1.1. Basic Eligibility

Basically, you are eligible for health care from the Department of Veterans Affairs if:

1. You served in the active military, naval or air service,

   "Served in the active military, naval or air services" means that you served in the uniformed services (Army, Navy, Marine Corps, Air Force, Coast Guard) on active duty.  If you were in the Reserves or National Guard AND you received federal orders calling you up for active duty AND you completed the full period for which you were called or ordered to active duty, then you may be eligible for VA health care.

   National Guard or Reserve duty does not count toward eligibility for VA healthcare if:

   1. It was ACDUTRA (Active Duty for Training), or
   2. It was by order of your state's Governor in response to an emergency.  (I know this stinks, but your service at the command of the Governor in response to a natural disaster or state emergency does NOT count toward VA health care eligibility.)
   3. For a period exceeding the minimum duty requirements,  depends on when you served in the active duty military.

2. Most veterans who enlisted after September 7, 1980, or entered active duty after October 16, 1981, must have served 24 continuous months or the full period for which they were called to active duty to be eligible.

   The minimum duty requirement may NOT apply if:

   1. You were discharged for a disability incurred or aggravated in the line of duty (typically this is known as a service-connected condition),
   2. You were discharged for a hardship,
   3. You received an "early out" (typically this is "for the good of the service"), or
   4. Any part of your service occurred prior to September 7, 1980.

   Note: There are a number of other exceptions to the minimum duty requirements, VA encourages all Veterans to apply so that VA can determine your enrollment eligibility if it's not clear.

3. Were separated under any condition other than dishonorable, 

   "Were separated from the service under conditions other than dishonorable"  simply means that you did NOT receive a DISHONORABLE DISCHARGE (DD) or a BAD CONDUCT DISCHARGE (BCD).  There are many different ways to be discharged or separated from the military.  Your separation code can be found on your DD-214.  It's Item 26.  You'll recall if you received a DD or BCD, because there would have been a court-martial involved.  For enlisted personnel, the general court martial would have resulted in a BCD (typically resulting in a confinement to a military prison), which would later be changed to a DD when all appellate reviews are completed.  For officers, the general court martial is considered dishonorable if the sentence included "dismissal" from the service.

   Like most everything in the VA, there are exceptions to almost every rule, including exceptions for some veterans with DD or BCD who may remain eligible for VA health care.  To see if an exception applies to your case, we suggest that you attempt to enroll in VA health care at your nearest VA facility and that you disclose the circumstances surrounding your DD or BCD to the VA's enrollment and eligibility department. 

    
4. Are in an eligible priority group designated annually by the Secretary.  For Prioity Groups, refer to section 1.2 of Chapter 1.

    

 

 

 

 

1.2. Enrollment Priority Groups

Each year, Congress allocates a certain amount of money for VA health care.  Based upon the amount of money, the Secretary of the Department of Veterans Affairs determines the number of veterans who can be enrolled in VA's health care programs.  Enrollment priority groups have been established so that the Secretary can exclude veterans in certain priority groups if inadequate funds are provided by Congress to serve all veterans.

When you enroll for health care, you will be assigned to a priority group.  If you qualify under multiple priority groups based on different criteria, you will be assigned to the highest priority group for which you are eligible.

Priority groups range from 1 (highest eligibility) to 8 (lowest eligibility) and take into consideration any service-connected disabilities, military awards, 1151 benefits, catastrophic disabilities, geographic means tests and other factors.  It is probably easiest to determine your priority group by referencing the table below.

Priority Group	Who Qualifies
1	Veterans with a VA service-connected rating of 50% or more. Veterans assigned a total disability rating for compensation based on unemployability (TDIU or IU)
2	Veterans with a VA service-connected rating of 30% or 40%.
3	Veterans who are former prisoners of war (POWs). Veterans who were awarded a Purple Heart. Veterans who were awarded the Medal of Honor. Veterans whose discharge was for a disability incurred or aggravated in the line of duty. Veterans with a VA service-connected rating of 10% or 20%. Veterans awarded special eligibility classification under 38 USC 1151, "benefits for individuals disabled by VA treatment or vocational rehabilitation."
4	Veterans receiving increased compensation or pension based upon their need for regular Aid and Attendance or by reason of being permanently housebound. Veterans determined by VA to be catastrophically disabled.  (See related Catastrophically Disabled Veterans page below.)
5	Nonservice-connected veterans and noncompensable service-connected veterans rated 0%, whose annual income and/or net worth are not greater than the VA financial thresholds. Veterans receiving VA pension benefits. Veterans eligible for Medicaid benefits.
6	Compensable service-connected veterans rated 0%. Veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima or Nagasaki. Project 112/SHAD participants. Veterans who served in the Republic of Vietnam between January 9, 1962 and May 7, 1975. Veterans who served in Southwest Asia theater of operations from August 2, 1990, through November 11, 1998. Veterans who served in a theater of combat operations after November 11, 1998, as follows: Veterans discharged from active duty on or after January 28, 2003, for five years post-discharge.  (See related Combat Veterans page below.)
7	Veterans with incomes below the geographic means test (GMT) threshold and who agree to pay the applicable copayments.
8	Veterans with gross household incomes above the VA national income threshold and the geographically-adjusted income threshold for their resident location and who agrees to pay copays.  If you are in priority group 8, see sub-priority group table below.

 

Priority group 8, Sub-priority groups

Sub-Priority Groups	Which Priority Group 8 veterans qualify
8a	Veterans who are noncompensable 0% service-connected and who were enrolled for VA healthcare as of January 16, 2003, and who have remained enrolled since that date and/ or placed in this subpriority due to changed eligibility status.
8b	Veterans who are noncompensable 0% service-connected and who enrolled for VA health care on or after June 15, 2009 and whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less.
8c	Veterans who are nonservice-connected and who enrolled for VA health care as January 16, 2003, and who remained enrolled since that date and/ or placed in this subpriority due to changed eligibility status
8d	Veterans who are nonservice-connected and who enrolled for VA health care on or after June 15, 2009 and whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less
8e	Veterans not meeting the criteria above and who are noncompensable 0% service connected.
8f	Veterans not meeting the criteria above and who are nonservice-connected.

1.3. Catastrophically Disabled Veterans

Veterans are Catastrophically Disabled when their injury, disorder or disease:

• Compromises their ability to carry out activities of daily living to such a degree that one requires personal or mechanical assistance to leave home or bed; or
• Requires constant supervision to avoid physical harm to oneself or others.

Benefits of the Catastrophically Disabled determination:

• The Veteran will be placed into priority group 4 ,unless eligible for a higher priority group.
• As of May 5, 2010 Per Public Law 111-163, the Caregiver and Veterans Omnibus Health Services Act of 2011,  Catastrophically disabled veterans are exempted from inpatient, outpatient, and prescription copays.   However, Veterans of this status may still be subject to copayments for extended care, long-term care, services.

The catastrophically disabled evaluation occurs when:

• A VA Clinician determines that there is sufficient medical documentation without further evaluation.
• A Veteran requests the evaluation by contacting:
  • the Enrollment Coordinator at their local VA health care facility, or
  • The Veteran should request to be evaluated by your VA primary care physician or VA Rehabilitation physician.  If you have medical evidence of a permanent, severely disabling injury, disorder or disease, from a non-VA physician or hospital, bring a copy of the evidence with you. Your VA physician may have to repeat certain tests, but bringing the evidence may speed up the evaluation process.  Note that the VA policy is to provide the evaluation wtihin 30 days of the request and there is no charge for the evaluation.

