Enrolling in the Veterans Health Care System

Those seeking a VA benefit for the first time must submit a copy of their service discharge form (DD-214, DD-215, or for WWII veterans, a WD form), which documents service dates and type of discharge. The veteran's service discharge form should be kept in a safe location accessible to the veteran and next of kin or designated representative.

For most veterans, entry into the VA health care system begins by applying for enrollment. Application is submitted through VA Form 10-10EZ, Application for Health Benefits, which may be obtained from any VA health care facility or regional benefits office, or by calling 1-877-222-VETS (8387). Once enrolled, veterans can receive services at VA facilities anywhere in the country.

Veterans who are enrolled for VA health care are afforded privacy rights under federal law. VA's Notice of Privacy Practices is available at the VA health care Web site.

During enrollment, veterans are assigned to one of the priority groups VA uses to balance demand with resources. Changes in available resources may reduce the number of priority groups VA can enroll. If this occurs, VA will publicize the changes and notify affected enrollees. Veterans will be enrolled to the extent Congressional appropriations allow. If appropriations are limited, enrollment will occur based on the following priorities: (Please note that lower priority numbers generally mean no co-pays for medical services i.e. services are free)

Group 1: Veterans with service-connected disabilities rated 50 percent or more and/or veterans determined by VA to be unemployable due to service-connected conditions.

Group 2: Veterans with service-connected disabilities rated 30 or 40 percent.

Group 3: Veterans with service-connected disabilities rated 10 and 20 percent, veterans who are former Prisoners of War (POW) or were awarded a Purple Heart, veterans awarded special eligibility for disabilities incurred in treatment or participation in a VA Vocational Rehabilitation program, and veterans whose discharge was for a disability incurred or aggravated in the line of duty.

Group 4: Veterans receiving aid and attendance or housebound benefits and/or veterans determined by VA to be catastrophically disabled. Some veterans in this group may be responsible for co-pays.

Group 5: Veterans receiving VA pension benefits or eligible for Medicaid programs, and non service-connected veterans and non compensable, zero percent service-connected veterans whose annual income and net worth are below the established VA means test thresholds.

Group 6: Veterans of the Mexican border period or World War I; veterans seeking care solely for certain conditions associated with exposure to radiation or exposure to herbicides while serving inVietnam; for any illness associated with combat service in a war after the Gulf War or during a period of hostility after Nov. 11, 1998; for any illness associated with participation in tests conducted by the Defense Department as part of Project 112/Project SHAD; and veterans with zero percent service-connected disabilities who are receiving disability compensation benefits.

Group 7: Non service-connected veterans and non-compensable, zero percent service-connected veterans with income above VA's national means test threshold and below VA's geographic means test threshold, or with income below both the VA national threshold and the VA geographically based threshold, but whose net worth exceeds VA's ceiling (currently $80,000) who agree to pay co-pays.

Group 8: All other non service-connected veterans and zero percent, non-compensable service-connected veterans who agree to pay co-pays. (Note: Effective Jan. 17, 2003, VA no longer enrolls new veterans in priority group 8).

Co-payments for Medical Services -- Veterans Means Testing

VA uses means testing to determine a veteran's level of co-payments for medical services and in addition to accept or deny certain veterans applying for the first-time. Prior to 2003 VA allowed veterans to apply for medical coverage with any income level who were not required to meet means testing. These are veterans classified as priority 8. VA will no longer accept applications from these veterans. As the demand for services grows faster than funding, VA, in the future, may also exclude priority 7 veterans from enrolling in the system.

Although there are exceptions, as a general rule, veterans in priority categories 2 through 6 do not have to pay co-pays for the following services

  • inpatient services,
  • outpatient services or
  • long term care services.

In other words these services are free.

Veterans in priority categories 7 and 8 generally do have to pay co-pays but there are some exceptions if the veteran meets VA's mean test or the geographic means test.

In some states VA's mean test for maximum income is less than the geographic means test and in other states it is just the opposite.

