1 Mar 2023 • Military.com • By Amanda Miller
Veterans who received care at non-VA emergency rooms since 2010 could now get some of their out-of-pocket costs reimbursed years later, even if their claims were previously denied.
The VA is finalizing a new rule, published Feb. 22 and taking effect April 24, that would cover those past costs and reimburse veterans going forward.
The prior patients will have to file a new claim with the VA by Feb. 22, 2024, to get the money. The retroactive reimbursements apply only to VA patients who received emergency treatment for a non-service-connected condition and who also had health insurance through a third-party insurer.
The VA will reimburse only coinsurance — defined as the patient’s out-of-pocket, cost-sharing percentage with their third-party insurer — at non-VA emergency departments and won’t reimburse flat-rate copayments or payments toward flat-rate deductibles. Emergency transportation such as an ambulance ride also counts as care.
Typically, the VA can pay for emergency medical care if the treated condition is service-related or caused by a condition tied to a veteran’s service, and care isn’t available at a VA facility, according to its website.
For conditions not considered service-connected, VA can also pay for emergency medical care but only under certain conditions: Care must be provided in a hospital emergency department; care must be given to treat life or health-threatening conditions; the required care must not be available to the veteran at a VA; and the veteran must have received care at a VA facility within the past two years. In an emergency, the VA says the veteran should go to the “nearest emergency department.”
The new reimbursement rule affects veterans who are covered by both VA and private insurance.
The VA will pay the reimbursements retroactive to care received on or after Feb. 1, 2010, the effective date of the Expansion of Veteran Eligibility for Reimbursement Act. The change was made after a prolonged series of court battles, public comment periods, letters from both houses of Congress and the consideration by VA of some existing precedent.
The initial case was filed by a veteran who went to the emergency room at a non-VA hospital in December 2010, sued the VA and won in 2016. The VA addressed the decision in 2018 with a new interim rule, but other patients later challenged the agency’s interpretation of what it would cover. A court order in 2022 then triggered the latest change.
After the initial 2016 court decision, the VA decided it wasn’t legally obligated to reimburse copayments, deductibles or coinsurance because it interpreted the deductibles and coinsurance as “similar” to copays under the law.
A federal court decision in 2022, however, ruled on what constituted a “similar payment” to a copay — excluding coinsurance because it’s not a flat fee — and ordered the VA to update its rules accordingly.
That means the VA still doesn’t have to reimburse copays and deductibles for the non-VA emergency care, but it must reimburse coinsurance if the veteran files a new claim within the year.
The VA acknowledged in its final rule that some veterans may never have filed a claim because they knew the claim would have been denied.
The agency said patients who never filed the claim at the time they received their care can still file a new claim by the Feb. 22, 2024, deadline.
