ACA and VA Care

[Buck2520]

I am a little confused and/or concerned about how the ACA Insurance exchange (with subsidy for under 400% of FPL) works if one spouse needs to buy it there and the other has VA or Medicare coverage. From everything I have been able to find, when only one family member needs to buy medical coverage off the exchange the family is still charged the same amount of money as if both of them are buying coverage. The family income level, the premium amount, and/or the subsidy are not adjusted if only one member of the family is buying from the exchange. I have VA medical coverage but my wife will have no coverage after I retire from my current job. The ACA is making it possible for us to retire a little early but it seems like some of us are not getting the full financial benefit of others because I have earned VA coverage through service to our country. Our income level will definitely qualify us for the subsidy, but we will still be paying the same amount for one person coverage that others are paying for two person coverage.
Now if this is just the way it is then I am prepared to pay the cost because it will still allow us to get coverage for the spouse, but it seems a little unfair that we will pay the same amount as other two person families with the same income when only one person gets coverage. Kind of like being financially punished for serving my country and earning VA medical coverage. I think the same issue would apply if one spouse has Medicare coverage but the other still needs to buy it off the exchange. Is this correct? Any thoughts!

 

[fritz]

I am a little confused and/or concerned about how the ACA Insurance exchange (with subsidy for under 400% of FPL) works if one spouse needs to buy it there and the other has VA or Medicare coverage. From everything I have been able to find, when only one family member needs to buy medical coverage off the exchange the family is still charged the same amount of money as if both of them are buying coverage. The family income level, the premium amount, and/or the subsidy are not adjusted if only one member of the family is buying from the exchange. I have VA medical coverage but my wife will have no coverage after I retire from my current job. The ACA is making it possible for us to retire a little early but it seems like some of us are not getting the full financial benefit of others because I have earned VA coverage through service to our country. Our income level will definitely qualify us for the subsidy, but we will still be paying the same amount for one person coverage that others are paying for two person coverage.
Now if this is just the way it is then I am prepared to pay the cost because it will still allow us to get coverage for the spouse, but it seems a little unfair that we will pay the same amount as other two person families with the same income when only one person gets coverage. Kind of like being financially punished for serving my country and earning VA medical coverage. I think the same issue would apply if one spouse has Medicare coverage but the other still needs to buy it off the exchange. Is this correct? Any thoughts!

We retired early (59/57) and I also have VA coverage. Having served in Vietnam - I qualified as Class 6 (but this is not a reward). The VA (as I understand it) gives me medical coverage at any VA hospital, and I am registered with the local VA clinic (you must register with each VA clinic nationwide, and can only have one as your primary). They also provide me with my prescription coverage (copay). We have had to purchase individual medical policies as wife is not VA qualified, and for me for medical emergencies.

It has always been my understanding that I have to purchase additional outside insurance in case of a medical emergency. VA does not cover medical emergencies outside of the VA medical system except for those retired from a military career (and their families). This has been a catch 22 for me as the VA uncovered a thyroid condition and my (then) new individual policy permanently excluded any coverage related to thyroid issues.

I have been looking forward to the beginning of the ACA as it should allow us to purchase healthcare coverage at an affordable rate with no preexisting conditions (if I get taken to a non VA hospital with a thyroid emergency - I have no medical coverage).

I have also read that the ACA accepts VA coverage for veterans - allowing veterans to not have to pay any penalty for not buying coverage in 2014. I find this confusing myself as I still have to purchase healthcare coverage for medical emergencies outside of the VA system. There's something wrong with this scenario as I get all my primary medical coverage from the VA and have to pay for outside coverage ICE. I would happily pay the VA system the money I've been giving BCBS over the years for this just in case coverage. You'd think that they would have taken advantage of this opportunity themselves. Anyway, look forward to buying health coverage on the exchanges this fall for next year and losing the scary scenario I'm currently in with BCBS.......

 

[BLS53]

I never understood the logic behind the VA healthcare system. Before they started closing military installations all over the country, retiree healthcare was fine. But now, no base hospitals are nearby, so it's Tricare Standard with a 25% copay. VA hospital in town, but no go, because I was never injured in a war. So an Army clerk, who sprained his knee unloading a truck during the Vietnam War, with 2 years active duty gets to use the VA hospital. Meanwhile, someone with 20 years service, and at one time had "guaranteed" free healthcare for life, has to pay a 25% copay.

 

[mickeyd]

I am rated as Priority Group 2 in the VA system yet I have never used their services. I have also been eligible for Tricare because I am retired military. Tricare seems like a better option for us because we have a large military medical presence in the region.

Since I graduated to Medicare a few years ago I am now covered by Tricare For Life which picks up what M/C does not pay. I have never paid a copay or fee for treatment or medications.

I understand that if I received treatment at a VA facility (there are several in the area) I would have to pay a small fee per visit. But I would not have to pay for medicare Pt B as I now do.

VA may be less costly in the long run, but I would have fewer options.

Check with me a 30 years and I'll tell you how it worked out.

 

[Htown Harry]

I think the same issue would apply if one spouse has Medicare coverage but the other still needs to buy it off the exchange. Is this correct?

Yes, this appears to be the case. The California exchange calculator has exactly this example in their instructions. Following their instructions for a subsidy-eligible couple, the net payment to the exchange by the household will be the same for both the one medicare / one exchange policy couple and the two exchange policy couple.

Health Insurance Calculator | Covered California?

Of course, looking at premiums alone isn't the full picture of participation costs for a given health policy or program. I'll hold off before jumping from "same cost for different coverage" to "unfair".

That said, won't the premium discrepancy will be even more skewed between MCare + Exc. couples vs. 2 Exc. couples after taking into account premiums paid for Medicare?

I hope others with more knowledge of Medicare and the VA programs post (non-political) responses on the scenario of one spouse aging into Medicare several years before the other. This would appear to be something all married ER couples with an age difference will need to factor into their health care cost projections.

 

[Buck2520]

Fritz. I think I have a pretty good handle on my VA coverage. I am a Purple Heart veteran so I am a priority 3 and do not have to pay copays, except for the prescription copay. VA does cover emergency treatment as long as it is in a VA facility or if outside the VA it needs to really be an emergency and you have to quickly get approval and transfer to a VA facility if they tell you to. There are drawbacks to VA care and you have to plan ahead so you know where the VA facilities are. You may also have to wait to get appointment, but that could happen anywhere. As I understand it, if you have VA coverage you meet ACA requirements and you can still buy coverage on the exchange, but you are not able to get the subsidy since you already have VA coverage.

