It’s important to know that VA health care is a health care system, not health insurance, though eligibility and enrollment in VA health care meets the health insurance requirement under the Affordable Healthcare Act.
Veterans are often confused or upset if they receive a bill from a private medical facility, if that facility billed the VA and VA refused payment. In some cases, the VA will pay outside providers, but only in specific circumstances and only for veterans enrolled in VA health care.
For example, if a veteran has no health insurance and is only enrolled in VA health care, the VA will pay for emergency room care at a non-VA facility, but only if the condition is a life-threatening emergency that requires the veteran to go to the nearest hospital. If it’s not a life-threatening emergency, the veteran is expected to go to the nearest VA medical center. If a veteran goes to a private hospital ER and the problem is not deemed an emergency, VA will not pay the bill and the veteran is responsible for payment.
If the ER visit to a private hospital is for a life-threatening emergency, the hospital must submit the ER report to the VA when requesting payment. But if a veteran has health insurance, the bill for services will be sent to the private insurer, and VA has no part in payment. The hospital might also send the bill to the VA in addition to an insurer as a matter of course, but the VA will never pay for ER care for a veteran who has health insurance. The veteran will get a letter from the VA saying that the VA would not pay for the submitted bill because the veteran has health insurance that is responsible for payment.
Another example where the VA would pay a private doctor or medical facility is if a veteran is enrolled in VA health care, with or without health insurance, and the veteran’s VA primary care doctor has referred the veteran’s care out to a private facility or doctor. This is known as a “fee-based” service. The VA often sends veterans to contracted private providers, such a medical specialist, when VA doctors or facility can’t treat a veteran in a timely manner (determined by the severity of the condition). Depending on your category, co-pays may apply.
Veterans who are enrolled in VA health care and also have traditional Medicare need to be especially careful. Some decline Medicare Part B (medical insurance for doctor and outpatient care) because they want to save money, as Part B requires a premium, usually deducted from monthly Social Security. There is no premium for Medicare Part A (hospital insurance). These veterans assume they can be seen by VA for all doctor and outpatient visits normally covered by Part B. However, if an urgent illness or accident occurs and they go to a private medical facility, they are responsible for any doctor bills or charges not covered by Medicare Part A. In other words, it can be financially risky to decline Medicare Part B, unless you have other private insurance that will pay for things normally covered under Part B.
In addition, co-pays are sometimes required for services or drugs within the VA health care system, based on the percentage of your service-connected disabilities, your category and your family’s annual income.
Since many veterans enrolled in VA health care are also covered by a variety of different insurance plans, both government-run (Tricare, Medicare, Medicaid) and private plans (Blue Cross Blue Shield, Cigna, privately purchased Medigap or drug plans), it is important to make sure you understand the benefits and restrictions under each.
Sandy Britt is a Montgomery County veterans service officer.
For More Information: The Leaf Chronicle