Hospital Eligibilityand

NON- VA CareOutside VA

Presented byVBR 3 Randy Lingerfelt

OBJECTIVE: Brief understanding of the categories

for EnrollmentIn the VA Health system

and NON- VA care outside of the VA.

Enrollment Restriction: In order to ensure the availability of quality and timely health care to veterans with service connected conditions, special authority based on military service, low income, and those with special health care needs, in January 2003 VA made the difficult decision to stop enrolling new Priority Group 8 (high income) veterans whose income exceeded VA Income Thresholds.

The new regulations went into effect on June 15, 2009 (10% Increase)and enable the Department of Veterans Affairs (VA) to relax income restrictions on enrollment for health benefits. While this new provision does not remove consideration of income, it does increase income thresholds. You may be eligible for enrollment under this new provision.

38 CFR 17.36

Enrollment Priority Groups Priority Group Definition

1 Veterans with VA-rated service-connected disabilities 50% or more disabling Veterans determined by VA to be unemployable due to service-connected conditions

2 Veterans with VA-rated service-connected disabilities 30% or 40% disabling

3 Veterans who are Former Prisoners of War (POWs) Veterans awarded a Purple Heart medal Veterans whose discharge was for a disability that was incurred or aggravated in the line of duty Veterans with VA-rated service-connected disabilities 10% or 20% disabling Veterans awarded special eligibility classification under Title 38, U.S.C., § 1151, “benefits for individuals disabled by treatment or vocational rehabilitation” Veterans awarded the Medal Of Honor (MOH)

4 Veterans who are receiving aid and attendance or housebound benefits from VA Veterans who have been determined by VA to be catastrophically disabled

5 Nonservice-connected veterans and noncompensable service-connected veterans rated 0% disabled by VA with annual income and/or net worth below the VA national income threshold and geographically-adjusted income threshold for their resident location Veterans receiving VA pension benefits Veterans eligible for Medicaid programs

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 the Republic of Vietnam between January 9,1962 and May 7,1975 Veterans of the Persian Gulf War that served between August 2, 1990 and November 11, 1998 Veterans who served in a theater of combat operations after November 11, 1998 as follows: Currently enrolled Veterans and new enrollees who were discharged from active duty on or after January 28, 2003, are eligible for the enhanced benefits for 5 years post discharge

Note: At the end of this enhanced enrollment priority group placement time period Veterans will be assigned to the highest Priority Group their unique eligibility status at that time qualifies for.

7 Veterans with gross household income below the geographically-adjusted income threshold (GMT) for their resident location and who agree to pay copays

8 Veterans with gross household income above the VA national income threshold and the geographically-adjusted income threshold for their resident location and who agrees to pay copays

38 CFR 17.36

Veterans eligible for enrollment: Noncompensable 0% service-connected and: Subpriority a: Enrolled as of January 16, 2003, and who have remained enrolled since that date and/or placed in this subpriority due to changed eligibility status

Subpriority b: Enrolled on or after June 15, 2009 whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less

Veterans eligible for enrollment: Nonservice-connected and: Subpriority c: Enrolled as of January 16, 2003, and who have remained enrolled since that date and/or placed in this subpriority due to changed eligibility status

Subpriority d: Enrolled on or after June 15, 2009 whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less

Veterans not eligible for enrollment: Veterans not meeting the criteria above: Subpriority e: Noncompensable 0% service-connected Subpriority g: Nonservice-connected

ENROLLMENT FOR VA HEALTH CARE

The following four categories of veterans are not required to enroll, but are urged to do so to permit better planning of health resources:

1. Veterans with a service-connected disability of 50 percent or more.

2. Veterans seeking care for a disability the military determined was incurred or aggravated in the line of duty, but which VA has not yet rated, within 12 months of discharge.

3.Veterans seeking care for a service-connected disability only.

4.Veterans seeking registry examinations (Ionizing Radiation, Agent Orange, Gulf War/Operation Iraqi Freedom and Depleted Uranium).

Emergency Unauthorized Eligibility38 U.S.C.172838 CFR 17. 120

Must meet (1) criteria listed below

1. A service-Connected-Disability2. NSC aggravating a SC “Adjunct condition”3. Any condition, if P & T as a result of a SC disability4. Vocational Rehabilitation Chapter 31

AND

• VA was not feasibly available• must meet prudent layperson definition of an emergency• (2) year timely filing requirement• Claim is paid to point of stability-• (Refer to PL-110-387 paying past POS & Prudent Layperson)

Non- Service-ConnectedEmergency Eligibility

38 U.S.C.172538 CFR 17. 1002

Must meet ALL criteria listed below

1. Enrolled in Primary Care2. Must have been seen in VA in the last 24 months3. NO other health “coverage” see Medicare4. NO 3rd party liability5. NO other VA program (including 1728)6. Veteran is financially liable7. VA not feasibly available

AND

• must meet prudent layperson definition of an emergency• (90) day timely filing requirement• Claim is paid to point of stability-• (refer to PL-110-387 paying past POS)

1500 form submitted by Health Insurance (must be original RED form no copy)

UB-04 Doctor submits claim to VA (must be original form RED no copy)

FOREIGN MEDICAL PROGRAMProgram is for Veterans that travel or live outside the U. S. that have Service Connected conditions rated not NSC.

GENERAL INFORMATION:

Claims are submitted to :

Health Administration Center, Foreign Medical Program, PO Box 469021, Denver, CO. 80246-9021

Basic Information:

* No Pre- Authorization required * No Relationship to CHAMPVA/TRICARE * Claims are reviewed for SC conditions

References Fact Sheet 01-17 and Fact sheet 01-05

38 CFR 17.35

QUESTIONS ?