2011 2011 Service OfficeService Office

SeminarSeminar

Service Office WebsiteService Office Website

www.vfwilserviceoffice.comwww.vfwilserviceoffice.com

National Policy ChangesNational Policy Changes

Post SO RecordsPost SO RecordsPost SO ActionsPost SO Actions

REVIEWREVIEWVA Claim BacklogVA Claim BacklogPTSD ChangesPTSD ChangesAgent Orange ChangesAgent Orange ChangesOIF / OEF ChangesOIF / OEF ChangesCamp Lejeune MarinesCamp Lejeune Marines

VA Claim BacklogVA Claim Backlog 12-26-0912-26-09 481,751481,751 12-27-1012-27-10 704,599704,599 6-27-116-27-11 832,674832,674 7-25-117-25-11 839,301839,301 8-29-118-29-11 846,079846,079 9-26-119-26-11 849,709849,709

PTSD ChangesPTSD Changes

Changes in regulation relaxed Changes in regulation relaxed requirement for veteran to requirement for veteran to provide evidence of a provide evidence of a “verifiable” stressor – “verifiable” stressor –

effective July 12, 2010effective July 12, 2010

AO ChangesAO Changes

New PresumptivesNew PresumptivesKorean ServiceKorean ServiceThailand ServiceThailand ServiceBlue Water SailorsBlue Water Sailors

OIF / OEF ChangesOIF / OEF Changes

New Presumptives added to list of New Presumptives added to list of disabilities under 38 CFR 3.317disabilities under 38 CFR 3.317

Camp Lejeune MarinesCamp Lejeune Marines

https://clnr.hqi.usmc.mil/clwater/https://clnr.hqi.usmc.mil/clwater/

index.aspxindex.aspxRegister with the Navy research Register with the Navy research

program if on base 1957-1987program if on base 1957-1987File a claim with the VAFile a claim with the VA

National Research CouncilNational Research Council

The National Academy of The National Academy of Sciences’ National Research Sciences’ National Research Council published its Council published its Contaminated Water Supplies at Contaminated Water Supplies at Camp Lejeune, Assessing Camp Lejeune, Assessing Potential Health Effects, in 2009. Potential Health Effects, in 2009.

This report included a review of This report included a review of studies addressing exposure to studies addressing exposure to Trichloroethylene (TCE), and Trichloroethylene (TCE), and Tetrachloroethylene or Tetrachloroethylene or Perchloroethylene (PCE), as well as Perchloroethylene (PCE), as well as a mixture of the two, and a a mixture of the two, and a discussion of disease manifestations discussion of disease manifestations potentially associated with such potentially associated with such exposure. exposure.

Fourteen disease conditions were Fourteen disease conditions were identified as having identified as having

limited/suggestive evidence of an limited/suggestive evidence of an association with TCE, PCE, or a association with TCE, PCE, or a solvent mixture exposure. They solvent mixture exposure. They include: include: esophageal canceresophageal cancerlung cancer lung cancer

breast cancer breast cancer bladder cancer bladder cancer kidney cancer kidney cancer adult leukemia adult leukemia multiple myeloma multiple myeloma myleodisplasic syndromes myleodisplasic syndromes

renal toxicity renal toxicity hepatic steatosis hepatic steatosis female infertility female infertility miscarriage, with exposure miscarriage, with exposure

during pregnancyduring pregnancyscleroderma scleroderma neurobehavioral effectsneurobehavioral effects

Public Law 111-275Public Law 111-275Changes in VA Program Benefits:Burial & Plot AllowancesSMC changes for amputation levelsSMC changes for TBIEarlier date for survivors of POWExtends Eligibility for Auto AllowanceIncreases Auto Allowance

Veteran Population 9-30-10Veteran Population 9-30-10 National TotalNational Total 22,658,14522,658,145 Illinois TotalIllinois Total 782,747 782,747 Illinois MaleIllinois Male 725,626 725,626 IL Gulf War EraIL Gulf War Era 190,079 190,079 IL Vietnam War EraIL Vietnam War Era 251,301 251,301 IL Korean War Era IL Korean War Era 84,132 84,132 IL WW II EraIL WW II Era 72,44172,441

VA Health Care BenefitsVA Health Care Benefits

VA FacilitiesVA Facilities

VISNs (Regional centers for VISNs (Regional centers for administrative control)administrative control)

