Closer look at VA health care copay rates


By Harold B. Wolford - Veterans Corner



Let’s take a closer look at VA health care 2020 copay rates for VA and VA-approved health, effective Jan. 1, 2020. VA can help with your questions about debt and other financial concerns. Some veterans don’t have to pay copays (they’re “exempt”) due to their disability rating, income level, or special eligibility factors.

Urgent care copay rates (care for minor illnesses and injuries): There’s no limit to how many times you can use urgent care. To be eligible for urgent care benefits, including through VA network of approved community providers, you must be enrolled in the VA health care system and have received care from VA within the past 24 months. You won’t have to pay any copay for a visit where you’re only getting a flu shot, no matter your priority group.

Urgent care copay rates are based on priority group. Priority groups 1 to 5 copay amount for the first three visits in each calendar year is $0. Priority group 6; if related to a condition that’s covered by a special authority, $0 for the first three visits, if not related to a condition covered by a special authority, $30 each visit. Copay amount for each additional visit in the same year for all priority groups is $30. Priority groups 7 and 8 has a $30 copay for all visits.

Special authorities include conditions related to combat service and exposures (like Agent Orange, active duty at Camp Lejeune, ionizing radiation, Project Shipboard Hazard and Defense (SHAD/Project 112), Southwest Asia conditions) as well as military sexual trauma, and presumptions applicable to certain veterans with psychosis and other mental illness.

Outpatient care copay rates (primary or specialty care that doesn’t require an overnight stay): If you have a service-connected disability rating of 10% or higher, you won’t need to pay a copay for outpatient care.

If you don’t have a service-connected disability rating of 10% or higher, you may need to pay a copay for outpatient care for conditions not related to your military service.

Outpatient care copay rates are based on type of outpatient care. Primary care services (like a visit to your primary care doctor), $15. Specialty care services (like a visit to a hearing specialist, eye doctor, surgeon, or cardiologist), $50. Specialty tests (like an MRI or CT scan), $50. You won’t need to pay any copays for X-rays, lab tests, or preventive tests and services like health screenings or immunizations.

Inpatient care copay rates (care that requires you to stay one or more days in a hospital): If you have a service-connected disability rating of 10% or higher, you won’t need to pay a copay for inpatient care.

If you’re in priority group 7 or 8, you’ll pay either the VA full copay rate or reduced copay rate. If you live in a high-cost area, you may qualify for a reduced inpatient copay rate no matter what priority group you’re in.

Reduced inpatient care copay rates for priority group 7. First 90 days of care during a 365-day period is $281.60 copay plus $2 charge per day. Each additional 90 days of care during a 365-day period is $140.80 copay plus $2 charge per day.

You may be in priority group 7 and qualify for these rates if you don’t meet eligibility requirements for priority groups 1 through 6, but you have a gross household income below our income limits for where you live and you agree to pay copays.

Full inpatient care copay rates for priority group 8. First 90 days of care during a 365-day period is $1,408 copay plus $10 charge per day. Each additional 90 days of care during a 365-day period is $704 copay plus $10 charge per day.

You may be in priority group 8 and qualify for these rates if you don’t meet eligibility requirements for priority groups 1 through 6, and you have a gross household income above our income limits for where you live, agree to pay copays, and meet other specific enrollment and service-connected eligibility criteria.

Medication copay rates are based on priority group. If you’re in priority group 1 you won’t pay a copay for any medications. If you’re in priority groups 2-8, you’ll pay a copay for medications your health care provider prescribes to treat non-service-connected conditions, and over-the-counter medications (like aspirin, cough syrup or vitamins) that you get from a VA pharmacy. You may want to consider buying your over-the-counter medications on your own. The cost for any medications you receive while staying in a VA or other approved hospital or health facility are covered by your inpatient care copay.

The amount you’ll pay for these medications will depend on the “tier” of the medication and the amount of medication you’re getting, which VA determines by days of supply. Once you’ve paid $700 in medication copays within a calendar year (Jan. 1 to Dec. 31), you won’t have to pay any more that year, even if you still get more medications. This is called a copay cap.

Tier 1 (preferred generic prescription medicines) 1-30 day supply, $5; 31-60 day supply $10; 61-90 day supply, $15. Tier 2 (non-preferred generic prescription medicines and some over-the-counter medicines) 1-30 day supply, $8; 31-60 day supply, $16; 61-90 day supply, $24. Tier 3 (brand-name prescription medicines) 1-30 day supply, $11; 31-60 day supply, $22; 61-90 day supply, $33.

If you have a service-connected rating of 40% or less and your income falls at or below the national income limits for receiving free medications, you may want to provide your income information to VA for them to determine if you qualify for free medications.

You won’t need to pay a copay for geriatric care (also called elder care) or extended care (also called long-term care) for the first 21 days of care in a 12-month period. Starting on the 22nd day of care, VA will base your copays on two factors: the level of care you’re receiving, and the financial information you provide on your Application for Extended Care Services.

Geriatric and extended care copay amounts by level of care. Inpatient care copay amount for each day of care up to $97. Outpatient care copay amount for each day of care up to $15. Domiciliary care for homeless Veterans copay amount for each day of care up to $5.

You won’t need to pay a copay for any of the services listed below, no matter what your disability rating is or what priority group you’re in. 1 – Readjustment counseling and related mental health services. 2 – Counseling and care for issues related to military sexual trauma. 3 – Exams to determine your risk of health problems linked to your military service. 4 – Care that may be related to combat service for Veterans that served in a theater of combat operations after November 11, 1998. 5 – VA claim exams (also called compensation and pension, or C&P, exams). 6 – Care related to a VA-rated service-connected disability. 7 – Care for cancer of head or neck caused by nose or throat radium treatments received while in the military. 8 – Individual or group programs to help you quit smoking or lose weight. 9 – Care that’s part of a VA research project (like the Million Veteran Program). 10 – Laboratory (lab) tests. 11 – Electrocardiograms (EKGs or ECGs) to check for heart disease or other heart problems. 12 – VA health initiatives that are open to the public (like health fairs).

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By Harold B. Wolford

Veterans Corner

Harold B. Wolford is president of the Vietnam Veterans of America Chapter 1095. He served in the United States Army from 1970 to 1973. Wolford can be reached via email at harold@wolfordhome.com.

Harold B. Wolford is president of the Vietnam Veterans of America Chapter 1095. He served in the United States Army from 1970 to 1973. Wolford can be reached via email at harold@wolfordhome.com.