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Medicare 101

How Veterans Can Make Sense of Medicare and VA Benefits

You can have both VA benefits and be in enrolled in Medicare at the same time. Here's what you need to know to get the most out of your health care coverage.

Christian Worstell

by Christian Worstell | Published October 31, 2023 | Reviewed by John Krahnert

Veterans who receive health care benefits through the U.S. Department of Veterans Affairs (VA) can also enroll in Medicare upon turning 65.

Because each offers different benefits, having both at your disposal will broaden your health insurance coverage options.

If you’re a veteran, it’s important to understand how VA benefits and Medicare work in tandem before you make the choice.

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What Is Medicare VA?

Medicare and the Veterans Affairs (VA) are actually 2 separate entities that don't work together. Medicare won't pay for any care that you may receive from the VA and vice versa. 

To receive coverage from the VA you generally must receive care from a VA facility. 

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What Are Veteran's Benefits?

If you served in active duty and were discharged or released under conditions other than dishonorable, you may be eligible for VA benefits .

The minimum duty requirements for VA benefits call for 24 months of continuous service, which also applies to members of the National Guard and the Reserves.

But because there are many exceptions to these requirements , such as whether you were discharged for a disability incurred during active service, the VA encourages all veterans to apply for VA health coverage.

All veterans who qualify for VA health benefits are assigned to a priority group numbered 1 through 8 , with 1 being the highest and 8 being the lowest.

Your priority number, which depends on factors such as your income level and if you have a service-connected disability, determines everything from copayments to out-of-pocket costs to when you can schedule a medical appointment.

Regardless of the number, all veterans receive the VA’s Uniform Benefit Package, which includes services that Medicare doesn’t offer.

Should Veterans Enroll in Medicare?

The VA’s health care package and Medicare are two distinct programs. They do not work together, but rather, alongside one another.

While the VA’s plan provides veterans with benefits that Medicare does not offer, such as dental coverage and long-term nursing care, your medical costs are only covered if you receive care at a VA facility, or at a non-VA facility with prior authorization from a VA doctor .

Having both VA benefits and Medicare insurance broadens your coverage to include Medicare-approved hospitals and doctors.

The VA usually encourages veterans to enroll in both Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

You typically don't have to pay a premium for Part A, while the standard Part B premium for 2024 is $174.70 or higher, depending on your income.

Part B covers Medicare-approved doctor’s services and outpatient services, so what you spend on Part B premiums may save you money in the long run.

There are a few  advantages to enrolling in Medicare if you already have VA benefits:

In the case of an emergency, you may be taken to a non-VA facility. If you don’t have Medicare, you will be responsible for covering the costs.

The VA health plan depends on the annual appropriation of funds by Congress . From year to year there is no guarantee of sufficient funds to cover all priority groups.

Even if all your medical needs are presently met by VA doctors, there may come a time when you will require care from a non-VA provider.

If you don’t enroll in Part B when you’re first eligible and later change your mind, you will likely have to pay an ongoing late-enrollment Part B premium penalty of 10% for every 12-month period that you didn’t have it.

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How Should Veterans Receive Prescription Drug Coverage?

The VA’s prescription drug plan typically offers a more generous benefits package than Medicare Part D, the program's prescription drug benefit. The VA covers the cost of drugs that you get at VA pharmacies, while Part D covers those that you get at in-network pharmacies.

The VA’s drug plan is considered creditable coverage , meaning it’s as good or better than Medicare’s drug coverage, so veterans who later choose to enroll in Medicare Part D can do so without incurring a late enrollment penalty.

If you lose your VA benefits, you’ll have 63 days to enroll in a Part D plan before that penalty kicks in.

There are several reasons why a veteran would choose to supplement his or her VA drug plan with Medicare Part D:

If you are prescribed a drug by a private clinician or a Medicare Part B-approved doctor, the VA will not cover the cost of that drug without additional authorization from a VA provider.

If you enter a non-VA nursing home, you may want to get your drugs at the in-house pharmacy. A Part D plan could cover the cost of those drugs.

If you live far away from a VA facility or are suddenly in need of medicine, you may find it easier or necessary to go to a non-VA pharmacy.

If you have a low income, you may find that Medicare’s low-income subsidy (LIS) program Extra Help for Part D beneficiaries will lower your overall drug costs.

You can compare Part D plans available where you live and enroll in a Medicare prescription drug plan online when you visit MyRxPlans.com. 1

Enroll in Medicare Part D at MyRxPlans.com.

Combining va benefits, medicare and a medigap plan.

Just because you have both VA benefits and Medicare doesn’t mean all of your medical costs will be covered free-of-charge.

In addition to the 2024 Medicare Part A deductible of $1,632 per benefit period, coinsurance for hospital stays lasting longer than 60 days starts at $408 per day in 2024.

Moreover, after meeting your 2024 Part B deductible of $240  per year, you will likely be responsible for covering 20% of your medical costs.

A veteran may choose to supplement their Medicare coverage with a privately administered Medigap Insurance plan (also called Medicare Supplement Insurance), which helps cover the out-of-pocket costs associated with Medicare, such as deductibles, copayments, coinsurance and other fees.