VA Medical Centers (5 in Illinois)VA Medical Centers (5 in Illinois)

Outpatient ClinicsOutpatient Clinics

Vet CentersVet Centers

Eligibility ReformEligibility Reform

19851985

19971997

VA Eligibility ReformVA Eligibility Reform 1997 - Major improvements in VA Health Care 1997 - Major improvements in VA Health Care

DeliveryDelivery

a. Required an enrollment system a. Required an enrollment system for most veteransfor most veterans

b. Established a b. Established a Comprehensive Uniform Comprehensive Uniform Benefits PackageBenefits Package for veterans for veterans

c. Simplified application c. Simplified application

d. Catastrophic Disability Reformd. Catastrophic Disability Reform The most significant piece of legislation to be The most significant piece of legislation to be

passed in the history of VA health carepassed in the history of VA health care

VA Eligibility ReformVA Eligibility Reform Improvements as a result of Eligibility Improvements as a result of Eligibility

ReformReform

–Veteran Patient “Uniform Benefit Veteran Patient “Uniform Benefit Package”Package”

– Same level of VA medical benefits Same level of VA medical benefits regardless of geographic locationregardless of geographic location

–Assures comprehensive, portable Assures comprehensive, portable health benefitshealth benefits

Medical Benefits PackageMedical Benefits Package

Preventive Care ServicesPreventive Care Services

ImmunizationsImmunizations

Physical ExaminationsPhysical Examinations

Health Care AssessmentsHealth Care Assessments

Screening TestsScreening Tests

Health Education ProgramsHealth Education Programs

Ambulatory Diagnostic & Treatment Ambulatory Diagnostic & Treatment ServicesServices

ER outpatient care in VA facilitiesER outpatient care in VA facilities

Medical careMedical care

Surgical careSurgical care

Chiropractic careChiropractic care

Mental Health careMental Health care

Bereavement CounselingBereavement Counseling

Substance Abuse CounselingSubstance Abuse Counseling

Hospital Diagnostic & TreatmentHospital Diagnostic & Treatment

ER inpatient care in VA facilitiesER inpatient care in VA facilities

Medical careMedical care

Surgical careSurgical care

Mental Health CareMental Health Care

Substance Abuse CounselingSubstance Abuse Counseling

Medications & SuppliesMedications & Supplies

Prescription medicationsPrescription medications

Over the counter medicationsOver the counter medications

Medical & surgical suppliesMedical & surgical supplies

(Generally they must be prescribed (Generally they must be prescribed by a VA provider and be available by a VA provider and be available under VA’s national formulary)under VA’s national formulary)

Non VA PrescriptionsNon VA PrescriptionsGenerally only veterans with Generally only veterans with special eligibility, such as veterans special eligibility, such as veterans receiving NSC A&A or HB receiving NSC A&A or HB benefits, or who are approved by a benefits, or who are approved by a VA health care facility for Fee VA health care facility for Fee Basis are eligible to obtain Basis are eligible to obtain medications at VA expense.medications at VA expense.

If you see a non-VA provider and If you see a non-VA provider and want to have prescriptions filled want to have prescriptions filled by VA, all of the following by VA, all of the following criteria must be met: criteria must be met: You must be enrolled in VA You must be enrolled in VA health care. health care.

You need to have an assigned You need to have an assigned Primary Care Provider. Primary Care Provider.

It is your responsibility to It is your responsibility to provide your VA health care provide your VA health care provider with your medical provider with your medical records from your non-VA records from your non-VA provider. provider.

Your VA health care provider Your VA health care provider has to agree with the medication has to agree with the medication prescribed by your non-VA prescribed by your non-VA provider. provider.