The problem (if you want to call it that) is that since my spouse still needs coverage under the ACA, we will have to pay the same premium (with subsidy help) as a family of two. Just seems a little unfair when only one person needs it.

 

[fritz]

Fritz. I think I have a pretty good handle on my VA coverage. I am a Purple Heart veteran so I am a priority 3 and do not have to pay copays, except for the prescription copay. VA does cover emergency treatment as long as it is in a VA facility or if outside the VA it needs to really be an emergency and you have to quickly get approval and transfer to a VA facility if they tell you to. There are drawbacks to VA care and you have to plan ahead so you know where the VA facilities are. You may also have to wait to get appointment, but that could happen anywhere. As I understand it, if you have VA coverage you meet ACA requirements and you can still buy coverage on the exchange, but you are not able to get the subsidy since you already have VA coverage.

The problem (if you want to call it that) is that since my spouse still needs coverage under the ACA, we will have to pay the same premium (with subsidy help) as a family of two. Just seems a little unfair when only one person needs it.

I have never found this in writing (I have a VA booklet on coverage but the reference to emergency coverage page [10] is blank - the book is supposed to be customized for me personally), and the VA clinic could not confirm outside the VA emergency coverage when I asked them. They did tell me to remember the golden words for the ambulance "I'm a veteran and take me to a VA facility". Since we retired, I've purchased a high deductible BCBS policy as a just in case, but would appreciate any reference to this policy in writing. We snowbird in Florida a considerable distance from a VA hospital.

 

[Buckeye]

I am a little confused and/or concerned about how the ACA Insurance exchange (with subsidy for under 400% of FPL) works if one spouse needs to buy it there and the other has VA or Medicare coverage. From everything I have been able to find, when only one family member needs to buy medical coverage off the exchange the family is still charged the same amount of money as if both of them are buying coverage. The family income level, the premium amount, and/or the subsidy are not adjusted if only one member of the family is buying from the exchange. I have VA medical coverage but my wife will have no coverage after I retire from my current job. The ACA is making it possible for us to retire a little early but it seems like some of us are not getting the full financial benefit of others because I have earned VA coverage through service to our country. Our income level will definitely qualify us for the subsidy, but we will still be paying the same amount for one person coverage that others are paying for two person coverage.
Now if this is just the way it is then I am prepared to pay the cost because it will still allow us to get coverage for the spouse, but it seems a little unfair that we will pay the same amount as other two person families with the same income when only one person gets coverage. Kind of like being financially punished for serving my country and earning VA medical coverage. I think the same issue would apply if one spouse has Medicare coverage but the other still needs to buy it off the exchange. Is this correct? Any thoughts!

At least your VA care is free. The situation where one spouse is Medicare and paying premiums for part B and D and medi-gap and one spouse is ACA is the real bummer because we will get no "credit" for the money spent by the Medicare spouse AND our subsidy will be computed based on a family policy.

I'm okay with the situation because IMO the increased access to health insurance for the general population is more beneficial overall than the extra we may personally have to pay.

 

[Buck2520]

Fritz, I wish I could have exchange insurance to pay for things the VA may not cover, but from what i have read you cant get it (with subsidy) and we cant aford it without the subsidy. They have the following info about emergency care outside the VA system. I agree with you it may be a crap shoot getting them to pay, but there is a process. If my spouse and I could both have ACA policies that would be great, but I read you could not get (with subsidy) if you have other approved coverage like VA coverage. Maybe someone has more information.

Sorry this is so long, I copied it to my computer, and don't have the web link

How to Obtain Coverage of Emergency Care for Veterans in Non-VA Facilities

The U.S. Department of Veterans Affairs (VA) has the authority to pay for emergency healthcare provided to veterans in non-VA facilities. The VA will pay for emergency care provided in a non-VA facility if the VA “authorizes” such care shortly after the care is provided, or, for “unauthorized” care, if certain conditions are met.
(1) Payment of Authorized Services: The VA should grant authorization when (i) the careprovided in the non-VA facility was for a medical emergency that posed a serious threat to your life or health, and (ii) a VA facility was “not feasibly available, ” considering how far you would have had to travel and the urgency of your medical condition.
** Request Authorization within 72 hours of Admission **
Whenever possible, you should request authorization from the VA within 72 hours after admission to the non-VA facility (even if you have already been discharged). To request authorization, call the Fee Basis Department of the local VA medical center. Keep detailed notes of the telephone request, and send a follow up letter to the VA.
If a request for authorization is made within 72 hours of admission and approved, that authorization will be considered a “prior authorization.” If a request is made after 72 hours and
approved, that authorization will only cover expenses incurred after the request was made.
(2) Payment of Unauthorized Services: Even if you did not get authorization, the VA can pay for, or reimburse the cost of, emergency services provided in a non-VA facility. The rules and
timeframes for payment of “unauthorized” services are different depending on whether the care was for a service-connected or non-service-connected disability.
** Request Payment within 90 Days of Discharge **
If the emergency care was for a non-service-connected disability, you have to request payment or reimbursement within 90 days of discharge from the non-VA facility. To request payment, call the Fee Basis Department of the local VA medical center or 1-877-222-VETS. A VA representative will help you gather and submit any documents needed. If the emergency care was for a service-connected disability, you have to request payment within 2 years from the date the care was provided.
Certain conditions must be met for the VA to pay for unauthorized medical care in a non-VA facility (see 38 CFR § 17.120 & 38 CFR § 17.1002). A VA Fee Basis representative can explain these conditions to you.
** Request both methods of payment! When you are admitted into the non-VA facility, request authorization. If authorization is denied or unclear, then request payment of unauthorized services once you are discharged from the facility.
Appeal Rights: If your claim for payment of authorized or unauthorized medical services is denied by the VA, you have the right to appeal this decision.

********************************************************************
At some time in your life, you may need emergency care. This document explains what VA might be able to do for you. When it is not possible for you to go to a VA Medical Center, you should go to the nearest hospital that has an emergency room. If you are in an ambulance, the paramedics will usually take you to the closest emergency room.

