src/applications/combined-debt-portal/medical-copays/components/Modals.jsx
import React, { useState } from 'react';
import {
VaModal,
VaButton,
} from '@department-of-veterans-affairs/web-components/react-bindings';
import PropTypes from 'prop-types';
const Modals = ({ children, title }) => {
const [visible, setVisible] = useState(false);
return (
<div className="vads-u-margin-top--3 vads-u-margin-bottom--3">
<VaButton secondary onClick={() => setVisible(true)} text={title} />
<VaModal
onCloseEvent={() => setVisible(false)}
visible={visible}
modalTitle={title}
large
>
{children}
</VaModal>
</div>
);
};
Modals.Rights = () => (
<>
<h4>Collection</h4>
<p>
The U.S. Department of Veterans Affairs (VA) is required to collect debts
owed to the government. Action must be taken within sixty (60) days from
the initial billing statement to pay your debt in full or establish a
payment plan or your account may be referred for further collection
action. You have the right to inspect and copy the records related to the
debt. You also have the right to establish a payment plan. You have the
right to submit a compromise offer. Collection action includes referring
your delinquent balance to the Department of Treasury's Cross-Servicing
Program and Treasury Offset Program, which will include offset of any
federal and state payments to which you are entitled. This includes tax
refunds, social security benefits and salary or retirement benefits. In
addition, the Department of Treasury may refer your account to private
collection agencies, which will result in additional fees and interest
being added to your account. You may also be subject to garnishment of
non- federal wages under Treasury's Administrative Wage Garnishment
Program. Other collection actions include offset of any current or future
VA benefits to which you may become entitled. We may also report your
delinquent account to credit reporting agencies sixty (60) days from the
date of the initial billing statement. Additional information can be found
at:
<a
href="https://www.va.gov/healthbenefits/cost/"
className="vads-u-margin-left--0p5"
>
www.va.gov/healthbenefits/cost/.
</a>
</p>
<h4>Pay your bill</h4>
<p>
Pay the debt in full by the balance due date on the initial billing
statement to avoid late charges and collection action:
</p>
<ul>
<li>
In Person: At your local Veteran Affairs Medical Centers Agent Cashier's
Office
</li>
<li>
By Phone: Contact VA at
<va-telephone
international
contact="8888274817"
className="vads-u-margin-x--0p5"
/>
</li>
<li>
By Mail: Make check or money order payable to "VA" and include account
number and payment stub. Submit to: Department of Veterans Affairs, P.O.
Box 3978, Portland, OR 97208-3978
</li>
</ul>
<h4>Late charges</h4>
<p>
The VA is required to assess late charges on balances which remain unpaid
thirty (30) days after the statement date. These charges consist of
interest and administrative fees at rates established each year. Interest
will be charged from the date charges first appear on the statement. You
can avoid these charges by making timely payments by the balance due date
on the initial billing statement. A monthly administrative cost or
collection fee will be added to your debt if, within thirty (30) days of
the date of the statement on which charges first appear, full payment of
the debt is not received or a repayment plan agreement is not approved. If
an installment repayment plan is established and any installment is not
received by the due date, the monthly administrative cost or collection
fee will thereafter be charged until the debt is paid. Other collection
costs may also be added to the debt if additional collection actions
become necessary.
</p>
<h4>Waiver</h4>
<p>
You have the right to request a waiver of part or all of your debt. If the
waiver is granted you will not be required to pay the amount waived. To do
so, submit an explanation and a completed Financial Status Report (VA Form
5655) found at:
<a
aria-label="Financial Status Report (VA Form 5655) - Opens in new window"
className="vads-u-margin-left--0p5"
target="_blank"
rel="noopener noreferrer"
href="https://www.va.gov/vaforms/va/pdf/VA5655.pdf"
>
Financial Status Report (VA Form 5655)
</a>
. Your explanation should include why you are not responsible for the debt
and any undue hardship the payment of the debt would cause you. You have
the right to request a hearing in connection with your request for a
waiver. To do so, submit a written request for hearing with your waiver
request. VA will notify you of the date, time and place where the hearing
will be held. Refer to the "Customer Service" and "Submitting Your
Request" sections below for more information
</p>
<h4>Compromise offer</h4>
<p>
You have the right to request a compromise. A compromise means you may
propose a lesser amount as full settlement of the debt. To request a
compromise, submit your request in writing to VA, specifying the dollar
amount you are proposing VA should accept as payment in full, and a
completed Financial status Report (VA Form 5655) found at:
<a
aria-label="Financial Status Report (VA Form 5655) - Opens in new window"
className="vads-u-margin-left--0p5"
target="_blank"
rel="noopener noreferrer"
href="https://www.va.gov/vaforms/va/pdf/VA5655.pdf"
>
Financial Status Report (VA Form 5655)
</a>
. Refer to the “Customer Service” and “Submitting your Request” sections
below for more information.
</p>
<h4>Repayment plan</h4>
<p>
You have the right to establish a monthly repayment plan at any time
during your enrollment in VA health care if you cannot pay your debt in
full. To do so, submit a completed Agreement to Pay Indebtedness (VA Form
1100) found at:
<a
className="vads-u-margin-left--0p5"
href="http://www.va.gov/vaforms/va/pdf/VA1100.pdf"
>
www.va.gov/vaforms/va/pdf/VA1100.pdf
</a>
. Indicate your proposed monthly payment amount in paragraph 1A. Include
your first payment with the completed form. Make check or money order
payable to "VA" and include the account number and payment stub. Refer to
the "Customer Service" and "Submitting Your Request" sections below for
more information.
