BEWARE – Non Service Connected VA/TFL Healthcare Users

Aug 16 2013

over65testsEffective October 1, 2013 Tricare will only reimburse VA 20% of the allowable charge vice the past practice of paying  80% for non-service connected care received in the VA for Tricare for Life (TFL) beneficiaries rated at less than 50% disabled. While this is not a new law, it has not been enforced.

The rationale that supports this change follows:

  • Although VA Facilities are Tricare-authorized, they are not Medicare-certified.
  • Medicare, by statute, cannot reimburse for care provided by a Government facility.
  • Simply put, the VA can’t bill Medicare and Medicare can’t reimburse the VA for care.
  • Since the VA can’t be Medicare-certified, it presents as an opt-out Medicare provider.
  • Therefore, Tricare reimburses the VA what it would have paid if Medicare had been primary – which is 20% leaving you with a bill for the remaining 80%.

The solution:

  • For less than 50% VA rated, use your TFL benefit in the community for non-service connected TFL care to prevent being billed for 80% of the allowable charge.

The Tricare News Release of August 14, 2013 states:

As part of the intake process at VA facilities after October 1, 2013, TFL beneficiaries will be asked if they’re using their VA or TFL benefit or if they have other health insurance (OHI). When electing to use their TFL benefit at the VA, they will also be informed they must pay the remained bill after Tricare pays its portion of the Tricare-allowable charge. They may be asked to sign a form indicating they understand their responsibility……. Call the TFL support contractor Wisconsin Physicians Service (WPS) 866-773-0404 or visit www.tricare.mil/tfl  for more information.

32 responses so far

32 Responses to “BEWARE – Non Service Connected VA/TFL Healthcare Users”

  1. Nick Fuhson 23 Aug 2013 at 1:59 pm

    Totally confusing.
    If a vet is registered and/or entitled to VHA healthcare, why would the vet be billed for more than his VHA copays or even for those if TFL pays more than the copay amount?

  2. Lou E. Bellon 23 Aug 2013 at 3:31 pm

    Best solution would be to go to where the Medicare would be accepted and use TFL as the secondary. There seems to be no advantage for the veteran to go to VA if not covered by VA, not covered by Medicare, and only 20% coverage by TRL. Or am I missing something here?

  3. Roy Korkaloon 23 Aug 2013 at 3:34 pm

    How can this major change happen with little notice? I should say no notice from the VA.

  4. John Dykstraon 23 Aug 2013 at 8:02 pm

    Why is the VA Hospitals not MEDICARE certified? How will a vet know in advance whether a medical condition is service-connected or not (assuming this is a first visit) and why should it matter? Does the VA and the DOD want sick vets to visit two health care providers for medical care? Is this an oversight or betrayal??

  5. Derrickon 23 Aug 2013 at 10:01 pm

    Will this impact regular Tricare and Tricare Prime users?

  6. CAPT Roger Jay Pentzien MC USN (Ret)on 23 Aug 2013 at 10:43 pm

    This gives a whole new meaning to the phrase, “Thank you for your service.” The irresponsible spending of our past legislators should be held accountable as those of us in uniform were and are held accountable each day.

  7. Nick Fuhson 24 Aug 2013 at 12:26 am

    Someone needs to explain to us who is affected by this – I am on Medicare, TFL, and rated 100% disabled by the VA. This article suggests that i would have to pay 80% of the medicare allowed amount for VA services. Obviously, that is nonsense. Sowho would have to pay?

    Clarify before you create confusion and outrage among vets.

  8. Nick Fuhson 24 Aug 2013 at 12:49 am

    On re-reading the article , I see that this applies to retired Veterans with less than a 50% rating receiving VA treatment for non service connected conditions.

    So are you saying that for vets enrolled in VHA healthcare:

    A 64 year old retiree with Tricare standard and a 40% VA disability rating goes to the VAMC for non service connected treatment, he has a liability to the VA for certain VA copays. These are likely covered when the VA submits claims to Tricare standard.

