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Roger Hale, Veterans Law Attorney
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Medicare & VA Continued
Medicare hospital or doctor visits will cost you a copay. In broad terms, Medicare sets a rate that they will pay a doctor or hospital no matter what they bill in charges. Whatever that rate is you'll owe 20% of it. For example, I recently had a colonoscopy. My share of my doctor's bill under Medicare Part B was $44.00. I wouldn't have had to pay that at VA but my drive would have been 2 1/2 hours each way whereas keeping it at home was a 10 minute trip. There will be other bills associated with that (anesthesia, lab, etc.) but I estimate my entire out of pocket share will be less than $300.00.
No, I don't use supplemental insurance. That stuff is expensive. I expect that this year (2015) I may spend $1500.00 out of pocket to cover Medicare copays. That's 1/2 of what a supplemental policy would have cost and it wouldn't have paid all my expenses.
What happens if you need emergency care at a civilian hospital? Who do you tell them to bill? What can you do if you're unconscious
or unable to speak?
Medicare & VA Continued
You can and should plan in advance. Tell your spouse or family member you want to go to VA first. Be sure your VA emergency room is capable of handling your emergency before you need it. Some VA emergency rooms aren't full service. If you go to a civilian emergency room, stress (or have your family stress) that you must transfer to VA as soon as possible. If the civilian hospital gets your Medicare number,they will bill Medicare every time. VA health doesn't act as supplemental so you'll be stuck with the copay.
Jim Strickland is a Vietnam era Army veteran and nationally recognized expert on VA disability benefits and a member of the Stateside Legal Website Advisory Board. Jim's Mailbag, is a regular column where veterans, servicemembers, and family members can ask Jim their questions about VA and Social Security disability benefits.
You can browse all of these Q&As here, and search the Jim's Mailbag archives for helpful answers.
If Jim hasn't already addressed the questions you have, you can submit your own question.
Are you a veteran who has Medicare and VA care benefits? Do you understand how to use both to your advantage?
Using your Medicare benefits along with your VA health benefits is more a matter of individual choice than anything. I can only tell you what I do. What I do may not be ideal for you so you'll have to put some thought into this.
I like my VA doctor and clinic. It isn't always convenient for me though. Because of that I sometimes see civilian doctors using my Medicare Part A and Part B. Medicare Part A pays for hospital care, Medicare Part B pays for doctor and most outpatient services. Part A is required when you collect your Social Security retirement, Part B is elective and you'll pay an additional premium. Part D covers pharmacy prescription medicines and most experts tell us that if we get VA pharmacy, we do not need Part D.
Medicare & VA Continued
If you enter a civilian hospital and you aren't quickly transferred to VA you or your representative must persistently call the VA facility of choice to tell them you want to transfer there. DO NOT depend on the civilian hospital staff to do this for you. You must document when you called the VA facility and who you spoke with or what voice mail you reached. If you don't follow these steps you'll soon be billed for your portion of the Medicare payment and you'll be in a tussle with VA to try and get payment.
Not every veteran is eligible for emergency civilian care. Not every situation will be deemed as eligible because it's life threatening or a true emergency. If you go to a civilian ER for a bad flu or a broken toe, VA isn't likely to pick up the tab for you.
The bottom line is to think of your plan before a health emergency arises. Know the hospitals you want to use and be sure they can provide the services you want.
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Emergency Care in Non-VA Facilities
In 2001, the U.S. Congress provided VA with authorization (called the Mill Bill) to pay for emergency care in non-VA facilities for veterans enrolled in the VA health care system. The benefit will pay for emergency care rendered for non-service-connected conditions for enrolled veterans who have no other source of payment for the care. However, VA will only pay to the point of
medical stability. There are very strict guidelines concerning these types of claims. Veterans and their non-VA providers should be aware that these claims must be filed with the VA within 90 days from the last day of the emergent care.
How do I qualify?
This benefit is a safety net for enrolled veterans who have no other means of paying a private facility emergency bill. If another health insurance provider pays all or part of a bill, VA cannot provide any reimbursement. Veterans who retired from the U.S. military are covered by TRICARE/CHAMPUS insurance and cannot file a Mill Bill claim. To qualify, you must meet all of these criteria:
You were provided care in a hospital emergency department or similar facility providing emergency care.
You are enrolled in the VA Health Care System.
