Veteran’s benefits and coordination with Medicare

It is important that veterans take time to understand their options under the Medicare program, and how it works in conjunction with their VA medical benefits. As this article explains, it is a wise choice for veterans to be enrolled in both Medicare and VA medical benefits program for various reasons.

As you already know, Medicare is divided by types of care or service into inpatient (“Medicare Part A”), outpatient (“Medicare Part B”), and prescription drug (“Medicare Part D”): seniors can decide in which “parts” of Medicare they wish to participate. Alternatively, the VA offers a comprehensive medical benefits program that does not distinguish among the types of care or services received. Generally, veterans who are enrolled in VA health care are eligible for its entire medical benefits package (including prescription drugs). However, some veterans may be subject to co-pays for care or medications received.

Veterans are entitled to a wide range of services with VA medical benefits, including hospital inpatient and outpatient care, prescription drugs prescribed by a VA physician, emergency care at VA facilities, preventive care, rehabilitation, mental health and substance abuse treatment, home health, and hospice care. Veterans can receive care at any VA facility. There are no limits on the number of days of care or outpatient visits the VA will provide, as long as services are available and care is considered medically necessary.

Even with this comprehensive coverage, there are circumstances in which it could be beneficial to have Medicare coverage in addition to VA coverage. Unlike Medicare, which offers the same benefits for all enrollees, VA assigns enrollees to priority levels based on various eligibility factors, such as percentage of disability and income. There is no guarantee that in the future Congress will provide enough funds for the VA to provide medical care for all enrollment Priority Groups. This could leave veterans – especially those enrolled in one of the lower Priority Groups – with no access to VA health care coverage. For this reason, it is a good idea for a veteran to have a secondary source of coverage.

Some services are simply not available with VA coverage only. By law, the VA has to provide care within the VA system. Generally, the VA will not pay for medical services outside the VA system, unless the VA first authorizes the services in a non-VA facility. If the VA authorizes services in a non-VA hospital, but doesn’t pay for all of the services a veteran gets during his hospital stay, then Medicare may pay for the Medicare-covered part of the services that the VA doesn’t cover. And depending on your eligibility for care/priority level, VA may determine that you are not eligible for some services, or that you may be required to make co-payment for services. These same services may be fully covered by Medicare Parts A and B.

Additionally, a veteran may want the flexibility of options offered by enrolling in both VA and Medicare. If a veteran has both Medicare and Veterans medical benefits, he can get treatment under either program. Veterans enrolled in both programs have access to non-VA physicians under Medicare Part A or B. This may be especially helpful if a veteran lives far from a VA medical facility. By enrolling in Medicare Part D, the veteran may obtain prescription drugs that are not on the VA formulary if not prescribed by non- VA physicians and filled at their local pharmacies.

Veterans should be reminded that they will be subject to a penalty for late enrollment for Medicare Part B, even if they are enrolled in VA health care. If a veteran decides to enroll in Medicare Part B after his initial enrollment period, he would have to pay the late enrollment penalty, which is 10 percent of the current Part B premium for every 12-month period. He may then enroll only during the General Enrollment Period, Jan. 1 to March 31 every year, and their Part B would become effective the following July 1.

This is different than Medicare Part D (prescription drugs) where veterans can delay enrollment without a penalty if they are enrolled in a prescription drug plan that provides a benefit at least as good as that offered by Medicare (“creditable coverage”). The prescription drug benefit in the VA medical benefits program is at least as good as that offered by Medicare, so the veteran will not have to pay a penalty as long as he enrolls in the Medicare drug benefit within 63 days if losing VA benefits.

Although VA drug coverage is more comprehensive than Medicare drug coverage (it has no premium and no or limited co-pays for prescriptions), there may be reasons a veteran would want to enroll in a Part D plan. A veteran may want to join a Medicare private drug plan if he lives far from a VA facility and the Medicare private drug plan includes pharmacies in its network, or if he lives in a nursing home that does not accept VA drug benefits. A veteran may need to obtain prescription drugs that are not on the VA formulary (if prescribed by non-VA physicians and filled at their local retail pharmacies).

If a veteran has Medicare Parts A and B and has a prescription written by a non-VA provider, that prescription cannot be filled at a VA pharmacy. A veteran must fill prescriptions written by non-VA providers through a Medicare Part D plan pharmacy.

If you have any additional questions, you may call Pat Hafermann, elderly benefits specialist with the Aging and Disability Resource Center, at (920) 459-4389.

Resource: “The Specialist” October 2009