Veterans' Health Care Eligibility Reform Act of 2003

Veterans' Health Care Eligibility Reform Act of 2003 is sponsored by U.S. Department of Veterans Affairs. This opportunity supports mission-aligned projects and measurable outcomes.

Eligibility for VA Health Care Eligibility for VA Health Care The VA healthcare system is the largest single provider of healthcare in the United States and serves well over 9 million veterans. Not all veterans can receive care in the system.

Eligibility includes a large list of criteria to include service-connected disability, non-service-connected disability, special service recognition, recent combat, Vietnam veterans, Gulf War veterans or low income veterans.

The VA Healthcare System The Veterans Health Administration is America's largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites. VA healthcare serves about 9 million enrolled Veterans each year.

The division of VA known as Veterans Health Care Administration accounts for 39% of the VA's budget and includes 324,701 employees, representing 89% of the Department's workforce. Spending for medical care by VHA in 2019 was $76. 5 billion.

The VA health care system has routinely been recognized by numerous surveys as being one of the best providers of health care. Currently due to budget constraints resulting in inability to provide care to everyone, not all veterans can get into the system. Or they may receive care but have significant out-of-pocket co-pays for hospitalization and nursing home care.

For many of the beneficiaries in the system, services are free and medications for most veterans are $5. 00 per 30 day supply for generic drugs, $8. 00 per 30 days for non-preferred generic and over-the-counter and $11.

00 per 30 days for brand-name. For veterans rated 50% or more for Compensation, medications are free. Means tested veterans in the system provide co-pays for services.

Some beneficiaries have no out-of-pocket costs except for prescription co-pays. Some beneficiaries have no costs at all. There are no healthcare premiums for any beneficiaries in the system.

There may be co-pays for certain services for certain veterans in the system. Assistance can also be provided with disability-required home renovation grants of $2,000 or $6,800. Orthotics, prosthetics and in certain cases hearing aids and glasses are also available to many in the system.

Specialized benefits such as dental care for certain veterans and geriatric care services are also available. VA outpatient clinics are also available.

Length of Service and Duty Requirements for Healthcare Anyone enlisted after September 7, 1980, or who entered active duty after October 16, 1981, must have served 24 continuous months or the full period for which that person was called to active duty, unless any one of the descriptions below are true.

Discharged for a disability that was caused or made worse by active-duty service, or Discharged for a hardship or "early out," or Served prior to September 7, 1980 A current or former member of the Reserves or National Guard, must have been called to active duty by a federal order and completed the full period for which the person was called or ordered to active duty or served continuosly for 20 years.

Active-duty status for training purposes only, does not qualify for VA health care. Other Than Honorable, Bad Conduct, or Dishonorable Discharge Receiving one of the above discharge statuses, may result in ineligibility for VA benefits including health care.

There are 2 ways to try and qualify for healthcare with bad paper: apply for a discharge upgrade apply for a VA Character of Discharge review process Entitlement to VA Healthcare Once having met the eligibility requirements for time in service and for the character of discharge, a veteran must also meet at least one of the priority group requirements below.

In some cases, some veterans must pay for VA health care and some other veterans may be at the current time restricted from obtaining VA healthcare.

Receiving Compensation from VA for a service-connected disability Awarded special eligibility classification under Title 38, U.S.C § 1151, "benefits for individuals disabled by medical treatment or vocational rehabilitation" Receiving VA aid and attendance or housebound benefits Having received a VA determination of being catastrophically disabled Not currently having a service-connected disability, or having a non-compensable service-connected disability rated as 0% disabling, but having an annual income level that's below adjusted income limits (based on resident zip code) Receiving VA Pension benefits Having a compensable service-connected disability that is rated as 0% disabling Exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki Have participated in Project 112/SHAD Served in the Republic of Vietnam between January 9, 1962, and May 7, 1975 Served in the Persian Gulf War between August 2, 1990, and November 11, 1998 Served on active duty at Camp Lejeune for at least 30 days between August 1, 1953, and December 31, 1987 Are currently or newly enrolled in VA health care, and a.

Served in a theater of combat operations after November 11, 1998, or were discharged from active duty on or after January 28, 2003, and b. Were discharged less than 5 years ago Are returning combat Veteran, eligible for enhanced benefits for 5 years after discharge. At the end of this enhanced enrollment period, assigned to the highest priority group qualifying for at that time Are eligible for Priority group 7 based on a.

Gross household income is below the geographically adjusted income limits (GMT) for where you live, and b. agree to pay copays Are eligible for Priority group 8 based on a. Gross household income above VA income limits and geographically adjusted income limits for current location, and b.

Agree to pay copays Discharged for a disability resulting from something that happened during active service in the line of duty Noncompensable 0% service-connected (eligible for care of the specific service-connected condition only) Discharged for a disability that got worse in the line of duty Have been a former prisoner of war (POW) Received a Medal of Honor Qualified for or receiving Medicaid benefits Active duty for training or inactive duty for training during reserve duty does not qualify for VA health care benefits Being a Recently Discharged Combat Veteran Recently discharged OEF/OIF/OND combat veterans can receive free VA health care for up to 5 years after discharge or release for any condition related to to service in Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF) or Operation New Dawn (OND) in Iraq.

