Assuring Health Care Access for Service Members,
Veterans and their Caregivers: Health Care Eligibility
Vicki Rogers, John Alley, Bunner Gray
Jack C. Montgomery VAMC, Muskogee, OK
September 2014
Overview
• Eligibility for VA Health Care
• Income Thresholds
• Medical Benefits Package
• Eligibility for Beneficiary Travel
• Purchased Care Programs
•
My HealtheVet
VETERANS HEALTH ADMINISTRATION
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Definition of Veteran for VA Purposes
• Veteran is a person who:
– Served in active military
– Discharged or released under conditions other than
dishonorable
• Former or current Reservists if they served for full period
for which they were called (excludes training purposes)
• Former or current National Guard members if
activated/mobilized by Federal order
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Establishing Eligibility for VA Health Care
• Contact VA –
– Call 1-877-222-VETS (8387) or
– Internet (www.va.gov/healthbenefits)
– Visit nearest VA clinic or medical center
• VA has capability to verify Veteran’s basic eligibility information,
such as:
– Time in service
– Any service-connected disabilities as rated by Veteran Benefits
Administration (VBA)
– Combat-related eligibility and/or disability
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Establishing Caregiver Eligibility
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Included in Public Law 111-163, the “Caregiver and Veterans Omnibus
Health Services Act of 2010”
Provided for assistance to caregivers of Veterans
– Included the Family Caregiver provision for post 9-11 OEF/OIF Veterans
– Codified in statute as 38 USC 1720G
•
Varied benefits by type of caregiver
– Includes travel expenses, stipend, respite care, training and counseling
•
Apply for benefit using 10-10CG form
– Via phone at 1-877-222-VETS (8387)
– In person at VA medical centers through Caregiver Support Coordinators
– Mail completed form to VA
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For additional information see http://www.caregiver.va.gov/support_landing.asp
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Income Thresholds
• Certain Veterans are required to complete financial assessment (i.e.,
Means Test) to determine VA copayment status
• Uses Veteran’s household income, including spouse & dependents
prior year income & assets, for financial assessments
• Updated each calendar year based on income limits established by
U.S. Department of Housing and Urban Development (HUD)
• VA Means Test Threshold
• VA GMT (Geographically adjusted) Means Test Threshold
(based on geographic areas)
• http://www.va.gov/healthbenefits/cost/financial_assessment.asp
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Copayment Charges for Certain Veterans
• Veterans may be responsible for copayments for certain types of
services provided by VA
• Copayment amounts vary depending on type of service rendered &
financial assessment
• Copayments include:
– Outpatient
– Inpatient
– Medication
– Extended Care Services (e.g., community living center or
nursing homes, adult day health care, geriatric evaluations, etc.)
• No copayments & no insurance billing for treatment of service connected conditions
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What is a Service Connected Condition?
• Service Connected (SC) refers to VBA determination
(rating) that Veteran’s illness or injury was incurred in or
aggravated by military service
• VBA establishes degree of disability for each SC
condition represented by a percentage
• Veteran may have more than one adjudicated SC
condition
• If primary rated condition worsens over time, Veteran is
encouraged to have VBA complete reassessment of
rated disabilities
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What does SC % Rating Represent?
• Percentage assigned to each rated condition as far as can practically
be determined:
– Average impairment in earning capacity resulting from such
diseases
– Injuries & their residual conditions impact on civil occupations
• SC percentages determine compensation Veteran receives
• Whether Veteran is 0% SC or 100% SC for a condition, visit will be
marked as SC if rated condition is treated
• If Veteran is 100% SC for a condition, it doesn’t mean he/she is SC for
all illnesses or injuries, just rated condition
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Enrollment Priority Groups (PGs)
• Established system of patient enrollment that
designates Veterans by priority groups
• Priority groups are numbered 1-8 & group Veterans
based on their service connection or other special
eligibilities
• As a whole, priority groups have similar characteristics
regarding eligibility for care & copayment requirements
• Once enrolled in a priority group, Veterans have access
to all services included in medical benefits package
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Enrollment Priority Groups (PGs)
• PG 1: Service connected (SC) 50% or more, or unemployable
due to SC
• PG 2: SC 30% or 40%
• PG 3: SC 10 - 20%, Medal of Honor, Purple Heart, Former
POWs, discharged due to service disability, awarded special
eligibility under 38 U.S.C. 1151
• PG 4: Receiving aid & attendance, housebound or VA pension
benefits, or determined 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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Enrollment Priority Group (PG) 6
• 0% SC conditions & receiving VA compensation
• Served in:
– Combat in war after Gulf War or during period of hostility after
Nov. 11, 1998 for 5 years following discharge or release from
military
– Republic of Vietnam
– SW Asia theater of operations between Aug. 8, 1990 to Nov. 11,
1998
• Seek care for:
– Disorders relating to Ionizing Radiation
– Conditions related to participation in Project 112/SHAD
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Combat Veteran Eligibility
• Served on active duty in theater of combat after effective
date of legislation, Nov. 11, 1998