The most important thing to remember about co-pays is that a veteran receiving VA pension is classified a priority 5 veteran. Priority 5 veterans receive free; inpatient care, outpatient care and long term care. They have no co-payments for medical services. The priority 5 veteran must pay VA prescription drug co-pays unless that veteran has a household income below the current pension maximum income rate . Those pension incomes for 2008 are found in the first column of the table below. Also note that priority 5 veterans do not have to pay any more than $960 a year for their prescriptions from a VA pharmacy if they do have to pay for drugs.

Veterans Means Test for Co-Pays (Low Income Financial Test) -- Financial Test Year 2008

Veteran with Free VA prescriptions and travel benefits (maximum allowable rate) Pension Rates

Free VA Health Care

(0% service connected {noncompensable} and nonservice-connected veterans only)

Medical Expenses
Deduction (5% of maximum allowable pension rate from previous year)

0 dependents $11,180 or less $28,429 or less $559
1 dependent $14,642 or less $34,117 or less $732
2 dependents $16,551 or less $36,026 or less $828
3 dependents $18,460 or less $37,935 or less $923
4 dependents $20,369 or less $39,844 or less $1,019
For each additional dependent add: $1,909 $1,909 5% of Maximum Allowable Pension Rate
Medicare Deductible: $1,019 Income & Asset net worth: $80,000

The GMT Income Threshold Test (geographic means test) could be higher or lower than the VA's means test. To obtain GMT income thresholds per state for purposes of qualifying under an enrollment priority go to http://www.va.gov/healtheligibility/Library/pubs/GMTIncomeThresholds/

2008 Co-payment Rates -- Effective January 1, 2008

Outpatient Services\*

Basic Care Services—services provided by a primary care clinician $15/visit

Specialty Care Services—services provided by a clinical specialist such as surgeon, radiologist, audiologist, optometrist, cardiologist, and specialty tests such as magnetic resonance imagery (MRI), computerized axial tomography (CAT) scan, and nuclear medicine studies $50/visit

*Co-pay amount is limited to a single charge per visit regardless of the number of health care providers seen in a single day. The copay amount is based on the highest level of service received. There is no copy requirement for preventive care services such as screenings and immunizations.

Medications

For each 30-day or less supply of medication for treatment of nonservice-connected condition $8

(Veterans in Priority Groups 2 through 6 are limited to a $960 annual cap)

VA does not charge a copay for medications used for treatment of —

  • A veteran who is 50% or more service-connected
  • A veteran who has been determined by VA as unemployable due to their service-connected conditions
  • A veteran's specific service-connected disability
  • A veteran who is a former POW
  • A veteran whose income is below the maximum annual rate for VA pension
  • A veteran's conditions related to a veteran's exposure to:
  • Herbicides during the Vietnam-era, OR
  • Ionizing radiation during atmospheric testing, OR
  • Ionizing radiation during the occupation of Hiroshima and Nagasaki
  • A service-related condition of a veteran who served:
    • In the Gulf War, OR
    • In combat in a war after the Gulf War, OR
    • During a period of hostility after November 11, 1998
  • A veteran's military sexual trauma
  • A veteran's cancer of head or neck caused by nose or throat radium treatments given while in the military
  • A veteran participating in a VA approved research project

Inpatient Services*\*

Inpatient copy for first 90 days of care during a 365-day period $1,024

Inpatient Copy for each additional 90 days of care during a 365-day period $512

Per Diem Charge $10/day

**Based on geographically-based means testing, lower income veterans who live in high-cost areas may qualify for a reduction of 80% of inpatient copy charges.

Long-Term Care

Nursing Home Care/Inpatient Respite Care/Geriatric Evaluation maximum of $97/day

Adult Day Health Care/Outpatient Geriatric Evaluation or Outpatient Respite Care maximum of $15/day

Geriatric Evaluation

Domiciliary Care maximum of $5/day

Co-pays for Long-Term Care services start on the 22nd day of care during any 12-month period—there is no copy requirement for the first 21 days. Actual copy charges will vary from veteran to veteran depending upon financial information submitted on VA Form 10-10EC.

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