Emergency Medical Care
During a medical emergency, you should immediately seek care at the nearest medical facility. A medical emergency is an injury, illness or symptom so severe that without immediate treatment, you believe your life or health is in danger. If you believe your life or health is in danger, call 911 or go to the nearest emergency department right away.
You do not need to check with VA before calling for an ambulance or going to an emergency department. During a medical emergency, VA encourages you to seek immediate medical attention without delay. A claim for emergency care will never be denied based solely on VA not receiving notification prior to seeking care.
It is, however, important to promptly notify VA that you are receiving emergency care at a community emergency department. Notification should be made within 72 hours of admission, sooner is always better. You do not have to be the one to notify the VA, a family member or friend can notify them on your behalf. DO NOT assume the emergency department will contact the VA, even if they say they will, it is better to have someone contact the VA as well. This allows VA to assist you and/or the healthcare provider in coordinating necessary care or transfer, and helps to ensure that the administrative and clinical requirements for VA to pay for the care are met.
Service-Connected Emergency Care
In general, VA can pay for emergency medical care at a local emergency department for your service-connected condition, or if the care is related to your service-connected condition. Specifically, emergency medical care for your service-connected or related condition(s) is eligible for VA payment as long as the VA wasn’t reasonably available to provide the care.
In accordance with the following situations and requirements, VA can pay emergency care costs for:
- A Veteran who receives emergency treatment of a service-connected, or adjunct condition* in a community emergency department; OR
- A Veteran who is Permanently and Totally disabled (P&T) as the result of a service-connected condition is eligible for emergency treatment of ANY condition; OR
- 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(scenarios 1-3 must all meet #4)
- The emergency was of such a nature that the Veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy.
NOTE: A service-connected condition is one that has been adjudicated by the Veterans Benefits Administration (VBA) and a disability rating has been granted. An adjunct condition is one that, while not directly service-connected, is medically considered to be aggravating a service-connected condition. Legal authorities and payment methods for VA payment for emergency care for service-connected conditions are contained in Title 38 U.S.C. §1728, 38 CFR §17.120 and 38 CFR §17.132.
Nonservice-Connected Emergency Care
VA can also pay for emergency medical care at a community emergency departmebt for your nonservice-connected condition. However, there are several requirements and factors that affect the extent to which VA can cover those services. Specifically, emergency medical care for your nonservice-connected condition(s) is eligible for VA payment when all of the following five elements are true:
- Care was provided in a hospital emergency department (or similar public facility held to provide emergency treatment to the public); AND
- The emergency was of such a nature that the Veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy; AND
- A VA medical facility or another Federal facility was not reasonably available to provide the care; AND
- The Veteran is enrolled and has received care within a VA facility during the 24 months before the emergency care; AND
- The Veteran is financially liable to the provider of emergency treatment.
There are limitations on VA’s ability to provide coverage when you have other health insurance (OHI). If OHI does not fully cover the costs of treatment, VA can pay certain costs for which you are personally liable. By law, VA cannot pay copayments, coinsurance, deductibles, or similar payments a Veteran may owe to the provider as required by their OHI.
VA is also legally prohibited from providing coverage for individuals covered under a health plan contract because of a failure by the Veteran or the provider to comply with the provisions of that health plan contract, e.g., failure to submit a bill or medical records within specified time limits, or failure to exhaust appeals of the denial of payment.
After Receiving Care
Once your immediate emergency medical care needs have been addressed, you, a family member, or friend should contact the nearest VA medical facility within 72 hours. Once notified, VA staff will assist you and/or your representatives in understanding eligibility and how eligibility relates to services rendered in the community. VA staff will also ensure that, if desired, you are transferred to a VA medical center upon stabilization and that you are set up to receive additional care, post discharge, without interruption.
IMPORTANT: When you receive emergency medical care, notifying VA as quickly as possible is always best. It ensures maximum VA coverage and assists the VA in providing you with the care you need.
For more information on Emergency Medical Care click HERE.