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Co Pay And A.o. Presumptives

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Chuck75

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  • HadIt.com Elder

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

www.va.gov/healtheligibility/Library/pubs/CopayGlance

A second web reference

http://www4.va.gov/h...iptionCopay.asp

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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  • HadIt.com Elder

JBASSER, you are obviously dealing with a different VAMC than I am.

The local VAMC is pointing to the VBA & VARO, which point back to the VAMC. (Financial office, VAMC business office, etc. are doing the initial pointing) While copay is charged by the VAMCs, it or the lack of, falls under veteran's benefits, according to the VAMC people I've talked to. Thus VBA is involved.

I agree with the A.O. registry problems you mention. The designated "person" at my local VAMC had no idea how to place a Veteran in A.O. presumptive status, even when the Veteran's records show that there is an SC'd presumptive condition, and the VARO has them as an A.O. Veteran.

Some of the VAMC personnel that normally come in contact with veterans, claim (correctly or not) that they cannot see anything other than the veteran's current medical records . They can see that a condition is SC'd, but not why, or if it's "presumptive".

A.O. class status has to do with "clicking a box" on a screen in a computer program. The person responsible (by designation) at the "local" VAMC claims that they do not have access, (or don't know how) to get to the proper screen.

The means test is a totally different issue, and can place a veteran in other groups such as 4 or 5 or even 8 with no co pay. (Per VA fact sheet 164-8)

As to interest, the VA, by law, is not to get into a situation where it pays interest to a veteran. (Title 38?)

Some years back, I did receive a rebate of some copay, which was limited to copay for one of three DMII drugs, and clinic copay fees related to DMII only.

Nothing was mentioned about interest paid to the veteran. Refund of interest paid by the veteran was supposedly limited to three years or so.

In more recent times, I'm not charged for outpatient visits to the VA Clinic, and am charged for drug co pay for A.O presumptive conditions other than DMII. (IHD, etc.)

(This is related to the Veteran's drug act provisions.)

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.

J

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  • HadIt.com Elder

Chuck, what hospital are you speaking about, Atlanta or Macon?

The big problem here is I believe that you have a service connected disability and the VA is reluctant to move you into another Priority group as you are currently in group 2. This issue has been getting to you for some time now, isnt it.

A good avenue would be to find their procedure that they are supposed to follow and show it to them.

Co pays suck. I hated paying them.

J

Edited by jbasser
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  • HadIt.com Elder

PR, I don't think that you understand. (You are not alone!)

Evidently, you do not fully agree with the definition of an A.O. presumptive condition and the surrounding details. In short, Service Connected until proven otherwise. (And, the VA cannot easily prove otherwise, due to rules/law that pertain to "presumptive conditions".)

"Adjudication" is done as part of the compensation process, and is not a VAMC function. Co Pay is strictly a VAMC related item. Remember that the VA charges for the service of supplying the drugs, not the drugs themselves. In law, VA regs, etc., there are also guidelines as to how co pay and "medical services" are to be dealt with. These seem to be the basis for the statements in the VA documents I posted.

In this particular case, all the prerequisites have been completed and A.O. presumptive awards already made for other conditions.

Some of those conditions are or can be treated with the same drugs that the VA is charging co pay for. The VA's stated stance is that the drugs are "primarily" for an as yet "unadjucated" presumptive (IHD, etc.) The fact that some of the same drugs would be prescribed to treat the SC'd conditions if they were not already prescribed is ignored. Never mind VA/DOD treatment guides, related conditions, etc. The documents I posted previously clearly show that the public position of the VA is that they do not charge co pay for drugs related to the treatment of A.O. "presumptive" conditions. (Group 6, A.O. presumptives.)

It seems that the VA does not consider itself bound by it's public statements or documents, until forced to do so, or it's convenient. If it's not convenient, change the documents, of course! What else is new? Something about perfidious Albion comes to mind.

I'm waiting to see if the documents I cited and posted just disappear from the web sites, or get revised (reverted) to older versions that did not mention A.O. presumptives.

What is "proven" and on/in the VA file.

