The Tiered Copayment Medication Structure (TCMS) policy went into effect on February 27, 2017. The tiered structure established copayments for 30-day prescriptions at $5 for Tier 1 (top 75 generics), $8 for Tier 2 (all other generics) and $11 for Tier 3 (sole source/brand name). Veterans in Priority Groups 2 through 8 are limited to a $700 annual copayment cap.
Copayment rates may change annually, including the annual cap on medication copayments.
Veterans in Priority Group 1 do not pay for medications.
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)
There are two inpatient copayment rates – the full and reduced rate. The reduced inpatient copayment rate, which is 20% of the full inpatient rate, applies to Veterans enrolled in PG 7. Both the full and the reduced rates are computed over a 365-day period. This copayment is charged in addition to a standard copayment 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 copayment rates change each year, they are published separately and can be found online at va.gov/healthbenefits/cost/copays . For more copayment information, call 1-877-222-VETS (8387) Monday through Friday between 8 a.m. and 8 p.m. ET.
Long-Term Care Copay Rates*
Long-term care copayment is based on three levels of care (see “Available Long-Term Care Services” on page 17).
- 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
*Copayments for long-term care services start on the 22nd day of care during any 12-month period — there is no copayment requirement for the first 21 days. Actual copayment charges will vary from Veteran to Veteran, depending on the financial information submitted on VA Form 10-10EC (Application for Extended Care Services).
Cost-Free Care for Certain Veterans
Many Veterans qualify for cost-free health care and/or medications based on:
- Receipt of a Purple Heart
- Former Prisoner of War Status
- 50% or more Compensable VA service-connected disabilities (0-40% service-connected may take the co-pay test to determine medication copay status)
- Deemed catastrophically disabled by a VA provider
- Income below the income limit
- Other qualifying factors, including treatment related to their military service experience.
- Special registry examinations offered by VA to evaluate possible health risks associated with military service.
- VA policy on counseling and care for military sexual trauma
- Compensation and pension examinations requested by the VBA. This is a physical exam to establish service-related illnesses or injuries as part of a 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.
- Recommended readjustment counseling and related mental health services
- Care for cancer of the head or neck that was caused by nose or throat radium treatments received while in the military.
- Catastrophic disability exam.
- Participation in Individual or group smoking cessation or weight reduction services
- Publicly announced VA public health initiatives, such as health fairs.
- Care received that is potentially related to combat service of Veterans who served in a theater of combat operations after November 11, 1998. This benefit is effective for five years after the date of the Veteran’s most recent discharge from active duty.
- Conditions discovered in their laboratory and electrocardiograms
VA Has Programs That Can Help Veterans Pay Copays
VA offers a wide range of services to support Veterans, including financial assistance options. Veterans who have copayments associated with VA health care are responsible to pay those obligations in a timely manner. If Veterans are unable to pay their VA copayments, VA can help with alternate payment arrangements including repayment plans, waivers or a compromise. Once a debt becomes 120 days old, it is referred to the Department of Treasury for collection and VA can no longer accept payments or provide financial assistance.
*Note: Payments made to VA by a private health insurance carrier may allow VA to offset part or all of a Veteran’s VA copayment.
|Four possible options for Veterans unable to pay assessed copay charges|
|Hardship Determination||A hardship determination provides an exemption from outpatient and inpatient copayments 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||Veterans can request a waiver of part or all of their debt. If a waiver is granted, the Veteran will not be required to pay the amount waived. Veterans may submit a completed VA Form 5655 (Financial Status Report), along with an explanation of why the debt would cause a financial hardship. Veterans also may submit in writing a request for a waiver hearing. VA will notify the Veteran of the date, time and place where the hearing will be held. For more information on waivers, call VA customer service at 1-866-400-1238, Monday through Friday from 8 a.m. to 8 p.m. ET.|
|Offer in Compromise||Veterans can apply for a compromise and propose a lesser amount as full settlement of their debt by submitting a request in writing specifying the dollar amount they can pay along with a completed VA Form 5655 (Financial Status Report). For more information on compromises, call VA customer service at 1-866-400-1238, Monday through Friday from 8 a.m. to 8 p.m. ET.|
|Repayment Plans||Veterans can establish a monthly repayment plan if they cannot pay their copayment charges when due by submitting a VA Form 1100 (Agreement to Pay Indebtedness) indicating a proposed monthly payment amount and include the account number and payment stub. For more information on repayment plans, call VA customer service at 1-866-400-1238, Monday through Friday from 8 a.m. to 8 p.m. ET.|
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. 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, will be moved to PG 4.