The following is a list of some injuries, disorders and diseases that may qualify as a catastrophic disability:

• Spinal Cord Injury-Quadriplegia and Quadriparesis or Paraplegia
• Persistent Vegetative State
• Traumatic Brain Injury
• Blindness
• Amputations- two amptuations but not of the same limb
• Multiple Sclerosis
• Parkinson's Disease
• Lou Gehrig's Disease (Amyotrophic Lateral Sclerosis (ALS)
• Neurological Disorders
• Psychological Conditions

There are three qualifying categories for this determination on the VA Form 10-0383 Evaluation:

Category 1A : The Veteran is catastrophically disabled if the Veteran has one of the following permanent conditions: Quadriplegia and Quadriparesis, Paraplegia, Blindness, or Persistent Vegetative State

Category 1B : The Veteran is catastrophically disabled if the Veteran has a permanent condition resulting from two amputations that were not of the same limb.

Category 2   : The Veteran is catastrophically disabled if the Veteran meets one of the following conditions.  Choose the scale evaluation that reflects the Veterans situation.

• Dependent in 3 or more activities of daily living (eating, dressing, toileting, transferring, incontinence of bowel, and/or bladder) with at least 3 of the being permanent with a score of 1, using the Katz Scale { Pro- Test is simple & Con- Limited range of activities assessed with ratings being subjective}, or
• A score of 10 or lower using the Folstein Mini-Mental State Examination {A brief psychological test to differentiate amond dementia, psychosis, and affective disorders.  It measures and evaluates cognitive function and mental impairment.}, or  
• A score of 2 or lower on at least 4 of the 13 motor items using the functional independence measure (FIM) { Scale for measuring level of assistance in Physical Rehabilitation}, or
• A score of 30 or lower using the Global Assessment of Functioning (GAF) (This test subjectively rates the social, occupational, and psychological functioning of adults.  Scores are given in a range.   The score of 21-30 states: Behavior is considerabley influenced by delusions or hallucinations or serious impairment, in communication or judgement {sometimes inchoherent, acts grossly inappropriately, or suicidal preoccupation} or inability to function in almost all areas {stays in bed all day, no job, home or friends})

Benefits specific to the catastrophically disabled classification:

• Category 4 status, despite incomes over attributable income limit, unless the Veteran qualifies for a higher priority category being priority categories 1, 2 or 3. 
• No co-pays for: VA Hospital care, VA medical services including out-patient services, Non-institutional alternative extended care services such as adult day health care or VA medications prescribed on an outpatient basis.  Note: There is a co-pay for VA Nursing Home Care.

 

         

 

1.4. Enhanced Health Care for Combat Veterans

"Combat Veterans" are defined as:

• Veterans, including activated Reservists and members of the National Guard, who served on active duty in a theater of combat operations after November 11, 1998,  and
• Have been discharged under other than dishonorable conditions

"Combat Veterans" are assigned to Priority Group 6, unless eligible for enrollment in a higher priority group, for a period of five years after discharge.  During this time, VA provides cost-free (no VA copayments) health care services and nursing home care for conditions potentially related to service in the theater of operations. 

Sometime during the 5 year period of cost-free care, Veterans need to enroll in the VA Health Care System using the VA Form 10-10EZ.  Enrollment during the 5 years of cost-free care, maintains the Veterans enrollment status in the VA Health Care System when the 5 year period ends.   At that time, VA will reassess the Veteran's eligibility and make a new enrollment priority group determination. 

 

2.1. Overview of the VA Medical Benefits Package

A medial benefits package is a package of health care services that is designed to promote good health, preserve your current health and/or restore you to better health.  Within the VA, the medical benefits package includes treating illnesses and injuries, preventing secondary health conditions or future health problems, improving functional abilities and enhancing your quality of life.

The VA is one of the Nation's largest health care providers and educators of the future medical practitioners.  The VA provides a full range of medically necessary services.  These services are provided based upon the judgment of a VA primary care physician and in accordance with the generally accepted standards of clinical practice.   Services provided by the VA include:

• Primary care – This is typically the first stop for VA medical services.  Once enrolled in the VA healthcare system, you will be assigned a primary care physician who will evaluate your overall health and coordinate additional services that are deemed medically necessary.
• Health promotion
• Disease prevention
• Diagnosis
• Palliative care
• Surgery
• Pharmacy benefits
• Prosthetics and durable medical equipment
• Critical care
• Mental health care and counseling
• Women's health care
• Orthopedics
• Radiology
• Physical and Occupational therapy
• Rehabilitation

2.2. VA's Specialized Care Units

There are a number of specialized care units in the VA health care system.  These inpatient units provide specialized health services to veterans with certain medical needs.  

• Intensive Care Units (medical, surgical, mental health, cardiac)
• Transplant Care Units
• Spinal Cord Injury (SCI) Centers
• Traumatic Brain Injury (TBI) Units
• PolyTrauma Centers

2.3. Polytrauma Care

Polytrauma care is for veterans and returning servicemembers who have sustained injuries to one or more physical region or organ system, one of which may be life threatening, and which results in physical, cognitive, psychological or psychosocial impairment and functional disability.

Polytrauma care is provide in a hub and spoke system.  That means that there are different levels of services that are provided at different VA facilities, but they should coordinate with one another to ensure that a veteran in need of PolyTrauma services is always receiving the most medically appropriate services by a competent team of experts.

Learn more about the VA Polytrauma Rehabilitation System.

There are: 

• Five (5) Polytrauma Rehabilitation Centers. (PRCs)
• Hunter Holmes Maguire VA Medical Center, Richmond, VA - 804-675-5000
• James A. Haley Veterans' Hospital, Tampa, FL - 813-716-7787
• Minneapolis VA Health Care System, Minneapolis, MN - 612-725-2000
• South Texas VA Health Care System, San Antonio, TX - 210-617-5300
• VA Palo Alto Health Care System, Palo Alto, CA - 650-493-5000
• Four (4) Polytrauma Transitional Rehabilitation Programs (PTRPs)
• Hunter Holmes Maguire VA Medical Center, Richmond, VA - 804-675-5000
• James A. Haley Veterans' Hospital, Tampa, FL - 813-716-7787
• Minneapolis VA Health Care System, Minneapolis, MN - 612-725-2000
• VA Palo Alto Health Care System, Palo Alto, CA - 650-493-5000
• Twenty three (23) Polytrauma Network Sites (PNSs)
• Eighty seven (87) PolyTrauma Support Clinic Teams (PSCTs)
• Thirty eight (38) PolyTrauma Points of Contact (POCs)

2.4. Transplant Centers

Solid organ (kidney, kidney/pancreas, liver, heart, heart/lung, and lung) and bone marrow/stem cell transplants are an important, life- saving procedure provided to eligible veterans by the Department of Veterans Affairs (VA). VA Transplant Centers are located across the country and have offered solid organ transplant services since 1962 and bone marrow transplant services since 1982. The VA National Transplant Program (VA Program) received over 1,500 referrals last year and performed approximately 400 transplants.

The transplant referral process has several steps and begins at the primary VA medical center where the patient is enrolled and eligibility is determined. If the veteran is determined to be a potential transplant candidate by the local VA medical center, a transplant referral packet is prepared locally and submitted to the VA Program located in Washington, DC. Questions regarding this process can be directed to the VA Program at 202.461.7130 or 1.800.60.HEART.

Over 100,000 men, women, and children are currently listed on the United Network for Organ Sharing (UNOS) national waiting list. Those veterans listed through the VA Transplant Centers are part of that same waiting list. Every 12 minutes another name is added to the list and an average of 18 people die each day because there are not enough organs available in this country. VA encourages all veterans, their families, and VA employees to become an organ donor by signing a donor card, identifying yourself as an "organ donor" in your state, e.g., joining your state donor registry, notice on driver's license; and discussing your decision to be an organ, tissue and eye donor with your family.

