Veterans Health Administration Chief Business Office

VHA Health Care Benefits Eligibility Overview

Establishing Eligibility

Applying for VA health care– Application for Health Benefits – VA Form 10-10EZ– Various ways to apply

• In person at VA clinic or medical center• By submitting a completed application to a VA

clinic or medical center• Online at www.va.gov/healtheligibility

Note: Appreciate DD214 with application but not required

A veteran is a person who:

•Served in the active military•Discharged or released under conditions other than dishonorable

including•Reservists/National Guard Members if activated/mobilized by a Federal order AND served for the full period for which they were called (excludes training purposes)

Enrollment Veterans generally must be enrolled to receive VA Health Care

Enrollment assures veterans that comprehensive health care services will be available when they are needed

Health care benefits are completely portable throughout the entire VA system

VA Enrollment System

The Veterans’ Health Care Eligibility Reform Act of 1996 (PL 104-262) enacted 10/1/96

Law required implementation of an annual enrollment system to ensure treatment is timely and acceptable

• Enrollment is managed in accordance with 8 specified priorities, with 1 being the highest priority

• Medical Benefits Package available to all enrollees – a standard enhanced health benefits plan

Enrollment Priority Groups 1 - 8

Priority Groups 1-5

PG 1 - Service-Connected 50% or more disability rating or Unemployable due to a VA SC condition

PG 2 - Service-Connected 30% or 40%PG 3 - SC 10-20%, Purple Heart, former POWs, veterans

discharged due to disability incurred in servicePG 4 - Veterans receiving Aid &Attendance or Housebound VA

pension benefits, or determined by VHA to be catastrophically disabled

PG 5 - NSC & 0% SC noncompensable veterans with income below threshold, or receiving VA pension and/or eligible for Medicaid benefits

Priority Group 6• World War I veterans• Compensable 0% service-connected veterans• Veterans exposed to ionizing radiation during atmospheric

testing or during the occupation of Hiroshima and Nagasaki• Project 112/SHAD participants• Veterans who served in a theater of combat operations after

November 11, 1998 as follows:– Veterans discharged from active duty on or after January

28, 2003, who were enrolled as of January 28, 2008 and veterans who apply for enrollment after January 28, 2008, for 5 years post discharge

– Veterans discharged from active duty before January 28, 2003, who apply for enrollment after January 28, 2008, until January 27, 2011

Priority Group 7

• PG 7 - Veterans who agree to specified copays with income and/or net worth above the VA income threshold and income below the Geographic Means Test (GMT) income thresholds

Priority Group 8• PG 8 - Veterans who agree to specified copays with income

and/or net worth above the VA Income threshold and the GMT thresholds– Subpriority a: Noncompensable 0% service-connected veterans

enrolled as of January 16, 2003 and who have remained enrolled since that date

– Subpriority c: Nonservice-connected veterans enrolled as of January 16, 2003 and who have remained enrolled since that date

– Subpriority e: Noncompensable 0% service-connected veterans applying for enrollment after January 16, 2003

– Subpriority g: Nonservice-connected veterans applying for enrollment after January 16, 2003

• Effective January 17, 2003, VA no longer enrolls new veterans in Priority 8e or 8g. Veterans in Priority 8e are eligible for VA care of their service-connected conditions

Copays and Charges• There is no monthly premium to use VA care• Some veterans assessed copays for care and/or

medications• Exempt from medical care copays:

– Receiving a Purple Heart Medal, or – Former Prisoner of War Status, or – Compensable service-connected disabilities, or – Low income, or – Other qualifying factors including treatment related to military

service experience

• Billable insurance plans reimbursement may cover the cost of applicable VA copays

Inpatient Copays• Means Test Copay Required Status:

– Copays based upon Medicare deductible (currently $1,024) for the first 90 days of inpatient care and $512 for subsequent 90 days of care within one calendar year

– Per diem charge of $10 for each day of inpatient care• Geographic Means Test (GMT) Copay Required status (e.g.

Priority Group (PG) 7 or those who migrate from PG7 to PG 4 based on a VHA Catastrophic Disability determination), charges reduced by 80%: – Medicare deductible inpatient copay rate is $204.80 for the first

90 days of care and $102.40 for subsequent 90 days of care– Per diem charge is $2 per day of inpatient care

Outpatient Copays• Veterans charged outpatient copays are also subject

to inpatient copays• 2008 Outpatient Copay rates

– $15 for each basic care outpatient visit – $50 for each specialty care outpatient visit– $0 for preventive screenings, immunizations, lab tests, flat

film radiology and EKGs

Outpatient Medication Copays• Priority Groups 2-8 charged $8 for each 30-day or less

supply of medication provided by VA for NSC conditions. Exceptions: – Former POWs– Receipt of a VA NSC Pension– Income below $11,181 (if single), $14,643 (if married) plus $1,909 for

each additional dependent ; Higher A&A rate applicable for veterans determined to be in need of A&A by VHA practitioner

– Veterans when receiving medications for special eligibility conditions such as Project 112, ionizing radiation, military sexual trauma, combat veterans within special eligibility period, etc.

• Amount of copays payable in a calendar year is capped at $960 for Priority Groups 2-6. No cap is applied for Priority Groups 7 and 8

• Copay rates and thresholds are adjusted annually

Copays for Long Term Care• Long term care copay are based on three levels of

care: • Inpatient ................ $97 per day

– Nursing Home – Respite– Geriatric Evaluation

• Outpatient ................ $15 per day – Adult Day Health Care– Respite– Geriatric Evaluation

• Domiciliary ..................$5 per day

Chief Business Office

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