What is an emergency?
A medical emergency is an injury or illness that is so severe that without immediate treatment, it threatens your life or health.
How do I know my situation is an emergency?
Your situation is an emergency if you believe your life or health is in danger.
If I believe my life or health is in danger, do I need to call the VA before I call for an ambulance or go to an emergency room?
No. Call 911 or go to the nearest emergency room right away.
When should I contact the VA regarding an emergency room visit?
You, your family, friends or hospital staff should contact the nearest VA medical center as soon as possible, preferably within 72 hours of your emergency, so you are better aware of what services VA may or may not cover. Provide VA with information about your emergency and what services are being provided to you. Ask VA for guidance on what emergency charges may or may not be covered so you can plan accordingly.
If the doctor then wants to admit me to the hospital, must I obtain advance approval from the VA?
If the admission is an emergency–NO, although prompt notification of the VA is necessary.
If the admission is not an emergency–YES

If a VA bed is available and I can be safely transferred, do I have to move to the VA hospital?
YES. If you want VA to continue to pay for your care. If you refuse to be transferred, VA will not pay for any further care.
If I am admitted to the hospital as a result of an emergency, how much will VA pay?
This depends on your VA eligibility. VA may pay all, some, or none of the charges. Some highlights are listed in the next column.
For service-connected conditions, here are some of the criteria that must be met:
1. Care or services were provided in a medical emergency, and
2. VA or another federal facility were not feasibly available, and
3. VA was notified within 72 hours of the admission.
4. Ask your local VA Medical Center’s Non-VA (Fee) Care Office for further eligibility guidance.

For non-service-connected conditions, here are some of the criteria that must be met:
1. Veteran is enrolled in the VA Health Care System, and
2. Veteran has received health care services from VA within the previous 24 months, and
3. Veteran has no other health insurance coverage.
4. Ask your local VA Medical Center’s Non-VA (Fee) Care Office for further eligibility guidance.

How do I know if I have a service-connected condition?
A service-connected condition refers to an illness or injury that was incurred in or aggravated by military service and has a rating assigned by the Veterans Benefits Administration.
How long do I have to file a claim for reimbursement for emergency medical care?
File your claim with the nearest VA Medical Center quickly because time limits usually apply. For non-service-connected care, the time limit is 90 days. Again, consult your local VA Medical Center for more information.


Will VA pay for emergency care received outside the United States?
VA will only pay for emergency care outside the U.S. if your emergency is related to a service-connected condition. For more information about care provided outside the U.S., contact the Foreign Medical Program (FMP) at
(877) 345-8179, or go to the FMP website at: http://www. va.gov/hac/forbeneficiaries/fmp
For more information on non-VA emergency care, visit National Non-VA Care Program Office
****************************************************************************************************************************************
VA Implements Medicare Payment Rates for non-VA Care
December 23, 2010—The Department of Veterans Affairs (VA) published in the Dec. 17 Federal Register a final rule implementing Medicare payment rates for inpatient and outpatient care for veterans that is provided outside of the VA system. Under the new rule, all non-VA inpatient and outpatient health care professional services and associated charges will now be reimbursed based on the applicable Medicare payment methodology (Medicare fee schedule or prospective payment system). The rule is effective Feb. 15, 2011.
The change will apply to charges associated with a range of services outside of the VA including clinical lab services, outpatient dialysis/ESRD services, Ambulatory Surgery Center charges, and hospital outpatient department and ER charges. For the time being, however, the new payment system will not apply to home health or hospice care. In response to comments, the VA has clarified that that this rule does not preclude providers from contracting with the VA for higher or lower rates. In such situations, providers will be reimbursed based on the negotiated contract rates, rather than the Medicare rates.
The rule also does not negate any existing contacts, such as multi-Veterans Integrate Service Network (VISN) contracts or contracts based on the Federal Acquisition Regulation (FAR) or the VA Acquisition Regulation (VAAR). In the absence of a negotiated contract rate, the VA will pay a provider the lowest of either the Medicare rate, the amount negotiated by a repricing agent, or the amount the provider charges the general public for the same service. In cases where no established Medicare rate exists, reimbursement will be based on the current VA Fee Schedule. The rule also further forbids providers from billing veterans an additional amount on top of what providers collect from the VA.
Implementation of the Medicare payment rates is expected to aid the VA with cost containment by controlling expenditures and making care costs more predictable. The rule notes that the VA does not believe switching to this system will adversely impact access to care.
Contact: Ivy Baer, J.D.
Sr. Director and Regulatory Counsel Telephone: 202-828-0499 E-mail: ibaer@aamc.org
Abeba Habtemarian, J.D.
Legal Fellow, Health Care Affairs Telephone: 202-828-6675 E-mail: ahabtemariam@aamc.org

 

[fritz]

Fritz, I wish I could have exchange insurance to pay for things the VA may not cover, but from what i have read you cant get it (with subsidy) and we cant aford it without the subsidy. They have the following info about emergency care outside the VA system. I agree with you it may be a crap shoot getting them to pay, but there is a process. If my spouse and I could both have ACA policies that would be great, but I read you could not get (with subsidy) if you have other approved coverage like VA coverage. Maybe someone has more information.

Sorry this is so long, I copied it to my computer, and don't have the web link

How to Obtain Coverage of Emergency Care for Veterans in Non-VA Facilities

The U.S. Department of Veterans Affairs (VA) has the authority to pay for emergency healthcare provided to veterans in non-VA facilities. The VA will pay for emergency care provided in a non-VA facility if the VA “authorizes” such care shortly after the care is provided, or, for “unauthorized” care, if certain conditions are met.
(1) Payment of Authorized Services: The VA should grant authorization when (i) the careprovided in the non-VA facility was for a medical emergency that posed a serious threat to your life or health, and (ii) a VA facility was “not feasibly available, ” considering how far you would have had to travel and the urgency of your medical condition.
** Request Authorization within 72 hours of Admission **
Whenever possible, you should request authorization from the VA within 72 hours after admission to the non-VA facility (even if you have already been discharged). To request authorization, call the Fee Basis Department of the local VA medical center. Keep detailed notes of the telephone request, and send a follow up letter to the VA.
If a request for authorization is made within 72 hours of admission and approved, that authorization will be considered a “prior authorization.” If a request is made after 72 hours and
approved, that authorization will only cover expenses incurred after the request was made.
(2) Payment of Unauthorized Services: Even if you did not get authorization, the VA can pay for, or reimburse the cost of, emergency services provided in a non-VA facility. The rules and
timeframes for payment of “unauthorized” services are different depending on whether the care was for a service-connected or non-service-connected disability.
** Request Payment within 90 Days of Discharge **
If the emergency care was for a non-service-connected disability, you have to request payment or reimbursement within 90 days of discharge from the non-VA facility. To request payment, call the Fee Basis Department of the local VA medical center or 1-877-222-VETS. A VA representative will help you gather and submit any documents needed. If the emergency care was for a service-connected disability, you have to request payment within 2 years from the date the care was provided.
Certain conditions must be met for the VA to pay for unauthorized medical care in a non-VA facility (see 38 CFR § 17.120 & 38 CFR § 17.1002). A VA Fee Basis representative can explain these conditions to you.
** Request both methods of payment! When you are admitted into the non-VA facility, request authorization. If authorization is denied or unclear, then request payment of unauthorized services once you are discharged from the facility.
Appeal Rights: If your claim for payment of authorized or unauthorized medical services is denied by the VA, you have the right to appeal this decision.

