Eligibility Reform
In October 1996, Congress passed Public Law 104-262, the Veterans’ Health Care Eligibility Reform Act of 1996. This legislation led the way for the creation of a Uniform Benefits Package - a standard health benefit plan available to all veterans. The package not only opens up services to veterans , but simplifies the process by which veterans can receive the services.
For the first time, VA can offer enrolled veterans a Uniform Benefits Package that emphasizes preventive medicine and primary care, and that provides a comprehensive healthcare benefit plan including inpatient and outpatient treatment.
The law has simplified the rules for providing healthcare to veterans. It has also streamlined the process by which veterans present themselves for care - the enrollment process. These changes will make it easier for veterans to receive care than ever before.
What hasn’t changed is VA’s service orientation. As an organization, we have made a renewed commitment to excellence. And as healthcare professionals, we have reaffirmed our dedication to the well-being of our patients—America’s veterans.
An emphasis on needed care
With the new law, the determining factor is no longer the care that a patient is eligible to receive, but the kind of care that the patient needs.
This means that enrolled veterans are our patients for most outpatient and hospital care that they need.
Under the Uniform Benefits Package, "need" means any necessary medical outpatient or inpatient care that will:
promote, preserve, or restore health,
has been prescribed by a VA clinical care provider,
is consistent with generally accepted standards of clinical practice.
Veterans must first be enrolled to receive care
To receive healthcare under the new program, veterans must first be enrolled.
Veterans can obtain application forms for enrollment by visiting, calling, or writing to their nearest VA healthcare facility or veterans benefits office. Completed applications may be submitted in person or by mail.
A veteran who has received care from VA between October 1, 1996 and January 30, 1998 may have their application for enrollment automatically processed. They should check with their local VA location of care to be sure. Veterans may apply for enrollment at any time, even after October 1, 1998.
Some veterans are not required to apply…
Veterans are not required to apply for enrollment if they fall into one of the following categories:
VA has rated them disabled with a service-connected condition of 50% or more
Less than one year has passed since they were discharged from military service for a disability that the military determined was incurred or aggravated in the line of duty,
but that VA has not yet ratedThey are seeking care from VA only for a service-connected disability
…but VA is encouraging all veterans to apply
VA is encouraging all veterans to apply, even if they fall into one of these categories. Their application will help us plan more effectively to meet future healthcare needs, and will also help us provide better preventive care.
Enrollment means comprehensive care under the Uniform Benefits Package
Enrollment means veterans are eligible for a comprehensive healthcare benefits package of inpatient and outpatient services. Among these services are the following:
Preventive services, including immunizations, screening tests, and health education and training classes
Primary medical care, including outpatient surgery
Diagnosis and treatment
Surgery
Mental Health and Substance Abuse Treatment
Home healthcare
Respite and Hospice Care
Emergency care in VA facilities
Drugs and Pharmaceuticals
Hearing Aid & Eyeglass Restrictions
Hearing aids and eyeglasses require a service-connected disability rating of 10% or more, and are not usually provided for normal hearing or vision loss.
Healthcare tailored to the individual medical needs of veterans
VA healthcare is no longer restricted to specific "disabilities." Enrolled veterans will receive all the medical services and hospital care they need in the clinical setting that is most appropriate for them—inpatient, outpatient, or at home. This means that VA can now offer primary care that is readily accessible and integrated with other healthcare services. We offer programs that integrate primary care with case management, that promote good health, and that prevent illness.
Exclusions
Some medical services not normally covered by the Uniform Benefits Package include cosmetic surgery, sterilization, abortion, membership in health clubs or spas for rehabilitation, special private duty nursing, and gender alteration.
Drugs and medical devices not approved by the Food and Drug Administration are not covered, except under special circumstances.
Benefits for maternity care are currently not covered, though this coverage is still under consideration and may be offered in the future.
The law has not changed the requirements for limited home nursing care,
domiciliary care, limited dental care, adult health day care, homeless programs, sexual trauma counseling, and non-VA hospitalization. Enrolled veterans may be eligible for these programs, but they are not part of the Uniform Benefits Package.
Veterans should keep their existing healthcare coverage
VA encourages veterans to retain any existing healthcare coverage they may have. VA enrollment can be used as a complement to such coverage.
