Did You Know ... Outpatient Copayment
The Department of Veterans Affairs (VA) is required bylaw (PL 99-272) to charge veterans,in certain income categories, a copayment for their outpatient visits.The Veterans Millennium Health Care and Benefits Act (PL 106-117) authorized VA to decrease the outpatient copayment amount provided for some services.As a result,VA has made changes and is implementing a three-tiered outpatient copayment structure.
The copayments will be based on primary care visits($15), specialty care visits ($50), and no copayment designations. This three-tiered copayment system will be effective for all services provided on an outpatient basis,as follows:
1. No Copayments
Services for which there will be no copayment are:
- Publicly announced VA public health initiatives (for example,health fairs);or
- An outpatient visit solely consisting of preventive screening and immunizations,for example:
- Influenza immunization
- Pneumonococcal immunization
- Hypertension screening
- Hepatitis C screening
- Tobacco screening
- Alcohol screening
- Hyperlipidemia screening
- Breast cancer screening
- Cervical cancer screening
- Screening for colorectal cancer by fecal occult blood testing
- Education about the risks and benefits of prostate cancer screening
Other services would also not be charged copayments. These services are routine diagnostic tests not requiring the immediate presence of a physician (for example, laboratory, routine flat film radiology services, and electrocardiograms).
2. Primary Care ($15 Copayment)
A primary care outpatient visit is an episode of care furnished in a primary care clinic that provides health care services. Each patient's identified primary care clinician delivers services as part of a primary care team. Patients do not need a referral to access the primary care clinician and most of the primary care team.
3. Specialty Care ($50 Copayment)
A specialty care outpatient visit is an episode of care furnished in a clinic that does not provide primary care, and is only provided through a referral. Some examples of specialty care provided at a specialty care clinic are surgical consultative services, radiology services requiring the immediate presence of a physician, audiology,optometry, cardiology, magnetic resonance imagery (MRI), computerized axial tomography (CAT) scan, nuclear medicine studies, and ambulatory surgery.
If you have more than one primary care encounter on the same day and no specialty care encounters on that day, you will be billed for one primary copayment only. If you have one or more primary care encounters and one or more specialty care encounters on the same day, you will be billed for one specialty care copayment only.
Service-connected veterans are exempt from outpatient copayment charges. Most nonservice-connected veterans and noncompensable 0 percent service-connected veterans are required to complete an annual means test.The means test is a measure of your family's income and assets. Means test threshold levels change on an annual basis.
If your income and assets fall below the means test threshold, you will not be charged copayments for medical care and treatment. If your income and assets exceed the means test threshold, you will be charged copayments for nonservice-connected medical care and treatment.
VA is required by law to bill health insurance carriers for the cost of medical care and treatment provided to veterans for nonservice-connected conditions. If you have health insurance coverage, it is important to provide that insurance information to the VA. Always bring your insurance card(s)with you when you come to VA for health care — most of the insurance information VA needs is on the card(s).
Reimbursements received from insurance carriers can be used to offset your copayment debt. In some instances, your copayment debt may be partially covered, and in other instances, totally covered by the insurance reimbursement.
When the insurance carrier does not reimburse VA for the health care services provided, you are responsible for paying the copayment. The unpaid copayment balance remains your payment responsibility. Eligibility for VA medical care is not affected by your insurance coverage.
Monthly statements will be mailed listing current charges,including interest and administrative charges, payments and outstanding balances. To avoid interest and administrative charges, payments must be made before your next monthly billing statement. We encourage you to pay by check or money order. You should not send money through the mail. The national payment address is printed on the monthly billing statement.
Funds collected from outpatient copayments, medication copayments, other VA copayments, and health insurance reimbursements are returned to the local VA health care facility. These funds are used to provide additional health care services to veterans at that facility.
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VA National Means Test Income Threshold |
GMT Income Threshold
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Health Care Eligibility Site Map
For questions about Health Care Eligibility, please visit the VA inquiry website.
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