(Your VA health care provider is (Your VA health care provider is under no obligation to prescribe under no obligation to prescribe a medication recommended by a a medication recommended by a non-VA provider. )non-VA provider. )

VA Eligibility ReformVA Eligibility ReformVeterans rated 50% or more SC Veterans rated 50% or more SC

and those receiving care for their and those receiving care for their SC conditions do not need to SC conditions do not need to formally enroll formally enroll

All other veterans are required All other veterans are required to enrollto enroll

VA Eligibility ReformVA Eligibility Reform

Based on eligibility and income Based on eligibility and income information, the veteran is information, the veteran is placed into one of eight placed into one of eight enrollment priority groupsenrollment priority groups

VA Eligibility ReformVA Eligibility Reform

1) Veterans rated 50% or more SC1) Veterans rated 50% or more SC

2) Veterans rated 30% or 40% SC2) Veterans rated 30% or 40% SC

3) 3) Veterans rated 10% or 20% SC;Veterans rated 10% or 20% SC;Former POWs; Former POWs; Recipients of Purple Heart;Recipients of Purple Heart;Recipients of the Medal of Honor;Recipients of the Medal of Honor;

3) Continued:3) Continued:Veterans discharged from Active Veterans discharged from Active Duty due to disability incurred or Duty due to disability incurred or aggravated inline of duty;aggravated inline of duty;Veterans receiving compensation Veterans receiving compensation under 38 USC 1151; under 38 USC 1151;

4) 4) Veterans receiving NSC A&A or Veterans receiving NSC A&A or

NSC Housebound benefits; NSC Housebound benefits; or those determined to be or those determined to be

“Catastrophically Disabled”“Catastrophically Disabled”

“…“…permanent severely disabling permanent severely disabling injury, disorder or disease that injury, disorder or disease that compromises the ability to carry compromises the ability to carry out the activities of daily living out the activities of daily living that requires constant supervision that requires constant supervision to avoid physical harm to self or to avoid physical harm to self or others.”others.”

5) 5) 0% noncompensable SC 0% noncompensable SC Veterans whose income and net Veterans whose income and net worth are below threshold; worth are below threshold; NSC Veterans below income and NSC Veterans below income and net worth threshold;net worth threshold;Veterans receiving NSC Pension;Veterans receiving NSC Pension;Veterans eligible for MedicaidVeterans eligible for Medicaid

6) 6) Veterans Veterans solely seeking care solely seeking care for for a disorder associated with a disorder associated with exposure to toxic substance or exposure to toxic substance or radiation; radiation;

6) Continued:6) Continued:for a disorder associated with for a disorder associated with service in the Southwest Asia service in the Southwest Asia theater of operations during the theater of operations during the Gulf War; Gulf War;

6) Continued:6) Continued: for any illness associated with for any illness associated with

service in combat in a war after service in combat in a war after the Gulf War or during a period the Gulf War or during a period of hostility after November 11, of hostility after November 11, 1998;1998;

0% SC veterans receiving 0% SC veterans receiving compensationcompensation

7) Veterans whose income is above 7) Veterans whose income is above the VA Means Test threshold the VA Means Test threshold but below the Geographic Means but below the Geographic Means Test threshold who agree to Test threshold who agree to copayments copayments

(inpatient copays reduced by (inpatient copays reduced by 80%)80%)

8) Noncompensable 0% SC Veterans;8) Noncompensable 0% SC Veterans;

Veterans with gross income above the Veterans with gross income above the geographically adjusted income geographically adjusted income threshold for their resident location by threshold for their resident location by 10% or less and who agree to pay 10% or less and who agree to pay copays.copays.

VA Eligibility ReformVA Eligibility Reform Enrollment: VA form 10-10EZEnrollment: VA form 10-10EZ The information is input electronically The information is input electronically

into the local Vista system & transmitted into the local Vista system & transmitted to the EC for eligibility verificationto the EC for eligibility verification

The information is verified against VBA The information is verified against VBA C&P master files, with corrections C&P master files, with corrections returned to the ECreturned to the EC

The EC transmits the verified data to all The EC transmits the verified data to all facilities having the veteran in their data facilities having the veteran in their data base the following nightbase the following night

VA National Income Thresholds:VA National Income Thresholds:

Groups thru 7Groups thru 7

Household Income less than:Household Income less than:

Free Presrip:Free Presrip: Health Care:Health Care:

VetVet $11,830$11,830 $29,402$29,402

Vet+1Vet+1 $15,493$15,493 $35,284$35,284

Vet+2Vet+2 $17,513$17,513 $37,304$37,304

VA National Income Thresholds:VA National Income Thresholds:

Group 8Group 8

Household Income less than:Household Income less than:

Health Care:Health Care:

VetVet $32,342$32,342

Vet+1Vet+1 $38,812$38,812

Vet+2Vet+2 $41,034$41,034

VA Eligibility ReformVA Eligibility Reform Geographic Means TestGeographic Means Test

