Court rules VA must pay for veterans' emergency room care

[Senator]

This decision is a long time coming. As a disabled vet, I have already given the government a signed blank check to be filled out for any amount up to and including my life.

I assume you have to already be seen by the VA Health Care, but I have always avoided buying extra insurance because of this exact same thing. it was a risk I was willing to take.

The Department of Veterans Affairs must reimburse veterans for emergency medical care at non-VA facilities

 

[ivinsfan]

Define emergency that's always been the problem with the VA.....

 

[Fireup2020]

Oh fun:

"VA is aware of this decision and reviewing it," a department spokesperson told The Hill in an email.

--This report was updated on Sept. 11 at 10:26 a.m.

This will take forever!

 

[Senator]

Define emergency that's always been the problem with the VA.....

From what I heard directly from the VA when I was inquiring a few years ago, if your visit is coded as an ER visit, it would be considered an emergency.

Probably urgent care would not be an emergency, although now there are many private urgent care clinics added to the VA network.

 

[bolt]

Remember this?
I believe it's still policy.

https://www.researchgate.net/publication/289252242_EMTALA_Turns_30_Unconstitutional_from_Birth

Nixon did more to this country than many realize.
He eliminated the gold standard, when call upon by France to pay up.

 

[ivinsfan]

From what I heard directly from the VA when I was inquiring a few years ago, if your visit is coded as an ER visit, it would be considered an emergency.

Probably urgent care would not be an emergency, although now there are many private urgent care clinics added to the VA network.

OK, but the 64 dollar question is what happens when it's more then an ER visit and you get transferred inpatient to a non VA hospital. I think this is where it gets confusing...Those bills are not necessarily covered...

 

[Senator]

OK, but the 64 dollar question is what happens when it's more then an ER visit and you get transferred inpatient to a non VA hospital. I think this is where it gets confusing...Those bills are not necessarily covered...

You have to let them know within 72 hours so they can transfer you, or keep you there. If you do that, the bills are covered.

The VA is still your doctor. The VA still makes the decisions. If a veteran thinks the care is better elsewhere, the veteran can pay for it elsewhere.

A medical emergency is an injury, illness or symptom so severe that without immediate treatment, you believe your life or health is in danger. If you believe your life or health is in danger, call 911 or go to the nearest emergency department right away.

Veterans do not need to check with VA before calling for an ambulance or going to an emergency department. During a medical emergency, VA encourages all Veterans to seek immediate medical attention without delay. A claim for emergency care will never be denied based solely on VA not receiving notification prior to seeking care.

It is, however, important to promptly notify VA after receiving emergency care at a community emergency department. Notification should be made within 72 hours of admission to a community medical facility. This allows VA to assist the Veteran in coordinating necessary care or transfer, and helps to ensure that the administrative and clinical requirements for VA to pay for the care are met.

https://www.va.gov/COMMUNITYCARE/programs/veterans/Emergency_Care.asp

 

[ivinsfan]

You have to let them know within 72 hours so they can transfer you, or keep you there. If you do that, the bills are covered.

The VA is still your doctor. The VA still makes the decisions. If a veteran thinks the care is better elsewhere, the veteran can pay for it elsewhere.

Well yes. but remember you are talking the government here. 72 hours seems long enough but who knows? MY DH got admitted to a private hospital thru a VA urgent care visit. When he got put in the ambulance I had a written and signed paper in my hand saying VA will be responsible for any and all bills.

This happened around 4 oclock on a Friday afternoon and it was Monday morning before I could talk to anybody, anywhere...it sure felt better having the signed paper plus having BCBS coverage. …. it did help that there is huge VA clinic in the town and the hospital didn't find this kind of admission at all unusual.

I also wonder about the comment it won't be denied "solely" on the basis of prior notification. So apparently they have other reasons they can use to deny ER claims.. which is why they got sued I guess.

 

[Senator]

Well yes. but remember you are talking the government here. 72 hours seems long enough but who knows? MY DH got admitted to a private hospital thru a VA urgent care visit. When he got put in the ambulance I had a written and signed paper in my hand saying VA will be responsible for any and all bills.

This happened around 4 oclock on a Friday afternoon and it was Monday morning before I could talk to anybody, anywhere...it sure felt better having the signed paper plus having BCBS coverage. …. it did help that there is huge VA clinic in the town and the hospital didn't find this kind of admission at all unusual.

