Health Care for Veterans:
Answers to Frequently Asked Questions

Sidath Viranga Panangala
Specialist in Veterans Policy
Erin Bagalman
Analyst in Health Policy
February 25, 2014
Congressional Research Service
7-5700
www.crs.gov
R42747


Health Care for Veterans: Answers to Frequently Asked Questions

Summary
The Veterans Health Administration (VHA), within the Department of Veterans Affairs (VA),
operates the nation’s largest integrated health care delivery system, provides care to
approximately 5.75 million unique veteran patients, and employs more than 270,000 full-time
equivalent employees.
Eligibility and Enrollment. Contrary to claims concerning promises of “free health care for
life,” not every veteran is automatically entitled to medical care from the VA. Eligibility for VA
health care is based primarily on veteran status resulting from military service. Generally,
veterans must also meet minimum service requirements; however, exceptions are made for
veterans discharged due to service-connected disabilities, members of the Reserve and National
Guard (under certain circumstances), and returning combat veterans. The VA categorizes veterans
into eight Priority Groups, based on factors such as service-connected disabilities and income
(among others). Dependents, caregivers, and survivors of certain veterans are eligible for the
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), which
reimburses non-VA providers or facilities for their medical care.
Medical Benefits. All enrolled veterans are offered a standard medical benefits package, which
includes (but is not limited to) inpatient and outpatient medical services, pharmaceuticals, durable
medical equipment, and prosthetic devices.
For female veterans, the VA provides gender-specific care, such as gynecological care, breast and
reproductive oncology, infertility treatment, maternity care, and care for conditions related to
military sexual trauma. Under current regulations, the VA is not authorized to provide, or cover
the costs of, in vitro fertilization, abortion counseling, abortions, or medication to induce
abortions.
Generally the VA provides audiology and eye care services (including preventive services and
routine vision testing) for all enrolled veterans, but eyeglasses and hearing aids are provided only
to veterans meeting certain criteria. Eligibility for VA dental care is limited and differs
significantly from eligibility for medical care. For veterans with service-connected disabilities
who meet certain criteria, the VA provides short- and long-term nursing care, respite, and end-of-
life care.
Under certain circumstances, the VA may reimburse non-VA providers for health care services
rendered to VA-enrolled veterans on a fee-for-service basis. Such Fee Basis Care may include
outpatient care, inpatient care, emergency care, medical transportation, and dental services.
Costs to Veterans and Insurance Collections. While enrolled veterans do not pay premiums for
VA care, some veterans are required to pay copayments for medical services and outpatient
medications related to the treatment of nonservice-connected conditions. Copayment amounts
vary by Priority Group and type of service (e.g., inpatient versus outpatient). The VA has the
authority to bill most health care insurers for nonservice-connected care; any insurer’s payment
received by the VA is used to offset ‘‘dollar for dollar’’ a veteran’s VA copayment responsibility.
The VA is statutorily prohibited from receiving Medicare payments (with a narrow exception).


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Health Care for Veterans: Answers to Frequently Asked Questions

Contents
Introduction ...................................................................................................................................... 1
Enrollment in VA Health Care ......................................................................................................... 1
Can All Veterans Enroll in VA Health Care? ............................................................................. 1
Which Veterans Can Enroll in VA Health Care? ....................................................................... 2
Is Enrollment Different for Returning Combat Veterans? ................................................... 3
Is Enrollment Different for Members of the Reserves? ...................................................... 3
Is Enrollment Different for Members of the National Guard? ............................................ 4
How Do Veterans Enroll in VA Health Care? ............................................................................ 4
Are Veterans’ Family Members Eligible for VA Health Care? .................................................. 6
Medical Benefits .............................................................................................................................. 7
What Are the Standard Medical Benefits? ................................................................................. 7
Does the VA Provide Gender-Specific Services for Women? ................................................... 8
Does the VA Provide Dental Care? ............................................................................................ 8
Does the VA Provide Hearing Aids and Eyeglasses? .............................................................. 11
Does the VA Provide Long-Term Care? .................................................................................. 11
Does the VA Pay for Medical Care at Non-VA Facilities? ...................................................... 13
Does the VA Pay for Emergency Care at Non-VA Facilities? ................................................. 14
Costs to Veterans and Insurance Collections ................................................................................. 15
Do Veterans Have to Pay for Their Care?................................................................................ 15
Can the VA Bill Private Health Insurance? .............................................................................. 18
Can the VA Bill Medicare? ...................................................................................................... 18

Figures
Figure 1. VA Health Care Enrollment Process ................................................................................. 6

Tables
Table 1. Eligibility Criteria and Scope of Treatment for VA Dental Care ....................................... 9
Table 2. VA Reimbursement for Emergency Care ......................................................................... 14
Table 3. Copayments for Health Care Services (CY2014) ............................................................ 17
Table A-1. VA Priority Groups and Their Eligibility Criteria ........................................................ 21
Table A-2. National Income Thresholds for CY2014 .................................................................... 23

Appendixes
Appendix. VA Priority Groups and Their Eligibility Criteria ........................................................ 20

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Health Care for Veterans: Answers to Frequently Asked Questions

Contacts
Author Contact Information........................................................................................................... 23

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Health Care for Veterans: Answers to Frequently Asked Questions

Introduction
The Veterans Health Administration (VHA), within the Department of Veterans Affairs (VA),
operates the nation’s largest integrated direct health care delivery system, provides care to
approximately 5.75 million unique veteran patients,1 and employs more than 270,000 full-time
equivalent employees.2 While Medicare, Medicaid, and the Children’s Health Insurance Program
(CHIP) are also publicly funded programs, most health care services under these programs are
delivered by private providers in private facilities. In contrast, the VA health care system could be
categorized as a veteran-specific national health care system, in the sense that the federal
government owns the medical facilities and employs the health care providers.3
This report provides responses to frequently asked questions about health care provided to
veterans through the VHA. It is intended to serve as a quick reference to provide easy access to
information. Where applicable, it provides the legislative background pertaining to the question.
Enrollment in VA Health Care
Can All Veterans Enroll in VA Health Care?
Not every veteran is automatically eligible to enroll in VA health care, contrary to numerous
claims made concerning “promises” to military personnel and veterans with regard to “free
health care for life.”
4
Eligibility for enrollment in VA health care has evolved over time. Prior to eligibility reform in
1996, all veterans were technically eligible for some care; however, the actual provision of care
was based on available resources.5
The Veterans’ Health Care Eligibility Reform Act of 1996 (P.L. 104-262) established two
eligibility categories and required VHA to manage the provision of hospital care and medical
services through an enrollment system based on a system of priorities.6 (See the Appendix for the
criteria for the Priority Groups.) P.L. 104-262 authorized the VA to provide all needed hospital
care and medical services to veterans with service-connected disabilities;7 former prisoners of

