Veteran Access to Multiple Forms of Health Care Coverage

The U.S. health insurance system is composed of a variety of insurance and care coverage types with different eligibility requirements, coverage rules, and costs. U.S. residents may be eligible for more than one form of insurance coverage or ways to access free or low-cost care. For example, U.S. military veterans may be enrolled in the Veterans Health Administration (VHA) and might also be covered by Medicare. Having multiple ways to get health care coverage and seek health care can lead to confusion on the part of patients, providers, and institutions providing care, and those paying for care (i.e., private or government-sponsored insurers) about which source pays for — or should pay for — specific services. Enrollment in multiple forms of health care coverage indicates potential inefficiencies and raises questions about whether different programs are making duplicative payments for the same care or providing duplicative coverage for the same patient (Meyers et al., 2024). Throughout the paper, coverage is used to describe any way in which veterans receive health care and includes both insurance coverage and care coverage (such as the direct services that VHA provides).

This paper is intended for policymakers who are interested in creating a more efficient health care delivery system for veterans. We focus on veterans who are enrolled in VHA and have insurance coverage. First, we briefly describe which veterans are eligible to enroll in VHA and how the U.S. Department of Veterans Affairs (VA) health care system provides services, but is not insurance coverage. Next, we discuss the prevalence of insurance coverage (e.g., Medicare, private health insurance) among veterans enrolled in VHA, where veterans with other sources of health care coverage receive health care, and who pays for it. We discuss the situations in which potential overpayments for care and coverage may arise and conclude with suggested directions for future research and policy options to consider that may help to reduce potential overpayments for care and coverage.

Which Veterans Are Eligible to Enroll in VHA, and What Services Does VHA Provide?

VHA is a health care system, not an insurance program, that provides eligible veterans with health care services at VA-owned facilities and, in some cases, pays for care received from non-VA providers in the community (Panangala and Sussman, 2023; Rasmussen and Farmer, 2022). Not all veterans are eligible to enroll in VHA. Eligibility is based on how long a veteran served in the military, whether they have a health condition related to their military service, their income, and other factors. Veterans who are eligible must enroll with VHA and are assigned to one of eight priority groups, which determine how much they pay out of pocket for VHA services (VA, 2025a). Once veterans are enrolled with VHA, they do not need to reapply for benefits each year. However, the number of veterans for which VHA can provide services in a given year depends on the budget authorized by Congress for that year. Although, historically, VHA has not limited the provision of services to the different priority groups, the priority group structure allows the VA Secretary to limit access to services if there are budget constraints. Veterans in Priority Group 1 receive the highest priority for services, and veterans in Priority Group 8 receive the lowest priority.

VHA enrollees may seek care at VA facilities for both service-connected and non-service-connected conditions and may be required to pay a copayment depending on their priority group and the type of care they received (VA, 2025b). In 2025, VHA enrollees in all priority groups pay no copayments for primary care and specialist visits related to service-connected conditions, but those in Priority Groups 7 and 8 pay $15 for primary care visits and $50 for specialist visits for non-service-connected conditions. VHA enrollees in Priority Group 1 do not pay anything for prescription medications, while those in other groups pay $5, $8, or $11 copayments per month supply depending on the drug dispensed. In addition, VA does pay for services, such as elder care or long-term care, for the first 21 days of care in a 12-month period. After the first 21 days, the veteran has a daily copay of up to $97 per day, based on the veteran's income and the type of care they receive.

Veterans enrolled in VHA may also receive health insurance coverage from sources that include private commercial insurance, Medicare, Medicaid, and TRICARE. These other sources of coverage are described briefly in the following box.

In 2023, about 84 percent of more than 8.2 million VHA-enrolled veterans reported that they had some form of insurance coverage (Trilogy Federal, 2023). Table 1 shows the number and percentage of VHA enrollees with each type of health insurance coverage.

Insurance Type	Number Enrolled	Percentage Enrolleda
Medicare	4,151,876	50.5
TM	3,211,722	39.0
MA	940,154	11.4
Part Db	1,047,303	12.7
Medigapc	1,074,647	13.1
Medicaid	410,757	5.0
TRICARE	2,299,854	28.0
Private commercial	2,427,832	29.5
No other coverage	1,344,179	16.3

SOURCE: Trilogy Federal, 2023.

^a The percentage enrolled was calculated with all VHA enrollees as the denominator (weighted N = 8,228,035).

^b Beneficiaries enrolled in Part D are also enrolled in either TM or an MA plan.

^c Beneficiaries enrolled in Medigap plans are also enrolled in TM.

