Outpatient Care

Outpatient care is considered primary or specialty care that does not require the veteran to remain in the hospital overnight. In essence, any care that is not considered urgent care.

If you have a 10% service-connected disability rating, YOU DO NOT HAVE TO PAY A COPAY. Non-service connected ratings or any condition not connected to your service may be required to pay the following copays (and I use may, because if you are means tested and qualify for no-cost care, you won’t pay a copay).

Other services in this category where you won’t pay a copay include for:

• X-rays
• Lab tests
• Preventive tests
• Health screenings
• Immunizations

Inpatient Care

Inpatient care is care that requires you to remain in the hospital. If you have a 10% or higher service-connected disability rating, you won’t pay any copays.

If you belong to priority groups 7 or 8, you will either pay a full or reduced copay rate. However, if you live in a high cost of living area, you may qualify for a reduced rate, no matter in which priority group you belong. If you’re not sure if you qualify, you can call (877) 222-8387 (TTY: 711) to find out.

To learn more about priority groups, click here.

To see the VA national income limits, click here.

Medication Copay Rates

Medication copay rates vary by the priority group you belong to and which tier the prescription falls under. Unlike Medicare Advantage, where typically tiers 1 and 2 (the generic tiers) have a $0 copay, the VA has their own unique structure. It has a four (4) tier system with a Tier 0, versus a five (5) or six (6) tier Medicare Advantage structure. There is a $700 MOOP (Maximum Out Of Pocket Limit) for medications. Once you’ve spent $700 within a calendar year, you pay nothing until the following year.

NOTE: Also, if you receive any medications while in inpatient care, whether at a VA facility or approved community facility, you will pay NO copays, as it’s considered care provided by your hospital stay.

Geriatric and Extended Care

Elder care and long-term care are available through the VA. Like many Skilled Nursing Facility policies in Medicare Advantage plans, the first 21 days of a 12-month period are at no cost (20 days for Medicare Advantage plans). However, on day 22, the following copays may apply depending on the level of care you are receiving and income qualifications.

If you are not sure if you qualify for no-cost care, submit your financial information via form 10-10EC (click here to download the form).

What Alternatives Do I Have?

If you fall under priority groups 7 or 8 and do not qualify for reduced or no-cost care, and you are either:

• Receiving SSDI for 24+ months (no matter your age)
• Are 65 or older

…you may consider using a Medicare Advantage plan. Why? Most Medicare Advantage plans offer:

• $0 copay for primary care visits
• $10 to $20 copay for specialty visits
• $0 copay for generic medications on tiers 1 and 2
• If you qualify for Extra Help (which we can check and apply for if you do), if there is a copay for a generic, it will be no more than $1.40 to $4.15 (depending on the level of qualification), and no more than $4.00 to $10.35 for brand name drugs.
• Several plans give a portion or the entirety of your Part-B premium back to you (can be as much as $1,978.80 more in the bank for the year
• Dental insurance
• Many plans give over-the-counter allowances for vitamins and other OTC products
• Free gym membership
• And other benefits like Flex cards for Food/Utility/Rent cards (which are not income, since it’s a benefit from your plan.

So, there you have it. The new Copay Rates for 2023 and what you can do about it, if it affects your budget. If you have any questions, please feel free to leave a comment below or reach out to us via our CONTACT page. There is never a charge for any of our service! We would love to answer your questions and help you. Thank you for your service!