Veterans have choices when it comes to their healthcare. Many assume that all veterans receive their care through the Department of Veteran Affairs (VA) hospitals and clinics, but less than half of the country’s approximately 22 million veterans receive VA healthcare.1 To be sure, approximately nine million are enrolled in the Veterans Health Administration (VHA) -- it is the nation’s largest integrated health system.2 But eligibility, breadth of VA coverage, and copayment rates depend on a number of factors, including a veteran’s income, whether the veteran has service-connected disabilities, and whether he or she is a former Prisoner of War. Taking these factors into consideration will help a veteran determine where best to go for healthcare.
Some veterans do not use the VA healthcare system because they do not qualify for VA care,3 the closest VA facility is geographically inconvenient, or outside medical care is preferred or necessary.4 In those instances, veterans may choose to purchase private insurance, qualify for Medicaid or Medicare, or be able to participate in programs such as the Veterans Choice Program, TRICARE, the Non-VA Medical Care Program, the Patient Centered Community Care Program, or the new CVS MinuteClinic Initiative that permit them to receive care at non-VA facilities. These programs allow veterans to receive care through referrals based on contracts negotiated by the VA or reimbursements for necessary or emergency services unavailable to veterans through the VA.5
The veteran healthcare landscape is filled with options, and therefore can be daunting for consumers, providers, and advocates alike. This article seeks to provide an overview of the non-VA healthcare options available to veterans, and some insight into how these various systems and programs work together to serve our nation’s veterans.
Veterans may choose to purchase a health insurance plan privately in order to receive non-VA healthcare. Depending on the state the veteran lives in, the method of enrolling in private health insurance plans varies. For example, in New York State, plans can be purchased through the Official Health Plan Marketplace, which was developed in response to the passage of the Patient Protection and Affordable Care Act.6 Once a veteran enters his or her personal information, he or she will be guided to a page with plan options and costs. Each plan will show what it covers, the costs, and in-network and out-of-network benefits.
If a veteran has private health insurance and uses the VA healthcare system, the VA is required to submit health services claims to the third-party insurance carrier for any nonservice-connected7 medical care provided to the veteran.8 This includes any medical supplies and medications for the nonservice-connected treatment, as well. This can work to the advantage of the veteran because the calculated VA copayment can be offset “dollar for dollar” by the amount received from the private health insurance provider. Because the VA healthcare system is not considered medical insurance, a veterans’ copayment amounts are not uniform. Medical services copayments are based on various factors such as whether the veteran is rated for a service connected disability, is a former Prisoner of War, the types of medals the veteran has received, the veteran’s income, and other facts about the veteran’s time in the service.9 The enrollment categories are termed “priority groups,” of which there are eight. For example, priority group 1 includes veterans who are rated at 50 percent or more for service-connected disabilities and those determined to be unemployable due to their service-connected disabilities. In contrast, those veterans allocated to priority group 7 are those with gross household income below the geographically-adjusted income limit for where they reside and they agree to pay the copayments.10 Thus, in looking at the priority group and whether a veteran has a copayment within the VA system, if the veteran has private health insurance, then the payment the VA receives from the private insurance may be applied to the veteran’s VA copayment amount. Additionally, depending on the veteran’s priority group, he or she may not be held responsible for any unpaid balance that the private health insurance provider does not remit.11
Medicaid and Medicare
Veterans may be eligible for joint federal-state programs such as Medicaid, as well as federal programs such as Medicare. As of 2009, approximately 60 percent of veterans had public health insurance including Medicaid and Medicare.12 In a 2015 report, approximately 51 percent of veterans who are enrolled in the VA healthcare system have Medicare, and approximately seven percent have Medicaid coverage.13 The programs provide an important source of supplementary healthcare to veterans who are elderly, have low income, or other special needs.
Approximately 1.75 million veterans have Medicaid, according to the latest data available.14 Medicaid is administered by individual states meeting specific federal requirements.15 Eligible groups regardless of veteran status include low-income families and individuals, pregnant women, and aged, blind and disabled individuals. If a veteran qualifies under one of these categories, then he or she can seek healthcare in his or her community using Medicaid. The advantages for those veterans who have Medicaid based on low income status, who also receive healthcare through the VA system, include the fact that Medicaid can cover spouses and children, veterans will typically have no out-of-pocket VA healthcare costs,16 and the veteran may choose an outside healthcare facility based on the Medicaid coverage alone.17
Another important benefit of Medicaid to veterans is to help cover costs of long-term care, including home care. The VA system offers nursing homes and community living centers for long-term inpatient geriatric care. Veterans who are not able to enter the VA’s nursing home and long-term care facilities based on issues of eligibility or lack of open beds at the closest VA location can apply for Medicaid to cover the expenses of a nursing home outside of the VA system and additional home care. The veteran may still go to the VA for his or her regular medical care.