This is called an enhanced eligibility period. Enrollment for VA health care until after the enhanced eligibility period ends, won't necessarily make OEF/OIF/OND combat veterans ineligible for further enrollment. Instead, VA will base eligibility on factors such as income or VA disability rating.

VA encourages recently discharged combat veterans to apply for VA health care right away to take advantage of the enhanced eligibility period. Application for VA health care is available through filing Form 10-10 EZ through hardcopy or online or by visiting a local VA medical center. Or one can call the health benefits hotline at 877-222-8387 to connect with a benefits counselor.

For hearing loss, call TTY: 800-877-8339. Counselors are available Monday through Friday, 8:00 a. m.

to 8:00 p. m. ET.

A successful applicant for VA health care will be assigned to one of 8 priority groups. This priority group system helps to make sure that Veterans who need care right away can get signed up quickly. It also helps to make sure that all enrolled veterans receive high quality care.

VA assigns Veterans with service-connected disabilities the highest priority. The lowest priority is assigned to Veterans who earn a higher income and who don't have any service-connected disabilities qualifying them for disability compensation.

Veteran has a service-connected disability that is rated as 50% or more disabling, OR has a service-connected disability being paid at 100% for individual unemployability, OR Veteran received the Medal of Honor (MOH) Veteran has a service-connected disability rated as 30% or 40% disabling Veteran is a former prisoner of war (POW), OR Veteran received the Purple Heart medal, OR Veteran was discharged for a disability that was caused byor got worse because active-duty service, OR Veteran has a a service-connected disability rated as 10% or 20% disabling, OR Veteran was awarded special eligibility classification under Title 38, U.S.C § 1151, "benefits for individuals disabled by treatment or vocational rehabilitation" Veteran is receiving VA aid and attendance or housebound benefits, OR Veteran has received a VA determination of being catastrophically disabled Veteran does not have a service-connected disability, or you has a non-compensable service-connected disability that rated as 0% disabling, and has an annual income level that's below our adjusted income limits (based on resident zip code), OR Veteran is receiving VA pension benefits, OR Veteran is eligible for Medicaid programs Veteran has a compensable service-connected disability that rated as 0% disabling, OR Veteran was exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki, OR Veteran Participated in Project 112/SHAD, OR Veteran Served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, OR Veteran Served in the Persian Gulf War between August 2, 1990, and November 11, 1998, OR Veteran Served on active duty at Camp Lejeune for at least 30 days between August 1, 1953, and December 31, 1987 Veteran is currently or newly enrolled in VA health care, and Served in a theater of combat operations after November 11, 1998, or was discharged from active duty on or after January 28, 2003, and was discharged less than 5 years ago Note: a returning combat Veteran, is eligible for these enhanced benefits for 5 years after discharge.

At the end of this enhanced enrollment period, VA assigns the veteran to the highest priority group for which he or she would qualify for at that time.

Veteran may be assigned to priority group 7 if the household income is below the geographically adjusted income limits (GMT) for residence location and the veteran agrees to co-pays Veteran may be assigned to priority group 8 if the gross household income is above VA income limits and geographically adjusted income limits for residence location and the veteran agrees to co-pays.

Special Rules for Priority Groups 7 and 8 Although veterans in priority groups 7 and 8 do not pay enrollment fees, they make copayments, and VA can bill their private insurance plans for reimbursement. Together, the copayments and reimbursements cover about 14 percent of VA's costs of care for those groups.

In 2017, VA incurred $6 billion in net costs for those patients, or about 9 percent of the department's net spending for veterans' medical care. When priority groups were established in 1996, the Secretary of the Department of Veterans Affairs was given the authority to decide which groups VA would serve each year. Because of budgetary constraints, VA ended enrollment of veterans in priority group 8 in 2003.

Veterans who were enrolled at that time were allowed to remain in VA's health care system. In 2009, enrollment was reopened to certain veterans in that group. For veterans assigned to priority group 8, eligibility for VA health care benefits will depend on which subpriority group the beneficiaries placed in.

Those in priority group 8 do not have service-connected disabilities, and their income is above both the national and the geographic thresholds. In 2017, about 2 million veterans were in priority groups 7 and 8.

Priority subgroups for Priorities 7 and 8 Veterans who are rated with a noncompensable 0% service-connected and are: Subpriority a : enrolled as of January 16, 2003, and who have remained enrolled since that date and/or were placed in this subpriority due to changed eligibility status.

Subpriority b : enrolled on or after June 15, 2009, and whose income exceeds the current VA income limits or the geographically-adjusted VA income limits by 10% or less. Veterans who are nonservice-connected and: Subpriority c: enrolled as of January 16, 2003, and who have remained enrolled since that date and/or were placed in this subpriority due to changed eligibility status.

Subpriority d: enrolled on or after June 15, 2009, and whose income exceeds the current VA income limit and geographic income limit by 10% or less. Veterans not meeting the criteria above and not eligible for full healthcare: Subpriority e : noncompensable 0% service-connected (eligible for care of the specific service-connected condition only). Subpriority g : nonservice-connected.

