Veterans Health Administration Chief Business Office

1. Veterans Health Administration Chief Business Office VHA Health Care Benefits Eligibility Overview

2. 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)

4. 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

5. 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

6. Enrollment Priority Groups 1 - 8

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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 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

15. 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

16. Chief Business Office QUESTIONS?