1 CRS Report R43179, Veterans’ Medical Care: FY2014 Appropriations, by Sidath Viranga Panangala.
2 U.S. Department of Veterans Affairs, 2013 Performance and Accountability Report, Washington, DC, December 16,
2013. The VHA was established on January 3, 1946, as the Department of Medicine and Surgery by P.L. 79-293,
succeeded in 1989 by the Veterans Health Services and Research Administration, and renamed the Veterans Health
Administration in 1991.
3 Adam Oliver, “The Veterans Health Administration: An American Success Story?” The Milbank Quarterly, vol. 85,
no. 1 (March 2007), pp. 5-35.
4 For a detailed discussion of “promised benefits,” see CRS Report 98-1006, Military Health Care: The Issue of
"Promised" Benefits
, by David F. Burrelli.
5 Barbara Sydell, “Restructuring the VA Health Care System: Safety Net, Training and Other Considerations,” National
Health Policy Forum, Issue Brief no. 716, March 1998.
6 U.S. Congress, House Committee on Veterans Affairs, Veterans’ Health Care Eligibility Reform Act of 1996, report
to accompany H.R. 3118, 104th Cong. 2nd sess., H.Rept. 104-690, p. 2.
7 A service-connected disability is a disability that was incurred or aggravated in the line of duty in the U.S. Armed
(continued...)
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war; veterans exposed to toxic substances and environmental hazards such as Agent Orange;
veterans whose attributable income and net worth are not greater than an established “means
test”; and veterans of World War I. These veterans are generally known as “higher priority” or
“core” veterans.8 The other category of veterans are those with no service-connected disabilities
and with attributable incomes above an established “means test.”
P.L. 104-262 also authorized the VA to establish a patient enrollment system to manage access to
VA health care. As stated in the report language accompanying P.L. 104-262,
[t]he Act would direct the Secretary, in providing for the care of ‘core’ veterans, to establish
and operate a system of annual patient enrollment and require that veterans be enrolled in a
manner giving relative degrees of preference in accordance with specified priorities. At the
same time, it would vest discretion in the Secretary to determine the manner in which such
enrollment system would operate.9
Furthermore, P.L. 104-262 was clear in its intent that the provision of health care to veterans was
dependent upon available resources. The committee report accompanying P.L. 104-262 states that
the provision of hospital care and medical services would be provided to “the extent and in the
amount provided in advance in appropriations Acts for these purposes. Such language is intended
to clarify that these services would continue to depend upon discretionary appropriations.”10
Which Veterans Can Enroll in VA Health Care?
Enrollment in VA health care is based primarily on veteran status (i.e., previous military service),
service-connected disability,
11 and income.12
Generally, veteran status is established by (1) active duty service in the military, naval, or air
service; (2) satisfying a minimum period of duty;13 and (3) receiving an other than dishonorable
discharge or release.14 Exact requirements for enrollment eligibility depend on various criteria,

(...continued)
Forces (38 U.S.C. §101 (16)). The VA determines whether veterans have service-connected disabilities, and for those
with such disabilities, assigns ratings from 0% to 100% based on the severity of the disability. Percentages are assigned
in increments of 10% (38 C.F.R. §§4.1-4.31).
8 H.Rept. 104-690, p. 5.
9 Ibid., p. 6.
10 Ibid., p. 5.
11 A service-connected disability is a disability that was incurred or aggravated in the line of duty in the U.S. Armed
Forces (38 U.S.C. §101 (16)). The VA determines whether veterans have service-connected disabilities, and for those
with such disabilities, assigns ratings from 0% to 100% based on the severity of the disability. Percentages are assigned
in increments of 10% (38 C.F.R. §§4.1-4.31).
12 Veterans meeting certain income criteria may be eligible to enroll in the VA without a service-connected condition.
13 Generally, persons enlisting in one of the Armed Forces after September 7, 1980, and officers commissioned after
October 16, 1981, must have completed two years of active duty or the full period of their initial service obligation to
be eligible for VA health care benefits. Servicemembers discharged at any time because of service-connected
disabilities are not held to this requirement. For more information about how duty periods are defined, see U.S.
Department of Veterans Affairs, “Duty Periods for Establishing Eligibility for Health Care,” 78 Federal Register
78260, December 26, 2013.
14 A veteran with an “other than honorable” discharge or “bad conduct” discharge may still retain eligibility for VA
health care benefits for disabilities incurred or aggravated during service in the military. For more information on the
nature of discharge requirements, see CRS Report R42324, “Who is a Veteran?”—Basic Eligibility for Veterans’
(continued...)
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such as when and in which component (i.e., active, Reserves, or National Guard) the veteran
served. See below for questions and answers about returning combat veterans and members of the
Reserves and National Guard.
Is Enrollment Different for Returning Combat Veterans?
Veterans returning from combat operations are eligible to enroll in VA health care for five years
from the date of their most recent discharge without having to demonstrate a service-connected
disability or satisfy an income requirement.
Veterans who enroll under this extended enrollment
authority continue to be enrolled even after the five-year eligibility period ends.

This special period of enrollment eligibility for VA health care was first established in 1998 and
was expanded in 2007. In 1998, Congress, responding to the growing concerns of Persian Gulf
War veterans’ undiagnosed illnesses, passed the Veterans Programs Enhancement Act of 1998
(P.L. 105-368), entitling a veteran who served on active duty in a theater of combat operations
during a period of war after the Persian Gulf War to be eligible to enroll in VA health care during
a two-year period following the date of discharge.
In 2007, the National Defense Authorization Act (NDAA), FY2008 (P.L. 110-181) extended the
period of enrollment eligibility for VA health care from two to five years for veterans who served
in a theater of combat operations after November 11, 1998.15 If returning veterans do not enroll
during this five-year enrollment window (from the date of discharge), future applications for
enrollment will be evaluated according to the Priority Group classifications described in the
Appendix. For this reason, the VA encourages veterans to take advantage of the enhanced
enrollment period.
Is Enrollment Different for Members of the Reserves?
When not activated to full-time federal service, members of the Reserve components have limited
eligibility for VA health care services.

Similar to regular active duty servicemembers, members of the Reserve components may be
eligible for enrollment for VA health care based on veteran status (i.e., previous military service),
service-connected disability,16 and income.

(...continued)
Benefits, by Umar Moulta-Ali.
15 For those servicemembers who are called to duty multiple times, this will be the most recent discharge date.
Generally, returning combat veterans are assigned to Priority Group 6, unless eligible for a higher Priority Group, and
are not charged copays for medication and/or treatment of conditions that are potentially related to their combat service.
At the end of the five-year period, veterans enrolled in Priority Group 6 may be re-enrolled in Priority Group 7 or 8,
depending on their service-connected disability status and income level, and may be required to make copayments for
nonservice-connected conditions. The above criteria apply to National Guard and Reserve personnel who were called to
active duty by federal executive order and served in a theater of combat operations after November 11, 1998.
16 A service-connected disability is a disability that was incurred or aggravated in the line of duty in the U.S. Armed
Forces (38 U.S.C. §101 (16)). The VA determines whether veterans have service-connected disabilities, and for those
with such disabilities, assigns ratings from 0% to 100% based on the severity of the disability. Percentages are assigned
in increments of 10% (38 C.F.R. §§4.1-4.31).
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Reservists achieve veteran status and are exempt from the 24-month minimum duty requirement
(as described above) if they (1) were called to active duty, (2) completed the term for which they
were called, and (3) were granted an other-than-dishonorable discharge.
Members of the Reserve components may be granted service-connection for any injury they
incurred or aggravated in the line of duty while attending inactive duty training assemblies,
annual training, active duty for training, or while going directly to or returning directly from such
duty. In addition, Reserve component servicemembers may be granted service-connection for a
heart attack or stroke if such an event occurs during these same periods. The granting of service-
connection makes them eligible to receive care from the VA for those conditions.
Is Enrollment Different for Members of the National Guard?
When not activated to full-time federal service, members of the National Guard have limited
eligibility for VA health care services.

