How VA Health Care Works With Other Health Insurance

The Veterans Health Administration offers first-class health care to eligible veterans. Enrollment in VA health care fulfills the Affordable Care Act (ACA) coverage requirement. Despite this, the VA encourages veterans to keep their private insurance – like Tricare – which can help pay for services the VA doesn’t cover, such as non-service connected conditions.

While the VA is at the core of health care for veterans – including veterans with disabilities or low income – civilian health care also plays a vital part in your overall care. In fact, a recent report (2020) by the National Center for Veterans Analysis and Statistics showed that less than half of all veterans used any VA services or benefits in 2017.

That means at least half of all veterans used some other health care — a private insurance plan, Tricare, Medicare or Medicaid — for at least some of their care.

Read on to find out what VA health care covers and how it works with your other health insurance.

What Does VA Health Care Cover?

Though VA health care qualifies as minimum essential coverage under the affordable care act, VA Health Care is not an insurance plan.

Your eligibility for VA services depends on a number of factors, including your VA disability rating. When you apply for VA Health Care, the VA assigns you a priority group. Your priority group determines what VA Health Care will cover.

Depending on your priority group, VA health care benefits packages may include:

• Health exams, including gender-specific exams
• Health education (including nutrition education)
• Immunizations
• Genetic disease counseling
• Surgeries
• Inpatient medical treatments
• Kidney dialysis
• Acute care
• Specialized care (including organ transplants, intensive care for mental and physical conditions, and care for traumatic injuries).
• Mental health services, including post-traumatic stress disorder (PTSD) and military sexual trauma (MST), depression and substance abuse
• Assisted living and home health care (based on individual need, income and space available)
• Prescriptions from a VA provider

Other services the VA covers:

• Vision care
• Dental care (if you meet certain conditions)
• Health care assessments and education programs
• Dental care (if eligible)
• Gender-affirming hormone therapy
• Substance and tobacco use treatment
• In-vitro fertilization (when infertility is service-related)
• Other fertility services, including surgical corrections and vasectomy reversal
• Bereavement counseling
• Reconstructive surgery, excluding non-medical cosmetic surgery
• Maternity care, including pregnancy, delivery and postpartum
• Emergency care in non-VA facilities (you must file in a timely manner)
• Abortion counseling and abortion services (see below for more information)

Services the VA Does Not Cover:

• Cosmetic surgery, unless medically necessary as determined by the VA
• Gender-affirming surgical interventions, though the VA has initiated a rule-changing process to allow them
• Drugs and medical devices not approved by the FDA (exceptions exist for clinical trials and when there are no comparable treatment options)
• Spa and health club memberships
• Treatment for patience and inmates of non-VA institutions

Newly Available: Abortion Counseling and Abortion Services

On Sept. 1, 2022, the VA submitted an interim final rule to the Federal Register updating its reproductive health policies to allow abortion counseling and abortion services under certain circumstances, according to a Sept. 2 press release.

The VA took these steps to protect pregnant veterans and CHAMPVA beneficiaries from medical emergencies caused by abortion restrictions, said Dr. Shereef Elnahal, VA’s Under Secretary for Health in the press release. “Offering this care will save veterans’ health and lives, and there is nothing more important than that,” Shereef said.

How the VA works with Tricare

TRICARE is a health care platform for uniformed active-duty, National Guard and reserve service members, retired service members, military dependent family members and survivors of fallen service members.

Most Tricare plans to meet the minimum essential coverage (MEC) requirements for the Affordable Care Act (ACA).

However, if you are switching to new Tricare coverage or losing your current Tricare eligibility, review your options to avoid any penalties for not meeting MEC requirements.

Active duty service members, military retirees and their families who have Tricare Select meet ACA’s minimum requirements. Service members who qualify for Tricare For Life and have a Medicare Part B plan also meet minimum requirements.

Every VA facility has a Tricare point of contact (POC) and an established check-in process. When you register for a service, be sure to tell the VA provider that you are using your Tricare benefit.

If you don’t, you may be charged higher out-of-pocket costs or payment may be denied.

VA Health Care for Tricare Beneficiaries

For primary care services, some VA facilities will see Tricare beneficiaries. Prior to making an appointment, check with your regional contractor to see if you can enroll with a VA Tricare provider.

Keep in mind that primary care with Tricare and the VA are separate, and you can’t use both. That means that eligible beneficiaries can choose to use either their VA or Tricare benefits for each separate treatment of care.

» MORE: Check your VA home loan eligibility with today’s top lenders

Supplemental insurance pays after TRICARE pays its share of the bill. In other words, Tricare reimburses you for medical expenses paid out-of-pocket to civilian providers.

