Case Management Update

Proper Screening for VA Medical Eligibility
Can Ease Pressure ob State ADAP Programs

Thomas P. McCormack  
TIICANN Benefits and .Eligibility Consultant
Revised 04/20/04


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Table of Contents


1998 Census data, recently released by the Department of Veterans’ Affairs (VA), suggests that state drug assistance programs may be bearing some medical costs for patients actually eligible for free or low-fee VA medical care.

State programs have long been rightfully viewed as last resorts. Those eligible for medical care and drugs from other programs should use that coverage before turning to the state. Thus, medical care coverage available from the VA should—unless there are exceptional circumstances—be turned to before limited state monies are spent.

But virtually all members of the public, many state officials and even most veterans themselves wrongly assume that one must be a combat or wartime veteran or have been injured or become sick on active duty to get VA medical care. As a result, some states don’t bother to screen at all for VA medical care eligibility. Or, just as worse, they ask veterans themselves whether they’re eligible for VA medical care. And—not surprisingly, since even veterans themselves don’t know the correct eligibility rules—few  applicants indicate that they’re VA-eligible!

To be eligible for VA medical care, a veteran must have served at least 180 days active duty and have an honorable or general discharge. Those with service-connected disabilities, former prisoners of war and any veteran whose served in a combat zone within the last two years are guaranteed high-priority, copayment-free care. However, veterans who first enlisted after September 7, 1980, must also have served at least two years; see the note below for details about, and exceptions to, that rule .*  But, in general,  veterans do not need to have served in combat or in wartime; have been injured or become ill while on duty; be disabled; or even have been overseas.

VA Health Care Priority Groups, Service-Connected Veterans and Co-Payment

Except for genuine emergencies, the VA prioritizes access, waiting times and availability of medical
services for elective and other non-emergency care, using eight priority groups:

  1. 50% or more service-connected disabled veterans

  2. 30% and 40% service-connected disabled veterans

  3. 10% and 20% service-connected disabled veterans; former prisoners of war; Purple Heart

  4. Veterans found by the VA to be “catastrophically disabled”, even from a non-service-connected
    cause (see below) or who get pension or compensation add-ons for Aid and Attendance or as
    Housebound; those who served in combat zones within last 2 years

  5. Non-service-connected veterans considered “poor” under VA income/asset rules (see below)

  6. Vietnam War (1962-75) Agent Orange victims; First Gulf War (1990-91) and Iraq War (1998- )
    veterans with Gulf War Syndrome; World War I (1917-21) and Mexican Border War (1916-17)

  7. Non-service-connected veterans considered “near poor” under VA income/asset rules (see below)

  8. Non-service-connected veterans not considered poor under VA income/asset rules (see below;
    new enrollments in this category were suspended as of 1/03)

  9. Service-connected veterans always get free care, without even the $7 prescription
    copayment, for their service-connected conditions---no matter how high their income or assets.
    If they have private health insurance it is never billed for treatment of service-connected conditions.

  10. But service-connected and other Priority 1 through 4 veterans must pay the copayments of
    the Priority 5, 7 or 8 Groups that their incomes and assets would ordinarily place them in for
    treatment  of non-service-connected conditions----except for those rated 30% or more
    service-connected disabled, who are exempted from paying the (Priority Group 5, 7 or 8)
    -prescription copayments even for non-service connected conditions’ care that their
    incomes and assets would otherwise require of them. In other words, a service-connected
    veteran, no matter how high his income or assets, is exempted even from paying the
    applicable income/asset-based Priority  5, 7 or 8 copayments (except for prescription
    copayments) that he “deserves”, for care of a non-service-connected condition, if he’s
    rated 30% or more service-connected disabled

In effect, then, service-connected and other Priority 1 through 4 veterans---especially those rated 30% or below---need to have their income and assets evaluated in order to be assigned the  applicable Priority Group 5, 7 or 8 copayment schedule (plus, if they’re very poor, the extra prescription copayment exemptions mentioned below) for treatment of non service-connected conditions. Debts owed the VA for any copayments can be waived on grounds of “equity and good conscience” by hospital fiscal officers (see amendment to 38CFR17.05 in the April 20, 2004 Federal Register).

2004 VA Medical Care Income/Asset Eligibility Levels and Copayments for Poor Priority 5 Veterans

To get free care (except for a $7 copayment per prescription), a “Priority Group 5” veteran can have up to $80,000 in assets, not counting household goods, a lived-in home of any value and one vehicle of any value. In addition, monthly income can’t exceed the following:

  • Single veteran……..………………... $2, 096.83

  • Veteran with one dependent…….. …$    419.58 more

  • For each additional dependent….…  $    140.67 more

However, if the “Priority Group 5” veteran does have some private health insurance the VA will bill and  collect what it can from the private insurance.  It will then give the veteran “credit” towards whatever  prescription copayments he owes for the insurance money it collects.

(In 2004, the first $7950 yearly in wages actually earned by a child under age 18 are not counted.  Actually received child support and spouses’ incomes are fully counted, though.)

2004 Income & Asset Levels and Copayments For Wealthier, “Priority 7” Veterans

To get very heavily discounted care, veterans can have even more than $2096.83 in monthly income (up to about $28,000 to $35,000, depending on where they live) or $80,000 in assets, not counting household goods, a lived-in home of any value and one vehicle of any value. . They’d still qualify as“ Priority Group 7” veterans and get care when space is available (it usually is, except in the most  overcrowded hospitals). They must pay the following small copayments for care in 2004

  • $7 per prescription

  • $15 to $50 per doctor, clinic or emergency room visit

  • $2 per day for each inpatient hospitalization

  • $175.20 more for the first inpatient hospitalization per year

  • $87.60 more for subsequent hospitalizations per year

However, if the “Priority Group 7” veteran does have some private health insurance the VA will bill and
collect what it can from the private insurance.  It will then give the veteran “credit” towards whatever
copayments he owes for the insurance money it collects. 

