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VAWatchdog Has All You Ever Wanted To Know About VA Benefits But Didn't Know Who To Ask.
This Is Your VA Benefits Place!
Using Medicare with your VA Benefits
Many veterans will find themselves in the enviable position of having health benefits from both VA and Medicare. There are a number of advantages as well as some pitfalls to be aware of.
Your VA covers you in a sort of stepped fashion that depends on your % rating. Generally speaking, all conditions you may present to VA (except dental) are covered but varying copays may be required for some services. The copays are usually very small considering the usually high quality of service. The veteran who is 100% rated, when the rating is noted as permanent, is also eligible for dental care.
The veteran who is awarded SSDI by the Social Security Administration or who has reached the age of 65 will be entered into the Medicare program. Opting out isn't advisable.
Medicare has 3 distinct sections. Part A is that insurance that covers hospital bills. Part B covers doctor bills and many outpatient services. Part D is a pharmacy benefit.
Each Medicare benefit is unique and provides varying levels of coverage. Each Medicare benefit has a required deductible that the patient must pay. There are some deductibles for the overall service and then another for each individual service. This can be quite confusing. Most hospitals and physicians offices will make an expert available to walk you through your benefit and the potential out of pocket expense to you should you use Medicare.
Not all doctors will accept Medicare patients. Physicians are not required to take Medicare patients. Many doctors see the payment as too low for the amount of paperwork required. If you want to use your Medicare Part B benefit you may have to shop around for a physician you like who does take Medicare.
All hospitals accept Medicare...that's the Part A benefit. As America's population ages, hospitals have found that a great many of their sickest patients are those seniors who have Medicare. To turn down Medicare patients would not be financially possible for hospitals even though Medicare pays much less than more traditional private insurance. Hospitals rely on the high volume of Medicare patients and many cost cutting initiatives to make a small profit of their Medicare patient population.
The Part D benefit is usually not recommended for VA patients. VA will provide almost all VA eligible patients with the pharmacy benefit even if a prescription arises from a non-VA provider. Copays are very small and there is no obligation to pay any monthly premiums as with Medicare Part D.
Medicare supplemental insurance plans (such as the infamous AARP plan) may be purchased to cover some or all of those Medicare deductibles. These plans may cost anywhere from a few dollars to hundreds of dollars each month and provide widely varying levels of coverage.
Retired veterans may also be eligible for Tricare For Life as well as Medicare and VA medical care.
What should the veteran who is eligible for all benefits do? As you would expect, there are no pat answers that cover every situation. Each individual must assess a risk/value for their own lifestyle to decide. Should you save money by not taking Part B? Is it safe to rely on only your VA care? Can you abandon VA care and use only Medicare and Tricare?
Jim's Mailbag Read more of Jim's Mailbag here and here.
Dear Jim,
With interest, I read an article on your website. Currently, I am considered a veteran determined byVA to be unemployable due to service connected conditions. Since I have the VA primary medical care, I also have medicare part A and part B. I live a few hours away from a VAMC, and in a situation where I might have to go to a local civilian hospital or clinic. Would you suggest informing the VA that I have now medicare part A and part B? As well, if I decide to get part D, will be charged for prescripions from VA? I believe that VA and Medicare cannot charge each other, due to being government departments. How does the VA and medicare handle a situation, when an emergency or VA fee based occurs.
Thank you...
Reply,
"Would you suggest informing the VA that I have now medicare part A and part B?"
"if I decide to get part D"
"How does the VA and medicare handle a situation, when an emergency or VA fee based occurs."
The solution to this is advance planning. I urge all vets to work with a family member or close friend to make an action plan in case you are acutely ill and can't speak for yourself. Provide the direct number to your VA hospital and so on so that they can begin the process to transfer you to a VA facility. Even if you aren't transferred, the effort is what counts.