*********************************************************
This is the VA Fact Sheet on Medical Emergencies
At some time in your life, you may need emergency care. This document explains what VA might be able to do for you. When it is not possible for you to go to a VA Medical Center, you should go to the nearest hospital that has an emergency room. If you are in an ambulance, the paramedics will usually take you to the closest emergency room.

What is an emergency?
A medical emergency is an injury or illness that is so severe that without immediate treatment, it threatens your life or health.
How do I know my situation is an emergency?
Your situation is an emergency if you believe your life or health is in danger.
If I believe my life or health is in danger, do I need to call the VA before I call for an ambulance or go to an emergency room?
No. Call 911 or go to the nearest emergency room right away.
When should I contact the VA regarding an emergency room visit?
You, your family, friends or hospital staff should contact the nearest VA medical center as soon as possible, preferably within 72 hours of your emergency, so you are better aware of what services VA may or may not cover. Provide VA with information about your emergency and what services are being provided to you. Ask VA for guidance on what emergency charges may or may not be covered so you can plan accordingly.
If the doctor then wants to admit me to the hospital, must I obtain advance approval from the VA?
If the admission is an emergency–NO, although prompt notification of the VA is necessary.
If the admission is not an emergency–YES

If a VA bed is available and I can be safely transferred, do I have to move to the VA hospital?
YES. If you want VA to continue to pay for your care. If you refuse to be transferred, VA will not pay for any further care.
If I am admitted to the hospital as a result of an emergency, how much will VA pay?
This depends on your VA eligibility. VA may pay all, some, or none of the charges. Some highlights are listed in the next column.
For service-connected conditions, here are some of the criteria that must be met:
1. Care or services were provided in a medical emergency, and
2. VA or another federal facility were not feasibly available, and
3. VA was notified within 72 hours of the admission.
4. Ask your local VA Medical Center’s Non-VA (Fee) Care Office for further eligibility guidance.

For non-service-connected conditions, here are some of the criteria that must be met:
1. Veteran is enrolled in the VA Health Care System, and
2. Veteran has received health care services from VA within the previous 24 months, and
3. Veteran has no other health insurance coverage.
4. Ask your local VA Medical Center’s Non-VA (Fee) Care Office for further eligibility guidance.

How do I know if I have a service-connected condition?
A service-connected condition refers to an illness or injury that was incurred in or aggravated by military service and has a rating assigned by the Veterans Benefits Administration.
How long do I have to file a claim for reimbursement for emergency medical care?
File your claim with the nearest VA Medical Center quickly because time limits usually apply. For non-service-connected care, the time limit is 90 days. Again, consult your local VA Medical Center for more information.


Will VA pay for emergency care received outside the United States?
VA will only pay for emergency care outside the U.S. if your emergency is related to a service-connected condition. For more information about care provided outside the U.S., contact the Foreign Medical Program (FMP) at
(877) 345-8179, or go to the FMP website at: http://www. va.gov/hac/forbeneficiaries/fmp
For more information on non-VA emergency care, visit National Non-VA Care Program Office
****************************************************************************************************************************************
VA Implements Medicare Payment Rates for non-VA Care
December 23, 2010—The Department of Veterans Affairs (VA) published in the Dec. 17 Federal Register a final rule implementing Medicare payment rates for inpatient and outpatient care for veterans that is provided outside of the VA system. Under the new rule, all non-VA inpatient and outpatient health care professional services and associated charges will now be reimbursed based on the applicable Medicare payment methodology (Medicare fee schedule or prospective payment system). The rule is effective Feb. 15, 2011.
The change will apply to charges associated with a range of services outside of the VA including clinical lab services, outpatient dialysis/ESRD services, Ambulatory Surgery Center charges, and hospital outpatient department and ER charges. For the time being, however, the new payment system will not apply to home health or hospice care. In response to comments, the VA has clarified that that this rule does not preclude providers from contracting with the VA for higher or lower rates. In such situations, providers will be reimbursed based on the negotiated contract rates, rather than the Medicare rates.
The rule also does not negate any existing contacts, such as multi-Veterans Integrate Service Network (VISN) contracts or contracts based on the Federal Acquisition Regulation (FAR) or the VA Acquisition Regulation (VAAR). In the absence of a negotiated contract rate, the VA will pay a provider the lowest of either the Medicare rate, the amount negotiated by a repricing agent, or the amount the provider charges the general public for the same service. In cases where no established Medicare rate exists, reimbursement will be based on the current VA Fee Schedule. The rule also further forbids providers from billing veterans an additional amount on top of what providers collect from the VA.
Implementation of the Medicare payment rates is expected to aid the VA with cost containment by controlling expenditures and making care costs more predictable. The rule notes that the VA does not believe switching to this system will adversely impact access to care.
Contact: Ivy Baer, J.D.
Sr. Director and Regulatory Counsel Telephone: 202-828-0499 E-mail: ibaer@aamc.org
Abeba Habtemarian, J.D.
Legal Fellow, Health Care Affairs Telephone: 202-828-6675 E-mail: ahabtemariam@aamc.org

Appreciate your efforts here, but I have read these items (please see attachments) and they still leave uncertainty as to coverage for non VA emergency care/non-service connected (see the areas in bold above). Everything I have come across tells you to contact your local VA care provider, but when I talked to the VA clinic folks - even they were unsure of the coverage. Can't be going down the road and have a heart attack (non-service connected) and wonder if that will be covered - need to have no doubt in my mind it is covered (the reason I carry separate medical insurance, that does not provide thyroid related coverage per permanent exemption).