–Enrollment Priority Group 7 for inpatient Enrollment Priority Group 7 for inpatient care will be those veterans with incomes care will be those veterans with incomes above the VA MT threshold but below above the VA MT threshold but below the HUD index for their areathe HUD index for their area

– Inpatient co-pay will be 20% of regular Inpatient co-pay will be 20% of regular co-payco-pay

–Outpatient co-pay unchangedOutpatient co-pay unchanged

VA Eligibility ReformVA Eligibility Reform Geographic MT cont:Geographic MT cont:

–Enrollment Priority Group 8 for Enrollment Priority Group 8 for inpatient care will be those inpatient care will be those veterans with incomes above the veterans with incomes above the VA MT and HUD thresholdsVA MT and HUD thresholds

–Full co-pay for both inpatient and Full co-pay for both inpatient and outpatientoutpatient

Geographical Means TestGeographical Means Test

Refer to State chart by CountyRefer to State chart by County

HandoutHandout

VA Eligibility ReformVA Eligibility Reform

Co-payments for health careCo-payments for health care 0$ Preventative Medicine 0$ Preventative Medicine 15$ Primary Care Visit15$ Primary Care Visit 50$ Specialty Care Visit50$ Specialty Care Visit 8$ Groups 2-6 each 30 day supply8$ Groups 2-6 each 30 day supply 9$ Groups 7-8 each 30 day supply9$ Groups 7-8 each 30 day supply

VA Health Care Enrollment VA Health Care Enrollment Decisions AnnuallyDecisions Annually

It’s important to remember that VA health care It’s important to remember that VA health care depends primarily on congressional funding, depends primarily on congressional funding, which may affect VA’s ability to care for all which may affect VA’s ability to care for all priority groups. Subsequent appropriations priority groups. Subsequent appropriations which do not meet the needs to treat all priority which do not meet the needs to treat all priority groups may require dis-enrollment of some groups may require dis-enrollment of some priority groups, therefore encourage veterans to priority groups, therefore encourage veterans to keep any health care insurance they may have.keep any health care insurance they may have.

Enrollment ReviewEnrollment Review

Annually the VA will require Annually the VA will require verification of enrollment via verification of enrollment via VA Form 10-10EZRVA Form 10-10EZR

National EnrollmentNational Enrollment

Enrollment is National, Enrollment is National,

HOWEVER…HOWEVER…

Billing Health Insurance Billing Health Insurance CompaniesCompanies

When applying for medical care, all When applying for medical care, all veterans must provide information veterans must provide information pertaining to your health insurance pertaining to your health insurance coverage, including your spouse’s coverage, including your spouse’s insurance policy. A veteran’s eligibility insurance policy. A veteran’s eligibility for VA health care benefits is not for VA health care benefits is not affected by health insurance coverage.affected by health insurance coverage.

Billing Health Insurance Billing Health Insurance CompaniesCompanies

The VA will bill private insurance The VA will bill private insurance carriers for all non service connected carriers for all non service connected treatment regardless of your priority treatment regardless of your priority group. group.

VA is not allowed to bill Medicare or VA is not allowed to bill Medicare or Medicaid.Medicaid.

If the full cost of your care is not If the full cost of your care is not fully recovered, VA will not collect fully recovered, VA will not collect nor otherwise hold you responsible nor otherwise hold you responsible for the charges not covered by the for the charges not covered by the insurance company. insurance company.

VA will not reimburse or credit VA will not reimburse or credit co-pays based on collected co-pays based on collected insurance payments.insurance payments.

Special GroupsSpecial Groups

Former POWsFormer POWs Purple Heart RecipientsPurple Heart Recipients Incarcerated VeteransIncarcerated Veterans Homeless VeteransHomeless Veterans Woman VeteransWoman Veterans

Travel PayTravel Pay Veteran SC 30% or more, orVeteran SC 30% or more, or Treatment of SC disability, orTreatment of SC disability, or Receiving NSC Pension, orReceiving NSC Pension, or Scheduled C&P examination, orScheduled C&P examination, or Income less than the max VA Income less than the max VA