I also wonder about the comment it won't be denied "solely" on the basis of prior notification. So apparently they have other reasons they can use to deny ER claims.. which is why they got sued I guess.

100% correct, that is why so many people are opposed to a single-payer system. The VA does have the criteria that must be met on their website. I would guess that after the court ruling, the law or website will be changed.

Nonservice-Connected Emergency Care
VA can also pay for emergency medical care at a community ED for a Veteran’s nonservice-connected condition. However, there are several requirements and factors that affect the extent to which VA can cover those services. Specifically, emergency medical care for a Veteran’s nonservice-connected condition(s) is eligible for VA payment when all of the following five elements are true:

1. Care was provided in a hospital emergency department (or similar public facility held to provide emergency treatment to the public); AND
2. The emergency was of such a nature that the Veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy; AND
3. A VA medical facility or another Federal facility was not reasonably available to provide the care; AND
4. The Veteran is enrolled and has received care within a VA facility during the 24 months before the emergency care; AND
5. The Veteran is financially liable to the provider of emergency treatment.

There are limitations on VA’s ability to provide coverage when a Veteran has other health insurance (OHI). If OHI does not fully cover the costs of treatment, VA can pay certain costs for which the Veteran is personally liable. By law, VA cannot pay copayments, coinsurance, deductibles, or similar payments a Veteran may owe to the provider as required by their OHI.

VA is also legally prohibited from providing coverage for individuals covered under a health plan contract because of a failure by the Veteran or the provider to comply with the provisions of that health plan contract, e.g., failure to submit a bill or medical records within specified time limits, or failure to exhaust appeals of the denial of payment.

https://www.va.gov/communitycare/pr...n pay,a Veteran's service-connected condition.

 

[MrsHaloFIRE]

Question on this:

Say there's a vet rated 10pct disabled due to knee injury. I thought VA was only responsible for knee related things. Say he cuts off a digit in a tragic chainsaw incident and presents at the ER for extensive reattachment. VA now on the hook for it even though it's completely unrelated to VA disability of tge knee??

 

[exnavynuke]

Question on this:

Say there's a vet rated 10pct disabled due to knee injury. I thought VA was only responsible for knee related things. Say he cuts off a digit in a tragic chainsaw incident and presents at the ER for extensive reattachment. VA now on the hook for it even though it's completely unrelated to VA disability of tge knee??

There are different sides to the VA system. The "disability" compensation comes from the VA's "Veterans Benefits Administration" side. The health care is provided by the "Veterans Health Administration" side. These are related, but separate entities. Having a disability rating does not enroll you in the Veterans Health Administration for medical coverage.

The "coverage" being discussed in this thread only applies to veterans enrolled with the Veterans Health Administration and "actively using" it (i.e. within the past two years has been seen). Additionally, not all veterans are eligible to enroll in the VA's medical side. They must either have sufficient financial need, or have at least one rated disability (many veterans do not have any).

For those that are enrolled. How much of the cost of care the VA passes on depends on both what the care is for (as you somewhat referenced) AND what the disability rating is. For veterans enrolled in the VA medical system that have a disability rating below 50%, only care for their service connected conditions is covered without charge. The VA will bill them for medical services not related to those conditions that are service connected. Veterans with a 50% or higher rating are not responsible for any copayments for any medical coverage through the VA however.

My understanding of the situation you described is that the vet with a low disability rating who is enrolled in VA healthcare would have his hospital bill covered by the VA, but the VA would then bill them the same amount they would have billed them had they been seen at a VA emergency room instead of another facility. A vet with a 50% or higher rating who is enrolled in VA healthcare would have the hospital bill covered and wouldn't receive a bill from the VA. A veteran who was not enrolled in VA healthcare, or who hadn't been seen for more than 24 months, however, would be on the hood for the entire hospital bill and the VA would pay nothing.

 

[ivinsfan]

There are different sides to the VA system. The "disability" compensation comes from the VA's "Veterans Benefits Administration" side. The health care is provided by the "Veterans Health Administration" side. These are related, but separate entities. Having a disability rating does not enroll you in the Veterans Health Administration for medical coverage.

