What Michigan Can Learn from Other States About Protecting Citizens with Brain Injuries

Recently a new model for public policy in support of people living with brain injury became law in Arkansas. Act 348 mandates that health insurance carriers in the state provide essential post-acute brain injury rehabilitation services. Specifically, the bill identifies the following services:

·       Cognitive communication therapy

·       Cognitive rehabilitation therapy

·       Community reintegration services

·       Fucntional rehabilitation therapy

·       Home and community-based treatment

·       Neurobehavioral therapy and rehabilitation

·       Neurofeedback therapy

·       Neuropsychological testing

·       Outpatient and day treatment services

·       Post-acute care residential treatment

In addition, the law prohibits insurance carriers from placing arbitrary limits on access to medically necessary rehabilitation services.

Several other states are in the process of advocating for similar legislation, and Arkansas has built on the work done over the past decade in Texas to mandate post-acute brain injury services and make necessary amendments to address attempts by insurers in that state to deny services.

Expanding Access in Michigan

For decades Michigan served as the model to other states with the rehabilitation and long-term care accessible to people suffering a traumatic brain injury in an automobile accident. The system that guaranteed access to reasonably necessary rehabilitation and care for injuries arising from a car crash enabled Michigan to build a network of post-acute brain injury services unparalleled in other states.

Due to relentless efforts to undermine and ultimately eliminate this model system of healthcare, culminating in the destructive Public Act 21 of 2019, healthcare providers, consumer protection coalitions, and patient advocates have been forced to devote their resources to protect the no-fault system. The natural consequence was limited opportunity to advocate for equal and equitable access to care for all people living with brain injury.

While the fight to restore access to post-acute brain injury services for those injured in a car crash continues with a narrow solution to the non-Medicare post-acute fee schedule (see Diving Deeper 8/8/23, 8/14/23 , 8/21/23, 8/30/23), MBIPC – along with our partners at the Brain Injury Association of Michigan – have made it a priority to expand our efforts, diversify the use and aims of our resources, and advance public policy that expands access to essential rehabilitation services for all people living with a brain injury. Mandating health insurance coverage is an important part of this effort.

Moving the Needle in Public Policy Development

The understanding of brain injury has significantly increased over the last two decades. Certainly, sports related concussions, the prevalence of brain injury in veterans returning from combat, and celebrities experiencing brain injury have shed a public spotlight on the issue and advanced public awareness; but, it hasn’t done enough to move the needle significantly in public policy development. The relatively recent designation by the Centers for Medicare and Medicaid Services (CMS) of brain injury as a chronic disease (see Diving Deeper 8/2/24) should help validate the advocacy for the appropriate coverage for rehabilitation services in the health insurance market.

Take for example post-acute residential rehabilitation programs. The Commission for the Accreditation of Rehabilitation Facilities (CARF) defines residential services as:

“Residential Rehabilitation Programs are provided for persons who need services designed to achieve predicted outcomes focused on home and community integration and engagement in productive activities. Consistent with the needs of the persons served, services foster improvement or stability in functional and social performance and health. These programs occur in residential settings and may be transitional or long term in nature. The residences in which the services are provided may be owned or leased directly by the persons served or the organization.” (CARF 2023 Medical Rehabilitation Program Descriptions)

In the state of Michigan, these programs are licensed by the state as small group or large group adult foster care homes (through the Department of Licensing and Regulatory Affairs) and those providing this service to people living with a brain injury should be accredited through CARF as a Brain Injury Specialty Program.

In Michigan these services are accessible through various funding streams; but rarely through commercial health insurance plans. Veterans’ Affairs and Workers Compensation commonly approves these services. The State’s Medicaid plan includes the Brain Injury Services Program which supports transitional residential rehabilitation. Auto No-Fault has historically paid for short-term and long-term care in these programs (although access since the 2019 law has been drastically hampered, not due to the recognition of the necessity of the service, but because of the draconian fee schedule that limits reimbursement below the actual cost of care).

Despite the VA, Workers’ Compensation, Medicaid and auto insurance routinely covering these services, they are rarely covered by commercial health plans. There may be single case agreements that occur from time to time, but there certainly is no consistent approval for continued rehabilitation in these settings. The reasons typically lie in the location of the services being rendered. Health insurance plans recognize acute and sub-acute rehabilitation (i.e. hospitals and skilled nursing facilities) but they do not recognize an adult foster care home as a location covered in their plans (despite them being licensed by the state and accredited by an international accrediting body).

Michigan Can Learn From Texas and Arkansas

The laws in Texas and Arkansas aim to eliminate this type of barrier, recognizing the importance and validity of specialized post-acute brain injury services to effectively treat the chronic condition. Michigan needs to learn from these states – examine the legislation and adapt it to meet the needs of our citizens living with a brain injury.

Naturally all inquiries about the impact of proposed public policy lead to questions about cost. When the notion of a state mandated coverage of a chronic condition is discussed, the concern over rising insurance premiums should be evaluated and considered. In this case, however, there is evidence to support the fact that an insurance mandate like that in Texas and Arkansas does not add significant cost to the private insurance market.

A 2022 report from Public Sector Consultants states the following:

“A 2017 Texas Department of Insurance (TDI) report estimated the ABI mandate's total cost across all health plans in the individual market to be $21,639,414 from October 2015 to September 2016 (0.38 percent of total claims paid) (TDI 2016). Between 2007 and 2015, the ABI mandate accounted for 0.10 percent to 0.24 percent of total claims paid. TDI estimated the average annual cost of the mandate on health insurance premiums to be $18.09 for individual coverage and $39.38 for family coverage.

In the group coverage market, the total cost of the ABI mandate was $78,386,255 (0.70 percent of total claims paid) in the same period. Between 2007 and 2015, the TBI mandate accounted for 0.33 percent to 0.40 percent of total claims paid in the group coverage market. The estimated annual average cost of the mandate on health insurance premiums in the group market were $27.76 for individual coverage and $73.35 for family coverage.”

In 2024 House Bill 6154 was introduced by Representative Julie Rogers; however, it did not advance in committee before the end of the legislative session. MBIPC is optimistic that an opportunity will come soon to introduce a similar bill that builds off the success of the laws in Texas and Arkansas. All Michiganders should have an equitable chance at rehabilitation and care after sustaining a brain injury regardless of how the injury is sustained and what insurance coverage the individual maintains. Understanding of brain injury has increased to the point where it is recognized as a chronic condition – it is time our insurance markets catch up so that all Michigan citizens have a chance at successful rehabilitation and a high quality of life.

Sincerely,

Tom Judd

Executive Director