Similar to regular active duty servicemembers, members of the National Guard may be eligible
for enrollment in VA health care based on veteran status (i.e., previous military service), service-
connected disability,17 and income.
National Guard members achieve veteran status and are exempt from the 24-month minimum
duty requirement (as described above) if they (1) were called to active duty by federal executive
order, (2) completed the term for which they were called, and (3) were granted an other than
dishonorable discharge.
National Guard members are not granted service-connection for any injury, heart attack, or stroke
that occurs while performing duty ordered by a governor for state emergencies or activities.18
How Do Veterans Enroll in VA Health Care?
To receive VA health care, most veterans must enroll by completing and submitting the VA’s
Application for Health Benefits (VA Form 10-10EZ).
19
The following eight-step VA health care enrollment process is illustrated in Figure 1:
1. A veteran may apply for enrollment at any time of year by submitting the
application for enrollment (online, in person, by mail, or by fax) to a VA health

17 A service-connected disability is a disability that was incurred or aggravated in the line of duty in the U.S. Armed
Forces (38 U.S.C. §101 (16)). The VA determines whether veterans have service-connected disabilities, and for those
with such disabilities, assigns ratings from 0% to 100% based on the severity of the disability. Percentages are assigned
in increments of 10% (38 C.F.R. §§4.1-4.31).
18 38.U.S.C. §101(24); 38 C.F.R. §3.6(c).
19 VA Form 10-10EZ is available at https://www.1010ez.med.va.gov/sec/vha/1010ez/. Veterans do not need to apply
for enrollment in the VA’s health care system if they fall into one of the following categories: veterans with a service-
connected disability rated at 50% or more (percentages of disability are based upon the severity of the disability, and
those with a rating of 50% or more are placed in Priority Group 1); veterans for whom less than one year has passed
since the veteran was discharged from military service for a disability that the military determined was incurred or
aggravated in the line of duty, but the VA has not yet rated; or the veteran is seeking care from the VA only for a
service-connected disability (even if the rating is only 10%).
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care facility. The application form includes information about the veteran’s
military service, demographics, and (as applicable) financial status.
2. Upon receipt of the enrollment application, the VA health care facility enters the
information into the Veterans Health Information Systems and Technology
Architecture (VistA) system, which creates an electronic record for the veteran.
(If the enrollment application is submitted in person, a preliminary eligibility
determination is typically provided at the time of application.)
3. The VistA system transmits the veteran’s application information to the VA’s
centralized Eligibility and Enrollment System.
4. The VA’s centralized Eligibility and Enrollment System establishes the veteran’s
record and queries the Veterans Benefits Administration (VBA) records.
5. The VBA returns information about the veteran’s military status and/or
compensation and pension benefits.
6. The VA’s centralized Eligibility and Enrollment System verifies the veteran’s
enrollment eligibility and shares these data with VistA. (If the enrollment system
is unable to determine eligibility, it alerts the veteran’s local VA medical center to
take further action.)
7. When a determination has been made, the VA’s centralized Eligibility and
Enrollment System sends the veteran a letter with that information.
8. The veteran receives the letter from the VA.
The VA developed this enrollment process pursuant to the Veterans’ Health Care Eligibility
Reform Act of 1996 (P.L. 104-262), which required the establishment of a national enrollment
system to manage the delivery of veterans’ inpatient and outpatient medical care. Congress
created the new eligibility standard to “ensure that medical judgment rather than legal criteria will
determine when care will be provided and the level at which care will be furnished.”20
The VA classifies veterans into eight enrollment Priority Groups based on an array of factors,
including (but not limited to) service-connected disabilities or exposures,21 prisoner of war
(POW) status, receipt of a Purple Heart or Medal of Honor, and income. (The criteria for each
Priority Group are summarized in the Appendix.) Once a veteran is enrolled in the VA health care
system, the veteran remains in the system and does not have to reapply for enrollment annually.
However, those veterans who have been enrolled in Priority Group 5 based on income are
generally reevaluated annually with updated financial information. The VA receives income
information from the Internal Revenue Service (IRS) and the Social Security Administration
(SSA). If this information changes, the veteran may be asked to provide updated financial
information; however, any veteran may submit information at any time using VA Form 10–
10EZR (e.g., if he or she believes it will affect his or her enrollment status).22

20 H.Rept. 104-690, p. 4.
21 For example, veterans who may have been exposed to Agent Orange during the Vietnam War or veterans who may
have diseases potentially related to service in the Gulf War may be eligible to receive care.
22 U.S. Department of Veterans Affairs, “Discontinuance of Annual Financial Assessments,” 78 Federal Register
64066, October 25, 2013.
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Figure 1. VA Health Care Enrollment Process

Source: Institute of Medicine, Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment
Needs of Veterans, Service Members, and Their Families
, 2010, p. 124, adapted by Congressional Research Service.
Notes: VistA = Veterans Health Information Systems and Technology Architecture; VBA = Veterans Benefits
Administration; VAMC = VA Medical Center.
Are Veterans’ Family Members Eligible for VA Health Care?
Veterans’ family members are not eligible for enrollment in VA health care services. However,
certain dependents and survivors may receive reimbursement from the VA for some medical
expenses.

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
pays for health care services to dependents and survivors of certain veterans. It is primarily a fee-
for-service program that provides reimbursement for most medical care that is provided by non-
VA providers or facilities. On May 5, 2010, President Barack Obama signed into law the
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Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163), which expanded
the CHAMPVA program to include the primary family caregiver of an eligible veteran who has
no other form of health insurance, including Medicare and Medicaid.23 Health care services
provided include counseling, training, and mental health services for the primary family
caregiver. For more information, see CRS Report RS22483, Health Care for Dependents and
Survivors of Veterans
, by Sidath Viranga Panangala.
Medical Benefits
What Are the Standard Medical Benefits?
The VA offers all enrolled veterans a standard medical benefits package that includes (among
other things) inpatient care, outpatient care, and prescription drugs.

The VA’s standard medical benefits package includes a broad spectrum of inpatient, outpatient,
and preventive medical services, such as the following:
• medical, surgical, and mental health care, including care for substance abuse;
• prescription drugs, including over-the-counter drugs, and medical and surgical
supplies available under the VA national formulary system;
• durable medical equipment and prosthetic and orthotic devices, including hearing
aids and eyeglasses (subject to limitations);24
• home health services, hospice care, palliative care, and institutional respite care;
• noninstitutional adult day health care and noninstitutional respite care; and
• periodic medical exams, among other services.25
The medical benefits package does not include the following:
• abortions and abortion counseling;
• in vitro fertilization;
• drugs, biologicals, and medical devices not approved by the Food and Drug
Administration (FDA), unless the treating medical facility is conducting formal
clinical trials under an Investigational Device Exemption (IDE) or an
Investigational New Drug (IND) application, or the drugs, biologicals, or medical
devices are prescribed under a compassionate use exemption;
• gender alterations;

23 For more information on the VA family caregiver program, see http://www.caregiver.va.gov/support_benefits.asp.
24 Hearing aids and eyeglasses are part of the standard medical package for veterans meeting either of the following
criteria: (1) any veteran with a service-connected condition rated 50% or more on one or more disabilities or based on
Individual Unemployability or (2) veterans needing care for a service-connected condition.
25 A detailed listing of the VHA’s standard medical benefits package is available at 38 C.F.R. §17.38.
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• hospital and outpatient care for a veteran who is either a patient or inmate in an
institution of another government agency if that agency has a duty to give such
care or services; and
• membership in spas and health clubs.26
Does the VA Provide Gender-Specific Services for Women?
The VA’s standard medical benefits package addresses the health care needs of enrolled female
veterans by providing (directly or through access to non-VA providers) gynecological care,
maternity care, infertility, breast and reproductive oncology, and care for conditions related to
military sexual trauma (MST), among other services.

In addition, the Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163)
authorized the VA to provide certain health care services to a newborn child of a female veteran
receiving maternity care furnished by the VA. Health care for the newborn will be authorized for
a maximum of seven days after the birth of the child if the veteran delivered the child in a VA
facility or in another facility pursuant to a VA contract for maternity services.
Under current regulations, the VA is not authorized to provide or cover the cost of in vitro
fertilization (IVF), abortions, abortion counseling, or medication to induce an abortion (e.g.,
mifepristone, also known as RU-486).27
Does the VA Provide Dental Care?
Eligibility for dental care is extremely limited, and differs significantly from eligibility
requirements for medical care.

