View 2020 copay rates for VA and VA-approved health care.
This co-pay assistance program can be used to reduce the amount of an eligible patient’s out-of-pocket expenses for Viatris’ Ogivri ® (trastuzumab-dkst) for injection 150 mg/vial and/or 420 mg/vial up to the maximum aggregate amount set forth on Viatris’ website while this co-pay assistance program remains in effect (such aggregate. You pay this: $1,484 Deductible glossary for each Benefit period. Days 1–60: $0 Coinsurance for each benefit period. Days 61–90: $371 coinsurance per day of each benefit period. Days 91 and beyond: $742 coinsurance per each 'lifetime reserve day' after day 90 for each benefit period (up to.
Want to see current health care copay rates?
Get rates for the current year
We can help with your questions about debt and other financial concerns
Get the latest information about concerns like managing VA debt, or paying your VA copays or VA-backed home loan during this time.
Go to our coronavirus FAQs
Effective January 1, 2020
Note: Some Veterans don't have to pay copays (they're 'exempt') due to their disability rating, income level, or special eligibility factors.
Urgent care copay rates
(Care for minor illnesses and injuries)
There's no limit to how many times you can use urgent care. To be eligible for urgent care benefits, including through our network of approved community providers, you must:
- Be enrolled in the VA health care system, and
- Have received care from us within the past 24 months (2 years)
You won’t have to pay any copay for a visit where you’re only getting a flu shot, no matter your priority group.
| Priority group | Copay amount for first 3 visits in each calendar year | Copay amount for each additional visit in the same year | |||
|---|---|---|---|---|---|
| Priority group | 1 to 5 | Copay amount for first 3 visits in each calendar year | $0 (no copay) | Copay amount for each additional visit in the same year | $30 |
| Priority group | 6 | Copay amount for first 3 visits in each calendar year | If related to a condition that's covered by a special authority*: $0 (no copay) If not related to a condition covered by a special authority*: $30 each visit | Copay amount for each additional visit in the same year | $30 |
| Priority group | 7 to 8 | Copay amount for first 3 visits in each calendar year | $30 | Copay amount for each additional visit in the same year | $30 |
* Special authorities include conditions related to combat service and exposures (like Agent Orange, active duty at Camp Lejeune, ionizing radiation, Project Shipboard Hazard and Defense (SHAD/Project 112), Southwest Asia Conditions) as well as military sexual trauma, and presumptions applicable to certain Veterans with psychosis and other mental illness.
Outpatient care copay rates
(Primary or specialty care that doesn't require an overnight stay)
If you have a service-connected disability rating of 10% or higher
Rituxan Co Pay Card Program
You won't need to pay a copay for outpatient care.
If you don't have a service-connected disability rating of 10% or higher
You may need to pay a copay for outpatient care for conditions not related to your military service, at the rates listed below.
| Type of outpatient care | Copay amount for each visit or test | ||
|---|---|---|---|
| Type of outpatient care | Primary care services (like a visit to your primary care doctor) | Copay amount for each visit or test | $15 |
| Type of outpatient care | Specialty care services (like a visit to a hearing specialist, eye doctor, surgeon, or cardiologist) | Copay amount for each visit or test | $50 |
| Type of outpatient care | Specialty tests (like an MRI or CT scan) | Copay amount for each visit or test | $50 |
Note: You won’t need to pay any copays for X-rays, lab tests, or preventive tests and services like health screenings or immunizations.
Inpatient care copay rates
(Care that requires you to stay one or more days in a hospital)
If you have a service-connected disability rating of 10% or higher
You won't need to pay a copay for inpatient care.
