Medicare Coverage for Traumatic Brain Injury
Key Takeaways
- Traumatic brain injury is damage to the brain from an outside source.
- In the U.S., older adults have the highest levels of hospitalization and death due to TBI, often the result of falls.
- Brain injury Medicare coverage can help pay for brain scans, treatment, and rehabilitation after an injury.
- The Centers for Medicare and Medicaid Services has authorized TBI for inclusion in Chronic Condition Special Needs Plans (C-SNPs), Medicare Advantage plans that are designed for people with specific healthcare needs.
Impacts to the head can have lasting consequences. According to the Centers for Disease Control and Prevention (CDC), the most recent available data shows traumatic brain injury (TBI) leads to more than 200,000 hospitalizations and nearly 70,000 deaths each year. People who are 75 years or older are at the highest risk.
Most U.S. adults 65 or older get their health insurance from the federal government’s Original Medicare program (also called Medicare Parts A and B) or through a Medicare Advantage plan (also called Medicare Part C) from a private insurance carrier. Medicare coverage for traumatic brain injury gives patients access to diagnostics, services, and treatments.
When you understand how your health insurance covers care for TBI, you can make informed choices about managing the possible long-term effects of head injuries.
Traumatic Brain Injury Causes and Symptoms
TBI is caused by an outside source, such as a blow directly to the skull, a hit to the body that jolts the head around, or an object that pierces brain tissue. Among adults over 65, falls are the most common reason for hospitalizations and deaths from TBI.
Slips and falls result in millions of emergency room visits for older people in the U.S. each year. These accidents happen because of issues like lower-body weakness, vitamin D deficiency, challenges with movement and balance, or vision problems. Certain medications can also cause side effects, making it harder to move around safely.
A brain injury can either be primary, in which the damage happens immediately, or secondary, meaning it takes hours, days, or weeks to develop after the initial impact.
TBI symptoms may include:
- Headache
- Light-headedness and dizziness
- Fatigue or drowsiness
- Loss of consciousness
- Seizures
- Blurry vision or other vision problems
- Ears ringing or other hearing problems
- Clear fluids from the nose or ears
- Nausea and vomiting
- Slurred speech
- Weakness in the arms, legs, or face
- Loss of balance and coordination
- Difficulty sleeping or waking up
- Confusion or disorientation
- Problems with memory and concentration
- Difficulty making decisions
- Mood swings or irritability
- Bad taste in the mouth
- Sensitivity to light or sound
- Anxiety or depression
- Loss of energy and motivation
Most TBIs are non-life-threatening concussions, but even in relatively mild cases, you should see a healthcare provider to check for signs of danger and help with recovery. In more severe cases, an injury could cause long-term brain damage, coma, seizures, infections, damage to blood vessels, and stroke.
Ready for a new Medicare Advantage plan?
Does Medicare Cover Brain Scans?
Brain scans are vital to assess the severity of TBI and determine the best course of treatment. Healthcare providers may use a variety of imaging tools to understand the extent of damage:
- Magnetic resonance imaging (MRI) provides highly accurate imaging for spotting problems in the brain and signs of bleeding. Healthcare providers use MRIs to diagnose chronic conditions and decide on the best course of treatment.
- X-ray computed tomography (CT) is less precise than MRI but faster, so it’s often used in the hours right after a TBI to find indications of bleeding, blood clots, bruising, or swelling in the brain.
- Positron emission tomography (PET) can guide a long-term prognosis for a specific type of TBI called diffuse axonal injury, in which the brain moves inside the skull and tears nerve fibers.
- Single-photon emission computed tomography (SPECT) can detect problems with blood flow through the brain.
- Angiography may reveal damage to your blood vessels.
Along with imaging tests, a doctor may need to check for pressure inside your skull that could cause further damage. In those situations, an intracranial pressure monitor will be inserted into your skull.
Medicare Part B, which is medical insurance, covers these diagnostic tests. After meeting your Part B deductible for the year, you’ll pay 20% of the Medicare-approved amount for a test.