Veterans can apply at any VA medical facility or veterans benefit office,
at any time, in any year
After veterans have completed the application for enrollment, including means test and income screening, if appropriate, VA staff will determine their initial priority group and process their application. The Health Eligibility Center will validate the information and send veterans a letter concerning their enrollment. For patients new to VA, their applications for enrollment will be generated automatically as part of their patient registration process the first time they visit a VA health facility for care.
New, simplified application process: VA Form 10-10EZ
VA Form 10-10 EZ is a one page application form, front and back. It replaces an 11-page application form. With the introduction of the VA Form 10-10 EZ, application time has been reduced from more than three hours to less than 15 minutes for most veterans.
Enrollments are renewed annually
Once enrolled, veterans will remain enrolled for one year. Renewal is automatic, unless the veteran asks not to re-enroll, or changes in VA funding have reduced the number of enrollment priority groups treated in a given fiscal year. Each year veterans will receive
a VA Form 10-10 EZR on which they can indicate changes in demographics or personal financial status.
Veterans may select a "preferred VA facility" to provide their primary care
Enrolled veterans may select a "preferred facility" for receiving primary care. A preferred facility is any VA location of care—for example, VA Medical Center, Independent Clinic, or Community Based Outpatient Clinic—that the veteran identifies as the facility at which they wish their primary care to be delivered.
The preferred VA facility is responsible for providing the healthcare veterans need
If for any reason a selected facility is unable to provide the healthcare needed by an enrolled veteran, that facility must make arrangements for that care to be provided by another VA facility or by one of VA’s private sector contract affiliates.
Enrollment assures veterans the same level of care throughout the VA system
Enrollment gives the veteran access to a uniform level of care anywhere in the VA healthcare system—including 1,100 facilities nationwide. For the first time, patients receive a comprehensive healthcare benefits package that is completely portable across the entire VA system.
RIGHT Now
Key Points
A veteran may apply to enroll at any VA healthcare facility or veterans benefit office at any time, in any year. There is no time limit regarding application for enrollment.
Veterans must be enrolled to receive care from a VA healthcare facility.
Enrollment is on an annual basis, and enrollments are reviewed every year.
Renewal is automatic, unless the veteran chooses not to enroll or if VA resources limit the number of veterans to whom VA can provide care.
Enrollment levels are based on seven priority groups established by Congress.
Comprehensive care includes all needed outpatient and inpatient services.
Domiciliary care, nursing home, limited dental care and community nursing home care are not part of the uniform benefits package, though some enrolled veterans may be eligible for these programs under other VA authorities for care.
There is a new emphasis on preventive medicine and primary care.
Medications are covered by the program, as long as they have been prescribed by a physician employed by or under contract to VA. Some veterans will be required to make a co-payment for medication.
Veterans are encouraged to retain any existing healthcare coverage they may already have
Veterans may choose their preferred facility for receiving primary care
An enrolled veteran can receive a uniform level of care anywhere in the VA system—over 1,100 facilities in all.
Priority Groups
Priority Group 1
Veterans with service-connected conditions rated 50 percent or more disabling
Priority Group 2
Veterans with service-connected conditions rated 30 to 40 percent or more disabling
Priority Group 3
Veterans who are former POWs
Veterans with service-connected conditions rated 10 or 20 percent disabling
Veterans discharged from active duty for a disability occurred or aggravated in the line of duty
Veterans awarded special eligibility classification under 38 U.S.C., Section 1151
Priority Group 4
Veterans who are receiving aid and attendance or housebound benefits
Veterans who have been determined by VA to be catastrophically disabled
Priority Group 5
Nonservice-connected veterans and service-connected veterans rated zero percent disabled, whose income and net worth are below the established dollar thresholds
Priority Group 6
All other eligible veterans who are not required to make co-payments for their care, including:
World War I and Mexican Border War veterans
Veterans solely seeking care for disorders associated with exposure to a toxic substance, radiation, or for disorders associated with service in the Persian Gulf
Compensable zero percent service-connected veterans
Priority Group 7
Nonservice-connected veterans and zero percent service-connected veterans with income and net worth above the statutory threshold and who agree to pay specified co-payments.