I've also suggested that if you don't want Medicare billed for a civilian hospital stay that you don't give them your Medicare card. Rather, only provide your VA card. They're much more likely to assist you with transfer to a VA facility that way and all their billing will be directed to VA so that won't get confusing. If you do give the civilian hospital your Medicare card, you may be responsible for the copay and that can be expensive.
I use both VA and Part B for convenience. Part B is really pretty inexpensive. For example, if a doctor bills $100.00 for a visit, Medicare may allow that visit to be billed at $40.00. The doctor must write off the $60.00 balance. Of that $40.00, you will pay 20% as the copay. That's pretty affordable for most of us. I've used my Part B for local civilian podiatry and orthopedic appointments because my VA hospital just isn't doing very well in those departments. I've had
outpatient surgery procedures performed at local doctor owned
facilities and Part B covers that with similar deductibles and payments.
I don't use any Medicare supplemental insurance. I've investigated the costs of supplemental policies to learn that they can be very expensive. Many people report to me that even a supplemental policy leaves them with copays that they didn't expect. Rather than paying a supplemental insurer, I save the equal amount of money in a bank account so that I can easily afford any copay but the most catastrophic one.
I also use a civilian general practice doctor for the times that I may need treatment for a cold or flu-like symptoms and I just don't feel like dealing with the VA. Don't get me wrong...I enjoy my VA primary care doctor and I believe I get good care there. However, the telephone calls, the triage process and so on can be an issue when I don't feel well. My civilian primary care is 10 minutes from my home, my VA clinic is 60 minutes and my VA hospital is 1 1/2 hours away. Often enough, I'm willing to pay the small copay to visit the civilian and avoid the often unfriendly VA process.
Keep in mind that not all civilian family/primary care doctors will accept Medicare. All hospitals do accept Medicare and all doctors who work for the hospitals are also Medicare providers. Many family practice doctors focus their own efforts on private pay patient customers who have a higher paying insurance like Blue Cross/Blue Shield and so on. I had to speak with 3 or 4 doctor's offices before I found one who would accept my Medicare. This is a business decision by individual doctors and is legal and ethical. Many private practice family doctors no longer have any hospital practice at all as hospitals now tend to use their own "intensivists" (physician employees) to care for you while you're in their facility.
None of this has much to do with "fee basis". Fee basis is a prearranged, preapproved VA process of farming you out to a civilian who has already agreed to accept VA payments. Fee basis is often set up for certain specialty doctors or procedures when VA can't reasonably accommodate you. Everything other than life threatening emergencies must be approved in advance to qualify for fee basis. Veterans who use a civilian and then submit the bill to VA are often
rudely surprised to discover that VA takes a hard line and won't reimburse them.
Using your benefits wisely is just a matter of deciding in advance how you want to get your care delivered and preparing for it. Once you have your plan, you'll be getting what may be the best care at the lowest cost in America.
Best,
Jim
Jim,
I was just reading your article about using Medicare with your VA benefits. I do have VA benefits, but have 0% rating. I have AARP suppliment. In all your dealings with this, what do you recommend as the best supplement?
Reply,
My expertise, such as it is, is focused on VA benefits. I also have Medicare Part A & Part B. I don't understand nor do I use Medicare supplemental policies. I can't recommend any particular supplemental policy.
I can tell you what I do personally.
I don't know what those things cost but I assume they range in the neighborhood of $100.00 to $250.00 per month, depending on any number of variables. Rather than paying that money to an insurance company, I put it in my savings account at my bank. Then, when I do use a civilian health care provider, I pay any copay out of my pocket. I try to keep a fairly significant sum of money set aside for copays. The money is in an interest bearing account, although the interest paid these days probably doesn't equal the rate of inflation.
The way I do things is a calculated risk. In years past, I've saved money by not giving it to an insurance company. If I were to have a sudden catastrophic illness and I were admitted to a local civilian hospital, I'd be in danger of generating a huge debt for a few days or even a few hours of care. It's not unusual to see hospital bills that are in the range of tens of thousands of dollars per hour for the initial period of care.
