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To receive health care, veterans generally must be enrolled with VA. A veteran may apply for enrollment at any time. Veterans do not have to be enrolled if they: (1) have a service-connected disability of 50 percent or more; (2) want care for a disability that the military determined was incurred or aggravated in the line of duty, but which VA has not yet rated, during the 12-month period following discharge; (3) want care for a service-connected disability only; or (4) are seeking registry examinations (Ionizing Radiation, Agent Orange, Gulf War/Operation Iraqi Freedom and Depleted Uranium). To permit better planning of health resources, however, these three categories of veterans also are urged to enroll.
The Veterans' Health Care Eligibility Reform Act of 1996, Public Law 104-262, established a two-tier system for providing medical treatment. Veterans are classified into one of two categories that determine how their medical care is provided. These categories are explained in the "Veterans Affairs (VA) Benefits - Medical Treatment Categories" topic. In general, veterans with disabilities, veterans with limited incomes and net worth, and elderly veterans are classified into "Category 1 - Category A". All others fall into "Category 2 - Category C" status. The VA health system is mandated to serve the "Category 1 - Category A" veterans, but serves the "Category 2 - Category C" veterans as funding, local resources, and space allow.
Additionally, Congressional appropriations may limit the number of veterans who can be enrolled. A priority system determines the order in which certain groups are furnished medical care. These groups are defined in the "Veterans Affairs (VA) Benefits - Treatment Priority Groups" topic. Enrollment will be reviewed each year. Veterans will be notified in writing of any change in their enrollment status.
Veterans with service-connected disabilities rated 50 percent or more based on one or more disabilities or unemployability and veterans receiving care for a service-connected disability receive priority in the scheduling of appointments for outpatient medical services and admissions for inpatient hospital care.
Effective Jan. 28, 2008, veterans discharged from active duty on or after Jan. 28, 2003, are eligible for enhanced enrollment placement into Priority Group 6 (unless eligible for higher enrollment Priority Group placement) for 5 years post discharge. Veterans with combat service after Nov. 11, 1998, who were discharged from active duty before Jan. 28, 2003, and who apply for enrollment on or after Jan. 28, 2008, are eligible for this enhanced enrollment benefit through Jan. 27, 2011.
Veterans, including activated reservists and members of the National Guard, are eligible if they served on active duty in a theater of combat operations after Nov. 11, 1998, and, have been discharged under other than dishonorable conditions.
Veterans who enroll with VA under this "Combat Veteran" authority will retain enrollment eligibility even after their five-year post discharge period ends. At the end of their post discharge period, VA will reassess the veteran’s information (including all applicable eligibility factors) and make a new enrollment decision. For additional information, call 1-877-222-VETS (8387).
Most veterans not receiving VA disability compensation or pension payments must provide VA with information on their annual income and net worth to determine whether they are below the "means test" threshold. The threshold is adjusted annually and announced in January. The threshold limits for may be seen in the topic "Veterans Affairs (VA) Benefits - Means Test Thresholds". In making the assessment, the veteran's total household income, including the veteran's spouse and dependents, is considered.
The "means test" eligibility assessment includes all household income and net worth, including Social Security, U.S. Civil Service retirement, U.S. Railroad Retirement, military retirement, unemployment insurance, any other retirement income, total wages from all employers, interest and dividends, workers' compensation, black lung benefits, and any other gross income for the calendar year prior to application for care. Also considered are assets such as the market value of property that is not the primary residence, stocks, bonds, notes, individual retirement accounts, bank deposits, savings accounts and cash. The patient may fill out VA Form 10-10EZ at the time application for enrollment is made. VA forms are available at the VA forms website:
http://www.va.gov/vaforms/
VA also is required to compare veterans' financial assessment information with a geographically based income threshold. If the veteran's income is below the threshold where the veteran lives, he or she is eligible for an 80 percent reduction in the inpatient copayment rates. VA may compare income information provided by the veteran with information obtained from the Social Security Administration and the Internal Revenue Service.
Veterans in certain treatment priority groups whose income is above the "financial means test" threshold and/or the "geographic means test" threshold must agree to pay copayments for care. If the veteran does not agree to make copayments, the veteran may be ineligible for VA care.
The rules for determining which veterans are responsible for which copayments are complex. This version of WorkWORLD contains a PDF document (requires Adobe Acrobat Reader) that summarizes these requirements for the various types of benefits.
NOTE: Click here to view the Copayment Responsibility tables.
