Va Healthcare: In-Network Insurance?

Veterans Affairs (VA) health care is not considered a health insurance plan. However, VA health benefits can be used alongside other forms of health insurance coverage, such as private insurance plans, Medicare, Medicaid, or TRICARE. While VA health care is not required to sign up for Medicare, veterans are encouraged to do so to increase their options for care. VA health benefits provide coverage for VA clinics and hospitals, while Medicare covers non-VA facilities and doctors. VA health benefits typically won't cover hospitals, doctors, and providers that participate in Medicare, nor will they cover Medicare deductibles, copayments, and coinsurance. The VA occasionally pays for out-of-network care with prior authorization, and Medicare can help with additional costs if only some services are authorized.

VA health care and private insurance

VA health care is not considered a health insurance plan. However, if you qualify for VA health care, you can use it alongside other forms of health care coverage, such as a private insurance plan, Medicare, Medicaid, or TRICARE. This means that if you are enrolled in TRICARE or the Veterans health care program, you are considered covered under the health care law.

Veterans with private health insurance may choose to use it as a supplement to their VA health care benefits. VA is required by law to bill private health insurance providers for medical care, supplies, and prescriptions provided for the treatment of non-service-connected conditions (illnesses or injuries unrelated to military service). Veterans are not responsible for any remaining balance that their insurance provider does not pay.

It is important to note that VA health care and private insurance work together, and providing your VA doctor with information about your health insurance coverage helps coordinate your care effectively.

VA health care and Medicare

If you have other forms of health care coverage (like a private insurance plan, Medicare, Medicaid, or TRICARE), you can use VA health care benefits alongside these plans. However, VA benefits will not pay for Medicare cost-sharing (deductibles, copayments, and coinsurances).

If you qualify for veterans' healthcare benefits and choose to enroll in Medicare, you can opt to get treatment under either program, but you must decide which benefits program you want to use before receiving care.

If you choose not to enroll in Medicare and keep your VA coverage, you will not have health insurance for facilities outside the VA health system. Some choose to enroll in Medicare Part A because it's premium-free but turn down Part B because of the additional monthly premium. If you want to enroll in Medicare in the future, you may face penalties and would likely have to wait to enroll during the General Enrollment Period (GEP).

Enrolling in both VA and Medicare can provide veterans with flexibility. For example, veterans enrolled in both programs would have access to community physicians (under Medicare Part A or Part B) and can obtain prescription drugs not on the VA formulary if prescribed by community physicians and filled at their local retail pharmacies (under Medicare Part D).

It is always a good idea to inform your doctors if you are receiving care outside of the VA so your health care can be coordinated.

VA health care and Medicaid

• Treating illnesses and injuries
• Preventive care, such as health exams, immunizations, and health education
• Inpatient hospital services, including acute care and specialized care
• Urgent and emergency care
• Mental health services
• Assisted living and home health care
• Prescription medications
• Diagnostic tests, therapy, and rehabilitation services
• Ancillary services, such as prosthetic items, audiology, and radiation oncology

Veterans can apply for VA health care and receive coverage for most of their healthcare needs. VA health care is not considered a health insurance plan, and it is available to veterans regardless of their income level or other factors that may impact Medicaid eligibility.

Medicaid:

Medicaid is a joint federal and state government program that provides free or low-cost health coverage to eligible individuals and families with low incomes. Each state has its own Medicaid program and sets its own eligibility requirements within federal guidelines.

Eligibility for Medicaid is typically based on income level, age, disability status, family size, and other factors. For example, in Virginia, individuals must meet residency requirements, have a low or very low income, and fall into specific categories, such as being responsible for a child under 18 or having a disability.

Medicaid typically covers inpatient and outpatient hospital services, physician and surgical services, laboratory tests, family planning, prenatal and delivery services, and other optional benefits that states may choose to include.

Using VA Health Care and Medicaid Together:

If an individual qualifies for both VA health care and Medicaid, they can use these programs together. VA health care can be used alongside other forms of health care coverage, including private insurance plans, Medicare, Medicaid, or TRICARE.

While the VA does not bill Medicare or Medicaid, having multiple sources of coverage can provide flexibility and ensure that individuals have access to the care they need. For example, veterans enrolled in both VA and Medicare can access community physicians and obtain prescription drugs not available through the VA.

In conclusion, VA health care and Medicaid are distinct programs that serve different populations. VA health care provides comprehensive benefits to veterans, while Medicaid assists low-income individuals and families. Individuals can use the benefits of both programs simultaneously to ensure they have access to the healthcare services they require.