2004 Income and Asset Levels  with Even Bigger Copays for Still Wealthier
Priority Group 8 Veterans

On October 1, 2002, the VA created a new Priority Group 8 for health care eligibility  to implement the VA Health Care Programs Enhancement Act, which was enacted in January, 2002. Priority 8 patients are those non-service-connected veterans with assets over the levels allowed for Priority 7 or income over the levels used by HUD as the upper limits for housing assistance eligibility. The HUD levels vary state-by-state, and by Standard Metropolitan Statistical Areas (SMSAs) within states, depending upon regional costs-of-living (for one person, they generally range from about $28,000 yearly to about  $35,000). See the sidebar below to calculate local area Priority 8 income levels.

The family-sized upper income limit for housing assistance in a locality is now the maximum Priority 7 income allowed for Priority 7. Non-service-connected veterans’ with income ABOVE  this income level are now in Priority Group 8 !  (One can call 1-800-245-2691 and at least attempt to get the low-paid, clerical-level contractor telephone bank employees answering to provide locality- specific and family-sized] upper income limits for federal housing assistance.)

Priority 8 patients must pay the copayments of $7 per prescription, $15 to $50 per outpatient encounter,$876 plus $10 per night for the first inpatient hospital stay in a year and $438 plus $10 per night for most subsequent hospitalizations in a year.

However, if the “Priority Group 8” veteran does have some private health insurance the VA will bill and collect what it can from the private insurance.  It will then give the veteran “credit” towards whatever copayments he owes for the insurance money it collects.

Moreover, on January 17, 2003, the VA published Interim Final Regulations in the Federal Register (Vol. 68, No. 12, pp.2669-2673) immediately suspending further enrollment of Priority 8 veterans. But those veterans now classified as Priority 8 who are already enrolled ---plus those already who originally qualified as Priority Group 5 or 7 but whose income or assets only later rise into the Priority Group 8 range---are  "grandfathered-in".

VA Medical Care Eligibility and Enrollment Procedures

Veterans typically begin the enrollment process with interviews at VA medical facilities, bringing discharge papers (DD214s)*, documentation of any private health insurance and, for those of limited income seeking Priority Group 5 or 7 care, proof of dependents, income and “net worth” (assets). Enrollment is completed once veterans are assigned to a Primary Care Team (often denoted by colors: “red’, “green”, etc.) and are scheduled for Team intake examinations---after which referral to specific departments and clinics for ongoing care is arranged.

But, anytime, those presenting themselves at the emergency room for genuine emergencies---even hose who haven’t yet completed the regular enrollment process!--- are seen with the same medical triaging, waiting, processing, physician treatment and necessary prescription issuances as are used at any hospital emergency room.

Assume a veteran moves from one area of the country to another---and, in particular, if he or she (perhaps only nominally and temporarily) moves from one area to another to avoid long queues in his own home area (for example, to take advantage of shorter waits for the initial intake examination and primary care team assignment in a less-crowded area) for Priority 5 or 7 non-service-connected veterans' health care. Does the move to the new area mean that he or she has to re-enroll all over again and still again go through a long wait for his initial intake examination and assignment to a "primary care team"?  No. When an already-enrolled, already-examination-intaked Priority 5 or 7 non-service-connected veteran moves to a new area, he or she need only appear at the nearest VA hospital or clinic for care or the routine scheduling of care, without the need to wait for a new intake examination.

Showing his VA ID card (issued at first enrollment) and mentioning his Social Security number calls up his record on the VA's nationwide computer. In such cases, the veteran would, of course, be assigned by clerical intake staff to a "new" primary care team at the new hospital or clinic (a necessity, of course, because of the move!). There would then be only the same waits for primary care appointments or specialty care referrals as are faced any other local, already-enrolled, already-intake-examined veteran. (But, of course, those "routine" waits can be, and often are, weeks and sometimes months even in the least busy VA hospitals and clinics.)

In recent years, more and more older World War II, Korea, Vietnam and Cold War veterans who don’t have prescription coverage have learned that they can get prescriptions from the VA and have begun crowding into VA hospitals. Since 1996, VA patient enrollment has grown from 2 million to 6 million. In some areas with many retirees---parts of Florida and North Carolina, for example ---this has caused delays of many weeks, or even months, in scheduling newly-enrolling veterans for their intake examination appointments. But again, even those who are still awaiting intake examinations can present themselves anytime at VA hospitals for necessary, emergent treatment (including necessary prescription  issuance).

By late 2002, over 260,000 veterans were awaiting intake. To cope with this, in September, 2002, the VA issued interim final regulations to give first priority in scheduling these intake examinations to those veterans who have service-connected, VA-recognized disabilities; others, including those whose disabilities are non-service-connected (e.g., only recognized by Social Security), have second priority in scheduling intake examinations. Nevertheless, Congress has appropriated massive increases in recent years for the VA health budget and will continue to do so to handle the crowding. Higher VA health budgets are popular with Congress: Conservatives favor it as a sort of military expense; while liberals know that the VA cares for the poor, the disabled and the elderly.

Upgrading Bad Conduct, Dishonorable, Less-Than-Honorable and Undesirable Discharges;  Having Discharge Reclassified To Being For Disability or Hardship

Bad conduct, dishonorable, less-than-honorable or undesirable military discharges---and often unexplained, early discharges that need to be rewritten to reflect that they were actually for hardship or disability reasons---which now prevent eligibility for VA medical care, pensions, compensation and other benefits can be changed by applying to appropriate military discharge review boards. The website offers clear and concise explanations and instructions, with relevant forms and addresses. For attorneys and other professional-level advocates who need more exhaustive information,  the National Veterans Legal Services Program sells a comprehensive manual for about $100.

What About Those Veterans Who Seek Only VA Prescription Drugs But Want To Retain Their Own Civilian Doctors?