    But if a year later, the now 65 year old Medicare and TFL enrolled veteran goes to the VAMC for the same treatment of the same non service connected conditions, he now owes the VA 80% of the medicare allowed amount rather than just the VA copays (assuming that the TFL 20% payment did not pay enough to cover them)?

    Meanwhile, a non military retired vet with a 40% rating and Medicare only owes the VA copays for the non service connected treatment?

    Are you sure that you are not confusing what Tricare pays with what the veteran VHA liability is?

  9. Capt. Jack Woodheadon 24 Aug 2013 at 1:18 am

    Is this yet ANOTHER reneging on the legal contracts with those who were promised “free healthcare for life after satisfying military retirement with pay?” (To say nothing about those who accessed when it was public LAW.)

    “Duty, Honor, Country”

    “My word is my bond.”

    “Integrity”

    etc.

    etc.

    Are they all meaningless now?

  10. Maurice Knowleson 24 Aug 2013 at 2:34 am

    Getting screwed again by the government, what happened to FREE medical are after 20 plus years of Military Service.

  11. Robert Coleon 24 Aug 2013 at 3:23 am

    This may be the way the various laws actually work, but it is a sad example of how our military veterans are treated by our budget cutting government. At the very least, this is burdensom to veterans in this category because they either have to go to two different treatment resources: 1) “community” doctors, clinics & hospitals for non service- connected care; and 2) VA for service-connected health problems; or go to the VA facilities and pay through the nose for anything the VA says is not service-connected. The affected veterans can ill-afford to pay an 80% share. What if a veteran is in a VA hospital or other facility for urgently needed care (service-connected), and also urgently needs care for a non service-connected health issue and cannot afford (who can) to pay 80% of the bill? Do they plop the unfortunate vet into a wheelchair, hang his IV bags & oxygen tank on the chair and let him wheel himself down (or up) the hill to his community (civilian) doctors office or hospital so he can get medicare to pay for that non service-connected care? If he (or she) needs hospitalization for both kinds of issues, maybe they could have him shuttle himself back & forth on alternate days between the hospitals. Thank you for your service private, but you can’t stay here tonight, it is your medicare day. (Technically the hospital transfers would have to be done at midnight so as not to have two facilities providing the care on the same day.) Continuity of treatment would be a huge joke. I am sure that congress and the president have provided a better system for themselves, so they ought to be able to provide a better system for those who have served in the military (as few in congress have).

  12. David Sharenoon 24 Aug 2013 at 10:52 am

    You’ve got to love the VA. Why don’t they just re-name it the “Disabled Destitute Veterans Administration”? They are making it quite clear through their policies that they don’t want to treat anyone who has minor or no service-related disabilities, or who actually went out and made a life for himself after his or her service. Their motto should be, “We’re here to help you out…which way did you come in?”

  13. William G. Chareston 24 Aug 2013 at 12:00 pm

    I have a 20% service-connected disability. Your email was a bit ambiguous (in my opinion) because it says that people with less than a 50% disability will only receive from TFL, 20% of the cost of medical care given by VA. It doesn’t specifically say whether the 50% must be service-connected or non service-connected. Maybe I missed something in your intended sentence structure. In my situation, would I have to pay 80% of the VA cost out of pocket?

    Please explain in more detail.

    Thank you.

    William G. Charest, CW3, USA (Retired)

  14. Albert Stewarton 24 Aug 2013 at 5:49 pm

    Is the policy change regarding this payment scheme for the benefit of Wisconsin Physician Service or the DoD? Will there be a corresponding reduction of VA funding since a great many of those TFL eligible beneficiaries with less than 50 per cent disability will obviously opt to use civilian providers rather than absorb an 80 per cent co-pay which continued use of the VA will require? With Medicare’s financial status already a serious concern, won’t this policy exacerbate that problem even more? When WPS won the competition to manage TFL in its applicable regions was this change already contemplated? Would the WPS competitors in that competition, had they won, have taken the same action? If not, how would that have affected the bidding outcome?