Medicare is the single largest source of insurance coverage for VHA enrollees, with over 50 percent enrolled in either TM or an MA plan. Of those beneficiaries with Medicare coverage, about three-quarters chose TM, and one-quarter chose to enroll in an MA plan. These enrollment choices may be because of the ability of beneficiaries with TM to see any provider who accepts Medicare; MA can have more-limited provider networks and prior authorization requirements. About one-quarter of VHA enrollees with Medicare also chose to enroll in a Medicare Part D plan, which provides coverage for prescription drugs filled via retail or mail-order pharmacies. A similar proportion elected to enroll in a Medicare supplemental (Medigap) plan.

TRICARE and private commercial insurance are the second and third largest sources of insurance coverage, with 28.0 and 29.5 percent of VHA enrollees indicating that they have each of these two types, respectively. Finally, relatively few VHA enrollees have Medicaid coverage, with only 5 percent reporting this type. Only 16.3 percent of VHA enrollees have no other coverage at all.

Is VHA Care Not Enough?

VHA enrollees may choose to enroll in or maintain insurance coverage from private companies or government-subsidized programs to preserve their ability to choose where to seek care, including via VA facilities or private hospitals and providers. For VHA enrollees in lower priority groups (e.g., those in Priority Groups 7 or 8), this approach also protects them in the event that the VHA budget for a given year does not permit VHA to provide health care services to those priority levels. VHA encourages veterans specifically to keep other sources of coverage for this reason and also notes that veterans may wish to maintain other coverage to ensure that their family members are covered (VHA does not provide services to veterans' family members). VHA also reminds veterans who are eligible for Medicare Part B that if they decline Part B coverage, they may not be able to reenroll until the following calendar year and may pay a penalty in the form of a higher premium if they do reenroll (VA, 2022).

How Does Insurance Coverage Interact with VHA?

The interaction between VHA and insurance coverage varies depending on the type of insurance. Because VHA is a health care system that provides services directly to enrolled veterans and, in some cases, pays for care received in the community, VHA does not generally interact with other payers like insurers often do. That is, one insurer might be the primary payer for a specific enrollee, and another insurer might pay as the secondary payer for any copayments or other outstanding costs of coverage. In contrast, VHA is generally siloed and, in most cases, does not ask insurers to pay for or request payments for health care services rendered.

More specifically, VHA enrollees with TM or MA who seek care either do so within VA facilities or via VA-covered community care (both of these care options will be paid for by VA), or they seek care with private providers that will bill TM or the patient's MA plan for covered services. Neither VHA nor Medicare acts as secondary coverage for the other. In other words, the program that is not paying for the care provided will not step in after the primary payer has paid to cover any remaining charges or cost-sharing owed by the veteran. The two systems are essentially siloed off from each other in terms of payment. The same is also true of VHA-enrolled veterans who have other forms of government-paid coverage, such as TRICARE and Medicaid coverage.

Private health insurance coverage is different. VHA asks that enrollees with private health insurance coverage, including Medicare supplemental (Medigap) plans and employer-sponsored coverage, provide VHA with information about that coverage so that VHA may bill the insurers for care provided at VA facilities for non-service-related conditions. VHA notes that there are benefits to veterans in providing this information. Specifically, enabling VHA to bill private insurers may reduce or offset any copayments the veteran might owe for the health care services provided; in addition, the private insurer may apply any VHA service charges toward the plan's annual health care deductible. The application of charges toward the deductible can reduce any amounts the veteran must pay for other services received outside VHA that are covered by their private plan (VA, 2022).

Although VHA enrollees do not pay a monthly premium for being enrolled in VA's health care system, veterans with other sources of coverage may pay monthly premiums along with deductibles and cost-sharing when they seek care. Table 2 captures the out-of-pocket and premium costs that VHA enrollees may face for their insurance coverage.

