EVERYTHING YOU NEED TO KNOW ABOUT YOUR VA COPAY


By bblouin
Talking about the VA copay and payment options with a provider.

Receiving healthcare is complex. Thus, understanding your VA copay is important both for your well-being and finances. VA copays are required by many Veterans, but some may have exemptions. Below, we’re breaking down how much you can expect to pay, how to pay your bill, services that do not require copayments, and more.

Does the VA Charge a Copay?

Veterans, eligible dependents, and spouses may be required to cover a VA copay for nonservice-connected healthcare, medication, and long-term care services your insurance won’t cover. Here’s how they break down:

  • Inpatient care
  • Outpatient care
  • Prescription medication (outpatient)
  • Extended/geriatric care

You are responsible for covering VA copayments when you are discharged from a hospital. If you don’t pay them at that time, you’ll be billed within 30 days.

VA Copays Waived

There are several healthcare services that have no VA copayments. Here are some of the current examples of healthcare the VA waves copays for:

  • Health exams for certain problems linked to your military service, claim exams, lab tests, and electrocardiograms (EKGs or ECGs).
  • Healthcare for Vets related to combat who served in a theater of combat operations after November 11, 1998.
  • Healthcare for VA-rated service-connected disabilities, cancer of the head or neck due to nose or throat radium treatments received while serving.
  • Individual or group programs that help you lose weight or quit smoking.
  • Public VA health initiatives and VA research projects.
  • Mental health services for readjustment counseling or military sexual trauma (MST).
  • Your first three mental health appointments, including substance abuse disorder, between June 27, 2023, and December 29, 2027. Medication is not included.

How Much Are VA Copays?

VA copay rates can change every year and are affected by the tier of medication you require, the type of healthcare you are receiving, and your priority group. Below is a breakdown of what you can expect to pay based on these factors:

VA Urgent Care Copay

If you are in priority groups 1-5, your first three visits within a calendar year have no copays. You’ll then pay $30 per visit for the rest of the calendar year. For priority group 6, you’ll pay no copays if you are receiving care for a condition covered by a special authority and $30 per additional visit. If you are at urgent care for something not related to a condition covered by a special authority, you’ll also owe a $30 copay. Veterans in priority groups 7 and 8 pay $30 VA copays per visit.

Outpatient Rates

There is no copay for those with a disability rating of 10% or higher. For anyone else, there may be copayments if you receive outpatient healthcare not related to your service:

  • $15 per visit or test when receiving primary care.
  • $50 per visit to specialty healthcare services, such as going to the eye doctor. You also pay this rate for specialty tests, such as an MRI.

Inpatient Rates

Vets with a disability rating of 10% or higher don’t have copays for inpatient care. For VA copay priority groups 7 or 8, you may receive a reduced rate. Furthermore, all Veterans living in areas with a high cost of living, regardless of their priority group, may qualify for a reduced copay rate. You can find out if you qualify by calling 877-222-8387 (TTY: 711):

  • Priority group 7 pays a $326.40 copay in addition to a $2 per day charge for the first 90 days of a 365-day period. Vets will need to cover a $163.20 copay and $2 per day charge for each extra 90 days of care per 365-day period.
  • Priority group 8 pays a $1,632 copay in addition to a $10 per day charge for the first 90 days of a 365-day period. Vets will need to cover a $816 copay and $10 per day charge for each extra 90 days of care per 365-day period.

VA Medication Copay Tier List

Veterans who are a part of priority group 1 don’t have a copay on medication. If you are in priority groups 2 through 8, you’ll need to cover prescriptions for non-service-connected conditions and over-the-counter medication from VA pharmacies. How much you pay will depend on the tier of drug and amount you are receiving; however, it’s important to remember:

  • Inpatient copays cover medication while you are in a VA or approved facility.
  • You have a copay cap of $700 each year in you won’t receive any additional copay charges until January 1 of the following year.

Here are the current outpatient copay amounts Vets pay for medication:

  • The Tier 0 drugs are $0.
  • Tier 1 drugs have a $5 copay for a 1-30 day supply, $10 for a 31-60 day supply, and $15 for a 61-90 day supply.
  • Tier 2 drugs have a $8 copay for a 1-30 day supply, $16 for a 31-60 day supply, and $24 for a 61-90 day supply.
  • Lastly, Tier 3 drugs have a $11 copay for a 1-30 day supply, $22 for a 31-60 day supply, and $33 for a 61-90 day supply.

Extended Care and Geriatric Rates

The first 21 days of elder and long-term care don’t have a copay. Beginning on the 22nd day, VA copays are determined based on your finances as shown on VA Form 10-10EC, and the level of care you require. For services that do require a VA copay, this is the current rate breakdown:

  • Inpatient care caps at $97 per day.
  • Outpatient care caps at $15 per day.
  • Domiciliary care for homeless Veterans caps at $5 per day.

Does Medicare Pay VA Copays?

For the most part, if you have Original Medicare (Medicare Parts A and B) or Medicaid, the VA won’t bill them. If you have a Medicare Supplement plan, otherwise known as Medigap, the VA may bill them. All parts of healthcare are complex. Medicare is no exception. To better understand your specific coverage and what is covered, you’ll need to speak with your licensed Medicare agent.

How Do I Pay My VA Copay Online?

If you’d like to make your VA copay payment, you can do so online, over the phone, through the mail, or in person. Keep in mind if you don’t pay by your due date, you may face interest and late fees, and your debt could be sent to collections.

Waivers, Exceptions, Income Limits, and Assistance

Sometimes financial hardships can make it difficult for Veterans to cover their copays; however, there are options available, including for those who require prescriptions but only have a service-connected rating of 40% or under. You can receive a VA copay waiver by requesting financial hardship assistance online. Additionally, you’ll find options for requesting help through the mail or in person. Veterans who experience a sudden drop in income or sudden increases in healthcare expenses for their families can also receive exceptions from copays in the future. Changes in your income or financial standing should be reported to the VA as soon as possible, as they can review your income and potentially adjust your copay requirements. There is also an income threshold that will affect how much you pay. The VA income limits for copay that applies to you will vary. They are based on the zip code you lived in the following year. To determine your VA copay income threshold, search by zip code to find which applies to you. Related reads:

Sources: Billing & Insurance, VA. Accessed May 2024. https://www.visn4.va.gov/VISN4/patients/billing.asp Current VA health care copay rates, VA. Accessed May 2024. https://www.va.gov/health-care/copay-rates/


CONNECT WITH US
VeteranLife Logo

©2024 VeteranLife. All rights reserved.