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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

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Veterans health administration chief business office

Veterans Health Administration Chief Business Office

VHA Health Care Benefits

Eligibility Overview


Establishing eligibility

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

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

Enrollment

  • Veterans generally must be enrolled to receive VA Health Care

  • Enrollment assures veterans that comprehensive health care services will be available when theyare needed

  • Health care benefits are completely portable throughout the entire VA system


Va enrollment 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


Veterans health administration chief business office

Enrollment Priority Groups 1 - 8


Priority groups 1 5

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 service

PG 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

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

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

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

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

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

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

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

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

Chief Business Office

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