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Inpatient Care: Priority Group 7 and certain other veterans subject to copayment requirements are responsible for paying 20 percent of VA's inpatient copay for the first 90 days of care during any 365-day period. For each additional 90 days of hospital care, the patient is charged 10 percent of the inpatient copay. In addition to these charges, the patient is charged $2 a day for hospital care.
Priority Group 8 and certain other non service-connected veterans and non compensable, zero percent service-connected veterans with incomes above the VA national and geographic income thresholds will be charged the VA inpatient copay for the first 90 days of care during any 365-day period and $10 per day. For each additional 90 days, they are charged one half of the inpatient copay and the per diem charge.
Extended Care: With certain exceptions, a veteran must agree to pay copayments for the receipt of extended care services. A veteran's application for extended care services (VAF 10-10EC) requires financial information that is used to determine the monthly copayment amount, based on each individual veteran's financial situation.
Medication: Most veterans are charged $8 for a 30-day or less supply of medication for treatment of nonservice-connected conditions.
Outpatient Care: A three-tiered copayment system is effective for all services provided on an outpatient basis. The copayment is $15 for a primary care visit and $50 for some specialty care visits. Certain services do not require a copayment.
Outpatient visits for which no copayment will be assessed include: publicly announced VA public health initiatives (e.g., health fairs) or an outpatient visit solely consisting of preventive screening and/or immunizations, such as influenza immunization, pneumonococcal immunization, hypertension screening, hepatitis C screening, tobacco screening, alcohol screening, hyperlipidemia screening, breast cancer screening, cervical cancer screening, screening for colorectal cancer by fecal occult blood testing, and education about the risks and benefits of prostate cancer screening. Laboratory, flat film radiology services, and electrocardiograms are also exempt from copayments.
VA is required to submit claims to health insurance carriers for recovery of VA's reasonable charges in providing medical care to nonservice-connected veterans and to service-connected veterans for nonservice-connected conditions. Money collected in this way is used to maintain and improve VA's health-care system for veterans. Generally, VA cannot bill Medicare for medical services provided to veterans; however, VA can bill Medicare supplemental health insurance for medical care and services that are covered by the supplemental insurance but not covered by Medicare.
All veterans applying for VA medical care are required to provide information on their health insurance coverage, including coverage provided under policies of their spouses. Veterans are not responsible for paying any remaining balance of VA's insurance claim that is not paid or covered by their health insurance, and any payment received by VA may be used to offset "dollar for dollar" a veteran's copayment responsibility.
VA provides nursing home services through three national programs: VA owned and operated nursing homes, state veterans homes owned and operated by the state, and contract community nursing homes. Each program has its own admission and eligibility criteria.
VA Nursing Homes: VA owned and operated homes typically admit residents requiring short-term skilled care, or who have a 70 percent or more service-connected disability, or who require nursing home care because of a service-connected disability.
State Veterans' Home Program: The state veterans home program is a cooperative venture between VA and the states whereby VA provides matching construction funds to help build the home and the state, the veteran, and VA pay a portion of the per diem. The per diem is set in legislation. State veterans homes accept all veterans in need of long-term or short-term nursing home care. Specialized services offered are dependent upon the capability of the home to render them.
Community Nursing Home Program: VA maintains contracts with community nursing homes though every VA medical center. The contract nursing home program is designed to meet the long-term nursing home care needs of veterans who may not be eligible and/or qualify for placement in a VA or state veterans home or if there is no VA or state home available in their community.
Admission Criteria: To be placed in a nursing home, veterans generally must be medically stable, have a condition that requires inpatient nursing home care, and be assessed by an appropriate medical provider to be in need of institutional nursing home care. They also must meet the eligibility requirements for the home to which they are applying. For VA nursing homes, they may have to pay a copayment depending on their financial status. VA social workers can help interpret eligibility and co-payment requirements.
In addition to nursing home care, VA offers other extended care services either directly or by contract with community agencies, including adult day care, respite care, geriatric evaluation and management, hospice and palliative care, and home based primary care. These services may require copayment.
Domiciliary care provides rehabilitative and long-term, health-maintenance care for veterans who require minimal medical care but who do not need the skilled nursing services provided in nursing homes. A Domiciliary also provides rehabilitative care for veterans who are homeless.
VA may provide domiciliary care to veterans whose annual income does not exceed the maximum annual rate of VA pension or to veterans the Secretary of Veterans Affairs determines have no adequate means of support. The copayments for extended care services apply to domiciliary care. Call your nearest benefits or health-care facility to obtain the latest information.
