Page 9 - Medicare Benefit Policy Manual

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