VA Transplant Centers are located at:

Bone Marrow

• Nashville, TN
• San Antonio, TX
• Seattle, WA

Kidney

• Birmingham, AL
• Miami, FL
• Iowa City, IA (Kidney and Pancreas)
• Nashville, TN
• Pittsburgh, PA
• Portland, OR

Liver

• Miami, FL
• Houston, TX
• Nashville, TN 
• Pittsburgh, PA
• Portland, OR
• Richmond, VA 
• Madison, WI

Heart

• Madison, WI 
• Nashville, TN 
• Palo Alto, CA 
• Richmond, VA
• Salt Lake City, UT 

Lung

• Baltimore, MD
• Seattle, WA
• Madison, WI 

2.5. Dental Services

Dental Services in the VA are provided to Veterans with certain eligibility requirements and they differ significantly from eligiblity requirements for all other types of medical care.  The dental benefits are categorized into eligibility classes.  Categories Class I, IIA, IIC, or IV are eligible to receive any necessary dental care to maintain or restore oral health and masticatory function, including repeat care.   Other classes have time and/or service limitations.   

If eligible, You can ask your VA primary care physician to obtain a referral to the outpatient dental clinic at the nearest VA medical facility or  by using VA Form 10-10EZ "Application for Health Benefits" to apply online at https://www.1010ez.med.va.gov. 

If you are not eligible for one of the classes, you may obtain dental services and treatment via the VA  comprehensive national VA Dental Insurance Program, VADIP, which provides enrolled VA Healthcare Veterans and CHAMPVA receipients with the opportunity to purchase reduced cost dental insurance either with Delta Dental or MetLife.   Participation is voluntary.  Purchasing a plan does not affect the Veterans current eligibility for VA dental services and treatment.

You are eligible for outpatient dental care if you meet one of the following criteria: 

If you:	You are eligible for:	Through
Have a service-connected compensable dental disability or condition.	Any needed dental care	Class I
Are a former prisoner of war.	Any needed dental care.	Class IIC
Have service-connected disabilities rated 100% disabling, or are unemployable and paid at the 100% rate due to service-connected conditions.	Any needed dental care. [Please note: Veterans paid at the 100% rate based on a temporary rating, such as extended hospitalization for a service-connected disability, convalescence or pre-stabilization are not eligible for comprehensive outpatient dental services based on this temporary rating].	Class IV
Apply for dental care within 180 days of discharge or release (under conditions other than dishonorable) from a period of active duty of 90 days or more during the Persian Gulf War era.	One-time dental care if your DD214 certificate of discharge does not indicate that a complete dental examination and all appropriate dental treatment had been rendered prior to discharge.*	Class II

Have a service-connected noncompensable dental condition or disability resulting from combat wounds or service trauma.	Any dental care necessary to provide and maintain a functioning dentition. A Dental Trauma Rating (VA Form 10-564-D) or VA Regional Office Rating Decision letter (VA Form 10-7131) identifies the tooth/teeth/condition(s) that are trauma rated.	Class IIA
Have a dental condition clinically determined by VA to be associated with and aggravating a service-connected medical condition.	Dental care to treat the oral conditions that are determined by a VA dental professional to have a direct and material detrimental effect to your service connected medical condition.	Class III
Are actively engaged in a 38 USC Chapter 31 vocational rehabilitation program.	Dental care to the extent necessary as determined by a VA dental professional to: Make possible your entrance into a rehabilitation program Achieve the goals of your vocational rehabilitation program Prevent interruption of your rehabilitation program Hasten the return to a rehabilitation program if you are in interrupted or leave status Hasten the return to a rehabilitation program of a Veteran placed in discontinued status because of illness, injury or a dental condition, or Secure and adjust to employment during the period of employment assistance, or enable you to achieve maximum independence in daily living.	Class V
Are receiving VA care or are scheduled for inpatient care and require dental care for a condition complicating a medical condition currently under treatment.	Dental care to treat the oral conditions that are determined by a VA dental professional to complicate your medical condition currently under treatment.	Class VI
Are an enrolled Veteran who may be homeless and receiving care under VHA Directive 2007-039.	A one-time course of dental care that is determined medically necessary to relieve pain, assist you to gain employment, or treat moderate, severe, or complicated and severe gingival and periodontal conditions.	Class IIB

 

VA Dental Insurance Program (VADIP)

VADIP was created to assess Veterans' interest in and the effectiveness of providing a premium-based dental insurance plan to eligible individuals. The program is mandated by Public Law 111-163, Caregivers and Veterans Omnibus Health Services Act of 2010. The three-year, national pilot program was launched January 1, 2014.

Eligibility for VADIP

Veterans enrolled in the VA health care program and CHAMPVA beneficiaries are eligible to participate in VADIP. Participation in VADIP does not affect Veterans' eligibility for VA dental services and treatment. Dependents of Veterans, except those eligible under CHAMPVA, are not eligible for VADIP.

Dental Plan Information

VA has contracted with Delta Dental and MetLife, private insurers, to administer VADIP. Individuals interested in participating in VADIP can complete an application online, over the phone or by mail. A direct link to each provider's VADIP webpage is available from www.va.gov/healthbenefits/VADIP. The following table shows contact information for each provider.

PROVIDER	TOLL-FREE NUMBER	WEBSITE	MAILING ADDRESS
Delta Dental	1-855-460-3302	www.deltadentalvadip.org	Delta Dental of California Federal Government Programs PO Box 537009 Sacramento, CA 95853-7009
MetLife	1-888-310-1681	www.metlife.com/VADIP	MetLife Dental Claims PO Box 981282 El Paso, TX 79998-1282

 

Coverage will be provided throughout the United States and its territories. The initial participation period will be at least 12 calendar months. Afterward, VADIP beneficiaries can renew their participation for another 12-month period or be covered month-to-month, as long as the participant remains eligible for coverage and VA continues VADIP. Multiple plan options allow participants to select a plan that provides benefits and premiums that meet their dental needs and budget. Offered plans vary and may include diagnostic, preventative, surgical, emergency and endodontic/restorative treatment. Each participant will pay a fixed monthly premium for coverage, in addition to any copayments required by his or her plan. 

For more information on VADIP, visit www.va.gov/healthbenefits/VADIP and click the insurer's link for specific information regarding registration, rates and services, or call Delta Dental at 1-855-370-3303 or MetLife at 1-888-310-1681.

 

Notes

a. Veterans paid at the 100% rate based on a temporary rating, such as extended hospitalization for a service-connected disability, convalescence or pre-stabilization are not eligible for comprehensive outpatient dental services based on this temporary rating.

b. Public Law 83 enacted June 16, 1955 amended Veterans' eligibility for outpatient dental services. As a result, any Veteran who received a dental award letter from VBA dated before 1955 in which VBA determined conditions to be noncompensable are no longer eligible for Class II outpatient dental treatment.

 

 

2.6. Pharmacy Services

The VA Pharmacy dispenses medically necessary medications as prescribed by VA physicians and authorized medical personnel. The VA uses a formulary, or a list of medications and medical supplies, that it keeps in stock at all times.  According to VA, the formulary medications are preferred because they are:

• High Quality
• Effective
• Safe 
• A good value

Because the VA is one of the Nation's largest buyers of medications and medical supplies, it receives tremendous discounts when it purchases large quantities of the same medications from the same manufacturers.  This is not to say that a Veteran cannot get a non-formulary medication or supply item, it simply means that the VA will require the Veteran's physician to go through a process for "non-formulary items".  In essence, the VA clinician will have to explain why the non-formulary item is medically necessary and why the formulary item isn't as medically safe or effective.

Will the VA fill prescriptions from non-VA physicians or providers?

In general, the answer is no.  The VA Pharmacy is not authorized to fill prescriptions unless they written by a VA provider.  The exception is that the VA will fill non-VA prescriptions for Veterans who are in receipt of Aid and Attendance or Housebound benefits.  Veterans in receipt of Aid and Attendance or Housebound benefits should contact their local VA's Pharmacy service for more information.

