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
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Enrollment History
• The Veterans Health Care Eligibility Reform Act of 1996 (PL104262) 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
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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
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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
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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
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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
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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

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Basic Eligibility
Long Term Care
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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 benefits)
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Basic Eligibility
General Exclusions (partial listing)
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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
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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
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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
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Beneficiary Travel Eligibility
Veterans
Non-Veterans
• SC 30% or more for all conditions
• Allied Beneficiaries if country
reimburses VA
• 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
• Attendants: when VA determines
medially required
• Beneficiaries of Other Federal
Agencies if Agency reimburses
VA
• Donors/Support person: If part of
VA transplant care
• Travel for C&P exam
• Caregivers: National Caregiver
Support Program
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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
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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
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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
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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
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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
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QUESTIONS
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