Types of Copayments
No copayments are charged for treatment of service-connected conditions.
This copay is based on the highest of two levels of service on any individual day.
- Primary Care Services – Services provided in a primary care setting to address overall patient care – $15
- Specialty Care Services – In general, services delivered in a specialty outpatient clinic provided by highly-specialized, narrowly-focused health care professionals –$50
Services provided in Specialty Care areas, such as:
- and specialty tests such as:
- magnetic resonance imagery (MRI)
- computerized axial tomography (CAT) scan
- nuclear medicine studies (highest level of service)
*There is no copay requirement for preventive care services, such as screenings or immunizations.
|Priority Group||Outpatient Medication Tier||Copayment amount|
|2-8||1-30 day supply||31-60 day supply||61-90 day supply|
(Non-Preferred Generics and some OTCs)
|$700 Medication Copayment Cap|
Effective February 27, 2017
Veterans in Priority Groups 2-8, are required to pay for each 30-day or less supply of medication for treatment of nonservice-connected condition (unless otherwise exempt).
|30-day or less supply for Tier 1 (Preferred Generics) Medications for certain Veterans:||$5|
|30-day or less supply for Tier 2 (Non-Preferred Generics & some OTCs) Medications for certain Veterans:||$8|
|30-day or less supply for Tier 3 (Brand Name) Medications for certain Veterans:||$11|
(Veterans in Priority Groups 2 through 8 are limited to $700 annual cap)
Veterans in Priority Group 1 do not pay for medications.
There are two inpatient copay rates – the full rate and the reduced rate. The reduced inpatient copay rate, which is 20% of the full inpatient rate, applies to Veterans enrolled in PG 7. Both the full inpatient copay rate and the reduced inpatient copay rate are computed over a 365-day period. This copay is charged in addition to a standard copay for each 90 days of care within a 365-day period, regardless of the level of service (such as intensive care, surgical care or general medical care); a per diem charge will be assessed for each day of hospitalization. Because the Inpatient Copay rates change each year, they are published separately and can be found online at www.va.gov/healthbenefits/cost or for more copayment information, call toll free 1-877-222-VETS (8387) Monday - Friday between 8 a.m. and 8 p.m. ET.
Long-Term Care Copay Rates*
This copay is based on three levels of care (see “Available Long-Term Care Services” in 5_Medical Benefits Package for definitions).
- Inpatient: Community Living Centers (nursing home) Care/Inpatient Respite Care/Geriatric Evaluation - Up to $97 per day
- Outpatient: Adult Day Health Care/Outpatient Geriatric Evaluation/Outpatient Respite Care -
$15 per day
- Domiciliary Care: - $5 per day
*Copays for Long-Term Care services start on the 22nd day of care during any 12-month period — there is no copay requirement for the first 21 days. Actual copay charges will vary from Veteran to Veteran, depending on the financial information submitted on VA Form 10-10EC (Application for Extended Care Services).
NOTE: There are no copayments for hospice care provided in any setting.
Annual Changes to Copay Rates
Copay rates may change annually, including the annual cap on medication copayments. Current-year rates can be found at any VA health care facility or on VA’s web site at www.va.gov/healthbenefits/cost/copay_rates.asp.
Cost-Free Care for Certain Veterans
Many Veterans qualify for cost-free health care and/or medications based on:
- Receipt of a Purple Heart, or
- Former Prisoner of War Status, or
- 50% or more Compensable VA service-connected disabilities (0-40% service-connected may take co-pay test to determine medication copay status), or
- Veterans deemed catastrophically disabled by a VA provider, or
- Veterans with income below the income limit, or
- Other qualifying factors, including treatment related to their military service experience.
Cost-Free Medical Services (Partial list)
- Special registry examinations offered by VA to evaluate possible health risks associated with military service
- Counseling and care for military sexual trauma
- Compensation and pension examinations requested by the Veterans Benefits Administration (VBA). This is a physical exam to determine service-related illness or injuries for determination of a Veteran’s entitlement to compensation and pension benefits.
