5 Reasons Veterans Need Medicare They May Have Overlooked
The American veteran is a special breed. Fewer than 1% of citizens take up the mantle to stand a post on the wall to keep our enemies at bay. So, we thank you for your selfless act of patriotism! With the sacrifice comes benefits you’ve earned, and it’s not just VA benefits. One of those is Medicare and too many veterans choose to ignore it, because either:
- They have Tricare for Life
- Or VA health benefits
While the VA does the best they can to care for veterans, there are times when what you need is lacking. And, if you fall in priority groups 7 and 8, where a vast majority do, you have copays – it’s not totally free. So, let’s look at five reasons why you need Medicare with your benefits and/or Tricare for Life. A bonus reason at the end addresses those with Tricare for Life.
VA Healthcare Benefits Are NOT Insurance
The first thing I often hear from veterans is, “I already have insurance. I have the VA.” It’s easy to think it’s insurance and that it will never go away, but it’s not and you can lose it. According to the VA:
The VA does not recommend Veterans cancel or decline coverage in Medicare…solely because they are enrolled in VA health care. Unlike Medicare, …VA assigns enrollees to priority levels based on a variety of eligibility factors… There is no guarantee that in subsequent years Congress will appropriate sufficient medical care funds for VA to provide care for all enrollment Priority groups. This could leave Veterans, especially those enrolled in one of the lower priority groups, with no access to VA health care coverage. https://www.va.gov/HEALTHBENEFITS/resources/publications/hbco/hbco_va_other_insurance.asp
Those lower priority groups are groups 7 and 8.
Since VA Healthcare is NOT Insurance, We Will Get Penalties When We Eventually Take Medicare
Medicare imposes lifetime penalties on those who do not take Medicare during either:
- Their Initial Enrollment Period (IEP)
- Or within the allotted time if they have creditable coverage
Creditable coverage is group insurance with 20 or more employees, or group Medicare, which some employers provide. If you or your spouse have this coverage which includes you as a beneficiary, once you lose it, you have 8 months to take your Medicare Part B or be penalized 10% of whatever the premium is for the year, for every 12-month period you went without it.
Since VA Healthcare prescription drug program is considered creditable coverage, there is no penalty for Part D imposed.
These are lifetime penalties that will never go away unless you qualify for Extra Help and/or a Medicare Savings Program.
IMPORTANT: VA healthcare and Medicare DO NOT talk to each other. Therefore, you are not giving one up for the other. You have two options.
So, what are some of those reasons that may make us realize we need to take Medicare? Let’s look at three reasons, to culminate our five.
Copays for Primary Care, Specialists, Emergency Room and Hospitalization
Depending on which Priority group you belong to, you will be charged varying copays. The following are 2021’s copays.
- Urgent care visits: Priority groups 1 through 5 get three free visits per year. After that they pay $30 per visit.
- Urgent care visits: Priority group 6 pays no copay for service-connected visits, $30 copay for all other visits.
For outpatient care, if you have a service-connected disability rating of 10% or higher, you pay nothing. However, if your disability rating is NOT service connected, or you have none, you will pay:
- $15 per primary care physician visit
- $50 per specialist visit(s). Whether you have one or two specialist appointments on the same day, you pay $50 for the day.
- $50 for specialty tests (MRI, CT scan, etc.)
For prescription drug copays, if you do not qualify for free means-tested prescriptions or your prescription is not related to your disability, you will pay:
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Tier 1 generic:
- 1-30 day supply: $5
- 31-60 day supply: $10
- 61-90 day supply: $15
- Tier 2 non-preferred generic:
- 1-30 day supply: $8
- 31-60 day supply: $16
- 61-90 day supply: $24
- Tier 3 brand name:
- 1-30 day supply: $11
- 31-60 day supply: $22
- 61-90 day supply: $33
If you’re in Priority Group 2 through 8, there is a $700 cap on prescriptions. Once you’ve spent $700, you will pay nothing for the remainder of the year.
For inpatient care, what one pays is determined by whether they qualify for reduced copays through means testing or not. These only apply to Priority groups 7 and 8.
