SSA - POMS: HI 00620.070 - Illustrations

A. State veterans homes

Many State governments operate veterans homes and hospitals. These institutions are generally open only to veterans and certain dependents of veterans, and include domiciliary, hospital, infirmary, and nursing home type facilities. These institutions are financed primarily from State funds; in addition, most receive nominal per diem payments from the VA for domiciliary, hospital, or nursing home type care for each veteran who would also qualify for admission to a VA hospital or domiciliary.

Where such a participating institution charges its residents and patients to the extent of their ability to pay, or seeks payment from available sources other than Medicare, benefits are payable for covered items and services furnished to Medicare beneficiaries. However, if it is the policy of the institution to admit and treat a veteran without charge simply because the individual is a veteran, or because the individual has a service-connected condition, payment is precluded under title XVIII.

Per diem amounts paid by the VA to State veterans homes on behalf of patients who are otherwise eligible for care in a VA facility may be credited towards any deductible, coinsurance, or noncovered amounts required to be paid by the patient. However, if a State veterans home collects amounts from the VA in excess of the applicable deductible and coinsurance, the Medicare payment is reduced to the extent of such excess.

B. State and local psychiatric hospitals

Payment may be made under Medicare for covered services furnished without charge by State or local psychiatric hospitals which serve the community. However, payment may not be made for services furnished without charge to individuals who have been committed under a penal statute (e.g., defective delinquents, persons found not guilty by reason of insanity, and persons incompetent to stand trial). For Medicare purposes such individuals are “prisoners,” as defined in subsection C, and may have services paid by Medicare only under the exceptional circumstances described there.

C. Prisoners

Generally, no payment is made for items or services rendered to prisoners, since the State (or other government component which operates the prison) is responsible for their medical and other needs.

For this purpose, the term “prisoner” means a person who is in the custody of the police, penal authorities, or other agency of a governmental entity. This is a rebuttable presumption that may be overcome only at the initiative of the government entity. However, the entity must establish that:

1.

State or local law requires that individuals in custody repay the cost of the services.
2.

The State or local government entity enforces the requirement to pay by billing and seeking collection from all individuals in custody with the same legal status (e.g., not guilty by reason of insanity), whether insured or uninsured, and by pursuing collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts. This includes collection of any Medicare deductible and coinsurance amounts and the cost of items and services not covered by Medicare.
3.

The State or local entity documents its case with copies of regulations, manual instructions, directives, etc., spelling out the rules and procedures for billing and collecting amounts paid for by prisoners' medical expenses.

D. TRICARE and CHAMPVA (Civilian Health and Medical Program of the Veterans Administration)

1. General

TRICARE and CHAMPVA are similar programs administered by the Department of Defense, and Veterans Administration, respectively.

TRICARE is the Department of Defense's health care program for retired members of the uniformed services, as well as the spouses and children of active duty, retired and deceased service members.

TRICARE is considered a group health plan for SEP and premium surcharge rollback purposes. However, these provisions apply only to beneficiaries whose coverage under TRICARE is based on active-duty military status. These individuals can enroll (or reenroll) in SMI during any month while they are covered under TRICARE or during the 8-month period that begins the month following the last month that TRICARE coverage was based on active-duty military status.

CHAMPVA provides benefits for spouses and children of veterans who are entitled to VA permanent and total disability benefits and to surviving spouses and children of veterans who died of service-connected disabilities.

The governmental entity exclusion does not preclude Medicare payment for items or service furnished to a beneficiary who is also eligible for TRICARE/CHAMPVA benefit payment for the same services. Medicare is the primary payer for such items and services, and TRICARE/CHAMPVA is a supplementary payer.

2. Effect of Medicare eligibility on TRICARE entitlement

TRICARE beneficiaries, other than dependents of active duty members, lose their entitlement to TRICARE if they qualify for Medicare Part A on any basis except the premium-HI provisions. Individuals eligible for Medicare Part B benefits only, do not lose their entitlement to TRICARE benefits. If a Medicare beneficiary who has lost entitlement to TRICARE upon becoming entitled to Part A of Medicare, thereafter exhausts any Part A benefits, the individual can again be entitled to TRICARE. Once the individual reattains TRICARE benefits, the individual will not lose them by virtue of later again becoming eligible for Medicare Part A benefits. There is no similar provision for TRICARE which enables an individual to reattain TRICARE eligibility after exhausting Medicare Part A benefits. Direct questions concerning this provision to the TRICARE Center.

3. MEDICARE-TRICARE/CHAMPVA relationship

TRICARE - If an individual is eligible for both TRICARE and Medicare Part A, then in most cases, they must have Medicare Part B to keep TRICARE.

If an individual is eligible for TRICARE and has Medicare Part A and Part B, TRICARE For Life provides wraparound coverage which pays out-of-pocket costs in original Medicare for TRICARE covered services. Medicare and TRICARE coordinate benefits which eliminates the need for the individual to file claims.

For more information on how TRICARE and Medicare work together, visit the TRICARE website.

For information on active-duty beneficiaries or their spouses, see HI 00805.325.

CHAMPVA - An individual with CHAMPVA who also qualifies for Medicare at any age must have both Medicare Part A and B to continue their CHAMPVA eligibility. See the VA Fact Sheet for more information on CHAMPVA and Medicare.

If a CHAMPVA beneficiary also has Medicare coverage, CHAMPVA reduces its liability by the amount payable by Medicare, i.e., Medicare is the primary payer and CHAMPVA supplements Medicare by paying the Medicare deductible and coinsurance amounts and portions of the bill not covered by Medicare. Thus, dually entitled individuals may be reimbursed up to 100 percent of expenses for items and services covered by both programs

E. Active-duty members of the uniformed services

In limited circumstances, active-duty members of the Uniformed Services may have care in civilian facilities paid for by the Army, Navy, Air Force, Marine Corps, or other appropriate uniformed service. Except for emergency services, prior approval is generally required before such payment can be made. Services furnished pursuant to such approval and services paid for or expected to be paid for by the Uniformed Services are not reimbursable under Medicare.

Social Security

Program Operations Manual System (POMS)

HI 00620.070 Illustrations