Whether or not VA benefits alone provide enough coverage will depend on the individual and his or her unique medical needs. It's a good idea to speak to someone about your VA benefits to determine if you need a Medicare Supplement Insurance plan.

For more information about Medicare Supplement Insurance plans, call to speak with a licensed health insurance agent today.

coordination of benefits medicare and va

About the author

Christian Worstell   is a licensed insurance agent and a Senior Staff Writer for MedicareSupplement.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.

His work has been featured in outlets such as   Vox ,   MSN , and   The Washington Post , and he is a frequent contributor to health care and finance blogs.

Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, NC.

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Medicare and VA Benefits Every Veteran Should Know

coordination of benefits medicare and va

  • by Christian Worstell
  • January 12, 2024
  • Reviewed by John Krahnert

Medicare covers veterans in the same way as it covers most other Medicare beneficiaries. But there are a few things that veterans of the armed forces should know about Medicare.

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1. Medicare and VA coverage do not coordinate benefits

Medicare and VA (Veterans Affairs) insurance do not coordinate coverage. The only instance in which the two programs might team up to offer dual coverage is when the VA approves qualified care to be received at a non-VA facility.

Medicare coverage for people with VA insurance typically works like this:

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If you receive care at a VA facility, it will be covered by your VA insurance. If you have Medicare and receive Medicare-approved care at a non-VA facility, Medicare will provide coverage. Medicare will not provide coverage at a VA facility, and VA benefits will not provide coverage at a non-VA facility.

In other words, you must visit a VA hospital or medical facility in order to use your VA coverage, and you must visit a civilian hospital or medical facility in order to use your Medicare coverage.

VA benefits and Medicare coverage do not overlap.

2. There can be advantages to having both types of coverage

There can be some definite advantages in having VA benefits and Medicare insurance.

  • Having both types of coverage can give you more health care options. If you only have VA insurance, you are limited to receiving covered care at only VA facilities. But adding Medicare coverage can open up the range of hospitals, doctor’s offices, pharmacies and other types of health care locations in which you may receive covered care.
  • Having both types of coverage can benefit you in the event that an emergency occurs when you are not in close proximity to a VA hospital.
  • Most people do not have to pay a premium for Part A of Medicare.

3. You might be subject to late enrollment fees if you forego Medicare enrollment

If you do not sign up for Medicare Part B during your Initial Enrollment Period , you may be subject to late enrollment penalties if you decide to sign up later on.

The Part B late enrollment penalty is 10 percent of the Part B premium for each 12-month period in which you were eligible to enroll but did not. You will have to continue to pay the penalty for as long as you remain enrolled in Part B.

You may be able to avoid the Part B late enrollment penalty if you qualify for a Medicare Special Enrollment Period . Choosing not to enroll in Medicare Part B because you have VA coverage does not qualify you for a Special Enrollment Period. Learn more about the medicare enrollment period 2024 !

4. You may not have the same VA coverage forever

Another reason you may consider enrolling in Medicare is the possibility that you may lose your VA benefits at some point, leaving you without health insurance coverage.

VA health benefits depend on an annual appropriation of funds by Congress, and it’s unpredictable if enough funding will be approved in future years to care for all veterans. Those veterans in the lower priority groups are at particular risk to see a reduction or even a complete loss of their veteran’s benefits.

5. Prescription drug coverage can vary

VA coverage includes prescription drug benefits, and for this reason, many VA members may choose not to enroll in Medicare Part D (Medicare prescription drug plans).

And because VA drug benefits are considered “creditable coverage” by Medicare, VA members are not required to pay a late enrollment penalty if they choose to sign up for Medicare Part D at a later date.

You can use this helpful Medicare plan finder to look for Medicare prescription drug coverage that may be available in your area.

You can also compare Part D plans available where you live and enroll in a Medicare prescription drug plan online in as little as 10 minutes when you visit MyRxPlans.com. 1

Enroll in Medicare Part D at MyRxPlans.com

There are a few instances in which enrolling in a Part D plan or a Medicare Advantage Prescription Drug (MA-PD) plan  may make sense:

  • VA coverage includes its own drug formulary (a list of drugs covered by the plan). If the VA does not cover a specific drug that you need to take, you might consider enrolling in a Medicare Part D plan that covers that drug.
  • A drug prescribed by a doctor at a non-VA facility may not be covered by VA benefits without authorization.
  • A non-VA pharmacy may be a more convenient way to obtain your drugs, especially if you reside in a nursing home or other long-term care facility.
  • If you qualify for Medicare Extra Help , your overall drug costs may be lower with a Part D plan than under VA coverage.

6. If you have TRICARE, you may have to enroll in Original Medicare

If you are not on active duty and are entitled to premium-free Medicare Part A, then you must also enroll in Part B in order to keep TRICARE coverage.

You must also be enrolled in both Medicare Part A and Part B (Original Medicare) in order to have TRICARE For Life. The lone exception is when the beneficiary is the spouse of an active duty service member, in which case Medicare Part B enrollment is not necessary.

7. Medicare Advantage plans can be good options for veterans

A Medicare Advantage plan may be worth considering if you are a veteran.

