September 24, 2021

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Do You Need to Sign Up for Medicare If You Get VA Care?

Of the more than 19.5 million veterans alive today, 9.1 million are currently enrolled in VA Health Care. The majority of those enrollees are also eligible for Medicare. Should they sign up for Medicare too?

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Eligibility: Medicare vs. VA Health Care

Most people become eligible for Medicare when they turn 65 years old. You can also enroll in Medicare at a younger age if you have a qualifying disability.

People with amyotrophic lateral sclerosis (ALS) do not have a waiting period, but people on SSDI benefits for other disabilities will need to wait 24 months to get coverage. Medicare for end-stage renal disease has its own set of requirements.

VA Health Care eligibility, on the other hand, is not dependent on age or disability. It is determined based on service.

People who served in the active military, naval, or air service are eligible if:

  • They served before September 7, 1980. 
  • They enlisted after September 7, 1980 (or entered active duty after October 16, 1981) and served 24 continuous months or the full period assigned to active duty.
  • They were discharged due to a disability that occurred or was aggravated during active duty.
  • They were discharged for a hardship or an “early out.”

People who served in the Reserves or National Guard are eligible if they completed the full period assigned to active duty as long as that assignment was not for training purposes.

VA Health Care benefits are not granted to anyone who was dishonorably discharged.

Costs: Medicare vs. VA Health Care

While you may pay monthly premiums and annual deductibles for each part of Medicare, the same does not hold true for VA Health Care. There are no monthly premiums or deductibles for VA care. There are, however, copays to be paid.

For Medicare, these copays are fixed. For Part A, you will pay a flat rate for hospital stays and skilled nursing facility stays depending on the number of days you are in the facility. For Part B, you will pay 20% for most services. For people who cannot afford it, there are Medicare Savings Programs that can subsidize these expenses.

For VA Health Care, what you pay is determined by your priority status. Altogether, there are eight priority groups. Those with higher priority (priority group 1) generally pay less than those with lower status. They are also first to gain access to care.

The following factors are taken into account when assigning priority groups:

  • Disabilities related to service (e.g., disability severity, early discharge due to disability)
  • Income
  • Medicaid eligibility
  • Military service record (e.g., Prisoner of War, Medal of Honor, Purple Heart)
  • Other VA benefits (e.g., VA disability compensation, VA pension)

Disability status carries the most weight. Those with the greatest disability are placed in higher priority groups. Income only affects eligibility for priority groups 7 and 8, where people do not have service-related disabilities.

Coverage: Medicare vs. VA Health Care

Medicare does not cover everything. What especially stands out is that they do not pay for routine dental care or dentures, routine hearing exams or hearing aids, or routine vision exams or corrective lenses. Some Medicare Advantage plans could offer coverage for these services as a supplemental benefit, but that could require higher monthly premiums.

VA Health Care, however, does offer these services, but not to everyone.

Hearing and vision coverage is offered to veterans with the following:

  • Compensable service-related disability
  • Functional or cognitive impairment that decreases the ability to perform activities of daily living
  • Permanent homebound status
  • Prisoner of War
  • Purple Heart
  • Service-related hearing disability with a loss of communication ability
  • Title 38 United States Code (U.S.C.) 1151 benefits
  • Vision and/or hearing impairment related to a condition managed at the VA (e.g., cataracts, diabetes, stroke)
  • Vision and/or hearing impairment that interferes with the veteran’s medical treatment

Dental coverage is offered to veterans with the following:

  • Active duty (at least 90 days) during the Persian Gulf War
  • Dental disability or condition directly related to service
  • Dental condition related to a service-related disability
  • Prisoner of War
  • Severe service-related disabilities (e.g., 100% disability or an inability to work)

Access: Medicare vs. VA Health Care

People on Original Medicare can receive care nationwide from any provider who accepts Medicare for payment. As many as 93% of all primary care providers accept Medicare. People on Medicare Advantage are limited to a network of local providers, but could pay more (or be uncovered) if they receive care out of network.

Similar to people on Medicare Advantage, VA Health Care restricts care to their own network. This includes more than 1,200 VA health care facilities nationwide; 171 of them are VA Medical Centers.

Depending on where veterans live, their access to care could be limited by the number of facilities in their community. For example, Alaska, Hawaii, and New Hampshire do not have full-service VA medical facilities.

A scandal broke out in 2014 due to long wait times at a number of VA sites. This led to the development of the Veterans Choice Program.

When appointments were not available for 30 days or more at a local VA facility, veterans could seek care with a private non-VA physician. This rule also applied to veterans who needed to drive 40 or more miles to get to a VA facility or who otherwise had to travel by air, boat, or ferry to get there.

With the VA MISSION Act of 2018, the Veterans Community Care Program replaced the Veterans Choice Program. This decreased the wait times to 20 days for primary care and mental health care and 28 days for specialty care.

Instead of miles, driving time determined when veterans could see a non-VA physician. Driving times 30 minutes or longer for primary care and mental health care and 60 minutes for specialty care are now the standards. The VA MISSION Act also increased access to urgent care and walk-in clinics.

Why Veterans May Want to Sign Up for Medicare

Funding for VA Health Care is not guaranteed. The Department of Veterans Affairs submits a budget to the federal government every year, but there is no guarantee that the requested dollar amount will be appropriated. A lower budget could mean reduced coverage or loss of coverage altogether for people in lower priority groups.

Since the VA does not pay for care received out of network (unless it is part of the Veterans Community Care Program), Medicare could be a good option to cover you in an emergency or if you wanted to see certain non-VA physicians.

Medicare Part A

For people who contributed 40 or more quarters in Medicare-taxed employment, premiums for Part A are free. There is no financial burden for signing up.

Medicare Part B

If you sign up for Medicare Part B after the initial enrollment period and don’t otherwise qualify for special enrollment periods, you could face lifelong late penalties. Signing up now in case you lose your VA health benefits later could save you money in the long run.

You would have to start paying monthly premiums right away, but if you qualify for a Medicare Savings Program, those premiums could be free.

Medicare Part D

VA prescription drug coverage is seen as creditable, i.e., as good as Medicare. For this reason, you would not face late penalties if you signed up for a Medicare Part D plan at a later time. Still, there could be benefits to enrolling in a Part D plan.

For example, a drug you need may not be on the VA formulary, or a community pharmacy is closer to you than the VA pharmacy. Keep in mind that prescriptions written by non-VA physicians won’t necessarily be covered either (they will require authorization). If you qualify for Extra Help, your Part D costs would be reduced too.  

A Word From Verywell

VA Health Care is premium-free and deductible-free, and for some veterans it covers services that Medicare does not. However, access to care can sometimes be an issue, and coverage is not guaranteed from year to year. Signing up for Medicare, if you can afford it, could assure you have the coverage you need.