The Veterans Administration (VA) provides health care benefits to veterans. The plan covers a number of health care services, including preventative services, diagnostic and treatment services, and hospitalization. It may also cover nursing home and other long-term care options.
Who is Eligible?
To receive care, most veterans must be enrolled in the VA health system. Eligibility for the health system depends on a number of factors, including the nature of your discharge from military service, your length of service, whether you have service-connected disabilities, your income level, and available VA resources, among others.
To be eligible, you must not have been dishonorably discharged from the military. Your length of service may also be important. Former enlisted persons who started active duty before September 8, 1980, and former officers who first entered active duty before October 17, 1981, do not have a length-of-service requirement. Otherwise you must have 24 months of continuous active duty military service, though there are several exceptions for reservists, national guard members, service-connected disabilities, and hardship discharges, among others.
Certain veterans do not need to be enrolled in the VA health system to receive benefits if: you are 50 percent or more disabled from a service-connected disability, you are seeking care for a VA rated service-connected disability, or it has been less than one year since you were discharged for a disability that the military determined was caused or aggravated by your service, but the VA has not yet rated the disability.
The VA has limited resources, so if you are eligible for services, you will be assigned to a priority group. The priority groups range from 1-8 with 1 being the highest priority for enrollment. To see the priority list, click here. As of Jan. 17, 2003, veterans assigned to priority 8 are not eligible for enrollment or care for non-service connected conditions.
What Is Covered
The standard benefits package includes: Preventative care services, outpatient diagnostic and treatment services (including mental health and substance abuse treatment), inpatient diagnostic and treatment services, prescriptions, and long-term care (including nursing home care for some veterans).
Long-term care. The VA offers a number of long-term care options through its health plan.
All enrolled veterans are eligible for the following services:
- Geriatric evaluation—provides either an inpatient or outpatient evaluation of a veteran’s ability to care for him or herself.
- Adult day health care—a therapeutic day care program that provides medical and rehabilitation services to veterans
- Respite care—provides either inpatient or outpatient supportive care for veterans to allow caregivers to get a break
- Home care—nursing, physical therapy, and other services provided in the veteran’s home
- Hospice/palliative care—provides services for terminally ill veterans and their families
Some services are limited to certain veterans: nursing home care and domiciliary care are not automatically available to all veterans enrolled in the VA health plan.
The following veterans automatically qualify for unlimited nursing home care:
- Veterans who are seeking nursing home care for a service-related condition
- Veterans with a service-connected disability rating of 70 percent or more
- Veterans who have a service-connected disability of 60 percent and are unemployable
A service-connected disability is a disability that the VA has officially ruled was incurred or aggravated while on active duty in the military and in the line of duty. The VA must rule that your illness/condition is directly related to your active military service, and it assigns each disability a rating. The ratings are established by VA regional offices around the country.
NURSING HOME CARE
The VA may provide nursing home care to other veterans if space permits. Veterans with service-connected disabilities receive priority.
There are also state-run veteran’s nursing homes. The VA provides funds to states to help them build the homes and pays a portion of the costs for veterans eligible for VA health care. The states, however, set eligibility criteria for admission.
For more information click on the availability of Nursing Home Care for Veterans, click here.
A Domiciliary is a VA facility that provides care on an ambulatory self-care basis for veterans disabled by age or disease who are not in need of acute hospitalization and who do not need the skilled nursing services provided in a nursing home. Domiciliary care is available to low-income veterans with a disability.
There are no costs for certain veterans and low-income veterans. The following veterans are eligible to receive cost-free health care benefits automatically:
- A service-connected veteran receiving VA compensation benefits
- A veteran seeking care for a specific service-connected disability
- Former POWs
- Purple Heart Medal recipients
- A veteran with conditions related to exposure to herbicides during the Vietnam-era, ionizing radiation during atmospheric testing, ionizing radiation during the occupation of Hiroshima and Nagasaki
- A veteran who sustained a service-related condition while serving in the Gulf War, in combat in a war after the Gulf War, or during a period of hostility after November 11, 1998
- A veteran with military sexual trauma
- A veteran with cancer of the head or neck caused by nose or throat radium
treatments given while in the military
- A veteran who is participating in a VA approved research project
If you don’t fit into one of those categories, the VA will ask you to provide your household income and net worth from the previous year. If your income is below certain thresholds, you will not have to make a co-payment. Click here to view the thresholds for income. In addition, you must not have more than $80,000 in property. Those whose income exceeds the threshold or who refuse to submit to the means test may have to make a co-payment.
Unlike Medi-Cal program, there is currently no penalty for transferring assets before applying for veterans benefits, including long-term care. Remember, however, that if you do transfer assets it may affect your eligibility for Medi-Cal. CAUTION: the VA has announced that it intends to issue regulations to severely penalize asset transfers made within three (3) years of application, and we anticipate the release of these regulations in the Spring of 2016. We currently do not know whether they will have retroactive effect. So, before giving away assets as a planning technique, it would be wise to consult with an Elder Law Attorney who has been certified to handle veterans claims. For an article on topic for non-professionals click here, and for professionals click here.