A Medicare Advantage plan will provide all the same coverage as Original Medicare, and some Medicare Advantage plans may cover some benefits that Original Medicare doesn’t.

Seeking additional Medicare help

If you have additional questions about how veterans can make the most of their health insurance with the help of Medicare, contact a licensed insurance agent.

An agent can help you find the Medicare Advantage plan coverage that fits your unique health care needs.   

Can you have a Medicare Advantage Plan and VA Benefits?

Yes, you can have a medicare advantage plan and VA benefits at the same time. These benefits don't replace each other, they actually can complement each other. Having a Medicare Advantage plan gives you additional benefits that your VA benefits doesn't cover, and allows you to access hospitals and providers outside of the VA system.

Note: You can't use Medicare Advantage coverage at VA facilities, and vice-versa.

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Christian

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at [email protected] .

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  • Introduction

VA Benefits vs Medicare

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VA Benefits and Medicare

As a veteran, you’ve earned the right to have excellent healthcare, and we thank you for your service!

At the same time, when you approach the age of 65, you’ll also qualify for Medicare. You can carry both VA benefits and Medicare, but they don’t work together. Instead, some of your care will be covered by the VA and other medical needs by Medicare.

This guide will help you understand how to use both VA benefits and Medicare and when each coverage will apply. Let’s get started!

Both VA Benefits and Medicare provide comprehensive medical coverage for a variety of needs. However, they work in different places.

If you go to a VA facility for your medical care, your VA medical benefits will apply. However, outside that system, you have to pay the full cost yourself, even in an emergency.

With Medicare coverage, if you get care outside the VA but at a Medicare-certified provider, you can use your Medicare benefits. As a result, Medicare can be a vital coverage if you don’t live close to a VA facility or if you travel frequently.

It’s important to keep in mind that VA care is based on your priority level. If you have a lower assigned priority level and VA funding drops, you may not be able to get VA medical benefits anymore. That’s why having Medicare if you’re eligible is an important backup.

You might be wondering “Does the VA bill Medicare?” or “Does the VA bill Medicare Advantage plans?” The answer in both cases is no, they do not work together.

Instead, your coverage will depend on what medical facility you go to. If you go to a VA facility, your VA benefits will take care of your needs. Any non-VA but Medicare-certified care will be covered by Medicare.

Sometimes the VA will authorize care at a non-VA facility. This generally means that they will cover the costs of those services, but if they don’t, Medicare may pay for the Medicare-eligible services left over.

Medicare only applies to non-VA doctors. So in the VA, your VA benefits are primary. Everywhere else, Medicare is primary.

In general, you’ll get the same benefits from both Medicare and VA benefits, though your coverage amounts, copays, and other factors may differ. Your access to VA care, along with the out-of-pocket costs you have in the form of copayments, can vary depending on your priority level. If you have a lower priority number, you might have to wait for care at the VA or have to pay more for services or medications.

Medicare gives you another option that isn’t dependent on your VA priority. Instead, you can get non-VA care when you need it. You can also choose a Medicare Advantage plan that brings additional benefits, such as vision, dental, and other care. However, Medicare Advantage plans have a limited network, so you’ll have to see the approved providers.

Instead of thinking about which coverage is better, it’s best to consider the benefits of combining Medicare and VA benefits.

VA eligibility and Medicare eligibility are separate. To qualify for VA care, you need to be a veteran and meet the VA benefit requirements.

For Medicare, you need to be a U.S. resident or citizen who has lived in the country for at least five years, along with being 65 years of age or older, or having specific health conditions. You can qualify for VA but not Medicare, or you might qualify for both.

As we’ve mentioned, VA benefits are only applicable to VA medical centers. That’s why having Medicare as a secondary coverage can help.

You don’t have to, but you may face penalties if you don’t enroll during your initial enrollment period but decide to sign up later.

Most Americans get Part A automatically and it’s free. For Medicare Part B, you might be automatically enrolled or you may have to sign up. There is a monthly fee for Medicare Part B, but it will be higher if you skip enrollment and then change your mind later on. We put a guide together that explains the difference between Medicare Part A and Part B in further detail.

We highly recommend signing up for Medicare when you are initially eligible. It expands your available medical options and can bring peace of mind if you have a lower VA priority level.

Do VA patients need Medicare? It’s a common question. You might think it’s unnecessary to carry two forms of health coverage.

However, those with VA benefits can only go to VA medical centers. Anything else isn’t covered. With Medicare, you have a much wider range of care available, which can be essential if you’re traveling or live far from a VA center.

If you wait to enroll in Medicare Part B because you have VA benefits, you may have to pay a late-enrollment penalty when you do decide to sign up. VA benefits don’t give you a special enrollment period or an exemption from the late-enrollment fees.

Medicare Advantage , or Medicare Part C, is a full replacement for Original Medicare. Often you get additional benefits, such as discounts on health memberships, vision care, or dental coverage.

It does not. Instead, you use the plan that applies to the medical provider you see.

If you are eligible for Medicare, you can sign up for Medicare Advantage, even if you have VA benefits. As we’ve noted, VA benefits only apply at a VA health center. Medicare Advantage can be used anywhere within the plan’s medical network.