  15. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 7:40 pm

    you’re right that the issue is confusing…probably more than it should be. As I read it, the issue doesn’t affect retirees who are eligible for full VA health care, but only those who don’t qualify for full VA care and who have been having the VA bill TRICARE for their non-service-connected care.

    This highlights that there is a big difference…and two entirely statutory authorizations/requirements for VA care vs. TFL care.

    The TFL benefit is second-payer to Medicare. When a provider doesn’t (or isn’t allowed to) bill Medicare, then TFL by law can pay only the 20% of Medicare-authorized charges it would have paid if Medicare was being billed. The VA, by law, can’t bill Medicare. So visiting VA with a TFL benefit is the same as visiting a doctor who won’t take Medicare. In that case, TFL can only pay a small amount.

    In essence, TRICARE was inadvertently ignoring the law for more than 10 years. When this was recently discovered, they had to limit what they pay VA to get back in line with the law.

  16. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 7:44 pm

    It really wasn’t a VA problem so much as a TRICARE problem. But now that TRICARE can’t pay the full amount, you’re right that the information burden now falls on the VA to make sure they brief all retirees over 65 on what VA and TFL won’t cover. If you’re eligible for full VA care, then VA should cover the full cost…and not bill TFL. If they bill TFL, then the beneficiary could get hit with a significant copay. The key is to make sure you ask the VA what your VA health benefit is. If the VA won’t cover your non-service-connected care, then you’re better off going to a civilian Medicare provider for that care so you don’t get billed.

  17. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 7:50 pm

    It’s not really an issue of the VA “not being Medicare certified.” It’s a long-standing statutory bar against having Medicare reimburse another government agency for care. In that regard, military hospitals can’t bill Medicare if they treat Medicare-eligible retirees. Similarly, it’s against the law for VA to bill Medicare if they treat Medicare-eligible vets. From Congress’s standpoint, this makes sense. In essence the law says “If you (DoD or VA) are going to provide care to a person who is eligible for your care, then the cost should come out of your (DoD or VA) budget, not Medicare’s.”

    The one seeming disconnect with the law is that the law also requires TFL beneficiaries to pay Medicare Part B premiums. This makes sense if you consider that most TFL beneficiaries’ care is delivered through civilian Medicare-participating providers.

    It gets more messy when you consider that some TFL-eligibles get care from VA and DoD (and that others get their care overseas, where Medicare doesn’t pay anything). But MOAA has tried for years to get Congress to address those disconnects…without success. With Medicare already in financial problems, Congress isn’t interested in increasing Medicare outlays for these purposes.

  18. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 7:51 pm

    No, it won’t affect them. Only Medicare-eligibles.

  19. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 7:58 pm

    as indicated below, the clarity has to come from VA. If you’re authorized VA care for ALL of your care (not just conditions that are service-caused), then the VA should cover your care without billing TFL. With everyone scrambling for budget share, if the VA has you listed as a TFL-eligible, they’re likely going to bill TFL…which could mean you get billed, even if you’re technically eligible for full VA care. If you have any doubt if you are eligible for full VA care, you should check with your VA provider. If you are, then I’d think they shouldn’t be billing TFL for any of your care…even if you’re dually eligible for TFL.

    This new rule raises a high potential for confusion on the part of VA officials as well as for dual VA/TFL eligible beneficiaries.

  20. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 7:58 pm

    if you have a 100% VA disability rating, the VA shouldn’t be billing TFL for any of your care.

  21. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 8:07 pm

    the reality is that the “free care” was only care in military facilities. And the law was changed in 1957 to specify that was only if space was available. (Of course that didn’t stop recruiters and retention people from saying it, but the courts have ruled that doesn’t matter…it’s the law that counts.)

