Enrollment History and Basic Eligibility Programs

Objective

Understand Enrollment History

Define and Review the Elements of Basic

Eligibility

Understand Minimum Duty Exclusions

Outline the Medical Benefits Package

Overview of Beneficiary Travel

2

3

• The Veterans Health Care Eligibility Reform Act of 1996 (PL104-262) enacted 10/1/96.

• Law required implementation of an annual enrollment system

• 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

Enrollment History

4

Basic Eligibility

What are the basic eligibility criteria?

5

Define a Veteran

• A Veteran is a person who served in the active military, naval or air service and who was discharged or released under conditions other than dishonorable

• Former Reservists may be eligible for VA health care benefits if they served full-time and for operational or support (excludes training) purpose

• Former National Guard members may be eligible for care or enrollment if mobilized by a Federal order

Basic Eligibility

6

Basic Eligibility

Character of Service:

• Veterans with Honorable, General or Under Honorable Conditions character of discharge are eligible for VA health care benefits as long as minimum duty requirements are met

• Veterans given Other than Honorable (OTH) discharges and those upgraded from OTH to General require VARO review and decision before routine care may be provided

7

Minimum Duty Requirement

Persons enlisting in the Armed Forces after 9/7/80 (enlisted), or who entered on active duty after 10/16/81(officers), are not eligible for VHA benefits unless they completed:

24 months continuous active service, or

the full period for which they were called or ordered to active duty

Basic Eligibility

8

Excluded Minimum Duty Requirement

38 USC 5303A - Minimum active duty requirements do not apply to persons discharged or released from active duty for:

Early out (enlisted only)-- 21 of 24 month tour or 33 of 36 month tour

Hardship

Disability that was incurred or aggravated in line of duty or veterans with compensable SC disability

Basic Eligibility

9

Medical Benefits Package

Enrolled Veterans have access to all benefits included in the medical benefits package.

Basic Eligibility

Preventive Care Services Inpatient and Outpatient Diagnostics and Treatment Prescription Services (as prescribed by VA Physician) Limited Benefits

Ambulance Service Eyeglasses and Hearing Aids Non-VA Care Prosthetics, Durable Medical Equipment and

Rehabilitative Devices Dental Care Certain Counseling Services VA Foreign Medical Program

10

Long Term Care

Basic Eligibility

Geriatric Evaluations Adult Day Health Care Respite Care Home Health Care Hospice/Palliative care Nursing Home Care (limited benefits)

Veterans 70% or greater SC have mandatory access Domiciliary Care (limited benefits)

11

General Exclusions (partial listing)

Basic Eligibility

Abortion Counseling In-Vitro Fertilization Certain Cosmetic Surgeries Health club or spa membership Special private duty nursing Gender alteration Medical Care for Prisoners or inmates

Beneficiary Travel

Beneficiary Travel

• VA is authorized to provide eligible Veterans and other beneficiaries mileage reimbursement for VA or VA authorized non VA healthcare

or• when medically indicated “special mode”

(ambulance, wheelchair van) for travel to and from VA, or VA authorized health care

12

Beneficiary Travel Funding

Beneficiary Travel (BT) is a discretionary program with funding directly from the yearly VA medical care appropriation

VISN Directors, based on anticipated patient demand, determine the amount of their budget to devote to patient travel reimbursement

13

Beneficiary Travel Eligibility

Veterans

• SC 30% or more for all conditions

• Traveling in connection with care for SC disability

• In receipt VA pension

• Previous year income does not exceed maximum VA pension rate

• Projected income in travel year does not exceed maximum VA pension rate

• Travel for C&P exam

Non-Veterans

• Allied Beneficiaries if country reimburses VA

• Attendants: when VA determines medially required

• Beneficiaries of Other Federal Agencies if Agency reimburses VA

• Donors/Support person: If part of VA transplant care

• Caregivers: National Caregiver Support Program

14

Expenses Paid

• $0.41.5 per mile subject to deductibles

• Actual cost of ferry fares, bridge, road & tunnel tolls, parking, baggage, meals and lodging up to 50% of that for local government employees (receipts required)

• Actual cost of Special Mode transportation

• Actual cost of common carrier not to exceed mileage unless POV is not readily available

• Travel is paid from the Beneficiary’s residence (or place travel initiated) to and from the nearest VA facility that can actually provide the required care

• On a case by case basis travel may be paid for any distance if financially favorable to government

15

Criteria for Approval

Round trip reimbursement:

• Travel in connection with care or services scheduled prior to arrival at the VHA-designated facility, or

• For emergency treatment

Return (one-way) reimbursement:

• Travel in connection with care or services not scheduled prior to arrival at the VHA-designated facility, and

• Not for emergency treatment

16

Criteria for Approval (cont)

Special Mode Transportation:

• Beneficiary meets BT administrative eligibility criteria, and

• VA health care provider determines and documents that this mode of transport is clinically required

17

Application for Beneficiary Travel

• Apply orally or in writing: receipt for each expense other than mileage

• Apply for payment within 30 calendar days after travel (if NO special mode) or change in eligibility

• Must receive prior approval for meals, lodging, and luggage

• Generally payment AFTER appointment takes place

18

Expenses Not Paid

• VA determines payment is counter productive to therapy

• Solely for pick-up of medications or supplies when no care, treatment or examination is provided

• Return travel following an irregular inpatient discharge

19

QUESTIONS

20