For VA dental care eligibility, enrolled veterans are categorized into classes, which form the basis
for the scope of dental treatment provided. Table 1 describes the eligibility criteria and scope of
treatment for VA-provided dental care.

26 38 C.F.R. §17.38.
27 38 C.F.R. §17.38; and Department of Veterans Affairs, Veterans Health Administration, Health Care Services for
Women Veterans
, VHA Handbook 1330.01, May 21, 2010.
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Table 1. Eligibility Criteria and Scope of Treatment for VA Dental Care
Classification
Eligibility Criteria
Scope of Treatment Provided
Class I
Veteran has a service-connected compensable
Any necessary dental treatment to maintain or
(disability compensation paid) dental condition
restore oral health and masticatory function,
including repeat care
Class II
Veteran has a service-connected noncompensable A one-time course of dental treatment of the
dental condition (not subject to disability
service-connected noncompensable dental
compensation) shown to have been in existence
condition
at the time of discharge or release from active
duty service, which took place after September
30, 1981, if:
The veteran served at least 180 days (or 90
days if a veteran of the Gulf War era), and
The veteran’s DD214a does not bear
certification that the veteran was provided,
within 90 days immediately prior to
discharge or release, a complete dental
examination (including dental x-rays) and al
appropriate dental treatment indicated by
the examination to be needed, and
Application for treatment is received within
180 days of discharge
Class II (a)
Veteran has a service-connected noncompensable Any necessary dental treatment for the
dental condition or disability determined as
correction of the service-connected condition.
resulting from combat wounds or service trauma
Generally, a Dental Trauma Rating or VA
Regional Office Rating Decision letter
identifies the tooth/teeth eligible for care.
Class II(b)
Veteran is homeless or are otherwise enrolled in
A one-time course of dental treatment
certain VA-sponsored rehabilitation programs
Class II(c)
Veteran is a former prisoner of war (POW)
Any necessary dental treatment to maintain or
restore oral health and masticatory function,
including repeat care
Class III
Veteran has a nonservice-connected dental
A one-time course of dental treatment to
disability professionally determined to be
treat only the oral condition that is directly
aggravating a service-connected medical condition impacting the management of the service-
connected medical condition. Eligibility for
each new course of dental treatment is a
based on a new dental evaluation.
Class IV
Veteran whose service-connected disabilities
Any necessary dental treatment to maintain or
have been rated at 100% or who is receiving the
restore oral health and masticatory function,
100% rating by reason of individual
including repeat care
unemployability.
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Classification
Eligibility Criteria
Scope of Treatment Provided
Class V
Veteran who is approved for VA vocational
Dental care to the extent needed to meet any
rehabilitation training and who requires dental
of the fol owing goals:
treatment to participate in the training
1. make possible his or her entrance into
a rehabilitation program;
2. achieve the goals of the veteran’s
vocational rehabilitation program;
3. prevent interruption of a rehabilitation
program;
4. hasten the return to a rehabilitation
program of a veteran in interrupted or
leave status;
5. hasten the return to a rehabilitation
program of a veteran placed in
discontinued status because of a dental
condition;
6. secure and adjust to employment
during the period of employment
assistance; or
7. enable the veteran to achieve
maximum independence in daily living
Class VI
Veteran scheduled for admission to VA medical
A one-time course of dental treatment to
center or otherwise receiving care and services, if treat conditions that directly impact the
dental care is reasonably necessary to the
management of the nonservice-connected
provision of such care and services, that is, a
medical condition
dental condition is complicating a medical
condition currently under treatment.
(Examples: patients scheduled for cardiac surgery,
knee, hip, joint replacement surgery, or organ
transplant surgery may receive pre-bed care to
eliminate dental infection prior to their surgery
to help insure successful medical treatment)
Source: 38 C.F.R. §§17.160-162 and Department of Veterans Affairs, Veterans Health Administration, Criteria
and Standards for Dental Program
, VHA Handbook 1130.01, December 25, 2008.
a. When servicemembers separate from active military service, they each receive a certificate of release or
discharge from active duty, known as a DD-214. The DD-214 provides the member and the service with a
concise record of a period of service with the Armed Forces at the time of the member’s separation,
discharge, or change in military status (reserve/active duty). In addition, the form serves as an authoritative
source of information for both governmental agencies and the Armed Forces for purposes of employment,
benefit, and reenlistment eligibility, respectively.
The Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163) authorized the
VHA to conduct a three-year pilot program to assess the feasibility and advisability of providing
private, premium-based dental insurance coverage to eligible veterans and certain survivors and
dependents. Generally, survivors and dependents that would qualify for the program will be
Civilian Health and Medical Program of the VA (CHAMPVA) beneficiaries. Under the three-year
pilot program, the VHA would contract with qualified dental insurance carriers that will provide
dental insurance and administer all aspects of the dental insurance plan. The VHA would
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Health Care for Veterans: Answers to Frequently Asked Questions

administer the contract with the private insurer and verify eligibility of veterans, survivors, and
dependents.28
Does the VA Provide Hearing Aids and Eyeglasses?
Generally, the VA provides audiology and eye care services (including preventive care services
and routine vision testing) for all enrolled veterans. The VA does not provide hearing aids or eye
glasses for normally occurring hearing or vision loss.

Hearing aids and eyeglasses are provided to the following veterans:29
• Veterans with any compensable service-connected disability.
• Veterans who are former prisoners of war (POWs).
• Veterans who were awarded a Purple Heart.
• Veterans receiving compensation for an injury, or an aggravation of an injury,
that occurred as the result of VA treatment.
• Veterans in receipt of an increased pension based on being permanently
housebound and in need of regular aid and attendance.
• Veterans with hearing or vision impairment resulting from diseases or the
existence of another medical condition for which the veteran is receiving care or
services from VA, or which resulted from treatment of that medical condition
(e.g., stroke, polytrauma, traumatic brain injury, diabetes, multiple sclerosis,
vascular disease, geriatric chronic illnesses, toxicity from drugs, ocular
photosensitivity from drugs, cataract surgery, and/or other surgeries performed on
the eye, ear, or brain resulting in a vision or hearing impairment).
• Veterans with significant functional or cognitive impairment evidenced by
deficiencies in the ability to perform activities of daily living.30
• Veterans who have hearing and/or vision impairment severe enough that it
interferes with their ability to participate actively in their own medical treatment
and to reduce the impact of dual sensory impairment (combined hearing and
vision loss).
Does the VA Provide Long-Term Care?
The VA provides long-term care services (including residential, home-based, and community-
based care) for veterans meeting specified criteria, which may include service-connected
conditions and the need for such care.


