CMS Pub. 100-02, ch. 16, § 50.1.1

A3-3153.1.A, B3-2309.2, A3-3153.1.E, HO-260.3.B

Generally, an authorization issued by the Veterans’ Administration (VA) binds the VA to

pay in full for the items and services provided. No payment is made under Medicare for

such authorized services.

NOTE: Medicare can reimburse veterans for (or credit toward Medicare deductible or

coinsurance amounts) VA copayment amounts charged for VA authorized services

furnished by non-VA sources.

Medicare does not pay for any item or service rendered by a non-Federal provider

pursuant to an authorization issued by a Federal agency, under the terms of which the

Federal government agrees to pay for the services.

The VA may authorize non-Federal providers or private physicians or other suppliers to

render services at Federal expense. For example, the VA may pay for treatment of

veterans in non-VA hospitals for service connected disabilities and, in certain

circumstances, for nonservice-connected disabilities, provided the VA has given prior

authorization for the services. The VA may also agree to pay for emergency services

furnished a veteran who appears at a hospital without prior authorization, provided a

notification of the veteran’s admission and a request for authorization to provide care at

VA expense is submitted to the VA within 72 hours after the admission.

As a general rule, the VA does not authorize inpatient services at non-VA facilities for

treatment of nonservice-connected conditions. Accordingly, the A/B MAC (A) should

receive few, if any, requests for reimbursement for a VA copayment for treatment in a

non-VA provider. If a beneficiary requests reimbursement for the amount of the VA

copayment, the beneficiary must submit to the A/B MAC (A), along with their request,

VA Form 10-9014, Statement of Charges for Medical Care. These requests will be

handled on an ad hoc basis. For further guidance contact:

Centers for Medicare & Medicaid Services

Center for Medicare Management

Provider Billing Group

7500 Security Boulevard

Baltimore, Maryland 21244-1850

The VA may authorize up to six months of care in non-VA SNFs for veterans requiring

such care after transfer from a VA hospital. Services furnished pursuant to a VA

authorization do not count against the 100 days of extended care benefits available in a

benefit period. Where a veteran remains in a SNF until VA benefits are exhausted,

extended care benefits could begin under Medicare. Such benefits begin with the first

day after the VA benefits are exhausted, provided a physician certifies that the individual

still requires skilled nursing care on a continuing basis for a condition for which the

patient received inpatient hospital services or which arose while the patient was still

being treated in the facility for such a condition. The 3-day qualifying hospital stay and

30-day transfer requirements of the law must be met as of the time of entrance to the

facility.

Where an authorization from the VA was not given to the party rendering the services,

Medicare payment is not precluded even though the individual might have been entitled

to have payment made by the VA had they requested the authorization. Also, Medicare

secondary benefits may be payable where the VA authorizes fewer days than the total

number of covered days in the stay.

Generally it is advantageous for Medicare beneficiaries who are veterans to have items

and services paid for by the VA where possible, since in most cases the VA has no

deductible or coinsurance requirements. Also, services paid for in full by the VA do not

count against the individual’s maximum number of benefit days or visits available in a

Medicare benefit period.

However, the VA may charge veterans copayments for treatment of nonservice-connected conditions (during periods of 90 days duration within a period of 365 days) if a

veteran’s income exceeds a specified amount (38 CFR Part 17). The VA may charge the

beneficiary a copayment for physician/supplier and outpatient services. The amount of

the copayment is equal to 20 percent of the estimated average cost (during the calendar

year in which the services are furnished) of an outpatient visit in a VA facility. The VA

determines the estimated average cost. The beneficiary pays the copayment amount

directly to the VA, i.e., the VA does not reduce its payments to physicians/suppliers or

for outpatient services. The total amount of a veteran’s copayment obligation for all

services received (inpatient and outpatient, authorized or furnished directly by the VA)

during any 90-day period within the 365-day period cannot exceed the amount of the

inpatient Medicare deductible in effect on the first day of the 365-day period. Medicare

pays secondary benefits to the beneficiary for VA copayment amounts in accordance with

§§50.1.4.

The charges for the following services are credited to the Medicare deductibles, on the

basis of Medicare fee schedule or allowable amounts, even though the Federal Agency

(VA) has not yet paid for them.

• Charges for services that exceed the VA copayment;

• Services rendered in a non-VA facility that are not authorized by the VA; or

• Services rendered after VA benefits are exhausted in a non-VA facility.

Crediting of VA payments to Medicare deductibles is handled in the same manner as the

crediting of employer group health plan payments. See Pub 100-05, the Medicare

Secondary Payer (MSP) Manual, Chapter 3, for billing and Chapter 5 for payment

instructions. Medicare can pay for such services where neither the physician/supplier nor

beneficiary has claimed benefits from the VA.

Medicare may also pay for (covered) services for which the VA does not make any

payment. For example, if a veteran is authorized “fee basis” care at VA expense for a

service connected back injury, and receives treatment for a different condition for which

the VA does not pay, Medicare can pay for the (covered) services that are not

reimbursable by the VA.