Keep in mind that, unlike Original Medicare, a Medicare Advantage plan will have a limited network of providers, generally within a single geographical area. Make sure your non-VA doctors are part of the network and that the plan covers the prescriptions you need.

This guide has covered the most commonly asked questions that veterans have about Medicare coverage, but you might have additional concerns. That’s not a problem! We’re here to make it easy for you to understand your VA and Medicare options.

Often it helps to talk to a licensed insurance agent that can review your specific situation and help you find the coverage that works for you. If this is something you’d like to do, contact us today!

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10 Things to Know About Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs)

Salama Freed, Meredith Freed , Jeannie Fuglesten Biniek , Anthony Damico, Nolan Sroczynski , and Tricia Neuman Published: Feb 09, 2024

About 12.9 million people received health coverage under both Medicare and Medicaid in 2021. Medicare-Medicaid enrollees, known as dual-eligible individuals, are a diverse group , as nearly half are people of color and nearly 40% are under age 65. However, this group of people share some common characteristics, such as limited financial means and health care needs that are more wide-ranging and complex than the average Medicare enrollee.

Prior KFF research has described the complex landscape of coverage options available to dual-eligible individuals when enrolling in Medicare and Medicaid . Medicare, the primary source of health insurance coverage for dual-eligible individuals, may be provided under traditional Medicare or a Medicare Advantage plan. Medicaid, which typically wraps around Medicare, covers the cost of Medicare premiums and in many cases, cost sharing assistance. Full dual-eligible individuals are also eligible for benefits not otherwise covered by Medicare, such as long-term services and supports. Dual-eligible individuals may receive Medicaid benefits through fee-for-service or managed care , and coverage and eligibility vary by state. Separate eligibility requirements, benefits, and rules for Medicare and Medicaid sometimes contribute to what has been described as a “ fragmented and disjointed  system of care for dual eligibles” which may lead to difficulty in navigating care among dual-eligible individuals.

In 2023, 5.2 million dual-eligible individuals were enrolled in a Medicare Advantage plan designed specifically for dual-eligible individuals, known as Dual-Eligible Special Needs Plans (D-SNPs). D-SNPs are required to provide greater coordination of Medicare and Medicaid benefits than other Medicare Advantage plans to improve coordination across programs and patient outcomes. D-SNPs typically provide benefits not otherwise available in traditional Medicare and generally do not charge a premium.

This brief highlights 10 things to know about D-SNPs, including national and state enrollment trends, plan availability, insurer participation, benefits, and prior authorization rates and denials, based on data from various sources (see methods for details). While D-SNPs can help with coordination for dual-eligibles in Medicare and Medicaid and they are growing rapidly, fewer than one in ten D-SNP enrollees were in fully integrated dual eligible (FIDE) special needs plans (SNPs), raising questions about how well coverage and care is being coordinated between Medicare and Medicaid. In addition, gaps in data make it difficult to assess the quality of D-SNPs, prior authorization rates and denials by type of service, and the extent to which extra benefits are used.

1. About 3 in 10 (29%) dual-eligible individuals enrolled in D-SNPs in 2021.

In 2021, nearly 3 in 10 (29%) dual-eligible individuals were enrolled in a D-SNP. Between 2010 and 2021, the share of dual-eligible individuals enrolled in D-SNPs nearly tripled from 11% to 29%.

As of 2023, most D-SNP enrollees ( 57% ) were in coordination-only (CO) plans that are required to provide a minimum level of coordination between Medicare and Medicaid but are not fully integrated within the same plan. Another 35% of D-SNP enrollees were in what is known as highly integrated dual eligible (HIDE) SNPs that meet the requirements of CO plans and also require coverage of long-term services and supports and behavioral health. The remaining 8% were in plans that were fully integrated dual eligible (FIDE) special needs plans (SNPs), which coordinate care for dual-eligible individuals within a single managed care organization.

2. The share of dual-eligible individuals enrolled in D-SNPs varies by state, ranging from 5% (Nevada) to 58% (Hawaii) in 2021.

In 2021, D-SNP enrollment as a share of dual-eligible individuals ranged from 5% in Nevada to 58% in Hawaii, as compared to 29% nationwide. In seven states, 40% or more of all dual-eligible individuals were enrolled in D-SNPs: Alabama (42%), New York (42%), Florida (46%), Tennessee (46%), Arizona (47%), and Hawaii (58%), as well as in Puerto Rico (98%, not shown). Conversely, less than 10% of dual-eligible individuals were enrolled in D-SNPs in Nevada (5%), where D-SNPs were first available in 2021, and Montana (8%).

