Veterans Health Administration Chief Business Office

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Veterans Health Administration Chief Business
Office

• VHA Health Care Benefits
• Eligibility Overview

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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

3
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)

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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

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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

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Enrollment Priority Groups 1 - 8
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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

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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

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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

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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

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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

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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

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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

14
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 AA rate applicable for
  veterans determined to be in need of AA 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

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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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Chief Business Office

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