Inpatient/Outpatient
Care Co-payments
§17.108 Co-payments
for inpatient hospital care and outpatient medical care.
(a) General. This section sets forth requirements
regarding co-payments for inpatient hospital care and outpatient medical care
provided to veterans by VA.
(b) Co-payments for inpatient hospital care.
(1) Except as
provided in paragraphs (d) or (e) of this section, a veteran, as a condition of
receiving inpatient hospital care provided by VA (provided either directly by
VA or obtained by VA by contract), must agree to pay VA (and is obligated to
pay VA) the applicable co-payment, as set forth in paragraph (b)(2) of this section.
(2) The
co-payment for inpatient hospital care shall be, during any 365-day
period, a co-payment equaling the sum of:
(i) $10 for every day the veteran receives inpatient
hospital care, and
(ii)
The lesser of:
(A)
The sum of the inpatient Medicare deductible for the first 90 days of care and
one-half of the inpatient Medicare deductible for each subsequent 90 days of
care (or fraction thereof) after the first 90 days of such care during such
365-day period, or
(B)
VA’s cost of providing the care.
Note to §17.108(b): The requirement that a veteran agree
to pay the co-payment would be met by submitting to VA a signed VA Form
10-10EZ. This is the application form for enrollment in the VA healthcare
system and also is the document used for providing means-test information
annually.
(c) Co-payments for outpatient medical care.
(1) Except as
provided in paragraphs (d), (e) or (f) of this section, a veteran, as a
condition of receiving outpatient medical care provided by VA, must agree to
pay VA (and is obligated to pay VA) a co-payment as set forth in paragraph
(c)(2) of this section.
(2) The
co-payment for outpatient medical care is $15 for a primary care outpatient
visit and $50 for a specialty care outpatient visit. If a veteran has more than
one primary care encounter on the same day and no specialty care encounter on
that day, the co-payment amount is the co-payment for one primary care
outpatient visit. If a veteran has one or more primary care encounters and one
or more specialty care encounters on the same day, the co-payment amount is the
co-payment for one specialty care outpatient visit.
(3) For
purposes of this section, a primary care visit is an episode of care furnished
in a clinic that provides integrated, accessible healthcare services by
clinicians who are accountable for addressing a large majority of personal
healthcare needs, developing a sustained partnership with patients, and
practicing in the context of family and community. Primary care includes, but
is not limited to, diagnosis and management of acute and chronic biopsychosocial conditions, health promotion, disease prevention, overall care management, and patient and
caregiver education. Each patient’s identified primary care clinician delivers
services in the context of a larger interdisciplinary primary care team.
Note to §17.108(c): The requirement that a veteran
agree to pay the co-payment would be met by submitting to VA a signed VA Form
10-10EZ. This is the application form for enrollment in the VA healthcare
system and also is the document used for providing means-test information
annually.
(d) Veterans not subject to co-payment requirements for
inpatient hospital care or outpatient medical care. The following
veterans are not subject to the co-payment requirements of this section:
(1)
A veteran with a compensable service-connected disability;
(2)
A veteran who is a former prisoner of war;
(3)
A veteran awarded a Purple Heart;
(4)
A veteran who was discharged or released from active military service for a
disability incurred or aggravated in the line of duty;
(5)
A veteran who receives disability compensation under 38 U.S.C. 1151;
(6)
A veteran whose entitlement to disability compensation is suspended pursuant to
38 U.S.C. 1151, but only to the extent that the veteran’s continuing
eligibility for care is provided for in the judgment or settlement described in
38 U.S.C. 1151;
(7)
A veteran whose entitlement to disability compensation is suspended because of
the receipt of military retirement pay;
(8)
A veteran of the Mexican border period or of World War I;
(9)
A military retiree provided care under an interagency agreement as defined in
section 113 of Public Law 106-117, 113 Stat. 1545; or
(10)
A veteran who VA determines to be unable to defray the expenses of necessary
care under 38 U.S.C. 1722(a).
(e) Services not subject to co-payment requirements for
inpatient hospital care or outpatient medical care. The
following are not subject to the co-payment requirements under this section:
(1)
Care provided to a veteran for a non-compensable zero percent service-connected
disability;
(2)
Care authorized under 38 U.S.C. 1710(e) for Vietnam-era herbicide-exposed
veterans, radiation-exposed veterans, Gulf War veterans, or post-Gulf War
combat-exposed veterans;
(3)
Special registry examinations (including any follow-up examinations or testing
ordered as part of the special registry examination) offered by VA to evaluate
possible health risks associated with military service;
(4)
Counseling and care for sexual trauma as authorized under 38 U.S.C 1720D;
(5)
Compensation and pension examinations requested by the Veterans Benefits
Administration;
(6)
Care provided as part of a VA-approved research project authorized by 38 U.S.C.
7303;
(7)
Outpatient dental care provided under 38 U.S.C. 1712;
(8)
Readjustment counseling and related mental health services authorized under 38
U.S.C 1712A;
(9)
Emergency treatment paid for under 38 U.S.C. 1725 or
1728;
(10)
Care or services authorized under 38 U.S.C. 1720E for certain veterans
regarding cancer of the head or neck;
(11)
Publicly announced VA public health initiatives (e.g., health fairs) or an
outpatient visit solely consisting of preventive screening and immunizations
(e.g. influenza immunization, pneumonococcal
immunization, hypertension screening, hepatitis C screening, tobacco screening,
alcohol screening, hyperlipidemia screening, breast
cancer screening, cervical cancer screening, screening for colorectal cancer by
fecal occult blood testing, and education about the risks and benefits of
prostate cancer screening); and
(12)
Laboratory services, flat film radiology services, and electrocardiograms.
(f) Additional care not subject to outpatient co-payment. Outpatient
care is not subject to the outpatient co-payment requirements under this
section when provided to a veteran during a day for which the veteran is
required to make a co-payment for extended care services that were provided
either directly by VA or obtained for VA by contract. (Authority: 38 U.S.C. 1710)
[66
FR 63448,
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