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Co Pay And A.o. Presumptives


I ran into an interesting and frustrating situation that I and not a few other veterans seem to be in!

The VA has placed documents on it's web site(s) that indicate that an A.O. presumptive veteran is not charged Co-Pay for treatment (includes drugs)

of various problems that are related to A.O. exposure.

The first document is titled:

"VA Health Care Eligibility & Enrollment"

"Outpatient Prescription Copay"

And states:

"Exceptions to Copay Rules for Medication"

"VA does not charge a copay for medications used for treatment of --"




"A veteran's conditions related to a veteran's exposure to:"

"Herbicides during the Vietnam-era"


And so forth

The document also contains a statement relating to reduction of co-pay and to contact

the "Enrollment Coordinator at your local VAMC" or for further information call the VA at 1-877-222-8387

(Who profess to no knowledge and/or expound the co-pay until "adjudicated" VA stand)

Now, moving on to the next VA document ---

Fact Sheet 164-8

2010 Copay Requirements at a Glance

Dated July 2010

This document lists the one through eight "Priority Groups" that the VA places Veterans into, and lists Co-Pay requirements in a table corresponding to each group.

Three groups of the eight are involved.

"Group 2 & 3 (Service connection 10-30%) No medication co-pay for SC condition or ex POW"

(This applies to all conditions that have been "adjudicated" as being service connected. )

The real heart of the matter.

"Group 6 Combat Veteran SHAD, SC 0% - - - Agent Orange Exposure ---- Copay rules apply if unrelated to group 6 placement". Since "adjudicated" conditions fall under group 2 & 3, this can only apply to un"adjucated" or 0% conditions.

Evidently, the VA interprets a veteran's change to Group 2 or 3 from another Group, due to one or more "adjucated" condition(s) as removing the veteran from Group 6 entirely, thus making any un"adjudicated" conditions covered by Group 6 subject to co-pay.

THE VA IS CHARGING COPAY for Group 6 conditions, AND REFUSING TO STOP UNTIL A.O. PRESUMPTIVE CONDITIONS ARE "ADJUCATED", at which time a veteran changes from Group 6 to Group 2 or 3.

Web Reference


A second web reference


Further, The VA Finance, VAMC Business Office, VARO, the 1000 number, etc. take the same stance about "adjudication"

In other words, The VA is saying one thing in WRITING, and doing something different in actual fact! (What else is new!)

The VA is also ignoring the difference between an A.O. related presumptive condition and a directly connected (by adjudication or law) condition.

The key difference is that a presumptive condition is, by law and regulation, to be treated as a service connected condition, unless the VA can, under strict limitations, prove otherwise. (Adjudication)

Since the amounts per drug are "only" eight dollars, those in "high places" don't seem to be concerned, or even willing to look at the matter. (For that matter, they are almost unreachable by the average veteran.)

But, when you consider multiple thousands of veterans waiting to have A. O. & SHAD claims "adjucated", and take multiple prescription drugs for their conditions, The money involved is considerable.

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13 answers to this question

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I agree with Chuck. If you are in a group listed as a special group then there should be no co pays. They should placed into category 6 until their claims are resolved.


Edited by jbasser

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More than one version of "who pays" exists

The two documents I referred to are attached, along with an Iris web site page.

It's not only a "special group" It has to do with the definition of a "presumptive condition", and the legal status of presumptive conditions.

(They are "assumed" to be service connected, unless and until proven otherwise.)

I agree with Chuck. If you are in a group listed as a special group then there should be no co pays. They should placed into category 6 until their claims are resolved.

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post-1139-045934700 1289079605_thumb.jpg


Edited by Chuck75

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The point is that the VA is collecting "Co-pay" improperly from thousands of A.O. and SHAD veterans.

It's true that the veterans MAY eventually recover (without interest) the co pay amounts, possibly up to years later.

With such things as IHD and other similar conditions five or more drugs can be involved. If a veteran has s combination of IHD and DMII, along with other problems, more drugs are involved.

Why should the veteran have to request a refund. It should be automatic on award or classification of a condition as presumptive. Nehmer can also be involved.

I'm missing your point. I agree that until it's adjudicated the claimant must pay. Once SC'd they can request a refund.


Edited by Chuck75

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I guess you folks are not understanding me or the VA system. Prior to finding SC the VA needs to decide if you are 1.) a veteran? 2.) Wartime service? 3.) Honorable service? 4.) Necessary length of service?? 5.) etc?? This must all be done prior to deciding whether you fall under the "presumption." Just because you know you are doesn't cut it. There is a process that must be followed. jmo And yes, you should have to request the refund but that's another issue.


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Copayments are not an entity of the VBA. They are an entity of the VA Hospital system. The first thing you do is a means test that determines what Priority group a Veteran is to be placed in.If you have a service connected disability that will place you into the correct priority group. If the Vetern is placed onthe Agent Orange registry then they should be placed in the proper priority group. Once a Vet gets his service connection for his AO issues, then they can re do the means test to be placed into the correct priority group.

I have issues with this not being done as well as my private insurance being billed for service connected conditions / medications. If the insurance companies knew how much they were being ripped off by the VA something would be done.

As far as recoupment, the VA will pay interest.


Edited by jbasser

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