VetsFirst Advocacy Tip:  If you are an eligible Veteran and are enrolled in VA health care but you also see non-VA physicians, you should keep your VA primary care physician and any VA specialists up to date on any and all medications prescribed by your non-va providers.  There are a couple of important reasons for doing so:

1. Your VA and non-VA providers should be made aware of all prescription, over-the-counter, and herbal supplements so they can knowingly assess your medical condition and treatment plan.  
2. If your non-VA physician has prescribed a medication that is on the VA national formulary, then the VA physician may re-write the prescription using the VA Pharmacy's formulary.  If your non-VA physician has prescribed an item that is not on the VA's national formulary (a "non-formulary" item), then your VA physician may:

• Substitute a suitable VA formulary item.
• Coordinate with the non-VA provider to obtain medical records and follow the procedure to re-write and supply a "non-formulary" item.

2.7. Medical Equipment, Aids and Prosthetics

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VA's Prosthetics and Sensory Aids Service (PSAS) furnished properly prescribed prosthetic equipment, sensory aids and other devices to eligible Veterans.  PSAS' purpose is to provide the most appropriate medically prescribed technology to a Veteran, regardless of cost, in a timely manner. 

See the related Knowledge Books on VA Prosthetics for more detailed information.

VetsFirst Advocacy Tip: PSAS is the "case manager" for the prosthetic and equipment needs of Veterans.  With rare exception, PSAS personnel are purchasing agents who are tasked with fulfilling the prescriptions for prosthetics items and durable medical equipment that has been prescribed by your VA physician.  PSAS may coordinate or participate in certain clinics (i.e. Wheelchair and Seating Clinic), but they are not clinicians.  Be sure to discuss your specific needs with your VA physician or clinician, so that he or she can prescribe what he or she wants PSAS to purchase.  The items provided through PSAS are medical devices and should be treated with the same respect as other prescribed items such as medication. 

Eyeglasses

 

Hearing Aids

 

Automotive Adaptive Equipment

 

Automobile Access Equipment

 

Wheelchairs, Scooters, Walkers, Canes, and Crutches

 

Home Improvement and Structural Alteration (HISA) Grants

 

Clothing Allowance Benefits

2.8. Coordinated Care for Traveling Veterans

Coordinated Care for Traveling Veterans

The VA in 2015 has initiated a traveling Veterans program.   Traveling Veterans are Veterans who are enrolled in the VA Healthcare System and plan to spend extensive time away from their primary residence and preferred VA facility near their home.  

Traveling Veteran Categories:

• Veterans planning on traveling seasonally to a location away from their primary residence.
• Veterans planning an extended trip away from their primary residence or preferred VA facility.
• Veterans while on extended travel from home, will need continuation of their medical care, medication refills, or prosthetic equipment.
• Veterans who plan to seek medical care from a different VA facility away from their primary residence or preferred VA facility while traveling.

The VA medical facility closest to the Veteran's primary residence is called the Veteran's preferred facility.  The VA facility away from the Veteran's home is known as the Veteran's alternate VA facility.  The reason for the alternate facility is either due to extended time that the Veteran will be away from their primary residence or from complex clininical needs that are only provided by specific VA Medical Facilities.   An example of such a scenario would be a Veteran living in Philadelphia, PA who is enrolled in the Philadelphia, PA VA medical center.  The Philadelphia VA medical center would be the Veteran's preferred VA facility.  The Philadelphia Veteran spends 6 months a year in Florida.   The Tampa, Florida VA medical center would be the Philadelphia Veteran's alternate VA facility for the 6 months that the Veteran is visiting Tampa, Florida.

The program is implemented via the Traveling Veteran Coordinators (TVC) located at VA Medical Centers.   The Traveling Coordinators replace the Referral Case Managers.  TVC' must be a Registered Nurse, Physician Assistant, or Licensed Independent Practitioner.   

The process begins when the Veteran notifies their Primary Care Practitioner (PCP) or the Patient Aligned Care Team (PACT) of the Veteran's travel plans.  It is important to give as much advance notice of your departure date as possible.  The PCP or PACT will send a referral to the TVC.  The TVC will arrange for VA medical services at your alternate VA medical facility. 

It is vital that you make sure that your TVC has the correct temporary address and telephone number(s) so that your medication refills can be sent to your temporary address.  Always stay in touch with your traveling coordinator.   Make sure that your TVC is aware of your return date to your preferred or home VA medical facility.  Contact your TVC for unanticipated health care needs that arise while you are away, prosthetic device issues, medication issues, or other problems while you are away.

Traveling Veterans will not be assigned to a PACT, Patient Aligned Care Team, at the alternate VA medical facility.     Veterans at their home or preferred VA medical facility who have multi-PACT assignments or dual assignments might not be considered for the traveling Veteran program.  Clinical assessment and approval of muti-PACT assignments for the Veteran is required for the traveling program.   Exceptions to the one PACT rule for the traveling program are:

• Veterans with spinal cord injury and disorders (SCI&D) who are receiving highly complex care at two VA facilities of SCI&D, or
• If the Veteran requires complex primary care management and receives care between two VA facilities of residence (example: south in winter and north in summer).

 

 

 

 

2.9. Tobacco Use

There is a long history of smoking and tobacco use in the military. If you are a Veteran who uses tobacco, there is a good chance you started during your military service.

Many Veterans:

• Used tobacco more during deployment
• Face difficulties adjusting to a non-tobacco culture when returning home from deployment
• Find themselves around other Veterans who use tobacco
• Have turned to VA to help them successfully quit tobacco

In the past, some addiction counselors and providers were mistakenly taught that encouraging patients to smoke would help them overcome their other addictions.

The opposite is true—scientific studies have shown that quitting smoking will increase the chance that you can also successfully stop abusing alcohol and other drugs.

People who quit smoking in recovery are less likely to relapse to alcohol or other drug use

Talk to your addiction counselor or health care provider about quitting smoking. You can quit smoking at the same time you are quitting another substance, or, if you are worried that quitting smoking might interfere with your recovery, then wait until you feel ready to try to quit smoking.

If you do not attend a substance use clinic or your addiction counselor is not able to counsel you, your regular health care provider can help. He or she can provide you with counseling and medications and refer you to a smoking cessation specialty clinic.

Tobacco smoke contains harmful chemicals. These chemicals are responsible for many health problems in Veterans and those who breathe in secondhand smoke.

Learn more about harmful ingredients in tobacco from the U.S. Department of Health and Human Services.

Nicotine is the addictive chemical in tobacco. While nicotine itself does not cause cancer, the body can become addicted to it, causing physical cravings.

Increased risk of cancer

Tobacco use increases your risk of many types of cancer. While many people associate tobacco use with lung cancer, this is just one type of cancer it causes. Tobacco use and exposure to cigarette smoke can also result in:

• Pancreatic cancer
• Cancers in the throat region, mouth, voice box, and esophagus
• Kidney cancer
• Stomach cancer
• Cancers of the blood, like acute myeloid leukemia
• Bladder cancer

Women who smoke have almost 18 times the risk of dying of lung cancer compared to women who don't smoke. Learn more about women and smoking.

Tobacco worsens other health conditions

• Smoking can make mental health conditions worse. Learn how smoking affects your mental health.
• Quitting tobacco may actually make it easier to stop using drugs and alcohol. Learn about substance use and tobacco.
• If you have HIV and use tobacco, tobacco can make your HIV worse. Learn how smoking affects your HIV.

As you take this huge step in improving your health and life, VA is there for you.

Veterans enrolled in VA health care have access to:

• Medication and counseling
• 1-855-QUIT VET (1-855-784-8838), VA's smoking quitline
• Text message support from SmokefreeVET

Talk to your VA health care provider to customize a quit strategy.

3.1. Veteran-Directed Care

Veteran Directed Care was formerly called Veterans-Directed Home and Community Based Services or VD-HCBS.  It gives veterans of all ages the opportunity to receive the Home and Community Based Services they need in a consumer-directed way. This program is for eligible veterans who need personal care services and help with activities of daily living.

Examples include help with bathing, dressing, or fixing meals.  Veteran-Directed Care can be used to help veterans continue to live at home or in their community.

