Point Paper on VA Copays

By Larry E. Nazimek

  1. We veterans have earned our benefits, so we should not have to pay for them now.
  1. Copays for appointments with general practitioners (residents) are $15, and for specialists (usually fellows) are $50. There are also much higher copays for inpatient care. Only one copay for appointments per day is charged, so if a veteran has three appointments in one day, he pays $50. If there are two appointments, one with a resident and one with a specialist, the copay for the day is $50, the higher of $15 and $50. The problem is that it is difficult to get multiple appointments in a single day. Since the doctors from Northwestern and UIC only work at JBVAMC for a half day per week, your doctor in one specialty will probably not work on the same day as your doctor in another specialty. In other words, a veteran may have appointments on various days in a single week, for which he will be charged multiple copays.
  1. If a veteran feels sick and wants to see a doctor, he can go to a CBOC and see a resident, for which he will be charged $15. If, however, he goes to JBVAMC, he must report to the desk for the Emergency Room, where he will be evaluated by a Triage Nurse. If the veteran only needs to see a resident, the Triage Nurse will escort him to a clinic down the hall (Ogden Building), where he will be seen by a resident. (Residents are young doctors who are putting in their three year term of residency. After the three years, they can either become a fellow in a specialty, or they may stay as general medicine doctors. When one has an appt. with a resident or fellow, he is also evaluated by an “attending” doctor with more experience.) Even though the veteran will not actually enter the Emergency Room, he will be charged $50, the standard copay for Emergency Room visits. (I have discussed this at a meeting with Chief of Staff Dr. Sarah Underman.)
  1. Copays for prescriptions vary. For non-OTC items, they are less than what one would pay on the outside. For OTC items, however, they are often higher than what is available on the outside. A perfect example is Kerasal, a very popular item for toenail fungus. The VA says that the .33 oz tube should last for 3 months, so at the rate of $8/month, the bill is for $24. This same tube can be purchased at Walmart for $19.86 (+ tax). Walmart, however, sells a .34 oz generic alternative for $14.83 (+ tax). All outside stores charge for a product, and they do not care how long it will last. If a doctor’s instructions are to take a pill once per day, the veteran will be charged three times as much as if the instructions were to take three per day.
  1. Copays for prescriptions are usually based on 1-30 days. In other words, something that will last for 10 days will be charged as though it was for 30 days. If one is having a colonoscopy, he will be given 3 small orange pills for the prep, and it will be charged as though it were a 30 day supply. The same is true for the barium drink that one may have to drink prior to a CT Scan.
  1. Service-connected veterans are not required to make copays. Non-service connected veterans are charged copays, depending on their income. Those whose income falls below the lowest threshold are not charged copays. Those whose income falls between the two thresholds are charged for prescriptions, but not appointments. Those whose income is above the upper threshold pay for both appointments and prescriptions.

    One’s medical costs, up to a small limit, are deducted from his income.
  1. The VA has an “Income Verification Unit” in Atlanta, that gets one’s income information from the IRS. If the Unit feels that one’s income puts him above a higher threshold, they send a letter to the veteran in which he can either agree with their determination or contest it, something like an audit by mail, or as I put it, “financial colonoscopy.”

    A big problem here, is that if one sells shares of stock or a mutual fund, they see the proceeds of the sale, which they treat like a profit. Profit, however, is the proceeds of the sale minus the cost. If the cost exceeds the proceeds, the deal amounts to a capital loss and not a gain. Unfortunately, the veteran will get that letter, where he will have to explain to them that his capitol gain or loss is not the same as the proceeds figure that they are using.
  1. There are some differences in one’s income for IRS purposes and for VA purposes. A veteran who uses IRS type figures will be told, “That’s not the way we do it.”
  1. Considering the backlog in processing appeals, the VA should transfer the employees in the Unit to work on appeals.