Some veterans may argue that enrolling in VA medical care (for example, to get expensive prescription drugs costs from the VA rather than the state) might require their giving up their own civilian doctors (whom they see through Medicare or as patients in various low income clinic programs). Actually, this isn’t so. There’s no rule to deny  VA eligibles the right to also see civilian doctors---and, in fact, a surprising number do so. As mentioned in the previous paragraphs, VA facilities are now crowded precisely because many older veterans use their Medicare to see civilian doctors but subsequently use their VA eligibility to (redundantly) then see VA doctors to have the prescriptions they need ordered and written on VA prescription forms--- which they then fill at the VA at $7 each!

The VA’s rules still require that its prescription drugs can only be issued when the  prescriptions are written by VA doctors for patients they actually see. So, to get VA-covered drugs, many, many older patients go through the motions of seeing a VA doctor to get him to write the same prescriptions their civilian doctors ordered----but now on VA prescription forms. VA doctors know this and are quite used to it---they quickly assess the patient’s state of health and what prescriptions the civilian doctor ordered. If everything seems  reasonable and necessary they then write the very same (or equivalent) desired prescriptions on VA forms, send patients on their way and rapidly move on to the next waiting patient.

Of course, even abbreviated, “pro forma” VA patient visits like these are wasteful of VA resources (and the time of patients, who resent having to be seen by a second doctor just to get VA drugs). But under current rules, the VA requires that its own doctors be responsible for decisions to issue prescriptions. Some veterans, members of the public, Congressmen and the General Accounting Office have called for considering abandoning the “see a VA doctor first” prescription rule and the VA has begun to study doing so.

The VA will allow some eligible veterans with already-issued prescriptions from private, non-VA doctors---those who've signed up for VA care but still awaiting their post-enrollment "intake" exams for at least 30 days as of 7/25/03---to fill them via its mail-order system to ease the current backlog of veterans waiting to be in-processed to the VA system.

Only those privately-prescribed drugs that are otherwise VA-covered, that are non-narcotic, that don't have to be injected and that can be mailed out can be offered by this temporary stop-gap for those veterans queued-up in the backlog as of July 25, 2003. But those who only become "backlogged" in the future aren't eligible for this temporary, stopgap coverage unless VA rules are again changed.

The VA still maintains its requirement that, in general, VA-issued drugs can only be written by VA physicians for those veterans they actually see after full intake. Nevertheless, the GAO, many Members of Congress and some veterans' organizations still want regular, ongoing access to VA-issued drugs for those who remain in treatment with private doctors---and the VA has said it is still considering such a permanent change in policy.

A press release on the temporary new policy is at
The text of the temporary interim is printed in the 7/25/03 Federal Register at

More On VA Prescriptions

VA prescriptions are issued by the prescribing doctor on a VA prescription form, where he usually indicates how many refills are to be allowed. Patients then drop them off at in-house VA pharmacies---where, typically, dozens of patients are waiting at any given time. With often-long waits that usually exceed those at commercial pharmacies, patients are given their prescriptions after they pay their $7 co-payments. Those non-service-connected veterans claiming exemption from co-payments because they can’t afford them (see below) at this point can encounter time-consuming red tape that might well require an hour or two more of processing (and only then if the finance and pharmacy offices are open for such business).

Service-connected veterans are not charged co-payments for care related to their disabilities. And, yes, in practice the difficulties VA staff face in distinguishing, Solomon-like, between care for service-connected conditions and other conditions can, and often does, result in some service-connected veterans getting co-payment exemptions for care for their non-service-connected conditions.

Patients can---and, where it’s medically possible, many do---choose not to wait on-site for prescriptions to be filled: They can instead opt for mail delivery service to their homes. Yet this can, and often does, take a week or more; shipments are often late or lost in the mail; and medications that are narcotics or are heat- or refrigeration-sensitive can’t be mailed in any case.  On the other hand, patients choosing mail service can thereby avoid having to make on-the-spot cash co-payments at the VA  pharmacy window. Instead they’re mailed bills for the co-payments, which they can later pay by mailed checks or money orders. But those who become seriously delinquent may well then be required to make on-site, up-front cash co-payments for future prescriptions. 

The VA is not subject to applicable state medication prescribing laws. Hence, patients generally must accept what the VA physician orders; for example, they can’t (without convincing the prescribing doctor) ask for a generic or invoke other substitution options that might be available under state law at commercial pharmacies. On the other hand, the VA permits registered nurses and physician assistants to prescribe in many cases---even where state law wouldn’t permit this.

Moreover, the VA can, and often does, allow prescriptions to be refilled more times than is allowed at ”civilian” pharmacies. Patents can request this when first given prescriptions and as they drop them off at the VA’s on-site pharmacies. Refills can be scheduled/diaried for “automatic” mail refill or can be specifically re-ordered via telephoned- in computerized systems. Those who don’t wish to wait at the VA for their prescriptions---if they’re willing and able to pay cash themselves-- can fill those signed by a physician at commercial pharmacies. 

An important advantage of the  VA system is that it issues “prescriptions” (and at the often-attractive bargain price” of only $7!) for a wide variety of ”over-the-counter” items---bandages, dressings  braces, lotions, salves, cough medicines, digestive remedies, patent medicines, crutches, canes, walkers, adult diapers and many other first aid supplies---that aren’t legally considered “prescriptions”and that civilians simply pay cash for. Thus, asking VA doctors for prescriptions for such items can result in some savings.

Suspending All Prescription Co-pays for the Very Neediest Veterans

Priority Group 2 through 6 veterans’ prescription co-payments can be suspended for the rest of the year once they incur $840 of such charges in any given year—as is also true for any applicable prescription copayments that might otherwise be required of 40%-or-less service-connected disabled veterans or for treatment of a service-connected disabled veteran’s non-service-connected condition.  In addition, all veterans with incomes under the applicable basic pension level (in 2004, $824.50 monthly for a single veteran, plus  $255.42 for one dependent and $140.67 for each additional dependent) are exempt from any  prescription copayments.  When first enrolling for VA care, those under this income level should be sure to insist that their enrollment file specify that they’re copayment-exempt  and those who originally enrolled at higher income levels---but whose income later falls to within the exemption low income range---should re-visit the VA hospital or clinic’s enrollment/eligibility office with revised, current proofs of income to request that their records be corrected to exempt them from drug copayments.