• Service in theater of operations established by:
– Proof of receipt of Global War on Terrorism Expeditionary Medal
or similar medal demonstrating service in Afghanistan, Iraq or
other combat locations
– Copy of orders or other documentation indicating service in a
combat theater
– Proof of receipt of hostile fire, imminent danger pay or combat
pay tax credit
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Combat Veteran Eligibility
• Enhanced enrollment placement into Priority Group 6 (if
not eligible for higher priority group) for 5-year period
following military service separation
• Copayment-free care for conditions determined possibly
related to theater of operations during post 5-year
discharge period
• Must apply within 5 years of discharge/release from
active duty to receive benefit
• Continuous enrollment after 5 years (even if assigned a
lower priority group)
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Enrollment Priority Groups (PGs) 7 & 8
•
PG 7:
– Income BELOW geographic means test (GMT) income
thresholds and
– Income ABOVE VA national income thresholds
– Agree to pay VA copayments
• PG 8:
– Effective June 15, 2009, Veterans with income 10% or less
ABOVE the VA national means test threshold or GMT threshold
– Note: Enrollment restrictions still apply to Veterans with income
ABOVE 10% of VA national means test threshold or GMT
threshold
– Agree to pay VA copayments
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Veterans with Other than Honorable
Discharges
• “Other than Honorable” or “Bad Conduct” discharges
generally prevent eligibility for VA health care
• Determination made by VBA if discharge is complete bar
to benefits or if limited health care eligibility exists for
service-incurred or service-aggravated disabilities
• Until determination is made, only emergency treatment
may be provided & Veteran should be counseled that
they may be responsible for payment if later determined
to be ineligible
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VA Comprehensive Medical Benefits
Package
• Benefits include:
– Preventive Care Services
– Inpatient & Outpatient Diagnostic & Treatment Services
– Prescription Services
• Prescribed by VA Physician
– Prosthetic & Rehabilitative Devices
• Includes Durable Medical Equipment
• Once enrolled, Veterans have access to complete
Medical Benefits Package
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VA Comprehensive Medical Benefits
Package
• Benefits NOT included:
– Abortion or abortion counseling
– In vitro fertilization
– Drugs, biologicals &medical devices not approved by Food and
Drug Administration unless used under approved clinical
research trials
– Gender alterations
– Hospital & outpatient care for Veteran who is either a patient or
inmate in an institution of another government agency, if that
agency has a duty to give care or services
– Membership in spas or health clubs
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Beneficiary Travel Overview
• VA authorized to provide eligible Veterans mileage
reimbursement or when medically indicated “special
mode” (ambulance, wheelchair van) for travel to and
from VA, or VA authorized health care
• Beneficiary Travel eligibility is based on SC, low income,
or special eligibility, including:
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Rating of 30 percent or more SC
Traveling for treatment of a SC condition
Receipt of VA pension
Income does not exceed maximum annual VA pension rate
Travel for scheduled compensation or pension examination
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Beneficiary Travel Overview
• Mileage reimbursement rate Congressionally
mandated in PL 111-163 at $0.415 per mile
• Reimbursements subject to deductibles with a
calendar month cap
• Deductible may be waived if it creates hardship
once certain income criteria are met for both
non-service-connected and service-connected
Veterans
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Purchased Care Programs
• VHA Chief Business Office for Purchased Care (CBO-PC)
business line supports & augments delivery of health care
benefits through enterprise program management & oversight of
Purchased Care services.
– National Non-VA Care Program: enterprise management of
purchase of health services when unavailable at VA facilities
– Contract Management: centralized management of contracts
covering areas such as commercial re-pricing agents and
recovery audits.
– State Home Program: partnership with State governments to
provide long-term care to Veterans; managed by State
governments with some financial assistance from VA
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Why VA Purchases Care
• Ensure complete continuum of quality care when VA does not have internal
resources available
• Unable to access VA health care facilities
• Demand exceeds VA health care facility capacity
• Need for diagnostic support services for VA clinicians
• Need for scarce specialty resources (e.g., obstetrics, hyperbaric, burn care,
oncology) and/or when VA resources are not available due to constraints
(e.g., staffing, space)
• Satisfying patient wait-time requirements
• Ensure cost-effectiveness for VA (whereby outside procurement vs.
maintaining &operating like services in VA facilities and/or infrequent use is
more appropriate)
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Authorities Governing the Purchased Care
Program
1. 38 USC 1703: Pays for preauthorized inpatient and outpatient
emergency, routine, and diagnostic medical care for certain Veterans
2. 38 USC 1728: Pays for emergency care provided to service connected
Veterans that was not preauthorized
3. 38 USC 1725: Pays for emergency care provided to non-service
connected Veterans enrolled in VA health care
4. 38 USC 8153: Provides the authority for a VA facility to enter into a
contract or other form of agreement with Non-VA health care entities to
secure health care services that are either unavailable or not costeffective at the VA facility.
