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New York/New Jersey VA Health Care Network

 

Billing

Billing Frequently Asked Questions

Other Helpful Resources
 Veteran Services Frequently Asked Questions
 Copayments and Charges
  1. Will my private health insurance cover the co-pay charge?


  2. Should I wait for my insurance company to pay before I pay anything on my account?


  3. Is the co-pay for the current calendar year based on the previous calendar year's income?


  4. Why doesn't the VA bill Medicare?


  5. If the co-pay for prescriptions is $8.00, why is my bill for $24.00?


  6. I am a Purple Heart recipient. Am I charged a co-pay?


  7. What do I do if I cannot afford to pay my co-pay bills for outpatient visits and/or Pharmacy charges?


  8. Was my insurance company billed for my Service-Connected visit?


  9. What is a Means Test?


  10. How often do I have to update the Means Test?


  11. What is the Geographic Means Test (GMT)?


  12. Are Combat veterans eligible for medical services after separation from military service?

         
Question 1. Will my private health insurance cover the co-pay charge?

Answer VA is authorized to submit claims to health insurance carriers for recovery of VA's "reasonable charges" in providing medical care to nonservice-connected veterans and to service-connected veterans for nonservice-connected conditions. Third party insurance companies: VA bills "Reasonable and Customary Charges" and insurance companies pay based on the veteran's individual policy (ex. If he/she has a deductible to be met). The veteran should contact his/her insurance carrier and ask how it pays VA. The amount applied to the co-pay ( i.e. $8 per prescription fill, $15 per Primary Care visit, $50 per Specialty visit, $1068 per admission when applicable) will be whatever the insurance carrier pays for services rendered.

All veterans applying for VA medical care will be asked to provide information on their health insurance coverage, including coverage provided under policies of their spouses. Veterans are not responsible for paying any remaining balance of VA's insurance claim that is not paid or covered by their health insurance. However, veterans whose income is above the "means test" threshold are responsible for VA co-payments, required by Federal law.

HMO policies require you to see one of their participating providers or facilities and the VA is not a participant (unless the care received was emergent-Emergent care is billable to an HMO policy).

Question 2. Should I wait for my insurance company to pay before I pay anything on my account?

Answer No. It is important that you pay the bill when you receive it. Often VA does not receive payment from insurance companies for several billing cycles, which causes accumulation of interest and administrative charges on your account. You are financially responsible for these additional charges. Veterans should be aware that accounts over $25 and not paid within 90 days (3 billing cycles) will automatically go into collections and money can be taken from any Federal money received [i.e. Income Tax return, Social Security check] through the Treasury Offset Program and Debt Management Center.

Please note: if a veteran has paid the charges and his/her insurance company then pays VA, VA will credit that payment to the account. If there is no current balance on the account, a refund will be issued to the veteran.

Question 3. Is the co-pay for the current calendar year based on the previous calendar year's income?

Answer Outpatient co-pays are determined by a veteran's eligibility status and are based on the previous calendar year's income.

Long Term co-pays are determined by a veteran's eligibility status and are based on current year income, assets, and expenses.

Question 4. Why doesn't the VA bill Medicare?

Answer According to Federal Law, federal agencies are prohibited from billing Medicare/Medicaid for prescriptions and /or services furnished at their facilities. No benefits will be provided to our facility. We are, however, able to bill reimbursable and/or Medicare supplemental health insurance policies. Veterans should check with their insurance carrier for individual benefits.

Question 5. If the co-pay for prescriptions is $8.00, why is my bill for $24.00?

Answer Pharmacy co-pay is $8.00 per prescription, 30 days or less. The $24.00 charge is because it is a 61- 90 day prescription.

Question   6. I am a Purple Heart recipient. Am I charged a co-pay?

Answer Effective 11-30-99, all Purple Heart recipients are classified as Priority Group 3 and are exempt from all inpatient and outpatient co-payment charges. However, this exemption does NOT include pharmacy co-payments. (Reminder: It is the veteran's responsibility to notify the Veterans Service Center, located at each VA facility, of Purple Heart award and provide documentation so that Purple Heart status can be recorded.)

Question 7. What do I do if I cannot afford to pay my co-pay bills for outpatient visits and/or Pharmacy charges?

Answer Contact the Veterans Service Center at your VA facility for information and guidance.

Question 8. Was my insurance company billed for my Service-Connected visit?

Answer VA does not bill for treatment of service-connected conditions.

Question   9. What is a Means Test?

Answer Public Law 99-272 established an income base (Means Test) for determining eligibility for medical care for non-service connected (NSC) veterans.

A Means Test is a report of your previous year's household income (this includes veteran, spouse & dependents who contribute to the household income) total income, assets, and allowable deductions. It is used to determine co-pay status for outpatient and inpatient visits. If income and assets fall below the means test threshold, there is no co-payment for medical treatment*.

*The means test threshold for 2009 is $29,402 for a single veteran, $35,284 for a veteran with one dependent, plus $2,020 for each additional dependent. The means test threshold amounts change every year on January 1. In addition, if income and assets together equal $80,000 the co-payments apply.

Question 10. How often do I have to update the Means Test?

Answer Veterans in a "Means Test Co-pay Exempt" status must update financial information annually.

Veterans in a "Means Test Co-pay Required" status are not required to complete annual update.

Question   11. What is the Geographic Means Test (GMT)?

Answer The GMT is VA's system of determining veterans' ability to pay for health care and to provide veterans whose incomes are above the VA Means Test threshold but below the U.S. and Department of Housing and Urban Development (HUD) low-income limits for their area, with an 80 percent reduction in the inpatient co-pay rates. Outpatient co-pay is unchanged. These veterans will now be enrolled in Priority Group 7. Enrollment Priority Group 8 will be those veterans with incomes above the VA Means Test and HUD thresholds. GMT status will identify veterans who qualify for a reduced inpatient GMT co-pay rate. The veteran's permanent address will be used to determine the geographic income threshold.

Question 12. Are Combat veterans eligible for medical services after separation from military service?

Answer Veterans who served in combat operations during a period of war after the Gulf War, or in combat against hostile force after November 11, 1998, must be provided hospital care, medical services, and community living centers for any illness medically determined to be related to combat service for a 5-year period following separation from military service, not withstanding that there is insufficient medical evidence to conclude that such condition is attributable to such service. Veterans under this authority will not be subject to co-payments for care.