Savvy Consumer: Federal Benefits for Veterans and Dependents

Federal Benefits for Veterans and Dependents
2004 Edition

Health Care Benefits (continued)

Outpatient Pharmacy Services

Outpatient pharmacy services are provided free to:

(1) veterans with a service-connected disability of 50 percent or more;
(2) veterans receiving medication for treatment of service-connected conditions;
(3) veterans whose income does not exceed the maximum VA annual rate of the VA pension;
(4) veterans receiving medication for conditions related to exposure to ionizing radiation;
(5) veterans receiving medication for conditions related to combat service in a war after the Gulf War or against a hostile force in a period of hostilities beginning after Nov. 11, 1998;
(6) veterans receiving medication for conditions related to participation in Defense Department tests conducted as part of Project 112/Project SHAD;
(7) veterans receiving medication for conditions related to sexual trauma experienced while serving on active duty;
(8) certain veterans receiving medication for treatment of cancer of the head or neck; and
(9) veterans receiving medication as part of a VA-approved research project.

Other veterans will be charged a copayment of $7 for each 30-day or less supply of medication. To eliminate a financial hardship for veterans who require an unusually large amount of medications, there is a maximum copayment amount that veterans enrolled in Priority Groups 2 through 6 pay in any single year. Veterans do not pay copayments for medications dispensed during the remainder of a calendar year in which this annual cap amount has been paid. For calendar year 2004, the cap is $840.

The medication copayment applies to prescription and over-the-counter medications, such as aspirin, cough syrup or vitamins, dispensed by a VA pharmacy. Medication copayments are not charged for medications injected during the course of treatment or for medical supplies, such as syringes or alcohol wipes. In the event over-the-counter drugs are ordered, the veteran can choose to purchase them at a local pharmacy rather than pay $7 for items such as aspirin, cough syrup or vitamins.

Nursing-Home Care
VA provides nursing home services through three national programs: VA owned and operated nursing homes, state veterans homes owned and operated by the state, and contract community nursing homes. Each program has its own admission and eligibility criteria.

VA owned and operated homes typically admit residents requiring short-term skilled care, or who have a 70 percent or more serviceconnected disability, or who require nursing home care because of a service-connected disability. The state veterans home program is a cooperative venture between VA and the states whereby VA provides funds to help build the home and pays a portion of the costs for veterans eligible for VA health care. The states, however, set eligibility criteria for admission. The contract nursing home program is designed to meet the long-term nursing home care needs of veterans who may not be eligible and/or qualify for placement in a VA or state veterans home or if there is no VA or state home available.

To be placed in a nursing home, veterans generally must be medically stable, have a condition that requires inpatient nursing home care, and be assessed by an appropriate medical provider to be in need of institutional nursing home care. They also must meet the eligibility requirements for the home to which they are applying. For VA nursing homes, they may have to pay a copayment depending on their financial status. VA social workers can help interpret eligibility and co-payment requirements.

In addition to nursing home care, VA offers other extended care services either directly or by contract with community agencies, including adult day care, respite care, geriatric evaluation and management, hospice and palliative care, and home based primary care. These services may require copayment.

Domiciliary Care

Domiciliary care provides rehabilitative and long-term, health maintenance care for veterans who require minimal medical care but who do not need the skilled nursing services provided in nursing homes. VA may provide domiciliary care to veterans whose annual income does not exceed the maximum annual rate of VA pension or to veterans the Secretary of Veterans Affairs determines have no adequate means of support. The copayments for extended care services apply to domiciliary care. Call your nearest benefits or health-care facility for information.

Medical Care for Dependents and Survivors

CHAMPVA, the Civilian Health and Medical Program of the Department of Veterans Affairs, provides reimbursement for most medical expenses - inpatient, outpatient, mental health, prescription medication, skilled nursing care and durable medical equipment. To be eligible for CHAMPVA, an individual cannot be eligible for TRICARE (the medical program for civilian dependents provided by the Department of Defense) and must be one of the following:

The spouse or child of a veteran who VA has rated permanently and totally disabled for a service-connected disability.
The surviving spouse or child of a veteran who died from a VA-rated service-connected disability, or who, at the time of death, was rated permanently and totally disabled.
The surviving spouse or child of a military member who died in the line of duty, not due to misconduct. However, in most of these cases, these family members are eligible for TRICARE, not CHAMPVA.