    Nondisabled vets (including retirees) have never been guaranteed free care in VA facilities. Medicare-eligible retirees who couldn’t be seen in military or VA facilities have had to enroll in Medicare since the 1960s. And thousands who didn’t enroll when first eligible (thinking they’d always get care in military or VA facilities) got a rude awakening at having to pay a hefty Medicare late enrollment premium when those facilities were closed or downsized.

  22. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 8:13 pm

    this has always been budget driven. In the past, the VA made it very clear that VA care was only for service-connected conditions, for those with relatively severe disabilities, or for vets below certain income levels. It was only about 10 years ago that that VA started aggressively enrolling so-called category 7 and 8 eligibles…mostly nondisabled retirees.

    While nobody was going to argue about getting more care to vets, there were a lot of us who thought budget crunches would eventually end up cutting back on those enrollments…and generating understandably bitter responses from those who told they could get care there.

    Now the crunch times are coming again. The VA budget has been one of the exceptions that has continued to grow significantly while the rest of the federal budget is getting tightened up. The hard reality is that won’t go on forever in this environment.

  23. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 8:16 pm

    there’s a reasonable chance you will. Whatever your 20% disability rating is for, those conditions qualify for cost-free treatment by the VA. If you get treated for a condition that you don’t have a service-connected rating for, you could end up getting billed for 80% of the Medicare-allowed charge for that care (that is, for what Medicare would have paid a civilian doctor who treated you for that condition.

  24. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 8:21 pm

    WPS is only a claims processor for TRICARE. this doesn’t save them any money. It will save TRICARE money. From Congress’s standpoint, the change is stopping TRICARE from paying for coverage that wasn’t allowed by law.

    the change has nothing to do with any contract. It’s a “oops, we just realized we’ve been breaking the law for the past 12 years” situation on DoD’s part. It would have happened no matter what company had the claims processing or any other contract.

    Similarly, the amount of money involved is in the noise level for the huge VA health budget, so it won’t make any significant difference there, either.

  25. Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 8:31 pm

    Seems to me the real question is “what does it mean when VA enrolls a category 7 or 8 (nondisabled) or other less-than-50% disabled vet for care in the VA system?”

    Does that enrollment constitute an agreement to provide VA care for all conditions without billing other insurance?

    Or is it conditional that “We (VA) will bill other insurance if you have it”?

    Put another way, does VA always bill TRICARE for treating category 7 and 8 enrolled retirees who are under 65?

    If not, then it seems like they shouldn’t bill TFL for Medicare-eligible either.

    If they do that for the under-65s, then at least the VA policy is consistent for the over-65s….though the “Medicare can’t pay VA” law would now mean a new financial hit for the latter.

    The real question is: If VA enrolls a person for VA care, is that enrollee allowed to say, in effect, “if you enroll me, VA should pay for my care, and in that circumstance, VA shouldn’t bill any other insurance for that care?”

    That’s probably a naïve thought, but the new rule makes it worth double-checking to be sure.

  26. ARMAND GABRIELE, LTCOL, USAF RETIREDon 25 Aug 2013 at 1:26 am

    TO ALL–

    In my communication with the Billing Department of the VA Hospital in Northport, New York it was assured that the Veteran is only responsible for the maximum co-pay billing of $50.00 for each specialty visit or even better —$ 50.00 per day maximum for any number of specialty visits on that one calendar day. A billing amount of no more than $50.00 will be billed to the veteran. The maximum billing by the VA to the veteran on appointments with a primary care doctor will only be $15.00 per visit.

    The accounting and reimbursements of the full value of the services provided to the veteran is between the VA, Medicare and TFL and does not affect the veteran receiving the services of the VA— and the monetary value of the co-pay limitation of $50.00 for specialty visits and $15.00 for primary care visits to the VA stands sacred to the veteran. It was further stated that the VA will give monetary billing credit to the veteran’s bill should any reimbursement be credited to the veteran from any other health programs that would reimburse tha VA for providing services to the veteranand may in any event possibly lower the veteran’s billied amount for that particular visit.

