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Military or Veteran Coverage


There may be coverage for veterans or military retirees and/or their dependents which coordinates with Medicare.  Most common are:

  • Veteran's Benefits
  • Tricare for Life - For military retirees
  • Civilian Health and Medical Program of VA (ChampVA) - For dependents of a living veteran with 100% service connected disabilities or who died as a result of the service-connected disability

For more information, contact your County Veterans Service Officer (CVSO).  They help veterans and their families to obtain local, state and federal benefits for which they may qualify.  They will also assist with the application process.  Click here to find the County Veteran Service Officer in your county.

Veteran's Benefits

Eligibility: A person who served in active military service and who was discharged or released under conditions other than dishonorable may qualify for VA health care benefits.  Reservists and National Guard members may also qualify for VA health care benefits if they were called to active duty (other than for training only) by a Federal order and completed the full period for which they were called or ordered.

Priority Groups: During the enrollment process, each veteran is assigned to a priority group.  VA uses priority groups (group 1 through group 8) to balance demand for VA health care enrollment with resources.  Changes in available resources may reduce the number of priority groups the VA can enroll.  If this occurs, the VA will publicize the changes and notify affected enrollees.

Costs:  There is no premium required for VA Healthcare benefits, however, some veterans may have co-pays to receive VA health care benefits and/or medications.  Services must be received in a VA approved facility.  (VA may reimburse or pay for medical care provided to certain enrolled or otherwise eligible veterans by non-VA facilities in cases of medical emergencies where VA or other federal facilities were not available. Other conditions also apply.)  A three-tiered co-pay system is used for all outpatient services with some exceptions.  Most Veterans are charged $8 for each 30-day or less supply of medication provided by the VA for treatment of conditions that are not service-connected.

Other Insurance:  The VA is required to bill private health insurance for medical care, supplies, and prescriptions provided for treatment of non-service connected conditions.  Generally, the VA cannot bill Medicare, but can bill a secondary health insurance for covered services, including Medicare supplement policies.

A common question from veterans is "do I need Part B of Medicare?"  VA benefits are primarily available through VA facilities.  If a beneficiary does not have access to convenient medical care or has an emergency for a non-service connected illness or injury and goes to a non-VA facility, having Medicare Part B would offer some coverage for services in those circumstances.  (Note: If the veteran decides to waive Part B, they may get Part B back during the General Enrollment Period and may have to pay a penalty for not taking Part B when first eligible.)

"Do I need to join a Medicare Prescription Drug Plan? (Part D)" is another frequently asked question.  If a veteran is eligible for VA benefits, including prescriptions, they would have "creditable coverage", thus they would not need to enroll in Part D.  A veteran may still choose to enroll in Part D if they need access to a local pharmacy or if they are eligible for the Medicare Part D Low Income Subsidy ("extra help") which would lower the costs of their prescriptions.

For additional information on VA health care, visit the U.S Department of Veterans Affairs website.

Tricare

TRICARE is a regionally managed health care program for Active Duty members, Activated Guard and Reservists, Retired members of the Uniformed Services, their families and survivors. TRICARE brings together the healthcare resources of all military branches and supplements them with networks of civilian healthcare professionals to provide better access and high quality care while maintaining the capability to support military operations.  Active Duty and Guard and Reserve service members are automatically enrolled in TRICARE Prime.  However, military dependents and retirees must choose the TRICARE option that best suits their needs.  For more information about TRICARE options, refer to HealthNet Federal Services, LLC (North Regions) at 1-800-874-2273 (1-800-TRICARE).

Prior to 2001, TRICARE coverage expired at age 65 forcing military retirees, their families and survivors to rely solely on Medicare.  TRICARE For LIFE (TFL) provides military health care coverage to TRICARE beneficiaries 65 years of age or older.  When TRICARE beneficiaries (other than eligible active duty family members) became entitled to Medicare Part A, on the basis of age or disability/end-stage renal disease and purchase Medicare Part B, they do not experience a break in TRICARE coverage.  TRICARE for Life pays secondary to Medicare.

Eligibility:  TFL is available for all dual TRICARE/Medicare eligible uniformed service retirees, including retired members of the Reserve Component who are receiving retiree pay, Medicare eligible family members, Medicare eligible widows/widowers, certain former spouses, and beneficiaries under age 65 who are also entitled to Medicare Part A because of a disability or chronic renal disease.

Cost:  There are no enrollment fees for TFL.  Beneficiaries, other than active duty family members, are required to enroll in Medicare Part B and to pay the appropriate Medicare Part B monthly premiums.

