Citation Nr: A21018399 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 210212-185946 DATE: November 17, 2021 REMANDED Entitlement to payment or reimbursement of non-Veterans Affairs (VA) ambulance services for February 23, 2020 is remanded. REASONS FOR REMAND Given the nature of the claim before the Board, the exact dates of the Veteran's service are not clear and have not been provided. The appellant is Warsaw Lincoln Ambulance District and is the proper claimant as the entity that furnished the treatment on February 23, 2020. See 38 U.S.C. § 1725, 38 C.F.R. § 17.1004. In February 2021, the Board of Veterans' Appeals (Board) received a VA Form 10182, Decision Review Request: Board Appeal electing the Direct Review docket. The Board may only consider the evidence of record at the time of the AOJ decision on appeal. 38 C.F.R. § 20.301. The Board finds remand is warranted to satisfy a statutory duty under 38 U.S.C. § 5104. 38 C.F.R. § 20.802(a) (the Board may remand for correction of any error by the AOJ in satisfying a regulatory or statutory duty if correction of the error would have a reasonable possibility of aiding in substantiating the claim). Generally, a claimant is entitled to notice of a decision by the Secretary that includes an explanation of the procedure for obtaining review of the decision. 38 U.S.C. § 5104(a). Such notice must include the following: 1. Identification of the issues adjudicated. 2. A summary of the evidence considered by the Secretary. 3. A summary of the applicable laws and regulations. 4. Identification of findings favorable to the claimant. 5. In the case of a denial, identification of elements not satisfied leading to the denial. 6. An explanation of how to obtain or access evidence used in making the decision. 7. If applicable, identification of the criteria that must be satisfied to grant service connection or the next higher level of compensation. 38 U.S.C. § 5104(b). Here, the Appellant was issued an Explanation of Payment (EOP) indicating that the billed charges for a February 23, 2020, episode of care was processed under 38 U.S.C. §1725, and that payment was made in the amount of $0 because medical records were not received or were insufficient to determine the decision of payment. This EOP generally identified the issue that was adjudicated, the law in question, and one element that was not satisfied leading to the denial. However, there was no summary of the evidence considered, summary of the applicable laws and regulations, or identification of favorable findings or other elements not satisfied which would lead to the denial. Without adequate notice of the basis for the denial, a claimant cannot make an informed decision as to whether or not to accept or appeal the decision nor can he or she know what evidence to submit in order to substantiate the appeal. See Ingram v. Nicholson, 21 Vet. App. 232, 252 (2007) (discussing the legislative history of 38 U.S.C. § 5104 and the importance of clear and informative notice of decisions). The evidence of record reflects the Veteran has Medicare and Medicaid and the evidence of record reports a separate ambulance ride from the hospital to the Veteran's residence was paid by Medicaid. With regard to the Veteran's Medicare and Medicaid coverage, the United States Court of Appeals for Veterans Claims has held that 38 C.F.R. § 17.1002 (f), which previously provided that a veteran must not have coverage "in whole or in part" under a health-plan contract as a condition of eligibility for VA reimbursement of unauthorized medical expenses was invalid, and that a Veteran with only partial coverage under a health care plan, including Medicare and Medicaid, could seek payment or reimbursement for the expenses for which he had personal liability. Staab v. McDonald, 28 Vet. App. 50 (2016). In short, partial coverage under a health-plan contract, including under Medicare or Medicaid, for the non-VA emergency ambulance services at issue, is not a bar to eligibility for VA reimbursement of any remaining uncovered balance under 38 U.S.C. § 1725. If the Veteran has only partial coverage by Medicare or Medicaid for his treatment, the appellant is not necessarily ineligible for reimbursement of any remaining balance. However, VA is not authorized to pay Medicare or Medicaid deductibles or co-payments. See 38 U.S.C. § 1725 (c)(4)(D). Here, if a balance remains after a claim is submitted to Medicare, the VA may provide reimbursement based on Staab v. McDonald if the Veteran meets all criteria found in 38 U.S.C. § 1725. In sum, the appellant was not put on notice of what additional evidence or argument could be presented to support an appeal. On remand, the AOJ must provide the Appellant with complete notice of the decision as required by 38 U.S.C. § 5104, including identification of whether or not the claim meets each of the criteria necessary for payment under 38 U.S.C. § 1725 and 38 C.F.R. § 17.1002. The matter is REMANDED for the following action: Issue the Appellant a decision and notice of decision on the issue of entitlement to payment of the cost of non- VA ambulance services provided to the Veteran on February 23, 2020, as described in 38 U.S.C. § 5104. The notice shall include but is not limited to: a summary of the evidence; a summary of the applicable laws and regulations; identification of findings favorable to the claimant; and, identification of the substantive conditions not satisfied but necessary for payment of the cost of non-VA emergency medical services under 38 U.S.C. § 1725 and 38 C.F.R. § 17.1002. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Mouzakis, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.