Medicare can also be used in conjunction with VA care by veterans. To be eligible, individuals must be 65 years or older, diagnosed with End-Stage Renal Disease, or deemed disabled and receiving Social Security Disability Insurance benefits.18 Medicare’s costs depend on whether the individual has earned enough work credits by paying into the federal system through payroll tax.19 Veterans are able to seek medical treatment where Medicare is accepted if he or she qualifies.
If the veteran uses the VA system for non-service connected conditions, in general the VA may only bill the supplemental health insurance for certain services and not the veteran himself or herself.20 Medicare21 specifically will not cover treatment received at the VA because Medicare is unable to cover services at a government facility.22 The veteran can choose whether or not to use the VA and pay the VA copayment based on his or her priority group, or use a facility outside of the VA which accepts Medicare. Medicare Part A, the hospital coverage, generally does not cost an individual extra and is a good idea to have if the veteran may use a hospital outside of the VA system.23
Additionally, veterans who have Medicare may opt to enroll in Part B, the medical insurance component of Medicare. In order to receive treatment outside of the VA system through the Medicare system, Part B is necessary.24 Typically, veterans who have Medicare will go to the VA for services generally not covered by Medicare, such as over-the-counter medications, annual physical exams, hearing aids, and specific treatments for service-connected disabilities.25
Notably, the VA and Medicare can’t cover the same services -- the veteran must choose whether service is sought under VA benefits or is billed to Medicare.26 Therefore, if a veteran seeks treatment at a facility outside of the VA and Medicare is billed, the VA will likely deny any claim the veteran submits, including for reimbursement of the Medicare copayment.
TRICARE is a health insurance program available to active service members, National Guard or Reserve members, retired service members, those registered in the Defense Enrollment Eligibility Reporting System,27 Medal of Honor Recipients, and survivors, former spouses, and service members’ families.28 Depending on which category the veteran or individual falls into, there are currently 11 TRICARE plans to choose from.29 Each plan has set guidelines as to where the participant may receive healthcare and specifies guidelines for the use of the Military Health System30 and outside providers.31 For example, active duty members can enroll in TRICARE Prime, Prime Remote, Prime Overseas, or Prime Remote Overseas depending on their duty station.32 It is possible that an active duty member can also be considered a former veteran if they were previously discharged under other than dishonorable conditions and since then re-enlisted.33
TRICARE can offer more options than if a veteran seeks treatment solely at a VA facility. Depending on the plan, the veteran may be able to seek treatment at a military hospital. TRICARE also acts as private insurance does, and allows veterans to use public medical facilities if they are a network provider. When an individual has TRICARE, he or she is assigned a primary care manager (PCM) which coordinates most of the healthcare.34 When choosing whether to go to through the VA system or opt for TRICARE, there are differences, such as where medications can be filled and to what extent specific services, such as vision screening, are offered.35 Depending on which TRICARE plan an individual is enrolled in, there are different premium costs and copayments. If a veteran uses the VA system for healthcare and has TRICARE, his or her VA priority code still determines the cost of copayments. Furthermore, if a veteran chooses to purchase private health insurance in addition to TRICARE, premiums and copayments will depend on the plan that is chosen.
Non-VA Medical Care Program
A veteran who is enrolled in the VHA system has an option to have specific community healthcare services pre-authorized by the VA, or reimbursed after the fact in certain circumstances. Formerly known as the Fee-Basis Program,36 the Non-VA Medical Care Program generally has an office in VA medical centers where veterans can submit claims. Deadlines for filing claims can depend on whether the veteran has a service-connected disability.37 For example, for emergency outside services the deadline for non-service connected claims are 90 days from the date of care, while for service-connected claims the time limit is two years from the date of care.38
The Non-VA Medical Care Program covers medical costs for veterans when the VA services are either unavailable at the VA, the closest VA facility is not accessible geographically, or the veteran had an emergency and was not able to travel the distance to the closest VA.39 Although some aspects of this program are similar to PC3 and VCP, discussed below, for the most part emergency services can only be reimbursed through the Non-VA Medical Care Program.40
Patient-Centered Community Care
An additional way for veterans to receive care from outside providers is through Patient-Centered Community Care (PC3 or PCCC). PC3 is a VA initiative to provide primary and specialty care to veterans when the VA is unable to offer sufficient services. The program was created in 2013 and integrated data from previous VA pilot programs in order to improve the care offered.41 PC3 has been expanded in the past few years to include more covered services.42
PC3 is administered by VHA. VHA enters into healthcare contracts which allow for inpatient and outpatient care, limited emergency care, care for female veterans who recently gave birth and some newborn care, mental health services, and primary care.43 In order to receive services through PC3, a veteran must first request such care at the local VA, and if it is determined that the specific care needed is unavailable at the VA, a PC3 contract may be utilized to purchase the care outside of the VA system.