Debts owed the VA for any copayments can be waived on grounds of “equity and good conscience” by hospital fiscal officers (see amendment to 38CFR17.05 in the April 20, 2004 Federal Register).

In early February, 2004, VA Secretary Principi asked Congress for authority to raise the prescription copayment exemption income level by an amount equal to the pension Aid and Attendance payment ($551.25 more monthly in 2004); knowledgeable observers consider this the only eligibility- or copayment-related Administration proposal likely to pass Congress (the Bush Administration also proposed raising drug copayments for Priority Groups 5, 7 and 8, and for treatment of non-service-connected conditions of service-connected disabled veterans, from $7 to $15 and imposing a yearly “enrollment fee” of $250 on Priority 7 and 8 veterans; these plans are opposed by the powerful national veterans groups and by both chairmen and ranking members of  Congressional veterans’ committees).

Special Rules For VA-Paid Care from Non-VA Medical Providers
Note that (except for rare, arranged-in-advance purchases of specialty care at non-VA hospitals) the VA does not pay for care at non-VA facilities, with three exceptions: 

  • First, with advance permission, some veterans—usually, only those who get service-connected
    compensation benefits (see below)-- can be treated by non-VA medical staff or facilities in
    Colorado, Wyoming, Utah, Montana, Idaho and parts of central Florida under special, limited pilot programs.

  • Second, service-connected compensationers--but not other veterans—can with advance permission be treated by approved foreign medical providers and, on a space-available basis, at foreign US military medical facilities, for emergencies when overseas. Contact the Medical Administration Service (136), Foreign and Insular Affairs Unit, VA Medical Center, 50 Irving Street, NW, Washington, DC 20422, telephone (202) 745-8242. There are numerous authorization and billing forms which are required. Request a copy of the pamphlet “Department of Veterans Affairs Foreign Medical Services Program”. Nevertheless, in spite of the restriction of care at overseas US military medical facilities to service-connected compensationers who have secured advance permission, there are anecdotal reports that other veterans with VA patient identity cards have secured emergency care at those facilities. This is because clerks there understandably have trouble mastering the VA’s complex rules. Hence, they often fail to distinguish between the classes of eligible and ineligible VA patient identity cardholders.

  • Third, otherwise eligible veterans----only if they have already enrolled for VA health benefits and have actually received some VA treatment----can receive emergency care paid for by the VA at a non-VA hospital in the US when 1) such a hospital is nearer than a VA one and 2) delaying care to reach a more distant VA facility (under a “prudent person” standard) would seriously endanger life or health. Ambulance and related emergency in-hospital medical services which seem necessary (also under a “prudent layperson” standard) can be covered too  In cases of inpatient admission, the veteran, his family, legal representative or the non-VA facility must get authorization from the veteran’s regular VA clinical staff within 48 hours. That VA staff also decides when the patient is medically ready to transfer to a VA facility---after which VA liability for payment for care at a non-VA facility ends.

2004 Priority Group 5 Copays; Copay Credit for Private Insurance Payments

In 2004, single veterans with annual incomes below $2,096.83 monthly ----known as Priority Group 5----are eligible for free care  (except for a $7 co-payment per prescription), after those with service-connected disabilities, former prisoners of war and certain other priority classes are served. ($419.58 more monthly is allowed for one dependent, and $140.67 more for additional ones; here, too, the first $7950 of  a child’s earnings is not counted.) Allowable assets per family include household goods, a lived-in home of any value, one vehicle of any value, and $80,000 in “net worth” (automobiles, bank accounts, other property , investments, etc.).  If a Priority 5, 7 or 8 veteran has private health insurance, the VA will bill the plan for what it can, but it will not bill the veteran if he or she has income below this level, except for the $7 prescription co-payment. 

Eyeglasses, Hearing Aids & Related Exams; Dental Care; Home Health Care

The VA not only covers eye examinations and audiology tests and writes eyeglass and hearing aid prescriptions for all its eligible patients. In many cases it also covers eyeglasses and hearing aids---even for some non-service-connected Priority 5 and 7 patients. Veterans' Health Administration Directive 2002-039 of July 5, 2002 [paragraph 4.a.(1)] authorizes eyeglasses and hearing aids for:

  • those getting service-connected compensation for any reason or at any percentage;

  • former prisoners of war;

  • those getting Housebound or Aid and Attendance increments to needs-based disability

  • those needing eyeglasses or hearing aids due to any other (even non-service-connected)
    medical cause; and

  • those with any other functional or cognitive impairment-- as shown by ADL deficiency(ies)
    --who need eyeglasses or hearing aids to participate in their own care.

Replacements are allowed in cases of loss and breakage and for new or changed prescriptions. Hearing aids, without a prescription change or loss, must last 4 years. Issuance of spares is determined by the audiologist or eye care specialist. It should be noted, however, that the VA website (accessed 1/9/04) now  states that hearing aid and eyeglasses are only available to service-connected disabled veterans, former prisoners of war and other special categories of veterans.

Dental services ordinarily are offered only to 100% disabled, service-connected veterans and those held as prisoners of war for at least 90 days; but other, non-service-connected veterans may apply, within 6 months of discharge, to get dental treatment that wasn’t completed while on active duty. Often, the VA then authorizes care with selected private dentists.

Those not eligible for VA eyeglass, hearing aid or dental care might contact the Seniors’ Eyecare Program ( 800-222-3937) if they’re limited-income citizens or legal aliens over 65; it offers some limited eye care---although not eyeglasses or eyeglass prescriptions.

  • Local Lions’ Clubs

  • United Way

  • Salvation Army
    local chapters sometimes offer help with eye exams, eyeglass prescriptions and/or eyeglasses.

  • Lenscrafters’ Gift of Sight Program
    sometimes offer help with eye exams, eyeglass prescriptions and/or eyeglasses. 

