During a medical emergency, veterans should immediately seek care at the nearest medical facility. A medical emergency is an injury, illness, or symptom so severe that without immediate treatment, you believe your life or health is in danger. If you believe your life or health is in danger, call 911 or go to the nearest emergency department right away.
Veterans do not need to check with the VA before calling for an ambulance or going to an emergency department. During a medical emergency, the VA encourages all veterans to seek immediate medical attention without delay. A claim for emergency care will never be denied based solely on the VA not receiving notification prior to seeking care.
It is, however, important to promptly notify the VA after receiving emergency care at a community emergency department. Notification should be made within 72 hours of admission to a community medical facility. This allows the VA to assist the veteran in coordinating necessary care or transfer and helps to ensure that the administrative and clinical requirements for the VA to pay for the care are met.
Important: An emergency department (ED) is a facility that is staffed and equipped to provide emergency treatment and does not include community facilities that provide medical treatment in situations other than emergencies.
Service-connected emergency care
In general, VA can pay for emergency medical care at a local ED for a veteran’s service-connected condition, or if the care is related to a veteran’s service-connected condition. Specifically, emergency medical care for a veteran’s service-connected or related (adjunct) condition(s) is eligible for VA payment as long as the VA wasn’t reasonably available to provide the care.
In accordance with the following situations and requirements, the VA can pay emergency care costs for: 1. A veteran who receives emergency treatment of a service-connected, or adjunct condition in a community emergency department; 2. A veteran who is permanently and totally disabled (P&T) as the result of a service-connected condition is eligible for emergency treatment of any condition; 3. A veteran who is participating in a VA Vocational Rehabilitation Program and who requires emergency treatment to expedite their return to the program, is eligible for emergency treatment for any condition; and (scenarios 1-3 must all meet No. 4); 4. The emergency was of such a nature that the veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy.
A service-connected condition is one that has been adjudicated by the Veterans Benefits Administration (VBA) and a disability rating has been granted. An adjunct condition is one that, while not directly service-connected, is medically considered to be aggravating a service-connected condition.
Nonservice-connected emergency care
VA can also pay for emergency medical care at a community ED for a veteran’s nonservice-connected condition. However, there are several requirements and factors that affect the extent to which the VA can cover those services. Specifically, emergency medical care for a veteran’s nonservice-connected condition(s) is eligible for VA payment when all of the following five elements are true: 1. Care was provided in a hospital emergency department (or similar public facility held to provide emergency treatment to the public); 2. The emergency was of such a nature that the veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy; 3. A VA medical facility or another federal facility was not reasonably available to provide the care; 4. The veteran is enrolled and has received care within a VA facility during the 24 months before the emergency care; and 5. The veteran is financially liable to the provider of emergency treatment.
There are limitations on the VA’s ability to provide coverage when a veteran has other health insurance (OHI). If OHI does not fully cover the costs of treatment, VA can pay certain costs for which the veteran is personally liable.
VA is also legally prohibited from providing coverage for individuals covered under a health plan contract because of a failure by the veteran or the provider to comply with the provisions of that health plan contract, e.g., failure to submit a bill or medical records within specified time limits, or failure to exhaust appeals of the denial of payment.
Previously, the VA site stated that “by law VA cannot pay copayments, coinsurance, deductibles, or similar payments a veteran may owe to the provider as required by their OHI.” On Sept. 9, 2019, the Court of Appeals for Veterans Claims ruled that the VA’s interpretation of the applicable law was wrong and that the VA cannot deny reimbursement of coinsurance and deductible amounts owed by a veteran under a health insurance plan.
This is to clarify that the VA can reimburse a veteran for coinsurance and deductibles amounts (but not copayments) that a veteran may owe to a provider under their health insurance plan.
After receiving care
Once a veteran’s immediate emergency medical care needs have been addressed, the veteran, a family member, friend, or hospital staff member should contact the nearest VA medical facility within 72 hours. Once notified, VA staff will assist the veteran and/or his/her representatives in understanding eligibility and how eligibility relates to services rendered in the community. VA staff will also ensure that, if desired, the veteran is transferred to a VA medical center upon stabilization and that the veteran is set up to receive additional care, post discharge, without interruption.
Important: When a veteran receives emergency medical care, notifying the VA as quickly as possible is always best. It ensures maximum VA coverage and assists the VA in providing the veteran with the care they need.
Filing a claim
Claims for emergency medical care should be submitted to the VA as soon as possible after care has been provided. The deadline for filing a claim depends on whether care was provided for a service-connected condition or a nonservice-connected condition.
Requirements for filing an emergency care claim for veterans or veterans’ representatives are as follows. Veterans or their personal representatives may file a claim for reimbursement of emergency treatment costs that they have incurred and paid to the provider. In this situation, veterans should obtain and submit all related treatment and billing records to the closest VA medical facility. In most cases, providers will submit a claim directly to the VA, and the veteran will not have to take further action.
Service-connected condition filing deadline: Claims must be submitted to the VA within two years of the date emergency medical care was received. However, filing the claim as soon as possible after care has been provided is highly recommended because it helps ensure that all required documentation is readily available and that providers receive their payment in a timely manner.
Nonservice-connected condition filing deadline: Claims must be submitted to the VA within 90 days of the date of discharge, or 90 days from the date that all attempts to receive required payments from a liable third party are completed and not successful in eliminating the veteran’s personal liability to the provider. A liable third party includes other health insurers, worker’s compensation, civil litigation, etc.
Payment rates for emergency care claims: Service-connected condition is generally 100% of Medicare rates. Nonservice-connected condition is generally 70% of Medicare rates.
Receiving payment from VA
Once a claim for emergency treatment is received by the VA, the claim will be administratively reviewed to determine veteran eligibility. If the veteran meets the administrative eligibility criteria to receive emergency care in the community, the treatment documentation will then be reviewed by a VA clinical staff to determine if the treatment received meets the clinical criteria necessary for the VA to pay for the care.
VA makes every effort to adjudicate claims for emergency treatment quickly and accurately. When further information or clarification is needed by the VA, claims processing may be delayed.
If a veteran is charged for emergency care received in the community and believes the charges should be covered by the VA, they should contact the nearest VA medical facility as soon as possible. VA staff will assist the veteran in understanding eligibility and in determining whether the bill received is appropriate. VA will assist the veteran and work to resolve any billing issues with the community provider.
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 firstname.lastname@example.org.