Outpatient pharmacy services are provided free to: (1) veterans with a service-connected disability of 50 percent or more; (2) veterans receiving medication for treatment of service-connected conditions; (3) veterans whose income does not exceed the maximum VA annual rate of the VA pension; (4) veterans enrolled in priority group 6 who receive medication for service-connected conditions; (5) veterans receiving medication for conditions related to sexual trauma experienced while serving on active duty; (6) certain veterans receiving medication for treatment of cancer of the head or neck; (7) veterans receiving medication as part of a VA-approved research project, and (8) former prisoners of war..
Other veterans will be charged a copayment of $8 for each 30-day or less supply of medication. To eliminate a financial hardship for veterans who require an unusually large amount of medications, there is a maximum copayment amount that veterans enrolled in Priority Groups 2 through 6 pay in any single year. (Priority groups are described in the topic Veterans Affairs (VA) Benefits - Treatment Priority Groups.)
Veterans do not pay copayments for medications dispensed during the remainder of a calendar year in which this annual cap amount has been paid. For calendar year 2012, the cap is $960.
The medication copayment applies to prescription and over-the counter medications, such as aspirin, cough syrup or vitamins, dispensed by a VA pharmacy. Medication copayments are not charged for medications injected during the course of treatment or for medical supplies, such as syringes or alcohol wipes. In the event over-the-counter drugs are ordered, the veteran can choose to purchase them at a local pharmacy rather than pay $8 for items such as aspirin, cough syrup or vitamins.
Outpatient dental treatment provided by VA includes examinations and the full spectrum of diagnostic, surgical, restorative and preventive procedures.
Veterans eligible to receive dental care include the following: (1) veterans having service-connected and compensable dental disabilities or conditions; (2) former prisoners of war; (3) veterans with service-connected, noncompensable dental conditions as a result of combat wounds or service injuries; (4) veterans with nonservice-connected dental conditions determined by VA to be aggravating a service-connected medical problem; (5) veterans having service-connected conditions rated as permanently and totally disabling or rated 100 percent by reason of individual un-employability; (6) veterans participating in a vocational rehabilitation program under chapter 31 of title 38; (7) certain enrolled homeless veterans participating in specific health care programs; (8) veterans with nonservice-connected dental conditions for which treatment was begun while the veteran was an inpatient in a VA facility when it is necessary to complete such treatment on an outpatient basis; and (9) veterans requiring treatment for dental conditions clinically determined to be complicating a medical condition currently under treatment.
Veterans may receive one-time dental treatment for service-connected and noncompensable dental disabilities or conditions if the following conditions are met: the dental condition can be shown to have existed at time of discharge; the veteran served on active military duty for at least 90 days, the veteran applied to VA for dental care within 90 days of discharge or release from active duty, and the certificate of discharge does not include certification that all appropriate dental treatment had been rendered prior to discharge.
Certain veterans can participate in a VA health registry and receive free medical examinations, including laboratory and other diagnostic tests deemed necessary by an examining clinician. VA maintains veteran health databases called registries to provide special health examinations and health-related information to certain groups of veterans.
Gulf War Registry: For veterans who served in the Gulf War (Aug. 2, 1990 to a date not yet established, including Operation Iraqi Freedom).
Depleted Uranium Registries: VA maintains two registries for veterans possibly exposed to depleted uranium. The first is for veterans who served in the Gulf War, including Operation Iraqi Freedom. The second is for veterans who served elsewhere, including Bosnia and Afghanistan.
Agent Orange Registry: For veterans possibly exposed to dioxin or other toxic substances in herbicides used during the Vietnam War (between 1962 and 1975), while serving in Korea between 1968 and 1969, or as a result of testing, transporting, or spraying herbicides for military purposes.
Ionizing Radiation Registry: For veterans possibly exposed to atomic radiation during the following activities: participation in tests involving the atmospheric detonation of a nuclear device; occupation of Hiroshima or Nagasaki from Aug. 6, 1945, through July 1, 1946; internment as a prisoner of war in Japan during World War II; serving in official military duties at the Department of Energy gaseous diffusion plants at Paducah, Ky.; Portsmouth, Ohio; or the K-25 area at Oak Ridge, Tenn., for at least 250 days before Feb. 1, 1992, or in Longshot, Milrow or Cannikin underground nuclear tests at Amchitka Island, Alaska, before Jan. 1, 1974; or treatment with nasopharyngeal (NP) radium during active military service.
