How Does Medicare Work With VA Benefits?

Medicare and VA Benefits are separate systems, but you can have coverage from both. VA benefits cover specialized services unique to military veterans not often covered by Medicare. Medicare usually pays for your more general care, and does not cover the things that VA benefits do.

Medicare typically covers services from hospitals, doctors and other providers that participate in Medicare. VA benefits cover mental and physical therapies that many veterans require. Benefits from VA will not cover Medicare deductibles, copayments or coinsurance. Additionally, there are differences for coordinating Medicare and Tricare for life coverage for military retirees.

Occasionally the VA will pay for services from out-of-network providers. In these instances, you need permission first before it will be covered. For services in non-VA facilities that were authorized by VA, Medicare can sometimes help cover the costs.

Let’s look at VA health & medical benefits

Coverage within the VA system will vary. You will be assigned to a priority group, which will determine your coverage and out-of-pocket costs. VA benefits cover a wide range of services, including hospital care, outpatient care, mental health services, and prescription medications. VA health care is designed to be a solid solution for veterans, including veteran-specific health issues and issues common with elderly veterans.

If you have coverage through the VA, you aren’t required to sign up for Medicare. However, you are able and encouraged to. The VA encourages veterans to sign up for Medicare Parts A and Part B during your initial enrollment period. This gives you more options for care coverage, including non-VA facilities and doctors.

Additionally, if you wait to sign up for Medicare later, you may have to pay a late enrollment fee. VA benefits and coverage can change, so it’s best to enroll in Medicare when first eligible. Some of the key benefits of VA coverage include:

• Service-Connected Conditions: VA health benefits directly address conditions that are unique to, or commonly derived from, a veteran’s military service.
• Costs and Eligibility: Eligibility for VA health benefits depends on several factors, like service history, income, and disability status. Some veterans may receive free healthcare services, while others may be subject to co-payments. Visit va.gov to determine eligibility.
• Specialized Care: The VA system provides specialized care for conditions that are common among veterans. Common specialized services include care for post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), and military sexual trauma (MST).

Exploring Medicare coverage

Medicare is federal health insurance coverage for Americans aged 65 and older. It also covers younger individuals with disabilities or under certain circumstances. Medicare is broken up into various services, each covering different health needs. In short, these parts generally consist of:

• Part A (Hospital Insurance): Covers hospital stays, skilled nursing facilities, hospices, and some home health care. Learn more about part A.
• Part B (Medical Insurance): Covers certain doctor services, outpatient care, preventive services, and durable medical equipment. Learn more about Part B.
• Part C (Medicare Advantage): Combines coverage from Part A, Part B, and often Part D. Often covers additional benefits as well, such as dental & vision, flex cards, gym memberships, & more options. Learn more about Medicare Advantage.
• Part D (Prescription Drug Coverage): Provides prescription drug coverage. Learn more about Part D.

The initial enrollment period is your best opportunity to apply. Initial enrollment is a period of 7 months, stretching 3 months before your birthday and 3 months afterwards. If you enroll later, you may be required to pay late enrollment fees. Medicare is recommended even with VA coverage, as they together provide more extensive coverage.

Should I buy Medicare Part D if I have VA drug coverage?

Whether or not you need Part D depends on whether or not the VA covers your prescription. Most of the time, if your drugs are covered by VA, you do not need Part D Medicare. Otherwise, a Part D plan could help save you money on drug costs.

Additionally, with VA drug coverage, you will not have to pay a late enrollment penalty for Part D later. VA coverage is considered “creditable coverage” by CMS, which means you can buy or switch later without penalty or restriction. You have 63 days after losing VA drug coverage to enroll in Medicare Part D without penalty.

However, VA health care has limitations. Most VA services are restricted to VA pharmacies, facilities and providers. Due to this, there are some situations Part D may be considered even with VA coverage. You may consider signing up for Part D if:

• VA does not cover your prescription
• You need your prescription filled at a pharmacy closer to you
• Co-payments for the drugs are lower on a Part D plan than from VA. VA copays for prescription drugs can vary by priority level

Primary Coverage and Coordination of Benefits

Veterans eligible for both VA benefits and Medicare often ask which is primary. This comes down to the Coordination of Benefits (COB).

The Coordination of Benefits (COB) is a clause in health plans that establishes the priority of payment. When multiple insurance policies cover the same medical claim, the COB determines the payment responsibilities. As a general rule, however, you can expect payment responsibilities as follows:

• Service-Connected Conditions: VA benefits usually take precedence for service-connected conditions.
• Non-Service Connected Conditions: For non-service connected conditions, Medicare often is the primary payer. This is especially true if the veteran isn’t eligible for free VA healthcare.
• Dual Eligibility: When eligible for both VA and Medicare benefits, they will work together to provide coverage.

Is VA coverage or Medicare best for me?

Veterans should explore the details of both programs to make an informed decision. Take into account your personal and family health needs. If you are eligible for both, it is often recommended to have coverage from both.

Still, the relationship between VA health benefits and Medicare can be difficult to understand. Many factors come down to personal circumstances, making it hard to understand. Veterans and their covered spouses should consult with VA representatives and Medicare experts to maximize their coverage.

If you are still unsure of what is best for you, our Medicare Advocates are ready to help. By filling out the form and giving us a call, we are able to view the best plans in your area and get you the coverage your health requires.

And thank you for your service!