Teen fighting brain injury - and insurance limit on rehab

She gets 60 sessions per year but needs far more, her family says
2012-07-26T00:00:00Z 2014-07-30T17:19:52Z Teen fighting brain injury - and insurance limit on rehabStephanie Innes Arizona Daily Star Arizona Daily Star
July 26, 2012 12:00 am  • 

When a driver crashed into the passenger side of the vehicle Jessyka Murray was riding in, the Tucson teen's life changed instantly and drastically.

The accident was in 2010. Jessyka suffered an extremely severe brain injury.

Jessyka just recently progressed from needing a feeding tube to eating on her own. She follows movement with her eyes, waves her left hand, takes steps while wearing leg braces and is able to communicate to her physical trainer when she's in pain by making sounds.

When asked to say hello, she makes a soft verbal response. Recently, she began reaching out and touching her iPad on command.

Jessyka's mother said medical bills have been piling up since the accident. She's begun to dread the mail.

Though the family has private health insurance, the policy limits Jessyka's rehabilitation to 60 sessions per year - far fewer than her family believes the 19-year-old needs to improve.

"That would be just five therapy sessions per month. She needs more than that every week," said Marcy Murray, who quit her bookkeeping job to take care of her daughter. "She would not have progressed this far had it not been for the continued aggressive therapy."

Brain injuries are difficult to gauge because they can be so different. The way someone recovers is impossible to predict. It's normal for insurance companies to limit therapies.

Some advocates of better coverage say that's because insurance policies for rehabilitation are tailored to broken bones, not damaged brains.

Progress often depends on how much families like the Murrays fight insurers and stand by their loved ones through months and even years of rigorous therapies.

The Murray family is not counting on insurance options for rehabilitation to change in 2014 when the main provisions of the new federal health law take effect.

On the upside, draft guidelines from the federal government do ensure that a category called "rehabilitative services" will be included as one of 10 essential benefits required for private policies sold under the new law. But limits on such services, if there are any, could vary in each state.

States have the leeway to choose their own transitional "benchmark plan" for a minimum two-year period of 2014 and 2015.

Arizona is working on choosing a benchmark plan, weighing such factors as whether to include benefit limitations that allow insurance companies to reasonably control costs.

Gov. Jan Brewer is taking input from the public via her website - azgovernor.gov/hix - until Aug. 1.

A plan is expected to be selected this year, and possibly introduced as a bill in the 2013 legislative session.

"Whatever your benchmark excludes, whatever limitations there are, that is what you get," said Don Hughes, Brewer's policy adviser for health care. "If a benchmark plan only has 12 physical therapy visits, for example, and we don't think that's enough, we don't get to add to them. Conversely, if it has 24 and we think it's too many, we don't get to subtract."

Jessyka's father, Tim Murray is a technician with Circle K Corp. His employer is self-insured through UnitedHealthcare.

UnitedHealthcare said the Murrays' plan includes 60 days of inpatient care and 60 outpatient visits.

"We understand their concern and have assisted the family with exercising its right to appeal the coverage afforded in the plan to an independent, binding external physician-review process," the company said in a statement. "The external independent-review organization upheld the coverage decision in this specific case, and that decision is binding for a self-funded plan. As always, we are committed to providing quality care to all of our members and the employer we serve."

The Murrays said they paid $25,000 out of pocket last year for inpatient rehabilitation when they weren't ready to bring Jessyka home. They needed to outfit their small townhome for Jessyka, who cannot climb stairs and sleeps in the living room.

The state provides the Murrays with a caregiver for 25 hours per week, plus an additional 10 therapy sessions per year through the Arizona Health Care Cost Containment System, which is the state's form of Medicaid. But it is still not enough, her family said.

Her parents said they are now paying a $50 co-pay for each therapy session, plus another $1,800 per month for aggressive physical therapy and an acupuncturist.

The coverage former U.S. Rep. Gabrielle Giffords receives through federal worker's compensation is an exception. Giffords was shot through the brain in an assassination attempt Jan. 8, 2011.

Since she was a federal worker injured on the job, Giffords' medical expenses are covered through the Federal Employees' Compensation Act, which does not cap medical benefits. Worker's compensation covers federal employees, "for as long as residuals of an injury continue."

But such coverage is "unheard of" for most patients with brain injuries, said Mattie Cummins, executive director of the Brain Injury Alliance of Arizona. And in Arizona recent cuts to AHCCCS have further limited services, she said.

"Unfortunately it's not that uncommon for comprehensive rehabilitation not to be covered," Cummins said.

Giffords put a spotlight on recovery from brain injuries, highlighting that improvements can occur even years after the injury. People with brain injuries don't have to "plateau" as long as they are doing rehabilitation, experts say. That's because the brain has an ability to regain function.

Jessyka "lost 27 percent of her brain," Marcy said. "The brain needs to reconnect, re-map and learn to use different areas. ... Jessyka has to learn all over again how to do the simplest things."

The Murrays said they have had to assert themselves all along, beginning with an insistence that Jessyka go into a rehabilitation program instead of a nursing home.

"There are miracles out there, and I am happy that she has that edge," Marcy said. "If you are not proactive as a parent and find the resources it takes for recovery, your child could be doomed to not having the best chance."

If you go

The second annual "Jogging for Jessyka" fundraiser is scheduled for 3 p.m. Oct. 14 at the Tucson Racquet and Fitness Club, 4001 N. Country Club Road.

There will be a 5K run, walk and skate along the Rillito River Path, as well as a one-mile fun run.

For information visit the Jessyka T. Murray Hope Fund page on Facebook.

Donations payable to the "Jessyka T. Murray Hope Fund" should be mailed to Bank of America, Attention: Frances Rebel, 2885 N. Campbell Ave., Tucson, 85719.

Information about Arizona's implementation of the federal health law: azgovernor.gov/hix

"There are miracles out there, and I am happy that she has that edge.

If you are not proactive as a parent and find the resources it takes for recovery, your child could be doomed to not having the best chance."

Marcy Murray, on the insistence that her daughter go into a rehabilitation program instead of a nursing home

Contact reporter Stephanie Innes at sinnes@azstarnet.com or 573-4134.

Copyright 2014 Arizona Daily Star. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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