Do I have to enroll to receive VA health care?
While most veterans must be enrolled to receive
VA health care, some veterans are not required to enroll due to
meeting special eligibility criteria. If you fall into one of the
following categories, you are not required to enroll:
- If you are seeking care for a VA-rated service-connected disability
- If VA has rated you with a service-connected disability of 50% or more
- If less than one year has passed since you were discharged for
a disability that the military determined was incurred or aggravated in
the line of duty, but that VA has not yet rated.
Why does VA encourage enrollment from these veterans
who are not required to enroll?
The reason we encourage all potential VA health care
patients to enroll is for planning and budgeting purposes. Enrollment numbers
help to identify the potential demand for VA services. By including all
potential patients in the enrollment count, including those who are not
required to enroll, we care in a much better position to identify necessary
funding levels to Congress.
What if the demand for VA services exceeds its budget?
When the demand for services exceeds our ability to provide
quality and timely health care, decisions will be made to ensure that the level
of services for enrolled veterans is not compromised. Those decisions may include
suspending enrollment of veterans in lower priority groups (such as VA's decision
to restrict higher income veterans who fall into Priority Groups 8e and 8g if they
apply for care after January 16, 2003) or, in more drastic times, may include removing
(disenrolling) lower priority group veterans from our enrollment system.
How can I verify my enrollment?
If you are uncertain of you enrollment status, check
with the Enrollment Coordinator at you local VA health care facility.
For a current telephone list of VA facilities, visit http://www.va.gov/directory
or you may call the VA Health Benefits Service Center at 1-877-222-VETS
(8387) to get the facility's telephone number.
Must I reapply every year and will I receive and enrollment confirmation?
If you have previously enrolled, your enrollment will be reviewed annually
without any action necessary on you part. Veterans who are required to update
their financial information are sill required to provide their income information
on an annual basis or when their income changes, using VA Form 10-10ZR. Depending
on your priority group and the automatically renewed without any action on your
part. Should there be any change to our enrollment status, you will be notified
If enrolled, must I use VA as my exclusive health care provider?
While there is no requirement that VA become your exclusive
provider of care, please be aware that our authority to pay for non-VA care is
extremely limited. You may, however, elect to use your private health insurance
benefits as a supplement for your VA health care benefits.
What income is counted for the Financial Assessment (Means Test) and is family size considered?
VA considers you pervious calendar year's total household
income and net worth. This includes the earned and unearned income and net worth
of you spouse and dependent(s). Earned income is usually wages you receive from
working. Unearned income can be interest earned, dividends assets. The number
of persons in your family will be factored into the calculation to determine
the applicable income threshold-both the VA national income threshold and
the income threshold for you geographic region.
What is Geographic Threshold?
By law, VA is required to identify veterans who are required to
defray the cost of medical care. Those veterans whose income falls between the VA means
test limits and the HUD low-income limits will have their inpatient medical care copays
reduced by 80%. The remaining higher income veterans will continue to pay the full inpatient
medical care copays and will be assigned the means test status "MT Copays Required". This
law has no effect on outpatient and medication copays.
For those veterans who have more then one residence, which address
is used for means testing under the geographically-based income thresholds?
The address used to determine your geographically based income
threshold is your permanent address and typically is the location where you declare
residency for voting and tax purposed. To view geographic income threshold, visit:
How frequently are the income thresholds updated?
Income thresholds, used for the Financial Assessment
as well as for geographic adjustment for high cost-of-living areas, are
updated annually. To view the current thresholds, visit:
How does application of the geographically based income
thresholds change the financial assessment process and the enrollment priority groups?
While the financial assessment procedures do not change, applications
of the geographically based income thresholds results in a division of the original Priority
Group 7 into two separate priority groups. Priority Group 7 is now limited to nonservice-connected
veterans and 0% noncompensable service-connected veterans whose combined income and net worth
exceed VA's annually established national income (means test) threshold.
What is a VA service-connected rating and how do I establish one?
A compensation and/or a service-connected rating is
and official ruling by VA Regional Office that your illness or condition
is directly related to your active military service. VA Regional Offices
are also responsible for administering educational benefits, vocational
rehabilitation, and other benefits programs including home loans. To obtain
more information or to apply for any of these benefits, contact your nearest
VA Regional Office at 1-800-827-1000 or visit us online at www.va.gov
Who does the VA consider to be "catastrophically" disabled?
