This is not legal advice. You should always seek the advice of an attorney who is qualified in Veterans' law before you make any decisions about your own benefits. Visit Stateside Legal (below) for assistance with legal issues.
NOTE: Letters in my Q&A columns are reprinted just as they come to me. Spelling and grammar are left as is and only small corrections are made to improve readability, ensure anonymity or delete expletives that may offend some readers. This is not legal advice. You should always seek the advice of an attorney who is qualified in Veterans' law before you make any decisions about your own benefits.
Using Medicare with your VA Benefits
Veterans are subject to a number of benefits ranging from disability assistance to TurboTax Military Edition. Aside from that, many veterans will find themselves in the enviable position of having health benefits from both VA and Medicare. There are a number of advantages as well as some pitfalls to be aware of.
Your VA covers you in a sort of stepped fashion that depends on your % rating. Generally speaking, all conditions you may present to VA (except dental) are covered but varying copays may be required for some services. The copays are usually very small considering the usually high quality of service. The veteran who is 100% rated, when the rating is noted as permanent, is also eligible for dental care.
The veteran who is awarded SSDI by the Social Security Administration or who has reached the age of 65 will be entered into the Medicare program. Opting out isn't advisable.
Medicare has 3 distinct sections. Part A is that insurance that covers hospital bills. Part B covers doctor bills and many outpatient services. Part D is a pharmacy benefit.
Each Medicare benefit is unique and provides varying levels of coverage. Each Medicare benefit has a required deductible that the patient must pay. There are some deductibles for the overall service and then another for each individual service. This can be quite confusing. Most hospitals and physicians offices will make an expert available to walk you through your benefit and the potential out of pocket expense to you should you use Medicare.
Not all doctors will accept Medicare patients. Physicians are not required to take Medicare patients. Many doctors see the payment as too low for the amount of paperwork required. If you want to use your Medicare Part B benefit you may have to shop around for a physician you like who does take Medicare.
All hospitals accept Medicare...that's the Part A benefit. As America's population ages, hospitals have found that a great many of their sickest patients are those seniors who have Medicare. To turn down Medicare patients would not be financially possible for hospitals even though Medicare pays much less than more traditional private insurance. Hospitals rely on the high volume of Medicare patients and many cost cutting initiatives to make a small profit of their Medicare patient population.
The Part D benefit is usually not recommended for VA patients. VA will provide almost all VA eligible patients with the pharmacy benefit even if a prescription arises from a non-VA provider. Copays are very small and there is no obligation to pay any monthly premiums as with Medicare Part D.
Medicare supplemental insurance plans (such as the infamous AARP plan) may be purchased to cover some or all of those Medicare deductibles. These plans may cost anywhere from a few dollars to hundreds of dollars each month and provide widely varying levels of coverage.
Retired veterans may also be eligible for Tricare For Life as well as Medicare and VA medical care.
What should the veteran who is eligible for all benefits do? As you would expect, there are no pat answers that cover every situation. Each individual must assess a risk/value for their own lifestyle to decide. Should you save money by not taking Part B? Is it safe to rely on only your VA care? Can you abandon VA care and use only Medicare and Tricare?
I can offer you what I do and my rationale. This makes sense to me and has worked well so far.
I have both a 100% Permanent and Total disability rating from VA and I have been awarded SSDI from the SSA. I am eligible for no copays at VA for any of my care and I have opted into both Medicare Part A and Part B.
I have not purchased any secondary coverage such as the AARP supplemental insurance.
I enjoy my VA health care. I trust my doctors and I find that I get my care with little fuss. I am a former health care technologist and I rose to the ranks of administration and consulting in my health care career. I study health care issues carefully and I believe my background allows me to make expert observations about the quality of care I receive.
Having said that, I know that my VA Medical Center (The Ralph H Johnson VAMC in Charleston, SC) is about a 2 1/2 hour drive away. I also happen to know that the bond between my VAMC and the Medical University of South Carolina (MUSC) makes my medical center one of the better ones and I get very good care.
However, even though I'm rated at 100% and I am to be prioritized to receive appointments within 30 days, the reality is that it doesn't always work that way. Our VA Medical Centers aren't well funded (Thanks a lot Congress) and the crowded clinics like orthopedics can't always make a slot for my convenience.
If I have any scheduling issues I want to be able to choose to pick a local provider to give me the care I need.
When I opt to use a civilian provider I must be prepared to pay my Medicare deductible and copays directly from my pocket. Remember I said that I do not have supplemental Medicare insurance.
I made that decision based on my risk assessment. I assume (I checked around) that a Medicare supplemental policy will cost me some $250.00 to $400.00 per month. That may mean I'm out of pocket for as much as $4000.00 plus each year. If I don't use the insurance for a couple of years or if I use it very little, I've lost money.
Rather than a supplemental policy, I bank the difference in savings. I force myself to pretend I'm paying for that extra insurance but I earmark the money and I do not spend it. It's a safety net for me.
In the last 4 years I've used my Part B some 6 or 7 times. Each time was simply for my own convenience. Once I needed some minor orthopedic surgery done so I could make a close future date for a motorcycle ride. There was no emergency but I knew I'd be more comfortable having the problem resolved before I went off on my bike.