28 Department of Veterans Affairs, “VA Dental Insurance Program,” 77 Federal Register 12517, March 1, 2012.
29 38 C.F.R. §17.149, and Department of Veterans Affairs, Prescribing Hearing Aids and Eyeglasses, VHA Directive
2008-070, October 28, 2008.
30 Activities of Daily Living (ADLs) generally refer to activities such as bathing, getting in and out of a bed or chair,
eating, dressing, walking across the room, and using the toilet.
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The Veterans Millennium Healthcare and Benefits Act (P.L. 106-117) requires the VA to provide
nursing home services to all enrolled veterans who are 70% or more service-connected disabled,
or 60% or more service-connected disabled and unemployable and in need of such care, or who
are service-connected for a condition that makes such care necessary.31 The VA meets the
requirements of P.L. 106-117 by providing short- and long-term nursing care, respite, and end-of-
life care through three different settings: Community Living Centers (CLCs) located on VA
medical campuses; contracted care in Community Nursing Homes (CNH); and through the State
Veterans Nursing Home (SVNH) program. Under the SVNH program, the VA subsidizes state-
operated, long-term care facilities for veterans through a grant and per diem program in states that
have petitioned the VA to build and operate a SVNH. The SVNH program primarily provides
long-stay, maintenance-level care. Each SVNH is owned and operated by its host state; however,
approximately two-thirds of new construction costs and about one-third of per diem costs are
provided by the VA. For those veterans who are 70% or more service-connected disabled and
reside in a SVNH, the VA provides the full cost of care.
The VA provides a range of non-institutional home and community based services for veterans,
which include the following:
• Skilled Home Care—the Purchased Skilled Home Care Program (formerly
known as fee basis home care) is a professional home care service that is
purchased from private-sector providers by every VA medical center. A VA
primary care provider must recommend Skilled Home Care in order for a veteran
to receive it. The professional home care services program covers mostly nursing
services, including medical care, social services, occupational therapy, physical
therapy, skilled nursing care, and speech and language pathology.
• Home Based Primary Care—This program (formerly known as Hospital Based
Home Care) began in 1970 and provides medical care to chronically ill or
disabled veterans in their own homes through an interdisciplinary treatment team.
These services are paid for by the VA and provided by VA personnel.
• Veteran-Directed Home & Community Based Care—The VA partners with
federal Area Agencies on Aging to purchase needed services. This program
allows the veteran to decide on a case mix of services to best meet care needs and
those of the caregiver.
• Spinal Cord Injury/Disorders Bowel & Bladder Care—These programs provide
specialized home care services for veterans with spinal cord injuries and related
disorders. Services include respite care, long-term care, bowel and bladder care,
and caregiver education to veterans.
• Homemaker/Home Health Aide—This program began in 1993 and provides
assistance with personal care and related support services for veterans in their
own homes through the homemaker/home health aide (H/HHA) benefit. H/HHA

31 This section is based on Carol J. Sheets and Heather Mahoney-Gleason, “Caregiver Support in the Veterans Health
Administration: Caring For Those Who Care,” GENERATIONS – Journal of the American Society on Aging, vol. 34,
no. 2 (Summer 2010), pp. 92-98.; U.S. Department of Veterans Affairs, Office of Care Coordination, Supporting
Veterans’ Caregivers: A Frequently Asked Questions Guide, November 29, 2006, pp. 15-18.; and U.S. Congress,
House Committee on Veterans’ Affairs, Subcommittee on Health, Legislative Hearing on H.R. 1293, H.R. 1197, H.R.
1302, H.R. 1335, H.R. 1546, H.R. 2734, H.R. 2738, H.R. 2770, H.R. 2898 and Draft Discussion Legislation,
111th
Cong., 1st sess., June 18, 2009 (Washington: GPO, 2009), pp. 57-58.
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services may include assistance with activities of daily living (ADLs), as well as
instrumental activities of daily living (IADLs).32 Eligibility for the H/HHA
program is based on a clinical judgment by the H/HHA Coordinator and
interdisciplinary team that determines if the veteran would, in the absence of
H/HHA services, require nursing home equivalent care. The VA pays for these
services. H/HHA services are provided by contracted providers. H/HHAs are
personnel who are trained and have completed a competency evaluation, and are
placed under the general supervision of a nurse.
• Community Residential Care (CRC)33—CRC is a form of enriched housing that
provides health care supervision to eligible veterans not in need of hospital or
nursing home care, but who, because of medical and psychiatric and/or
psychosocial limitations, as determined through a statement of needed care, are
not able to live independently and have no suitable family or significant others to
provide the needed supervision and supportive care. CRCs currently encompass
• assisted living facilities;
• personal care homes;
• family care homes;
• psychiatric community residential care homes; and
• medical foster homes.
In general, each of the settings listed above must provide room, board, assistance with Activities
of Daily Living (ADL), and supervision as determined on an individual basis. The individual
veteran makes the final choice of facility, and the cost of residential care is financed by the
veteran’s own resources. However, placement in residential settings is subject to inspection and
approval by the appropriate VA medical center.
Does the VA Pay for Medical Care at Non-VA Facilities?
Under certain circumstances, the VA may reimburse non-VA providers for health care services
rendered to VA-enrolled veterans on a fee-for-service basis.

Current law authorizes the VA to use Fee Basis Care under the following circumstances: (1) when
a clinical service cannot be provided at a VA medical center (VAMC); (2) when a veteran is
unable to access VA health care facilities due to geographic inaccessibility; or (3) in emergencies
when delays could lead to life-threatening situations.34 Fee Basis Care may include outpatient
care, inpatient care, emergency care, medical transportation, and dental services.35

32 Activities of Daily Living (ADLs) generally refer to activities such as bathing, getting in and out of a bed or chair,
eating, dressing, walking across the room, and using the toilet. Instrumental Activities of Daily Living (IADLs) may
include activities such as shopping for groceries, light housework, preparing hot meals, using the telephone, taking
medications, and managing money.
33 The CRC program is authorized under 38 U.S.C. §1730.
34 38 U.S.C. §§1703,1725, and 1728.
35 Department of Veterans Affairs, Veterans Health Administration, Audit of Non-VA Inpatient Fee Care Program,
Report No: 09-03408-227, Washington, DC, August 18, 2010, p. 1.
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Does the VA Pay for Emergency Care at Non-VA Facilities?
The VA may pay for emergency care provided to enrolled veterans by non-VA providers based on
several factors, such as whether the care is for a service-connected condition.

Generally, to be eligible for non-VA emergency care reimbursement veterans must
• be enrolled in the VA health care system, and
• have received VA medical services within the 24-month period preceding the
furnishing of emergency treatment.36
Once these general eligibility criteria are met, emergency care reimbursement falls into two
categories: (1) payment or reimbursement of emergency care for veterans for a service-connected
disability37 and (2) payment or reimbursement of emergency care for veterans for a nonservice-
connected disability.38 The distinct eligibility criteria for each of the two categories are
summarized in Table 2.
Table 2. VA Reimbursement for Emergency Care
Service-Connected Nonservice-Connected
The VA is required to pay or reimburse veterans for
The VA is required to pay or reimburse veterans for
medical expenses incurred in non-VA facilities when all
medical expenses incurred in non-VA facilities when all
three of the fol owing conditions apply:a
four of the fol owing conditions apply:
(1) Delay would have been hazardous to the life or
(1) Delay would have been hazardous to the life or
health of the veteran.
health of the veteran.
(2) VA or other federal facilities were not feasibly
(2) VA or other federal facilities were not feasibly
available (or treatment had been refused).
available.
(3) The care was provided for:
(3) The veteran has either:

a service-connected disability,

no health coverage (e.g., private health insurance or
Medicare) or

a nonservice-connected disability aggravating a
service-connected disability, or

coverage that would only partial y pay for the
emergency treatment.b

any disability of a veteran whose service-connected
disability is total and permanent in nature.
(4) In cases where the care was provided for a condition
caused by an accident or work-related injury, all claims
against a third party for payment have been exhausted
without success.
Source: CRS Summary of 38 U.S.C. §1728 and 38 U.S.C. §1725.
a. Prior to the enactment of the Veterans’ Mental Health and Other Care Improvements Act of 2008 (P.L.
110-387), the VA was not required to reimburse the non-VA facility for the cost of care after the point of
stabilization. P.L. 110-387 mandated that the VA reimburse or pay for the reasonable value of treatment for