</p>
<h4>Dispute the existence or amount of the debt </h4>
<p>
You have the right to dispute the existence or amount of the debt. To do
so, submit a letter explaining why you question the validity or amount of
the debt. To avoid late charges, you must submit a dispute by the balance
due date on the initial billing statement. VA will not initiate collection
if your dispute is received within sixty (60) days from the initial
billing statement. If VA receives your notice later than sixty (60) days
and collection has been initiated, it will continue while the dispute is
being reviewed. If the dispute is resolved in your favor, all late charges
will be removed from your account, and any amounts withheld from your VA
benefits, federal payments, or wages will be refunded to you. Refer to the
"Customer Service" and "Submitting Your Request" sections below for more
information.
</p>
<h4>Hardship determination</h4>
<p>
You have the right to request a Hardship Determination which provides an
exemption from future outpatient and inpatient copayments for the
remaining calendar year. To do so, send a letter explaining any financial
hardship these charges will cause you and a completed Request for Hardship
Determination (VA Form 10-10HS) found at:
<a
className="vads-u-margin-left--0p5"
href="http://www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf"
>
www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf
</a>
. If your gross household income has decreased, you may be eligible for
enrollment in a higher Priority Group which may qualify you for copayment
exemption. Submit a completed Health Benefits Renewal (VA form 10-10EZR)
found at:
<a className="vads-u-margin--0p5" href="http://www.1010ez.med.va.gov/">
www.1010ez.med.va.gov
</a>
to update your financial information. Refer to the "Customer Service" and
"Submitting Your Request" sections below for more information.
</p>
<h4>Customer service</h4>
<p>
For additional assistance or if you are unable to access the forms online:
</p>
<ul>
<li>
In Person: Contact your Patient Advocate or Enrollment Coordinator at
your local Veteran Affairs Medical Center
</li>
<li>
By Phone: Contact VA at
<va-telephone
international
contact="8884001238"
className="vads-u-margin-x--0p5"
/>
</li>
<li>
Online: Visit
<a
className="vads-u-margin--0p5"
href="http://www.va.gov/healthbenefits/cost"
>
www.va.gov/healthbenefits/cost
</a>
for additional information or
<a className="vads-u-margin--0p5" href="http://www.va.gov/vaforms">
www.va.gov/vaforms
</a>
to retrieve VA forms.
</li>
</ul>
<h4>Submitting your request</h4>
<p>
Submit the required VA forms or documents to apply for one of VA's
Financial Hardship Programs:
</p>
<ul>
<li>
In Person: At your local Veterans Affairs Medical Center's Business
Office or Health Administration Service Office
</li>
<li>
By Mail: Send completed forms and/or other required documentation to the
VA address at the top left of your statement to the attention of the
Business Office/Health Administration Service Office
</li>
</ul>
<p>
For additional information, to request necessary forms or assistance in
accessing forms online, contact VA at
<va-telephone
international
contact="8664001238"
className="vads-u-margin-left--0p5"
/>
.
</p>
<h4>Representation</h4>
<p>
An accredited representative of a Veteran Service Organization or other
service organization recognized by the Secretary of Veterans Affairs may
represent you without charge. You may employ an attorney or VA accredited
agent to assist you. The services of an attorney or accredited agent
representing you in adjudicated proceedings before VA are subject to a fee
limitation as set forth in 38 U.S.C 5904. If you desire representation and
have not already designated a representative, contact VA at
<va-telephone
international
contact="8664001238"
className="vads-u-margin--0p5"
/>
to request the necessary forms. If an attorney or accredited agent
represents you before VA, a copy of any agreement between you and the
attorney or accredited agent about the payment of the attorney's or
agent's fees must be filed at the following address: Counsel to the
Chairman (01C3), Board of Veterans Appeals, 810 Vermont Avenue N.W.,
Washington D.C. 20420.
</p>
<h4>Notice to customers making payment by check</h4>
<p>
When you provide a check as payment, you authorize VA to either use
information from your check to make a one-time electronic fund transfer
from your account or to process the payment as a check transaction. When
VA uses information from your check to make an electronic transfer, funds
may be withdrawn from your account as soon as the day we process your
payment, and you will not receive your check back from the financial
institution. A Privacy Act Statement required by 5 U.S.C & 552a(e)(3)
stating our authority for soliciting and collecting the information from
your check, and explaining the purposes and routine uses which will be
made of your check information, VA Notice of Privacy Practices, IB 10-163
is available online at
<a
className="vads-u-margin--0p5"
href="http://www.va.gov/vhapublications"
>
www.va.gov/vhapublications
</a>
or call toll free at
<va-telephone
international
contact="8664001238"
className="vads-u-margin-x--0p5"
/>
to obtain a copy by mail. Furnishing the check information is voluntary,
but a decision not to do so may require you to make payment by some other
method.
</p>
<h4>Questions about payments</h4>
<p>
Payments made in the past ten (10) days may not have been applied to your
account by the time your statement was prepared. If so, this payment will
be reflected in your account on the next statement. For assistance in
understanding your billing statement and assessed copayment charges
contact VA at
<va-telephone
international
contact="8664001238"
className="vads-u-margin-left--0p5"
/>
.
</p>
<h4>VA Privacy</h4>
<p>
The VA Notice of Privacy Practices, IB 10-163, which outlines your privacy
rights, is available online at
<a
className="vads-u-margin-left--0p5"
href="http://www.va.gov/vhapublications"
>
www.va.gov/vhapublications
</a>
, or you may obtain a copy by writing the VHA Privacy Office (10P2C1) at
810 Vermont Avenue NW, Washington, DC 20420
</p>
</>
);
Modals.propTypes = {
children: PropTypes.object,
title: PropTypes.string,
};
export default Modals;