The share of dual-eligible individuals enrolled in D-SNPs more than doubled in 19 states between 2018 and 2021. States with relatively low D-SNP enrollment relative to the dual-eligible population in 2018, such as Oklahoma, Iowa, and West Virginia, had the highest percentage growth in share of dual-eligible individuals enrolled in D-SNPs between 2018 and 2021. For example, the share of dual-eligible individuals enrolled in D-SNPs in Oklahoma increased from 1% in 2018 to 12% in 2021. Several states, such as Arizona (45% vs. 47%), California (10% vs. 10%), Hawaii (57 vs. 58%), Massachusetts (16% vs. 19%), and Minnesota (30% vs. 34%), maintained similar shares of dual-eligible individuals enrolled in D-SNPs between 2018 and 2021. New Mexico, Oregon, and Utah were the only states where a smaller share of dual-eligible individuals enrolled in D-SNPs in 2021 compared to 2018. Insurers in Alaska, Illinois, New Hampshire, Wyoming, Vermont, North Dakota, and South Dakota did not offer D-SNPs in 2018 or 2021. Overall, Medicare Advantage enrollment in these states tends to be lower than the national average, partially explaining the relatively low enrollment among dual-eligible individuals in D-SNPs.

Differences in D-SNP enrollment across states may be reflective of several factors, including variation in: state-level policies pertaining to D-SNP enrollment, demographic characteristics of the dual-eligible population in the state, firm strategy, and the ability to establish care networks for dual-eligible individuals.

3. Within states, the share of dual-eligible individuals enrolled in a D-SNP varied across counties in 2021.

Within states, D-SNP enrollment among dual-eligible individuals often varies by county. For example, in Northern California, 20% of dual-eligible individuals in San Francisco County were enrolled in D-SNPs in 2021, compared to only 5% in nearby Santa Clara County. Although there was roughly the same number of dual-eligible individuals in Alameda and Sacramento Counties in 2021, only 16% of dual-eligible individuals in Alameda County were enrolled in D-SNPs, while over one-third (34%) of dual-eligible individuals in Sacramento County were enrolled in D-SNPs. In Florida, the share of dual-eligible individuals in Orlando was 54% (Pasco County) compared to 64% in nearby Tampa (Osceola County). However, in counties in the Florida Panhandle, the share of dual-eligible individuals enrolled in D-SNPs was much lower: 24% in Jackson County and 45% in adjacent Gadsden County. In Puerto Rico (not shown), enrollment of dual-eligible individuals in D-SNPs is nearly universal.

Variations in D-SNP enrollment at the county level may be attributed to several factors, such as rurality and Medicare payment rates.

4. More than 9 in 10 dual-eligible individuals (92%) lived in a county that offered at least one D-SNP in 2022.

More than 9 in 10 (92%) dual-eligible individuals could choose from at least one D-SNP when selecting coverage for 2022, up from 86% in the 2018 plan year. Most of the remaining 8% of dual-eligible individuals without access to a D-SNP lived in the 5 states where D-SNPs were not available in 2022 (Illinois, New Hampshire, South Dakota, Vermont, and Alaska).

5. The average dual-eligible individual could choose from 10 D-SNPs in 2022.

The average dual-eligible individual could choose from 10 D-SNPs in 2022 – more D-SNPs than in any previous year. The number of D-SNPs available to the average dual-eligible individual has more than doubled since 2011. While the average dual-eligible individual could choose from 10 D-SNPs, plan availability varied widely by county in 2022. For example, dual-eligible individuals in most counties composing metropolitan New York City had access to up to 40 D-SNP options, while dual-eligible individuals in neighboring Suffolk County could choose from 17 plans. Dual-eligible individuals in states such as Wyoming and Montana were able to access only one D-SNP. Dual-eligible individuals in Illinois, North Dakota, New Hampshire, Vermont, and Alaska did not have access to a D-SNP in 2022 (and will also not have access to a D-SNP in 2024).

6. About half (52%) of D-SNP enrollees were in UnitedHealthcare or Humana plans in 2023.

UnitedHealthcare and Humana were the dominant providers of D-SNPs in 2023, accounting for 52% of total D-SNP enrollment. Enrollment in UnitedHealthcare plans alone accounted for nearly two-fifths of total D-SNP enrollment (37%) and exceeded combined enrollment of BCBS, Centene, Elevance Non-Blue, CVS Health, Kaiser Permanente, and Cigna (31%) in 2023.

Between 2018 and 2023, the share of enrollees in plans offered by smaller firms has declined from 27% to 17%. Between 2018 and 2023, the share of D-SNP enrollees choosing plans offered by Kaiser Permanente, Cigna, Centene, BCBS, and Elevance Non-Blue declined, while the share of enrollees choosing UnitedHealthcare, CVS Health, and Humana plans increased.

7. Every major insurer increased the number of D-SNP offerings between 2018 and 2024.

In plan year 2024, insurers are offering 851 plans , more than double the number offered in plan year 2018 (401). The growth in offerings between plan years 2018 and 2024 can be attributed to insurers increasing offerings in existing counties and expanding the number counties in which D-SNPs are offered.

Eight major insurers are offering 75% (638) of plans in 2024, up from 68% in plan year 2018. The remaining 25% (213) of plans are offered by smaller insurers. In plan year 2024, CVS will offer 105 plans, an increase of 98 plans since the 2018 plan year. This represents the largest growth in plan offerings among the major insurers. Kaiser Permanente will offer 10 plans, an increase of 5 plans since the 2018 plan year. This represents the smallest growth in plan offerings among major insurers.

One firm, Florida Complete Care, is entering the D-SNP market in 2024 (though it has offered other types of SNPs in prior years), while 5 firms that offered D-SNPs (Ascension, Health Choice Generations Utah, AgeWell New York, Essence Healthcare, and Vantage Health Plan) are exiting the D-SNP market. This differs from prior KFF analysis which examines entries and exits for the overall Medicare Advantage market.