Veterans eligible for participation in any VA registry may receive free, comprehensive registry medical examinations, including laboratory and other diagnostic tests deemed necessary by an examining clinician. Eligible veterans do not have to be enrolled in VA health care to participate in registry examinations. Veterans wishing to participate should contact the nearest VA health care facility or visit the Internet at:
http://www.va.gov/environagents/
Certain veterans may be eligible for payment or reimbursement for travel costs to receive VA medical care. Reimbursement is paid at 28.5 cents per mile and is subject to a deductible of $7.77 for each one-way trip and an $45.62 per month maximum payment. Two exceptions to the deductible are travel for a compensation or pension examination and travel by special modes of transportation, such as an ambulance or a specially equipped van.
Beneficiary travel payments may be made to the following: (1) veterans whose service-connected disabilities are rated at 30 percent or more; (2) veterans traveling for treatment of a service-connected condition; (3) veterans who receive a VA pension; (4) veterans traveling for scheduled compensation or pension examinations; (5) veterans whose income does not exceed the maximum VA pension rate, and; (6) veterans whose medical condition requires use of a special mode of transportation, if the veteran is unable to defray the costs and travel is pre-authorized. Advance authorization is not required in a medical emergency if a delay would be hazardous to life or health.
Veterans eligible for VA medical care may apply for substance abuse treatment. Contact the nearest VA medical facility to apply.
The Home Improvements and Structural Alterations program provides funding for eligible veterans to make home improvements necessary for the continuation of treatment or for disability access to the home and essential lavatory and sanitary facilities. Home improvement benefits up to $4,100 for service-connected veterans and up to $1,200 for nonservice-connected veterans may be provided. For application information, contact the prosthetic representative at the nearest VA medical center or outpatient clinic.
VA will furnish prosthetic appliances, equipment, and devices, such as artificial limbs, orthopedic braces and shoes, wheelchairs, crutches and canes, to veterans receiving VA care for any condition. VA will provide hearing aids and eyeglasses to veterans who receive increased pension based on the need for regular aid and attendance or being permanently housebound, receive compensation for a service-connected disability or are former prisoners of war. Otherwise, hearing aids and eyeglasses will be provided only in special circumstances, and not for generally occurring hearing or vision loss. For additional information, contact the prosthetic representative at your local VA health-care facility.
Blind veterans may be eligible for services at a VA medical center or for admission to a VA blind rehabilitation center. Services are available at all VA medical facilities through the Visual Impairment Services (VIS) coordinator. In addition, blind veterans entitled to receive disability compensation may receive VA aids for the blind. Aids and services for blind veterans include:
1. A total health and benefits review by a VA Visual Impairment Services team.
2. Adjustment to blindness training.
3. Home Improvements and Structural Alterations to homes.
4. Specially adapted housing and adaptations.
5. Automobile grant.
6. Low-vision aids and training in their use.
7. Electronic and mechanical aids for the blind, including adaptive computers and computer-assisted devices such as reading machines and electronic travel aids.
8. Guide dogs, including the expense of training the veteran to use the dog and the cost of the dog's medical care.
9. Talking books, tapes and Braille literature.
Eligible visually impaired veterans (who are not blind) enrolled in the VA health care system may receive:
1. A total health and benefits review.
2. Adjustment to vision loss counseling and training.
3. Low-vision devices and training in their use.
4. Electronic and mechanical aids for the visually impaired,including adaptive computers and computer-assisted devices such as reading machines and electronic travel aids, and training in their use.
Readjustment counseling is provided at 207 community-based Vet Centers located in all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands, and is designed to help combat veterans in their readjustment to civilian life.
Eligible veterans include those who served on active duty in a combat theater during World War II, the Korean War, the Vietnam War, the Gulf War, or the campaigns in Lebanon, Grenada, Panama, Somalia, Bosnia, Kosovo, Afghanistan, Iraq and the global War on Terror. Veterans who served in the active military during the Vietnam Era, but not in the Republic of Vietnam, are also eligible, provided they have requested services at a Vet Center before January 1, 2004.
Vet Center staff provide individual, group, family, military sexual trauma, and bereavement counseling. Services include treatment for post-traumatic stress disorder (PTSD) or help with any other issue that affects functioning within the family, work, school or other areas of everyday life plus a wide range of other services to include medical referral, homeless veteran, employment, VA benefit referral, and the brokering of non-VA services.