However, my family understands that if such a thing were to happen and I were unable to speak for myself, they are to aggressively see to my transfer to my VA medical center. Once I'm stabilized, I'll go to the VA facility where I trust my care will be as good as or better than the local civilian care. With luck, VA will pick up the cost of my initial care at the civilian center. I say "with luck" because that's usually a difficult option and VA argues against it most of the time. If the veteran documents well and pursues it, he or she will usually prevail.
In any case, I've used civilian providers successfully with my strategy. Most of my care is provided by VA and I'm happy with it. I run into occasions where I just can't get along with it though and I turn to a civilian provider. For example, in 2011 I needed a sleep study....I have sleep apnea. The VA sleep lab service is terribly backlogged and studies require months of waiting. VA does a traditional sleep lab study and most science says that isn't necessary these days. I found a civilian provider 5 minutes from my home who offered a home sleep study.
Once I determined that she accepted Medicare, I scheduled a visit. I got a fairly complete physical and in a week or so I stopped by to pick up my sleep study equipment to carry home that evening. It consisted of a headband that I was instructed to place around my forehead as I retired for the evening. It was reasonably simple to use. I returned it the next day. The doctor then sent the results to a pulmonary specialist who is certified to read and interpret the results. I was prescribed a CPAP machine and an appointment was made for me at a local office of a nationally known provider of home medical equipment. I met with a respiratory therapist who fixed me up with a high quality machine, mask and instructions for use.
All of this cost me less than $300.00 out of pocket. I believe that may be less money than if I had been paying for a supplemental policy that may or may not have paid for all my copays. I've used this strategy for orthopedic care and podiatry care. I've had minor surgical procedures performed locally by these providers and copays have been less than $100.00 out of my pocket.
My strategy has some small risk. But, to be honest, I just don't trust that any of the supplemental insurers have my best interests as their goal. My strategy also requires some self discipline. If you don't save the money, you can come up short one day and be unable to pay a few hundred dollars that will be required.
We have terrific health care benefits as veterans who have both VA care and Medicare. The great majority of Americans don't have anything close to our level of care. Although your 0% rating will require some small copays at the VA, you have access into the system and that's important. You may even ask that VA copays be waived, depending on your financial circumstances.
SSDI and VA Compensation...This information is provided courtesy of; Karl Kazmierczak, Esq.
Can you get VA disability benefits and Social Security Disability benefits?
I have noticed in my practice that many veterans do not know they can get both Social Security disability and VA compensation benefits. There is not an offset between these two programs. This means you can get your entire benefit under VA Compensation and your entire benefit under Social Security Disability at the same time. It gets a little more complex when we start to talk about VA pension.
VA pension is a needs-based program for disabled veterans of wartime service. Veterans under the pension program can receive money up to the total pension amount. The VA will look at a veteran’s assets and countable income and if this is below the pension amount they will receive money to bring them up to the pension total amount. Income that does not count against the pension is welfare and other needs-based payments. These include supplemental security income (SSI), state welfare, general systems and home relief. The VA does count all family members income which can reduce or eliminate the veteran's pension. Social Security disability payments will count to reduce or eliminate pension amounts.
This is because Social Security Disability unlike SSI is not a needs-based program. Workers compensation benefits paid either to the veteran or their spouse will count as income in calculating VA pension. It is also important to note here that even though VA pension is not offset by SSI payments, welfare or Medicaid these programs can count VA pension in determining eligibility for these programs. So unlike Social Security disability and VA compensation benefits, your amounts you get for SSI, Medicaid or welfare can be reduced or eliminated due to the income you receive from VA pension. So as you can see even though VA pensions are not offset by SSI payments, SSI payments are offset by VA pension benefits. This is done on the dollar for dollar basis.
So how will working affect my benefits? Service connection VA compensation benefits are usually not affected by employment. However, if the veteran has what they consider substantial gainful employment it may prevent benefits based on employability. Veteran’s pension benefits will be eliminated if the veteran is engaged in substantial gainful activity. This is because in order to get VA pension one must be totally disabled.
