Understanding Health Care Benefits for Veterans

Everything you need to know about insurance coverage as a civilian

Vicki Salemi,

AARP Experience Counts

Comments

En español

Published July 13, 2023

AVR Staff/Getty Images

If you’re having trouble deciphering health care benefits, you’re not alone. Transitioning from TRICARE’s free coverage as an active-duty member to coverage as a civilian, with costs and unfamiliar jargon, may feel overwhelming.

closeup of a rusty dog tag with the text thank you veterans engraved in it, next to a flag of the United States

You can subscribe here to AARP Veteran Report, a free e-newsletter published twice a month. If you have feedback or a story idea then please contact us here.

According to recent research, the majority of Americans said they’re “completely lost when it comes to understanding health insurance.”

Here’s a straightforward guide that breaks down coverage, so the next time you’re deciphering a PCP from an HMO, you’ll own the basics.

Securing health care benefits

TRICARE provides 180 days of free transitional health care when you transition from active-duty member to veteran.

You should apply for VA health care. All veterans are eligible for extensive free services that include preventive care, inpatient hospital services, urgent and emergency care services, mental health services, prescriptions (written by or approved by a VA doctor), and routine eye exams and preventive tests. Only some will qualify for added benefits, such as dental care.

Many vets secure coverage through their employer (a monthly premium is deducted from paychecks). If your employer doesn’t offer it or if you’re self-employed, you’ll select a plan through the government’s marketplace or an insurance provider. Coverage and costs vary. Universal coverage does not exist.

Every year in November and December, you can select a plan based on the coverage and amounts. Even if you roll over your current plan, costs usually increase. Additionally, when you experience a life change such as a change of address, you become eligible to update your health care coverage during the year outside of annual open enrollment.

Selecting your employer’s coverage

If you are in the process of getting a new job, ask the employer when your health coverage eligibility starts: Is it the first day of employment or the first day of the subsequent month? For instance, if you start on April 10, will it begin on April 10 or on May 1?

In case emergencies arise, there shouldn’t be gaps in coverage from your current coverage to your new coverage. Depending on your plan, it may be employee-only, or you may be eligible to add dependents.

Health care coverage tied to your employer means that when you no longer work there, you’ll no longer have this coverage.

If your job is terminated (or if you fall into another qualifying event), you’ll have 60 days to enroll in the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA provides a temporary extension of health coverage for up to 18 months. While the monthly premium is higher than what you paid as an employee, it can be extended to 36 months if you are eligible for a second qualifying event during this time (i.e., death of a spouse).

Understanding the network

Essentially, you’ll have one of two types of medical plans: the HMO or the PPO.

The health maintenance organization, better known as the HMO, has a network of doctors, hospitals and health care providers in its network. By contrast, a preferred provider organization, also known as a PPO, offers more flexibility to see providers who are in and out of the network.

HMO costs tend to be less expensive than PPO costs. Typically, the HMO requires your primary care physician (PCP) to provide referrals to other physicians in the network before you see them, whereas the PPO does not require referrals.

Breaking down dollars and cents

Similar to how plans vary, payment structures vary as well. If your copay is $50 for a doctor’s visit, then you can expect to pay $50 during that appointment.

Or your payment may be part of a deductible that needs to be reached with a subsequent percentage known as coinsurance. For instance, if a plan has a $2,000 deductible, you’ll be out of pocket for $2,000, and then you’ll pay 20 percent beyond that during the year (or whatever the coinsurance percentage is for your plan). Amounts differ by plan.

The key to understanding your plan involves comprehension of how payments work, especially when tests were done and a hospital stay was involved, and you receive a statement in the mail that indicates: “This is not a bill.”

When in doubt, call your insurance company to understand your out-of-pocket costs and when payments are due. Also, you may want to inquire about your prescription plan and costs for generic versus specialty drugs.

If your insurance company indicates that a test that your doctor performed was not necessary and is therefore not covered so you are responsible for the entire cost, you have the right to appeal.

Consider your health care coverage as not only a patient and paying customer, but as an informed consumer to know your rights as well. Don’t forget to check out the AARP Veterans Health Benefits Navigator.