If you’re in priority group 7 or 8
You'll pay either our full copay rate or reduced copay rate. If you live in a high-cost area, you may qualify for a reduced inpatient copay rate no matter what priority group you're in. To find out if you qualify for a reduced inpatient copay rate, call us toll-free at 877-222-8387. We're here Monday through Friday, 8:00 a.m. to 8:00 p.m. ET.
| Length of stay | Copay amount | ||
|---|---|---|---|
| Length of stay | First 90 days of care during a 365-day period | Copay amount | $281.60 copay + $2 charge per day |
| Length of stay | Each additional 90 days of care during a 365-day period | Copay amount | $140.80 copay + $2 charge per day |
Note: You may be in priority group 7 and qualify for these rates if you don't meet eligibility requirements for priority groups 1 through 6, but you have a gross household income below our income limits for where you live and you agree to pay copays.
| Length of stay | Copay amount | ||
|---|---|---|---|
| Length of stay | First 90 days of care during a 365-day period | Copay amount | $1,408 copay + $10 charge per day |
| Length of stay | Each additional 90 days of care during a 365-day period | Copay amount | $704 copay + $10 charge per day |
Note: You may be in priority group 8 and qualify for these rates if you don't meet eligibility requirements for priority groups 1 through 6, and you have a gross household income above our income limits for where you live, agree to pay copays, and meet other specific enrollment and service-connected eligibility criteria.
Medication copay rates
If you’re in priority group 1
You won’t pay a copay for any medications.
Note: You may be in priority group 1 if we've rated your service-connected disability at 50% or more disabling, if we've determined that you can't work because of your service-connected disability (called unemployable), or if you've received the Medal of Honor.
If you’re in priority groups 2 through 8
You'll pay a copay for:
- Medications your health care provider prescribes to treat non-service-connected conditions, and
- Over-the-counter medications (like aspirin, cough syrup, or vitamins) that you get from a VA pharmacy. You may want to consider buying your over-the-counter medications on your own.
Note: The cost for any medications you receive while staying in a VA or other approved hospital or health facility are covered by your inpatient care copay.
The amount you’ll pay for these medications will depend on the “tier” of the medication and the amount of medication you’re getting, which we determine by days of supply. Once you’ve paid $700 in medication copays within a calendar year (January 1 to December 31), you won’t have to pay any more that year—even if you still get more medications. This is called a copay cap.
| Outpatient medication tier | 1-30 day supply | 31-60 day supply | 61-90 day supply | ||||
|---|---|---|---|---|---|---|---|
| Outpatient medication tier | Tier 1 (preferred generic prescription medicines) | 1-30 day supply | $5 | 31-60 day supply | $10 | 61-90 day supply | $15 |
| Outpatient medication tier | Tier 2 (non-preferred generic prescription medicines and some over-the-counter medicines) | 1-30 day supply | $8 | 31-60 day supply | $16 | 61-90 day supply | $24 |
| Outpatient medication tier | Tier 3 (brand-name prescription medicines) | 1-30 day supply | $11 | 31-60 day supply | $22 | 61-90 day supply | $33 |
If you have a service-connected rating of 40% or less and your income falls at or below the national income limits for receiving free medications, you may want to provide your income information to us to determine if you qualify for free medications.
Geriatric and extended care copay rates
You won't need to pay a copay for geriatric care (also called elder care) or extended care (also called long-term care) for the first 21 days of care in a 12-month period. Starting on the 22nd day of care, we'll base your copays on 2 factors:
- The level of care you're receiving, and
- The financial information you provide on your Application for Extended Care Services (VA Form 10-10EC).
| Level of care | Types of care included | Copay amount for each day of care | |||
|---|---|---|---|---|---|
| Level of care | Inpatient care | Types of care included |
| Copay amount for each day of care | Up to $97 |
| Level of care | Outpatient care | Types of care included |
| Copay amount for each day of care | Up to $15 |
| Level of care | Domiciliary care for homeless Veterans | Types of care included |
| Copay amount for each day of care | Up to $5 |
Services that don't require a copay
You won't need to pay a copay for any of the services listed below, no matter what your disability rating is or what priority group you're in.
- Laboratory (lab) tests
- Electrocardiograms (EKGs or ECGs) to check for heart disease or other heart problems
- VA health initiatives that are open to the public (like health fairs)
Other information you may need
Pay your copay bill
Find out how to pay your copay bill—and what to do if you disagree with the charges or are having trouble making payments.