Even if your income is above the threshold, you do not have to make co-payments for the following services:
- Special registry examinations offered by the VA to evaluate possible health risks associated with military service
- Counseling and care for sexual trauma
- Compensation and pension examination requested by the Veterans Benefit Administration
- Care that is part of a VA-approved research project
- Outpatient dental care
- Readjustment counseling and related mental health services for Post Traumatic Stress Disorder
- Emergency Treatment at other than VA facilities
- Care for cancer of the head or neck caused from nose or throat radium treatments given while in the military
- Publicly announced VA public health initiatives — i.e., health fairs
- Care related to service for veterans who served in combat or against a hostile force during a period of hostilities after November 11, 1998
- Laboratory services such as flat film radiology services and electrocardiograms
Outpatient co-payments. The following are the outpatient co-payments for non-service-related conditions:
- Services provided by a primary care clinician are $15 (in 2008) for each visit
- Services provided by a clinical specialist are $50 (in 2008) for each visit
Preventive care services (such as screenings and immunizations) are free.
Inpatient co-payments. The inpatient co-payment is calculated by adding:
- $10 per day of hospitalization (in 2008), and
- $1,024 for the first 90 days of hospitalization and $512 for each additional 90 days (in 2008).
There is a reduced co-payment rate (20 percent of the full inpatient rate) for certain individuals whose income is above the VA income thresholds, but below the Geographic Means Threshold (GMT). Click here to see if you are below the GMT.
Prescription co-payments. Prescription co-payments are charged only for outpatient treatment. The following veterans do not have to pay anything for medications:
- A veteran who is 50 percent disabled or more with a service-connected disability
- A veteran who has been determined by the VA as unemployable due to his service-connected conditions
- A veteran who needs medication to treat a specific service-connected disability
- Former POWs
- A veteran whose income is below the maximum annual rate for a VA pension
- A veteran who needs medication to treat conditions related to a veteran’s exposure to herbicides during the Vietnam era ionizing radiation during atmospheric testing, or ionizing radiation during the occupation of Hiroshima and Nagasaki
- A veteran who served in the Gulf War, in combat after the Gulf War, or during a period of hostility after Nov. 11, 1998, and who needs medication to treat a service-related condition
- A veteran who needs medication to treat a military sexual trauma
- A veteran with cancer of the head or neck caused by nose or throat radium treatments given while in the military
- A veteran participating in a VA approved research project
If you don’t fit into one of these categories, you must pay $8 (in 2008) for each 30-day or less supply of medication. If you are in one of the Priority Groups 2 through 6, there is an annual limit on the amount you have to pay for prescriptions. You will not be charged more than $960 during the calendar year. If you are in Priority Groups 7 and 8, you will have to pay the full co-payment amount, with no annual limit.
The Medicare prescription drug benefit. As part of the new Medicare law enacted in December 2003, Congress added a modest prescription drug benefit, which took effect January 1, 2006. The benefit is available to anyone who is eligible for Medicare Part A or B coverage. The benefit is completely voluntary, so you must decide whether you want to participate in a plan or not based on your own situation. If you decide to participate in the Medicare plan, your VA prescription drug coverage will not be affected.
Most Medicare beneficiaries must choose a plan or be subject to significant financial penalties for late enrollment. However, because the VA prescription drug coverage is considered “creditable coverage,” you will not face a penalty if you do not sign up for the Medicare plan. If you disenroll or lose your VA prescription drug coverage, you will have 62 days to sign up for a Medicare plan without being subject to a penalty.
For more information on the Medicare Prescription Drug Benefit, click here.
Long-term care co-payments. The first 21 days of long-term care are free. Co-payments start on the 22nd day. Long-term care co-payments are calculated differently from other co-payments — they are set based on the individual veteran’s financial status. Veterans must fill out a financial assessment to determine their co-payments. This is a separate form from the form veterans had to fill out to determine if they were eligible for free health care. This form assesses your current income as opposed to the previous year’s income. The co-payments will be adjusted for each individual veteran based on his or her ability to pay. Once you have submitted a form, a social worker will contact you to let you know how much your co-payments will be.
What to do if you can’t afford co-payments. There are several options if you cannot afford your co-payments. One option is to request a waiver. You will have to submit proof that you can’t financially afford to make payments to the VA.
If your income changed since you applied for free health care, you can request a hardship determination. This will change your priority group assignment. To do this, you will need to provide current financial information to the VA.
Another option is to request a compromise and make a partial payment. Most compromise offers that are accepted must be for a lump sum payment payable in full 30 days from the date of acceptance of the offer.
