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Medicare For Veterans
Veterans that are eligible for benefits are typically covered by either the Veterans Administration or TRICARE. When they reach age 65, making a decision on whether or not to sign up for Medicare and other coverage can be confusing. This presentation is designed to answer those questions .
Options for Veterans
Veterans Administration
• Available to those that served in the active military, naval, or air service and didn’t receive a dishonorable discharge.
• If you enlisted after September 7, 1980, or entered active duty after October 16, 1981, you must have served 24 continuous months or the full period for which you were called to active duty, unless any of the descriptions below are true:
• Were discharged for a disability that was caused, or made worse, by your active-duty service, or
• Were discharged for a hardship or “early out”, or
• Served prior to September 7, 1980
• If you’re 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 don’t qualify for VA health care.
TRICARE
TRICARE is a health program for:
• Uniformed Service members and their families,
• National Guard/Reserve members and their families,
• Survivors
• Former spouses
• Medal of Honor recipients and their families, and
• Others registered in the Defense Enrollment Eligibility Reporting System (DEERS), like retired service members
Medicare & VA
Medicare and VA operate as separate entities, serving separate groups of individuals at separate facilities and providers. Essentially, VA pays for services at VA medical centers or other VA locations, or if they’re pre-authorized to get services in a non-VA hospital. Medicare, on the other hand, will pay for approved services at Medicare facilities and providers nationwide.
There are some small instances where Medicare may pay for services at a non-VA facility if the beneficiary received approval from the VA, otherwise Medicare and VA don’t mix coverage.
Should I Sign Up for Medicare?
According to the VA’s website, they encourage beneficiaries to sign up for Medicare as soon as they can, this is because:
• There’s no guarantee that Congress will provide enough funding in future years for the VA to provide care to all Veterans who are signed up for VA health care. If they’re in one of the lower priority groups (i.e. Groups 6-8), they could lose their VA health care benefits in the future.
• Having Medicare means they’re covered if they need to go to a non-VA hospital or doctor, so they have more options to choose from.
Depending on a beneficiary’s location to the nearest VA facility or hospital, it may be in their best interest to pursue options with Medicare coverage.
Part A – Hospital Insurance
If a beneficiary has worked 10 years/40 quarters paying Medicare taxes, they’ll automatically receive Part A when they turn age 65 premium-free. If they don’t qualify for premium-free Part A, and they delay enrolling in it, they’ll only be able to sign up during the General Enrollment period and may be penalized.
Part B – Outpatient Insurance
Also, VA is not creditable coverage towards Part B of Medicare, so delaying enrollment in Part B can lead to further delays in coverage (having to sign up during the GEP) and a possible penalty.
The penalty is equal to 10% for every 12-month period they go without activating their Part B coverage, and that’s payable for as long as they remain on Part B. For instance, if they delayed Part B for 60 months from their 65th birthday month, they would be liable to pay a 50% penalty (60 / 12 = 5 x 10 = 50%).
Part D – Prescription Insurance
VA is creditable coverage towards Part D, so beneficiaries can choose whether or not they want to add Part D coverage at any time without risk of receiving a penalty. The VA drug program only covers medications that have been prescribed by VA doctors, and only fills those prescriptions through the VA mail-order service.
If a beneficiary is diagnosed with a condition by a doctor that’s not part of the VA network, they will need to fill those prescriptions at a local retail pharmacy and could use Part D to cover the costs.
Medicare & TRICARE
Out of the 11 TRICARE programs available, once an eligible beneficiary qualifies for Medicare A and B they are automatically enrolled in TRICARE For Life, a Medicare-wraparound coverage. Even if the beneficiary only has Part A, they are required to sign up for Part B in order to continue their coverage through TRICARE.