You have been provided care by a VA health care provider within the last 24 months (excludes C & P, Agent Orange, Ionized Radiation and Persian Gulf exams).
You are financially liable to the provider of the emergency treatment for that treatment.
You have no other form of health care insurance.
You do not have coverage under Medicare, Medicaid, or a state program.
You do not have coverage under any other VA programs.
You have no other contractual or legal recourse against a third party (such as a Workman’s Comp Claim or a Motor Vehicle Accident) that will pay all or part of the bill.
Department of Veterans Affairs or other federal facilities were not feasibly available at time of the emergency.
The care must have been rendered in a medical emergency of such nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health.
Should I cancel my current insurance to meet these requirements?
VA encourages you to keep all current health insurance coverage. If you cancel your current insurance, your spouse may not retain health insurance coverage and spouses of veterans generally do not qualify for VA health care. Cancellation of current insurance coverage could result in you being disqualified for reinstatement based upon any pre-existing illnesses. If you are covered by Medicare Part B and you cancel it, it cannot be reinstated until January of the next year. If you are covered by a program or plan that would pay for the emergency care received, you would not qualify for this benefit.
What is the timeline to file?
Veterans have a responsibility to ensure that the VA Transfer Center is notified immediately upon any hospital admission. The MEDVAMC Transfer Center Coordinator can be reached during regular business hours at (813) 903-4221.
If you are calling after hours, dial (813) 972-2000 and ask to speak to the Medical Administrative Assistant on duty. Claims must be filed with the nearest VA Medical facility to where the services were rendered within 90 days of the discharge date of medical service; otherwise, the claim will be denied because it was not filed in a timely manner.
What type of emergency services will VA cover?
VA will reimburse health care providers for all medical services necessary to stabilize your condition up to the point you can be transferred to an approved VA health care facility or other federal facility.
What about pharmacy items?
The VA’s authority for reimbursement of pharmacy items to veterans from non-VA providers follows a strict set of guidelines. The veteran must be actively enrolled in a Fee Basis Program; the pharmacy item must be considered as urgent or emergent by the initiating physician; the pharmacy item cannot be reimbursed past a 10 day supply; and the prescription and receipts must be
turned in to the Fee Basis Unit. The reimbursement is based upon the U.S. Government’s Red Book cost and no taxes can be reimbursed.
Do I need to get approval before going to the emergency room?
No. If you are an eligible veteran, and a VA facility is not feasibly available when you believe your health or life is in immediate danger, report directly to the closest emergency room. If hospitalization is required, you, your representative or the treating facility should contact the nearest VA within 24 hours to arrange a transfer to VA care by calling the VA Transfer Center at (813) 972-7614.
How long will I stay in the private hospital?
If you are hospitalized, and the VA is notified, the VA will be in regular contact with your physician at the private hospital. As soon as your condition stabilizes, the VA will assist the private facility with arrangements to transport you to a VA, or VA-designated facility.
What if I do not wish to leave the private facility?
VA will pay for your emergency care services only until your condition is stabilized. If you stay beyond that point, you will assume full responsibility for the payment of costs associated with treatment.
Will I have to pay for my ambulance bill to the non-VA facility?
If the VA accepts responsibility for the emergency room visit and/or admission, the ambulance will be paid from the scene of the incident to the first non-VA facility providing necessary care.
Will I have to pay for an ambulance from the non-VA facility to a VA facility?
Yes. The VA is only authorized to pay for an ambulance to go from the scene of the incident to the first non-VA facility providing necessary care. Ambulance bills are considered unauthorized claims, and must be submitted to the VA in a timely manner.
What if the private hospital bills me for services?
If you are billed for emergency care services, contact the Veterans’ Hospital Fee Unit and a representative will assist you in resolving the issue. Under the law, payment from the VA is considered as “payment in full” for the dates authorized.
What documents are required by VA to process claims for emergency care in non-VA facilities?
The following page contains a list of documents necessary for the VA to process claims for emergency care in non-VA facilities. Remember, there is a 90-day deadline to file a Mill Bill Claim once you have been discharged from the Emergency Room/Hospital. Please submit all of the documents as a packet to the Veterans’ Hospital Fee Basis Office.
What documents to I need to provide to VA to pay for my emergency care in a non-VA facility?
Here is a checklist of all the documents you will need to provide to the VA in order for your claim to be processed: Check List
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