Veterans not currently receiving VA medical benefits must first apply and be found eligible for this benefit.  

If Veteran-Directed Care seems right for you and to find out if it is available in your area; please speak to your VA social worker, visit the link below, or view the attached flyer for more information about this program and where it's available.  

NOTE: This VA program is only available in certain locations.

https://www.va.gov/geriatrics/pages/Home_and_Community_Based_Services.asp

3.2. Home and Community Based Services

Each Medical Center provides several programs to eligible veterans enrolled in VA healthcare, such as:

Adult Day Health Care— is a program where veterans can go to during the day for social activities, peer support, companionship, and recreation.  The program is for veterans who need help with activities of daily living. Examples include help with bathing, dressing, or fixing meals. This program is also for veterans who are isolated or their caregiver is experiencing burden. 

Home Based Primary Care— is health care services provided to veterans in their home. A VA physician supervises the health care team who provides the services. Home Based Primary Care is for veterans who have complex health care needs for whom routine clinic-based care is not effective.  The program is for veterans who need team based in-home support for ongoing diseases and illnesses that affect their health and daily activities. This program is also for veterans who are isolated, or their caregiver is experiencing burden. 

Skilled Home Health Care Services- are in home services provided by trained personnel for veterans needing short-term care as they are moving from a hospital or nursing home back to their home. It can also be used to provide continuing care to people with ongoing needs.  The program is for veterans who need skilled services such as: skilled nursing, case management, physical therapy, occupational therapy, speech therapy, wound care, or IV antibiotics.  The care is delivered by a community-based home health agency that has a contract with VA.

Homemaker/Home Health Aid Services- are personal care and related support services that enable disabled veterans to live at home.  A trained person come to a veteran's home and help the veteran take care of themselves and their daily activities. Homemakers and Home Health Aides are not nurses, but they are supervised by a registered nurse who will help assess the veteran's daily living needs.  This program is for veterans who need personal care services, help with activities of daily living, who are isolated, or their caregiver is experiencing burden.  Homemaker Home Health Aides work for an organization that has a contract with VA. 

Hospice Care— is comfort care provided to veterans and family members, for those veterans with a terminal condition, with less than 6 months to live, and are no longer seeking treatment other than palliative care.  Hospice Care can be provided at home, in an outpatient clinic or in an inpatient setting.  The VA also works very closely with community and home hospice agencies to provide care in the home.

Palliative Care— uses comfort care with a focus on relieving suffering and controlling symptoms so that veterans can carry out day-to-day activities and continue to do what is most important to them. Palliative care aims to improve quality of life – in the mind, body and spirit.  Palliative Care helps veterans and their families manage illness with plans of care. 

Respite Care Program- for short term services to disabled veterans giving a caregiver a period of relief; to run errands, go out of town for a few days, etc.  Respite care is limited to 30 days per year to certain eligible veterans.   Respite Care can help lower the stress the veterans and their family caregiver may feel when managing a veteran's short-term or long-term care needs at home.

There are two types of respite:

(1)  Home Respite Care is a service that pays for a person to come to a veteran's home or for a veteran to go to an adult day health care program while their family caregiver takes a break or runs errands.

(2)  Nursing Home Respite Care is a service that pays for a veteran to go to a nursing home while the family goes out of town for a few days without worrying about leaving the veteran alone at home. 

Remote Monitoring— is a service that allows the veteran's physician or nurse to monitor the veteran's medical condition remotely using home monitoring equipment.  

To find out more about these various services offered both in a veterans home or in the community, please visit https://www.va.gov/geriatrics/pages/Home_and_Community_Based_Services.asp

 

3.3. Residential Settings and Nursing Homes

Each VA Medical Center offer a variety of residential care, nursing home care, and long-term care services either directly or by contract with community-based agencies.  Such services include:

Community Residential Care (CRC) - program is for veterans who do not need hospital or nursing home care but cannot live alone because of medical or psychiatric conditions.  The CRC program provides room, board, limited personal care and supervision. Veterans pay for their rent from VA compensation, VA pension, Social Security or other retirement or income sources.

Medical Foster Homes- are private homes, inspected and approved by VA, in which a trained caregiver provides services to veterans who require nursing home care but prefer a non-institutional setting with fewer residents.  The charge for a Medical Foster Home is about $1,500 to $3,000 each month based on a veteran’s income and level of care needed. 

Adult Family Homes (also called Adult Foster Homes)- are places where veterans can live in a rented room of a private home.  The homes have shared common spaces and veterans might share a bedroom and bathroom with another person.  There is a trained caregiver on duty 24 hours a day, 7 days a week. This person can help a veteran with activities of daily living (e.g., bathing and getting dressed

Assisted Living Facilities- are places where veterans can live in a rented room or apartment. There are some shared living spaces, like a dining room.  A trained caregiver is on duty 24 hours a day, 7 days a week. This person can help the veteran with activities of daily living (e.g., bathing and getting dressed).

Community Living Center (CLC)- is a VA Nursing Home that is designed to resemble a "home" as much as possible.  Veterans may stay for a short time or, in rare instances, for the rest of their life. It is a place where veterans can receive nursing home level of care, which includes help with activities of daily living (e.g., bathing and getting dressed) and skilled nursing and medical care.  The mission of a Community Living Center is to restore each veteran to his or her highest level of well-being. It is also to prevent declines in health and to provide comfort at the end of life.

Community Nursing Home- is a place where veterans can live full time and receive skilled nursing care any time of day or night near their homes and families.  VA contracts with community nursing homes to care for veterans.

State Veterans Homes- are facilities that provide nursing home, domiciliary or adult day care. They are owned, operated and managed by individual state governments and not the VA.   Each state establishes eligibility criteria and determine services offered for short and long-term care. 

VA pays a portion of the veteran's cost if the state meets VA standards.  Specialized services offered are dependent upon the capability of the home to render them.  Some State Veterans Homes may admit non-veteran spouses and gold star parents while others may admit only veterans.  VA does not pay for care for non-veterans.

State Veterans Homes are in all 50 states and Puerto Rico. Some states have more than one State Veterans Homes. For a list of locations, visit https://www.nasvh.org/state-homes/statedir.cfm.

To find out more about these Residential and Nursing Home services available to veterans, please visit https://www.va.gov/GERIATRICS/pages/Nursing_Home_and_Residential_Services.asp?utm_source=geriatrics_left_menu

 

4.1. Alabama

Listing of VA facility locations in Alabama:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=AL

4.2. Alaska

Listing of VA facility locations in Alaska:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=AK

4.3. Arizona

Listing of VA facility locations in Arizona:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=AZ

4.4. Arkansas

Listing of VA facility locations in Arkansas:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=AR

4.5. California

Listing of VA facility locations in California:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=CA

4.6. Colorado

Listing of VA facility locations in Colorado:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=CO

4.7. Connecticut

Listing of VA facility locations in Connecticut:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=CT

4.8. Delaware

Listing of VA facility locations in Delaware:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=DE

4.9. District of Columbia

Listing of VA facility locations in the District of Columbia:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=DC

4.10. Florida

Listing of VA facility locations in Florida:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=FL

4.11. Georgia

Listing of VA facility locations in Georgia:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=GA

4.12. Hawaii

Listing of VA facility locations in Hawaii:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=HI

4.13. Idaho

Listing of VA facility locations in Idaho:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=ID

4.14. Illinois

Listing of VA facility locations in Illinois:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=IL

4.15. Indiana

Listing of VA facility locations in Indiana:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=IN

4.16. Iowa

Listing of VA facility locations in Iowa:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=IA

4.17. Kansas

Listing of VA facility locations in Kansas:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=KS

4.18. Kentucky

Listing of VA facility locations in Kentucky:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=KY

4.19. Louisiana

Listing of VA facility locations in Louisiana:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=LA

4.20. Maine

Listing of VA facility locations in Maine:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=ME