How It Works
TRICARE For Life (TFL) beneficiaries can go to any Medicare facility or provider across the nation. TFL is secondary payer to Medicare in the United States and its territories, so claims are processed as such:
• Provider files the claim with Medicare
• Medicare pays its portion and send the claim to TFL for processing
• TFL pays the provider directly for TRICARE-covered services
There are no enrollment fees for TFL, but they must pay their Part B premiums. Coverage is available worldwide and they can see any provider they want. However, they’ll pay more if they get care from a Veteran’s Administration provider or a provider who opts-out of Medicare.
Prescription drug Coverage
TFL beneficiaries do not need to sign up for Part D to keep their TFL benefits. TRICARE’s pharmacy benefit is administered by Express Scripts, Inc. and provides several options for filling prescriptions across the country, including mail order. TFL beneficiaries with limited income and resources may benefit from Part D coverage, along with Extra Help from the federal government to reduce their out-of-pocket costs like premiums, deductibles, and cost-sharing.
Can You Get Other Coverage?
Over and above Part A and Part B benefits, Veterans have options to sign up for additional coverage to help cover potential out-of-pocket exposure like traditional Medicare beneficiaries.
Medicare Supplement
Available from private insurance companies, Medicare Supplement plans are designed to cover deductibles and coinsurances of Part A and Part B. With 10 modernized plan designs to choose from (in all states except MA, MN and WI), they are easy to compare in any given area and provide a list of benefits and prices that can fit any budget.
Medicare Supplement plans pay 2nd to Medicare, and beneficiaries can utilize any provider or facility that participates with Medicare nationwide.
Medicare Advantage
Offered by private insurance companies, Medicare Advantage plans (sometimes referred to as Medicare Part C) are another option to supplement Part A and Part B coverage. Plans will vary by state and county, are offered with usually low to $0 monthly premium, and may include Part D coverage. Most plans are either HMOs or PPOs that utilize local or national networks, and offer additional coverage for ancillary benefits like dental, vision, hearing, over-the-phone items, etc. (varies by plan).
VA Benefits & Other Coverage
Medicare Supplement
Since Medicare and VA benefits don’t mix, VA health care recipients can choose to sign up for a Medicare Supplement plan to complement their Part A and Part B coverage. This will give them access to Medicare providers and facilities nationwide in the event that obtaining care through the VA system isn’t feasible, or the VA refuses to treat a specific illness or chronic condition.
Medicare Advantage
Once again, VA beneficiaries can enroll in a Medicare Advantage plan to access their Medicare benefits at contracted providers in their service area. Depending on the need for Part D coverage, many VA health care recipients choose plans without drug coverage, sometime referred to as MA-only plans.
TRICARE For Life & Other Coverage
Medicare Supplement
Yes, TFL beneficiaries can sign up for a Medicare Supplement plan, but that may interfere with their TFL benefits. Since TFL is the secondary payer to Medicare, and care must be received by a Medicare provider, signing up for a Medicare Supplement plan will cause TFL to become the payer of last resort.
Since FTL is offered at no cost, signing up for a Medicare supplement plan is considered duplication of coverage and is not advised.
Medicare Advantage
TFL beneficiaries can enroll in a Medicare Advantage plan, and retain the ability for TFL to be the secondary payer. This will allow the TFL member to utilize the MA plan’s network and ancillary benefits, but still provide a way for their out-of-pocket costs to be covered.
Once a claim is incurred with the MA plan, the beneficiary needs to pay any applicable copays to the provider, then submit a paper claim with the FTL contractor, Wisconsin Physician Services (WPS). WPS will process the claim and pay TRICARE’s portion directly to them.
In Summary
Veterans have options when it comes to their Medicare coverage. While enrollment in Medicare is required for TRICARE For Life members, it is optional but strongly encouraged for those covered by VA Health Care Benefits.
VA is creditable coverage for the sake of delaying enrollment in Part D, but will give them access to cover prescriptions that were prescribed by a non-VA physician and filled at a non-VA pharmacy. Each situation is unique, and Veterans are encouraged to plan for their Medicare benefits prior to turning age 65 so no opportunity is missed.
Sources
• https://www.va.gov/health-care/about-va-health-benefits/va-health-care-and-other-insurance/