Medicare and VA Benefits

Are your clients eligible for both Veterans Affairs Benefits and Medicare? Per VA and Medicare, they can be covered under both plans but they each pay under different circumstances. It is important to understand what each benefit covers, how they can work together for more flexible coverage, and any consequences so you can help your clients with making an informed decision.  

VA versus Medicare… Who covers what?

VA Medical Benefits will only cover medical services at a VA hospital or doctor. Medicare, on the other hand, will cover hospital and doctor visits, but only outside the VA hospital or doctor. You can choose to sign up for Medicare while you have VA benefits. If you do receive both, then you’ll need to choose which benefits to use each time you receive care. This is because Medicare can’t pay for the same service that was covered by Veterans’ benefits, and your Veterans’ benefits can’t pay for the same service that was covered by Medicare. To use VA benefits, you’ll need to get care at a VA medical center or other VA location. They will also cover your care if they pre-authorize you (meaning we give you permission ahead of time) to get services in a non-VA hospital or other care setting. Keep in mind that you may need to pay a VA copayment for non-service-connected care.

Medicare will kick in if you need to go to a non-VA hospital or doctor. At this time, you will be covered under Part A and/or Part B. If you do not have Medicare in these circumstances, then you’d likely end up paying the cost yourself. This is important to consider if you live some distance from the nearest VA facility, have an emergency, or prefer a doctor outside the VA facility. Just remember, The Medicare and VA systems are entirely separate, with no coordination of benefits between them. If you visit a VA facility, then you would use your VA identity card and VA is billed. If you need medical care outside of VA, then you would use your Medicare card and Medicare is billed. 

Penalties: If your client decides forgo Medicare, specifically Part B, and only keep Veterans benefits then they could have a penalty down the road. As you know, in order to delay enrolling in Medicare Part B without penalty, they must maintain credible coverage. Depending on their level of VA Medical Benefits, it may not be considered credible coverage by Medicare’s definition. What does this mean? If they end up needing to enroll in Part B later, but their VA benefits did not qualify as credible coverage, then they will have to pay a lifetime penalty (see below on why VA encourages you to sign up for Medicare).

What does Veterans Affairs suggest?

Per the website, not only can you use the VA Health Care benefits alongside other insurance plans (i.e. Medicare), they actually encourage you to sign up for Medicare as soon as you are eligible. The VA lists the following reason on why they make this suggestion:

  • We don’t know if Congress will provide enough funding in future years for us to provide care for all Veterans who are signed up for VA health care. If you’re in one of the lower priority groups, you could lose your VA health care benefits in the future.
  • Having Medicare means you’re covered if you need to go to a non-VA hospital or doctor—so you have more options to choose from.
  • If you delay signing up for Medicare Part B (coverage for doctors and outpatient services) and then need to sign up later because you lose your VA health care benefits or need more choice in care options, you’ll pay a penalty. This penalty gets bigger each year you delay signing up—and you’ll pay it every year for the rest of your life.
  • If you sign up for Medicare Part D (coverage for prescription drugs), you’ll be able to use it to get medicine from non-VA doctors and fill your prescriptions at your local pharmacy instead of through the VA mail-order service. There’s no penalty for delaying Medicare Part D.

Part D – Prescription Drug Coverage

If your client gets prescription drug coverage through the Veterans Affairs (VA) program, it should qualify as credible Part D coverage. As long as they have credible VA Prescription drug coverage then they will not be subject to a Part D penalty if they choose to delay Medicare Part D. However, they may also join a Medicare Prescription Drug Plan on top of their VA Prescription benefits. This will be beneficial if they get medicine from non-VA doctors and fill their prescription at the local pharmacy rather than the VA. If they do get Medicare Part D and VA drug benefit, they can’t use both types of coverage for the same prescription at the same time.

If you have any other questions regarding Medicare and VA, or want to contract with our office to sell Medicare, please CONTACT US HERE.



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