CO-PAYMENTS FOR VA HEALTH-CARE


The VA is required to charge a co-payment to certain veterans for different types of medical care provided. These co-payments are for inpatient care, outpatient care, medications and nursing home care. The co-payments do not apply to all veterans and include many exemptions. In addition, the rates vary depending on the type of care provided.


The medication co-payment is $8.00 for each medication (30-day or less supply) or $9.00 for each medication (30-day or less supply) for certain higher income veterans.


The co-payment for outpatient care has been divided into a 3-tiered structure that includes (1) services for which there will be no co-payment; (2) Primary Care and (3) Specialty Care. Please refer to the last page of this guide for the current rate.


The co-payment for Basic Care Services is $15/visit. This is defined as a services provided by a primary care clinician. The Specialty Care Services co-payment is currently $50/visit. Specialty Care Services is a visit with a clinical specialist such as a surgeon, radiologist, audiologist, optometrist, cardiologist, and specialty tests such as MRI, CAT scan, and nuclear medicine studies.


Co-Payments for VA Health-Care System for Priority Group 1
Priority Group 1   
Treatment Type  Covered or Not 
Inpatient Co-payment:  No 
Outpatient Co-payment:  No 
Medication Co-payment:  No 
Extended Care Services Co-payment:  No 

Co-Payments for VA Health-Care System for Priority Group 2 & 3
Priority Group 2 & 3   
Treatment Type  Covered or Not 
Inpatient Co-payment:  No 
Outpatient Co-payment:  No 
Medication Co-payment:  Yes (if less than 50% SC and medication is for NSC Condition or income is within certain limits, then exempt) 
Extended Care Services Co-payment:  No 

Co-Payments for VA Health-Care System for Priority Group 4
Priority Group 4*   
Treatment Type  Covered or Not 
Inpatient Co-payment:  No 
Outpatient Co-payment:  No 
Medication Co-payment:  No* 
Extended Care Services Co-payment:  Yes 

* Note: Veterans determined by the VA to be Catastrophically Disabled are placed in Priority Group 4. These veterans are no longer subject to the medical and medication/pharmacy co-payments. However, they may be subject to co-pay for Extended Care Services, depending on income.

Co-Payments for VA Health-Care System for Priority Group 5
Priority Group 5   
Treatment Type  Covered or Not 
Inpatient Co-payment:  No 
Outpatient Co-payment:  No 
Medication Co-payment:  Yes 
Extended Care Services Co-payment:  Yes 

Co-Payments for VA Health-Care System for Priority Group 6
Priority Group 6 (Veterans Receiving Care for Exposure or Experience)   
Treatment Type  Covered or Not 
Inpatient Co-payment:  No* 
Outpatient Co-payment:  No* 
Medication Co-payment:  No* 
Extended Care Services Co-payment:  Yes* 

* All applicable co-payments will be assessed to veterans when the care is for conditions not related to their exposure or experience.

Co-Payments for VA Health-Care System for Priority Group 7
Priority Group 7*   
Treatment Type  Covered or Not 
Inpatient Co-payment:  Yes 
Outpatient Co-payment:  Yes 
Medication Co-payment:  Yes 
Extended Care Services Co-payment:  Yes* 

* Note: Priority 7 veterans are charged 20% of the inpatient co-payment that a Priority 8 veteran will be charged. This includes admission to a BRC program.

Co-Payments for VA Health-Care System for Priority Group 8
Priority Group 8*   
Treatment Type  Covered or Not 
Inpatient Co-payment:  Yes 
Outpatient Co-payment:  Yes 
Medication Co-payment:  Yes 
Extended Care Services Co-payment:  Yes* 

* Note: Veterans determined by the VA to be Catastrophically Disabled are placed in Priority Group 4. These veterans are no longer subject to the medical and medication/pharmacy co-payments.

For additional information on co-payments please check the VA website at the following link: http://www.va.gov/healthbenefits/cost/copays.asp

Reminder
REMINDER: It is important to periodically review VIST Roster cases that are assigned to Priority Group 8 to determine if they can be re-assigned to a higher eligibility group. Veterans in Priority Group 7 pay a significantly lower inpatient co-payment during hospitalization, including admission to a BRC. 

Medication Co-Payment Cap
Medication Co-Payment Cap: The VA has established a medication co-payment cap for veterans enrolled in priority groups 2-6. Medications will continue to be dispensed when the co-payment cap is met. An annual medication co-payment cap was NOT established for Priority group 7 and 8. 


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