The "coverage" being discussed in this thread only applies to veterans enrolled with the Veterans Health Administration and "actively using" it (i.e. within the past two years has been seen). Additionally, not all veterans are eligible to enroll in the VA's medical side. They must either have sufficient financial need, or have at least one rated disability (many veterans do not have any).

For those that are enrolled. How much of the cost of care the VA passes on depends on both what the care is for (as you somewhat referenced) AND what the disability rating is. For veterans enrolled in the VA medical system that have a disability rating below 50%, only care for their service connected conditions is covered without charge. The VA will bill them for medical services not related to those conditions that are service connected. Veterans with a 50% or higher rating are not responsible for any copayments for any medical coverage through the VA however.

My understanding of the situation you described is that the vet with a low disability rating who is enrolled in VA healthcare would have his hospital bill covered by the VA, but the VA would then bill them the same amount they would have billed them had they been seen at a VA emergency room instead of another facility. A vet with a 50% or higher rating who is enrolled in VA healthcare would have the hospital bill covered and wouldn't receive a bill from the VA. A veteran who was not enrolled in VA healthcare, or who hadn't been seen for more than 24 months, however, would be on the hood for the entire hospital bill and the VA would pay nothing.

You know my DH has a 10% rating..when he went from 0 to 10% the bills for the co pays stopped coming. The bills were for nonservice connected issues. And AFIK Vietnam vets (actual boots on the ground in VN) are taken into system without either financial need and or disability ratings. That's how my DH first got in. So vets if you aren't in the system, just go to the system and ask if you can get in, that's the safest way to go about it.....if your county has a VSO that's the place to start.

 

[Senator]

For veterans enrolled in the VA medical system that have a disability rating below 50%, only care for their service connected conditions is covered without charge. The VA will bill them for medical services not related to those conditions that are service connected. Veterans with a 50% or higher rating are not responsible for any copayments for any medical coverage through the VA however.

That was prior to the ACA. The ACA ruled that all healthcare plans have to cover what they cover. The VA plan was no exception. Otherwise, the VA Healthcare made no sense, a different plan would always be needed to be covered and be legal with the IRS.

I am at 10%, 100% of my care is free.

 

[exnavynuke]

You know my DH has a 10% rating..when he went from 0 to 10% the bills for the co pays stopped coming. The bills were for nonservice connected issues. And AFIK Vietnam vets (actual boots on the ground in VN) are taken into system without either financial need and or disability ratings. That's how my DH first got in. So vets if you aren't in the system, just go to the system and ask if you can get in, that's the safest way to go about it.....if your county has a VSO that's the place to start.

The VA, being a government organization, has a LOT of variations to rules (even their summaries are quite long on many things). I merely summarized the most relevant portions of things to paint the picture with a "large brush". I didn't think a 300 page explanation of every variation of how you can avoid co-payments or be enrolled was really necessary here.

I completely agree that any vet not in the system should see if they can get in though. I'm very happy to get my health care through the VA, especially with the changes made to where you can get care in recent times.

 

[exnavynuke]

That was prior to the ACA. The ACA ruled that all healthcare plans have to cover what they cover. The VA plan was no exception. Otherwise, the VA Healthcare made no sense, a different plan would always be needed to be covered and be legal with the IRS.

I am at 10%, 100% of my care is free.

They can still charge money for many things, despite the ACA mandating that "some" care be provided without charge to the patient. If you spend 6 days in the hospital for non-service connected issues, the VA will send you a bill, I promise. If you don't get the bill it's because you have other insurance and they got the bill.

From the VA website currently:

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.

 

[ivinsfan]

That was prior to the ACA. The ACA ruled that all healthcare plans have to cover what they cover. The VA plan was no exception. Otherwise, the VA Healthcare made no sense, a different plan would always be needed to be covered and be legal with the IRS.

I am at 10%, 100% of my care is free.

That's the confusion here.. the co-pay disability connection. MY DH has the same experience you do. I'm confused enough I wouldn't tell anyone anything except do your own research

Perhaps you just have routine stuff done at the VA and if something major came up, there would be a co-pay. So far VA is just the backup and now it's Medicare and supplement, since we want access to my DH's private cardio docs.

 

[ivinsfan]

The VA, being a government organization, has a LOT of variations to rules (even their summaries are quite long on many things). I merely summarized the most relevant portions of things to paint the picture with a "large brush". I didn't think a 300 page explanation of every variation of how you can avoid co-payments or be enrolled was really necessary here.