Veterans with No VA Health Care Benefits Limited benefits are available to non-eligible veterans who served in a combat zone and who are entitled to free private counseling, alcohol and drug assessment, and other support at one of VA healthcare's 300 community Vet Centers. Certain health care benefits are also available to non-eligible homeless veterans and non-eligible veterans struggling with substance abuse problems.

Co-Pay Rates Effective January 1, 2020 There is no copay for getting a flu shot, no matter the priority group. Urgent Care Co-Pay Rates (Care for minor illnesses and injuries) There's no limit to how many times urgent care can be used.

To be eligible for urgent care benefits, including through a network of approved community providers, patient must be enrolled in the VA healthcare system and have received care from VA within the past 24 months.

2019 urgent care copay rates Copay amount for first 3 visits in each calendar year Copay amount for each additional visit in the same year If related to a condition that's covered by a special authority*: $0 (no copay) If not related to a condition covered by a special authority*: $30 each visit * Special authorities include conditions related to combat service and exposures (like Agent Orange, active duty at Camp Lejeune, ionizing radiation, Project Shipboard Hazard and Defense (SHAD/Project 112), Southwest Asia Conditions) as well as military sexual trauma, and presumptions applicable to certain Veterans with psychosis and other mental illness.

Outpatient care copay rates (primary or specialty care that doesn't require an overnight stay) For a service-connected disability rating of 10% or higher there is no copay for outpatient care. If there is no service-connected disability rating of 10% or higher, there may be a copay for outpatient care for conditions not related to military service, at the rates listed below.

2019 outpatient care copay rates Copay amount for each visit or test (like a visit to your primary care doctor) (like a visit to a hearing specialist, eye doctor, surgeon, or cardiologist) (like an MRI or CAT scan) Note: There are no copays for X-rays, lab tests, or preventive tests and services like health screenings or immunizations.

Inpatient care copay rates (Care that requires you to stay one or more days in a hospital) For a service-connected disability rating of 10% or higher there is no copay for inpatient care. For priority groups 7 or 8 there is either a full copay rate or reduced copay rate. 2019 reduced inpatient care copay rates for priority group 7 First 90 days of care within a year (365 days) $281.

60 copay for total stay + $2 charge per day Each additional day within the same year (365 days) $140.

80 copay per day + $2 charge per day 2019 full inpatient care copay rates for priority group 8 First 90 days of care within a year (365 days) $1,408 copay for total stay + $10 charge per day Each additional day within the same year (365 days) $704 copay per day + $10 charge per day For those in priority group 1 there are no co-pays for any medications.

For those in priority groups 2 through 8 there are co-pays for medications the VA health care provider prescribes to treat non-service-connected conditions or over-the-counter medications (like aspirin, cough syrup, or vitamins) that obtained from a VA pharmacy. Patients may want to consider buying over-the-counter medications on their own.

The cost for any medications received while staying in a VA or other approved hospital or health facility are covered by the inpatient care copay. The amount paid for medications will depend on the "tier" of the medication and the days of supply. Once total out-of-pocket co-pay reaches $700 within a calendar year (January 1 to December 31), no more co-pays are due for that calendar year.

2020 outpatient medication copay amounts Outpatient medication tier (preferred generic prescription medicines) (non-preferred generic prescription medicines and some over-the-counter medicines) (brand-name prescription medicines) Geriatric and extended care copay rates There is no copay for geriatric care (also called elder care) or extended care (also called long-term care) for the first 21 days of care in a 12-month period.

Starting on the 22nd day of care, the VA will base copays on the level of care being received and the financial information provided on the Application for Extended Care Services (VA Form 10-10EC).

2020 geriatric and extended care copay amounts by level of care Copay amount for each day of care Short-term or long-term stays in a community living center (formerly called nursing homes) Overnight respite care (in-home or onsite care designed to give family caregivers a break, available up to 30 days each calendar year) Overnight geriatric evaluations (evaluations by a team of health care providers to help you and your family decide on a care plan) Adult day health care (care in your home or at a facility that provides daytime social activities, companionship, recreation, care, and support) Daily respite care (in-home or onsite care designed to give family caregivers a break, available up to 30 days each calendar year) Geriatric evaluations that don't require an overnight stay (evaluations by a team of health care providers to help you and your family decide on a care plan) Domiciliary care for homeless Veterans Short-term rehabilitation Long-term maintenance care Find Help in Your Area · Veterans Benefits · Resources · Contact Us The Ultimate Guide to Navigating Veterans & Survivors Benefits This 2025 Edition contains a wealth of knowledge and can help veterans, their survivors, and those who assist them submit Fully Developed Claims or decision reviews for a variety of VA benefits.

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Accreditation Study Materials CLE to Maintain VA Accreditation Correcting Your Military Discharge Find Home Care / Assisted Living Informal Claims / Effective Dates Service Connected Disabilities VA Aid and Attendance Benefit VA Help - Surviving Spouse VA Home Renovation Grants VA Long Term Care Benefits VA Pays Family for Eldercare This section provides downloadable files of the most commonly used VA Forms for senior veterans seeking benefits from the Department of Veterans Affairs.

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