This information is provided courtesy of Karl Kazmierczak, Esq.
Social Security Disability and SSI: The Basics
On this webpage I will explain Social Security disability and supplemental security income. If you are attempting to get disability under both or one of these programs the definition of disability is the same. The Social Security Administration defines disability as:
"The inability to engage in any substantial gainful activity by reason of the medically determinable impairment, physical or mental (or combination of impairments), which can be expected to result in death, or which has lasted or can be expected to last for continuous period of not less than 12 months."
I will now discuss the two programs. I will start with Social Security disability insurance.
Social Security disability also called Title II, SSD I, SSD and DIB.
To be eligible for Social Security Disability Benefits you must have paid into the social security system by way of Social Security tax that you pay the government from your work earnings. You must have sufficient work credits to be considered fully insured. As far as military tax preparation is concerned, this means you must of worked and paid taxes long enough to have enough credits to be eligible. You must also have recent work credits. Although this can depend on the claimants age in most situations a claimant must of worked five out of the last 10 years to be fully insured and eligible for SSD. To be eligible to receive benefits you must be found disable while you are insured. If you have worked consistently than you would normally have five years from the date you last worked before your insured status runs out. The date your insured status runs out is called your date last insured or DLI. If you are found disabled your benefits start on the six month after the month in which SSA found you to be disabled or one-year prior to the date of your application whichever is less. If you are found disabled you are also entitled to Medicare benefits two years and six months from the date SSA found disabled or after you have been receiving benefits for a period of two years.
Supplemental security income benefits also called Title 16 and most commonly SSI.
SSI is a federal welfare program for the disabled and elderly and it is based on financial need. Unlike SSD, where the benefits are paid from social security trust fund, the payments for SSI come from general tax revenues. Therefore, eligibility for SSI is not based on work credits, instead to be eligible for SSI one must have limited income and resources. To be eligible for SSI one must both be financially eligible and 65 or older or blind or disabled. How SSA determines if you are disabled is the same for both SSD and SSI and will be explained later in this page. I will now discuss the financial eligibility for SSI. To be eligible for supplemental security income one must have resources that are less than $2000 for an individual and $3000 for a married couple. The home is excluded from the calculation of resources. The cash value of other assets which include things like life insurance and investments are counted as resources. One car per household is excluded from the calculation of resources. What SSA considers to be resources can start to get a little complex. Earned and unearned income in the household in which the claimant lives will be calculated in determining eligibility. I should also note here that if you have a claim for SSD and SSI the SSD payments will be counted as income and can reduce or eliminate SSI benefits. In most situations, one must be a citizen to be eligible for SSI. There are exceptions to this rule that are too numerous to discuss here but the information exceptions to this rule can be found on my website at http://www.ultimatedisabilityguide.com/ssi.html and the SSA website.
The Social Security Disability and SSI five step process that determines if you are disabled.
Now that I have discussed the Social Security Administration's definition of disability and the two main programs for the disabled I will now explain how the decision-makers at SSA determines if you are disabled. They use a five step process to determine disability.
At step 1 of the process, SSA will determine whether you are considered working under their rules. This means you are working to an extent that they call substantial gainful activity or SGA. When SSA considers whether or not you are considered working at SGA level how they determine this will depend on whether you are an employee or self-employed. If you are an employee than substantial gainful activity will be found if you earn more than $980 gross a month for the year 2009. If you make less than $980 per month and then your work will probably be considered not SGA. Each year has a different SGA threshold so every year prior to 2009 the amount you can make is a little bit less each year you go back. If you are self-employed the rules can be quite complicated on what is and what is not SGA so you may need to seek legal advice if this pertains to you. If social security determines that you are working at SGA level then you will be found not disabled. If they find you are not working at SGA level then you proceed to the next step.