Coverage Under The Affordable Care Act
The Affordable Care Act (ACA), also known as the health care law, was created to expand access to coverage, control health care costs and improve health care quality and care coordination. The health care law does not change VA health benefits or Veterans’ out-of-pocket costs.
Three things you should know:
- VA wants all Veterans to receive health care that improves their health and well-being.
- If you are enrolled in any of these VA programs, you have coverage under the standards of the health care law:
- Veteran’s health care program
- Spina Bifida Health Care Benefits Program
- If you are not enrolled in VA health care, you can apply at any time.
Veterans and family members who are not eligible for VA health care and who do not have employer- provided health insurance should use the Marketplace to get health coverage by going to www.healthcare.gov/. To find in-person assistance nearby to help you apply, pick a plan and enroll for free, go to https://localhelp.healthcare.gov or call the Marketplace Call Center at 1-800-318-2596 24 hours a day, 7 days a week.
Note: U.S. taxpayers will need to declare that they have health coverage on their federal tax forms. In 2016, VA began notifying enrolled Veterans via mail of their period of health care coverage during the previous calendar year. This law also requires VA to provide notification to the Internal Revenue Service. For more information about ACA and VA health care, visit VA’s website at www.va.gov/health/aca or call toll free 1-877-222- VETS (8387) Monday - Friday between 8 a.m. and 8 p.m. ET.
If you are enrolled with VA for your health care, your enrollment with VA meets the standard for minimum health care coverage and you are not eligible for assistance to lower your cost of health insurance premiums if you chose to purchase additional health insurance on the Marketplace to complement your VA health care coverage. Remember, you cannot receive a tax credit for yourself when enrolling within the Marketplace if you are currently enrolled with VA for your health care.
Your VA health care enrollment satisfies the minimum essential coverage under the Affordable Care Act.
VA and Other Health Insurance
If you have other forms of health care coverage, such as a private insurance plan, Medicare, Medicaid or TRICARE, you can continue to use VA along with these plans. Remember, it is always a good idea to inform your doctors if you are receiving care outside of VA so your health care can be coordinated.
Private Health Insurance
Veterans with private health insurance may choose to use these sources of coverage as a supplement to their VA benefits. Veterans are not responsible to pay for VA medical services billed to their health insurance company that are not paid by their insurance carrier.
By law, VA is obligated to bill health insurance carriers for services provided to treat a Veteran’s nonservice- connected conditions. Veterans are asked to disclose all relevant health insurance information to ensure current insurance information is on file, including coverage through a spouse. Identification of insurance information is essential to VA because collections received from private health insurance companies help supplement the funding available to provide services to more Veterans. Enrolled Veterans can provide or update their insurance information by:
- Using the online 10-10-EZR, “Health Benefits Renewal” form at www.vets.gov/healthcare/apply/
- Calling 1-877-222-VETS (8387) Monday - Friday between 8 a.m. and 8 p.m. ET
- Using the self-service Kiosks available at their local VA health care facility. VA health care is NOT considered a health insurance plan.
If you are eligible for Medicare Part D prescription drug coverage, enrollment in the VA health care system is considered creditable coverage for Medicare Part D purposes. This means VA prescription drug coverage is at least as good as the Medicare Part D coverage. Since only Veterans can enroll in the VA health care system, dependents and family members do not receive credible coverage under the Veteran’s enrollment.
Under Medicare Part B, VA health care is NOT creditable coverage. Creditable coverage under Medicare Part B can only be provided through an employer. Although a Veteran may avoid the late enrollment penalty for Medicare Part D by citing VA health care enrollment, that enrollment would not help the Veteran avoid the late enrollment penalty for Part B.
VA does not recommend Veterans cancel or decline coverage in Medicare (or other health care or insurance programs) solely because they are enrolled in VA health care. Unlike Medicare, which offers the same benefits for all enrollees, VA assigns enrollees to enrollment priority groups based on a variety of eligibility factors, such as service-connection and income. There is no guarantee that in future years Congress will appropriate sufficient medical care funds for VA to provide care for all enrollment priority groups. This could leave Veterans, especially those enrolled in one of the lower-priority groups, with no access to VA health care coverage. For this reason, having a secondary source of coverage may be in the Veteran’s best interest.
Enrolling in both VA and Medicare can provide Veterans flexibility. For example, Veterans enrolled in both programs would have access to non-VA physicians (under Medicare Part A or Part B) and can obtain prescription drugs not on the VA formulary if prescribed by non-VA physicians and filled at their local retail pharmacies (under Medicare Part D).
For more information on Medicare coverage, visit the Health and Human Services Medicare website at www.medicare.gov.