  • American Academy of Otolaryngology
    lists some resources for free or discounted hearing exam and hearing aid resources-

  • Easter Seal Society
    lists some resources for free or discounted hearing exam and hearing aid resources- 

  • National Association of State Medicaid Directors
    All but a few state Medicaid programs deny dental care to adults. This web site has
    t contact
    information to inquire about any given state.

  • National Association of Dentistry for the Handicapped
    (303-573-0264) organizes dentist volunteers to give free dental care to poor persons with disabilities in at least 32 states.  Almost all dental schools offer free or heavily discounted
    dental care by student dentists working under the supervision of professional teacher-dentists;

  • American Dental Association
    has a list of all American dental colleges.

A 2003 GAO study found that nearly one-third of VA medical centers failed to provide  home health services and that some improperly denied this care to otherwise eligible non-service-connected veterans; in response, the VA promised to begin making home health care more widely and equally available (for details, see ).

Arranging/Subsidizing Transportation To Distant VA Hospitals & Clinics

In metropolitan areas with good, economical public transit, getting to VA medical care via buses or subways  costs relatively little and is reasonably available. But many patients living in rural or far-out suburban areas lack a family automobile, have little or no income to pay for their gas or reimburse others for rides or live in areas that aren’t served by any reliable or frequent-enough public transit or even long distance bus service (e.g.Greyhound).

Disabled American Veterans
a nationwide non-profit organization provides daily, free door-to-door van transport service to disabled and indigent veterans who otherwise can’t get to VA  medical appointments. On its website, the key terms “transportation network”, “hospital coordinator” and “volunteer services” refers one to a hospital-by-hospital listing of, and telephone numbers for, those DAV workers who supervise the van transport system serving that hospital. They can provide details about local van service, scheduling, reservations and priorities.  Almost all DAV van drivers---and even some of the hospital-based coordinators---are unpaid volunteers.

Case Management and Patient Advocacy for VA Patients

Because the VA is a classical large, often-impersonal bureaucracy, patients’ needs can sometimes be overlooked or forgotten: Mail-ordered prescriptions may not come on time or at all; mail-order and other prescriptions may expire, with their expiration perhaps being overlooked by busy physicians; and vulnerable, less self-proactive patients may not get the detailed case management and treatment/drug regimen training that they need.

While the VA benefits system does offer an appeals and hearings for those who are aggrieved, it is attuned almost exclusively to the needs of those seeking money Pension and Compensation payments rather than timely, quality medical care and related supportive services. Veterans have one year after the denial of a benefit, or being given a substandard service, to appeal in writing to their servicing VA Regional Office, using VA forms available at or even by simply writing a letter. The appeals system is clogged with hundreds of thousands of overdue appeals, and getting decisions often takes two or more years. Hence, it is not timely enough to be useful for medical care complaints. 

More vulnerable veterans—those who are frail, are intellectually-challenged, have limited education, are confused or intimidated by the massive, complex VA system or otherwise need detailed case management, guidance and assistance with appointment schedules,   treatment orders or drug therapy regimens--- can seek help from, or be referred to: the “service representatives” (middle-aged and older veteran volunteers from groups like the American Legion, the Veterans of Foreign Wars, etc., who work from offices in VA hospitals—although what skills they have are more often focused on Pension and Compensation questions); Patient Advocates and Ombudsmen (on staff in VA hospitals just as they are in civilian hospitals---with skills in handling patient complaints about treatment and quality of care); and---above all !—the VA hospitals’ own medical Social Work departments (which offer treatment-related supportive counseling and services to all VA patients, including even those treated by outpatient clinical departments).

The VA medical care system, at least theoretically, requires one to secure unscheduled or between-appointments medical care through the Emergency Room. But that can take many hours’ wait, and then only to be seen by a generalist physician unfamiliar with the patients’ individual care. He can (at most) offer temporary care solutions and impermanent, stopgap prescriptions for expired, lost-in-the-mail or about-to-expire medications. Some more proactive patients successfully deal with this inevitable eventuality by chatting up acquaintance-ships with their main treating clinical department’s receptionists, clerks, nurses and social workers. These contacts can then squeeze them in for an unanticipated appointments or arrange to have a physician renew an expiring prescription or write a stopgap for one lost or delayed in the mail.  

Techniques For States To Promote VA Care as a Prior, Alternate Resource

To get the most out of VA medical care as an alternative, states might consider altering  application forms to ask not just whether an applicant is eligible for VA medical care: after all, most veterans wrongly think they’re NOT eligible!  Instead, application forms could ask about the key, underlying eligibility factors: “Did you serve on active duty for over 180 days, or over two years, with the Army, Navy, Air Force, Marines, Coast Guard or, if  you were activated in the National Guard or Reserves, for the full activation tour of duty?” “Did you receive an Honorable or General discharge?” “Please attach a copy of your DD214 (discharge papers).”

State officials should also know that the state’s Medicaid eligibility electronic enrollment file staff (with whom they’ve likely already worked) can advise them about access to and use of federally-provided electronic data bases which might possibly check for veterans’ status and other key income and eligibility data matches. 

VA medical care is often unfairly looked down upon because so many of its patients are poor, minority and working class men. As a result, some veterans who are state clients may be reluctant to use (or even reveal) their VA medical care entitlement—preferring, instead, to receive their expensive care at state expense.  

But unless state eligibility procedures guard against this, expensive medical care (which the VA is responsible for) will be shifted unfairly to the state budget. This could limit access, drug formularies, or both in state programs.

To implement a VA eligibility-screening program, states might wish to consider other, supplementary policies as well:·    

  • Using state funds to pay copayments of those of the “Priority Group 7” veterans (the “over-income” ones) who cannot afford them. (But states should note that the VA does not require the veteran to front cash for care; it will bill later.)    

  • Using state funds to pay the $7 per prescription copayments due from the “Priority Group 5” (lower income) patients.