Pension ratePension rate

Travel PayTravel Pay

Rate: $0.41.5 per mileRate: $0.41.5 per mile Scheduled appointments – round tripScheduled appointments – round trip Unscheduled appointments may be Unscheduled appointments may be

limited to return mileage onlylimited to return mileage only

Travel PayTravel Pay Deductible: $3.00 each wayDeductible: $3.00 each way Deductible: Monthly cap of $18Deductible: Monthly cap of $18 After monthly cap remaining travel After monthly cap remaining travel

pay THAT month will be paid pay THAT month will be paid without further deductible without further deductible

Waiver of Travel Waiver of Travel DeductibleDeductible

In receipt of NSC PensionIn receipt of NSC Pension NSC veteran with income less than NSC veteran with income less than

pension ratepension rate SC veteran with income less than SC veteran with income less than

national means test thresholdnational means test threshold Veteran traveling for C&P examVeteran traveling for C&P exam

Travel PayTravel Pay

EXAMPLESEXAMPLES

HandoutHandout

Fee BasisFee Basis

When the VA cannot provide When the VA cannot provide treatment for a service connected treatment for a service connected disability or for a condition under disability or for a condition under VA care they MAY authorize VA care they MAY authorize community based fee basis community based fee basis treatment at VA expense.treatment at VA expense.

Fee BasisFee BasisTreatment must have:Treatment must have:

Prior authorization in writing from the Prior authorization in writing from the Medical Center of jurisdiction, Medical Center of jurisdiction, – name the provider, name the provider,

– the treatment, the treatment,

– the duration and the duration and

– the authorized fee.the authorized fee.

It will be the Medical Center’s It will be the Medical Center’s option to authorize community option to authorize community Fee Basis care or to require Fee Basis care or to require treatment by another VA treatment by another VA facility capable of providing the facility capable of providing the indicated treatment or surgery.indicated treatment or surgery.

Long Term CareLong Term Care

• VA Inpatient programs• VA Outpatient programs• State Veteran’s Homes

Long Term CareLong Term Care

• Veteran SC 70% or more• Veteran SC 60% and is P&T• Veteran requires nursing care due

to SC disability• Veterans who meet income & asset

criteria• Others on case by case basis

Nursing Home CareNursing Home Care

• VA Nursing Care Units• Contract Community Nursing

Homes• State Veterans Home

VA Nursing Care UnitVA Nursing Care Unit

Vary between VA facilities!•Long term•Short term

Transitional - stabilizationRehabilitation

Contract Nursing CareContract Nursing Care

Availability not uniform!•Placement by VA Social Worker.•Requires prior VA inpatient status.

State Veterans HomesState Veterans Homes• VA subsidizes cost of care by

contract.• Cost shared by veteran unless

placed by VA on contract.• Admission policies and resident

fees are controlled by the state.

Non-Institutional CareNon-Institutional CarePrograms VaryPrograms Vary

• Home based primary care• Contract home health care• Adult Day Health Care• Homemaker & Home Health Aide• Community Residential Care• Respite Care• Domiciliary Care

Hearing & Vision AidsHearing & Vision Aids

Dental CareDental CareFull EligibilityFull Eligibility

•Veteran has a SC compensable Veteran has a SC compensable DENTAL disabilityDENTAL disability•Veteran is a former POWVeteran is a former POW•Veteran is 100% SC rated or SC Veteran is 100% SC rated or SC with IUwith IU

Dental CareDental Care

One time dental care following One time dental care following AD of 90 days if applied for AD of 90 days if applied for within 180 days of discharge within 180 days of discharge from ADfrom AD

Dental CareDental Care

Needed care for a SC Needed care for a SC noncompensable dental condition noncompensable dental condition resulting from combat wounds or resulting from combat wounds or service trauma.service trauma.

Dental CareDental Care

Dental care to treat the oral Dental care to treat the oral condition that has a direct and condition that has a direct and material detrimental effect to a material detrimental effect to a service connected medical service connected medical conditioncondition

Dental CareDental Care

Dental care required to make Dental care required to make possible, to continue or prevent possible, to continue or prevent interruption of a Vocational interruption of a Vocational Rehabilitation program or to Rehabilitation program or to secure employment during the secure employment during the period of employment assistance.period of employment assistance.

Dental CareDental Care

Dental care to treat the oral Dental care to treat the oral condition that is determined to condition that is determined to complicate a medical condition complicate a medical condition currently under treatment.currently under treatment.