How to Enroll for Health Benefits
You can fill out the form to enroll for health benefits online at https://www.1010ez.med.va.gov/sec/vha/1010ez/ or you can receive the form by calling 1-877-222-VETS (8387).
Once you complete and sign the form, mail it to your local VA health care facility. Click here to find the facility nearest you.
DISABILITY BENEFITS: COMPENSATION & PENSION:
The VA offers two disability programs. Disability compensation is available only for veterans with service-connected disabilities, while the disability pension benefit is available to anyone who served during wartime and has a disability. The disability does not have to be related to military service.
Disability COMPENSATION: For Service Connected Injuries:
If you have an injury or disease that happened while on active duty or if active duty made an existing injury or disease worse, you may be eligible for disability compensation. The amount of compensation you get depends on how disabled you are and whether you have children or other dependents. Click here to see the current compensation rates. Additional funds may be available if you have severe disabilities, such as loss of limbs, or a seriously disabled spouse.
Disability PENSION Benefit: For Non-Service Connected Disabilities:
The VA pays a pension to disabled veterans who are not able to work. The pension is also available for surviving spouses and children. This pension is available whether or not your disability is service-connected, but to be eligible you must meet the following requirements:
- You must not have been discharged under dishonorable conditions.
- If you enlisted before September 7, 1980, you must have served 90 days or more of active duty with at least one day during a period of war. Anyone who enlisted after September 7, 1980, however, must serve at least 24 months or the full period for which that person was called to serve.
- You must be permanently and totally disabled, or age 65 or older. You will need a letter from your doctor to prove that you are disabled if under age 65.
In addition, your household income must be below the yearly limit set by law; called the Maximum Annual Pension Rate (MAPR). The MAPR rates for 2016 are below, in the monthly amount; there was no increase for 2016.
|Veteran with no dependents: Vet Needs Aid & Attendance||$1,788/month|
|Veteran with a spouse or a child; Vet Needs Aid & Attendance||$2,120/month|
|Housebound veteran with no dependents||$1,310/month|
|Housebound veteran with one dependent||$1,642/month|
|Additional children||$2,020 for each child|
Your pension depends on your income. The VA pays the difference between your income and the MAPR. The pension is usually paid in 12 equal payments, i.e. on a monthly basis.
Example: John is a single veteran and has a yearly income of $6,000 from Social Security. His pension benefit would be $5,830 (11,830 – 6,000). Therefore, he would get approximately $486 a month.
Your household income does not include welfare benefits or Supplemental Security Income. Further, the income is offset by the amount of un-reimbursed medical expenses actually paid by the veteran or a member of his or her family. This can include premium payment for Medicare, Medigap, and long-term care insurance premiums; over-the-counter medications taken at a doctor’s recommendation; the cost of an in-home attendant that provides some medical or nursing services; and the cost of an assisted living facility. These expenses must be un-reimbursed in order to offset household income. This means that insurance must not pay the expenses. The expenses should also be recurring — this means they should recur every month.
WRITTEN CARE AGREMENTS: A very important planning idea. If care is being rendered to the Veteran by a family member who is being paid for his or her services, these payments may be deductible if (1) rendered pursuant to a written Care Agreement and (2) if the need for the care is approved by a treating physician. However, if an adult child is rendering care without compensation, sometimes merely arranging to pay the child for that care via a written Care Agreement may establish financial eligibility for the Veteran! The use of written Care Agreements as a planning tool can sometimes make all the difference, and a knowledgeable Elder Law attorney can be very helpful in this situation.
Aid and attendance. A veteran who needs the help of an attendant may qualify for additional help on top of the disability pension benefit. The veteran needs to show that he or she needs the help of an attendant on a regular basis. A veteran who lives in an assisted living facility is presumed to need aid and attendance.
A veteran who meets these requirements will get the difference between his or her income and the MAPR for Aid and Attendance, as per the rates set forth below (2010 figures). Note: the 2009 amounts remain unchanged for 2010:
|Veteran who needs aid and attendance and has no dependents||$19,736|
|Veteran who needs aid and attendance and has one dependent||$23,396|
How To Apply
You can apply for both disability benefits by filling out VA Form 21-526, Veteran’s Application for Compensation Or Pension. If available, you should attach copies of dependency records (marriage & children’s birth certificates) and current medical evidence (doctor & hospital reports). You can apply online at http://vabenefits.vba.va.gov/vonapp. Another option is to consult our firm. Our Elder Law Attorney, Gene L. Osofsky, Esq., has been accredited by the Veterans Administration to handle claims for pension. While we cannot accept all cases, we do invite cases where other Estate Planning, Medi-Cal planning, or Long Term Care issues are also involved. We invite you to telephone our office at 510-247-2555 or 925-847-0737 for a complmentary telephone pre-interview with our staff to help determine if an in depth office consultation would be meaningful.
For information regarding Veteran’s Disability Pensions for Non-Service Connected Disabilities, visit “VA Pension Benefits” at the Veterans Administration website.