To be considered catastrophically disabled, you must have a severely
disabling injury, disorder, or disease, which permanently compromises your ability to carry
out the activities of daily living. The disability must be of such a degree that you
require personal or mechanical assistance to leave home or bed, or require constant
supervision to avoid physical harm to yourself or others. To request an evaluation,
contact the Enrollment Coordinator at your local VA health care facility. If it is
determined by a VA health care provider that you are catastrophically disabled, your
priority will be upgraded to Priority Group 4. If, however, you were previously required
to make copays, that requirement will continue until your financial situation qualifies
you for cost-free services.
I am a recently discharged combat veteran. Must I pay VA copays?
If the services are provided for the treatment of a condition that
may be related to your military service in a theater of combat operations, you will not be
charged any copays. This benefit is limited to a two-year period following military discharge.
Recently discharged combat veterans will be asked to complete the applicable financial
assessments (means test or medication copays tests) to determine if they qualify for a
higher enrollment priority assignment, whether they will be charged copays for care and/or
medication provided for treatment for treatment of non-combat related condition, as well
as their potential eligibility for beneficiary travel.
How many copay charges may be assessed during a single day?
For outpatient services, you will be charged one copay, regardless
of the number of health care providers you see in a single day. The amount of the outpatient
copay will be based on the highest level of service you received that day. For example, if
you have a specialty care visit and a primary care visit on the same day, you will be charged
only for the specialty care visit since it is a higher level of care. The number of
medication copays charged as a result of your outpatient visit depends on the number of
each 30-day supply or less of medication filled. Inpatient copays are based on both a
standard charge for each 90 days of care within a 365-day period as well as a per diem (
daily) charge. Together, the inpatient copay charges cover all services including medications.
With the exception of medication copays for outpatients, long-term care copays are a single,
Who qualifies for the annual cap on medication copays?
The annual cap on medication copays applies to Priority Groups
2 through 6 (Priority Group 1 is exempt from ALL copays). Because of their higher
financial status, veterans in Priority Groups 7 and 8 do NOT qualify for the medication
copay annual cap. For those that qualify, once the annual limit is reached, all
subsequent prescriptions filled during the calendar year will be free of the
What if I am Unable to Pay the Copay?
If there has been a significant decrease in you
earned income from the previous year, your current projected income
may be used on a case-by-case basis (VA calls this a Hardship Determination
process). To apply for a Hardship Determination, consult your
Enrollment Coordinator at your local VA medical facility. Hardship
Determinations apply only to future copay responsibility. For copay
debt that has already been established, you may apply for a waiver
by contacting the Enrollment Coordinator at the VA Medical Center
where you received your care.
What is the copay for a 90-day supply of medication?
Even though the prescription is written for 90-days,
each 30-days or les supply is subject to that year's applicable medication
copay rate. A 90-day supply would cost three times the medication copay rate.
Hearing aid & eyeglasses are listed as "limited" benefits. Under what circumstances do I qualify?
VA will provide hearing aids and eyeglasses to veterans who
received increased pension based on the need for regular aid and attendance or
being permanently housebound, receive compensation for a service-connected
disability or are former POW's. Otherwise, hearing aids and eyeglasses are
provided only in special circumstances, and not for normally occurring hearing
or vision loss. For additional information, contact the prosthetic representative
your local VA health care facility.
Am I eligible for dental care?
You are eligible for dental services if
your dental care is for either a compensable service-connected
condition, a dental condition resulting from service-connected
trauma, if you have a service-connected rating of 100 percent
or rated unemployable due to service-connected conditions. You
also qualify if you are a former Prisoner of War, a participant
in a VA vocational rehabilitation program, an enrolled homeless
veteran participating in specific health care programs, or if
your dental condition is aggravating a medical problem under
VA treatment. In addition, recently discharged veterans who
served on active duty 90 days or more and who apply for VA
dental care within 90 days- the veteran's certificate of
discharge does not indicated that the veteran received necessary
dental care within a 90-day period prior to discharge or release.
Am I limited to a specific number of inpatient days or outpatient visits during a given period of time?
For acute care services (inpatient days or outpatient visits) there are no limits.
Do I qualify for routine health care at non-VA facilities at VA expense?
To qualify for routine care at non-VA facilities at VA expense
(otherwise known as Fee Basis care), you must first be given specific authorization
by you VA provider. Included among the factors in determining whether such care will
be authorized is your medical condition and availability of VA services within your
Am I eligible for emergency care at non-VA facilities?
If you are being treated at a VA health care facility
and need emergency care that VA cannot provide, and VA refers you to a non-VA
facility for care, VA will pay for that care. When you do directly to a non-VA
facility for emergency care, there are three ways you man be eligible for the care.
In all cases, the care must have been provided in a medical emergency, VA
health care facilities were not feasibly available, and payment may only be
made until you are stable for transfer to VA or discharge.
