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Veterans Medical Benefits And Medicare

Freedom To Seek Treatment From Civilian Doctors And Hospitals

VA Benefits and Medicare for Veterans – Humana

Veterans relying on only VA coverage will often find that non-emergency medical treatment is generally only given at a VA facility. While your VA doctor may be able to coordinate outside referrals in some circumstances, there are never any guarantees.

Many Veterans enjoy using their Medicare to see a local civilian doctor for minor ailments and illnesses. Sometimes the VA clinic isnt nearby, or there are significant wait times to see a doctor.

Medicare, on the other hand, has hundreds of thousands of providers. Some of the very best doctors in their fields accept Medicare. If diagnosed with a severe condition, youll have choices for specialists outside the VA to receive the best care.

The same goes for VA drug benefits. The VA drug formulary has only about 60% of what a Medicare Part D plan has. Veterans should use the VA for their maintenance drugs. They would be wise also to have a Part D drug plan that they can use for short-term meds or specialty meds that the VA does not cover.

You also cannot take a prescription from a civilian doctor and fill it at the VA. You must make an appointment to consult with a VA doctor to get a prescription before you can fill it at the VA.

How Is The Veterans Choice Program Or Choice Card Program Administered

A private Third Party Administrator administers the program on behalf of the VA.

The VA signed contracts with two health care companiesHealth Net Federal Services, LLC, and TriWest Healthcare Alliance Corporationto help VA administer the Veterans Choice program. The TPA manages, among other things, the Choice Card distribution, call center, veteran counseling, health care provider management, appointment management, reporting, and billing. Health care providers are either part of the TPA network or out of network with TPA but meet requirements of the Choice Act. Generally, the TPA is required to provide a list of approved providers to the veteran to select from. Under the law, the veteran could also request a provider that is not in the TPA’s network of providers.

Do I Need To Pay For Medicare If I Have Va Benefits

For individuals who have worked at least ten years or 40 quarters paying Medicare tax, Medicare Part A is premium-free. Therefore, it is beneficial to enroll in the hospital insurance you earned through Medicare.

However, like other beneficiaries, veterans with VA benefits will need to pay a standard Medicare Part B premium for Medicares outpatient coverage. You will want to enroll in Medicare Part B as soon as you are eligible. Delaying Medicare Part B coverage can result in a lifelong late penalty. The penalty occurs because, unlike group health insurance through a large employer, VA benefits are not coverage for Medicare.

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As a result, you save money long-term when you enroll during your Initial Enrollment Period. If you are looking to enroll in Medicare Part B but are in need of financial assistance with your Medicare Part B premium, you may qualify for a Medicare Savings Program.

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Medicare And Veterans Health Benefits

Insurance agents will most likely come across a client new to Medicare that is also receiving Veterans Health Benefits . Agents and clients alike commonly ask if these two benefits coordinate with one another. To help insurance agents explain how Veterans Health Benefits and Medicare work together, we have provided information on how both benefits can help your client.

What is Veterans Health Benefits?

Veterans Health Benefits are available for those who have actively served in the military, naval, or air services and did not receive a dishonorable discharge. The benefits provide service members with preventive care, inpatient care, specialty care, mental health services, and other health services. These types of care are typically provided only in VA approved hospitals, facilities, and networks available around the country.

Medicare and VA Health Benefits

Your clients with Veterans Health Benefits can also enroll in Medicare when they are eligible. Both Medicare and Veterans Health Benefits can be used, however not at the same time for the same service. Typically, Medicare pays for Medicare approved services and items, while Veterans Health Benefits will cover what they are approved to pay for.

For example, if your client typically goes to a VA approved facility for their annual doctors appointment Medicare will not pay for their doctor appointment. Instead, the cost associated for that doctor appointment will be billed to the clients Veterans Health Benefits.

Eligibility For Va Medical Care

Providing Care for Veterans in Your Private Practice

You may be able to get VA health care benefits if you served in the active military and didnt receive a dishonorable discharge.

If you enlisted after Sept. 7, 1980, or entered active duty after Oct. 16, 1981, you must have served 24 continuous months or the full period for which you were called to active duty, unless you were:

  • Discharged for a disability that was causedor made worseby your active-duty service, or
  • Discharged for a hardship.

If youre a current or former member of the Reserves or National Guard, you must have been called to active duty by a federal order and completed the full period for which you were called or ordered to active duty. If you had or have active-duty status for training purposes only, you dont qualify for VA health care.

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Which Veterans Can Enroll In Va Health Care

Enrollment in VA health care is based primarily on veteran status , service-connected disability,14 and income.15

Generally, veteran status is established by active duty service in the military, naval, or air service satisfying a minimum period of duty 16 and receiving an other than dishonorable discharge or release.17 Exact requirements for enrollment eligibility depend on various criteria, such as when and in which component the veteran served. See below for questions and answers about returning combat veterans and members of the Reserves and National Guard.