  • Installing procedures to continue to provide care to those “Priority Group 7” patients whom the VA turns away or care when space is not available. (But even here, states might wish to refer patients to at other area VA facilities to see if they  have space available, before granting unfettered access to state benefits.)

  • Prohibiting use of state funds to pay for any prescription written on a VA prescription form. (This
    would prevent VA patients wishing to avoid their $7 VA copayments from using their state coverage  to secure lower copayment prescriptions—which, of course, results in shifting heavy expenses from the VA to the state.. But here, too, individual override procedures need to be developed for when a particular drug happens to be out of stock at a VA hospital.)

  • Using state funds for ambulance, taxi, bus or car mileage payments for transportation to distant VA hospitals| for care for those who cannot afford the travel.·       

  • Exemption procedures need to be developed for patients who live so far away from VA facilities that only state coverage would be cost effective or humane.

Screening/Referring For VA Medical Care Brings Veterans Total Medical Coverage (Not Just Drugs) and Helps Them Access Other VA Benefits Too

States can somewhat sugarcoat the imposition of these strict referral rules by bearing in mind and pointing out to veterans that the VA offers them not just prescription drugs but also comprehensive, total medical care---including physician, care, specialists’ care, hospital services, laboratory services and sometimes even eyeglasses, hearing aids and dental care. In addition, by screening for VA medical eligibility, states can also serve veterans by at least  preliminarily screening them for the VA’s disabled wartime veteran’s  “pension”. This welfare program pays up to the monthly amounts shown below. It is available to fully disabled veterans—whether or not their disability arose from their time in service, and whether or not they actually served in a war zone or overseas, unless their service fell wholly within these dates: January 1, 1946-June 27, 1950; February 1, 1955-August 4, 1964; and May 8, 1975-September 1, 1990.*  For a pension, family assets can include up to $30,000, not counting household goods, a lived-in home of any value and one vehicle of any value.

2004 monthly payment rates for VA pensions are $824.50 for a single veteran; $255.42 more with one
dependent; and $140.67 more for each additional dependent, after deducting other family income like Social Security, wages or pensions. (Thus, as with all welfare programs, other, non-welfare income reduces the VA pension dollar-for-dollar; where total family income exceeds the pension level, the family isn’t eligible at all for this program, while checking for VA medical care coverage, will enable states to ensure that eligible clients get the income they need.  

Death and Burial Benefits

The VA provides free burials and gravesites to any honorably- or generally-discharged active duty veteran, |veteran’s spouse or widow(er) or minor child at several dozen national cemeteries across the country and at dozens of state veterans’ cemeteries. Burials are done on a space-available basis; gravesites are no longer available at Arlington National Cemetery, except for high officials, highly decorated veterans and certain other notables) and in much of California. However, niches for cremated remains are available everywhere.  Free VA markers and (if permitted in that cemetery) full-size headstones for veterans are provided, and these can include not only the name and life dates, but also certain military decorations. The VA pays for transportation to a gravesite of the remains only if the veteran died in a VA hospital.   

The VA pays about $100 toward non-government headstones and up to about $150 for plots in private
cemeteries, but only for service-connected disability compensation recipients, “wartime” veterans or any other veteran otherwise entitled to a burial allowance. It pays about $300 for burial to survivors of disability payment recipients or survivors of any veteran dying in a VA hospital.

The VA also drapes a deceased veteran’s casket with an American flag (which is then presented to the next of kin) and arranges for a military honor guard and the blowing of Taps at graveside. In the early 1990s, the manpower-short military services and the VA tried to reduce the size of honor guard contingents, substitute honor guards from Reservist or even ROTC units and use tape-cassette Taps recordings rather than live buglers. An outcry by veterans groups and members of Congress stamped out most of these “economies”. But they could return at future times when military commitments reduce available manpower---as was demonstrated when the Army shipped the whole Arlington Cemetery ceremonial burial unit (well known for its horses,caissons, buglers, dress uniforms and gun salutes) to the Gulf as reinforcements in late 2003. 

The VA arranges for a letter signed by the President thanking the deceased veteran’s next of kin for his or her service to the nation. In addition to military life insurance, all military branches pay “death gratuities” of $12,000, all tax-free to survivors of those dying while on active duty. Such death-while-on-active-duty survivors also get up to 6 months of the service member’s housing allowances after the death, full coverage of burial costs, an income tax reduction for at least one year, tax breaks on survivors’ post-death home sales and child care, some military “space-available” travel and premium-free Tricare health coverage of survivors for 3 years (after which they can get premium free, lifetime CHAMPVA health coverage), plus any applicable VA and state veteran survivor benefits. See and “Armed Forces Tax Benefits” at for details. 

Additional State Benefits For Veterans, Dependents & Survivors

Surprisingly, almost all states not only have offices that provide free advocacy for federal VA benefits to their residents; all of them also provide their own, separate state veterans’ benefits as well ! These vary enormously from state to state---often depending upon whether a veteran is service-connected disabled, the percentage of the disability, wartime or combat service, or whether a veteran suffers from, or dies of,  war-, combat-, or service-connected causes, or was decorated.

They can include: free or reduced fee fishing, hunting, drivers’ or professional licenses; free, reduced fee and/or specially-marked auto license plates; free cemetery interment or burial allowances; exemption or reductions in state income taxes or even local real estate or personal property taxes; free or reduced tuition in state colleges and vocational training courses; other loans, grants or scholarships for veterans, children and spouses of disabled or deceased veterans; rights to reside for free or at low rates in state veterans’ group homes; home mortgage, or home or automobile disability adaptation assistance, to supplement what the VA provides; extra state payments to disabled, blind, combat  or wartime veterans; waivers of some or all state or local real estate or courthouse fees; extra state payments to decorated veterans; and a host of other miscellaneous benefits.

To find out which states offer which of this wide range of benefits (and, of course, most states don’t offer anything like all of them) contact staff at state veterans’ agencies, which are listed at or

Other Veterans’ Benefits

  • Veteran's Advantage
    for an annual membership fee of $19.95, offers a wide range of retail discounts---including
    15% or more off Amtrak fares. Call 1-866-838-7392 for Amtrak details , .