I haven't read that I "cannot" purchase coverage through the ACA exchanges if I have VA coverage. IIRC - it does say that it qualifies as the minimum coverage for veterans to avoid the penalties or having to pay for ACA coverage, but not that you aren't permitted to purchase coverage. Let me know where you read this statement.

 

[Buck2520]

Fritz, Here is a link to the info on the VA web site that says you are not eligible for the subsidy

http://www.va.gov/health/aca/FAQ.asp
it says;
Since VA care meets the standard for health care coverage, you wouldn’t be eligible for assistance to lower your cost of health insurance premiums if you chose to purchase additional health care coverage outside of VA. However, you may still purchase private health insurance on or off the Marketplace to complement your VA health care coverage

I agree with you it is good to have backup private insurance. I have it now since I am still working and it provides extra protection for me. The VA can also bill them and recoop some of their cost, and that is a good thing. The problem for me is that I can't get the subsidy for myself and I still have to pay for two persons when only one person needs it. There is no way I can afford an exchange policy without the subsidy. Seems this is the same issue for those families where one person has Medicare and the other does not. But like the other poster said, if that's just the way it is to expand health care I am willing to go along, it just seems a little unfair.

 

[fritz]

Fritz, Here is a link to the info on the VA web site that says you are not eligible for the (ACA) subsidy

http://www.va.gov/health/aca/FAQ.asp
it says;
Since VA care meets the standard for health care coverage, you wouldn’t be eligible for assistance to lower your cost of health insurance premiums if you chose to purchase additional health care coverage outside of VA. However, you may still purchase private health insurance on or off the Marketplace to complement your VA health care coverage

I agree with you it is good to have backup private insurance. I have it now since I am still working and it provides extra protection for me. The VA can also bill them and recoop some of their cost, and that is a good thing. The problem for me is that I can't get the subsidy for myself and I still have to pay for two persons when only one person needs it. There is no way I can afford an exchange policy without the subsidy. Seems this is the same issue for those families where one person has Medicare and the other does not. But like the other poster said, if that's just the way it is to expand health care I am willing to go along, it just seems a little unfair.

Thanks for the link and information. I called the VA 800 information line 1-877-222-VETS (8387) and asked about non VA care for non service related emergencies. I got the same answer that I've always gotten "you need to call the VA within 72 hrs to see if they will cover it" (that's a really big "if" in my book). I have to say the young lady assisting me was not the friendliest person (had real attitude). She also told me I'm not the first to call regarding the ACA and VA coverage eliminating the subsidy.

It would appear that the only way around this is to cancel your VA coverage and enroll in the ACA insurance. This is permissible, but the VA doesn't recommend it (for obvious reasons). I will have to weigh all my costs and see which way works out for both of us. Right now I pay BCBS $4,000.00 annually for a $5k deductible policy that I've never used (and it has permanent exemptions to some life threatening coverage). I have 3 years to go to medicare. What will be in my favor in 2014 is elimination of preexisting conditions where the VA is the only coverage I can get (and they are the ones who discovered it).

It would also appear that the ACA has left Veterans in a real "catch-22" scenario. A veteran could face financial ruin w/o outside coverage, and the VA denies outside coverage if you've purchased it. You'll also get no tax credit subsidy to purchase outside ACA healthcare (for emergency non VA care of non-service related issues) if enrolled in the VA, and the VA won't commit to covering non VA care for non service related emergencies.

I am surprised at the lack of interest in this thread - given the amount of military folks here. FYI - she told me that there will be a letter going out to all VA covered veterans in October regarding the ACA. Wonder if the VA will specifically address these pitfalls of of staying with the VA

 

[ivinsfan]

VA health care is so confusing, it seems they can't tell you what's covered until after something happens, which doesn't give you much peace of mind.

MY DH has VA care and had a condition they were watching as they thought it might turn into something more serious. Our main VA provider is about 60 miles from our home. Sure enough, one day last spring he suddenly noticed new symptoms and we drove together to urgent care VA provider. After checking things over they decided to put DH into the local hospital (non VA provider) as he needed some treatment immediately .
Before we even left the VA center we were given a signed and filled out form saying VA was paying for 100% of the cost for the hospital stay, which ended up being 4 nites. I took the form to hospital billing and 90 days later have not been billed for one penny. The billing office said VA signed off on everything. We also have full Blue Cross thru our business and the VA has not submitted any bills to Blue Cross over this incident.

Of course going to the VA provider instead of a non VA provider might have made a big difference, but in fact it was a true emergency. But it sure felt good to know Blue Cross would have stepped in, if things had gone differently.
I don' know if this information will help anybody, but our experience was pretty painless and didn't require any followup on our part.

 

[fritz]

VA health care is so confusing, it seems they can't tell you what's covered until after something happens, which doesn't give you much peace of mind.

MY DH has VA care and had a condition they were watching as they thought it might turn into something more serious. Our main VA provider is about 60 miles from our home. Sure enough, one day last spring he suddenly noticed new symptoms and we drove together to urgent care VA provider. After checking things over they decided to put DH into the local hospital (non VA provider) as he needed some treatment immediately .
Before we even left the VA center we were given a signed and filled out form saying VA was paying for 100% of the cost for the hospital stay, which ended up being 4 nites. I took the form to hospital billing and 90 days later have not been billed for one penny. The billing office said VA signed off on everything. We also have full Blue Cross thru our business and the VA has not submitted any bills to Blue Cross over this incident.

Of course going to the VA provider instead of a non VA provider might have made a big difference, but in fact it was a true emergency. But it sure felt good to know Blue Cross would have stepped in, if things had gone differently.
I don' know if this information will help anybody, but our experience was pretty painless and didn't require any followup on our part.

If your DH's approved medical emergency coverage was non-service related - this goes against what the Va publishes and is posted in this thread...

For non-service-connected conditions, here are some of the criteria that must be met:
1. Veteran is enrolled in the VA Health Care System, and
2. Veteran has received health care services from VA within the previous 24 months, and
3. Veteran has no other health insurance coverage.
4. Ask your local VA Medical Center’s Non-VA (Fee) Care Office for further eligibility guidance.

Could see this exemption if a VA hospital was not immediately available in your area (transport to it would have delayed needed care and it was a life or death emergency). Still in all, if you are covered by BCBS - would have worried that they would pull out this statement and expect you to cover it. This is my worry and why I carry additional coverage that appears to exempt me from the VA covering non-service related emergencies in non VA facilities.

