VA Reimbursement for Emergency Medical Care

CCK Law: Our Vital Role in Veterans Law

If you are experiencing a medical emergency, it is critical that you seek help immediately from the nearest emergency department. If you are worried about the cost of receiving treatment from a healthcare provider outside of VA, it is important to know that VA can pay for veterans’ emergency medical care at a local emergency department. However, a veteran must be eligible for reimbursement based on the standards set forth by VA.

Service-Connected Emergency Care

VA can pay for emergency care at a non-VA medical center for a veteran’s service-connected condition, or if the care is related to a service-connected condition, as long as VA was not reasonably available to provide the care. According to VA’s Community Care page, a veteran is eligible to receive reimbursement under these circumstances if he or she is:

1. “A veteran who receives emergency treatment of a service-connected, or adjunct condition in a community emergency department; or
2. A veteran who is permanently and totally disabled as the result of a service-connected condition is eligible for emergency treatment of any condition; or
3. A veteran who is participating in a VA Vocational Rehabilitation Program and who requires emergency treatment to expedite their return to the program, is eligible for emergency treatment for any condition; and
4. The emergency was of such a nature that the veteran would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy”.

Here, a veteran can qualify under any of the first three scenarios as long as the fourth specification is met.

Non-service-Connected Emergency Care  

Importantly, VA can also provide reimbursement for emergency medical care for non-service-connected conditions if a veteran’s situation meets all of the following elements:

1. Care was provided in a hospital emergency department; and
2. The emergency was of such a nature that the veteran would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy; and
3. A VA medical facility was not reasonably available to provide the care; and
4. The veteran is enrolled and has received care within a VA facility during the 24 months before the emergency care; and
5. The veteran is financially liable to the provider of emergency treatment.

However, VA cannot pay copayments, coinsurance, deductibles, or similar payments required by a veteran’s other, non-VA, health insurance.

Deadlines for Reimbursement

After receiving emergency care, it is crucial for the veteran or a family member, to contact the nearest VA medical facility. This must be done within 72 hours of the treatment so that VA can begin to assist in determining a veteran’s eligibility for reimbursement. In order to receive reimbursement for emergency medical care, veterans must file a claim. There are several deadlines involved in this process of which veterans should be aware.  Furthermore, the deadlines for filing such claims depend on whether the care was for a service-connected or non-service-connected condition. If the emergency medical care was for a service-connected condition, a veteran has two years from the date the medical care was received to file a claim for reimbursement. On the other hand, if the treatment was for a non-service-connected condition, a veteran only has 90 days from the date of discharge from the health care facility to file for reimbursement.

Receiving Payment from VA

Once a veteran has filed for reimbursement, the claim will be reviewed to determine if the veteran is eligible to receive payment from VA. If a veteran meets the above-mentioned criteria depending on his or her circumstances, then treatment documentation will be reviewed by VA clinical staff to ensure the treatment received meets the clinical criteria necessary for VA to pay for the care. From there, reimbursement will take place.

Unfortunately, VA is currently experiencing a significant backlog in the distribution of health care reimbursement. While VA has reportedly made proposals to reduce this buildup, it has yet to do so with success.