The first way you may be eligible is:
- When the nearest VA health care facility is notified of the
emergency within 72 hours of either inpatient or outpatient treatment,
or you med one of the eligibility requirements given below. Notification
can be made by you, a family member, or the provider, if:
- You are treated for a service-connected disability
- You have been rated by a VA as permanently or totally disabled due to a service-connected disability
- You receive care for a disability for which you were discharged from active duty.
- You receive care for a nonservice-connection disability that is associated with and aggravating a service-connected disability
- You are participating in a rehabilitation program under 3 U.S.C chapter 31
- You are a woman veteran
- When the nearest VA health care facility is notified of outpatient
emergency room treatment within 72 hours, and you meet one of the eligibility
requirements given below. Notification can be made by you, a family member,
or the provider, if:
- You have a service-connected rating of 50 percent or more
- You are a veteran of the Mexican border period or WWI
- You are receiving VA aid and attendance or housebound benefits
- You require emergency medical care during authorized travel
- You are receiving VA contract nursing home care
The second way you may be eligible is:
- When VA is not notified within 72 hours, or notified after you have been
discharged and you meet one of the eligibility requirements given below:
- You are treated for a service-connected disability
- You have been rated by VA as permanently and totally disabled due to a service-connected disability
- You receive care for a nonservice-connected disability that is associated with and aggravating a service-connected disability
- You are participating in a rehabilitation program under 38 U.S.C chapter 31
The third way you may be eligible is:
- When you are not eligible under the first two ways listed above and you meet all the following criteria:
- The emergency service were provided in a hospital emergency department
- The condition treated was of such nature that a delay in seeking treatment would have been hazardous to life or health
- VA facilities were not feasibly available
- You are enrolled in the VA health care system
- You received medical services from VA within the 24-month period preceding the emergency treatment
- You are financially liable for the treatment
- You have no coverage under a health plan for payment of the treatment
- You have exhausted all claims against third party without success
Is the VA approval needed before I obtain non-VA emergency services?
While approval is not required, you or another responsible person should
notify the nearest VA health care facility as soon as possible. Since VA payment is limited
to the point you condition is stable for transportation to a VA facility, notification allows
VA to make transfer arrangements as soon as possible.
Does the VA offer compensation for travel expenses to and from a VA facility?
If you meet specific criteria (see next question), you are eligible for
travel benefits. In most cases, travel benefits are subject to a deductible. Exceptions to
the deductible requirement are: 1) travel for a compensation and pension examination; and
2) travel by an ambulance or a specially equipped van. Because travel benefits are subjected to
annual mileage rate and deductible changes, we publish a separate document each year.
You can obtain a copy at any VA health care facility.
Do I qualify for travel benefits?
You may qualify for beneficiary travel payments if you fall into one of the following categories:
- You have a service-connected rating of 30 percent or more
- You are traveling for treatment of a service-connected condition
- You receive a VA pension
- Your income does no exceed the maximum annual VA pension rate
- You medical condition requires an ambulance or a specially equipped van, you are unable to defray the cost, and the travel is pre-authorized (authorization is not required for emergencies if a delay would endanger your life or health)
I already provided financial information on my initial
VA application, why is it necessary to complete a separate financial assessment for long-term care?
Unlike the information collected form the financial assessment,
which is based on your previous year's income, the 10-10EC is designed to assess your
current financial status, including current expenses. This in-depth analysis provides
the necessary monthly income/expense information to determine whether you qualify
for cost-free long-term care or a significant reduction from the maximum copay charge.
Once I submit a completed VA form 10-10EC, who notifies me of my long-term care copay requirements?
The social worker or case manager involved in you long-term care placement
will provide you with an annual projection of your monthly copay charges.
Assuming I qualify for nursing home care, how is it determined
whether the care will be provided in a VA facility or a private nursing home at VA expense?
Generally, if you qualify for indefinite nursing home care,
that care will be furnished in a VA facility. Care may be provided in a private
facility under VA contract when there is compelling medical or social need. If
you do not qualify for indefinite care, you may be placed in a community nursing
him-generally not to exceed six months-following and episode of VA car. The purpose
of this short-term placement is to provide assistance to you and your families while
alternative, long-term arrangements are explored.
For veterans who do not qualify for indefinite nursing home care at
VA expense, what assistance is available for making alternative arrangements?
When the need for nursing home care extends beyond the veteran's
eligibility, our social workers will help family members identify possible sources for
financial assistance. Out staff will review basic Medicare and Medicaid eligibility
and direct the family to the appropriate sources for further assistance, including
possible application for additional VA benefit programs.