How Should Veterans Receive Prescription Drug Coverage

The VAs prescription drug plan typically offers a more generous benefits package than Medicare Part D, the program’s prescription drug benefit. The VA covers the cost of drugs that you get at VA pharmacies, while Part D covers those that you get at in-network pharmacies.

The VAs drug plan is considered , meaning its as good or better than Medicares drug coverage, so veterans who later choose to enroll in Medicare Part D can do so without incurring a late enrollment penalty.

If you lose your VA benefits, youll have 63 days to enroll in a Part D plan before that penalty kicks in.

There are several reasons why a veteran would choose to supplement his or her VA drug plan with Medicare Part D:

  • If you are prescribed a drug by a private clinician or a Medicare Part B-approved doctor, the VA will not cover the cost of that drug without additional authorization from a VA provider.

  • If you enter a non-VA nursing home, you may want to get your drugs at the in-house pharmacy. A Part D plan could cover the cost of those drugs.

  • If you live far away from a VA facility or are suddenly in need of medicine, you may find it easier or necessary to go to a non-VA pharmacy.

  • If you have a low income, you may find that Medicares low-income subsidy program Extra Help for Part D beneficiaries will lower your overall drug costs.

You can compare Part D plans available where you live and enroll in a Medicare prescription drug plan online when you visit MyRxPlans.com.1

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General Frequently Asked Questions

When will I start Medicare? If you are turning 65, you are eligible to start Medicare the first day of the month that you turn 65. If you are over 65 and have or are leaving employer insurance you are eligible to start Medicare anytime. If you are disabled you will typically start Medicare 24 months after being awarded disability. If you have End Stage Renal Disease or ALS, you are usually awarded Medicare immediately.

What Costs Are Associated With Medicare? Medicare has 2 types of costs Monthly premiums and medical cost sharing. A premium is the cost you pay to have the coverage, typically monthly or quarterly. Cost sharing is what you pay when you have medical care. These are items such as deductibles and copays. The standard monthly premium most people pay in 2021 is $148.50. There are ways to lower your monthly premium such as Part B giveback and state programs.

When should I apply for Medicare? First, if you are already receiving Social Security payments when you become eligible for Medicare, you dont need to apply. You will be automatically enrolled in Medicare. If you are turning 65 and need to apply, you can do so 3 months before the first day of the month that you turn 65. If you are over age 65 and have insurance through your employer you can apply anytime and your coverage can begin as soon as the first day of the next month.

Can You Combine Medicare And Veterans Benefits

Veterans Medicare Benefits

Many seniors enhance their coverage and health care options by enrolling in both Medicare and VA benefits. In fact, retirees with VA benefits are encouraged to sign up for Medicare for more versatility and peace of mind.

When you or your loved one needs care, you can choose which benefits to use. Medicare allows seniors to visit non-VA facilities and doctors, which can be helpful for visits to specialists. Medicare Part D, which covers prescription drugs, also enables seniors to fill prescriptions through local pharmacies rather than through the VAs mail-order service.

In addition to these wider options, seniors should keep long-term health needs in mind. If a veteran doesnt sign up for Medicare when initially eligible but wants to sign up at a later date, they may encounter a penalty fee, according to the official Medicare website. Additionally, if the amount of government funding for the VA medical program changes, veterans in lower priority groups may be at risk for losing their coverage.

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Barriers To Getting Help

Advocates for many programs note that agencies serving older adults are facing staff shortages, which are complicating the efforts to provide assistance. Low pay is a commonly cited reason. For example, 41% of Area Agencies on Aging report staff vacancies of up to 15%, while an additional 18% report vacancies up to 25%, according to Markwood. Also, agencies have lost significant numbers of volunteers during the covid-19 pandemic.

At the same time, demand for help has risen, and clients’ needs have become more complex because of the pandemic and growing inflation.

“All of this is being amplified by the financial strains older adults are feeling,” Markwood said.

KHN is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF . KFF is an endowed nonprofit organization providing information on health issues to the nation.

All Va Benefits Are Not The Same

Another reason why veterans often enroll in Medicare is that VA benefits are not equal for everyone. There are eight levels to qualify for benefits. Certain veterans have higher priority levels based on service-related health conditions and based on income. Full medical benefits are limited to Veterans with a military-related disability who also has low income.

VA benefits can vary by region. They are also subject to changes based on funding from our federal government.

There is always a chance that your current benefits could be reduced in the future. If this were to happen, having alternate coverage like Medicare would be helpful. While you could add Medicare later on down the road, it will cost you.

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Things To Think About When Considering Your Tricare Options

If you are getting ready to retire from military service, there are three basic questions you should ask about your plans that could affect your healthcare choices. How close to being Medicare-eligible are you? Are you planning to retire stateside or do you plan to live overseas? And finally, how close to a military base will you be? This is important because you may need a TRICARE plan that does not require you to travel long distances to get care. The distance issue isnt a factor in all cases, but those requiring more specialized care should take travel into consideration.

