Copayments

There are four basic types of charges:

• Medication – Prescription copayment charges were established by Congress. The charge is $7 for each 30 day or less supply of medications provided on an outpatient basis for nonservice-connected conditions.

• Outpatient – The copayments will be based on primary care visits ($15), specialty care visits ($50) and no copayment designations. 

• Inpatient – Congress determined the appropriate inpatient copayment should be the current inpatient Medicare Deductible Rate plus $10 for the first 90 days that you remain in the hospital.

• Nursing Home – Congress determined the copayment should be the current Medicare deductible rate plus $5.00 for each day.

The Debt Collection Improvement Act of 1996 (Public Law 104-134) requires the Department of Veterans Affairs (VA) to refer any unpaid bills over 180 days old to the Treasury Department for potential offset. The Treasury Department or other authorized representatives will offset all or a portion of what you owe VA against almost any monies paid to you by the Federal Government. This could include, but is not limited to, social security benefits, federal income tax refunds and federal salary, or retirements benefits. Referral of your bills to Treasury may result in processing fees being charged to you. Processing fees will be charged for the referral and for each offset made.

If you can’t afford to make copayments there are two options:

1. The first option is to request a waiver for paying your current debt. If you request a waiver, you must submit sufficient proof that you can not financially afford to make payment to VA. This process could take several months; please contact the Revenue Coordinator at the VA health care facility where you receive care.      
2. The second option is to request a hardship determination to avoid future debts. You will need to submit specific financial information about your current year income. A decision will be made based on information you provide.

Which Veterans Pay for Which Services

Which veterans pay for which services at VA health care facilities?

Priority Group 1

If care is provided to priority group 1 veterans for a nonservice-connected condition, VA will bill the health insurance company. 

Priority Groups 2, 3, and 4

Veterans in priority groups 2, 3, or 4 are required to pay a prescription copayment if they are less than 50% service-connected and the medication is for a nonservice-connected condition. VA will bill the health insurance company of veterans receiving treatment for nonservice-connected conditions in priority groups 2, 3, or 4.

Priority Group 5

VA will bill the health insurance company of the priority group 5 veterans who are receiving treatment for nonservice-connected conditions.

Priority Group 6

WWI, Mexican Border, and compensable 0% Service Connected veterans

Priority Group 6 veterans are not required to pay copayments or medication copayments when they are receiving care for exposure/experience related conditions.  The insurance carrier will not be billed for treatment provided to related conditions. If care is provided to priority group 6 veterans for a nonservice-connected condition not related to their exposure/experience, VA will bill the insurance carrier. All applicable copayments will be assessed to veterans when the care is for conditions not related to their exposure or experience .

Priority Group 7

Priority group 7 veterans are required to pay inpatient copayment, outpatient copayment, prescription copayment, and nursing home copayment. VA will bill the health insurance company of priority group 7 veterans.

Special Categories of Veterans

Agent Orange, Ionizing Radiation, Gulf War, and women veterans receiving sexual trauma counseling are subject to means test copayments when the treatment they are receiving is not related to their exposure or experience. The initial registry examination and first follow-up visit to receive results of the examination are not billed to the health insurance carrier. However, VA will bill your insurance carrier for subsequent care of nonservice-connected disabilities that is not related to exposure.

Prescription Copayment Exemption

Service-connected veterans rated 50% or more or nonservice-connected veterans who meet the low income criteria are exempt from the prescription copayment. 

Non-veteran Care

VA does not have the authority to bill insurance carriers for care provided to employees or to non-veterans. Emergency medical care provided to a non-veteran will be billed directly to the person receiving the care. 

TRICARE Recipients 

TRICARE recipients are required to pay a prescription copayment. VA will bill private health insurance first and TRICARE second. TRICARE recipients are billed deductibles and copayments as required by TRICARE and will be collected by VA at the time treatment is provided. However, VA will not collect any deductibles and copayments that may be required by the third party health insurance carrier. 

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