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Department of Veterans Affairs: Priority Groups for Free Medical Care or Medical Care with Co-Payments

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The Department of Veterans Affairs has come a long way since it was first established on July 21, 1930. You may come to find out that the VA still has a long way to go depending on what veteran you ask. I am a disabled veteran myself and receive all of my medical care from The Department of Veterans Affairs.

My service connected disability is rated at 60%, which means I have absolutely no co-payments for any my medical care including prescriptions.  I ended up having shoulder surgery a couple of years ago and the surgery would’ve cost me tens of thousands of dollars, but with The Department of Veterans Affairs I paid absolutely nothing.

Many veterans are not so lucky and do have co-payments for their health care coverage and prescriptions. Depending on the level of disability rating a veteran receives from the VA they are placed in one of eight priority groups. Below is a description of each priority group given to a veteran by the Department of Veterans Affairs.

Group 1:  Veterans with service-connected disabilities rated 50 percent or more and/or veterans determined by VA to be unemployable due to service-connected conditions.

Group 2:  Veterans with service-connected disabilities rated 30 or 40 percent.

Group 3:  Veterans with service-connected disabilities rated 10 and 20 percent, veterans who are former Prisoners of War (POW) or were awarded a Purple Heart, veterans awarded special eligibility for disabilities incurred in treatment or participation in a VA Vocational Rehabilitation program, and veterans whose discharge was for a disability incurred or aggravated in the line of duty.

Group 4:  Veterans receiving aid and attendance or housebound benefits and/or veterans determined by VA to be catastrophically disabled. Some veterans in this group may be responsible for co-pays.

 Group 5:  Veterans receiving VA pension benefits or eligible for Medicaid programs, and non-service connected veterans and non-compensable, zero percent service-connected veterans whose annual income and net worth are below the established VA means test thresholds.

 Group 6:  Veterans of the Mexican border period or World War I; veterans seeking care solely for certain conditions associated with exposure to radiation or exposure to herbicides while serving in Vietnam; for any illness associated with combat service in a war after the Gulf War or during a period of hostility after Nov. 11, 1998; for any illness associated with participation in tests conducted by the Defense Department as part of Project 112/Project SHAD; and veterans with zero percent service-connected disabilities who are receiving disability compensation benefits.

 Group 7:  Non service-connected veterans and non-compensable, zero percent service-connected veterans with income above VA's national means test threshold and below VA's geographic means test threshold, or with income below both the VA national threshold and the VA geographically based threshold, but whose net worth exceeds VA's ceiling (currently $80,000) who agree to pay co-pays.

 Group 8:  All other non service-connected veterans and zero percent, non-compensable service-connected veterans who agree to pay co-pays. (Note: Effective Jan. 17, 2003, VA no longer enrolls new veterans in priority group 8).

 

Depending on which of the above Priority groups a veteran is placed in will determine the level of co-payment for services offered to them by the Department of Veterans Affairs.

Copayments for Medical Services -- Veterans Means Testing

VA uses means testing to determine a veteran's level of copayments for medical services and in addition to accept or deny certain veterans applying for the first-time.  Prior to 2003 The Department of Veterans Affairs allowed veterans to apply for medical coverage with any income level who were not required to meet means testing.  These are veterans classified as priority 8.  VA will no longer accept applications from these veterans.  As the demand for services grows faster than funding, VA, in the future, may also exclude priority 7 veterans from enrolling in the system.

 

Although there are exceptions, as a general rule, veterans in priority categories 2 through 6 do not have to pay co-pays for the following services (In other words these services are free):

  • inpatient services,
  • outpatient services or
  • long term care services.

Veterans in priority categories 7 and 8 generally do have to pay co-pays but there are some exceptions if the veteran meets VA's mean test or the geographic means test.

 In some states VA's mean test for maximum income is less than the geographic means test and in other states it is just the opposite.

Copayment Rates (for veterans that are in priority groups 7 and 8…or veterans who are determined liable by the VA means test to make co-payments)

 Outpatient Services*

 

Basic Care Services—services provided by a primary care clinician     $15/visit

 

Specialty Care Services—services provided by a clinical specialist such as surgeon, radiologist, audiologist, optometrist, cardiologist, and specialty tests such as magnetic resonance imagery (MRI), computerized axial tomography (CAT) scan, and nuclear medicine studies     $50/visit

 

*Copay amount is limited to a single charge per visit regardless of the number of health care providers seen in a single day. The copay amount is based on the highest level of service received. There is no copay requirement for preventive care services such as screenings and immunizations. 

 

Medications 

 

For each 30-day or less supply of medication for treatment of

 Non-service connected condition     $8

 

(Veterans in Priority Groups 2 through 6 are limited to a $960 annual cap) 

 VA does not charge a copay for medications used for treatment of:

  • A veteran who is 50% or more service-connected
  • A veteran who has been determined by VA as unemployable due to their service-connected conditions
  • A veteran's specific service-connected disability
  • A veteran who is a former POW
  • A veteran whose income is below the maximum annual rate for VA pension
  • A veteran's conditions related to a veteran's exposure to:
  • Herbicides during the Vietnam-era, OR
  • Ionizing radiation during atmospheric testing, OR
  • Ionizing radiation during the occupation of Hiroshima and Nagasaki
  • A service-related condition of a veteran who served:
  • In the Gulf War, OR
  • In combat in a war after the Gulf War, OR
  • During a period of hostility after November 11, 1998
  • A veteran's military sexual trauma
  • A veteran's cancer of head or neck caused by nose or throat radium treatments given while in the military
  • A veteran participating in a VA approved research project

Inpatient Services** 

Inpatient copay for first 90 days of care during a 365-day period     $1,068

 

Inpatient Copay for each additional 90 days of care during a 365-day period     $534

Per Diem Charge     $10/day

 

**Based on geographically-based means testing, lower income veterans who live in high-cost areas may qualify for a reduction of 80% of inpatient copay charges. 

 

Long-Term Care# 

 

Nursing Home Care/Inpatient Respite Care/Geriatric Evaluation maximum of $97/day 

 Adult Day Health Care/Outpatient Geriatric Evaluation or Outpatient Respite Care maximum of $15/day

 

Geriatric Evaluation

 Domiciliary Care maximum of $5/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 upon financial information submitted on VA Form 10-10EC.

 

 


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