To receive VA medical benefits after enrolling, depending on multiple influences, a veteran may have to pay a part of their costs. In some situations, no fee is required by the veteran, as it is wholly paid for by the VA, while in other cases the VA could pay the veteran to come in for medical evaluation.
If the VA requires a veteran to make a trip to a VA medical facility to be treated, they are obligated to pay the cost of travel is the veteran is eligible. In such a case, veterans are reimbursed 28.5 cents per mile.
Qualifications for travel reimbursement:
- A veteran has a service-related disability rating of 30 percent
- A veteran traveling for treatment of a service-related condition
- A veteran who received a VA pension
- A veteran with an income that doesn’t exceed the maximum annual VA pension rate
- A veteran who is traveling for a scheduled examination to determine eligibility for VA disability compensation or pension
If a veteran qualifies for more of the first four principles listed above they are eligible for reimbursement for special transportation such as ambulance and wheelchair van so long as travel is preauthorized by the VA. Preauthorization is waived in time of medical emergency if postponement could result in detriment to a veteran’s health or life.
Veterans can receive a deductible of $7.77 per one-way trip ($15.54 for a round trip) if they travel for medical care and qualify for the first two criteria above. The maximum deductible a veteran would be entitled to pay in a month is $46.62, and after this amount extraneous trips don’t qualify for the deductible.
The VA pays veterans 17 cents per mile in travel reimbursement (not subject to deductible) if the veteran requires follow-up trips to a VA medical facility for a second lab test, X-ray, or other exam to receive VA disability compensation.
A veteran is not obligated to share the costs of their inpatient or outpatient medical care they received through the VA if they fall into the Categorization of priority Groups 1 through 5 detailed in “Making sure you enroll in the right group.”
A veteran listed in Group 6 doesn’t have to pay any cost-share for VA medical treatment they require for a service-related medical condition or disability. If a veteran is given medical care from the VA for conditioned unrelated to their military service, however, they’re obligated to pay the full co-pay amounts.
Specialty care administered by clinical specialists such as surgeons, radiologists, audiologists, optometrists, and cardiologists require a co-pay of $50 per visit. Specialty tests include:
- Resonance imagery (MRI)
- Computerized axial tomography (CAT) scan
- Nuclear medicine studies
Publically proclaimed VA health fairs or outpatient visits for preventive screening, health education classes, smoking secession programs, laboratory, flat film radiology, electrocardiograms or immunizations do not apply to Co-pays.
Veterans categorized in Group 1 are not required to pay anything to receive extended care. Visit “Making sure you enroll in the right group” and “Seeking Extended Care” for more information.
Co-pay, however, is obligatory if a veteran falls under Group 5 with the exception that they receive a VA pension or hold assets and income levels that would entitle them for a VA pension. Save for when they were administered extended care for service-related disabilities or conditions placing them in Group 6, veterans in Group 5 must pay a co-pay.
The VA bases co-pay for extended care on income level or assets unlike co-pay for medical treatment and prescription which have set fees.
The financial information a veteran provides the VA with in the VA Form 10-10EC, Application for Extended Care Services dictates their decision. The form is available at any VA medical facility.
It is also available for download at www.va.gov/vaforms/medical/pdf/vha-10-10EC-fill.pdf.
The most co-pay for inpatient extended care facilities is $97 per day. This includes:
- Nursing homes
- Respite centers
- Geriatric evaluation centers
- Community residential care
- Home healthcare
- Homemaker/home health aide services
The most co-pay for outpatient services is $15 per day and includes:
- Geriatric evaluation
- Respite centers
- Adult day care
- Hospice/palliative services
The most co-pay for domiciliary care is $5 per day.
Co-pays for extended care services begin on the 22nd day of care as the initial 21 days are free.
Co-pay for VA medications
Veterans may also be obligated to pay a portion of the costs for prescriptions medications they require and the subsequent refills they obtain through the VA.
Veterans in Group 1 through 4 do not have to pay a co-pay for VA medications. More about the Groups can be found in the “Making sure you enroll in the right group”. If a veteran qualifies for groups 2, 3, or 5 they are not required to share in the costs of their medication if they are an ex-prisoner of war, need medication for treatment of a service-related medical condition, or have an income below the VA pension level. Free medication so long as it’s a necessity in treating a medical condition connected to their categorization of Group 6 is provided for veterans in Group 6. Those in Group 7 and 8 are required to pay the medication co-pay amount of $8 per 30-day supply.
A limit of $960 per calendar year exists for medication co-pay for all enrolled veterans.
Congress is in charge of regulating co-payments, and they are likely to change.
Using private health insurance
The VA is obligated to bill a veteran’s private health insurance provider for medical care, supplies, and prescriptions provided for treatment of non-service-related conditions if they have private healthcare insurance, including the spouse’s health care insurance. Though the VA can bill Medicare supplemental health insurance for services rendered, it can’t bill Medicare otherwise.
Veterans are required to provide information concerning other health insurance coverage when they apply for VA medical care, as well as coverage under a spouse’s policy. See “Making your case for VA medical care” for more information.
Terminated all other healthcare insurance is not advisable since the VA doesn’t cover family members who are provided for by private agencies. A veteran could also end up without healthcare coverage if Congress allocates agreeable funds for the VA to provide care to all enrollment priority groups.
Dealing with VA income limits
As discussed in “Making sure you enroll in the right group” earlier in this chapter, the VA utilizes two financial areas in determining whether to categorize a veteran into Group 7 or 8. Group 7 is applicable if a veteran’s income is above the VA’s national income limit but below the geographical income threshold. Group 8 is applicable if these things are above both criteria.
National income limits
The national income limits calculate a veteran’s household income and total capital against the national mean. The maximum household income limits can also sway whether a veteran is likely to receive free VA medical care or if they must pay co-pays.
Money acquired by a veteran, their spouse, or any children living at home is considered all gross household income and is what the VA measures to make their decision. This includes Social Security, retirement pay, unemployment insurance, interest and dividends, workers’ compensation, black lung benefits, and any other gross household income.
A veteran must have a net worth of $80,000 or less. Net worth constitutes assets like the market value of property (not including primary residence), stocks, bonds, notes, individual retirement accounts, bank deposits, savings accounts, and cash.
National income limit rates are subject to change.
Geographical income threshold
If a veteran’s income is above the VA national means test but remains under the geographic income threshold, they are eligible for Group 7 and a 20 percent reduction in inpatient co-pay rates. To determine this, the VA weighs financial assessments with geographically based income thresholds.
Geographic rates are inherent to where a veteran lives down to the county.