Understanding VA Medical Care Enrollment and Priority Groups
Explore the basics of VA Health Care System, enrollment process, priority group categories, and the extensive services offered to veterans. Gain insights into the eligibility criteria, types of services, and medical appeals process within the VA system.
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1 Entitlement to Basic VA Medical Care VFW Basic Training September 2021 James Moss Assistant Director Healthcare Policy JMoss@vfw.org
OBJECTIVES Review of the basic VA Health Care System (enrollment and priority group assignment) Identify the types of services within the Medical Benefits Package Identify Health Registries, Newsletters and review additional benefits Know the exclusions to the Medical Benefits Package Review the medical appeals process and role of the VA Patient Advocate
VAS NATIONWIDE HEALTH CARE SYSTEM Highly qualified and dedicated health care professionals More than 1,700 nationwide treatment sites Available health and treatment services when and where veterans need them Electronic medical records modernization MyHealtheVet website (24 hours access)
ENROLLMENT Veterans must enroll into the VA Health Care System as a condition for receiving the medical benefits package by submitting an application (VA Form 10-10EZ) Establishes eligibility and Priority Group assignment Veterans can be placed in Priority Group categories 1-8 (category 1 is the highest) 38 C.F.R. 17.36
PRIORITY GROUP CATEGORIES Priority Group Enrollment Determinations S/C 50% or greater, determined to be unemployable due to S/C, Medal of Honor recipients PG 1 PG 2 S/C 30% - 40% S/C 10% - 20%, POWs, Purple Heart Medal recipients, 1151, VR&E program participants PG 3 PG 4 A&A/Housebound, Catastrophically Disabled PG 5 NSC 0% (income based), receiving VA Pension, Medicaid eligible PG 6 S/C 0% Military exposures (i.e., herbicide, Camp Lejeune), Combat Operations (5 year enhanced benefits)
PRIORITY GROUP CATEGORIES Priority Group PG 7 (must agree to pay applicable copays) PG 8 (must agree to pay applicable copays) Enrollment Determinations NSC (household income below geo-adjusted VA threshold income limits) - NSC/Non-compensable 0% with household income exceeds geo-adjusted VA income limits - Not eligible Note: Initial enrollment requires income information No annual income verification. 38 U.S.C 1710 (e), (f), and (g), 38 CFR 17.36 U.S. Public Law 114-2 (Clay Hunt Act)
COMPREHENSIVE MEDICAL BENEFITS PACKAGE" Is designed to: Promote good health Preserve your current health Restore you to better health 38 C.F.R 17.38
MEDICAL BENEFITS PACKAGE Medically necessary services include: Primary Care Health Promotion Disease Prevention Diagnosis Palliative Care Surgery Prescriptions for Medications Prosthetics Critical Care Mental Health Care Women s Health Care Orthopedics Radiology Physical Therapy Rehabilitation Emergency Care Transplants Dental Care * Preventive Care Inpatient Care Ancillary Specialty Care Pharmacy Home Based Primary Care* Geriatric and Extended Care* Prosthetics and Sensory Aids https://www.va.gov/GERIATRICS/Guide/LongTermCare/index.asp
FAMILY CAREGIVER PROGRAM Provides support/assistance to eligible caregivers of qualifying veterans VA Mission Act of 2018 expands the eligibility and benefit of the Comprehensive Caregiver Program for caregivers of all eras. As of October 1, 2020, VA implemented the new Program of Comprehensive Assistance for Family Caregivers (PCAFC) which includes a stipend and other benefits for caregivers. www.caregiver.va.gov 38 C.F.R 71.10 - 71.50
HEALTH REGISTRIES Health Registries related to environmental and occupational exposure during military service Exposure Categories Environmental/Toxic Hazards (burn pit smoke, dust ) Chemicals (Agent Orange, contaminated water ) Occupational Hazards (Asbestos, lead ) Radiation (nuclear weapons, X-rays ) Warfare Agents (Chemical, biological weapons)
NEWSLETTERS, PUBLICATIONS, FACT SHEETS Agent Orange Review Gulf War Review Operation Iraqi/Enduring Freedom Review Ionizing Radiation Review https://www.publichealth.va.gov/exposures/meyh/publications /index.asp