8. D-SNPs are more likely than other Medicare Advantage plans to offer some extra benefits such as over the counter benefits and meal benefits.

The share of D-SNPs offering eye exams and/or eyeglasses (96%), dental care (95%), fitness benefits (94%), or hearing exams and/or aids (92%) was nearly universal for enrollees in D-SNPs as well as individual Medicare Advantage plans in 2024 (Figure 8). However, D-SNPs are more likely than individual Medicare Advantage plans to offer over the counter benefits (96% vs. 85%), meal benefits (86% vs. 72%), bathroom safety devices (32% vs. 22%), and in-home support services (23% vs. 9%). D-SNPs are also more likely to offer transportation services than other Medicare Advantage plans (88% vs. 36%). Many of the additional benefits may be covered by Medicaid as “ Medicaid wraparound services .” States are required to cover non-emergency medical transportation ( NEMT ), all states provide some home-based care (including meals, bathroom safety, or in-home supports), and many states cover some dental and vision services. D-SNPs may expand upon the services offered through Medicaid and it is unknown to what extent the D-SNP offerings supplement the Medicaid services for specific states or plans.

9. In 2021, dual-eligible individuals enrolled in a plan in a D-SNP-only contract were subject to one prior authorization request, on average.

CMS publishes prior authorization data by contract and not by plan type, which makes it impossible to document the total number of prior authorization requests or denials for D-SNP enrollees. This analysis, therefore, relies on data about contracts containing only D-SNPs, which account for about 19% of total D-SNP enrollment. Most D-SNP enrollees (81%) are in plans that are in a contract with other Medicare plan types, which means CMS does not collect or publish prior authorization data for most D-SNP enrollees.

On average, firms with contracts containing only D-SNPs received one prior authorization request per beneficiary in 2021, as compared to previous KFF analysis showing 1.5 prior authorization requests per enrollee for all Medicare Advantage plans, although that estimate included contracts that included both D-SNPs and other plans. This is somewhat surprising, considering dual-eligible individuals generally utilize more health care services than the average Medicare beneficiary.

Unlike other insurers, CVS had more prior authorization requests for enrollees in D-SNP-only contracts than for enrollees in all Medicare Advantage contracts. Prior authorizations ranged across firms from less than one per beneficiary (UnitedHealthcare) to 2.2 per beneficiary (BCBS) for contracts containing only D-SNPs.

10.Despite fewer prior authorizations in D-SNP-only plans compared to all Medicare Advantage plans, the rate of denials was twice as high.

In 2021, firms with contracts containing only D-SNPs received nearly 670,000 prior authorization requests, 12% of which were denied. This is double the denial rate for all Medicare Advantage plans (6%), according to previous KFF analysis . The rate of prior authorization request denials ranged from 5% (Humana) to 15% (CVS Health and Centene) among contracts containing only D-SNPs. Nearly 7% of just over 80,000 denials were appealed, compared to 11% of denials for all Medicare Advantage plans. Just over two-thirds (68%) of those appeals were resolved favorably, in contrast to prior KFF analysis that found over 82% of appeals for all Medicare Advantage contracts were resolved favorably.

Previous KFF analysis of Medicare Advantage prior authorization data revealed an inverse relationship between the insurer’s volume of prior authorization requests and share of requests that were denied. This relationship among D-SNP-only contracts holds for some firms, such as UnitedHealthcare and Humana, but not others. For example, Centene D-SNP-only contracts received on average 1.7 requests per enrollee, higher than the overall rate of one prior authorization request and denied 15% of those requests compared to 12% overall. As with prior authorization data, denial rates are collected and reported at the contract level, which means denial rates in D-SNP-only contracts represent a fraction of individuals enrolled in D-SNPs.

In 2021, nearly 3 in 10 (29%) dual-eligible individuals enrolled in D-SNPs, an increase from 20% in 2018. Growth in D-SNP enrollment may be driven by several factors. D-SNPs may be attractive to dual-eligible individuals due to the availability of extra benefits, including benefits that are offered more frequently in D-SNPs than Medicare Advantage plans for general enrollment, such as over the counter benefits and meals. There is also strong interest in D-SNPs among insurers, given relatively high margins . Since 2018, more insurers have offered D-SNPs and larger insurers have offered more plans. Growth in enrollment may be due to some extent to the automatic enrollment of some individuals into D-SNPs. In 2022, more than 9 in 10 dual-eligible individuals (92%) lived in counties where insurers offered at least one D-SNP, with an average of 10 D-SNPs offered per dual-eligible individual, compared to 6 plans in 2018.

While enrollment and plan availability continue to grow, it is not clear how well D-SNPs coordinate with Medicaid to provide the full range of benefits to dual-eligible enrollees. Fewer than one in ten D-SNP enrollees are in fully integrated plans.

