|Case Management Update
Proper Screening for VA
Thomas P. McCormack
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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.
Except for genuine emergencies, the VA
prioritizes access, waiting times and availability of medical
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:
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.)
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
However, if the “Priority
Group 7” veteran does have some private health insurance the VA will bill
2004 Income and Asset Levels with Even Bigger Copays for Still Wealthier
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
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.
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 www.usmilitary.about.com 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 www.avps.org sells a comprehensive manual for about $100.
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
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.
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
Special Rules For
VA-Paid Care from Non-VA Medical Providers
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.
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:
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 www.VA.gov (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 www.eyecareamerica.org ( 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.
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 http://www.gao.gov/cgi-bin/getrpt?GAO-03-487 ).
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
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 www.VA.gov 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.
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:·
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
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
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
“Armed Forces Tax Benefits” at
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
anything like all of them) contact staff at state veterans’ agencies, which
are listed at
Percentages of American Males,
By Age Band, Who Are Veterans
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Proper Screening for VA Medical Eligibility Can
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