It’s important to know that VA health care is a health care system, not health insurance, though eligibility and enrollment in VA health care meets the health insurance requirement under the Affordable Healthcare Act.
Veterans are often confused or upset if they receive a bill from a private medical facility, if that facility billed the VA and VA refused payment. In some cases, VA will pay outside providers, but only in specific circumstances and only for veterans enrolled in VA healthcare.
For example, if a veteran has no other health insurance and is only enrolled in VA healthcare, the VA will pay for emergency room care at a non-VA facility, but only if the condition is a life-threatening emergency that required the veteran to go to the nearest hospital. If not a life-threatening emergency, the veteran is expected to go to the nearest VA medical center. If a veteran goes to a private hospital ER and the problem was not deemed an emergency, VA will not pay the bill and the veteran is responsible for payment.
If a veteran has health insurance, the bill for services will be sent to the private insurer and VA has no part in payment. The hospital might also send the bill to the VA in addition to an insurer as a matter of course, but VA will never pay for ER care for a veteran who has private health insurance.
Another example where VA would pay a private doctor or medical facility is if a veteran is enrolled in VA healthcare, with or without health insurance, and the veteran’s VA primary care doctor referred the veteran’s care out to a private facility or doctor. This is known as a “fee-based” service. Depending on your category, co-pays may apply.
Veterans who are enrolled in VA health care and also have traditional Medicare need to be especially careful. Some veterans decline Medicare Part B (medical insurance for doctor and outpatient care) because they want to save money, as Part B requires a premium, usually deducted from monthly Social Security. There is no premium for Medicare Part A (hospital insurance). These veterans assume they can be seen by VA for all doctor and outpatient visits normally covered by Part B. However, if an urgent illness or accident occurs and they go to a private medical facility, they are responsible for any doctor bills or charges not covered by Medicare Part A. In other words, it can be financially risky to decline Medicare Part B, unless you have other private insurance that will pay for things normally covered under Part B.
In addition, co-pays are sometimes required for services or drugs within the VA health care system, based on the percentage of your service-connected disabilities, your category and your Family’s annual income.
Because many veterans enrolled in VA health care also are covered by a variety of different insurance plans, both government-run (Tricare, Medicare, Medicaid) as well as scores of private plans (Blue Cross Blue Shield, Cigna, etc., including privately-purchased Medigap or drug plans), it is important to make sure you understand the benefits and restrictions under each.
Sandy Britt is a Montgomery County, Tennessee, veterans service officer. If you have a general question, email firstname.lastname@example.org. Questions about a specific claim can be addressed only by calling the Montogomery County Veterans Service Office at 931-553-5173 for an appointment with a service officer.