  • Disabled American Veterans

  • Paralyzed Veterans of America

  • American Legion

  • Veterans of Foreign Wars 

  • Vietnam Veterans of America
    offer a wide range of  free or reasonably-priced benefits and group buying discounts—sometimes
    including health and life insurance policies---to members, dependents and survivors .

  • Operation Hero Miles
    transfers donated airline frequent flyer miles to combat-area, overseas military personnel to fly
    them from U.S. military reception airports (there are only 3) to their homes for family emergencies
    and any R & R leave that’s otherwise-uncovered; its donated miles are also available for needy
    family members’ travel to hospitalized service persons; check the website for other, related uses
    being developed.

  • NetPets
    Military, National Guard and Reserve personnel transferred to war zones or called for  active duty
    an get free (except for veterinary care) foster care for their pet dogs, cats and birds

  • USO
    (yes, the same organization that sponsored all those Bob Hope shows for the troops over the years
    andwas fictionalized in the Bette Midler film For the Boys) promotes free telephone calling cards for
    overseas troops

Percentages of American Males, By Age Band, Who Are Veterans

In March 1998, the Census Bureau’s Current Population Survey reported the following percentages of
American males to be veterans, by age band: 

  • Over 6560%+   World War II  and Korean War Era

  • 60-64…….50%     Korean War and Cold War Era

  • 55-59…….40%     Vietnam and Cold War Era

  • 50-54…….42%     Vietnam and Cold War Era

  • 45-49…….28%     End of Draft, Vietnam Wind-down

  • 40-44…….15%     End of Draft, Vietnam Wind-down, Gulf War, Grenada

  • 35-39…….12%     Central America , Gulf War, Panama

  • 30-34…….10%     Gulf War, Panama, Somalia, Haiti

  • 25-29…….. 8%     Somalia, Haiti, Bosnia, Ruanda, Kosovo

  • 20-24……  .4%     Bosnia, Ruanda, Kosovo

(The Veterans’ Administration notes that a small percentage of women are also veterans.)

Special Rules For Those Who First Enlisted After September 7, 1980

 *Those first enlisting after September 7, 1980 must, in addition, serve at least 24 months’ total active service

  1. They were activated Reservists or National Guardsmen who served out their full activated tour, even if it was less than 24 months (for a pension, the 90 days’ active service and one-day-of-wartime rules also apply; but medical care only requires the 180 days’ active service time minimum or being found service-connected disabled).

  2. They got early honorable or general discharges before 24 months because of hardship or disability (again, the 90 days’ active service minimum and one-day-of-wartime rules still apply for pensions; but medical care only requires the 180 days’ active service time minimum or being found service-connected disabled)

  3. They got early honorable or general discharges before 24 months because of hardship or disability (again, the 90 days’ active service minimum and one-day-of-wartime rules still apply for pensions; but medical care only requires the 180 days’ active service time minimum or being found service-connected disabled).

State Veterans Benefits Advocacy Agencies

(These state—not federal-- agencies provide free, expert help to state residents in applying for---or
appealing denials of--- VA compensation, pensions, medical care and other benefits. These are state
headquarters offices; in all but the smallest states, there are branch offices to assist veterans in local communities. Some larger states offer in-state 800-number service; ask your information operator to check under the state—not federal—listings. For a complete, nationwide and updated listing of addresses, telephone numbers, websites and email addresses
go to the website of the National Association of State Directors of Veterans Affairs.

Addendum A: Calculating New Regional Priority Group 8 Minimum Income Levels

  1. to see whether a particular locality is in, or not in, a Standard Metropolitan Statistical
    Area (SMSA) within a state, see tp:// and consult the document entitled  “Income Limit Area Definitions”. 

  2. to calculate that locality's SMSA or non-SMSA family-sized limits within a given
    state, consult Attachment 2 of a document called “Transmittal Notice on Estimated Median
    Family Incomes For FY 2003…” at that same site. Note the SMSA or non-SMSA family
    median for the state, as applicable to your  locality. 

  3. multiply that median figure by .80, which gives median of the housing programs’ maximum
    “low income” limit for an “average”  family.

  4. to then get the different levels (which of course will vary) for each family size, multiply that
    sum by .70 for one person; .80 for two; .90 for 3; 1.00 for 4; 1.08 for 5; 1.16 for 6; 1.24 for 7; and
    1.32 for 8.  

This  yields the family-sized upper income limit for housing assistance in a locality---and non-
service-connected veterans with income ABOVE this income level are now in Priority Group 8 !

(Those uncomfortable with these complex calculations can call 1-800-245-2691 and at least attempt
to get the poorly trained, clerical-level, low-paid contractor phone bank employees answering to
provide locality-specific [and family-sized] upper income limits for federal housing assistance.
Good luck !)

Addendum B: What Conditions Qualify as “Catastrophically Disabled”?

(Veterans with the following conditions---even if they’re non-service-connected and no matter how big
their income or assets—can apply and qualify for Priority Group 4 status.
But their copayments for
treatment of non-service-connected conditions---unless they’re rated 30% or more service-connected, 
in which case only the $7 drug copayment applies---would be those of  Priority Group 5,  7 or 8,
depending on  their income and assets.)

A. One of the following:

  1. Quadriplegia and quadriparesis  (International Classification of Diseases – 9th edition-Clinical
    Modification (ICD-9-CM) Code 344.0x: 344.00, 344.01, 344.02, 344.03, 344.04, 344.09).