At step two, SSA will determine if you have a severe impairment. Social Security defines a severe impairment as: "an impairment, or combination of impairments, is considered severe if this significantly limits your physical and mental abilities to do basic work activities." An impairment will be considered severe if that impairment imposes more than mild limitation on one's ability to perform work related activities. The severe impairment must last for 12 consecutive months or be expected to result in death. If you are found to have a severe impairment you then move to the next step. If your impairment is found to be not severe then you are found not disabled.
At step three, SSA will determine if you have an impairment that meets or equals a listed impairment. The medical listing of impairments is grouped into categories. A copy of the medical listing of impairments can be found on the SSA website at http://www.socialsecurity.gov/disability/professionals/bluebook/listing-impairments.htm . The medical listings are set up to find someone disabled where their condition is considered so severe that it would prevent the individual from doing any gainful activity without consideration to their age, education or work experience. If one doesn't exactly meet a particular medical listing they can also be found disabled at this stage if they are found to equal a listed impairment. This means their condition is at least equal in severity and duration of the criteria of any listed impairment. To be found disabled at this stage of the process it takes a medical opinion that you meet or equal one of the listing impairments. If you are found to meet or equal listed impairment you are found disabled. If you are found not to meet or equal listed impairment you then move to step for the process.
At step four, SSA will determine if your impairment prevents you from performing your past relevant work. In other words, if the limitations caused by your medical condition both exertional and non-exertional would prevent you from performing the requirements of your past relevant work. SSA considers the work you did in the prior 15 years as past relevant work. To make this determination and a determination at the next step the decision-maker will decide what your residual functional capacity is. This is defined as "the most a claimant can physically or mentally do despite his or her limitations". So in a nutshell, SSA will look at the requirements of your past work and compare it to your residual functional capacity to determine if you can perform any of your past work. When determining someone's residual functional capacity there exertional limitations are classified as sedentary, light, medium, heavy, or very heavy. There are also non-exertional limitations which are considered which include but are not limited to environmental limitations and mental limitations. If it is found that you cannot perform your past relevant work then you proceed to step five. If you it is found that you can perform your past work than you are found not disabled.
At step five, SSA will determine whether or not you can do other work existing in significant numbers in the regional and national economy based on your residual functional capacity. Your age education and past relevant work experience are all very important at this stage in the process. To determine whether or not there is significant number of jobs SSA will refer to the medical vocational guidelines also commonly called the GRIDS. For a full explanation of the GRIDS and how they are used you can visit my webpage at http://www.ultimatedisabilityguide.com/grid_rules.html . The GRID rules will look at your age, education and past work experience and your residual functional capacity and compare it to a chart that will direct the finding of disabled or not disabled. However, often times especially when one has non-exertional impairments they will not fit neatly into this chart. A vocational expert is often used as an expert witness to help determine what if any jobs and the number of those jobs an individual with your residual functional capacity could perform. So if after this evaluation the decision-maker decides there is a significant number of other jobs you could perform then you will be found not disabled. If SSA finds there is not a significant number of jobs you could perform or the GRID chart shows you are disabled then he will be found disabled.
The above is a quick summary of the five step process but if you want to give yourself the best chance to win your case you should research not only how SSA determines if you are disabled but what you can do to make your case stronger. I have authored a comprehensive website on Social Security disability and SSI which includes many helpful tips and strategies to win your case depending on your particular medical conditions. To continue your research feel free to read my comprehensive website at http://www.ultimatedisabilityguide.com/index.html . I will also in the future write from time to time addressing specific subjects on Social Security disability and VA compensation here on Jim Strickland's website.
Now that I have discussed the Social Security Administration's definition of disability and the two main programs for the disabled I will now explain how the decision-makers at SSA determines if you are disabled. They use a five step process to determine disability.