And finally, the TRICARE official site issues a reminder If you become eligible for Medicare under age 65 you are required to use Medicare Part B to keep TRICARE.

How Do Va Benefits And Medicare Work Together


VA benefits and Medicare are separate plans that dont overlap in coverage. Enrolling in Medicare does not affect VA benefits and vice versa.

Every time you receive care, you need to decide which benefits to use. You would use your Veteran Health Identification Card when accessing care at VA facilities and your Medicare card at other facilities.

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Eligibility: Medicare Vs Va Health Care

Most people become eligible for Medicare when they turn 65 years old. You can also enroll in Medicare at a younger age if you have a qualifying disability.

People with amyotrophic lateral sclerosis do not have a waiting period, but people on SSDI benefits for other disabilities will need to wait 24 months to get coverage. Medicare for end-stage renal disease has its own set of requirements.

VA Health Care eligibility, on the other hand, is not dependent on age or disability. It is determined based on service.

People who served in the active military, naval, or air service are eligible if:

  • They served before September 7, 1980.
  • They enlisted after September 7, 1980 and served 24 continuous months or the full period assigned to active duty.
  • They were discharged due to a disability that occurred or was aggravated during active duty.
  • They were discharged for a hardship or an early out.

People who served in the Reserves or National Guard are eligible if they completed the full period assigned to active duty as long as that assignment was not for training purposes.

VA Health Care benefits are not granted to anyone who was dishonorably discharged.

If You Dont Have Veterans Coverage

If youâre a veteran who isnât enrolled in VA benefits or other veterans health coverage, you can get coverage through the Health Insurance Marketplace®.

Depending on your household size and income, you may be able to get lower costs on monthly premiums and out-of-pocket costs on private insurance. Or you may qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program .

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How Do I Enroll In Medicare

You can easily enroll in Medicare online. There are just a few things to remember:

  • If you are approaching age 65, you may enroll during the initial enrollment period. Enrollment in Medicare parts A and B begins 3 months before you turn age 65, the month of your birthday, and 3 months after you turn 65 years old.
  • If you are not enrolled, want to make changes to an existing Medicare part A or B, or are over age 65 but still looking to enroll, the open enrollment period is January 1 to March 31 every year.

To get started with enrollment, visit Medicares enrollment page and follow the prompts.

When You Use A Va Hospital

Veterans 101: VA Healthcare v. Medicare

If you get medical care at a VA hospital, your VA benefits will generally cover the costs. This is because the VA uses providers who are covered under the plan, so you wont necessarily need the institution to submit any claims to Medicare. However, Medicare can also cover services included with your VA medical benefits. In some cases, you can choose which provider to use.

It’s worth noting that you cant use VA benefits and Medicare simultaneously. In other words, if the VA covers a treatment or office visit, Medicare cant cover services rendered at the same time. The only exception occurs when youre sent to a non-VA hospital by the VA. In that case, you can use your Medicare insurance plan to cover services that the VA wont.

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Do Veterans Need Medicare

Technically, veterans do not need Medicare because many veterans qualify for VA benefits and TRICARE. However, a private insurance plan called a Medicare Advantage plan may offer supplemental benefits that you cant receive with just VA benefits.

For example, some Medicare Advantage plans have a $0 monthly premium and some even come with a fitness benefit. That could mean that your Medicare Advantage plan provides a gym membership. VA benefits and TRICARE do not.

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Does The Va Provide Gender

The VA’s standard medical benefits package addresses the health care needs of enrolled female veterans by providing gynecological care, maternity care, infertility, breast and reproductive oncology, and care for conditions related to military sexual trauma , among other services.

In addition, the Caregivers and Veterans Omnibus Health Services Act of 2010 ” rel=”nofollow”> P.L. 111-163) authorized the VA to provide certain health care services to a newborn child of a female veteran receiving maternity care furnished by the VA. Health care for the newborn will be authorized for a maximum of seven days after the birth of the child if the veteran delivered the child in a VA facility or in another facility pursuant to a VA contract for maternity services.

Under current regulations, the VA is not authorized to provide or cover the cost of in vitro fertilization , abortions, abortion counseling, or medication to induce an abortion .31

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Working With The Va: What We Can Do For You

If you can’t get an answer from a federal agency – inlcuding the VA – in a timely fashion, or if you feel you have been treated unfairly, my office may be able to help resolve a problem or get you the information you need. While we cannot guarantee you a favorable outcome, we will do our best to help you receive a fair and timely response to your problem.

Residents of the 1st Congressional District of Pennsylvania can contact me for assistance in dealing with the VA. Please contact by district office at 579-8102.

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