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VA Healthcare Network Upstate New York - VISN 2
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Which Veterans Pay For Which Services at VA Healthcare Facilities
(NOTE: This chart does not include Long Term Care Co-payment Information.)
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Inpatient Copay |
Outpatient Copay |
Medication Copay* |
Insurance Billing |
Insurance Balanced Billing |
Insurance Deductible Copay |
Humanitarian Emergency Billing |
| |
GMT Copay |
MT Copay |
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| Priority Group 1 |
No |
No |
No |
No |
Yes - if care was for NSC condition |
No |
No |
No |
| Priority Groups* 2, 3**, 4*** |
No |
No |
No |
Yes - If less than 50% SC & medication is for NSC condition. Note: Former POWs are exempt from all medication copays |
Yes - if care was for NSC condition |
No |
No |
No |
| Priority Group* 5 |
No |
No |
No |
Yes |
Yes - if care was for NSC condition |
No |
No |
No |
Priority Group* 6
(WWI, Mexican Border & 0% SC Compensable) |
No |
No |
No |
Yes - if care was for NSC condition |
Yes - if care was for NSC condition |
No |
No |
No |
Priority Group 6*
(Veterans receiving care for exposure or experience****) | No**** |
No**** |
No**** |
No**** |
No**** |
No |
No |
No |
| Priority Group 7 and 7a |
Yes |
No |
Yes |
Yes - if provided for NSC condition |
Yes - if care was for NSC condition |
No |
No |
No |
| 7c |
Yes |
No |
Yes |
Yes |
Yes |
No |
No |
No |
| 7e |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
Yes |
| 7g |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
Yes |
Priority Group 8 and 8a
8a |
No |
Yes |
Yes |
Yes- if provided for NSC condition |
Yes - if care was for NSC condition |
No |
No |
No |
| 8c |
No |
Yes |
Yes |
Yes |
Yes |
No |
No |
No |
| 8e |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
Yes |
| 8g |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
Yes |
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*An annual medication copay cap of $960 has been established for veterans enrolled in priority groups 2-6. Medications will
continue to be dispensed when the copay cap is met. An annual medication copay cap was not established for veterans enrolled
in priority group 7 or 8.
**Veterans in receipt of a Purple Heart are in Priority Group 3.
**Veterans who are former POWs are in Priority Group 3 and are exempt from Medication Copays.
***Medical care copay required veterans who are determined to be Catastrophically Disabled and who are placed in Priority
Group 4 for treatment are still subject to the copay requirements. Catastrophically Disabled veterans in this priority group can
be subject to full medical care copays or to reduced inpatient copays under the Geographic Means Test criteria.
****Priority Group 6 - Health insurance and all applicable copays will be billed when the care is for conditions not related to
the veteran’s exposure or experience. Veterans in this priority group are subject to full medical care copays or to reduced inpatient
copays under Geographic Means Test criteria and to medication copays.
Special Categories of Veterans — (i.e., veterans claiming exposure to Agent Orange, veterans claiming exposure to Environmental Contaminants, veterans exposed to Ionizing Radiation, combat veterans within 2 years of discharge from military,
veterans who participated in Project 112/SHAD, veterans claiming military sexual trauma and veterans with head and neck
cancer who received nasopharyngeal radium treatment while in the military) are subject to copays when their treatment or mediation
is not related to their exposure or experience. The initial registry examination and follow-up visits to receive results of the
examination are not billed to the health insurance carrier and are not subject to copays. However, care provided not related to
exposure, if it is nonservice-connected will be billed to the insurance carrier and copays can apply.
Medication Copay Exemption — All veterans receiving prescriptions for NSC conditions who meet the low income criteria (income limits for the VA NSC pension program) are exempt from the medication copay.
Long Term Care Copays — Long Term Care copays are displayed on a separate chart.
Priority Group 7a and 7c Veterans — Veterans enrolled in this priority group have income above the VA Means Test threshold but below the Geographic Means Test threshold and are responsible for 20% of the inpatient copay and 20% of the inpatient
per diem copay. The geographic means test copay reduction does not apply to outpatient and medication copays and veterans
will be assessed the full applicable copay charges. Note that reduced inpatient copays can apply to veterans in Priority Groups
4 and 6 based upon the income of the veteran.
Priority Group 7e and 7g Veterans (not currently activated) — Veterans assigned to Priority Group 7e or 7g are not
eligible for enrollment if a decision to restrict enrollment of new Priority Group 7 veterans has been made. These veterans are
eligible for care of their NSC conditions on a humanitarian emergency basis and are charged the applicable tortuously liable
billing rate for services provided. Veterans in Priority Group 7e are eligible for care of SC conditions at no charge.
Priority Group 8a and 8c Veterans — Veterans enrolled in this priority group are responsible for the full inpatient copay and the inpatient per diem copay for care of their NSC conditions. Veterans in this priority group are also responsible for outpatient and medication copays for care of their NSC conditions.
Priority Group 8e and 8g Veterans — Veterans assigned to Priority Group 8e or 8g are not eligible for enrollment. These veterans are eligible for care of their NSC conditions on a humanitarian emergency basis and are charged the applicable tortuously
liable billing rate for services provided. Veterans in Priority Group 8e are eligible for care of SC conditions at no charge.
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| Reviewed/Updated Date: April 30, 2007 |
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