Yes, VA pays emergency room visits, but only if...

Jonathan Kaupanger
July 05, 2018 - 1:24 pm

Dreamstime

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Veterans are on the hook to pay about $800,000  from claims for more than 219,000 emergency room visits that were denied by Veterans Affairs.  Mainly because veterans simply don't understand the rules about emergency room visits at non-VA facilities.

Without insurance, ER visits can start anywhere between $150 to $3,000.  If surgery is required, add another $20k.  A doctor fee could then add hundreds or thousands of dollars to the final cost.  It adds up quickly. Which is why VA is trying to get the word out in regards to which ER visits are covered and which are not.  

Generally, VA pays for emergency medical care if the visit is treating the veteran’s service-connected condition or if the care is related to the service-connected condition.  If the visit is for something else, the VA can still pay, but there are three main requirements before VA will take on the bill.

  1. The amount VA can pay depends on if the veteran has health insurance.
    • If the veteran has insurance, VA can pay only after the health insurer has paid or denied the claim. Also, VA will pay only after the veteran has made any required copayments, cost shares or deductibles.
    • If the veteran does not have insurance, VA can pay the bill, but the amount is capped at 70 percent of Medicare rates.
  2. At the time of the emergency a VA medical facility or other federal facility wasn’t reasonably available.
  3. At the time of the emergency the veteran was enrolled in VA healthcare and has received medical services at VA within the last 24 months.

VA can pay for emergency visits for nonservice-connected conditions, but there are a few requirements that effect VA’s ability to pay.  And all five of these requirements must be met before VA will consider payment.

  1. Care was provided in a hospital ER or similar public facility that provides emergency treatment to the public.
  2. The emergency was of such a nature that the veteran (or other prudent person without medical training) believe that any delay in medical attention would put their life or health in jeopardy.
  3. A VA medical facility or another Federal facility wasn’t reasonably available to provide care.
  4. The veteran is enrolled and has received care at a VA facility during the 24 months before the ER visit.
  5. The veteran is financially liable to the provider of emergency treatment.

The VA has a few limitations to what it can pay if the veteran has health insurance.  If the insurance doesn’t cover the entire cost of treatment, VA can pay some costs that the veterans is personally liable to pay.  However, by law VA cannot pay copayments, coinsurance, deductibles or similar payments a veteran owes to the provider as required by their personal insurance. 

Once the emergency need has been met, someone should contact your closest VA medical clinic within 72 hours.  VA staff can then help you understand what’s eligible for payment and what’s not.  Claims for treatment outside the VA should be submitted as quickly as possible.  For service-connected conditions, you have up to two years to file your claim.  Claims for payment for nonservice-connected conditions must be submitted to the VA within 90 days of discharge from the emergency room.

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