for these services can be challenging for individuals with SCI who need personal attendant care. These services are almost exclusively funded by Medicaid.
If you have a spinal cord injury and you need help navigating health insurance, you can find free help at www.spinalpedia.com. If you need help holding accountable the parties responsible for your injury and health expenses, contact our firm today.
Phone: