Veterans lose again! Denied VA violation of 1722a claim
Lets assume you are at the VA picking up your prescription. You and the veteran in line in front of you are prescribed the exact same identical prescription of 30 pills. Both supplies carry a copay of $8. Right? But, your prescription requires that you split your supply. You now have a two month supply (15 pills 1/2 pill per day). This $8 supply now increases in copay cost to $16, for the exact pill medication and supply that costs $8. But let’s kick it up a notch, assume that veteran in front of you, having still the same prescription, his supply for a 30-day supply is instead 90 pills. Copay remains at $8 for this 30-day 90 pill supply.
Hope this explains, how the veteran is overcharged by the VA, and just got shafted again (3/13/07) by the Board of Veterans Appeals (BVA).What veterans have known as fact, is that veterans continue to lose benefits. This is just another example.
Criteria & Analysis by the Board of Veterans Appeals
“. …The appellant contends that the standard copayment is excessive in light of the pill splitting.” No where in my claim did I mention the word ‘standard.’ To determine what then is the standard $8, 30 day supply, one must compare 2 supplies. The VA apparently has two(2) standard supplies. A 30 day supply of 30-60-90 pills. Copayment cost $8. Then a second standard 30 day supply of 15 pills, $8 copay. Two distinct and different standards. A standard in cost, but no standard in supply. One does not have to read any further to see the unfairness of the BVA decision.
The BVA cites my argument, 38 U.S.C.A. Sec. 1722a “Copayment for medications. Paragraph (2) The Secretary may not require a veteran to pay an amount in excess of the cost to the Secretary for medication as described in paragraph (1).” As just described above.
Paragraph “(a)(1) Subject to paragraph (2), The Secretary shall require a veteran to pay the United States $8 for each 30-day supply of medication furnished such veteran under this chapter on an outpatient treatment of a non-service connected disability or condition. If the amount supplied is less than a 30-day supply, the amount of the charge may not be reduced.” If the ’standard’, as described in paragraph 1, is $8 for 30-day supplies of 30,60, or 90 pills, why are veterans charged $16 for a 2 month supply of 30 pills?
“In addition, the Board notes that the references to the cost of medication contained in 38 USC 1722a clearly pertains to VA’s cost in dispensing the medication, not the cost to the appellant.” That statement is incorrect. Copayment For Medication, 1722a, (listed above) clearly, makes no mention the VA’s cost of dispensing medication. It mentions only the veterans’ copayment obligation. A reference is made to the VA cost in the Federal Register, however, the “cost in dispensing the medication” is not the argument. It is the cost in overcharges to the veteran.
To you, and me it is quite simple. “The Secretary may not require a veteran to pay amount in excess of the cost to the Secretary for medication as described in paragraph (1).” If one supply can be a standard 60, or 90 pill 30 day supply with a copay of $8, how can a 30 day supply of 15 pills at a copay of $8 be standard supply? Therefore, an “excess of the cost” does indeed exist.
If given to an eight grade grammar school class this arithmetic problem of the two supplies to find the excess of the cost, what would be their answer? They too, would find that an excess of the cost does exist, “..for medication as described in paragraph (1)”
“(b) The Secretary, pursuant to regulations which the Secretary shall prescribe may-…(1) increase the copayment amount in effect under subsection (a);..” “Pursuant to regulations” means according to law, which the Secretary shall follow accordingly, and prescribe. What is being said, judging by the ruling, these are the VA standards the veteran! Squeeze the veteran! Citing..Under 38 C.F.R. Sec. 17.110 Copayments for medications.
“(b) Copayments. (1) Unless exempted under paragraph (c) of this section, a veteran is obligated to pay VA a copayment for each 30-day or less supply of medication provided by the VA on an outpatient basis (other than medication administered during treatment).” If ‘administered during treatment’ meant hospitalization, that’s not what it says, or should have been worded. But it did not. It is not ambiguous in the context in which it is presented. Citing, ‘on an outpatient basis, other than medication administered during treatment’ The meaning is quite clear. A patient receiving 60, or 90 day outpatient supply is clearly a treatment of a condition, such as a heart condition, diabetes, etc.
BVA mentions, “Thus, it is clear that the VA’s cost of filling the appellant’s 30-day prescription exceeds the $8 copayment under 38 C.F.R. Sec. 17.110.” Again the argument clearly is not the VA cost as noted in the Federal Register 12/6/2001. When determining the medication copay cost, VA factored in everything, except the cost of the medication. The BVA’s inadequacy, and mindset shown here, is for all to see.
BVA denial in part, “…adherence in the face of overwhelming evidence in support of the result in a particular case: such adherence would result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the claimant.” Never mind the burden of overcharges, or the benefit flowing to well over 1.1 million veterans whose prescriptions call for pill splitting.
It is clear, the BVA came up with this denial of overcharges claim due to national budget concerns due to the involvement in Iraq, Afghanistan, and who knows were else. Veterans did not cause that. But men and women went to military service because of it. This is how they get rewarded by a grateful nation. There are many things in life we do not like, but ignoring a veterans’ cause, or the law is not an option. Who lost? Having sat in the lobby of my VA hospital and observed those that passed by, it’s not hard to see, there are many who could use any help they can get, as well those returning from Iraq, Afghanistan, and Walter Reed.