Benefits:  For services payable by both Medicare and TFL, Medicare pays first, any other health insurance pays second, and the remaining beneficiary liability may be paid by TFL.  For services received from a civilian provider, the provider first files claims with Medicare.  Medicare pays its portion and electronically forwards the claim to TFL for processing.  TFL sends its payment  for the remaining beneficiary liability directly to the provider, and beneficiaries receive a Medicare summary notice (from Medicare) and a TFL explanation of benefits (EOB) that indicates the amount paid to the provider.

For services payable by TFL, but not Medicare, such as overseas travel, TFL pays the same as the TRICARE Standard Plan and beneficiaries are responsible for the fiscal year deductible and cost shares of the Standard Plan.

For services payable by Medicare, but not TFL, such as chiropractic services, Medicare pays as usual, however, TFL makes no payment.  Beneficiaries are responsible for Medicare co-insurance and deductibles.

For services not payable by Medicare or TRICARE, beneficiaries are responsible for the entire bill.

Tricare for life Pharmacy Pilot Program: Beginning March 14, 2013, this new pilot program requires TFL bneficiaries living in the United States who fill select maintenance medications at a retail pharmacy to switch these prescriptions to the TRICARE Pharmacy Home Delivery system or to a military pharmacy.  Medications included in the pilot which are not purchased via the Home Delivery system or from a military pharmacy after the start of this program will not be eligible for benefits after the 3rd fill and the beneficiary will be responsible for 100% of the cost.  If the beneficiary has other health insurance with a prescription benefit or they are not part of the pilot or in some cases of personal need, hardship, emergency, or other special circumstances (such as living abroad or in a nursing home) the beneficiary will be able to request a waiver.  They may opt out of the pilot altogether after using Home Delivery for at least 1 year.

Remember, Members enrolled in TRICARE for Life do not need to enroll in a Medicare Part D plan.

For more information on TRICARE, TRICARE for LIFE, and other TRICARE programs, visit Military.com benefits, Understanding TRICARE.

Civilian Health and Medical Program of the Department of Veterans Affairs (ChampVA)

CHAMPVA is a comprehensive health care program with which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.

Eligibility:  To be eligible for CHAMPVA, a family member of a qualifying sponsor cannot be eligible for TRICARE/CHAMPUS and must be in one of these categories:

  1. The spouse or children of veterans who have been rated permanently and totally disabled for service-connected disabilities by a VA regional office
  2. The surviving spouse or children of  veterans who died from VA rated service connected disabilities
  3. The surviving spouse or children of veterans who were, at the time of death, rated permanently and totally disabled from a service connected disability
  4. The surviving spouse or children of military members who died in the line of duty, not due to misconduct (in most of these cases, these family members are eligible for TRICARE, not CHAMPVA).

For More information on eligibility, please see the U.S. Department of Veterans Affairs CHAMPVA website.

Benefits:  The CHAMPVA program covers most health care services and supplies that are medically necessary.  CHAMPVA does not have a network of medical providers.  However, most TRICARE providers will also accept CHAMPVA patients.  Go to TRICARE Your Military Health Plan to locate a provider in your area, then contact them to ask if they also accept CHAMPVA patients.

Most Medicare providers will also accept CHAMPVA patients.  Medicare providers can be located through the U.S. Government's Medicare website.  Use the "Search Tools" at the bottom of that page to locate a Medicare provider.  (Important Note: All hospitals that participate in Medicare, and hospital-based health care professionals who are employed by, or contracted to such hospitals are required by law to accept CHAMPVA for inpatient hospital services.)

CHAMPVA and Medicare: CHAMPVA is always the secondary payer to Medicare.  As of June 5, 2001, Medicare beneficiaries are required to have both Part A and Part B of Medicare in order to be eligible for CHAMPVA.  A beneficiary may not have any out-of-pocket expenses for health care services covered under Medicare and CHAMPVA.

A beneficiary does not need to enroll in Part D to maintain their CHAMPVA eligibility.  There are some benefits of the CHAMPVA prescription programs that would no longer be available if the beneficiary did enroll in Part D.  Specifically, the Meds by Mail program, through which maintenance medications can be obtained at no cost (no premiums, no deductible and no co-payments).  CHAMPVA would pay secondary to the Part D plan, paying up to 75% of the CHAMPVA allowable amount.  A beneficiary would need to use the Part D network pharmacies if enrolled in Part D.

For more information on CHAMPVA and other military benefits contact your local County Veteran Service Officer.


 

 

 

Last Modified:   7/26/2016 1:46:55 PM   
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Board on Aging & Long Term Care
1402 Pankratz Street, Suite 111
Madison, Wisconsin  53704-4001
FAX:  608 246 7001
BOALTC@Wisconsin.Gov