4.21. Maryland

Listing of VA facility locations in Maryland:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=MD

4.22. Massachusetts

Listing of VA facility locations in Massachusetts:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=MA

4.23. Michigan

Listing of VA facility locations in Michigan:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=MI

4.24. Minnesota

Listing of VA facility locations in Minnesota:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=MI

4.25. Mississippi

Listing of VA facility locations in Mississippi:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=MS

4.26. Missouri

Listing of VA facility locations in Missouri:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=MO

4.27. Montana

Listing of VA facility locations in Montana:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=MO

4.28. Nebraska

Listing of VA facility locations in Nebraska:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=NE

4.29. Nevada

Listing of VA facility locations in Nevada:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=NV

4.30. New Hampshire

Listing of VA facility locations in New Hampshire:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=NH

4.31. New Jersey

Listing of VA facility locations in New Jersey:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=NJ

4.32. New Mexico

Listing of VA facility locations in New Mexico:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=NM

4.33. New York

Listing of VA facility locations in New York:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=NY

4.34. North Carolina

Listing of VA facility locations in North Carolina:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=NC

4.35. North Dakota

Listing of VA facility locations in North Dakota:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=ND

4.36. Ohio

Listing of VA facility locations in Ohio:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=OH

4.37. Oklahoma

Listing of VA facility locations in Oklahoma:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=OK

4.38. Oregon

Listing of VA facility locations in Oregon:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=OR

4.39. Pennsylvania

Listing of VA facility locations in Pennsylvania:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=PA

4.40. Rhode Island

Listing of VA facility locations in Rhode Island:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=RI

4.41. South Carolina

Listing of VA facility locations in South Carolina:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=SC

4.42. South Dakota

Listing of VA facility locations in South Dakota:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=SD

4.43. Tennessee

Listing of VA facility locations in Tennessee:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=TN

4.44. Texas

Listing of VA facility locations in Texas:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=TX

4.45. Utah

Listing of VA facility locations in Utah:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=UT

4.46. Vermont

Listing of VA facility locations in Vermont:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=VT

4.47. Virginia

Listing of VA facility locations in Virginia:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=VA

4.48. Washington

Listing of VA facility locations in Washington:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=WA

4.49. West Virginia

Listing of VA facility locations in West Virginia:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=WV

4.50. Wisconsin

Listing of VA facility locations in Wisconsin:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=WI

4.51. Wyoming

Listing of VA facility locations in Wyoming:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=WY

4.52. American Samoa

Listing of VA facility locations in American Samoa:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=AS

4.53. Guam

Listing of VA facility locations in Guam:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=GU

4.54. Philippines

Listing of VA facility locations in the Philippines:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=PI

4.55. Puerto Rico

Listing of VA facility locations in Puerto Rico:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=PR

4.56. Virgin Islands

Listing of VA facility locations in the U.S. Virgin Islands:

https://www.va.gov/directory/guide/state.asp?dnum=ALL&STATE=VI

5.1. Listing of VA Nursing Home Options by State

Nursing Home Care for Veterans

Please visit the link below and enter your location in the search box to view information about the quality of care provided in nursing homes in your area.

The nursing home options displayed are VA Community Living Centers and private sector nursing homes with whom VA contracts.

This data will be updated quarterly.

NOTE:  We recommend you contact each facility to determine if they still maintain a contract with VA or contact your nearest VA Medical Center’s Nursing Home Coordinator for an up-to-date listing. 

 For a complete listing of VA Nursing Homes in your area, please visit:

 https://www.accesstocare.va.gov/CNH/Statemap

6.1. Overview of VHA Appeals

Most veterans are aware they can appeal their compensation and pension decisions from the VA if they disagree with an entire VA decision or even just a portion of their decision.  An appeal is a veteran's disagreement with a determination by VA to deny a benefit, request for reconsideration of a determination, or direct appeal to a higher level, such as the Board of Veterans' Appeals (Board).

What many veterans don't know is that almost any VA decision, with a few exceptions, can be appealed in one way or another.  This includes many decision made by the Veterans Health Administration (VHA) as well.

Health benefit appeals are also known as medical appeals. Health benefits appeals include questions of eligibility for hospitalization, outpatient treatment, and nursing home and domiciliary care; for sensori-neural aids such as eyeglasses and hearing aids; and for other benefits administered by VHA. Health benefits appeals do not include medical determinations, such as the need for and appropriateness of specific types of medical care and treatment for an individual.   Refer to 38 CFR 20.101(b)

The majority  VHA appeals fall into three categories:

• Enrollment issues, including disputes as to priority group assignment and beneficiary travel,
• Claims related to non-VA unauthorized treatment, and/or
• Prosthetic-related claims involving home improvements and structural alterations (HISA)

As of the August, 2013, VHA Directive Provision, when a Veteran expresses disagreement with a VA benefit determination, the Veteran must be advised of the right to appeal the decision and the correct process for initiating the appeal.   This means that the VA Medical Center handling the appeal complies with all appeal procedures, such as notice of appellate rights and issuing Statement of the Case (SOC) and duties, such as, the duty to notify and duty to assist that apply in the VBA appeals process. 

There are two types of appeals stemming from a VHA decision and two different appeal paths. The first type of appeal is an administrative denial or an administrative appeal.  In this type of appeal a veteran is usually appealing some type of administrative decision such as a denial of medical service because a veteran is not eligible for VA care or an appeal for reimbursement for medical care. We also see these types of appeals where VA denied fee basis care, otherwise known as fee for care provided outside of the VA Medical System. These appeals pertain to VA decisions that are administrative in nature rather than medical in nature.  An administrative appeal can be appealed through the VHA administrative appeal process or through the traditional appeal process.  An administrative appeal, just like a compensation and pension appeal, can be heard by the Board, Court of Appeals for Veterans Claims (CAVC), Court of Appeals for the Federal Circuit (CAFC) and possibly by the United States Supreme Court (USSC). An administrative appeal provides you with greater due process protections and gives you more chances to prevail. 

The second type of appeal is a clinical appeal.  A clinical appeal relates to a VA medical decision such as denying a veteran a particular medication or a form of treatment.  These are decisions that rely upon the professional judgment of a medical professional rather than on VA administrative policy and procedures.  

Clinical appeals on the other hand can't be appealed above the local level. That is to say these types of appeals cannot be heard by the Board or any level above the Board as they lack jurisdiction over medical determinations.  If you are in disagreement with a VA medical decision by the VA Healthcare System, you have the right of a written notice of the decision and a copy of your appeal rights.   The VA has created a "Clinical Appeals process" for contested medical decisions.  A clinical appeal must be appealed through the VHA administrative appeal process.  The decision of the Clinical Appeals Process is final and there is no right to judicial review.    

 

6.2. Clinical Appeals

The Director of the VHA facility is responsible for attempting to resolve any clinical disputes.  VHA healthcare facilities are supposed to be the first point of contact for disputes and every effort should be made to resolve disputes as close to the point of care as possible.  It is also the facility Director's responsibility to provide written notice of the facility's final determination to the patient, or the patient's representatives.  This notification must also describe the clinical appeals process to the claimant.

That's right!  Not only must the VA notify you in writing but they must also provide you with information regarding how to initiate a clinical appeal.  So do not let the VA simply tell you "no." Make them put it in writing and inform you of your appellate rights.  It may be necessary for you, or your representative, to force the issue with the VA.  If the VA will not comply send them a polite and professional letter demanding a written notice of why your request was denied and also request VA provide you with a notice of your appellate rights.  Be sure to make a copy of this letter and mail it in some manner that allows you to track and confirm receipt.

In theory the Chief Medical Officer (CMO) acts as an intermediary between the veteran and the facility and all efforts to resolve the dispute are sent to the CMO by the medical facility.  The CMO determines the patient's current medical needs and acts to notify the patient and or representative that their appeal has been received and requests that submission of supporting documents be submitted within one week where applicable. 

