First, the easy part: If you are enrolled in TRICARE, you do not need to do anything different under the Affordable Care Act. Your TRICARE benefits are fully qualified under the terms of the ACA and you don’t need to take any action as long as you are in TRICARE.
For honorably discharged veterans, however, the situation is quite a bit more complicated. Unless you meet certain unusual conditions* the Affordable Care Act requires you to obtain a qualified health insurance policy by March 31, 2014. If you fail to do so, you will be subject to a fine of $95 per adult individual and $49 per family member, up to a max of $285 per family, or 1 percent of family income – whichever is greater.
After Jan 1, 2015, those penalties go up sharply: To $325 per adult and $162 per child, up to a family maximum penalty of $975, or 2 percent of annual income, whichever is less.
The penalty increases again on January 1, 2016. The penalty for that year is $695 per adult and $347 per child, up to $2,085 per family, or 2.5 percent of income, whichever is greater.
I’m a Veteran. Does VA Insurance Count?
Yes, VA insurance counts. But you actually have to enroll in the VA health program to have it qualify. It is not sufficient just to be a veteran. You must take positive steps to make sure you’re enrolled with the VA. Not everybody qualifies. For example, if you’re a Guard or Reserve member, and you’ve never been mobilized, and your only active duty time was for training, you don’t qualify for VA coverage.
Generally, you will qualify if you either served 24 consecutive months on active duty, or for the full period for which you were called for active duty if you were mobilized, and you enlisted after September 7th, 1980.
However, if you didn’t make 24 consecutive months, or had to leave duty early because of a wound or service-related injury, you can still qualify. You aren’t going to get disqualified just because you got hurt.
How to apply for VA coverage.
You aren’t automatically covered just because you are an honorably-discharged veteran, even if you meet the criteria. To enroll, visit the VA Benefits Explorer page on the Web. From that page, you can do a trial run to see if you qualify for VA coverage, and specifically what benefits and price structure you qualify for. (There are no premiums for VA coverage, but you will have to pay some copays and there are limits).
What about family members?
In most cases, the veteran’s family members will not qualify to enroll in the VA health care system. Spouses and children will generally need to obtain qualifying coverage, either through an employer plan or through an individual plan. The individual plan can be purchased either via the online exchanges or through a licensed health insurance agent.
VA Priority Groups
If you qualify, the VA will assign you to one of eight priority groups, based on your location, income and the nature of your service. If you qualify for more than one group, the VA will put you in the higher of the available groups. The groups are listed below:
Priority Group 1
- Veterans with VA Service-connected disabilities rated 50% or more.
- Veterans assigned a total disability rating for compensation based on unemployability.
Priority Group 2
- Veterans with VA Service-connected disabilities rated 30% or 40%.
Priority Group 3
- Veterans who are former POWs.
- Veterans awarded the Purple Heart Medal.
- Veterans awarded the Medal of Honor.
- Veterans whose discharge was for a disability incurred or aggravated in the line of duty.
- Veterans with VA Service-connected disabilities rated 10% or 20%.
- Veterans awarded special eligibility classification under Title 38, U.S.C., § 1151, “benefits for individuals disabled by treatment or vocational rehabilitation.”
Priority Group 4
- Veterans receiving increased compensation or pension based on their need for regular Aid and Attendance or by reason of being permanently Housebound.
- Veterans determined by VA to be catastrophically disabled.
Priority Group 5
- Non-service-connected Veterans and noncompensable Service-connected Veterans rated 0%, whose annual income and/or net worth are not greater than the VA financial thresholds.
- Veterans receiving VA Pension benefits.
- Veterans eligible for Medicaid benefits.
Priority Group 6
- Compensable 0% Service-connected Veterans.
- Veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki.
- Project 112/SHAD participants.
- Veterans who served in the Republic of Vietnam between January 9, 1962 and May 7, 1975.
- Veterans who served in the Southwest Asia theater of operations from August 2, 1990, through November 11, 1998.
- Veterans who served in a theater of combat operations after November 11, 1998, as follows:
- Veterans discharged from active duty on or after January 28, 2003, for five years post discharge
Priority Group 7
- Veterans with incomes below the geographic means test (GMT) income thresholds and who agree to pay the applicable copayment.
Priority Group 8
- Veterans with gross household incomes above the VA national income threshold and the geographically-adjusted income threshold for their resident location and who agrees to pay copays.
Veterans eligibility for enrollment:
Noncompensable 0% service-connected and:
- Subpriority a: Enrolled as of January 16, 2003, and who have remained enrolled since that date and/ or placed in this subpriority due to changed eligibility status.