  2. Paraplegia (ICD-9-CM Code 344.1).

  3. Blindness (ICD-9-CM Code 369.4).

  4. Persistent vegetative state (ICD-9-CM Code 780.03)


B.  A condition resulting from two of the following ICD-9-CM procedure codes or associated V
codes when available or Current Procedural Terminology (CPT) codes, provided the two
amputation procedures were not  on the same limb

  1. Amputation through hand. (ICD-9-CM Code 84.03 or V Code V49.63 or CPT Code 25927)

  2. Disarticulation of wrist. (ICD-9-CM Code 84.04 or V Code V49.64 or CPT Code 25920)

  3. Amputation through forearm. (ICD-9-CM Code 84.05 or V Code V49.65 or CPT Codes 25900,

  4. Disarticulation of forearm. (ICD-9-CM Code 84.05 or V Code V49.66 or CPT Codes 25900,

  5. Amputation or disarticulation through elbow. (ICD-9-CM Code 84.06 or V Code V49.66 or CPT Code 24999)

  6. Amputation through humerus. (ICD-9-CM Code 84.07 or V Code V49.66 or CPT Codes 24900, 24920)

  7. Shoulder disarticulation. (ICD-9-CM Code 84.08 or V Code V49.67 or CPT Code 23920)

  8. Forequarter amputation. (ICD-9-CM Code 84.09 or [no V Code] or CPT Code 23900)

  9. Lower limb amputation not otherwise specified. (ICD-9-CM Code 84.10 or V Code V49.70 or CPT Codes 27880, 27882)

  10. Amputation of great toe. (ICD-9-CM Code 84.11 or V Code V49.71 or see CPT Codes 28810, 28820) 
    The CPT codes do not delineate the “great” toe as does ICD-9-CM so a medical review of the record is needed to confirm the amputation was of the great toe.

  11. Amputation through foot. (ICD-9-CM Code 84.12 or V Code V49.73 or CPT Codes 28800, 28805) 

  12. Disarticulation of ankle. (ICD-9-CM Code 84.13 or V Code V49.74 or CPT Code 27889) 

  13. Other amputation below knee. (ICD-9-CM Code 84.15 or V Code V49.75 or CPT Codes 27880,
    27882)Disarticulation of knee. (ICD-9-CM Code 84.16 or V Code V49.76 or CPT Code 27598)

  14. Above knee amputation. (ICD-9-CM Code 84.17 or V Code V49.76 or CPT Code 27598)

  15. Disarticulation of hip. (ICD-9-CM Code 84.18 or V Code V49.77 or CPT Code 27295)

  16. Hindquarter amputation. (ICD-9-CM Code 84.19 or [no V Code] or CPT Code 27290)


C . One of the following permanent conditions: 

  1. Dependent in three or more Activities of Daily Living (ADL) i.e., eating, dressing, bathing
    toileting, transferring, incontinence of bowel and/or bladder, with at least three of the
    dependencies being permanent with a score of 1, using the Katz scale
    NOTE:   The Katz
    Index of ADL assigns a maximum of 18 points across all six ADLs.  The most dependent rating on each ADL is a 1, and an intermediate functional limitation is a rating of 2, with independence rated as 3.  To be catastrophically disabled, the veteran must have a rating of 1 on a minimum of three permanent ADLs.  For example, a veteran dependent in all ADLs would have a total Katz score of 6.  Similarly, a veteran dependent in three ADLs and needing less assistance in three other ADLs would score 9.

  2. A score of 10 or lower using the Folstein Mini-Mental State Examination (MMSE). 
    NOTE:  The MMSE has a maximum assignment of 30 points across eleven measures.  A score of less than 10 is consistent with severe cognitive impairment.  To qualify for catastrophically disabled status, there must  be documentation in addition to the MMSE score of 10 or lower, showing that the patient has a permanent cognitive impairment.  To show that the impairment is permanent, the reversible causes of cognitive impairment should be ruled out.  A common example is a delirious patient who may score very badly on the MMSE, but improve once the source of delirium is treated.  It is also important for evaluators to remember that a low MMSE score by itself is not diagnostic (i.e., it is not specifically diagnostic of
    dementia), but it is an indication of cognitive impairment that warrants further evaluation.

  3. A score of 2 or lower on at least four of the thirteen motor items using the Functional
    Independence Measure (FIM)
    NOTE:  The FIM contains eighteen measures in six domains.  The thirteen motor items are in four domains:  self-care; sphincter control; transfers; and locomotion.  The scores across all these domains range from needing a helper because of complete dependence (score of 1 for total assistance and a score of 2 for maximal assistance), with intermediate scores 3
    through 5 for modified independence, to scores 6 or 7 when no helper is needed.  To be catastrophically disabled, the veteran must have a score of 2 or lower on at least four permanent conditions of the thirteen motor items using the FIM.

  4. A score of 30 or lower using the Global Assessment of Functioning (GAF)
    NOTE:  The GA is taken directly from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), p. 32, except that VHA only includes scores from 1 to 100, excluding 0 (insufficient information)

  • GAF is a 100-point scale divided into ten defined levels, with higher scores indicating a higher overall level of functioning.  For example, the Description of the GAF level 21 to 30 is as follows: “Behavior is considerably influenced by delusions or hallucination or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, homeor friends).”

  • GAF is to be used only to reflect psychological, social, and occupational functioning. Impairment in functioning due to physical illness or environmental limitations are not to be taken into consideration in using this scale.  The scale rates both functioning and, particularly in the higher  ratings, the severity of symptoms due to a mental disorder.  Use of the GAF for documenting catastrophically disabled may be only done in the context of a mental disorder considered to be of a permanent nature.  For example, a patient with a serious suicidal attempt might well rate a score under 30, but generally within a few days or weeks will return to a much higher level both symptomatically and functionally. 

Most veterans keep copies on hand of their discharge forms (DD214s); but those who’ve lost them can request copies by writing to the National Personnel Records Center (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132 – 5100. One can also request military medical care and other records from this facility. Requests can be made with an ordinary written letter, or on a SF 180 form, downloadable at or at .
Provide one’s full name, date of birth, military service number, Social Security number, branch of service, dates of service, military rank at discharge and current address. Women who served before marriage should provide their maiden names Getting a response can take several months---and a catastrophic fire in 1973
destroyed the only known copies of many records from the early Cold War years.

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