Source of Other Health Care Coverage	Does a VHA Enrollee Pay for Coverage?
TM	Yes, while most beneficiaries pay no monthly premium for Part A, beneficiaries do generally pay a premium for Part B, which is $185 for most beneficiaries in 2025. Beneficiaries also pay a deductible ($1,676 in 2025) for hospital inpatient stays up to 60 days and daily copayments for longer hospital stays. Beneficiaries also pay 20 percent coinsurance for professional visits and other services covered by Part B.
MA	Yes, beneficiaries pay a monthly premium for Part B ($185 in 2025) and the monthly MA plan premium, if there is one. Many MA plans do not charge an additional premium, however. Coinsurance or copayments are determined by the MA plan's benefit package for inpatient stays and professional visits. These may differ from TM cost-sharing but must meet certain requirements of similarity with TM.
Medicare Part D	Yes, beneficiaries pay a monthly premium if the Part D plan charges a nonzero premium. Most MA plans do not charge a Part D premium, but stand-alone prescription drug plans that operate alongside TM charged an average premium of $46.50 in 2025. Coinsurance or copayments for prescriptions filled are on average 25 percent of drug cost but vary by plan.
Medicaid	Possibly; states may charge limited premiums for individuals in certain groups and may charge higher premiums to those with family incomes of 150 percent of the federal poverty level or greater. Some states may charge higher copayments for branded prescription drugs, but only for those with incomes greater than 150 percent of the federal poverty level. Individuals with lower incomes may pay nominal cost-sharing for both branded and generic drugs. States may charge deductibles and cost-sharing for medical services received and may vary the charges based on income. Medicaid recipients will never pay out-of-pocket costs for certain types of services, including emergency services or children's preventive checkups.
Private commercial insurance	Yes, employees generally share the premium costs for employer-sponsored coverage, and Marketplace plan enrollees pay a premium that varies by Marketplace plan design. Cost-sharing for medical services and prescription drugs varies by plan design as well but generally includes a deductible followed by copayments or coinsurance for services and prescription drugs.
TRICARE	TRICARE enrollees who are retired military service members pay an annual premium that depends on whether they enroll as an individual or a family (individual premiums range from $181.92 to $579 in 2025). Some TRICARE enrollees pay no deductible, while others pay a deductible that ranges from $50 to $150 for individuals. Enrollees pay copays for services, ranging from $0 for preventive care to $140 for an emergency room visit, depending on their group. Inpatient stays generally require a per diem copayment or a fixed fee (for example, $225) per admission.

SOURCES: Centers for Medicare & Medicaid Services, 2024a; Centers for Medicare & Medicaid Services, 2024b; Medicaid.gov, undated-a; Medicaid.gov, undated-b; TRICARE, 2025.

If VHA enrollees have insurance coverage, the payer for that coverage also incurs costs associated with the enrollment of a veteran in their coverage. For all sources of coverage except Medigap and private health insurance, the federal government is generally the payer (while the federal government shares the cost of Medicaid with the states). Specifically, the U.S. Department of Health and Human Services (HHS) pays for Medicare and the federal government share of Medicaid, while the U.S. Department of Defense pays for TRICARE. Individual enrollees pay the full premiums associated with Medigap plans. Private commercial insurance is often paid for in part by employers, while Marketplace enrollees may receive premium and cost-sharing subsidies paid by HHS and/or their state. Table 3 describes scenarios under which payers contribute to the costs of both coverage and any services received that are covered by an insurance plan.

Source of Other Health Care Coverage	Payer Incurs Costs Even if Care Is Not Received	Payer Incurs Costs When Care Is Received at VHA or via VA Community Care	Payer Incurs Costs When Care Received Outside VHA (Excluding VA Community Care)
TM	No	No	Yes, HHS pays for the cost of services minus any enrollee cost-sharing.
MA	Yes, HHS pays a monthly subsidy to MA plan for coverage.	No	Yes, MA plan pays for the cost of services minus any enrollee cost-sharing.
Medicare Part D	Yes, HHS pays a monthly subsidy to Part D plan for coverage.	No	Yes, Part D plan pays for medications minus any enrollee cost-sharing.
Medigap	No	Yes, Medigap plan pays copayments for VHA-provided services with a copayment (VHA bills the insurer).	Yes, Medigap pays for deductibles and cost-sharing not covered by TM.
Medicaid	Maybe; if enrollee is in a managed care plan, the state government may pay a monthly subsidy for the cost of coverage. If enrollee is in a fee-for-service arrangement, no.	No	Yes, Medicaid managed care or fee-for-service coverage will pay for the cost of services minus any enrollee cost-sharing.
Private commercial insurance	Yes, employer pays part of the monthly premium (if subsidized).	Yes, employer pays copayments for VHA-provided services with a copayment (VHA bills the insurer).	Yes, employer pays for services, minus any enrollee cost-sharing.
TRICARE	No	No	Yes, government pays for care minus enrollee cost-sharing.

How Do Multiple Sources of Coverage Affect Payer Budgets for VHA Enrollees?

An important issue that results from enrollment both in VHA and an insurance program is that veterans and payers outside VA are paying for coverage for VHA enrollees when those enrollees may not use any care paid for by that coverage. Table 4 indicates, for each source of coverage, whether the veteran and the payer for each source may make payments for coverage that duplicate the benefits of being enrolled in VHA.