Dental CareDental CareTo a Homeless enrolled veteran To a Homeless enrolled veteran under VHA Directive 2007-039 under VHA Directive 2007-039 a one time course of dental care a one time course of dental care determined medically determined medically necessary to relieve pain or to necessary to relieve pain or to assist in gaining employment.assist in gaining employment.

Dental CareDental Care

To a veteran receiving hospital, To a veteran receiving hospital, nursing home or domiciliary nursing home or domiciliary care determined to be essential care determined to be essential to the management of the to the management of the medical condition under active medical condition under active treatment.treatment.

My Healthe VetMy Healthe VetVA ‘s online Personal Health Record VA ‘s online Personal Health Record requires veteran to register online at:requires veteran to register online at:

www.myhealth.va.gov

Future enhancements to the program Future enhancements to the program will require personal authentication at will require personal authentication at a local VA medical facility.a local VA medical facility.

Misc VHA BenefitsMisc VHA BenefitsAutomobile AllowanceAutomobile AllowanceClothing AllowanceClothing AllowanceHome Improvement & Home Improvement &

Structural Alterations (HISA) Structural Alterations (HISA) GrantGrant

Automobile AllowanceAutomobile Allowance One lifetime automobile purchase grantOne lifetime automobile purchase grant

($11,000 increased to $18,900 10-1-11)($11,000 increased to $18,900 10-1-11) Adaptive equipment allowance every Adaptive equipment allowance every

four yearsfour years Requires Rating Board decision of loss Requires Rating Board decision of loss

of use of hand or foot or significant of use of hand or foot or significant vision impairment of both eyesvision impairment of both eyes

Clothing AllowanceClothing Allowance Annual allowance each August - $716Annual allowance each August - $716 Veteran with a prescription for a Veteran with a prescription for a

prosthetic or orthopedic appliance prosthetic or orthopedic appliance due to SC disabilitydue to SC disability

Veteran with a prescription for Veteran with a prescription for topical medication for SC skin topical medication for SC skin conditioncondition

HISA GrantHISA Grant Veteran with disability to provide Veteran with disability to provide

access to the home or to essential access to the home or to essential lavatory/sanitary facilitieslavatory/sanitary facilities

$6,800 for a SC condition$6,800 for a SC condition $6,800 for a NSC condition if $6,800 for a NSC condition if

veteran is SC 50% of moreveteran is SC 50% of more $2,000 for all other veterans$2,000 for all other veterans

Millennium Health Care Millennium Health Care ActAct

Background of the Millennium Background of the Millennium Act Emergency Care BenefitAct Emergency Care Benefit

Public Law 106-117, the “Veterans’ Millennium Public Law 106-117, the “Veterans’ Millennium Health Care and Benefits Act” authorizes the Health Care and Benefits Act” authorizes the Department of Veterans Affairs (VA), to Department of Veterans Affairs (VA), to reimburse claimants for emergent non VA reimburse claimants for emergent non VA treatment of non service-connected conditions. treatment of non service-connected conditions. Under this authority, a veteran must meet Under this authority, a veteran must meet certain conditions to be eligible for direct certain conditions to be eligible for direct payment of or reimbursement of payment for payment of or reimbursement of payment for the emergency medical services.the emergency medical services.

Background of the Millennium Background of the Millennium Act Emergency Care BenefitAct Emergency Care Benefit

This act was established as a safety net for This act was established as a safety net for veterans who have no other means of paying a veterans who have no other means of paying a non-VA facility emergency bill.non-VA facility emergency bill.

VA will pay for all medical care necessary to VA will pay for all medical care necessary to stabilize a emergent condition. Once the stabilize a emergent condition. Once the veteran can be stabilized and safely veteran can be stabilized and safely transported, VA will arrange for treatment at transported, VA will arrange for treatment at an appropriate VA facility, if necessary.an appropriate VA facility, if necessary.

Eligibility for BenefitEligibility for BenefitThis authority establishes VA as a This authority establishes VA as a payer of last resort. payer of last resort.

Therefore, as a payer of last resort, Therefore, as a payer of last resort, VA can only authorize payment or VA can only authorize payment or reimbursement under the reimbursement under the following conditions:following conditions:

Veteran is enrolled in the VA Veteran is enrolled in the VA Health Care System.Health Care System.

