Elder Law Firm of Andrew Olsen

Co-Payments for Veterans’ Health Care

December 14, 2015

The U.S. Department of Veterans Affairs (VA) provides health care benefits to veterans. The plan covers a number of health care services, including preventative services, diagnostic and treatment services, and hospitalization. It may also cover nursing home and other long-term care options.

The standard benefits package includes: Preventative care services, outpatient diagnostic and treatment services (including mental health and substance abuse treatment), inpatient diagnostic and treatment services, prescriptions, and long-term care (including nursing home care for some veterans).

There are no costs for certain veterans and low-income veterans. The following veterans are eligible to receive cost-free health care benefits automatically:

  • A service-connected veteran receiving VA compensation benefits
  • A veteran seeking care for a specific service-connected disability
  • Former POWs
  • Purple Heart Medal recipients
  • A veteran with conditions related to exposure to herbicides during the Vietnam-era, ionizing radiation during atmospheric testing, ionizing radiation during the occupation of Hiroshima and Nagasaki
  • A veteran who sustained a service-related condition while serving in the Gulf War, in combat in a war after the Gulf War, or during a period of hostility after November 11, 1998
  • A veteran with military sexual trauma
  • A veteran with cancer of the head or neck caused by nose or throat radium treatments given while in the military
  • A veteran who is participating in a VA approved research project

If you don’t fit into one of those categories, the VA will ask you to provide your household income from the previous year. If your income is below certain thresholds, you will not have to make a copayment. Click here to view the thresholds for income. Those whose income exceeds the threshold or who refuse to submit to the means test may have to make a copayment.

Unlike the Medicaid program, there is no penalty for transferring assets before applying for veterans benefits, including long-term care. Remember, however, that if you do transfer assets it may affect your eligibility for Medicaid.

Even if your income is above the threshold, you do not have to make co-payments for the following services:

  • Special registry examinations offered by the VA to evaluate possible health risks associated with military service
  • Counseling and care for sexual trauma
  • Compensation and pension examination requested by the Veterans Benefit Administration
  • Care that is part of a VA-approved research project
  • Outpatient dental care
  • Readjustment counseling and related mental health services for Post Traumatic Stress Disorder
  • Emergency Treatment at other than VA facilities
  • Care for cancer of the head or neck caused from nose or throat radium treatments given while in the military
  • Publicly announced VA public health initiatives — i.e., health fairs
  • Care related to service for veterans who served in combat or against a hostile force during a period of hostilities after November 11, 1998
  • Laboratory services such as flat film radiology services and electrocardiograms

Outpatient co-payments

The following are the outpatient co-payments for non-service-related conditions:

  • Services provided by a primary care clinician are $15 (in 2015) for each visit
  • Services provided by a clinical specialist are $50 (in 2015) for each visit
  • Preventive care services (such as screenings and immunizations) are free.

Inpatient co-payments

The inpatient co-payment is calculated by adding:

  • $10 per day of hospitalization (in 2015), and
  • $1,260 for the first 90 days of hospitalization and $630 for each additional 90 days (in 2015).

There is a reduced co-payment rate (20 percent of the full inpatient rate) for certain individuals whose income is above the VA income thresholds, but below the Geographic Means Threshold (GMT). Click here to see if you are below the GMT.

Prescription co-payments

Prescription co-payments are charged only for outpatient treatment. The following veterans do not have to pay anything for medications:

  • A veteran who is 50 percent disabled or more with a service-connected disability
  • A veteran who has been determined by the VA as unemployable due to his service-connected conditions
  • A veteran who needs medication to treat a specific service-connected disability
  • Former POWs
  • A veteran whose income is below the maximum annual rate for a VA pension
  • A veteran who needs medication to treat conditions related to a veteran’s exposure to herbicides during the Vietnam era ionizing radiation during atmospheric testing, or ionizing radiation during the occupation of Hiroshima and Nagasaki
  • A veteran who served in the Gulf War, in combat after the Gulf War, or during a period of hostility after Nov. 11, 1998, and who needs medication to treat a service-related condition
  • A veteran who needs medication to treat a military sexual trauma
  • A veteran with cancer of the head or neck caused by nose or throat radium treatments given while in the military
  • A veteran participating in a VA approved research project

Veterans in Priority Groups 2 through 6, must pay $8 (in 2015) for each 30-day or less supply of medication for treatment of nonservice-connected condition. Veterans in Priority Groups 7 and 8 must pay $9 (in 2015) for each 30-day or less supply of medication. If you are in one of the Priority Groups 2 through 6, there is an annual limit on the amount you have to pay for prescriptions. You will not be charged more than $960 during the calendar year. If you are in Priority Groups 7 and 8, you will have to pay the full co-payment amount, with no annual limit.

The Medicare prescription drug benefit

As part of the new Medicare law enacted in December 2003, Congress added a modest prescription drug benefit, which took effect January 1, 2006. The benefit is available to anyone who is eligible for Medicare Part A or B coverage. The benefit is completely voluntary, so you must decide whether you want to participate in a plan or not based on your own situation. If you decide to participate in the Medicare plan, your VA prescription drug coverage will not be affected.

Most Medicare beneficiaries must choose a plan or be subject to significant financial penalties for late enrollment. However, because the VA prescription drug coverage is considered “creditable coverage,” you will not face a penalty if you do not sign up for the Medicare plan. If you disenroll or lose your VA prescription drug coverage, you will have 62 days to sign up for a Medicare plan without being subject to a penalty.

Long-term care co-payments

The first 21 days of long-term care are free. Co-payments start on the 22nd day. Long-term care co-payments are calculated differently from other co-payments because they are set based on the individual veteran’s financial status. Veterans must fill out a financial assessment to determine their co-payments. This is a separate form from the form veterans had to fill out to determine if they were eligible for free health care. This form assesses your current income as opposed to the previous year’s income. The co-payments will be adjusted for each individual veteran based on his or her ability to pay. Once you have submitted a form, a social worker will contact you to let you know how much your co-payments will be.

What to do if you can’t afford co-payments

There are several options if you cannot afford your co-payments. One option is to request a waiver. You will have to submit proof that you can’t financially afford to make payments to the VA.

If your income changed since you applied for free health care, you can request a hardship determination. This will change your priority group assignment. To do this, you will need to provide current financial information to the VA.

Another option is to request a compromise and make a partial payment. Most compromise offers that are accepted must be for a lump sum payment payable in full 30 days from the date of acceptance of the offer.

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