36 Under current law, “emergency treatment” is defined as medical services furnished, in the judgment of the VA
Secretary (1) when VA or other federal facilities are not feasibly available and an attempt to use them beforehand
would not be reasonable; (2) when such services are rendered in a medical emergency of such nature that a prudent
layperson reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health;
and (3) until such time as the veteran can be transferred safely to a VA facility (38 U.S.C. §1725(f)(1)).
37 38 U.S.C. §1728.
38 38 U.S.C. §1725.
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any veteran who meets above eligibility criteria and defined “emergency treatment” as continuing until the
veteran can be transferred safely to a VA or other federal facility, and the VA or other federal facility agrees
to accept such a transfer.
b. Prior to the passage of the Veterans’ Emergency Care Fairness Act (P.L. 111-137), a veteran who was
enrol ed in the VA’s health care system was reimbursed for emergency treatment received at a non-VA
hospital. However, the statute only permitted such VA reimbursement if the veteran had no other outside
health insurance, no matter how limited that other coverage was. P.L. 111-137 would require the VA to pay
for emergency treatment for a nonservice-connected condition if a third party is not responsible for paying
for the full cost of care. The law also set two limitations on reimbursement as follows: (1) the VA is the
secondary payer where a third-party insurer covers a part of the veteran’s medical liability (e.g., his or her
automobile insurance coverage, private health insurance, or Medicare Part A and Medicare Part B); and (2)
the VA is only responsible for the difference between the amount paid by the third-party insurer and the
VA al owable amount. Veterans would continue to be responsible for copayments owed to the third-party
insurer; if the veteran were responsible for copayments under a private health insurance or Medicare plan,
then the veteran would still be liable to pay this (copayment rates and or coinsurance rates are set by the
individual insurance policy or Medicare and not the VA). P.L. 111-137 clarifies that veterans are not liable
for any remaining balance due to the provider after the third-party insurer and the VA have made their
payments.
Costs to Veterans and Insurance Collections
Do Veterans Have to Pay for Their Care?
Whether a veteran is required to pay for VA health care services depends primarily on (1)
whether the condition being treated is service-connected, and/or (2) the veteran’s enrollment
Priority Group.
39
Veterans who are enrolled in the VA health care system do not pay any premiums; however, some
veterans are required to pay copayments for medical services and outpatient medications related
to the treatment of a nonservice-connected condition.
Table 3 summarizes which Priority Groups are charged copayments for inpatient care, outpatient
care, outpatient medication, and long-term care services. Only veterans in Priority Group 1 (those
who have been rated 50% or more service-connected) and veterans who are deemed
catastrophically disabled by a VA provider are never charged a copayment, even for treatment of a
nonservice-connected condition.40 For veterans in other priority groups, VHA currently has four
types of nonservice-connected copayments for which veterans may be charged: outpatient,
inpatient, extended care services, and medication. Veterans in all priority groups are not charged
copayments for a number of outpatient services, including the following: publicly announced VA
health fairs; screenings and immunizations; smoking and weight loss counseling; telephone care;
laboratory services; flat film radiology; and electrocardiograms.

39 The VA classifies veterans into eight enrollment Priority Groups based on an array of factors including (but not
limited to) service-connected disabilities or exposures, prisoner of war (POW) status, receipt of a Purple Heart or
Medal of Honor, and income. The criteria for each Priority Group are summarized in the Appendix.
40 The manner in which the VA determines that a veteran is catastrophically disabled is established in regulation. The
determinations are based on clinical criteria, rather than (as was formerly the case) medical codes, which change over
time. For more information, see U.S. Department of Veterans Affairs, “Criteria for a Catastrophically Disabled
Determination for Purposes of Enrollment,” 78 Federal Register 72576-72579, December 3, 2013.
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For primary care outpatient visits, there is a $15 copayment charge and for specialty care
outpatient visits, a $50 copayment. Veterans do not receive more than one outpatient copayment
charge per day. That is, if the veteran has a primary care visit and a specialty care visit on the
same day, the veteran pays only for the specialty care visit. For veterans required to pay an
inpatient copayment charge, rates vary based upon whether the veteran is enrolled in Priority
Group 7 or not. Veterans enrolled in Priority Group 8 and certain other veterans are responsible
for the VA’s full inpatient copayment, and veterans enrolled in Priority Group 7 and certain other
veterans are responsible for paying 20% of the VA’s inpatient copayment. Veterans in Priority
Groups 1 through 5 do not have to pay inpatient or outpatient copayments. Veterans in Priority
Group 6 may be exempt due to special eligibility for treatment of certain conditions.
For veterans required to pay long-term care copayments, these charges are based on three levels
of nonservice-connected care, including inpatient, non-institutional, and adult day health care.
Actual copayments vary depending on the veteran’s financial situation.
For medication copayments, veterans are not billed if they have a service-connected disability
rated 50% or greater, if they are former prisoners of war, or if their medications are related to
certain eligibility exceptions. Veterans enrolled in Priority Groups 2 through 6 have a $960
calendar-year cap on the amount that they can be charged for these copayments.41 Veterans who
are unable to pay VA’s copayment charges may submit requests for assistance, including waivers,
hardships, compromises, and repayment plans.42
The VHA bills private health insurers for medical care, supplies, and prescriptions provided to
veterans for their nonservice-connected conditions. While the VA cannot bill Medicare, it can bill
Medicare supplemental health insurance carriers for covered services.43 Veterans are not
responsible for paying any remaining balance of the VA’s insurance claim that is not paid or
covered by their health insurance carrier. Any payment received by the VA is used to offset
‘‘dollar for dollar’’ a veteran’s VA copayment responsibility.44

41 U.S. Department of Veterans Affairs, “Copayments for Medications in 2014,” 78 Federal Register 79315, December
30, 2013.
42 U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, Identifying the Causes of
Inappropriate Billing Practices by the U.S. Department of Veterans Affairs
, 111th Cong., 1st sess., October 15, 2009
(Washington: GPO, 2010), p. 43.
43 38 U.S.C. §1729.
44 U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, Identifying the Causes of
Inappropriate Billing Practices by the U.S. Department of Veterans Affairs
, 111th Cong., 1st sess., October 15, 2009
(Washington: GPO, 2010), p. 43.
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Table 3. Copayments for Health Care Services (CY2014)