Veteran must have been Veteran must have been provided care by a VA clinician provided care by a VA clinician or provider within the last 24 or provider within the last 24 months.months.

Veteran was provided care in a Veteran was provided care in a hospital emergency hospital emergency department or similar facility department or similar facility providing emergency care.providing emergency care.

Veteran has no other form of Veteran has no other form of health insurance.health insurance.

VA Medical Center of VA Medical Center of jurisdiction was timely jurisdiction was timely informed (48 hours).informed (48 hours).

Veteran agrees to transfer to Veteran agrees to transfer to VA facility upon medical VA facility upon medical stabilization.stabilization.

Veteran has no coverage underVeteran has no coverage underMedicare, Medicaid, or a stateMedicare, Medicaid, or a stateprogram.program.Veteran has no coverage underVeteran has no coverage underany other VA programs.any other VA programs.

Department of Veterans Affairs Department of Veterans Affairs or other Federal facilities are or other Federal facilities are not feasibly available at time of not feasibly available at time of emergency event.emergency event.

A reasonable lay person would A reasonable lay person would judge that any delay in medical judge that any delay in medical attention would endanger your attention would endanger your health or life.health or life.

The veteran is financially liable The veteran is financially liable to the provider of the to the provider of the emergency treatment for that emergency treatment for that treatmenttreatment

The veteran has no other The veteran has no other contractual or legal recourse contractual or legal recourse against a third party.against a third party.

The new rule does not affectThe new rule does not affect

veterans who are already coveredveterans who are already covered

for non-VA emergency services,for non-VA emergency services,

for example, veterans receivingfor example, veterans receiving

fee basis care for a servicefee basis care for a service

connected disability.connected disability.

Should the VA determine the Should the VA determine the emergency care meets the criteria of emergency care meets the criteria of the Mill Bill, transportation costs the Mill Bill, transportation costs from the home to emergency facility from the home to emergency facility may be paid. Should transportation may be paid. Should transportation from the emergency facility to a VA from the emergency facility to a VA approved facility be required, the approved facility be required, the veteran must meet beneficiary travel veteran must meet beneficiary travel regulations.regulations.

Where Do You SendWhere Do You SendThe Claim? The Claim?

To initiate a claim for emergency To initiate a claim for emergency treatment a claimant must submit VA treatment a claimant must submit VA Form 10-583 to the Fee Basis unit of Form 10-583 to the Fee Basis unit of the VA medical facility of jurisdiction the VA medical facility of jurisdiction (defined as the nearest VA medical (defined as the nearest VA medical facility to where the emergency facility to where the emergency service was provided).service was provided).

Regulatory Time Frames for Regulatory Time Frames for Submitting ClaimsSubmitting Claims

To receive payment or reimbursement for To receive payment or reimbursement for emergency services, a claimant must file a emergency services, a claimant must file a claim within 90 days after the latest of the claim within 90 days after the latest of the following:following:

(1) The date that the veteran was discharged from the facility that furnished the emergency treatment;

(2) The date of death, but only if the death (2) The date of death, but only if the death occurred during transportation to a facility occurred during transportation to a facility for emergency treatment or if the death for emergency treatment or if the death occurred during the stay in the facility that occurred during the stay in the facility that included the provision of the emergency included the provision of the emergency treatment; ortreatment; or

(3) The date the veteran finally exhausted, (3) The date the veteran finally exhausted, without success, action to obtain payment or without success, action to obtain payment or reimbursement for the treatment from a reimbursement for the treatment from a third partythird party

Delegation of AuthorityDelegation of Authority

The Chief of the Health Administration The Chief of the Health Administration Service or an equivalent official at the Service or an equivalent official at the VA medical facility of jurisdiction will VA medical facility of jurisdiction will make all determinations regarding make all determinations regarding payment or reimbursement under 38 payment or reimbursement under 38 U.S.C. 1725U.S.C. 1725

Prudent Lay PersonPrudent Lay Person The Fee Service Review Physician or The Fee Service Review Physician or

equivalent officer at the VA medical equivalent officer at the VA medical facility of jurisdiction will make facility of jurisdiction will make determinations regarding the “prudent determinations regarding the “prudent layperson”, feasibility of VA facilities layperson”, feasibility of VA facilities and point of stabilization criteria.and point of stabilization criteria.

An MD concurrence is necessary for all An MD concurrence is necessary for all denials.denials.

