Emergency care at non-VA facilities
8/18/2011

The Department of Veterans Affairs (VA) has two authorities to pay for emergency care in non-VA facilities for eligible Veterans. These authorities allow VA to pay for emergency care rendered for service-connected Veterans and non service-connected conditions for enrolled Veterans who have no other source of payment for the care. 
 
1.  How do I qualify?
Emergency Treatment for service connected conditions
Service-connected Veterans may be eligible for payment or reimbursement for emergency treatment received in non-VA emergency departments if they receive emergency treatment for:
◦An adjudicated service-connected disability,
◦A non-service connected disability associated with and held to be aggravating a service-connected disability,
◦Any disability of a Veteran who has a total disability permanent in nature from a service-connected disability, or
◦For any illness, injury, or dental condition in the case of Veteran who is a participant in a vocational rehabilitation program.
-and-
◦A VA clinician determines that the initial complaint requiring treatment was emergent based upon the “prudent layperson” definition of emergency. The “prudent layperson” definition is as follows: “The claim for payment or reimbursement for the initial evaluation and treatment is for a condition of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. This standard would be met if there were an emergency medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.”
-and-
◦A VA clinician determines that a VA facility or other Federal facility was not feasibly available, and an attempt to use them beforehand would not have been reasonable, sound, wise, or practical.

Emergency Treatment for Non-service connected conditions
This benefit is a safety net for enrolled Veterans who have no other means of paying a non-VA emergency bill. Currently, if another health insurance provider pays all or part of a bill, VA cannot provide any reimbursement*. To qualify you must meet all of the following criteria:
◦You were provided care in a hospital emergency department or similar facility providing emergency care
◦You are enrolled in the VA health care system
◦You have been provided care by a VA health care provider within the last 24 months
◦You are financially liable to the provider of the emergency treatment for that treatment
◦You have no other form of health care insurance
◦You do not have coverage under Medicare, Medicaid, or a state program
◦You do not have coverage under any other VA programs
◦You have no other contractual or legal recourse against a third party that will pay all of the bill
◦Department of Veterans Affairs or other Federal facilities were not feasibly available at time of the emergency
◦The care must have been rendered in a medical emergency of such nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health
*In limited circumstances VA may be secondary payer to state mandated automobile reparations insurance, less the third party payment up to the VA allowable, less deductible, co-payments.

2. Should I cancel my current insurance?
If you are a service-connected Veteran, receive emergency non-VA treatment and meet the above eligibility requirements (Emergency treatment for Service-connected Veterans) then having other insurance does not disqualify you from becoming eligible.
If you receive emergency treatment for a non-service connected condition, do not have a VA adjudicated service-connected condition and are covered by a program or plan that would pay for the emergency care received, you would not qualify to receive payment or reimbursement for emergency treatment of a non-service connected condition. However, VA encourages you to keep all current health insurance. Remember that spouses of Veterans generally do not qualify for VA health care. If you cancel your current insurance, your spouse may not retain health insurance coverage. If you are covered by Medicare Part B and you decide to have it canceled, it cannot be reinstated until January of the next year.
 
3.  What type of emergency services will VA cover?
If you are determined to be eligible, VA will reimburse health care providers for all hospital care or medical services necessary to stabilize your condition up to the point you can be transferred to an approved VA health care facility. In some special circumstances if VA is unable accept your transfer when you are stabilized but require continued non-emergent inpatient care, VA may be able to reimburse for the cost of that continued non-emergent care.
 
4.  Do I need to get approval before going to the emergency room?
No. If you are an eligible veteran, a VA facility is not feasibly available, and you believe your health or life is in immediate danger, report directly to the closest emergency room. You, your representative, or the treating facility should then contact the nearest VA as soon as possible (within 48 hours) to arrange a transfer to VA care, if hospitalization is required.
 
5.  How long will I stay in the private hospital?
If you are hospitalized and notification of your hospitalization is provided to VA then VA will be in regular contact with your physician at the private hospital. As soon as your condition stabilizes, VA will arrange to transport you to a VA, or VA-designated facility.
 
6.  What if I do not wish to leave the private facility?
VA will pay for your emergency care services only until your condition is stabilized. If you stay beyond that point, you will assume responsibility for the payment of costs associated with treatment.
 
7.  Will I have to pay for transportation to a VA designated facility?
VA will assist with transportation arrangements and may be able to pay for such expenses. Please contact your local facility for current guidelines.
  
8.  What if the hospital bills me for services?
If you are billed for emergency care services, contact your local VA health care facility and representative will assist you in resolving the issue.
 
9.  What if my claim is denied?

To resolve claims issues, VA has established official appeals processes to make sure your case is thoroughly reviewed. Please see your local VA health care facility for current procedures


 

 

 

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