Vet Centers also provide bereavement counseling to all family members including spouses, children, parents and siblings of service members who die while on active duty. This includes federally activated members of the National Guard and reserve components. Bereavement services may be accessed by phone at (202) 273-9116 or e-mail to vet.center@va.gov.
For additional information, contact the nearest Vet Center, listed in the federal government section of telephone directories, or visit the Internet at:
http://www.va.gov/rcs/
CHAMPVA, the Civilian Health and Medical Program of the Department of Veterans Affairs, provides reimbursement for most medical expenses - inpatient, outpatient, mental health, prescription medication, skilled nursing care, and durable medical equipment. To be eligible for CHAMPVA, an individual cannot be eligible for TRICARE (the medical program for civilian dependents provided by the Department of Defense formerly called CHAMPUS) and must be one of the following:
1. The spouse or child of a veteran who VA has rated as permanently and totally disabled for a service-connected disability.
2. The surviving spouse or child of a veteran who died from a VA-rated service-connected disability or who, at the time of death, was rated permanently and totally disabled.
3. The surviving spouse or child of a person who died in the line of duty, and not due to misconduct. In most of these cases, these family members are eligible for TRICARE, not CHAMPVA.
A surviving spouse under age 55 who remarries loses CHAMPVA eligibility on midnight of the date of remarriage. However eligibility may be re-established if the remarriage is terminated by death, divorce or annulment effective the first day of the month after the termination of the remarriage or Dec. 1, 1999, whichever date is later. A CHAMPVA eligible surviving spouse who is 55 or older does not lose eligibility upon remarriage.
Individuals who have Medicare entitlement may also have CHAMPVA eligibility secondary to Medicare. However eligibility limitations apply to those with Medicare Part A only. The following individuals must be enrolled in Medicare Part B to establish CHAMPVA eligibility: (1) under age 65 and entitled to Medicare Part A; (2) 65 or older when first eligible for CHAMPVA and entitled to Medicare Part A; (3) 65 or older prior to June 5, 2001, who are otherwise entitled to CHAMPVA and have Medicare Part A and B; (4) 65 or older on or after June 5, 2001, who are entitled to Medicare Part A.
NOTE: VA made the following announcement on March 12, 2003:
New CHAMPVA Policy to Benefit Surviving Spouses
A new law will reinstate health care benefits for some older surviving spouses covered by the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) if they apply by Feb. 4, 2004.
The surviving husband or wife who lost access to CHAMP Veterans Affairs (VA) benefits by remarrying before Feb. 4, 2003, can be reinstated into the program if they remarried after becoming age 55 and if they apply for reinstatement by Feb. 4, 2004. Similarly, a surviving spouse who remarried after becoming age 55 and lost access to TRICARE benefits may now be eligible for CHAMPVA coverage.
Under the current restoration policy that has been in effect since 1998 and will continue, surviving spouses who remarry at a younger age and lose their CHAMP Veterans Affairs (VA) benefits can have these benefits restored if their later marriage is annulled or ends due to death or divorce.
NOTE: VA made the following announcement on March 25, 2004:
CHAMPVA Policy for Some Surviving Spouses Extended
An extended deadline will allow more time for some remarried surviving spouses of veterans to seek health care insurance under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).
Under rules announced in March 2003, those survivors had until Feb. 4, 2004, to apply for reinstatement of their CHAMPVA coverage. The March 2004 announcement gives them until Dec. 16, 2004, to apply for reinstatement.
This restoration policy has been in effect since 1998, but VA officials are concerned widows or widowers may overlook this benefit if a subsequent marriage ends years later.
For more information, or to apply for CHAMPVA benefits, visit the CHAMPVA Web site (http://www.va.gov/hac/), call 1-800-733-8387 or contact the VA Health Administration Center, P.O. Box 65023, Denver, CO 80206.
Many VA medical centers provide services to CHAMPVA beneficiaries under the CHAMPVA In House Treatment Initiative (CITI) program. Contact the nearest VA medical center to determine if it is a participating facility. Beneficiaries who use a CITI facility incur no cost for the services they receive, however services are provided on a space available basis, after the needs of veterans are met. Therefore, not all services are available at all times, nor are the same services available every day. CHAMPVA beneficiaries with Medicare entitlement are not eligible to participate in the CITI program.
Some information for this topic was drawn from:
http://www.va.gov/healtheligibility/costs/
http://www.va.gov/healtheligibility/Library/pubs/CopayRates/
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