Rather than waiting for the VA system to react, I went to a local ortho doctor on a Friday (taking my VA x-rays with me) and by Tuesday morning I was in his groups office based outpatient surgery suites. Physician owned (indeed most) outpatient facilities are covered by Part B. I was home in a couple of hours without the long drive to my VAMC and I made my ride with a comfortably booted foot.
I paid some $400.00 out of my pocket. It was well worth the cost to me...I had already saved that money for just this sort of thing so I was well prepared for it.
In another example, I've known I need a sleep study. To use my VA system means a trip to Charleston for an overnight visit and a traditional sleep study in a heavily monitored room. Reading up on sleep studies I became aware that Medicare approves of an "In-Home" study that requires only a small, simple to use device to be worn in the comfort of your own bedroom.
I found a local Internal Medicine doctor who accepts Medicare and she also offers that sort of sleep study. I started to see her as a patient to supplement my VA care. Her office is 10 minutes from my home and although the wait times are sometimes longer than my VA clinic, overall it is less total time for me out of my day.
She recommended a sleep study based on my symptoms. Her office staff put me on the list to use one of the devices from her office. Within 2 weeks I was called to come by to pick up the device. Her staff had already queried Medicare and Medicare had agreed to pay 100% of my costs...no deductible or copay. They coached me in using it and I went home to what I thought was a good nights sleep.
As it happens, like so many others, my snoring is definitely sleep apnea. The device showed that I struggled to breathe as I snored. My doctor counseled me and went over the details carefully. I'm now schedule to meet with a respiratory therapy provider locally to be fitted for a CPAP machine. My understanding is that Medicare will provide the machine and any in-home services for me at no out of pocket costs.
On the other hand, I use my VAMC gastroenterology services always. I have ulcerative colitis and I'm subjected to colonoscopy on a regular basis every 2 years. I've found the services at my VAMC to be excellent. The early morning journey is a bit of a chore but they are efficient and I'm very comfortable that I'm getting great care. I've also used my VAMC for eye surgery and routine general surgery services.
The message is pretty simple. I have the best of all worlds with a little extra expense. Careful planning and thinking it through allows me to have better health care options than most Americans.
Let's talk about Medicare Part A...hospital coverage.
You must take Medicare Part A to be able to purchase Medicare Part B. Part A covers the much more expensive hospitalizations you may face in a civilian setting. Whereas your doctor bills may run into an obligation of thousands of dollars for you, a hospital bill can quickly run to the hundreds of thousands of dollars.
I anticipate that I will never use a civilian hospital other than for an extreme emergency. If I'm in an accident or if I have a heart attack, I have no other expectations than to get to a good trauma center asap.
Once there though, I will only offer them my VA identification card, never my Medicare card. I do not carry my Medicare ID with me in my wallet. If I'm unconscious I only want hospital billing staff to find my VA identification.
Medicare and VA do not supplement each other. In other words, if you go to a civilian hospital and they bill Medicare, VA will not make up the copays that you'll owe...even if you go for your service connected condition. Given the choice, hospital financial staff will always bill Medicare. Medicare pays more and as slow as it is, it pays more efficiently than VA does.
In most cases that you may find yourself in a civilian hospital, the very first thing you'll do when you are able is to begin requesting a transfer to a VAMC. Veterans should coach family members that if you aren't able to do this for yourself, they should do it for you.
This may be very challenging to accomplish. The civilian hospital knows the drill and often they are reluctant to try to work through the complex VA system to arrange a transfer. The VA may respond that no beds are available or some other reason they can't accept you.
The wise veteran knows that at this time we begin to document the paper trail. We ask for notes in our medical record of attempts made to transfer. We demand names and titles of anyone we speak to at the VAMC. We repeat calls to request a transfer until we get a positive response or until we are sure that we have fee basis approval to stay at the civilian center.
VA will pay for your emergency care at a civilian center in most cases. The law requires that. However, once you are "stable" the rules say you must be taken to the nearest federal facility that is able to accept you.
If you fail to make the many required phone calls and if you don't adequately document every communication, you may find that in a month or two VA has denied any payment to the civilian provider and you are responsible for all of it.
What happens if you hand over your Medicare card?
The civilian hospital will instantly bill Medicare. They may also bill VA if you give both cards. In every case I've seen this happen Medicare has paid their portion and then VA will say that since this was covered by Medicare, the VA owes nothing. Yes...this is even for your service connected condition that may need emergency attention.
If your condition is urgent but probably not life threatening and you believe you need care sooner than later, you may want to walk in to your local VA outpatient clinic. Don't call to ask permission, just walk in and ask to be triaged to your primary care doc or another provider. Once you're there they have to do something with you.
Often enough your clinic doctors will tell you to head to a local civilian emergency room on a fee basis approval. Again, if you also have Medicare, don't show them the card or you'll confuse the issue.
The prior approval of the VA physician makes any subsequent billing issues much simpler to deal with.
The secret to using the benefits that you've earned is simple; Plan ahead. It's no more complex than that. If you wait until you have an emergency or an urgent need for health care, it will all become very confusing and may overwhelm you. Speak with your family and get them involved. You'll be glad you did and maybe a lot healthier for the trouble.