PC3 is the “preferred mechanism for external medical services.”44 The study also notes, however, that PC3 is utilized less than other types of programs with similar goals.
Veterans Choice Program
Initially created in 2014 as a temporary program by passage of the Veterans Access, Choice, and Accountability Act,45 the Veterans Choice Program (VCP) allows veterans to be referred to outside medical facilities based on set criteria. The program was instituted because VA appointment wait times had been shown to be excessive, sometimes close to eight months.46 Although this program is very similar to PC3, the eligibility criteria are different. PC3 is utilized when the VA is “not able to furnish necessary care,” while the VCP looks more at wait times and the distance to the nearest VA facility.47
In order to qualify for outside services through the VCP, certain requirements must be met. If the wait time for an appointment is 30 days or more, the VA facility is more than 40 miles away from where the veteran resides, the veteran would need to travel by plane or boat, or there is an “unusual or excessive burden”48 to reach the closest VA hospital, then the VA can refer the patient to an outside provider. If a veteran resides in a state or territory without a VA hospital which provides hospital, emergency, and surgical care, and also is more than 20 miles away from such facility, then he or she may be eligible for the VCP; generally this applies to residents of Alaska, Hawaii, Guam, American Samoa, the U.S. Virgin Islands, the Commonwealth of the Northern Mariana Islands, and some areas of New Hampshire.49 If the veteran is eligible for VCP-provided coverage, the veteran may be approved for an “episode” of care. The episode of outside care is a fixed time period “not in excess of 60 days” for the authorization of the specific needed care.50
Originally Congress appropriated $10 billion for the VCP, and when exhausted, the program was to end. In August 2017, President Trump authorized $2.1 billion more for the VCP by signing the VA Choice and Quality Employment Act of 2017.51 This will ensure the continuation of the program until the funds are depleted. In comparison, PC3 receives its funding through the Veterans Health Administration (VHA), which receives general funding for programs within VHA’s discretion.52
There have been some issues with the VCP where providers are claiming they are not being paid for their services.53 Although there are challenges with the program, veterans’ wait times have decreased and healthcare has become more accessible.54
CVS Minute Clinic Initiative
In April 2017,55 VA Secretary David Shulkin instituted the CVS MinuteClinic Initiative to reduce wait times for treatment of minor injuries or illnesses. The VA is currently testing the new program in Phoenix, Arizona.56 CVS MinuteClinics offer services such as treatment for minor wounds and infections, routine lab testing, and administration of some vaccinations.57
This program would also relieve the burden on local VA facilities, and also allow veterans to receive faster and more convenient service when the treatment is more minor or routine.58 The VA’s deputy undersecretary for health for community care stated, “The launch of this partnership will enable [the] VA to provide more care for veterans in their neighborhoods.”59 If the test run is successful, it is possible that the over 1,100 CVS MinuteClinics located in 33 states and the District of Columbia will be made available to veterans in the future. As of December 25, 2017, approximately 783 veterans were served through this initiative and patients “report that they’re happy with the program.”60
Executive Order Provides For Mental Health Care to New Veterans
On January 9, 2018, President Trump signed the Executive Order “Supporting Our Veterans During Their Transition From Uniformed Service to Civilian Life.”61 This order develops a plan for the Department of Defense, the VA, and Homeland Security to work together in order to secure mental healthcare for all new veterans during his or her first year after discharge from service. This order seeks to eliminate obstacles for veterans who would not have been eligible for mental healthcare based on a lack of service-connected disabilities and possibly other ineligibility factors. It is estimated that this will open up mental healthcare to 60 percent of new veterans who would not otherwise qualify.62
Veterans receive healthcare through multiple systems and programs, and can compare which is most convenient or beneficial to their health and wallet before deciding which to choose. The options for veterans to seek non-VA system healthcare have evolved throughout the years and most likely will continue to change. There is no clear program or health insurance that is best for veterans today. Veterans, their providers and advocates must survey the complicated healthcare landscape, along with individual needs of veterans, and then determine eligibility and which available option can best serve them. It is advisable for a veteran to compare costs and coverages through TRICARE, the VA system, Medicaid and Medicare, and private insurance before making a decision as to which one is best for his or her personal situation.
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Katie Ocampo is a staff attorney at LegalHealth and staffs the legal clinic at Northport VA Center. Prior to joining LegalHealth, she was awarded a Post-Graduate Fellowship to work at the Suffolk County District Attorney’s Office. While in law school, Ms. Ocampo was a member of the Moot Court Team and completed an externship, where she provided legal services in the area of family law. She graduated from William and Mary Law School, and graduated with distinction from the University of Hawaii at Manoa. She may be reached at firstname.lastname@example.org.
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