Outpatient
Inpatient care
Outpatient care
medication
Long-term care services
(Institutional nursing home
($8 per 30-day
care units, respite care,
supply and a
geriatric evaluation:
($10/day +
calendar year cap
$0-97 per day.
$1,216 for first
of $960 for Priority Non-institutional respite care,
90 days and $608
($15 Primary Care;
Groups 2-6; $9 for
geriatric evaluation, adult day
after 90 days;
$50 Specialty Care;
30-day supply for
healthcare:
based on
$0 for x-rays, lab,
Priority Groups
$15 per day.
365-day period)
immunizations, etc.)
7 and 8)a
Domiciliary care: $5 per day)
Priority Group 1
NO
NO
NO
NO
Priority Group 2b NO
NO
YES
NO
Priority Group 3b NO
NO
YES
NO
Priority Group 4c NO
NO
NO
NO
Priority Group 5d NO
NO
YES
YES
Priority Group 6e NO
NO
NO
NO
Priority Group 7f YES
YES
YES
YES
Priority Group 8g YES
YES
YES
YES
Source: CRS summary based on U.S. Department of Veterans Affairs, Health Benefits Home: Determine Cost of
Care: Copays: Copay Rates
, Updated February 13, 2014, http://www.va.gov/healthbenefits/cost/copay_rates.asp.
Notes: “NO” means the veteran is not responsible for paying copayments. “YES” means the veteran may be
liable for partial or full copayments.
a. For the period from July 1, 2010, through December 31, 2014, the copayment amount for veterans in Priority
Groups 2 through 6 is $8. There is an annual cap of $960 per calendar year. When veterans reach the annual
cap, they continue to receive medications without making a copayment. For veterans in Priority Groups 7 and 8
the copayment amount from July 1, 2010, through December 31, 2014, is $9. There is no annual cap for these
priority groups.
b. No medication copayments if medication is for a service-connected disability. Former POWs are exempt from
all medication copayments.
c. The Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163) exempted veterans
determined by VA to be catastrophical y disabled from inpatient, outpatient and prescription copayments.
d. No medication or long-term care copayments if veteran is in receipt of VA pension or has an income below
applicable pension threshold.
e. Priority Group 6 are veterans claiming exposure to Agent Orange; veterans claiming exposure to environmental
contaminants; veterans exposed to ionizing radiation; combat veterans within five years of discharge from the
military; veterans who participated in Project 112/SHAD; veterans claiming military sexual trauma; and veterans
with head and neck cancer who received nasopharyngeal radium treatment while in the military are subject to
copayments when their treatment or medication is not related to their exposure or experience. The initial
registry examination and follow-up visits to receive results of the examination are not billed to the health
insurance carrier and are not subject to copayments. However, care provided that is not related to exposure, if
it is nonservice-connected, will be billed to the insurance carrier and copayments can apply.
f.
Priority Group 7a and 7c veterans have incomes above the VA Means Test threshold but below the Geographic
Means Test threshold and are responsible for 20% of the inpatient copayment and 20% of the inpatient per diem
copayment. The Geographic Means Test copayment reduction does not apply to outpatient and medication
copayments, and veterans will be assessed the full applicable copayment charges.
g. Priority Group 8a and 8c veterans have incomes above the VA Means Test threshold and above the Geographic
Means Test threshold. Veterans enrol ed in these priority groups are responsible for the ful inpatient copayment
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and the inpatient per diem copayment for care of their nonservice-connected conditions. Veterans in these
priority groups are also responsible for outpatient and medication copayments for care of their nonservice-
connected conditions.
Can the VA Bill Private Health Insurance?
The VA has the authority to bill most health care insurers for nonservice-connected care provided
to veterans enrolled in the VA health care system.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99-272), enacted into law in
1986, gave the VHA the authority to bill some veterans and most health care insurers for
nonservice-connected care provided to veterans enrolled in the VA health care system to help
defray the cost of delivering medical services to veterans.45 This law also established means
testing for veterans seeking care for nonservice-connected conditions.
Congress authorized the VHA to collect reasonable charges for medical care or services
(including the provision of prescription drugs) from a third party to the extent that the veteran or
the provider of the care or services would be eligible to receive payment from the third party for
(1) a nonservice-connected disability for which the veteran is entitled to care (or the payment of
expenses of care) under a health plan contract;46 (2) a nonservice-connected disability incurred as
a result of the veteran’s employment and covered under a worker’s compensation law or plan that
provides reimbursement or indemnification for such care and services;47 or (3) a nonservice-
connected disability incurred as a result of a motor vehicle accident in a state that requires
automobile accident reparations (no fault) insurance.48 Similarly, the VHA can receive payments
from Medicare supplemental coverage plans for nonservice-connected conditions for which the
veterans receives care at VHA facilities.
Veterans are not responsible for paying any remaining balance of the VA’s insurance claim not
paid or covered by their health insurance. Any payment received by the VA is used to offset
‘‘dollar for dollar’’ a veteran’s VA copayment responsibility.49
Can the VA Bill Medicare?
The VA is statutorily prohibited from billing Medicare50 in most situations.
In general, Medicare is prohibited from reimbursing for any services provided by a federal health
care provider unless

45 Veterans’ Health-Care and Compensation Rate Amendments of 1985 (P.L. 99-272).
46 38 U.S.C. §1729(a)(2)(D), and 38 C.F.R. §17.101(a)(1)(i).
47 38 U.S.C. §1729(a)(2)(A), and 38 C.F.R. §17.101(a)(1)(ii).
48 38 U.S.C. §1729(a)(2)(B), and 38 C.F.R. §17.101(a)(1)(III).
49 U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, Identifying the Causes of
Inappropriate Billing Practices by the U.S. Department of Veterans Affairs
, 111th Cong., 1st sess., October 15, 2009
(Washington: GPO, 2010), p. 43.
50 “Medicare is a federal insurance program that pays for covered health care services of qualified beneficiaries.” CRS
Report R40425, Medicare Primer, coordinated by Patricia A. Davis and Scott R. Talaga.
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• the provider is determined by the Secretary of Health and Human Services (HHS)
to be providing services to the public as a community institution or agency;
• the provider is providing services through facilities operated by the Indian Health
Service (IHS);51 or
• the services were provided in an emergency (in a hospital setting).
Medicare is also prohibited from making payments to any federal health care provider who is
obligated by law or contract to render services at public expense.52 Therefore, the VHA is
statutorily prohibited from receiving Medicare payments for services provided to Medicare-
covered veterans.53 Although the legislative history does not indicate congressional intent for this
decision, “a safe assumption to be drawn from the exclusion of Medicare [from paying for health
care services provided through other federal entities] is that Congress wanted to avoid the
unnecessary transfer of federal funds from Medicare to the VA when the money is all coming out
of the same coffer.”54
It should be noted that there is a narrow exception to this statutory prohibition of Medicare
reimbursing the VHA. Under current law the VHA can be reimbursed by Medicare
(notwithstanding any condition, limitation, or other provision in title XVIII of the Social Security
Act) when the VA provides services to Medicare-covered individuals who are not eligible for care
under Chapter 17 of Title 38 United States Code (U.S.C.)55 and who are afforded VA care or
services under a “sharing” agreement.56

51 In 1976, Congress authorized Medicare and Medicaid payments for services delivered in Indian health facilities
(whether operated by the IHS or Tribes) through amendments to the Social Security Act made in the Indian Health
Care Improvement Act of 1976 (P.L. 94-437) (IHCIA). This was permanently authorized by the Patient Protection and
Affordable Care Act (PPACA; P.L. 111-148). According to the Centers for Medicare and Medicaid Services American
Indian and Alaska Native Strategic Plan 2010–2015:
“this entitlement funding was expected to provide critical
resources to improve the quality of health care for American Indians and Alaska Natives and to reduce the health status
disparities. There is a provision in the IHCIA that Medicaid and Medicare revenues shall not offset congressional
appropriations for the IHS, so that the total amount of funding for Indian health care would increase and not merely be
shifted from one funding stream to another”(available at http://www.cmsttag.org/docs/CMS%20Strategic%20Plan%20-
%20June%2010,%202009%20FINAL.pdf).
52 42 U.S.C. §§1395f(c), 1395n(d), 1395f(a).
53 42 U.S.C §1395f(c), and 38 U.S.C. §1729(i)(1)(B)(i).
54 United States v. Blue Cross & Blue Shield of Maryland, Inc., 989 F.2d 718, 727 n. 5 (4th Cir.).
55 Chapter 17 of Title 38 U.S.C. details the eligibility criteria as well as programs relating to the provision of medical
care, and nursing home care, among other things, for veterans and their eligible dependents.
56 38 U.S.C. §8153(d). A sharing agreement is a written contract that allows VHA to buy, sell, or exchange health care
resources and services with non-VA facilities. VHA could enter into noncompetitive sharing agreements with affiliated
institutions (such as affiliated medical schools ) and other entities associated with these affiliated institutions (such as
university hospitals).
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Appendix. VA Priority Groups and Their
Eligibility Criteria

