Which Veterans Pay For Which Services at VA Healthcare Facilities

	Inpatient Copayment	Outpatient Copayment	Medication Copayment*	Nursing Home Copayment	Insurance Billing	Insurance Balanced Billing	Insurance Deductible/ Copayment
Priority Group 1	No	No	No	No	Yes – If care was for NSC condition	No	No
Priority Groups 2, 3**, 4**	No	No	Yes – If less than 50% SC & medication is for NSC condition	No	Yes – if care was for NSC condition	No	No
Priority Group 5	No	No	Yes	No	Yes – if care was for NSC condition	No	No
Priority Group 6 (WWI and Mexican Border)	No	No	Yes	No	Yes – If care was for NSC condition	No	No
Priority Group 6 (Veterans receiving care for exposure or experience***)	No***	No***	No***	No***	Yes – if care was for NSC condition not related to exposure or experience	No	No
Priority Group 7	Yes	Yes	Yes	Yes	Yes – If care was for NSC condition	No	No

*An annual medication copayment cap has been established for veterans enrolled in priority groups 2-6. Medications will continue to be dispensed when the copayment cap is met. An annual medication copayment cap was not established for veterans enrolled in priority group 7.

**Veterans in receipt of a Purple Heart are in Priority Group 3. This change occurred with the enactment of PL 106-117 on November 30, 1999

**Priority Group 7 veterans who are determined to be Catastrophically Disabled and who are placed in Priority Group 4 for treatment are still subject to the copayment requirements as a Priority Group 7 veteran.

***Priority Group 6 - All applicable copayments will be assessed to veterans when the care is for conditions not related to their exposure or experience.

Special Categories of Veterans – (i.e., Agent Orange, Ionizing Radiation, Persian Gulf, women veterans receiving sexual trauma counseling) are subject to means test copayments when the treatment they are receiving 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. However, care provided not related to exposure, if it is nonservice-connected will be billed to the insurance carrier.

Prescription Copayment Exemption – All veterans receiving prescriptions for NSC conditions who meet the low income criteria are exempt from the prescription copayment.

UPDATED January 2, 2002

ENROLLMENT PRIORITIES

Priority Group 1:

Ø Veterans with service-connected conditions rated 50 percent or more disabling

Priority Group 2:

Ø Veterans with service-connected conditions rated 30 to 40 percent or more disabling

Priority Group 3:

Ø Veterans who are former POWs

Ø Veterans who are awarded the Purple Heart

Ø Veterans with service-connected conditions rated 10 or 20 percent disabling

Ø Veterans discharged from active duty for a disability incurred or aggravated in the line of duty

Ø Veterans awarded special eligibility classification under 38 U.S.C., Section 1151

Priority Group 4

Ø Veterans who are receiving aid and attendance or housebound benefits

Ø Veterans who have been determined by VA to be catastrophically disabled

Priority Group 5

Ø Nonservice-connected veterans, whose income and net worth are below the established dollar threshold

Ø Zero percent service-connected veterans, whose income and net worth are below the established dollar threshold

Priority Group 6

Includes all other eligible veterans who are not required to make a co-payment for their medical care, including:

Ø World War I and Mexican Border War veterans

Ø Veterans solely seeking care for disorders associated with exposure to a toxic substance, radiation, or for disorders associated with service in the
Gulf War, or;

Ø For any illness associated with service in combat in a war after the Gulf War or during a period of hostility after November 11, 1998

Ø Compensable zero percent service-connected veterans

Priority Group 7

Ø Nonservice-connected veterans and zero percent non-compensable service-connected veterans with income and net worth above the established threshold and who agree to pay specified co-payments