Relatedly, little is known about the quality of D-SNPs. Because quality ratings are reported at the contract level, rather than the plan level, it is not possible to assess the quality of D-SNPs that are included in contracts with other plans, affecting most D-SNP enrollees. Most D-SNP enrollees (81%) are in plans that are part of a contract with other plans, which means the quality ratings are at the contract level, not of their specific plan. Further, MedPAC has raised concerns that the current quality measures are not sufficient to adequately assess care delivery in D-SNPs. Early attempts at quality measurements have produced mixed results, with some reporting little variation in quality measurements between plans and others reporting little difference in care quality between D-SNPs and other methods of care for dual-eligible individuals.

Lack of data transparency also contributes to limited understanding of the impact of prior authorization requirements and denials for dual-eligible individuals enrolled in D-SNPs. KFF’s analysis suggests that contracts containing D-SNPs (but no other plans) deny prior authorization requests at a much higher rate than Medicare Advantage plans overall, even though firms with contracts containing only D-SNPs received few authorization requests per enrollee. Again, because prior authorization requests and denials are reported at the contract level, it is not possible to document the number of prior authorization requests for D-SNP enrollees overall or per person, or denial rates.

Further, although most plans offer some extra benefits to D-SNP enrollees, it is not clear how often D-SNP enrollees take advantage of these extra benefits, whether insurers offer adequate networks to access these services, and whether they are of value to a population with such diverse health needs. A recent proposed rule by the Biden Administration would require insurance providers to periodically notify D-SNP enrollees if they are not utilizing supplemental benefits offered by their plan, but there is an absence of comprehensive data pertaining to the use of supplemental benefits among D-SNP and other Medicare Advantage enrollees, according to KFF . In addition, there is some concern among advocates and policymakers about marketing benefits, such as transportation, dental, and vision when dual-eligible individuals may already be eligible for these services through Medicaid . Given the significant needs of the dual-eligible population, and incentives for rapid growth in D-SNP enrollment, including proposed policy changes to institute Special Enrollment Periods to increase D-SNP participation, greater insight into the experiences of D-SNP enrollees would be valuable for beneficiaries and policymakers.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Salama Freed, Meredith Freed, Jeannie Fuglesten Biniek, Nolan Sroczynski, and Tricia Neuman are with KFF. Anthony Damico is an independent consultant.

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What veterans need to know about Medicare enrollment

There is value in enrolling in Medicare at 65 even if you’re a veteran who uses VA benefits.

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Dear Toni: My husband, Jason, is a Vietnam veteran and never enrolled in Medicare Part B because he uses the VA for medical care. He is 77 years old and retired at 65.

Because he is having heart issues, he wants to go to a local cardiologist that his best friend uses and must now enroll in Medicare for that to happen. Social Security advised Jason that he must pay more to enroll in Part B because he never enrolled when he turned 65 in 2011.

We need your guidance. Is there a way that he can take Part B without having to pay the extra penalty? — Christina from Tampa, Florida

Dear Christina: Because Jason did not enroll in Medicare when he turned 65 and was no longer working with true employer benefits, he will incur a penalty when he applies during Medicare’s general enrollment period (Jan. 1 to March 31).

Now is the time for Jason to enroll in both Part A and Part B. His late enrollment penalty will be 10 percent for each year that he could have had Part B but did not sign up for it. In his case, it will amount to an extra 120 percent each month for the rest of his Medicare life. For 2024, that would add $209.60 per month to the Part B premium of $174.70.

No one ever knows when they will need health care beyond what the VA offers. This is the value of enrolling in Medicare at 65, whether you’re a veteran who uses the VA or someone who only has Medicare.

But there is some good news for Jason. Not enrolling in Medicare Part D prescription drug coverage is a different story. Medicare considers the VA to be creditable coverage, so when veterans with VA benefits enroll in Part D later, they do not incur a late-enrollment penalty.

And some more good news: If the premium is too expensive, Jason can remain with the VA and explore his options for non-VA medical care by contacting his VA center and asking for outside referrals.

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email [email protected] or call 832-519-8664.

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  1. PDF Your guide to who pays first.

    Coordination of benefits If you have Medicare and other health coverage, you may have questions about how Medicare works with your other insurance and who pays your bills first . Each type of coverage is called a "payer ." When there's more than one payer, "coordination of benefits" rules decide who pays first .

  2. VA Health Care And Other Insurance

    Yes. We encourage you to sign up for Medicare as soon as you can. This is because: Having Medicare means you're covered if you need to go to a non-VA hospital or doctor—so you have more options to choose from. Funding for VA health care could change in the future.

  3. VA and Other Health Insurance

    Enrolled Veterans can provide or update their insurance information by: Using the online Health Benefits Renewal form (10-10-EZR) at www.vets.gov/healthcare/apply/ Calling 1-877-222-VETS (8387) Monday through Friday between 8 a.m. and 8 p.m. ET.

  4. Coordination of Benefits

    Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more t...

  5. How Veteran Affairs (VA) Benefits & Medicare Work Together

    There is no coordination of benefits between the two health care programs. In some cases though, the VA can authorize health care services in a non-VA hospital. If the VA did not authorize all the medical care you received while there, Medicare may step in to pay for Medicare-approved services you received.