Next the CMO develops a decision paper regarding the appeal and sends it to the Veterans Integrated Service Network (VISN) Director.  The VISN Director then makes a decision whether or not to request an external audit.

Whether an external audit is requested or not ultimately the veteran and their representative receive a final decision within 30 to 45 days.  The decision will officially place the veteran on notice of what the VA decided in their appeal.  If the appeal was a clinical appeal regarding a VA medical decision the appeal is over as the decision cannot be appealed to the Board.  There may be unofficial action a veteran can take but there is no official appellate review after this decision is issued.

Please remember that both a clinical appeal and an administrative appeal can follow the above path.  Although an administrative appeal could be prosecuted in this manner it is usually advantageous to follow the traditional or administrative appeal process.

6.3. Administrative Appeals

When a veteran applies for any type of benefit (for example, disability compensation, outpatient treatment, hospitalization, and prosthetic appliances, etc.) which a VA facility denies in whole or in part, that veteran or accredited representative has the right to appeal the denial decision, which is known as due process.  When a VA health facility or the Health Eligibility Center (HEC) determines that a veteran is not legally entitled to the benefits sought, the veteran or his or her accredited representative must be notified in writing of this decision.

The VA facility or HEC must include VA Form 4107, Notice of Procedural and Appellate Rights (http://www.va.gov/vaforms/va/pdf/VA4107.pdf), with each denial letter.  This form advises a veteran of their right to appeal the decision made by the VA facility or the HEC, the time limits for filing the appeal, the veteran's right to representation and all other pertinent facts relating to the appeal process.   VA must also include VA Form 4107 when denying a private healthcare provider's request for reimbursement.  Private healthcare providers also have the right to appeal a denied claim.

A veteran, medical provider or the veteran's accredited representative, such as an attorney, fiduciary or an estate representative for a deceased veteran, may send a written statement, disagreeing with a factual or legal conclusion of the VA.  There is no set wording or form necessary, and the statement does not have to make specific allegations of error of fact or law.  It is not material that the claimant's contentions may appear to have no merit.

The written statement may contain wording such as:

Please consider payment of my bills, this was an emergency, the VA hospital was called      and they told us to go to the nearest hospital

or other similar statements.  These statements may be considered as a NOD and the NOD must be signed and dated by the veteran or duly appointed representative.  A complaint letter will not automatically be considered to be a NOD. 

Although the minimum requirements for a NOD are established by law, there is no specific VA form required to submit a NOD.  Although many claimants use VA Form 21-4138 (Statement in Support of Claim), a NOD can be as simple as a letter to the regional office. Whatever means is used, a NOD must be dated, state the date of the rating decision with which the claimant disagrees, and be signed by the claimant or the claimant's VA-accredited representative.  A claimant does not have to give any reasons for disagreeing with the decision, although he or she can do so.  It is also good practice to specifically put "NOTICE OF DISAGREEMENT" somewhere in the NOD.

It is also extremely important that a NOD be filed with the correct office or facility.  NOD's regarding a change in status from copay exempt to copay required should be filed directly with HEC and not the facility providing care.  If a veteran sends or takes it to their local facility, the local facility should forward it to the HEC for processing and the issuance of a Statement of the Case (SOC). 

Remember if VA denies you a benefit they should inform you where you should submit your NOD.  If you are unsure whether you should submit your NOD to your local VA facility or the HEC play it safe and submit it to both.  As always submit your NOD in some manner that allows for tracking receipt by VA.

A NOD must be filed within one year.  The year to file a NOD starts on the date on the VA letter forwarding the rating decision, which VA presumes to be the mailing date.  The NOD must be postmarked within one year of the date of the VA letter forwarding the decision.  Where the date on the VA letter is much different (earlier) than the postmark on the envelope, there is a chance that VA may allow a NOD within one year of the postmark date.  There is absolutely no reason to risk an appeal in this way as a NOD can and should be submitted as soon as possible following an unfavorable decision.  DO NOT WAIT ANY LONGER THAN NECESSARY.

If the claimant does not file a NOD within one year of the date of the adverse rating decision, the decision becomes final.  If this occurs, under most circumstances any benefits for the period since the application was filed are lost and cannot be recovered.  The exceptions to finality rule are discussed elsewhere in this KNOWLEDGE BOOK.

Once VA receives the NOD they should send the claimant or representative or both a letter, stating that the NOD was received and that the appeal process will be initiated.  This step is not required but some VA facilities follow this practice.

A veteran may request that the VA facility reconsider their request or they may appeal directly to the Board.  The veteran has 60-days from the initial denial to submit a reconsideration request; however, the file can be reopened during the one year period from the initial date of the denial.

Any reconsideration should be made by the immediate supervisor of the initial VA decision maker.

The immediate supervisor should review the entire record, including the claimant's statement on the NOD, to determine if additional development is needed.  The supervisor should also attempt to obtain any evidence the claimant indicates is available or that the VA failed to attempt to obtain previously.  Additionally they should correct any previous oversights that may be discovered and take necessary steps to assist the claimant in developing the evidence needed to substantiate the appeal including:

     - Obtaining medical documentation and reports from private healthcare providers

     - Obtaining service department or VA records

     -Obtaining Vocational Rehabilitation records

 

After reviewing the entire claim and associated evidence a written decision is rendered that will affirm, reverse or modify the initial decision.

To convey their decision to the veteran the VA will issue a Statement of the Case (SOC).  An SOC is another explanation for why VA decided the issue or issues the way it did.  For each claim appealed, the SOC must contain a description of the evidence considered by the VA in making the decision, the VA regulations applicable to the decision, and an explanation of and reasons for the decision.

A SOC can be very lengthy, but should be carefully read.  Despite their length, SOC's sometime contains errors of fact or law or are otherwise inaccurate.  Claimants should review the SOC in order to identify any errors which could affect the appeal.

The SOC may be divided into the following sections:

            -Cover page containing notice to the appellant

This gives directions to the claimant about the appeal, when to submit the substantive appeal and information about representation.

            -Issue

                        This states the specific benefit or benefits that were denied by VA

           

            Summary of the Evidence

Should list the veterans' service branch, dates or active duty military service, any service-connected disabilities and the effective dates.  In chronological order every action taken from the date the benefit was sought or treatment provided to the date the Statement of the Case was prepared.  VA will not necessarily go into great detail of each event since all records and documents will eventually be made available to the Board if necessary.

            Pertinent Laws and VA Regulations

A listing of the specific Code of Federal Regulations or U.S. Code sections VA relied upon when making their decision.

            Decision

                        Restates the issue and the VA's decision to grant or deny.

            Reasons for Decision

Fully explains how the decision was reached and how evidence was applied according to cited regulations.  Explain why the veteran was or was not eligible for the benefit sought.

            Signatures

The original SOC should include a signature section listing who prepared the decision with date, printed name, credentials, signature of the person who prepared the SOC and "approved by" with date; printed name and signature of the approving official.

VA will then forward a copy of the SOC to the veteran along with a VA Form 9 (http://www.va.gov/vaforms/va/pdf/VA9.pdf) and instructions.  A copy should also be sent to the veterans representative if applicable.  To "perfect" an appeal the VA Form 9 must be filed with the office or facility that issued the SOC.  By statute, a claimant must perfect an appeal within 60 days after the date of the SOC cover letter or within one year from the date of the initial rating decision that is being appealed, whichever is longer. If a claimant does not meet this deadline, the rating decision will become final. A claimant must use a VA Form 9 to perfect an appeal.  Not using this form risks rejection of the appeal.

After an appeal has been perfected the local VA facility or office must take certain steps which include reviewing the entire record and take appropriate action such as:

            -Award the benefit sought

            -Uphold the denial

-Determine the appeal is deficient in either information contained, fact or law and advise the claimant and any representative of the deficiencies.  VA will usually provide the claimant with a certain time period in which to respond if they can help cure the defects.