 

[ivinsfan]

That was our impression as well, we fully expected Blue Cross to be brought into the picture as VA is an approved BC provider, as was the hospital where he was treated, so we certainly has all the bases covered. I was never worried that it wouldn't be covered by someone. Our BC coverage is on file at the local VA clinic so they knew all of the details.

But I agree the rules are very confusing and for that reason when my DH turns 65 in Jan we will probably be buying a medicare supplement, we just aren't confident enough in the rules to be without the peace of mind of extra coverage. No SC on the reason for the hospital admission.

 

[fritz]

That was our impression as well, we fully expected Blue Cross to be brought into the picture as VA is an approved BC provider, as was the hospital where he was treated, so we certainly has all the bases covered. I was never worried that it wouldn't be covered by someone. Our BC coverage is on file at the local VA clinic so they knew all of the details.

But I agree the rules are very confusing and for that reason when my DH turns 65 in Jan we will probably be buying a medicare supplement, we just aren't confident enough in the rules to be without the peace of mind of extra coverage. No SC on the reason for the hospital admission.

The VA clinic(s) I go to requires you to keep your outside medical coverage on file with them (they copy my BCBS card for their files). They do this annually along with requiring you to provide your (your families) total net worth to them for setting/maintaining your priority rating. Only Govt. agency I've dealt with that requires this information and punishes those who've become successful with priority 8 or fails to provide the financial information (failure to provide the net worth information may get you not approved for VA care). You can't just state that you agree to pay the co-pays - even though there is a box to check to agree to this as they caution you might not be classified.....

I ran into some trouble classifying with the Florida VA clinic I registered with when we retired, and they put me in priority 8 even though I qualify for priority 6 (am registered in Illinois also). I found out that you must register with each VA clinic you wish to use, even though you may have only one primary one. They were able to get into my tax filing for that year and accused me of making a low-mid six figure income (I've been living off savings and showed only non-qualified dividends in my income). This was actually me moving some taxable money around (exchanges) that year in preparation for retirement and they saw the total (not actual capital gains) as income. Scary what different arms of the govt. can obtain about you (all my 1099s).

 

[ivinsfan]

Once again, a system- VA -where everyone seems to have a different set of rules. MY DH is boots on the ground Vietnam and we have NEVER given VA any sort of financial info what so ever. Nothing,NADA, so no income info and full BC yet completely covered by VA, in the example I used of his recent health event. We are responsible for some minor co-pays since we didn't give financial info to the VA. However, VA submits regular checkup and lab work to BC and seems to be happy with the BC payments. We never get billed for the co-pays.

All this makes me wonder how the new national health care system is actually going to work, certainly VA handles fewer patients, yet the rules and regs are a major source of confusion for the patients and the providers!

 

[jclarksnakes]

Thanks for the link and information. I called the VA

I am surprised at the lack of interest in this thread - given the amount of military folks here. FYI - she told me that there will be a letter going out to all VA covered veterans in October regarding the ACA. Wonder if the VA will specifically address these pitfalls of of staying with the VA

A lot of folks on this forum are active or retired military and primarily using Tricare for our health care needs. Compared to Tricare the VA health system seems way too complicated.

 

[braumeister]

For the sake of those who might be wondering about all this talk of priority groups, the VA health care program enrolls people based on eight priority groups.

The number of Veterans who can be enrolled in the health care program is determined by the amount of money Congress gives VA each year. Since funds are limited, VA set up Priority Groups to make sure that certain groups of Veterans are able to be enrolled before others.

Once you apply for enrollment, your eligibility will be verified. Based on your specific eligibility status, you will be assigned a Priority Group. The Priority Groups range from 1-8 with 1 being the highest priority for enrollment. Some Veterans may have to agree to pay copay to be placed in certain Priority Groups.

The full descriptions of the groups can be found here:
Health Benefits :: Priority Groups Table

 

[braumeister]

I am rated as Priority Group 2 in the VA system yet I have never used their services. I have also been eligible for Tricare because I am retired military. Tricare seems like a better option for us because we have a large military medical presence in the region.

Mickey, I'm in a similar situation. VA Group 3, and using Medicare/TFL.

But I'm also enrolled in the VA system. There is no reason not to take advantage of both Medicare/TFL and VA.

I get all my medical care through Medicare/TFL and I'm very happy with it.

But I also go in for an annual checkup at my nearest VA clinic. There is no cost, and the first time I did this, I asked the doc if it wouldn't be better for me to simply stay away to leave their resources available for those who need them more.

Much to my surprise, she said "Absolutely not." It seems that the number of people enrolled in any VA clinic (who show up at least once a year for a very cursory checkup like I do) is something their funding is based on. So my going in for a 20 minute appointment every summer helps them out with their budget justification and actually makes medical care more available to the vets around here who truly rely on them.

Obviously, you don't have to enroll with your nearby facility, but I'm pretty sure they would be glad if you did.

 

[fritz]

Once again, a system- VA -where everyone seems to have a different set of rules. MY DH is boots on the ground Vietnam and we have NEVER given VA any sort of financial info what so ever. Nothing,NADA, so no income info and full BC yet completely covered by VA, in the example I used of his recent health event. We are responsible for some minor co-pays since we didn't give financial info to the VA. However, VA submits regular checkup and lab work to BC and seems to be happy with the BC payments. We never get billed for the co-pays.

All this makes me wonder how the new national health care system is actually going to work, certainly VA handles fewer patients, yet the rules and regs are a major source of confusion for the patients and the providers!

Every year, just like clockwork - I get the form letters requesting I verify our income and total net worth - do you get these? I also understood that it was not mandatory to provide the VA our total net worth (ours is above the norm). I only provided them with our annual income which was well above the priority group minimum to qualify for reduced or no co-payments, but Florida went and obtained our federal tax filings and accused us of making a nice six-figure income (as mentioned, they confused the total exchange of funds for retirement with the actual capital gains on the exchange, and I had to clarify their mistake to them).

In Illinois, I am priority group six as a Vietnam veteran exposed to agent orange, and this status supposedly applies to all Vietnam vets. Florida has me classified as priority group eight. I guess they felt I deserved it for not providing total net worth at the time (which I did when I clarified the mistake on their part). When I get the VA letter for Illinois - I just call them and they adjust their paperwork to show that I complied (they waive the financial information requirement for Vietnam Vet - agent orange exposure, priority six status).