The VA classifies veterans into eight enrollment Priority Groups based on an array of factors
including (but not limited to) service-connected disabilities or exposures,57 prisoner of war
(POW) status, receipt of a Purple Heart or Medal of Honor, and income. The criteria for each
Priority Group are summarized in Table A-1.
The eight Priority Groups fall into two broad categories. The first group is composed of veterans
with service-connected disabilities or with incomes below an established means test. These
veterans are regarded by the VA as “high priority” veterans, and they are enrolled in Priority
Groups 1-6. Veterans enrolled in Priority Groups 1-6 include the following:
• veterans in need of care for a service-connected disability;
• veterans who have a compensable service-connected condition;
• veterans whose discharge or release from active military, naval, or air service was
for a compensable disability that was incurred or aggravated in the line of duty;
• veterans who are former prisoners of war (POWs);
• veterans awarded the Purple Heart;
• veterans who have been determined by the VA to be catastrophically disabled;
• veterans of World War I;
• veterans who were exposed to hazardous agents (such as Agent Orange in
Vietnam) while on active duty; and
• veterans who have an annual income and net worth below a VA-established
means test threshold.
The VA looks at applicants’ income and net worth to determine their specific priority category
and whether they have to pay copayments for nonservice-connected care. In addition, veterans are
asked to provide the VA with information on any health insurance coverage they have, including
coverage through employment or through a spouse. The VA may bill these payers for treatment of
conditions that are not a result of injuries or illnesses incurred or aggravated during military
service.
The second group of veterans is composed of those who do not fall into one of the first six
priority groups—primarily veterans with nonservice-connected medical conditions and with
incomes and net worth above the VA-established means test threshold. These veterans are
enrolled in Priority Groups 7 or 8.58

57 For example, veterans who may have been exposed to Agent Orange during the Vietnam War or veterans who may
have diseases potentially related to service in the Gulf War may be eligible to receive care.
58 The VA considers a veteran’s previous year’s total household income (both earned and unearned income, as well as
his/her spouse’s and dependent children’s income). Earned income is usually wages received from working. Unearned
income includes interest earned, dividends received, money from retirement funds, Social Security payments, annuities,
and earnings from other assets. The number of persons in the veterans’ family will be factored into the calculation to
(continued...)
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Health Care for Veterans: Answers to Frequently Asked Questions

Table A-2 provides information on income thresholds for VA health care benefits.
Table A-1. VA Priority Groups and Their Eligibility Criteria
Priority Group 1
Veterans with service-connected disabilities rated 50% or more disabling
Veterans determined by VA to be unemployable due to service-connected conditions
Priority Group 2
Veterans with service-connected disabilities rated 30% or 40% disabling
Priority Group 3
Veterans who are former POWsa
Veterans awarded the Purple Heartb
Veterans in receipt of the Medal of Honorc
Veterans whose discharge was for a disability that was incurred or aggravated in the line of duty
Veterans with service-connected disabilities rated 10% or 20% disabling
Veterans awarded special eligibility classification under Title 38, U.S.C., Section 1151, “benefits for individuals disabled
by treatment or vocational rehabilitation”
Priority Group 4
Veterans who are receiving aid and attendance or housebound benefits
Veterans who have been determined by VA to be catastrophical y disabled
Priority Group 5
Nonservice-connected veterans and noncompensable service-connected veterans rated 0% disabled whose annual
income and net worth are below the established VA means test thresholds
Veterans receiving VA pension benefits
Veterans eligible for Medicaid benefits
Priority Group 6
Compensable 0% service-connected veterans
Mexican Border War veterans
Veterans solely seeking care for disorders associated with
—exposure to herbicides while serving in Vietnam; or
—ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki; or
—service in the Gulf War; or
—being stationed at Camp Lejeune for 30 days or more between January 1, 1957, and December 31, 1987d

(...continued)
determine the applicable income threshold. 38 C.F.R. §17.36(b)(7) (2009).
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Health Care for Veterans: Answers to Frequently Asked Questions

—for any illness associated with service in combat in a war after the Gulf War or during a period of hostility after
November 11, 1998 as fol ows:
—Veterans discharged from active duty on or after January 28, 2003, who were enrol ed as of January 28, 2008, and
veterans who apply for enrol ment after January 28, 2008, for five years post discharge
—Veterans discharged from active duty before January 28, 2003, who apply for enrol ment after January 28, 2008,
until January 27, 2011
Veterans who served on active duty at Camp Lejeune in North Carolina for not less than 30 days during the period
beginning on January 1, 1957, and ending on December 31, 1987, for any of the 15 medical conditions specified in 38
U.S.C. 1710(e)(1)(F)e
Priority Group 7
Veterans who agree to pay specified copayments with income and/or net worth above the VA means test threshold
and income below the VA national geographic income thresholds
Priority Group 8
Veterans who agree to pay specified copayments with income and/or net worth above the VA means test threshold
and the VA national geographic threshold
Subpriority a: Noncompensable 0% service-connected and enrol ed as of January 16, 2003, and who have remained
enrolled since that date and/or placed in this subpriority due to changed eligibility status
Subpriority b: Noncompensable 0% service-connected and enrol ed on or after June 15, 2009, whose income exceeds
the current VA means test threshold or VA national geographic income thresholds by 10% or less
Subpriority c: Nonservice-connected veterans enrol ed as of January 16, 2003, and who have remained enrol ed since
that date and/or placed in this subpriority due to changed eligibility status
Subpriority d: Nonservice-connected veterans enrol ed on or after June 15, 2009, whose income exceeds the current
VA means test threshold or VA national geographic income thresholds by 10% or less
Subpriority e: Noncompensable 0% service-connected veterans not meeting the above criteria
Subpriority g: Nonservice-connected veterans not meeting the above criteria
Source: Department of Veterans Affairs.
Notes: Service-connected disability means with respect to disability, that such disability was incurred or
aggravated in the line of duty in the active military, naval or air service.
a. Veterans who are former prisoners of war (POWs) are in Priority Group 3. This began with the enactment
of the Former Prisoner of War Benefits Act of 1981 (P.L. 97-37) on August 14, 1981.
b. Veterans in receipt of a Purple Heart are in Priority Group 3. This began with the enactment of the
Veterans Millennium Health Care and Benefits Act (P.L. 106-117) on November 30, 1999.
c. Veterans in receipt of the Medal of Honor are in Priority Group 3. This began with the enactment of the
Caregiver and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163) on May 5, 2010.
d. The Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012 (P.L. 112-154),
enacted on August 6, 2012, provided this authority.
e. Veterans who served on active duty at Camp Lejeune in North Carolina between January 1, 1957, and
December 31, 1987, are placed in Priority Group 6. These veterans are eligible to receive free medical care
for the following 15 illnesses or conditions: esophageal cancer; lung cancer; breast cancer; bladder cancer;
kidney cancer; leukemia; multiple myeloma; myleodysplasic syndromes; renal toxicity; hepatic steatosis;
female infertility; miscarriage; scleroderma; neurobehavioral effects; and non-Hodgkin's lymphoma. This
change occurred with the enactment of the Honoring America's Veterans and Caring for Camp Lejeune
Families Act of 2012 (P.L. 112-154) on August 6, 2012.

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Health Care for Veterans: Answers to Frequently Asked Questions

Table A-2. National Income Thresholds for CY2014
Free VA prescriptions and
Free VA Heath Care
Enrollment in Priority
travel benefits for veterans
for veterans with
Group 8 for veterans with
Veterans with—
with incomes of—
incomes of—
incomes of—
No dependents
$12,652 or less
$31,443 or less
$34,587 or less
1 dependent
$16,569 or less
$37,733 or less
$41,506 or less
2 dependents
$18,730 or less
$39,894 or less
$43,883 or less
3 dependents
$20,891 or less
$42,055 or less
$46,260 or less
4 dependents
$23,052 or less
$44,216 or less
$48,637 or less
For each
additional
$2,161 $2,161
$2,161
dependent, add:
Source: Department of Veterans Affairs.
Notes: For geographic variations, see http://www.va.gov/healthbenefits/cost/income_thresholds.asp (accessed
January 10, 2014).

Author Contact Information

Sidath Viranga Panangala
Erin Bagalman
Specialist in Veterans Policy
Analyst in Health Policy
spanangala@crs.loc.gov, 7-0623
ebagalman@crs.loc.gov, 7-5345

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