Medicare Advantage plans must at least match the coverage you would get from Original Medicare, including for diagnostic tests. Unlike Original Medicare, Medicare Advantage plans set an out-of-pocket maximum for your total annual spending on covered services. However, your plan may require you to see doctors in a provider network to get the most out of your coverage.
Does Medicare Cover Brain Surgery?
As part of treatment for severe TBI, a doctor may recommend surgery to:
- Repair fractures in the skull
- Stop bleeding in the brain
- Remove debris or pools of clotted blood called hematomas
- Reduce pressure in the skull by draining fluids or making room for swollen tissue
Original Medicare and Medicare Advantage plans include coverage for medically necessary surgery. Under Original Medicare, inpatient procedures are covered by Medicare Part A, which is hospital insurance. Part B covers outpatient procedures that require less than two nights in the hospital.
Coverage for Prescriptions After TBI
For mild TBI, healthcare providers often advise getting plenty of rest and taking over-the-counter pain relievers. However, in more severe cases, they may prescribe a variety of medications to address secondary damage:
- Anticonvulsants prevent seizures that can happen in the week after an injury.
- Muscle relaxants can stop spasms.
- Anti-anxiety medications or antidepressants treat the psychological effects of an injury.
- Anticoagulants may prevent blood clots.
- Diuretics can reduce fluids in tissues to lower the pressure on the brain.
Original Medicare generally covers drugs administered in a medical setting like a doctor’s office or hospital, but not prescriptions you take at home. You’ll need a Medicare Part D prescription drug plan from a private insurance carrier to help with these costs. Most Medicare Advantage plans include Part D coverage.
Ready for a new Medicare Advantage plan?
Rehabilitation Coverage
After a brain injury, you may need multiple forms of rehabilitation:
- Physical therapy helps with mobility challenges like walking and keeping your balance.
- Occupational therapy teaches any skills necessary to resume your usual responsibilities and activities.
- Speech therapy develops communication skills and prepares you to use any assistive devices.
- Psychiatric care treats issues with thinking, mood, and behavior, which may involve taking medications.
- Social support through the recovery process may come from professionals such as social workers and from support groups.
Medicare Part A covers intensive services requiring an inpatient stay at a rehabilitation facility like other hospital stays. That means after you reach the deductible amount, Medicare covers the costs for the first 60 days. If you need to stay longer, daily coinsurance rates apply.
Medicare Part B covers outpatient physical therapy, occupational therapy, speech-language pathology, and mental health services. You will pay a portion of the Medicare-approved cost in coinsurance for treatment covered under Part B. However, there’s no limit to the therapy you receive in a year as long as it’s considered medically necessary.
Medicare Advantage plans must cover at least the same level of services as Original Medicare, and certain plans may provide additional benefits such as transportation, food, and companion care.
Traumatic Brain Injury Medicare Plans
As of 2025, the Centers for Medicare and Medicaid Services recognizes TBI as a chronic condition. That means TBI can be covered by a type of Medicare Advantage plan called a Chronic Special Needs Plan (C-SNP).
C-SNPs coordinate care for people with certain chronic conditions, often providing additional coverage for specialists, medications, and treatments. All C-SNPs feature Medicare Part D prescription drug coverage and may offer a range of other benefits, like more covered hospital days, vision, hearing, dental, and credit for groceries or over-the-counter items.
Like other types of Medicare Advantage plans, you’ll get the fullest coverage from a C-SNP by seeing doctors in your plan’s provider network, and plan availability depends on where you live. Talk with a licensed insurance agent to check whether there are plans in your area that fit your needs.
Recovery from a traumatic brain injury can be a long, complicated, and difficult process. By learning about your treatment options and what’s covered by your insurance, you can make decisions that prevent further damage and help you achieve better outcomes.
Sources
Health Disparities in TBI. CDC.
Traumatic Brain Injury in Older Adults: Epidemiology, Outcomes, and Future Implications. Journal of the American Geriatrics Society.
Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program for Contract Year 2024. Federal Register.