Vietnam "Feet on Ground" veteran. Service in units granted "A.O. Presumption" by the VA List. Honorable DD214 & 215 showing multiple combat related awards, such as CAR. Medical conditions (Now all presumptive A.O. conditions) are a matter of record, and recognized and awarded 100% by SSA years ago. Nehmer Class Veteran. Valid evidence (in any court of law) of the existence and level of the A.O. presumptive medical conditions. (The SSA determination is just one item, and made on now A.O. presumptive conditions alone.)

"And yes, you should have to request the refund but that's another issue"

The VA should have (With their propensity to generate forms) a form to do this. The only form presented so far is the Financial Waiver Form, which is inappropriate, and does not deal with the situation.

It can also be argued that if the VAMC is using "adjudication", then it should be a part of a claim award, and automatic. The Veteran has already requested "all the benefits entitled to", implicit or implied. (Another area the VA plays games with !)

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.

pr

Edited by Chuck75
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  • HadIt.com Elder

I don't consider my statements a lesson. Just the facts as I see them. There are aspects of this situation that really disturb me.

The general situation I'm harping on applies to presumptives. A.O. and SHAD veterans in particular. (Hot buttons themselves)

The VA in general, HATES presumptives, and in the past, changed the M-21 more than once to try and reduce the favorable impact of presumptive status on veteran's claims.

One example: (Lots of claims and compensation involved.)

In the case of DMII & heart disease (Now IHD) - - when DMII was made presumptive, the VA removed statements linking DMII and heart disease by relocating a particular section, and dropping the associative language in the relocated section.

Notice was made of the relocation, but not the dropping of the language. The VA and now VA/DOD treatment guides still link the diseases, but subtle changes seem to have been made, downgrading the importance. The M-21 ignores the fact that DMII often exists many years prior to diagnosis, and this period is commonly when heart disease occurs. Again, the VA/DOD treatment guides acknowledge the situation. The M-21, last time I looked, had a "decision tree" that instructed the RO to deny heart related conditions, unless they occurred after DMII was diagnosed. The heart conditions are a common indicator of existing or pending DMII, even when blood sugar levels are well below the levels used to confirm a DMII diagnosis.

1. The VA has the ability to "attach" part of a veteran's VA compensation or even other payments, even when the amounts in question are disputed, and lacks an effective "formal" process to resolve disputes.

The attachments can continue until a court of law is involved, or other interventions occur (political, etc.).

Next, the amount of money is often such that many disabled veterans will give up rather than deal with the aggravation.

2. The amount of "buck passing" is unbelievable. Those who are in positions that should deal with such things don't, and point to others instead.

3. Time and time again, over quite a few years, I've been told that once the VA starts charging "co-pay", it's difficult (polite understatement) to get them to stop.

4. Lawyers don't want to get involved, due to the hassle and relatively small amounts of money involved.

5. Getting enough information to determine how often the VA does this sort of thing is very difficult. (Naturally, since this information can be the basis of a class action suit.)

One of the un addressed side issues-- A veteran's "drug" co pay supposedly stops if a veterans payments reach ~ $960.

It is not clear in the regs/documents, etc.as to what is or can be considered "credit" towards the $960.

Example -- prescription drugs obtained from other than the VA. (Currently several of the drugs used for treatment of IHD and it's associated conditions are on the "$4.00" drug lists of many pharmacies)

What I see is that the VA will go to great lengths to deal with things that may or do result in a reduction of actual payment to a veteran, and almost ignore (until forced) information/situations that would increase payment or services to a veteran.

m

Chuck75 - I gotcha now. Thank you for spelling it out!!! You are right, I was confusing the VAMC w/claims. I see your point and stand corrected. Thank you for taking the time for the remedial lesson! ;-)

pr

Edited by Chuck75
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  • HadIt.com Elder

Chuck

I agree with what you are saying. I think the VA just feels it is their duty to get every dime out of any vet who uses the system even if they are 100% and on their death bed. I even got charged for a C&P exam through my insurance. They are cost shifting to my private insurance thus helping to drive up rates for the whole group.

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