CAMP LEJEUNE WATER CONTAMINATION BENEFITS Veteran and/or family members must have resided at Camp Lejeune for 30 days or more between August 1, 1953 to December 31, 1987 to receive care under the new law (no requirement for consecutive days). The VA recognizes a total of 15 qualifying health conditions Eight conditions eligible for presumptive service connection for Veterans 38 CFR 17.129 and 38 CFR 17.400 (Health Care) 38 CFR 3.309(f) (Service Connection)
COMMUNITY CARE PROGRAM Based on access standards for average Drive time: 30 minute drive time for primary care, mental health and non-institutional care services Drive time: 60 minute drive time for specialty care Appointment wait time: 20 days for primary care, mental health and non-institutional care services Appointment wait time: 28 days for specialty care 38 C.F.R 17.4000 17.4040
URGENT CARE PROGRAM Based on Veteran s assigned Priority Group and required copayment Priority Group 1-5 $30 copay charged for fourth visit and all subsequent visits in calendar year. Priority Group 6 Visits related to specialty authority or exposure, then $30 copay for all unrelated conditions and subsequent visits in calendar year. Priority Groups 7-8 $30 copay per visit 38 C.F.R 17.105, 17.108 and 17.4600
EMERGENCY MEDICAL CARE PROGRAM (EMCP) The EMCP has 2 important parts that must be understood and considered when related to emergency care Medical emergency for service connected verses non-service connected conditions Emergency Transportation (Ambulance) https://www.va.gov/COMMUNITYCARE/docs/pubfiles/factsheets/F actSheet_20-02.pdf (Emergency Medical Care) https://www.va.gov/COMMUNITYCARE/docs/pubfiles/factsheets/F actSheet_20-05.pdf (Emergency Transportation)
EXCLUSIONS OF THE VA MEDICAL BENEFITS PACKAGE Abortions/Birth Termination/Counseling Non-FDA approved drugs/devices Cosmetic Surgery Health Club/Spa Membership Veterans housed in institutions (incarcerated in state or government facility), the legal obligation to provide services and care is the responsibility of the agency with a veteran inmate. 38 C.F.R 17.38 (c)
MEDICAL APPEALS Initiated at the Agency of Original Jurisdiction (AOJ) *If an appeal that is benefit related is not resolved at the AOJ level to the appellant s satisfaction, the appellant may formally continue appeal to the Board of Veterans Appeal (BVA) for a BVA de novo review and issuance of a final decision. 38 CFR 19.25 and 38 CFR 19.26
PATIENT ADVOCATE PROGRAM Patient Advocates VA employee specifically designated to manage feedback received from Veterans and their family members. *Complaints, suggestions and/or concerns should always be addressed with the care team first, and if the disagreement or concern continues, speak with the individual s supervisor or Chief of Service. If still unresolved, contact the Patient Advocate and request assistance filing an appeal for a review of the concern.
LIMITED BENEFITS Ambulance Services Eyeglasses Hearing Aids Home Health Care Dental Care Certain Counseling Services
VETERANS CARE OUTSIDE THE UNITED STATES VA s Foreign Medical Program (FMP) furnishes care to veterans residing outside the US if: Treatment is for a service-connected disability, or a disability determined as aggravating the service-connected disability. The veteran is a participant in a Chapter 31 rehabilitation program with specific determining eligibility. 38 CFR 17.35
WHO TO CONTACT FOR HELP If you are working with a veteran who needs assistance with their healthcare needs, first try to resolve the issue using local resources such as the patient advocate or Chief of Service. If unsuccessful, the VFW Healthcare Team may be able to help. James Moss Assistant Director, Veterans Health Policy (202) 608-8371 Jmoss@vfw.org Meggan Thomas Veterans Casework Consultant (202) 608-8364 Mthomas@vfw.org
REFERENCES www.caregiver.va.gov www.publichealth.va.gov https://www.va.gov/find-locations/ 38 U.S.C. 1151 38 U.S.C. 1710 (e), (f), and (g) 38 U.S.C. 1712 38 U.S.C. 1722 (a) U.S. Public Law 114-2 (Clay Hunt Act)
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