5. REGULATION SPECIFIC TO WOMEN VETERANS
6. Women Veterans are eligible for preauthorized hospital care under the
Code of Federal Regulations (38 CFR) 17.52(a)(4)
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VA Care & Other Health Plans
•
VA is required by law to bill any health insurance carrier that provides
coverage for Veterans, including policies held by spouse
– Exception: Care for Veterans who are entitled to specified health care
benefits for service-connected conditions
•
When VA purchases health care for Veteran from community – VA cannot
share costs with any other health plan
– Exception: VA may share costs for some emergency events partially
covered by automobile liability coverage under PL 111-137
•
VA is not authorized to reimburse emergency health care costs of nonservice-connected events of Veterans who have other health plans (i.e.,
Medicare, Medicaid, etc.) or third party liability
•
Copays remain in place as if care was provided within VA facility
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Emergency Care
• When Veteran seeks emergency care at non-VA
facility, non-VA provider should contact closest
VA facility promptly (within 72 hours):
• Notify VA of Veteran treatment/admission
• Verify eligibility of Veteran for reimbursement of
claim & identify VA of jurisdiction to submit claims
• Obtain instructions for transfer of VA patient to VA
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VA Health Care Enrollment & Eligibility
Contact Information
• John Alley, Medical Administrative Specialist/Indian Health
Liaison
– Jack C. Montgomery VAMC, Muskogee
– 918-577-4261
• Lonnie Pinneke, Enrollment Coordinator
– Jack C. Montgomery VAMC, Muskogee
– 918-577-3653
• Vicki Rogers, Business Office Manager
– Jack C. Montgomery VAMC, Muskogee
– 918-577-3844
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VA Tribal/IHS Reimbursement Program
Milestones for Jack C. Montgomery
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Effective Dates of Agreements
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Creek Nation: July 1, 2012
Choctaw Nation: March 1, 2013
Pawnee IHS: March 22, 2013
Pawhuska IHS: May 16, 2013
Claremore IHS: May 16, 2013
Northeastern Tribal Health System January 31, 2014
Indian Health Care Resource Center of Tulsa April 10, 2014
Cherokee Nation: May 19, 2014
VETERANS HEALTH ADMINISTRATION
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VA Tribal/IHS Reimbursement Program
Milestones for Oklahoma City VA Medical Center
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Effective Dates of Agreements
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Wewoka Indian Health Center: May 16, 2013
Clinton Indian Health Center: May 16, 2013
Lawton Indian Health Center: May 16, 2013
Anadarko Indian Health Center: May 16, 2013
Carnegie Indian Health Center: May 16, 2013
El Reno Indian Health Center: May 16, 2013
Watonga Indian Health Center: May 16, 2013
Chickasaw Nation: November 21, 2013
Ponca Tribe of Oklahoma: November 21, 2013
Kaw Nation: June 18, 2014
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VA Tribal/IHS Reimbursement Program
•
To establish a Tribal/IHS Reimbursement Agreement or questions about the
Program
–Tribal.Agreements@va.gov
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Bunner Gray
Native American Program Coordinator
& Minority Veterans Coordinator,
Jack C. Montgomery VAMC
918-577-3977
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Registering is Quick, Easy & for YOU!
Go to www.myhealth.va.gov
Select the green “Register Today!” button
Make sure you register exactly as your name is on your VA medical
ID card
• As a VA patient you must select “VA Patient” to get the most out of
your account. It is very important that you select “VA Patient” so
that you connect your My HealtheVet account to your VA health
care information.
• Now create your User ID and Password. Make sure you write this
information down so you do not forget them.
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User ID:____________________________
Password:___________________________
Answer 1:___________________________
Answer 2:___________________________
Select and Accept the Terms & Conditions and Privacy Policy
agreements
• Click SAVE button & you have completed registering for your
MHV account
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• Upgrade Your Account to a Premium Account
• In-Person Authentication can be done the next time you visit
your local VA health care facility. Simply follow these three
steps:
– 1. Print, read & sign VA Release of Information form (10-5345aMHV)
– 2. Take signed form & your Veterans Identification Card or valid
driver's license to your local VA health facility & give to qualified
VA staff member
– 3. After VA staff verifies information, your My HealtheVet
account can be upgraded to Premium account
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• Where are functions at?
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Refill My Prescriptions
VA Appointments
VA Lab Results
Secure Messaging
• Website Features
– My HealtheVet is website created especially for Veterans. You can use
it to:
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Use Secure Messaging to communicate with your VA provider
Refill your VA prescriptions & get information about your medicines
View your VA appointments
View your lab reports & selected parts of your VA medical record
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• Refill My Prescriptions: Check box to refill each medication. If there is box ,
refill request can be made.
• VA Appointments: Click refresh button on page &it will update your
appointment data. See your appointments, no matter location, anywhere
in VA system.
• VA Labs: Your labs will be able to view 7 days after results are in VA’s
computer. This time frame gives VA provider opportunity to call you if an
explanation is needed for lab result.
• Secure Messaging: Now you can click on "New Message" button & send
message to your Primary Care Team & other areas using secure
messaging. Your Team typically includes Clerk, LPN, RN & Provider. Your
message will be triaged to appropriate member of team who can answer
your questions.
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Questions
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