I completely agree that any vet not in the system should see if they can get in though. I'm very happy to get my health care through the VA, especially with the changes made to where you can get care in recent times.

Yep, a VSO, DAV, VFW, American Legion can be very helpful to a vet trying to navigate the system. Point being if you aren't in the system, don't assume you don't qualify, check it out.

 

[Senator]

They can still charge money for many things, despite the ACA mandating that "some" care be provided without charge to the patient. If you spend 6 days in the hospital for non-service connected issues, the VA will send you a bill, I promise. If you don't get the bill it's because you have other insurance and they got the bill.

From the VA website currently:

I have been to the VA for many non-service connected issues in the last 5-6 years. I NEVER get a bill. I have never spent 6 days in the VA hospital, however I would not expect a bill for that either. If you are enrolled in the VA healthcare, it meets and covers what the ACA requires. If you had a co-pay before, you likely still have one. If you did not, the VA did not add one.

I did have outside insurance while I was still working for ~2 years. The VA billed them, and the 'patient responsibility' part of the EOB was never even sent to me by the VA. My deductible was closer to being met with the private insurance, with $0 out of pocket for me.

I do not have any other insurance. I use the VA for 100% of my healthcare needs. I am 10% disabled.

I go to the VA a few times every year, just to stay current with them, as required. Blood work, eye glasses, annual physical, dermatology, colonoscopy, sprained ankle, kidney stone, etc. All free, none service connected. Ironically, I have never been to the VA for any service connected issues.

No enrollment fee, monthly premiums, or deductibles. Most Veterans have no out-of-pocket costs. Some Veterans may have to pay small copayments for health care or prescription drugs.
https://www.va.gov/health/aca/EnrolledVeterans.asp

 

[ivinsfan]

I have been to the VA for many non-service connected issues in the last 5-6 years. I NEVER get a bill. I have never spent 6 days in the VA hospital, however I would not expect a bill for that either. If you are enrolled in the VA healthcare, it meets and covers what the ACA requires. If you had a co-pay before, you likely still have one. If you did not, the VA did not add one.

I did have outside insurance while I was still working for ~2 years. The VA billed them, and the 'patient responsibility' part of the EOB was never even sent to me by the VA. My deductible was closer to being met with the private insurance, with $0 out of pocket for me.

I do not have any other insurance. I use the VA for 100% of my healthcare needs. I am 10% disabled.

I go to the VA a few times every year, just to stay current with them, as required. Blood work, eye glasses, annual physical, dermatology, colonoscopy, sprained ankle, kidney stone, etc. All free, none service connected. Ironically, I have never been to the VA for any service connected issues.

They used to bill our BCBS too and would often collect a few bucks from them but never asked us for any money OOP. Never enough to meet our deductible and the balance never got billed. Our state MN has great VA healthcare. I'm guess some places can't say that.

 

[exnavynuke]

I have been to the VA for many non-service connected issues in the last 5-6 years. I NEVER get a bill. I have never spent 6 days in the VA hospital, however I would not expect a bill for that either. If you are enrolled in the VA healthcare, it meets and covers what the ACA requires. If you had a co-pay before, you likely still have one. If you did not, the VA did not add one.

I did have outside insurance while I was still working for ~2 years. The VA billed them, and the 'patient responsibility' part of the EOB was never even sent to me by the VA. My deductible was closer to being met with the private insurance, with $0 out of pocket for me.

I do not have any other insurance. I use the VA for 100% of my healthcare needs. I am 10% disabled.

I go to the VA a few times every year, just to stay current with them, as required. Blood work, eye glasses, annual physical, dermatology, colonoscopy, sprained ankle, kidney stone, etc. All free, none service connected. Ironically, I have never been to the VA for any service connected issues.

I've gotten multiple bills. Fortunately, now I get none because I'm over 50% at this point. I linked you the page outlining what vets may be charged for if they don't have anything exempting them from the charges. You can choose to believe that your experience applies to everything for everyone, of you can choose to believe that the VA actually does bill some vets for some things from my experience and the VA saying that they do. That's up to you and it won't change the reality at all for those that do get the bills.