  6. PDF Coordination of Benefits.

    To help coordinate benefits, insurance companies must tell Medicare about coverage they ofer people with Medicare. Your insurance company or your employer may ask you for your name, date of birth, gender, and Medicare Number (located on your red, white, and blue Medicare card) so they can update Medicare about your other insurance.

  7. Making Part B enrollment decisions with VA benefits

    VA benefits will not pay for Medicare cost-sharing (deductibles, copayments, coinsurances). Note: If the VA authorizes services in a non-VA hospital, but does not pay for all the services you get during your hospital stay, Medicare may pay for Medicare-covered services the VA does not pay for.

  8. VA benefits basics

    Health benefits include coverage for: Medical and mental health care (including substance abuse treatment) Home health care. Nursing home care. Durable medical equipment (DME) Medicare-excluded items (including over-the-counter medications and supplies, annual physical exams, hearing aids, and eyeglasses under certain circumstances) Eligibility ...

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    If a beneficiary has Medicare and other health insurance, Coordination of Benefits (COB) rules decide which entity pays first. There are a variety of methods and programs used to identify situations in which Medicare beneficiaries have other insurance that is primary to Medicare.

  10. How Veterans Can Make Sense of Medicare and VA Benefits

    The VA usually encourages veterans to enroll in both Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). You typically don't have to pay a premium for Part A, while the standard Part B premium for 2024 is $174.70 or higher, depending on your income. Part B covers Medicare-approved doctor's services and outpatient ...

  11. PDF Module 5: Coordination of Benefits

    You may complete the Initial Enrollment Questionnaire online at MyMedicare.gov, or over the phone by calling the Coordination of Benefits Contractor at 1-800-999-1118. TTY users should call 1-800-318-8782. The COB Contractor initiates an investigation when it learns that a person has other insurance.

  12. Medicare for Veterans

    Medicare and VA coverage do not coordinate benefits Medicare and VA (Veterans Affairs) insurance do not coordinate coverage. The only instance in which the two programs might team up to offer dual coverage is when the VA approves qualified care to be received at a non-VA facility.

  13. Coordinating Medicare with Other Types of Insurance

    Access exclusive toolkits full of useful fliers, infographics, presentations, and more to help you navigate complex Medicare topics. Receive updates about Medicare Interactive and special discounts for MI Pro courses, webinars, and more. These sections explain how Medicare coordinates with other kinds of insurance to cover care, and how to ...

  14. Health insurance: How coordination of benefits works

    Coordination of benefits (COB) allows you to have multiple health insurance plans. COB allows insurers to determine which insurance company will be the primary payer and which will be the secondary if you have two separate plans.

  15. VA Benefits & Medicare

    Both VA Benefits and Medicare provide comprehensive medical coverage for a variety of needs. However, they work in different places. If you go to a VA facility for your medical care, your VA medical benefits will apply. However, outside that system, you have to pay the full cost yourself, even in an emergency. ...

  16. Medicare Coordination of Benefits

    Key Takeaways If you have Medicare along with another health plan, the coordination of benefits determines which plan pays first when you receive health care. The insurer who pays first is called the primary payer and pays all costs up to the limit of that plan.

  17. Guide to Medicare Coverage and Enrollment for Veterans

    For Veterans to be eligible for Medicare, they must be 65 years or older and enrolled in Medicare Part B or have end stage renal disease (ESRD), a qualifying disability, or amyotrophic lateral ...

  18. Affordable Care Act (ACA) And Your Coverage

    The Affordable Care Act (ACA) and your VA health care coverage. The Affordable Care Act (ACA)—also known as the health care law—was created to expand access to coverage, control health care costs, and improve health care quality and care coordination. Find out what you need to know about the ACA and your health coverage.

  19. Coordination of benefits basics

    Coordination of benefits basics. Access monthly virtual presentations on current Medicare topics hosted by the Medicare Rights Center. Bookmark your favorite courses and answers for quick reference. Access exclusive toolkits full of useful fliers, infographics, presentations, and more to help you navigate complex Medicare topics.

  20. 10 Things to Know About Medicare Advantage Dual-Eligible Special ...

    D-SNPs are required to provide greater coordination of Medicare and Medicaid benefits than other Medicare Advantage plans to improve coordination across programs and patient outcomes ...

  21. CHAMPVA Benefits

    You'll need to apply for these benefits. To apply, submit these required documents: Application for CHAMPVA Benefits (VA Form 10-10d), and. Other Health Insurance Certification (VA Form 10-7959c), and. Documents related to your Medicare status: If you qualify for Medicare for any reason, you'll need to submit a copy of your Medicare card.

  22. What veterans need to know about Medicare enrollment

    Dear Toni: My husband, Jason, is a Vietnam veteran and never enrolled in Medicare Part B because he uses the VA for medical care. He is 77 years old and retired at 65. Because he is having heart ...

  23. 2024 Recovery Thresholds for Certain Liability Insurance, No-Fault

    Medicare-Medicaid Coordination Office; Qualified Medicare beneficiary program; Financial alignment initiative; Initiative to reduce avoidable hospitalizations ; Program of All-Inclusive Care for the Elderly (PACE) Resources for Medicare-Medicaid plans; Resources for state Medicaid agencies; Center for Program Integrity; Healthcare Fraud ...