I have started the filing process for an appeal with the Court of Appeals for Veterans Claims.
William H. Heino Sr
VA prescription over-charges UPDATE
As you may know, veterans pay a co-pay of $8.00 for each 30-day prescription. However, there are well over 1.1 million VA prescriptions that veterans are being over-charged for, in violation of the law. In other words double the cost. Something I’ve been fighting for over 5 years. Veterans continue to be over-charged and they will never recover their loss. I began informing the Veterans Administration in March 2002, that the VA is in violation of 38 USC 1722a, regarding prescription co-payment over-charges. Where is this case at the moment? But first, being unfamiliar with my claim, briefly.. paragraph 1 states, that a veteran is required to pay $8 for a 30-day prescription. This 30-day supply can be 30, 60 or 90 pills, all for the $8 co-pay cost. Here‘s the United States Code; 38 USC 1722a. “Paragraph (a)(1) subject to paragraph (2), the Secretary shall require a veteran to pay the United States $8.00 for each 30 day supply of medicine…if the amount supplied is less than a 30 day supply the amount of the charge may not be reduced.” Paragraph 2. ” The Secretary may not require a veteran to pay an amount in excess of the cost to the Secretary for medication as described in paragraph 1.” I will explain the VA violation by illustrating in this example, a normal 30 day supply, using a 30 pill prescription, $8 veteran co-payment. The VA, using creative accounting, will use this same exact identical prescription and supply, and increase the cost from $8 to $16. Double the cost. Why? Because… the prescription requires splitting pills. This 30 pill, $8 supply is now a 2 month, split 15 pill, 30 day, $16 co-pay supply. While your taking in that $16 supply, keep in mind the 30,60,90 pill, 30-day supplies at $8 copay. Paragraph 2, states, “The Secretary may not require a veteran to pay an amount in excess of the cost to the Secretary for medication as described in paragraph 1.” And what was the described co-pay cost? To the veteran who’s prescription for the exact identical 30-day, 30 pill supply, “..as described in paragraph 1″, it was $8. There may be those who want to believe, these 15 split pill prescriptions, in reality, are $8 co-pay, 30-day supplies, as paragraph 1 suggests. I submit that, with no mention of quantity, but considering the abundant supplies shipped, the amount of the 30-day supplies involved, neither the Code of Federal regulations, or the United States Code itself, gives reference, to greater co-pay costs beyond what has been established for like 30-day, $8 co-pay supplies. This generous abundance…. of seemingly endless supply, and availability of medication of 30, 60, 90 or more, $8, 30-day supplies, stops at a prescription that calls for pill splitting. This $8, 30-day supply has been limited to only 15 pills, and has doubled in cost. To those of you, as well as those at the Veterans Administration, who may be confused, to the meaning of 30 day supplies, 38 USC 1722a paragraph 1 states, “..the Secretary shall require a veteran to pay the United States $8.00 for each 30 day supply of medication.” The Veterans’ Medical Care Appropriations and Funding Process, dated 9/30/2004. Congressional Research Service (CRS) report for Congress explains and supports further my BVA claim, and this 30-day or less cost. Stated in the …. The Veterans Millennium Health Care and Benefits Act of 1999 (P. L. 106-117)authorized VA to increase the medication co-payment amount and to establish annual caps on the medication co-payment amount 26 “This law allowed VA to increase the co-payment amount for each 30-day or less supply of medication provided on a outpatient basis (other than medication administered during treatment) for treatment of a non-service-connected condition.” “Other than medication administered during treatment”, CRS documentation describing the co-pay charge, and how it is to be applied. This is of further significance in understanding 38 USC 1722a. Meaning medication required in the treatment of more than one 30-day supply of 15 pills (split), this law does not allow an increase in the co-payment for, “..an amount in excess of the cost to the Secretary for medication as described in paragraph 1.” If the cost to the Secretary for a 45 pill, or more, 30-day monthly supply is $8.00, as described in paragraph 1, why then are veterans’ being charged $24.00 (split pill) for an $8.00 30-day supply? Imagine, 30, 60, 90, or more 30 day $8 supplies of medication so low in cost to the VA, and considered by the VA so insignificant it was not even considered as a factor in determining and setting the co-pay cost. 12/6/01,Federal Register: “VHA conducted a study of the pharmacy administrative costs relating to the dispensing of medication on an out-patient medication… even without consideration of the actual cost of the medication.” Update to my Board of Veterans Appeals claim submitted Dec. 29, 2005. My claim effecting VA prescription over-charges for split pill supplies of well over 1.1 million veterans’ remains on the docket as originally scheduled. Illinois Senator Richard Durbin made an appeal on my behalf to advance my case on the docket, because of the “general application” nature of my claim, effecting millions of veterans’. However, the requirement to advance relies on the precise language, “general application effecting other claims’. Because my claim may perhaps be the only claim, the BVA would not budge. Never mind the over-charges for those millions of veterans. For them, and me, these over-charges will continue. During my recent call to them, I was told the Board is presently working on claims submitted in March 2005.
William H. Heino Sr
