Q. I am a retiree with more than 31 years of service, but when I go to the VA, I have to pay a co-payment. They cannot accept payment from Medicare or Tricare for Life, and no one seems to know why. Can you please explain?
A. As you may know, VA facilities are considered Tricare network providers and will care for Tricare beneficiaries for illnesses that are not considered service-connected if the facility has space or, in some circumstances, to ensure that patients maintain continuity of care.
But some veterans are required to make co-payments for care for nonservice-connected conditions, and until Oct. 1, 2013, Tricare covered the cost of the co-payment for veterans who are eligible for health care through both VA and Tricare for Life.
But after Tricare officials examined the statutes that oversee VA, Medicare and Tricare, they determined that such reimbursements were improper and changed the co-payment reimbursement policy.
Under TFL, Tricare serves as second payer, covering health care after Medicare has paid its share; by law, Tricare must be last payer to all other health insurance except in very limited and specific circumstances.
VA facilities are Tricare-authorized, but they are not Medicare-certified — which means VA can’t bill Medicare for any care related to nonservice-connected conditions. Such bills would pass directly to Tricare, as last payer. But by law, TFL can cover no more than 20 percent of the Tricare-allowable charge on such claims.
So beneficiaries in the scenario would be responsible for the 80 percent of the charge that Medicare won't pay because VA is not Medicare-certified, and Tricare can't pay because it can cover only 20 percent of the allowable charge.
The policy is confusing because some veterans who use VA health care are exempt from any co-pays for any care, such as those with disability ratings of 50 percent or higher for service-connected conditions.
Short answer is, the law says Medicare cannot cover the cost of any co-payments at a VA facility and Tricare can only reimburse 20 percent of the cost.
Write to Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or firstname.lastname@example.org. In email, include the word "Tricare" in the subject line and do not attach files.