How Is the Fee Basis Amount Determined for VHA?
With more than 150 comprehensive medical facilities and thousands of community clinics, the Veterans Health Administration system, serving the 24 million living veterans, is the largest medical system in the United States. In 2004, Congress expanded access to VHA heath care to include all qualified U.S. veterans. The VHA uses eight classifications to determine health care services priority and fees for eligible veterans. In some cases, the VHA waives fees for low-income veterans, regardless of their priority classification.
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High Priority Groups
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Veterans with service-connected health conditions get a disability rating from the Veterans Administration. A 50 to 100 percent disabled veteran falls into the Priority 1 classification and gets free healthcare from the VHA. The VHA reserves the next two priority classifications for veterans who have service-connected health conditions and a disability rating of 10 to 20 percent. Priority 4 veterans are housebound, catastrophically disabled or receiving VA aid and attendance payments. Generally, these veterans do not pay for VHA services.
Lower Priority Groups
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The VA groups all other veterans into one of four lower priority classes, starting at Priority 5. These veterans are eligible for Medicaid or have income below a set threshold, including VA pensions. The Priority 6 group veterans are from specific theaters of war, recently discharged combat veterans and those with war-related exposures to toxins. The two lowest priority groups are veterans whose eligibility requires a means test and full disclosure of the veteran’s financial situation. When the veteran’s income falls below the VA threshold only or under both the VA and Housing and Urban Development guidelines, the VA determines that the veteran is low-income eligible.
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Types of Care Fees
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All other veterans who do fit a priority group for disability, pension or means must make co-payments for services received at VA facilities. These veterans pay $15 per regular outpatient visit in a VA facility or $50 for a specialist visit. The co-pay for inpatient services is $992, for the first 90 days, according to the Congressional Budget Office. Medications from the VA formulary have no co-pay for groups 1 through 6, but veterans in other groups have an annual cap of $960.
Non-VA Care
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In some cases, a veteran cannot easily access a VA facility or has a medical crisis that might be made worse by waiting for transportation to the closest VA. For these situations, the VA authorizes veterans' use of alternate healthcare facilities. The fees that the veteran pays are pre-approved by the VA and reimbursed in accordance with federal government regulations. The fee-basis services apply to outpatient and emergency room treatment. According to the Department of Veteran's Affairs website, this healthcare option is not intended to replace normal VA healthcare. It will only be approved when treatment in a VA operated facility is not feasible or could require a delay that might be life threatening.
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