- Subpriority b: Enrolled on or after June 15, 2009 whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less
Veterans eligible for enrollment:
- Subpriority c: Enrolled as January 16, 2003, and who remained enrolled since that date and/ or placed in this subpriority due to changed eligibility status
- Subpriority d: Enrolled on or after June 15, 2009 whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less
Veterans not eligible for enrollment:
Veterans not meeting the criteria above:
- Subpriority e: Noncompensable 0% service-connected
- Subpriority g: Non-service-connected
*Exceptions apply if you are:
- A member of a religious group that is opposed to accepting benefits from an insurance policy
- You are an illegal alien
- You are incarcerated
- You are a member of an Indian tribe
- Your family is below the income threshold for filing an income tax return ($10,000 per individual and $20,000 for family members starting in 2013)
- You have to pay more than 8 percent of your income for health insurance, net of any tax credit or employer contribution.
You may also be exempt if:
- You were enrolled in Medicare, Medicaid or the Children’s Health Insurance Program (CHIP) at any time during the year
- You’re enrolled in TRICARE
- You’re in an employer-sponsored plan
- You have insurance of your own that is “Bronze” level or better,
- You have a grandfathered health plan that was in existence prior to the ACA.
Under the ACA, income is defined as total income in excess of the filing threshold. The penalty is pro-rated by the number of months without coverage. There is no penalty for gaps of 3 months or less. The penalty cannot be greater than the national average cost of a Bronze-level plan offered on the exchanges. (Source: Kaiser Family Foundation).
Any big new government initiative brings confusion with it, and the Patient Protection and Affordable Care Act – known colloquially as “Obamacare” – is no exception. The flood of information about mandates, exchanges, fines, taxes, penalties, lawsuits and rulings has boosted the noise-to-signal ratio about the ACA, and left millions – especially seniors – scratching their heads.
Naturally, a small army of frausters, shysters and criminals have stepped in to exploit the confusion.
This article from CNBC outlines some of the scams we’re already seeing – and Obamacare hasn’t even been rolled out yet.
- Con artists have created websites designed to fool people into thinking they are logging onto the online exchange system to buy health insurance when they are not.
- Criminals are telling seniors that in order to qualify for coverage under Obamacare, they must buy an “insurance card.” In some cases, con artists are telling seniors they can even go to jail if they don’t buy the card.
- Fraudsters are calling people and posing as “navigators,” there to help people through the system. Once they earn the mark’s trust, they exploit it to gain personal information, including Social Security numbers, birthdates, bank account numbers and other sensitive information. They then empty the victim’s accounts and disappear.
- Some of these criminals are claiming to be officials with Medicare, Medicaid, the Department of Health, Obamacare, or other government agency.
Here are some things to keep in mind that are of particular relevance for veterans and military families:
Tricare beneficiaries do not need to do anything. Tricare continues as it has before, and is not affected by the Affordable Care Act at all. You don’t need ‘navigators,’ and you don’t need to go onto the online exchanges. The same applies to veterans enrolled with the Veterans Administration for their health care.
The exchanges are not even slated to be live until October 1. You cannot buy a policy under the exchanges until that date. Any website billing itself as an Obamacare ‘exchange’ and trying to sell you a policy before that date is likely fraudulent.
You do not need to buy an “insurance card.”
No one from the government is or will be calling to get personal information over the phone.
If you are not a Tricare or VA health care beneficiary and you want more information about health care and the exchanges in your state, start with www.healthcare.gov.
“If you like your health care plan, you can keep it.” That was the promise Barack Obama made in 2009, selling his health reform plan that became the Affordable Care Act.
It turns out that’s not even true for federal TRICARE beneficiaries.
If you live more than 40 miles from a military installation, chances are you are no longer welcome with TRICARE Prime. Pentagon officials have announced that most of these retired and surviving widow(ers) will be booted from TRICARE Prime as of October 1.
Most of those affected will have to enroll in TRICARE Standard.
The change will not affect those enrolled in Medicare and using TRICARE for Life, nor will those on active duty. However, the change will affect any adults under age 26 enrolled in the TRICARE Young Adult program, if they are over 40 miles from a military installation.
This is actually a six-month reprieve – officials were originally considering forcing enrollees off of TRICARE Prime as of April 1.
TRICARE officials are looking at making an exception for those within 100 miles of primary care managers if they sign a drive-time access waiver.
What does this mean? According to the Reserve Officers Association of America, you may have to find a new doctor.
Also, your costs will change: You will no longer pay flat co-payments per visit and an annual enrollment fee. Instead, you will have to pay a deductible of $150 per year (for singles) or $300 per year (for families), as well as a 25 percent co-insurance – up to $3,000 per fiscal year.
There is the potential for an exception for retired servicemembers, military families, and young adults to remain in Prime if they reside within 100 miles of an available primary care manager and sign a drive-time access waiver.
The Pentagon estimates that limiting TRICARE Prime coverage to those outside of 40 miles of military installations will save taxpayers some $56 million per year.
TRICARE Standard, incidentally, has higher customer satisfaction ratings than TRICARE Prime, according to the Military Officers Association of America.
Ironically, even as the U.S. government kicks 170,000 of its own retirees, survivors and adult children of servicemembers off of their preferred health insurance plan, the White House still maintains on its website that rumors of people being forced to change doctors or forced off their health care plans is a “myth.”