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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
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
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