    Still, I recommend visiting or calling your VA institution to assure the above is the way it works—

  27. Tony Koncelon 25 Aug 2013 at 2:21 am

    If I am reading this article correctly, the DOD has been subsidizing the VA for the past 10 years with TFL funds and no one sees a problem with it? Could someone please explain to me why?

  28. Nick Fuhson 25 Aug 2013 at 8:40 pm

    Col Strodbridge writes:
    “# Col. Steve Strobridge, USAF-Ret.on 24 Aug 2013 at 7:58 pm

    if you have a 100% VA disability rating, the VA shouldn’t be billing TFL for any of your care.”

    This is not correct.. VA is required by law to bill health insurance, including medicare supplements and/orTricare, for any non service connected treatment, including 100% rated vets. The insurance company will issue an Explanation of benefits to the insured showing what was paid, if anything, and what the insurance company considers patient liablity ( or patient owes). Vets enrolled in VHA healthcare can ignore the EOB – the vet liability to he VHA, if any, is what is the copay described in the vet’s VA health insurance booklet.

    I really think MOAA has this wrong. There may have been a change in TFL’s payment methodology but there has been no change in VHA health benefits, to include cost sharing, for enrolled vets.

    Insurance payments to the VHA may reduce the vet’s copay liability ( by paying the VHA an amount greater than what the Vet owed in copay) but would never increase the enrolled vet’s VHA liability beyond what he would owe without insurance.

    Please revisit this.

  29. Roy Korkaloon 26 Aug 2013 at 2:56 pm

    I have talked to several VA offices and they know nothing about the said 1 Oct billing change. Portland, OR suggested I call the VA Health Revenue (or Resource) Center at 866-290-4618 who handles all the billing. I called and was told they know nothing about a change. Medicare is billed by VA and does not pay, then TRL is secondary. There is no change 1 Oct. Who knows something about this 80% co-pay for less than 50% VA rated? Did MOAA research the article published?

  30. John Clarkon 30 Aug 2013 at 3:30 pm

    My Q was “reverse:” Just got off phone w/ TFL to confirm that, for those of us who have <50% VA Disability but choose MEDICARE/TFL providers/facilities/services over VA, no change?"

    TFL answer: "No change. Regardless of VA Disability rating, IF Service-connected, encouraged use of VA, since no cost to TRICARE. BUT if NOT Service-connected, encouraged to NOT use VA, but MEDICARE providers and services instead, since MEDICARE cannot and will not cover at VA."

  31. Jim whiteon 09 Sep 2013 at 6:48 pm

    I have 10% disability. I only use the VA for a hearing problem and get my hearing aids and batteries from them. Other medical care is through my local doctors using Medicare and TFL. Now my concern is, the 10% is not because of hearing loss, when I go back to have my hearing aids checked and perhaps am in need of new ones, am I going to be paying 80% of the retail cost, 80% of hat the VA pays for them, or will nothing change? Medicare does not pay for hearing aids.

    I don’t think there is any chance of me getting my disability revisited, not with all the modern veterans needing things much more than me. When I retired the hearing wasn’t bad. Years later I am almost completely deaf, thus the need For hearing aids. Besides, my problem was being addressed by the VA, so no need to pursue any course of action. Now I’m afraid, I will have to start that process.

    Gonna make a visit there this week and have the aids cleaned and serviced. No way to get any congressional help for us from our current representatives.

    Can anyone address my earlier questions. It’s too confusing for this 76 year old.

    Thanks

  32. CDR Katherine O'Neill Tracy, USNR-Ret.on 10 Sep 2013 at 7:22 am

    Jim White – As indicated, please check with your local VA as to how they will implement.