Veterans Health Administration Chief Business Office

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Transcript Veterans Health Administration Chief Business Office

Enrollment History and Basic Eligibility Programs

Objective

Understand Enrollment History

Define and Review the Elements of Basic Eligibility

Understand Minimum Duty Exclusions

Outline the Medical Benefits Package

Overview of Beneficiary Travel 2

Enrollment History

The Veterans Health Care Eligibility Reform Act of 1996 (PL104 262) enacted 10/1/96.

Law required implementation of an annual enrollment system

Enrollment is managed in accordance with 8 specified priorities, with 1 being the highest priority

Medical Benefits Package available to all enrollees – a standard enhanced health benefits plan 3

Basic Eligibility What are the basic eligibility criteria?

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Basic Eligibility Define a Veteran

A Veteran is a person who served in the active military, naval or air service and who was discharged or released under conditions other than dishonorable

Former Reservists may be eligible for VA health care benefits if they served full-time and for operational or support (excludes training) purpose

Former National Guard members may be eligible for care or enrollment if mobilized by a Federal order 5

Basic Eligibility Character of Service:

Veterans with Honorable, General or Under Honorable Conditions character of discharge are eligible for VA health care benefits as long as minimum duty

requirements are met

Veterans given Other than Honorable (OTH) discharges and those upgraded from OTH to General require VARO review and decision before routine care may be provided 6

Basic Eligibility Minimum Duty Requirement

Persons enlisting in the Armed Forces after 9/7/80 (enlisted), or who entered on active duty after 10/16/81(officers), are not eligible for VHA benefits unless they completed:

24 months continuous active service, or

the full period for which they were called or ordered to active duty 7

Basic Eligibility Excluded Minimum Duty Requirement 38 USC 5303A - Minimum active duty requirements do not apply to persons discharged or released from active duty for:

Early out (enlisted only) -- 21 of 24 month tour or 33 of 36 month tour

Hardship

Disability that was incurred or aggravated in line of duty or veterans with compensable SC disability 8

Basic Eligibility Medical Benefits Package Enrolled Veterans have access to all benefits included in the medical benefits package.

   

Preventive Care Services Inpatient and Outpatient Diagnostics and Treatment Prescription Services (as prescribed by VA Physician)

Limited Benefits Ambulance Service

Eyeglasses and Hearing Aids

Non-VA Care

Prosthetics, Durable Medical Equipment and Rehabilitative Devices

Dental Care

Certain Counseling Services

VA Foreign Medical Program 9

Basic Eligibility Long Term Care

      

Geriatric Evaluations Adult Day Health Care Respite Care Home Health Care Hospice/Palliative care

Nursing Home Care (limited benefits) Veterans 70% or greater SC have mandatory access Domiciliary Care (limited b

enefits)

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Basic Eligibility General Exclusions (partial listing)

      

Abortion Counseling In-Vitro Fertilization Certain Cosmetic Surgeries Health club or spa membership Special private duty nursing Gender alteration Medical Care for Prisoners or inmates 11

Beneficiary Travel

Beneficiary Travel

VA is authorized to provide eligible Veterans and other beneficiaries mileage reimbursement for VA or VA authorized non VA healthcare or

when medically indicated “special mode” (ambulance, wheelchair van) for travel to and from VA, or VA authorized health care 12

Beneficiary Travel Funding

Beneficiary Travel (BT) is a discretionary program with funding directly from the yearly VA medical care appropriation

VISN Directors, based on anticipated patient demand, determine the amount of their budget to devote to patient travel reimbursement 13

Beneficiary Travel Eligibility

Veterans

SC 30% or more for all conditions

Traveling in connection with care for SC disability

In receipt VA pension

Previous year income does not exceed maximum VA pension rate

Projected income in travel year does not exceed maximum VA pension rate

Travel for C&P exam Non-Veterans

Allied Beneficiaries if country reimburses VA

Attendants: when VA determines medially required

Beneficiaries of Other Federal Agencies if Agency reimburses VA

Donors/Support person: If part of VA transplant care

Caregivers: National Caregiver Support Program 14

Expenses Paid

$0.41.5 per mile subject to deductibles

Actual cost of ferry fares, bridge, road & tunnel tolls, parking, baggage, meals and lodging up to 50% of that for local government employees (receipts required)

Actual cost of Special Mode transportation

Actual cost of common carrier not to exceed mileage unless POV is not readily available

Travel is paid from the Beneficiary’s residence (or place travel initiated) to and from the nearest VA facility that can actually provide the required care

On a case by case basis travel may be paid for any distance if financially favorable to government 15

Criteria for Approval

Round trip reimbursement:

Travel in connection with care or services scheduled prior to arrival at the VHA-designated facility, or

For emergency treatment Return (one-way) reimbursement:

Travel in connection with care or services not scheduled prior to arrival at the VHA-designated facility, and

Not for emergency treatment 16

Criteria for Approval (cont)

Special Mode Transportation:

Beneficiary meets BT administrative eligibility criteria, and

VA health care provider determines and documents that this mode of transport is clinically required 17

Application for Beneficiary Travel

Apply orally or in writing: receipt for each expense other than mileage

Apply for payment within 30 calendar days after travel (if NO special mode) or change in eligibility

Must receive prior approval for meals, lodging, and luggage

Generally payment AFTER appointment takes place 18

Expenses Not Paid

VA determines payment is counter productive to therapy

Solely for pick-up of medications or supplies when no care, treatment or examination is provided

Return travel following an irregular inpatient discharge 19

QUESTIONS

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