From the veterans' perspective, they may make premium payments for insurance coverage above and beyond the access to services they receive at VHA. Veterans may view premium payments as worthwhile costs that enable them to maintain outside insurance coverage, because the coverage gives veterans additional options for seeking care outside VA.

Duplicative payments become a substantial and potentially very costly concern for MA and Medicare Part D. For both, the government pays a monthly subsidy to the plans, providing coverage to enrollees even when the enrollee does not use the benefit. Specifically, MA plans receive monthly subsidies from the government to pay for the government's share of the cost of MA coverage for each enrollee. These subsidies are paid regardless of whether the veteran seeks care covered by the MA plan or receives care at a VHA facility that is not covered by MA. One study estimated that VA paid more than $12 billion in health care costs in 2020 for veterans who also had an MA plan (Meyers et al., 2024), and a subsequent Wall Street Journal investigation estimated that $44 billion in payments were made between 2018 and 2021 for veterans enrolled in an MA plan who received care at VHA (Maremont, Weaver, and McGinty, 2024). These findings raise important questions about how much care these dually enrolled veterans used that was covered by their MA plan, if any. In addition, Medicare Part D plans are paid monthly subsidies for the government's share of the coverage cost, whereas veterans may never fill a prescription covered by Part D and instead receive their prescriptions through a VHA pharmacy. However, duplicative payments are less of a concern for VHA-enrolled veterans who have non-VA fee-for-service coverage, such as TM and Medicaid, for which payments are only made if care covered by the specific plan is received.

Source of Insurance Coverage	Potential for Duplicative Payments for Costs of Coverage and Receipt of Care?
TM	Yes for the veteran, if the veteran does not use any care covered by Medicare (for a premium paid by the veteran). No for the government, because Medicare only pays for care if the patient seeks it outside VHA.
MA	Yes for the veteran, if there is a nonzero premium and the veteran does not use any MA-covered care. Yes for the government, which pays a monthly subsidy for coverage to the MA plan regardless of whether the patient uses any care covered by the plan.
Medicare Part D	Yes for the veteran, if there is a nonzero premium and the veteran does not use any Part D–covered drugs. Yes for the government, because the government pays the monthly subsidy regardless of whether the patient uses a Part D drug.
Medicaid	No for the veteran, because payments are only made if the patient receives care covered by Medicaid under fee-for-service arrangements. Yes for the government, if Medicaid programs contract with managed care plans and pay them a monthly subsidy for covering Medicaid enrollees.
Private commercial insurance	Yes for the veteran, if the patient does not receive care covered by the commercial plan, because premiums are paid regardless. Yes for the employer or insurer, because the employer likely contributes a portion of the cost of the monthly premium. The insurer may also pay monthly amounts to providers if there are capitated payment contracts in place.
TRICARE	No for the veteran or government, because payments are only made if the patient receives care covered by TRICARE.

Although the MISSION Act of 2018 allowed VHA to bill private insurers for the copayments that veterans would otherwise pay for the care provided at VHA (Public Law 115-182, 2018), in 2024, this was only applied to those in Priority Groups 7 and 8, which make up 13 percent of the VHA patient population (N = 849,486 veterans) (VA, 2024). Furthermore, the law only extends to TRICARE and private insurance and does not extend to either Medicare or Medicaid programs, leaving a substantial proportion of potentially duplicative payments unaddressed.

Directions for Future Research and Policy

Given the potential for duplicative payments for those veterans enrolled in VHA who also have a type of health insurance coverage, a series of potential directions for future research and potential policy options should be considered.

First, VHA should access additional enrollment and claims data from all payers to create detailed combined datasets to track the utilization of and payment for coverage and services under different multiple-coverage scenarios. VHA has already accessed Medicare claims data to conduct budget planning exercises. However, making further use of Medicare, TRICARE, private insurer, and Medicaid claims and MA encounter, payment, and other administrative data in combination with VHA enrollment, utilization, and cost data would enable VHA to better track the sources of care for its enrolled veterans and to project likely future utilization and cost patterns more accurately. These data should improve VA's ability to better forecast its budget needs for future years and may provide important insights into care patterns that could inform future policy recommendations.