- Care that is part of a VA-approved research project
- Care related to a VA-rated service-connected disability
- Readjustment counseling and related mental health services
- Care for cancer of head or neck caused by nose or throat radium treatments received while in the military
- Catastrophic disability exam
- Individual or group smoking cessation or weight reduction services
- Publicly announced VA public health initiatives, such as health fairs
- Care potentially related to combat service for Veterans who served in a theater of combat operations after November 11, 1998. This benefit is effective for five years after the date of Veteran’s most recent discharge from active duty.
- Laboratory and electrocardiograms
Struggling To Pay VA Copayments? VA Has Programs That Can Help
VA has programs that can assist enrolled Veterans who may be suffering from financial distress, struggling to pay VA copayments, who have lost a job, incurred increases in out-of-pocket Veteran or family health care expenses or currently face a significant decrease in household income. VA’s Medical Care Hardship program could help Veterans qualify for VA health care enrollment for health care services if they had a recent change in their income, even if they were previously denied enrollment based on their household income. Veterans who have not applied for VA enrollment because they thought their previous year household income was too high may want to reconsider applying if their projected current year’s household income is lower. If your current and projected household income puts you below VA income limits or geographic income limits for your area, you may qualify for enrollment and cost-free VA medical care.
|Four possible options for Veterans unable to pay assessed copay charges|
|Hardship Determination||A hardship determination provides an exemption from outpatient and inpatient copays for the remaining calendar year. If your projected household income is substantially below your prior year’s income, you may request a hardship determination by contacting your local enrollment coordinator.|
|Waiver||A waiver or “write-off” refers to an agreement to forgive payment of an existing VA debt. If your projected household income for the current year is substantially reduced and will affect your ability to repay your debt, you can request a waiver of your copayment debt. You must request a waiver within 180 days of the date of your billing statement. For more information on billing and copay, call VA’s billing and copay staff at 1-866-400-1238 Monday – Friday between 8 a.m. and 8 p.m. ET.|
|Offer in Compromise||A compromise is an “offer to settle” your past VA debts. VA will consider both current and future household income in making a determination. Generally, offers of compromise that are accepted must be paid in full within 30 days from the date of acceptance. To request a compromise, contact VA’s billing and copay staff at 1-866-400-1238.|
|Repayment Plans||Another option that may be available to you is a VA repayment plan, known as “collection by installment.” To request a repayment plan, call VA’s billing and copay staff toll free at 1-866-400-1238 Monday – Friday between 8 a.m. and 8 p.m. ET.|
VA’s Medical Care Hardship program may help you qualify for VA Health Care enrollment
If your income has recently changed, you may qualify for enrollment even if it was denied previously based on your household income. Or, perhaps you have put off applying for enrollment because you think your income is too high. Now may be the time to provide updated financial information or apply for enrollment.
Personal circumstances, such as loss of employment, sudden decrease in income, or increases of out-of-pocket family health care expenses factor into VA’s hardship determination.
If your current and projected household income puts you below the VA Income Limits or Geographic Income Limits for your area, you may qualify for enrollment and cost-free VA medical care.
For more information and qualifications for this program, contact your local VA at 1-877-222 VETS (8387) between 8AM and 8PM ET, Monday – Friday.
Veterans with Catastrophic Disabilities
Veterans who were previously not eligible for enrollment because their income is over the income limits, and are deemed catastrophically disabled by VA, are eligible for enrollment.
To be considered catastrophically disabled, a Veteran must be determined by a VA provider to have a severely disabling injury, disorder or disease that compromises their ability to carry out the activities of daily living to such a degree that personal or mechanical assistance is required to leave home or bed, or constant supervision is required to avoid physical harm to themselves or others. Veterans may request a catastrophic disability evaluation by contacting the enrollment coordinator at their local VA health care facility. VA will make every effort to schedule an evaluation within 30 days of the request, and there is no charge for the evaluation. If found to be catastrophically disabled, the Veteran will be enrolled and receive cost-free VA medical care and medications; however, Veterans in this category may be subject to copayments for extended care (long-term care). Additionally, enrolled Veterans in a lower priority group, such as PG 7 or 8 you will be moved to PG 4.