ReimbursementReimbursement The non-VA facility will file for The non-VA facility will file for

reimbursement from the VA. Eligible reimbursement from the VA. Eligible veterans will not be required to pay any veterans will not be required to pay any fees should the non-VA facility accept fees should the non-VA facility accept VA payment for the care. If the non-VA payment for the care. If the non-VA facility bills the veteran directly, VA facility bills the veteran directly, the veteran should contact his local VA the veteran should contact his local VA health care facility and a representative health care facility and a representative will assist in resolving the issue.will assist in resolving the issue.

VA will pay 70 percent of the VA will pay 70 percent of the Medicare fee schedule, or if no Medicare fee schedule, or if no schedule, 70% what the VA would schedule, 70% what the VA would normally pay under guidelines which normally pay under guidelines which are in compliance with 38 CFR, or VA are in compliance with 38 CFR, or VA regulations.regulations.

Other Significant MillenniumOther Significant MillenniumBill ChangesBill Changes

• Required VHA to establish chiropractic care policy provided to veterans, which is now in effect

• Restored eligibility for CHAMPVA surviving spouses who remarry (and lose eligibility) and then later terminate those marriages

Caregiver SupportCaregiver SupportEligible Veterans:Eligible Veterans:Sustained a serious injury on or Sustained a serious injury on or after 9-11-01after 9-11-01In need of personal care services die In need of personal care services die to inability to perform one or more to inability to perform one or more activities of daily living or need activities of daily living or need protection due to symptomsprotection due to symptoms

Veteran must enroll for VA health Veteran must enroll for VA health servicesservices

Veteran must apply for Caregiver Veteran must apply for Caregiver programprogram

Approved caregiver will receive specific Approved caregiver will receive specific trainingtraining

Caregiver will receive monthly stipend Caregiver will receive monthly stipend based on level of need for assistance based on level of need for assistance

Caregiver Benefits for Caregiver Benefits for Other Era VeteransOther Era Veterans

In home and community based careIn home and community based care Respite careRespite care Caregiver education & trainingCaregiver education & training Caregiver support groupsCaregiver support groups Equipment & aidsEquipment & aids

Medical Benefits forMedical Benefits forFamily MembersFamily Members

CHAMPVACHAMPVA Spina Bifida ProgramSpina Bifida Program Children of Women Vietnam Children of Women Vietnam

VeteransVeterans Bereavement CounselingBereavement Counseling Services for CaregiversServices for Caregivers

CaregiversCaregivers

Caregivers enrolled in VA Caregivers enrolled in VA Caregiver program who do not Caregiver program who do not have other medical insurance have other medical insurance coverage may receive CHAMPVA coverage may receive CHAMPVA insurance coverageinsurance coverage

Bereavement Counseling Veteran patients and family Veteran patients and family

membersmembers Parents, spouses, children of Armed Parents, spouses, children of Armed

Forces personnel who died on active Forces personnel who died on active dutyduty

Counseling offered by ministry staff Counseling offered by ministry staff or at Vet Centersor at Vet Centers

Children of WomenVietnam Veterans

Biological children of women Biological children of women veterans who served in Vietnamveterans who served in Vietnam

Monetary benefits payable for Monetary benefits payable for certain birth defects associated with certain birth defects associated with the mother’s service in Vietnam: the mother’s service in Vietnam: 38 CFR 3.81538 CFR 3.815

Reimbursement for medical care services provided for birth defects on a Fee for Service program for community based treatment.

Some preauthorization required

Spina Bifida Program

Biological children of Vietnam Biological children of Vietnam veteran with spina bifidaveteran with spina bifida

Monetary benefits paid based on Monetary benefits paid based on association with veteran’s service in association with veteran’s service in Vietnam: 38 CFR 3.814Vietnam: 38 CFR 3.814

For qualified beneficiaries comprehensive health care considered medically necessary and appropriate

Some preauthorization required

CHAMPVA Comprehensive health care programComprehensive health care program Beneficiary not eligible for TRICAREBeneficiary not eligible for TRICARE Spouse or child of SC P&T veteranSpouse or child of SC P&T veteran Spouse or child of veteran who died Spouse or child of veteran who died

from a SC disabilityfrom a SC disability Spouse or child of service member who Spouse or child of service member who

died in the line of dutydied in the line of duty

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