-Prepare case for review by the Board

-Prepare a Supplemental Statement of the Case (SSOC) if it discovered that the SOC contained a material error or the claimant submitted additional evidence.

The claimant will then have 60 days from the date of mailing the SSOC to respond.  A response to the SSOC is optional and is not required to perfect the appeal.  At the expiration of the time period the appeal will be certified to the Board.  In many cases it can take years for an appeal to be certified to the Board.  Be prepared for a marathon and not a sprint.

The Board is an independent organization within VA that has jurisdiction to review all factual and legal issues in a rating decision without considering how the VHA decided the issues.  The Board consists of a Chairman and approximately sixty members who are designated as a "Veteran Law Judge" ("VLJ"). Although historically the Board sat in panels of three members, the typical appeal is now decided by a single VLJ.

An appeal can be resolved "on the papers" or following a hearing with a VLJ.  Hearings can either be in person in Washington, DC, or at a local regional office or by video conference. Before the Board, a claimant (technically an "appellant" once the appeal is certified) can represent himself or herself or can be represented by a person of his or her choosing, including a service officer, non-attorney agent, or attorney.  Board hearings are informal and a claimant can submit written material, such as a summary of the claimant's argument, for consideration by the Board.  

The Board is required to review all the evidence presented to it and issue a written decision.  The Board can grant or deny a claim, or remand (send back) all or part of a claim to the regional office or the Appeals Management Center ("AMC") for further development.  The AMC is an office in Washington, DC, that VA uses to assist regional offices on appeals were the claimant is self-represented or has designated a Veterans Service Organization ("VSO") as his or her representative.  A Board decision is required to be written and identify the "reasons and bases" for each conclusion.  The Board's reasons are important because inadequate reasons and bases are the most common ground for challenging a Board decision denying an award.

If the Board agrees with a claimant – now called an "appellant" – and orders an award, the claims file is returned to the regional office, possibly via the AMC, for processing of the resulting benefit payment.  Action by the regional office also may include deciding any issues that were not resolved by the Board.  For example, if a claim was initially denied and the Board ordered an award, the regional office will need to determine a numerical rating and effective date before payments can begin.  In addition, even if the Board decided all the issues for an award, only the regional office can authorize payments.  So, unless the Board denies all aspects of an appealed decision, the C-file must be returned to the regional office for additional action.

If the Board agrees with a claimant that the decision contained errors but is not sure whether or not an award should be granted, it will order the rating decision withdrawn and require the AMC or regional office or other VA facility to take specific actions to further develop the claim.  While not an award, a remand provides a claimant a further opportunity to provide additional evidence in support of his or her claims.  Additionally, a remand means that there will be further delay in resolving a claim.

A claimant disappointed by a Board decision can request the Board "reconsider" or "vacate" its decision.  The Board rarely grants reconsideration.  If it does, the Board decision will be withdrawn and a new decision issued.  A motion for Board reconsideration can be filed at any time.

A disappointed appellant can also appeal an unfavorable Board decision to the Court of Appeals for Veterans Claims, known as the "CAVC" or "Court."  The CAVC was established by Congress in 1988 to provide a further level of review for claimants denied benefits.  The Court exists primarily to review Board decisions for legal errors.  As a practical matter, this means that a claimant-appellant must identify a legal error in a Board decision to win an argument before the Court.  Simply disagreeing with a Board decision is not enough to win an appeal at the Court.

Unlike a motion for Board reconsideration, an appeal to the Court has a very specific period in which to file for Court review.  To appeal to the Court, an appellant has 120 days from the date of mailing of the Board decision to file a "Notice of Appeal" at the Court, not the regional office or the Board.  As many veterans have sadly learned, the Court takes this 120-day period very seriously and strictly enforces it.  A claimant-appellant wanting to appeal a Board decision should file his or her Notice of Appeal as soon as possible to avoid missing this deadline.  VA cannot appeal a Board decision.

The process at the Court is very different than at the regional office or Board.  The VA Secretary is now formally an "opposing party" and will argue against the claimant-appellant's position in an adversarial legal action.  This means, among other things, that it is now the claimant-appellant's duty to identify the legal basis for his or her appeal and why the Board decision is wrong.  Claimant-appellants are also responsible for meeting all the Court's deadlines and following the Court's rules.  In other words, VA will no longer assist the claimant in his or her case.  So, while claimants can and do represent themselves before the Court, it is much harder to do effectively than when the claim is being developed.

Once a number of procedural matters are completed a claimant-appellant submits a Brief, the Secretary submits his Brief, and the claimant-appellant can submit a Reply Brief.  Initially, a single judge is assigned to each case.  If one or more of the issues in the case is deemed significant enough, the Court assigns a three-judge panel to decide the case.  Oral argument can be requested and, while not common, is scheduled for significant issues.

In its decision, the Court will either (1) affirm (agree with) the Board, (2) remand one or more issues for further development, or (2) reverse (overrule) the Board.  Reversals are rare, with the most common result being either affirmation of the Board decision or remand for further consideration by the Board of one or more issues.  As with the Board, the Court does not calculate awards or authorize payments, so even if a claimant-appellant wins a fully favorable decision at the Court, the decision and the C-file must be returned, first to the Board and then to the AMC or regional office from which it came.

Either the claimant-appellant or the Secretary can appeal an unfavorable CAVC decision to the Court of Appeals for the Federal Circuit and, after that, to the United States Supreme Court. Appeals to these courts are significant and expensive actions that need to be carefully considered.  For those reasons, VETSFIRST does not recommend claimants undertake such appeals without competent legal advice and representation.

 

7.1. Respect and Nondiscrimination

• You will be treated with dignity, compassion, and respect as an individual. Your privacy will be protected. You will receive care in a safe environment. VA will honor your personal and religious values.
• You — and any persons you choose — will be involved in all decisions about your care. You can agree to or refuse treatment, and consider options. Refusing treatment will not affect your rights to future care, but you take responsibility for the possible results.
• You may allow a family member, friend, or other individual to be present with you for emotional support during your hospital stay.  (NOTE: The presence of a support individual of your choice is allowed, unless that individual's presence infringes on others' rights, safety, or is medically or therapeutically contraindicated.  This individual may or may not be your surrogate decision maker or legally authorized representative.)
• You will be given the name and title of all providers involved in your care, including students and trainees. 
• You have the right to be fully informed about your treatment plan.  If you believe you cannot follow the treatment plan, you have a responsibility to notify your provider or treatment team.
• You have the right to have your pain assessed, to receive treatment to manage your pain, and to participate in developing a pain management plan.
• You have the right to choose whether you will participate in any research project related to your treatment.
• Treatment will respect your personal freedoms. In rare cases, the use of medication and physical restraints may be used if all other efforts to keep you or others free from harm have not worked.
• You will be involved in resolving any ethical issues about your care — including participation in decision-making and care at the end of life — and you may seek guidance from your health care facility's Medical Ethics Consultation Service.
• You or someone you choose has the right to keep and spend your money. You have the right to receive an accounting of any VA held funds.
• As an inpatient or nursing home resident, you may wear your own clothes. You may keep personal items. This will depend on your medical condition.
• As an inpatient or nursing home resident, you have the right to social interaction and regular exercise. You will have the opportunity for religious worship and spiritual support. You may decide whether to participate in these activities. You may decide whether or not to perform tasks in or for the Medical Center.
• As an inpatient or nursing home resident, you have the right to communicate freely and privately. You may have or refuse visitors. You will have access to public telephones. You may participate in civic rights, such as voting and free speech.
• As a nursing home resident, you can organize and take part in resident groups in the facility. Your family also can meet with the families of other residents.
• In order to provide a safe treatment environment for all patients or residents and staff, you are expected to respect other patients, residents and staff and to follow the facility's rules. Avoid unsafe acts that place others at risk for accidents or injuries. Please immediately report any condition you believe to be unsafe.
• Veterans Health Administration (VHA) prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.