VA health care and TRICARE

VA health care facilities have participated in the TRICARE Network as providers since 1995. VA can provide care for active-duty service members, military retirees, and family members under their TRICARE benefit on a space-available basis. Each VA health care facility can serve as a primary care manager for TRICARE beneficiaries, but TRICARE referrals are more commonly used for specialty care.

VA facilities are not Medicare-authorized providers, even if they are in the TRICARE network. Medicare cannot pay for care at a government facility. If you use TRICARE For Life for a non-service-connected condition at a VA facility, the VA cannot bill Medicare. TRICARE can pay only up to 20% of the TRICARE allowable charge, and you will have to pay the remaining amount. TRICARE and the VA recommend that you get care for your service-connected disability at a VA facility. For all of your other care, consider all of your options, including using a Medicare-certified provider. When using Medicare providers, you typically have no out-of-pocket costs for services covered by both Medicare and TRICARE.

If you have other forms of health care coverage (like a private insurance plan, Medicare, Medicaid, or TRICARE), you can use VA health care benefits alongside these plans. VA is required by law to bill your health insurance (including your spouse's insurance if you're covered under their policy). The money collected goes back to VA medical centers to support health care costs for all veterans.

When and how you get care at a VA facility depends on your military status and your health care needs. For example, active-duty/guard and reserve members can get limited health care services at VA facilities, including emergency care without a referral or authorization. Separated and retired service members may qualify for VA benefits upon separation or retirement. If you separate or retire before qualifying for retirement, you will eventually lose all TRICARE benefits. After losing TRICARE coverage, you can get care through the VA when you qualify. If you retire and qualify for VA benefits, you can use your TRICARE and VA benefits together.

VA health care and copayments

VA health care is not considered a health insurance plan. However, if you qualify for VA health care, you’ll receive coverage for the services you need to help you get and stay healthy. This includes treating illnesses and injuries, preventing future health problems, improving your ability to function, and enhancing your quality of life.

If you have other forms of health care coverage, such as a private insurance plan, Medicare, Medicaid, or TRICARE, you can continue to use VA health care benefits alongside these plans. You are not responsible for paying any remaining balance of VA’s insurance claim not paid or covered by your health insurance.

VA health care is required by law to bill private health insurance providers for medical care, supplies, and prescriptions provided for the treatment of veterans' non-service-connected conditions. All veterans applying for VA medical care are required to provide information on their health insurance coverage, including their spouse's coverage if they are covered under their spouse's policy.

The amount you pay for VA health care depends on your priority group. Veterans in Priority Group 1 have no copay for any VA medical service. Those in Priority Groups 2-8 get treatment for any service-connected conditions for free. All other medical treatment probably has a copay, usually based on your income.

• Urgent care: There is no copay if you are only getting a flu shot. For priority groups 1-5, there is no copay for the first three visits in a calendar year and a $30 copay for each additional visit. For priority group 6, there is no copay if the visit is related to a covered condition; otherwise, there is a $30 copay for each visit.
• Outpatient care: If you have a service-connected disability rating of 10% or higher, there is no copay for outpatient care. For those without this rating, there is a $15 copay for primary care services and a $50 copay for specialty care services and specialty tests. There are no copays for X-rays, lab tests, or preventive tests and services.
• Inpatient care: If you have a service-connected disability rating of 10% or higher, there is no copay for inpatient care. For priority group 7, there is a reduced copay rate of 20% of the full inpatient rate. For priority group 8, there is a full copay rate. The specific rates vary annually and are published online.
• Medication: Priority Group 1 does not pay for medications. For Priority Groups 2-8, there is a copay for medications to treat non-service-connected conditions and over-the-counter medications from a VA pharmacy. The copay amount depends on the medication tier and the amount of medication received. Once medication copay charges reach a certain threshold in a calendar year, there are no additional copay charges for the rest of the year.
• Geriatric and extended care: There is no copay for the first 21 days of care in a 12-month period. After that, copays are based on the level of care received and the financial information provided on the Application for Extended Care Services.

Some services are not charged a copay, including special registry examinations, counseling and care for military sexual trauma, care related to a VA-rated service-connected disability, readjustment counseling and related mental health services, care for cancer of the head or neck caused by nose or throat radium treatments received during military service, smoking cessation or weight reduction services, publicly announced VA health initiatives, laboratory tests, electrocardiograms, and VA health examinations.

If you are unable to pay your VA copayments, the VA can help with alternate payment arrangements, including repayment plans, waivers, or a compromise.

Frequently asked questions