Your health care costs
Learn how we assess and verify your income to help determine if you're eligible for VA health care and whether you'll need to pay copays for certain types of care, tests, and medications.
Copayments for maternity care (PDF)
We cover maternity care for eligible Veterans through arrangements with community providers. Download this fact sheet to find out more about copays.
Last Updated : 06/12/20194 min read
Many people may think that staying overnight at the hospital automatically means they’re inpatients. But the distinction between inpatient vs. outpatient isn’t as simple as you might think.
Find affordable Medicare plans in your area
Learn the difference between inpatient vs. outpatient and how this hospital status may affect your Medicare costs and coverage.
Inpatient vs. outpatient: what’s the difference?
According to the Centers for Medicare & Medicaid Services (CMS), here’s how Medicare decides inpatient versus outpatient status:
- Inpatient: this status starts the day your doctor writes a formal order to admit you to the hospital.
- Outpatient: this status applies when you’re getting services or tests (whether they be outpatient procedures or urgent care services) and the doctor hasn’t written an order to formally admit you as inpatient.
It’s important to note that just because you’re staying overnight in the hospital does not automatically mean you’re an inpatient.
For example, a doctor may decide to put you on “observation” before deciding whether to admit you as an inpatient or discharge you. If you’re under observation, you’re still an outpatient, even if you stay overnight at the hospital.
Also note that whether you’re inpatient versus outpatient isn’t about the types of procedures or tests you’re getting, which may overlap between the two statuses. If you’re not sure if you have inpatient vs. outpatient status, be sure to clarify with your doctor.
Inpatient vs. outpatient: how this affects costs
To put it simply, the costs you pay can be very different depending on whether you’re an inpatient vs. outpatient.
As an inpatient, you’re generally covered under Medicare Part A:
- You’ll pay a deductible for each benefit period and $0 coinsurance for the first 60 days.
As an outpatient, you may be covered under Medicare Part B and owe:
- The Part B annual deductible (if you haven’t already paid it).
- A copayment or coinsurance amount for each covered hospital outpatient service.
- A 20% coinsurance for doctor services.
Please note that Part B usually only covers medications you can’t give yourself, such as infusion drugs. Hospitals might not let you bring prescription drugs with you if you’re a hospital outpatient. However, if you have Medicare prescription drug coverage, it may cover self-administered prescription drugs in an outpatient setting. You may need to pay out of pocket first and submit a claim to your Medicare plan afterwards.
Inpatient vs. outpatient: eligibility for skilled nursing facility coverage
Whether you’re admitted as an inpatient vs. outpatient also affects your coverage for skilled nursing facility services. This is helpful to know should you need them after your hospital stay.
Along with other criteria, Medicare may cover skilled nursing care if you have a qualifying hospital stay. This qualifying hospital stay has to be of at least 3 consecutive inpatient days, not including the day you were discharged. You must also enter the nursing facility within 30 days of being discharged. Importantly, any time in the hospital as an outpatient doesn’t count towards the 3-day inpatient requirement.
Inpatient vs. outpatient: how this decision is made
According to Medicare.gov, being given an inpatient versus outpatient status is usually determined by your doctor’s medical judgment of your health and whether inpatient hospital care is medically necessary.
Typically, a doctor will order that you be admitted as an inpatient if he determines that you need two or more nights of medically necessary hospital services. However, your hospital status as inpatient vs. outpatient is ultimately still based on the doctor’s determination and requires a formal order admitting you as an inpatient.
Inpatient vs. outpatient: how Medicare Advantage coverage works
Medicare Advantage plans cover everything that Medicare Part A and Part B cover, except hospice care, which is still covered under Part A. Please note that Medicare Advantage plans vary when it comes to costs for inpatient vs. outpatient coverage. You’ll need to check with the specific plan for more details. The Evidence of Coverage document is a good place to start.
Co Pay Relief
Hopefully, you now have a clearer picture of why the inpatient vs. outpatient distinction matters. If you’d like to explore Medicare plan options, you can do that easily from the convenience of your computer, tablet, or phone. Just enter your zip code on this page to get started.