Most veterans not receiving VA disability compensation or pension payments must provide information on their gross annual household income and net worth to determine whether they are below the annually adjusted financial thresholds. Veterans who decline to disclose their information or have income above the thresholds must agree to pay copays in order to receive certain health benefits, effectively placing them in Priority Group 8. VA is currently not enrolling new applicants who decline to provide financial information unless they have a special eligibility factor.
This financial assessment includes all household income and net worth, including Social Security, retirement pay, unemployment insurance, interest and dividends, workers’ compensation, black lung benefits and any other income. Also considered are assets such as the market value of property that is not the primary residence, stocks, bonds, notes, individual retirement accounts, bank deposits, savings accounts and cash.
VA also compares veterans’ financial assessment with geographically based income thresholds. If the veteran’s gross annual household income is above VA’s national means test threshold and below VA’s geographic means test threshold, or is below both the VA national threshold and the VA geographically based threshold, but their gross annual household income plus net worth exceeds VA’s ceiling (currently $80,000) the veteran is eligible for an 80-percent reduction in inpatient copay rates.
VA Medical Services and Supplies Requiring Copays
Some veterans must make copays to receive VA health care.
Inpatient Care: Priority Group 7 and certain other veterans are responsible for paying 20 percent of VA’s inpatient copay or $204.80 for the first 90 days of inpatient hospital care during any 365-day period. For each additional 90 days, the charge is $102.40. In addition, there is a $2 per diem charge.
Priority Group 8 and certain other veterans are responsible for VA’s
inpatient copay of $1,024 for the first 90 days of care during any 365-
day period and $10 per day. For each additional 90 days, the charge
is $512 plus a $10 per diem charge.
Extended Care: For extended care services, veterans may be
subject to a copay determined by information supplied by completing a VA Form 10-10EC. VA social workers can help veterans interpret their eligibility and copay requirements. The copay amount is based on each veteran’s financial situation and is determined upon application for extended care services and will range from $0 to $97 a day.
Medication: Most veterans are currently charged $8 for each 30-day or less supply of medication provided by VA for treatment of conditions that are not service-connected. For veterans enrolled in Priority Groups 2 through 6, the maximum copay for medications that will be charged in calendar year 2008 is $960. The following groups of veterans are not charged medication copays: veterans with a service-connected disability of 50 percent or more; veterans receiving medication for service-connected conditions; veterans whose annual income does not exceed the maximum annual rate of the VA pension; veterans enrolled in Priority Group 6 who receive medication under their special authority; veterans receiving medication for conditions related to sexual trauma related to service on active duty; certain veterans receiving medication for treatment of cancer of the head or neck; veterans receiving medication for a VA-approved research project; and former POWs.
NOTE: Copays apply to prescription and over-the-counter medications,
such as aspirin, cough syrup or vitamins, dispensed by a VA pharmacy. However, veterans may prefer to purchase over-the-counter drugs, such as aspirin or vitamins, at a local pharmacy rather than making the copay. Copays are not charged for medications injected during the course of treatment or for medical supplies, such as syringes or alcohol wipes.
Outpatient Care: A three-tiered copay system is used for all outpatient services. The copay is $15 for a primary care visit and $50 for
some specialized care. Certain services are not charged a copay.
Outpatient Visits Not Requiring Copays
Copays do not apply to publicly announced VA health fairs or outpatient
visits solely for preventive screening and/or immunizations, such as immunizations for influenza and pneumococcal, or screening for hypertension, hepatitis C, tobacco, alcohol, hyperlipidemia, breast cancer, cervical cancer, colorectal cancer by fecal occult blood testing, education about the risks and benefits of prostate cancer screening, and smoking cessation counseling (individual and group). Laboratory, flat film radiology, and electrocardiograms are also exempt from copays.
Private Health Insurance Billing
VA is required to bill private health insurance providers for medical care, supplies and prescriptions provided for treatment of veterans’ non service-connected conditions. Generally, VA cannot bill Medicare, but can bill Medicare supplemental health insurance for covered services.
All veterans applying for VA medical care are required to provide information on their health insurance coverage, including coverage provided under policies of their spouses. Veterans are not responsible
for paying any remaining balance of VA’s insurance claim not paid or covered by their health insurance, and any payment received by VA may be used to offset “dollar for dollar” a veteran’s VA copay responsibility.
Reimbursement of Travel Costs
Certain veterans may be provided special mode travel (e.g. wheelchair
van, ambulance) or reimbursed for travel costs when traveling for approved VA medical care. Reimbursement is paid at 28.5 cents per mile -and is subject to a deductible of $7.77 for each one-way trip and $15.54 for a round trip; with a maximum deductible of $45.62 per calendar month. Two exceptions to the deductible are travel for C&P exam and special modes of transportation, such as an ambulance or a specially equipped van. These deductibles may be waived when their imposition would cause a severe financial hardship.
Eligibility: Payments may be made to the following:
1. Veterans whose service-connected disabilities are rated 30 percent or more.
2. Veterans traveling for treatment of service-connected conditions.
3. Veterans who receive a VA pension.
4. Veterans traveling for scheduled compensation or pension examinations.
5. Veterans whose gross household income does not exceed the
maximum annual VA pension rate.
6. Veterans whose medical condition requires a special mode of transportation, if they are unable to defray the costs and travel is pre-authorized. Advance authorization is not required in an emergency if a delay would be hazardous to life or health.