Second, VHA should estimate the costs to payers and patients associated with multiple sources of coverage and analyze the potential impacts of different coverage and payment scenarios. The combined datasets noted previously could also be used to estimate the costs to both payers and patients with multiple sources of coverage. Identification of the costs to different parts of the federal government, as well as state governments and employers, would provide further evidence that could be used to inform policy options to address the multiple payments. In addition, the results of quantitative analyses could be used to model the impacts of different alternative payment scenarios on government and private payer budgets and costs.

Third, VHA should gather expert input on policy options to address multiple payments while maintaining access to coverage for veterans. Using the data and estimates described previously, we recommend that experts convene to provide input on policy options to address multiple payments associated with enrollment in VHA and other insurance coverage. For example, experts might consider allowing more cross-payment or secondary payer options. One pathway to accomplish this could be to allow VHA to partner with MA plans or with Medicare in general to streamline coverage and care access options that include VHA rather than silo it off.

Conclusion

With government and private payer costs rising for health care, it is important to consider areas where duplicative spending may be occurring. One such area is health care for veterans with multiple sources of health care coverage. Veterans may pay monthly premiums to maintain enrollment in these plans, and the government or private insurers are likely spending substantial sums of money each month for veterans enrolled in plans that are paid for via monthly subsidies, but veterans may not be using this coverage if they access all or most of their care through VHA. Future research should consider the extent of these duplicate payments for coverage and care, as well as policy options that preserve veterans' access to health care while reducing unnecessary government and private payer spending on insurance subsidies.

References

• Centers for Medicare & Medicaid Services, "Medicare Advantage and Medicare Prescription Drug Programs to Remain Stable as CMS Implements Improvements to the Programs in 2025," webpage, press release, September 27, 2024a. As of July 2, 2025: https://www.cms.gov/newsroom/press-releases/medicare-advantage-and-medicare-prescription-drug-programs-remain-stable-cms-implements-improvements
• Centers for Medicare & Medicaid Services, "2025 Medicare Parts A & B Premiums and Deductibles," webpage, fact sheet, November 8, 2024b. As of July 2, 2025: https://www.cms.gov/newsroom/fact-sheets/2025-medicare-parts-b-premiums-and-deductibles
• Maremont, Mark, Christopher Weaver, and Tom McGinty, "Insurers Collected Billions From Medicare for Veterans Who Cost Them Almost Nothing," Wall Street Journal, December 2, 2024.
• Medicaid.gov, "Cost Sharing," webpage, undated-a. As of July 2, 2025: https://www.medicaid.gov/medicaid/cost-sharing
• Medicaid.gov, "Cost Sharing Out of Pocket Costs," webpage, undated-b. As of July 2, 2025: https://www.medicaid.gov/medicaid/cost-sharing/cost-sharing-out-pocket-costs
• Meyers, David J., Aaron L. Schwartz, Lan Jiang, Jean Yoon, and Amal N. Trivedi, "Spending by the Veterans Health Administration for Medicare Advantage Dual Enrollees, 2011–2020," JAMA, Vol. 332, No. 16, October 22/29, 2024.
• Panangala, Sidath Viranga, and Jared S. Sussman, "Introduction to Veterans Health Care," Congressional Research Service, IF 10555, Version 8, last updated June 28, 2023.
• Public Law 115-182, VA MISSION Act of 2018, June 6, 2018.
• Rasmussen, Petra W., and Carrie M. Farmer, The Promise and Challenges of VA Community Care: Veterans' Issues in Focus, RAND Corporation, PE-A1363-5, September 2022. As of July 2, 2025: https://www.rand.org/pubs/perspectives/PEA1363-5.html
• TRICARE, "TRICARE Costs and Fees Sheet," webpage, last updated April 30, 2025. As of July 2, 2025: https://tricare.mil/Publications/Costs/costs_fees
• Trilogy Federal, 2023 Survey of Veteran Enrollees' Health and Use of Health Care, December 18, 2023.
• U.S. Department of Veterans Affairs, "VA Health Care and Other Insurance," webpage, last updated October 12, 2022. As of July 2, 2025: https://www.va.gov/health-care/about-va-health-benefits/va-health-care-and-other-insurance/
• U.S. Department of Veterans Affairs, FY 2025 Budget Submission: Vol. 2, Medical Programs, March 2024.
• U.S. Department of Veterans Affairs, "VA Priority Groups," webpage, last updated April 3, 2025a. As of July 2, 2025: https://www.va.gov/health-care/eligibility/priority-groups/
• U.S. Department of Veterans Affairs, "Current VA Health Care Copay Rates," webpage, last updated June 30, 2025b. As of July 2, 2025: https://www.va.gov/health-care/copay-rates/
• VA — See U.S. Department of Veterans Affairs.

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