Florida on the other hand, is difficult, but that could be because I'm a veteran of Illinois (Michigan native). I tried to use them last year when I was down there and having issues from treatment in Illinois. It was very difficult to get in and ended up going home early to get follow-up treatment at the Illinois VA. This shouldn't happen to anyone who's enrolled in the VA. As mentioned, I had to apply the year before when I was there to even get them to see me (I felt it was a good idea to enroll to have a local medical facility while we wintered there). You can't just call them up or walk in and get treatment at a VA clinic, but you can at any VA hospital. The local VA hospital is 4-5 hrs away in Florida.

I find the VA system to be lacking in nationwide ease of care and for coverage of non-VA medical care in non-service related medical emergencies, and am going to have to seriously evaluate leaving the system if it works out that we are better off financially (and medically) with the ACA exchanges. I'm forced to stay with the VA until the end of the year when the preexisting conditions on my individual policy goes away due to the ACA (thank God).

 

[Buckeye]

Mickey, I'm in a similar situation. VA Group 3, and using Medicare/TFL.

But I'm also enrolled in the VA system. There is no reason not to take advantage of both Medicare/TFL and VA.

I get all my medical care through Medicare/TFL and I'm very happy with it.

But I also go in for an annual checkup at my nearest VA clinic. There is no cost, and the first time I did this, I asked the doc if it wouldn't be better for me to simply stay away to leave their resources available for those who need them more.

Much to my surprise, she said "Absolutely not." It seems that the number of people enrolled in any VA clinic (who show up at least once a year for a very cursory checkup like I do) is something their funding is based on. So my going in for a 20 minute appointment every summer helps them out with their budget justification and actually makes medical care more available to the vets around here who truly rely on them.

Obviously, you don't have to enroll with your nearby facility, but I'm pretty sure they would be glad if you did.

I just realized this affects DH and I because we "joined" the local VA hospital over a year ago although we have yet to receive care there. We also have a high deductible policy to provide choices and guaranteed covered for emergencies.

I wonder how many people will leave the VA system due to the ACA subsidy issue and whether the exodus will have a material effect on their funding?

 

[ivinsfan]

As far as people leaving VA care it might happen, but I think there are enough people always trying to get in to keep the numbers steady. Even when you have co-pays it's virtually free. I guess the government considers VA care and subsidy money as double-dipping. But a vet earned his VA thru service and to say it's a freebie is a bit of a reach.

We have seen that many vet groups are activists about benefits, so I expect this issue to get some attention. Those of you that are directly involved in this issue might want to contact VFW,Legion, DAV and express your concern.

 

[Buck2520]

reply from VA

I recently sent in this message to the VA and got the following response. Guess it is settled for now. I will keep my VA coverage and obtain health coverage for my spouse on the exchange, even though we pay the same amount for one person as it would cost for two people.

Question to VA
Ok, I know you have been asked this already as it is timely topic. I know VA care qualifies under the ACA and I have read on your own site that if you have VA health care then you can still buy Insurance on the Health Exchange (and in fact VA wants veterans to maintain other health insurance). However, I also know that if you have VA health care you are not able to get the subsidy to help in buying health insurance from the exchange. I also know if you need emergency care outside of the VA system there is a process for the VA to pick up the cost, but there are so many loopholes for the VA to wiggle out of paying that it is pretty impractical to rely on the VA to cover all your health needs and cost. I would like to have private health insurance under the ACA (both to insure I have emergency coverage for needs outside the VA system, and to help the VA recover some cost for service) but I can’t afford to buy it without the subsidy because of my limited income.
So is this issue being addressed at a higher level? What is the official answer, how is a Veteran supposed to rely on the VA when there is such a large doubt about receiving emergency care outside the VA system and we are not able to buy exchange insurance with subsidy help?
Is this something that needs Congressional scrutiny or is it something the VA can address? Does the VA have an official answer? Is the VA attempting to address these issues?
This confirms receipt of the electronic message you just sent to the Department of Veterans Affairs (VA). The reference number for your question is #130807-001037

Here is the answer I got

Recently you requested assistance from VA. Below is a summary of your request and our response.

If you wish to reopen this issue, you may do so within the next 14 days by clicking on Reply, entering your new information, and then clicking Send.

Thank you for allowing us to be of service to you.


Discussion Thread
Response via Email Via Email (Dept of Veterans Affais)

08/08/2013 12:02 PM​

Mr Weir

The short answer is, all Veterans have the ability to cancel their VA coverage. If they do so, and then wish to obtain it again in the future, they will need to meet the new requirements set by congress for enrolling vets. Currently, the subsidy program is set up to assist people that are unfortunate and cannot afford heath care or qualify for it thru other means. If a veteran has benefits thru the VA he is covered at all VA facilities.

As to the emergency care, there are qualifications. They are quite basic and require little to qualify.
1. Be enrolled in the VA and have received care at a VA facility sometime in the last 2 years. If you keep up to date on your yearly physical this will be easily met. 2. Have no other coverage, including medicare, medicaid, or state funded insurance. If you have other insurance, they are expected to pay the bill.
3. You are financially liable for the care provided. If the hospital waives your charges, or care is received at a free clinic, there is no reason for the VA to pay. 4. You have no other legal recourse against a third party. If you are in a car wreck and are suing the insurance company, they VA will not pay the bill. If you are suing a homeowner, business, or property owner for an injury in which you received care, the VA will not pay the bill.
5. The care is preformed at an emergency facility, and a layperson would assume that delaying care could injure your life or limb. You cannot go into the ER for a stubbed toe and expect the VA to pay. You also cannot choose to use a primary care doctor based on personal preference and expect the VA to pay.
6. The VA will only pay for stabilization. Once you are stabilized you must contact the VA medical center for future plans. They may choose to transport you to the VA or they may choose to pay to keep you at the current facility. They will make that determination based on your needs, the resources of the VA, and the availability at the time.
These rules are not meant for the VA to "weasel out of paying the bill" but so that veterans know the policy and procedure.

If you wish to decline or cancel enrollment in the Department of Veterans Affairs (VA) Health Care System, you should contact the Enrollment Coordinator at your local VA facility.

You will be required to submit a signed and dated written statement requesting disenrollment.