At step 1 of the process, SSA will determine whether you are considered working under their rules. This means you are working to an extent that they call substantial gainful activity or SGA. When SSA considers whether or not you are considered working at SGA level how they determine this will depend on whether you are an employee or self-employed. If you are an employee than substantial gainful activity will be found if you earn more than $980 gross a month for the year 2009. If you make less than $980 per month and then your work will probably be considered not SGA. Each year has a different SGA threshold so every year prior to 2009 the amount you can make is a little bit less each year you go back. If you are self-employed the rules can be quite complicated on what is and what is not SGA so you may need to seek legal advice if this pertains to you. If social security determines that you are working at SGA level then you will be found not disabled. If they find you are not working at SGA level then you proceed to the next step.
At step two, SSA will determine if you have a severe impairment. Social Security defines a severe impairment as: "an impairment, or combination of impairments, is considered severe if this significantly limits your physical and mental abilities to do basic work activities." An impairment will be considered severe if that impairment imposes more than mild limitation on one's ability to perform work related activities. The severe impairment must last for 12 consecutive months or be expected to result in death. If you are found to have a severe impairment you then move to the next step. If your impairment is found to be not severe then you are found not disabled.
At step three, SSA will determine if you have an impairment that meets or equals a listed impairment. The medical listing of impairments is grouped into categories. A copy of the medical listing of impairments can be found on the SSA website at http://www.socialsecurity.gov/disability/professionals/bluebook/listing-impairments.htm . The medical listings are set up to find someone disabled where their condition is considered so severe that it would prevent the individual from doing any gainful activity without consideration to their age, education or work experience. If one doesn't exactly meet a particular medical listing they can also be found disabled at this stage if they are found to equal a listed impairment. This means their condition is at least equal in severity and duration of the criteria of any listed impairment. To be found disabled at this stage of the process it takes a medical opinion that you meet or equal one of the listing impairments. If you are found to meet or equal listed impairment you are found disabled. If you are found not to meet or equal listed impairment you then move to step for the process.
At step four, SSA will determine if your impairment prevents you from performing your past relevant work. In other words, if the limitations caused by your medical condition both exertional and non-exertional would prevent you from performing the requirements of your past relevant work. SSA considers the work you did in the prior 15 years as past relevant work. To make this determination and a determination at the next step the decision-maker will decide what your residual functional capacity is. This is defined as "the most a claimant can physically or mentally do despite his or her limitations". So in a nutshell, SSA will look at the requirements of your past work and compare it to your residual functional capacity to determine if you can perform any of your past work. When determining someone's residual functional capacity there exertional limitations are classified as sedentary, light, medium, heavy, or very heavy. There are also non-exertional limitations which are considered which include but are not limited to environmental limitations and mental limitations. If it is found that you cannot perform your past relevant work then you proceed to step five. If you it is found that you can perform your past work than you are found not disabled.
At step five, SSA will determine whether or not you can do other work existing in significant numbers in the regional and national economy based on your residual functional capacity. Your age education and past relevant work experience are all very important at this stage in the process. To determine whether or not there is significant number of jobs SSA will refer to the medical vocational guidelines also commonly called the GRIDS. For a full explanation of the GRIDS and how they are used you can visit my webpage at http://www.ultimatedisabilityguide.com/grid_rules.html . The GRID rules will look at your age, education and past work experience and your residual functional capacity and compare it to a chart that will direct the finding of disabled or not disabled. However, often times especially when one has non-exertional impairments they will not fit neatly into this chart. A vocational expert is often used as an expert witness to help determine what if any jobs and the number of those jobs an individual with your residual functional capacity could perform. So if after this evaluation the decision-maker decides there is a significant number of other jobs you could perform then you will be found not disabled. If SSA finds there is not a significant number of jobs you could perform or the GRID chart shows you are disabled then he will be found disabled.
The above is a quick summary of the five step process but if you want to give yourself the best chance to win your case you should research not only how SSA determines if you are disabled but what you can do to make your case stronger. I have authored a comprehensive website on Social Security disability and SSI which includes many helpful tips and strategies to win your case depending on your particular medical conditions. To continue your research feel free to read my comprehensive website at http://www.ultimatedisabilityguide.com/index.html . I will also in the future write from time to time addressing specific subjects on Social Security disability and VA compensation here on Jim Strickland's website.