 

[Senator]

I've gotten multiple bills. Fortunately, now I get none because I'm over 50% at this point. I linked you the page outlining what vets may be charged for if they don't have anything exempting them from the charges. You can choose to believe that your experience applies to everything for everyone, of you can choose to believe that the VA actually does bill some vets for some things from my experience and the VA saying that they do. That's up to you and it won't change the reality at all for those that do get the bills.

Have you been billed in the last 3 years or so, and meet all the other requirements? 10%+ disabled at that time, being seen by the VA at least 1x every 24 months, etc.?

Did you start as a level 8 priority? Rather than a 3?

 

[exnavynuke]

Have you been billed in the last 3 years or so, and meet all the other requirements? 10%+ disabled at that time, being seen by the VA at least 1x every 24 months, etc.?

Did you start as a level 8 priority? Rather than a 3?

Nope, but friends have received bills for medication and one of them for his inpatient care. If you read the link I put in above, you can clearly see what items veterans who don't meet an exception are required to pay for still today, and it includes a number of things. Just "going to the doctor" isn't one of them, but things like prescriptions for non-service connected conditions, hospital stays, etc are still things that veterans without an exception from the copays are responsible to pay and they will still get a bill for those healthcare services. That bill can be thousands of dollars in some cases.

It's in black and white on their website. I linked it in this thread. People are paying those bills today. I don't understand why you're trying to argue that it isn't true when it's 100% clear to see. Perhaps you missed the link?

Here are some samples:

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.

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 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

Use of urgent care can cost from $0-30 per visit depending on priority group and how many times you go, outpatient care services can be from $15-50 per visit, in-patient care up to $1,364 for the first 90 days of care with up to $10/day charges.


Not everything is free today. Inpatient, outpatient, urgent care, long term care, prescriptions... all things vets "can" be billed for depending on the circumstances.

Oh, and as a priority group 1 vet, if I go to the urgent care one more time this year I will get a bill.

 

[ivinsfan]

I've gotten multiple bills. Fortunately, now I get none because I'm over 50% at this point. I linked you the page outlining what vets may be charged for if they don't have anything exempting them from the charges. You can choose to believe that your experience applies to everything for everyone, of you can choose to believe that the VA actually does bill some vets for some things from my experience and the VA saying that they do. That's up to you and it won't change the reality at all for those that do get the bills.

Confusion solved the link for co-pays clearly says no copay for inpatient or outpatient care with a rating of 10% or higher. It's dated 10/17 so maybe a more recent change. So copays are based on disability rating (if any), priority group and or financial means. No confusion here..

if you want to read a more clear summary go directly to the cost and billing header at the at the VA benefits and health care site.

Not trying to prove a point or argue with anybody, just want posters asking questions here to realize it's complicated.

 

[exnavynuke]

Confusion solved the link for co-pays clearly says no copay for inpatient or outpatient care with a rating of 10% or higher. It's dated 10/17 so maybe a more recent change. So copays are based on disability rating (if any), priority group and or financial means. No confusion here..

if you want to read a more clear summary go directly to the cost and billing header at the at the VA benefits and health care site.

Not trying to prove a point or argue with anybody, just want posters asking questions here to realize it's complicated.

I completely agree that it's complicated. A vet in priority group 8 today with the same medical conditions I have, but not service connected for them, is going to max out their $700 copays on prescriptions, have more copays for urgent care (if used the same as I did this year), and be subject to copays I'm exempt from if inpatient or outpatient care is needed. That same vet gets 10% disability and some of those copays go away, but they still have to pay others (such as meds for non-service connected conditions). Move to 50% rating and now everything is free until you look at geriatric care, then even the priority group 1 vets may have significant charges.

Be a veteran with no service connected disabilities, and no financial hardship, and you may not be eligible to enroll in VA health care at all, and thus the VA pays nothing for your medical care and won't even be your PCP.

Senator at 10%, who hasn't had any care that requires a copay yet, seems to believe that copays don't exist and that all care he could require will always be free. That isn't the case however, they just haven't received any care that they have to make copays for yet. That's all I've been trying to explain.

 

[ivinsfan]

It can be a great program for vets and I'm kind of surprised by the number of vets that don't even check into it and see if they can enroll. Just because you get your HC through work or spouses work doesn't mean you shouldn't get into the system if you can..

It's combining both medical care and the government so of course it's complicated but everything to do with HC is complicated today.

I'm not posting any links because I think a vet or family member should do their own research since not all vets are considered equal by the VA.