Tricare Referrals for VA Health Care

If you want to obtain specialty care at a VA facility and you’re enrolled in Tricare Prime, you must have a referral. If you’re enrolled in Tricare Select, a referral is usually not required, but prior authorization might be required for some services.

VA Prescriptions for Tricare Beneficiaries

By law, the VA must bill private health insurance providers first for medical care and prescriptions you receive for non-service-connected conditions. For that reason, the VA requires you to tell them when you have outside insurance, including Tricare.

You can provide your insurance information when you apply for VA health care or, if you’re are already enrolled, you can update your health insurance information by using the online Health Benefits Renewal (10-10-EZR) form here.

You can get your VA prescriptions filled online through My HealtheVet, by phone on the Rx Refill mobile app, or through the mail. You can also refill your VA prescriptions at VA facilities. When filling your VA prescriptions out of network, you may be able to use your Tricare benefit to pay for the prescription.

Prescription drug coverage is available to all Tricare beneficiaries through the Tricare Pharmacy Program. You can get your prescriptions filled at any Tricare retail network pharmacy, military pharmacies, non-network pharmacies and through Tricare Pharmacy Home Delivery. If you have a non-covered drug prescription, you may have to pay the full cost of the prescription out-of-pocket.

If you only qualify for premium-based coverage with VA health care, you must obtain one of the options below or purchase other qualifying health coverage to meet the minimum requirement.

Tricare Plans that meet minimum coverage requirements include:

• TRICARE for Life
• TRICARE Prime
• US Family Health Plan
• TRICARE Young Adult
• TRICARE Prime Remote
• TRICARE Reserve Select
• TRICARE Retired Reserve
• TRICARE Prime Overseas
• TRICARE Standard and Extra
• TRICARE Standard Overseas
• TRICARE Prime Remote Overseas
• Continued Health Care Benefit Program
• Transitional Assistance Management Program

How VA Health Care Works With Civilian Health Insurance

If you have other health care coverage, like private or civilian insurance plans—Tricare, Medicare or Medicaid—you can still receive your VA health care benefits together with these plans.

As with Tricare, the VA will bill your civilian health insurance for treatment that is not service-connected.

However, if you are a veteran who is not enrolled in VA benefits, you can get civilian coverage through the Health Insurance Marketplace.

Plans vary by price, quality and benefits. Plus, your VA benefits can co-exist alongside civilian health care.

Veterans applying for VA medical care must provide information about other health insurance coverage, including if you’re covered under your spouse’s health care insurance coverage or coverage provided by your current job.

Creditable Coverage for Medicare Part D

If you are enrolled in the VA health care system, you already have creditable coverage for Medicare Part D. However, your family members can not receive creditable coverage since only veterans can enroll in the VA health care system.

The Civilian Health and Medical Program (CHAMPVA)

The Civilian Health and Medical Program (CHAMPVA) may provide health care benefits for eligible VA beneficiaries. With this program, the VA shares the cost of covered health care services performed by a primary physician.

However, to receive benefits, your beneficiaries can not be entitled to health care under another health insurance plan, such as Medicare, Medicaid or Tricare. This program also fulfills the minimum essential coverage requirement for the Affordable Care Act (ACA).

Beneficiaries who are eligible for health care under the CHAMPVA program must be spouses or children of:

• Veterans (living or deceased) who have received permanent and total (“P&T”) rating from the VA for a service-related disability.
• Veterans who died in the line of duty or from a service-connected disability.
• Veterans who died while serving but dependents are not eligible for Tricare benefits

Moreover, if a surviving spouse remarries before turning 55, they will lose their CHAMPVA benefits.

VA Health Care FAQs

If You Have VA Health Care, Should You Give up Your Civilian or Other Health Insurance?

If you give up other health care coverage when authorized for VA coverage, you’ll likely save money on premiums. However, there are risks.

The VA doesn’t typically provide care for your family members. Also, if you cancel your current Medicare Part B plan, you can’t reclaim this coverage until January of the following year. Plus, you might have to pay a penalty when you reinstate coverage.

Can You Use Your Health Reimbursement Arrangement (HRA) or Health Savings Account (HSA) to Help Defer the Cost of VA Care for Non-Service-Related Conditions?

The VA will bill High-Deductible health care Plans (HDHPs) such as HRAs and HSAs for non-service-related conditions. Also, if you have an HDHP tied to your HSA, you can use your HSA plan to help pay VA copays.

Does the VA Need Your Permission to Bill Your Other Insurance if Related to a Sensitive Diagnosis?

The VA is required by law (the VA MISSION Act of 2018) to bill any other health insurance provider if the care you receive is related to a sensitive diagnosis, such as HIV testing and drug or alcohol abuse, without the need to obtain your permission.