A Comprehensive Cerebral Palsy Resource

What Insurance Will Do for You: How to Pay for SDR Surgery

As everyone knows, health insurance is a complicated and fraught issue in the United States these days. Since things are changing due to ObamaCare (more formally known as The Patient Protection and Affordable Care Act) the information given here may change too, but the current truth is that most private health insurance plans cover selective dorsal rhizotomy surgery. However, this is not universally true because there are cases where insurance plans will deny coverage due to a preexisting condition, which cerebral palsy is if you change insurance plans any time after your child is diagnosed. In addition, the rules are different for publicly funded options like Medicare and Medicaid, and for health maintenance organizations (HMOs), which are private but require a complex system of in-network referrals by primary care physicians. The bottom line is that you must thoroughly research your own particular insurance company and its policies before undertaking any major surgical procedure such as SDR surgery to make sure you aren’t left holding the bill, which is often in the $40,000-50,000 range, and that is before you pay for the associated physical therapy. Below are some of the other options available to you to help cover the costs of the surgery itself and the follow up treatment.

Early intervention programs, which are often provided by the state for children with cerebral palsy, especially those under the age of three, usually do not cover any medical costs but may help with physical therapy.

The preexisting condition clause of many insurance plans is more of a problem for adults who want SDR surgery than for children, which leaves Medicaid as their best option. Note though that the coverage differs from state to state because each state can administer their version of the plan however they like. In addition, Medicaid is usually only available to people within a certain low income bracket.

Medicare, which is federally funded, is a different program available for senior citizens and those with disabilities, which includes cerebral palsy. However, Medicare patients must pay a co-pay and a deductible for services and don’t get as widespread coverage as Medicaid patients. Sometimes adults with cerebral palsy find that their best bet is to enroll in both programs at once and cover costs with a combination of services from each.

The last option is supplemental security income, or SSI. This is something you have to apply for, and thus you can be denied coverage, but basically it is part of the social security network that provides benefits to disabled adults. It does not require paying into the system from previous paychecks, as social security does, but it does have restrictions based on finances.

The upshot is that insurance coverage is complicated when you are negotiating how to pay for SDR surgery and any of the associated physical therapy costs and hospital stays. Unfortunately there is often no simple answer; you just have to study your policy and see what your insurance company is willing to do. SDR surgery improves the patient’s quality of life so much that it is certainly worth fighting for!