A surviving spouse under age 55 who remarries loses CHAMPVA eligibility on midnight of the date of remarriage. However eligibility may be re-established if the remarriage is terminated by death, divorce or annulment effective the first day of the month after the termination of the remarriage or Dec. 1, 1999, whichever date is later. A CHAMPVA eligible surviving spouse who is 55 or older does not lose eligibility upon remarriage.

Individuals who have Medicare entitlement may also have CHAMPVA eligibility secondary to Medicare. However eligibility limitations apply to those with Medicare Part A only. The following individuals must be enrolled in Medicare Part B to establish CHAMPVA eligibility: (1) under age 65 and entitled to Medicare Part A; (2) 65 or older when first eligible for CHAMPVA and entitled to Medicare Part A; (3) 65 or older prior to June 5, 2001, who are otherwise entitled to CHAMPVA and have Medicare Part A and B; (4) 65 or older on or after June 5, 2001, who are entitled to Medicare Part A.

For additional information or to apply for CHAMPVA benefits, visit the CHAMMVA Web site (http://www.va.gov/hac/), call 1-800-733-8387 or contact the VA Health Administration Center, P.O. Box 65023, Denver, CO 80206.

Many VA medical centers provide services to CHAMPVA beneficiaries under the CHAMPVA In House Treatment Initiative (CITI) program. Contact the nearest VA medical center to determine if it is a participating facility. Beneficiaries who use a CITI facility incur no cost for services they receive, however services are provided on a space available basis, after the needs of veterans are met. Therefore, not all services are available at all times, nor are the same services available every day. CHAMPVA beneficiaries with Medicare entitlement are not eligible to participate in the CITI program.

Beneficiary Travel

Certain veterans may be eligible for payment or reimbursement for travel costs to receive VA medical care. Reimbursement is paid at $.11 per mile and is subject to a deductible of $3 for each one-way trip and an $18-per-month maximum payment. Two exceptions to the deductible are travel for a compensation or pension examination and travel by special modes of transportation, such as an ambulance or a specially equipped van. Beneficiary travel payments may be made to the following:

(1) veterans whose service-connected disabilities are rated at 30 percent or more;
(2) veterans traveling for treatment of a service-connected condition;
(3) veterans who receive a VA pension;
(4) veterans traveling for scheduled compensation or pension examinations;
(5) veterans whose income does not exceed the maximum annual VA pension rate; and
(6) veterans whose medical condition requires special mode of transportation, if the veteran is unable to defray the costs and travel is pre-authorized. Advance authorization is not required in a medical emergency if a delay would be hazardous to life or health.

Emergency Medical Care in Non-VA Facilities

VA may provide reimbursement or payment for medical care provided to enrolled veterans by non-VA facilities only in cases of medical emergencies where VA or other federal facilities were not feasibly available. Other conditions also apply. To determine eligibility or to initiate a claim, contact the VA medical facility nearest to where the emergency service was provided.

Veterans Living or Traveling Overseas

VA will pay veterans living or traveling overseas for medical care associated with a service-connected condition. See the Overseas Benefits section for more information.

Merchant Marine Seamen

Merchant Marine seamen who served in World War II may qualify for veterans benefits. When applying for medical care, seamen must present their discharge certificate from the Department of Defense to the VA medical facility. VA regional offices can assist in obtaining a certificate.

Allied Veterans

VA is authorized to provide medical care to certain veterans of nations allied or associated with the United States during World War I or World War II. Such treatment is available at any VA medical facility if authorized and reimbursed by the foreign government. VA also is authorized to provide hospitalization, outpatient and domiciliary care to former members of the armed forces of Czechoslovakia or Poland who participated during World Wars I or II in armed conflict against an enemy of the United States, if they have been citizens of the United States for at least 10 years.

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