Things to consider before asking to be disenrolled:

1. If you reapply you will be considered as a new applicant and enrollment will be based upon the criteria in place at that time.
2. If you are a Veteran who is required to be enrolled to receive VA health care:
you will not be eligible for care of your non-service connected conditions.
if emergency treatment is provided at a VA facility you will be billed at the humanitarian rate. you will not be eligible for non-VA emergency care.
3. Veterans who are 50% or more service-connected are not required to be enrolled in the VA health care system to receive benefits offered in the Medical Benefits Package.

 

[fritz]

I recently sent in this message to the VA and got the following response. Guess it is settled for now. I will keep my VA coverage and obtain health coverage for my spouse on the exchange, even though we pay the same amount for one person as it would cost for two people.

Question to VA
Ok, I know you have been asked this already as it is timely topic. I know VA care qualifies under the ACA and I have read on your own site that if you have VA health care then you can still buy Insurance on the Health Exchange (and in fact VA wants veterans to maintain other health insurance). However, I also know that if you have VA health care you are not able to get the subsidy to help in buying health insurance from the exchange. I also know if you need emergency care outside of the VA system there is a process for the VA to pick up the cost, but there are so many loopholes for the VA to wiggle out of paying that it is pretty impractical to rely on the VA to cover all your health needs and cost. I would like to have private health insurance under the ACA (both to insure I have emergency coverage for needs outside the VA system, and to help the VA recover some cost for service) but I can’t afford to buy it without the subsidy because of my limited income.
So is this issue being addressed at a higher level? What is the official answer, how is a Veteran supposed to rely on the VA when there is such a large doubt about receiving emergency care outside the VA system and we are not able to buy exchange insurance with subsidy help?
Is this something that needs Congressional scrutiny or is it something the VA can address? Does the VA have an official answer? Is the VA attempting to address these issues?
This confirms receipt of the electronic message you just sent to the Department of Veterans Affairs (VA). The reference number for your question is #130807-001037

Here is the answer I got

Recently you requested assistance from VA. Below is a summary of your request and our response.

If you wish to reopen this issue, you may do so within the next 14 days by clicking on Reply, entering your new information, and then clicking Send.

Thank you for allowing us to be of service to you.


Discussion Thread
Response via Email Via Email (Dept of Veterans Affais)

08/08/2013 12:02 PM​

Mr Weir

The short answer is, all Veterans have the ability to cancel their VA coverage. If they do so, and then wish to obtain it again in the future, they will need to meet the new requirements set by congress for enrolling vets. Currently, the subsidy program is set up to assist people that are unfortunate and cannot afford heath care or qualify for it thru other means. If a veteran has benefits thru the VA he is covered at all VA facilities.

As to the emergency care, there are qualifications. They are quite basic and require little to qualify.
1. Be enrolled in the VA and have received care at a VA facility sometime in the last 2 years. If you keep up to date on your yearly physical this will be easily met. 2. Have no other coverage, including medicare, medicaid, or state funded insurance. If you have other insurance, they are expected to pay the bill.
3. You are financially liable for the care provided. If the hospital waives your charges, or care is received at a free clinic, there is no reason for the VA to pay. 4. You have no other legal recourse against a third party. If you are in a car wreck and are suing the insurance company, they VA will not pay the bill. If you are suing a homeowner, business, or property owner for an injury in which you received care, the VA will not pay the bill.
5. The care is preformed at an emergency facility, and a layperson would assume that delaying care could injure your life or limb. You cannot go into the ER for a stubbed toe and expect the VA to pay. You also cannot choose to use a primary care doctor based on personal preference and expect the VA to pay.
6. The VA will only pay for stabilization. Once you are stabilized you must contact the VA medical center for future plans. They may choose to transport you to the VA or they may choose to pay to keep you at the current facility. They will make that determination based on your needs, the resources of the VA, and the availability at the time.
These rules are not meant for the VA to "weasel out of paying the bill" but so that veterans know the policy and procedure.

If you wish to decline or cancel enrollment in the Department of Veterans Affairs (VA) Health Care System, you should contact the Enrollment Coordinator at your local VA facility.

You will be required to submit a signed and dated written statement requesting disenrollment.

Things to consider before asking to be disenrolled:

1. If you reapply you will be considered as a new applicant and enrollment will be based upon the criteria in place at that time.
2. If you are a Veteran who is required to be enrolled to receive VA health care:
you will not be eligible for care of your non-service connected conditions.
if emergency treatment is provided at a VA facility you will be billed at the humanitarian rate. you will not be eligible for non-VA emergency care. (what's this mean - you've lost coverages ?)
3. Veterans who are 50% or more service-connected are not required to be enrolled in the VA health care system to receive benefits offered in the Medical Benefits Package.

You mentioned that you currently have outside insurance at work that would cover non service related emergencies at non VA facilities, but cannot afford to buy insurance off the exchange w/o the subsidy for yourself in retirement - just your wife.

Are you planning to forgo purchasing outside insurance for yourself when you stay with the VA, and just purchase your wife's health insurance off the exchange? I can't bring myself to do that given the uncertainty of their responses to non service related care at non VA facilities.

Purchasing insurance off the ACA exchanges for you and your wife costs pretty much the same with the subsidy as if she or you were purchasing it as a single (just the subsidy amount changes - the out of pocket is identical for the most part according to the Kaiser calculator). Even the ACA website is touting the Kaiser calculator. Since you mentioned that you cannot afford the ACA insurance for yourself w/o the subsidy - your ACA health insurance costs should be very attractive for you and your wife based on your income in retirement, vs. the additional costs of outside insurance and staying with the VA.

Our estimated costs using the ACA for both me and my wife would run under $3k annually out of pocket (I can manipulate our investment income to keep our MAGI fairly stable until we reach medicare age). Even with a $2500.00 deductible on the silver plans subsidy estimate - the savings of me "not" having to buy outside insurance w/o the subsidy currently at $4k @62 yrs old (with a $5k deductible) makes the ACA exchange pricing very attractive. I would imagine we might also be able to purchase a better plan (gold or platinum off the exchange for better coverage with the $6,500 we'd be spending with her only on ACA and my staying with the VA and outside coverage, but we'll see what the future brings). It makes leaving the VA healthcare system financially attractive, even though it would be a real loss personally.

From the last comments on the VA email reply - kind of comes across as a threat (fact) of loss of coverage of future non service related emergencies at VA "or" non VA facilities when considering disenrolling. If I didn't know better, it sounds like don't bother coming back, it won't be there for you anymore...