Reduced Rate Inpatient Care Copays
- First 90 days in a 365-day period: $296.80 for the period, plus $2 per day hospitalized. For example, if you were hospitalized for 30 days, it would cost you $296.80 plus $60 ($2 per day X 30 days) = $356.80
- Each additional 90-day period within the current 365-day period: $148.40 plus $2 per day.
Full Inpatient Care Copays
- First 90 days in a 365-day period: $1,484 for the period, plus $10 per day hospitalized. For example, if you were hospitalized for 30 days, it would cost you $1,484 plus $300 ($10 per day X 30 days) = $1,784
- Each additional 90-day period within the current 365-day period: $742 plus $10 per day.
Most Medicare Advantage plans have:
- $0 copay for prescriptions in tiers 1 and 2 for generics
- $0 copay for primary care visits
- $0 to $20 copays for specialist visits
- $0 to $100 (depending on where the tests are done) for specialty tests
- $0 to $20 copays for urgent care
- $0 to $300 copay per the first 3 to 6 days one is hospitalized per benefit period. In the Tampa Bay area, $125 copay per day for the first 4 days is an average (all depends on the plan you qualify for and select).
The savings really add up.
Dental Benefits
According to Stars and Stripes, in an article titled, VA Opposes Bill to Grant Dental Care to All Veterans, by Nikki Wentling, publish July 23, 2020, it states: “Brownley said that is equal to about one in 17 VA enrollees being eligible for dental care.”
If are part of the 16, Medicare Advantage provides dental benefits. And depending on the plan you choose, where you live and what you qualify for, you may be able to receive a dental allowance from $1,000 to $2,000 per year (like in Tampa Bay where I’m located). This allowance can be used at any Medicare participating dentist of your choice.
Emergency Care Outside the VA
Whenever I bring this up, I typically get, “I’m not worried about that. The VA pays for emergency care.” The answer to that is yes and no.
While the VA says it will pay for care if any reasonable person would believe that life or limb, or significant risk to health is at stake. But even that has criteria. If the VA agrees with you:
- If it’s service connected, they will pay 100% (No worries)
- If it’s NOT service connected, they will only pay 70% of Medicare rates. You are balanced billed by the hospital for the difference of the full rate, not the Medicare rate.
If you have a heart attack, stroke, broken hip, are in a car accident, fall, etc.; these are not service-connected illnesses. Hence you would be left paying whatever the balance of the bill would be.
If you have a Medicare Advantage plan, an emergency-room copay varies between $0 to $125 on average, depending on your plan.
BONUS: Tricare for Life and Medicare Advantage, and Copays and Coinsurances
If you have Tricare for Life, you have a Medicare wraparound for Tricare. However, you do not have dental. Medicare Advantage plans not only provide dental, but there are plans that also:
- Provide Part-B premium credits that vary from $30 to $144, depending on your plan. What this means is that of the $148.50 (for 2021) Medicare deducts from your social security check, it would only take the difference after your credit. If you have a $100 credit, they deduct only $48.50.
- Give over-the-counter allowances that put money in your pocket, by providing items you purchase every month at Walmart, Walgreens, CVS or your favorite store.
IMPORTANT! Plus, if you choose a Medicare Advantage plan to fill those gaps:
- You DO NOT lose Tricare for Life. Medicare Advantage becomes primary, Tricare becomes secondary.
- If you are charged a copay or coinsurance that Tricare for Life does not charge, you can submit a DD2642 form and Tricare for Life will reimburse you the difference of what they would have charged and what Medicare Advantage charged.
If Tricare for Life would have charged nothing, you will receive the entire amount. If they would have charged half the copay, you would be reimbursed the 50% difference.
There are five more reasons to consider, and I will cover those in my next article. If you’ve not subscribed to our newsletter, you will want to do so to ensure you don’t miss it and any other future articles.
In the meantime, get your questions answered. Make sure you are speaking with a veteran Medicare specialist, as not all Medicare agents are fully versed on how Medicare works with VA healthcare and Tricare for Life. Leave no benefits on the table. Make sure you take advantage of everything you deserve.
If you live in the Florida or South Carolina and would like to speak with us, fill out our contact form or call (727) 459-1887, and we would be happy to answer all your questions.
Eddie Velez | Licensed Florida Medicare Advantage Specialist
