# Copayments

**§17.108 Copayments for inpatient hospital care and outpatient medical
care.**

\(a\) *General*. This section sets forth requirements regarding
copayments for inpatient hospital care and outpatient medical care
provided to veterans by VA.

\(b\) *Copayments for inpatient hospital care*.

\(1\) Except as provided in paragraphs (d) or (e) of this section, a
veteran, as a condition of receiving inpatient hospital care provided by
VA (provided either directly by VA or obtained by VA by contract), must
agree to pay VA (and is obligated to pay VA) the applicable copayment,
as set forth in paragraph (b)(2) or (b)(3) of this section.

\(2\) The copayment for inpatient hospital care shall be, during any
365-day period, a copayment equaling the sum of:

> \(i\) \$10 for every day the veteran receives inpatient hospital care,
> and
>
> \(ii\) The lesser of:
>
> \(A\) The sum of the inpatient Medicare deductible for the first 90
> days of care and one-half of the inpatient Medicare deductible for
> each subsequent 90 days of care (or fraction thereof) after the first
> 90 days of such care during such 365-day period, or
>
> \(B\) VA's cost of providing the care.

\(3\) The copayment for inpatient hospital care for veterans enrolled in
priority category 7 shall be 20 percent of the amount computed under
paragraph (b)(2) of this section.

**Note to §17.108(b):** The requirement that a veteran agree to pay the
copayment would be met by submitting to VA a signed VA Form 10-10EZ.
This is the application form for enrollment in the VA healthcare system
and also is the document used for providing means-test information
annually.

\(c\) *Copayments for outpatient medical care*.

\(1\) Except as provided in paragraphs (d), (e) or (f) of this section,
a veteran, as a condition of receiving outpatient medical care provided
by VA, must agree to pay VA (and is obligated to pay VA) a copayment as
set forth in paragraph (c)(2) of this section.

\(2\) The copayment for outpatient medical care is \$15 for a primary
care outpatient visit and \$50 for a specialty care outpatient visit. If
a veteran has more than one primary care encounter on the same day and
no specialty care encounter on that day, the copayment amount is the
copayment for one primary care outpatient visit. If a veteran has one or
more primary care encounters and one or more specialty care encounters
on the same day, the copayment amount is the copayment for one specialty
care outpatient visit.

\(3\) For purposes of this section, a primary care visit is an episode
of care furnished in a clinic that provides integrated, accessible
healthcare services by clinicians who are accountable for addressing a
large majority of personal healthcare needs, developing a sustained
partnership with patients, and practicing in the context of family and
community. Primary care includes, but is not limited to, diagnosis and
management of acute and chronic biopsychosocial conditions, health
promotion, disease prevention, overall care management, and patient and
caregiver education. Each patient's identified primary care clinician
delivers services in the context of a larger interdisciplinary primary
care team. Patients have access to the primary care clinician and much
of the primary care team without need of a referral. In contrast,
specialty care is generally provided through referral. A specialty care
outpatient visit is an episode of care furnished in a clinic that does
not provide primary care, and is only provided through a referral. Some
examples of specialty care provided at a specialty care clinic are
radiology services requiring the immediate presence of a physician,
audiology, optometry, magnetic resonance imagery (MRI), computerized
axial tomography (CAT) scan, nuclear medicine studies, surgical
consultative services, and ambulatory surgery.

**Note to §17.108(c):** The requirement that a veteran agree to pay the
copayment would be met by submitting to VA a signed VA Form 10-10EZ.
This is the application form for enrollment in the VA healthcare system
and also is the document used for providing means-test information
annually.

\(d\) *Veterans not subject to copayment requirements for inpatient
hospital care or outpatient medical care*. The following veterans are
not subject to the copayment requirements of this section:

> \(1\) A veteran with a compensable service-connected disability;
>
> \(2\) A veteran who is a former prisoner of war;
>
> \(3\) A veteran awarded a Purple Heart;
>
> \(4\) A veteran who was discharged or released from active military
> service for a disability incurred or aggravated in the line of duty;
>
> \(5\) A veteran who receives disability compensation under 38 U.S.C.
> 1151;
>
> \(6\) A veteran whose entitlement to disability compensation is
> suspended pursuant to 38 U.S.C. 1151, but only to the extent that the
> veteran's continuing eligibility for care is provided for in the
> judgment or settlement described in 38 U.S.C. 1151;
>
> \(7\) A veteran whose entitlement to disability compensation is
> suspended because of the receipt of military retirement pay;
>
> \(8\) A veteran of the Mexican border period or of World War I;
>
> \(9\) A military retiree provided care under an interagency agreement
> as defined in section 113 of Public Law 106-117, 113 Stat. 1545; or
>
> \(10\) A veteran who VA determines to be unable to defray the expenses
> of necessary care under 38 U.S.C. 1722(a).

\(e\) *Services not subject to copayment requirements for inpatient
hospital care or outpatient medical care*. The following are not subject
to the copayment requirements under this section:

> \(1\) Care provided to a veteran for a noncompensable zero percent
> service-connected disability;
>
> \(2\) Care authorized under 38 U.S.C. 1710(e) for Vietnam-era
> herbicide-exposed veterans, radiation-exposed veterans, Gulf War
> veterans, or post-Gulf War combat-exposed veterans;
>
> \(3\) Special registry examinations (including any follow-up
> examinations or testing ordered as part of the special registry
> examination) offered by VA to evaluate possible health risks
> associated with military service;
>
> \(4\) Counseling and care for sexual trauma as authorized under 38
> U.S.C 1720D;
>
> \(5\) Compensation and pension examinations requested by the Veterans
> Benefits Administration;
>
> \(6\) Care provided as part of a VA-approved research project
> authorized by 38 U.S.C. 7303;
>
> \(7\) Outpatient dental care provided under 38 U.S.C. 1712;
>
> \(8\) Readjustment counseling and related mental health services
> authorized under 38 U.S.C 1712A;
>
> \(9\) Emergency treatment paid for under 38 U.S.C. 1725 or 1728;
>
> \(10\) Care or services authorized under 38 U.S.C. 1720E for certain
> veterans regarding cancer of the head or neck;
>
> \(11\) Publicly announced VA public health initiatives (e.g., health
> fairs) or an outpatient visit solely consisting of preventive
> screening and immunizations (e.g. influenza immunization,
> pneumonococcal immunization, hypertension screening, hepatitis C
> screening, tobacco screening, alcohol screening, hyperlipidemia
> screening, breast cancer screening, cervical cancer screening,
> screening for colorectal cancer by fecal occult blood testing, and
> education about the risks and benefits of prostate cancer screening);
>
> \(12\) Weight management counseling (individual and group);

\(13\) Smoking cessation counseling (individual and group); and

> \(14\) Laboratory services, flat film radiology services, and
> electrocardiograms.

\(f\) *Additional care not subject to outpatient copayment*. Outpatient
care is not subject to the outpatient copayment requirements under this
section when provided to a veteran during a day for which the veteran is
required to make a copayment for extended care services that were
provided either directly by VA or obtained for VA by contract.
(Authority: 38 U.S.C. 1710)

\[66 FR 63448, Dec. 6, 2001, as amended at 66 FR 64904, Dec. 14, 2001;
67 FR 21998, May 2, 2002; 68 FR 60854, Oct. 24, 2003; 70 FR 22596, May
2, 2005; 71 FR 2464, Jan. 17, 2006; 73 FR 20532, Apr. 16, 2008\]

**Supplement *Highlights* references**: 21(1), 27(1), 31(1), 40(1).

*Next Section is §17.110*