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The Civilian’s Guide to Health Care for Veterans

Navigating health care through the VA can be tricky, and the local system has scaled back its outreach efforts to explain what’s available.

Veterans eligible for health care coverage through the VA have a pretty sweet package available to them – if they know to enroll and jump through the appropriate hoops.

“This system is very complicated and I think we need to do better at trying to help people figure out how to get through,” said Cindy Butler, director of public affairs for the VA San Diego Health Care System. “And that’s what I’ve tried to do in my job – turn it into English, try not to have people use acronyms, all that kind of stuff, because it just puts people off.”

VASDHS (I know, I’m defying Butler’s acronym warning) has scaled back its efforts to connect with veterans and explain the care it offers, which could disproportionately affect older veterans. These days, members of the military about to leave active duty are required to take a transition workshop, during which federal VA officials lay out the benefits available. But there are plenty of clauses and crannies that can be intimidating to someone unfamiliar with the process.

Let’s break down what health care looks like for San Diego’s veteran community.

Who’s Eligible

As long as someone has served in active military service for longer than 24 consecutive months, and left under conditions other than dishonorable, they likely qualify for VA health care benefits. New veterans from wars in Iraq and Afghanistan have an even greater incentive to enroll.

The acronyms OEF, OIF, OND – Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn – refer to this group of veterans.

For five years after their official separation from active duty, combat veterans from those wars can walk into a VA hospital, enroll and get free care and medications for injuries or illnesses “incurred or aggravated” during service. During that time of so-called “enhanced eligibility,” vets are encouraged to file any disability claims. They’ll stay enrolled after their five years are up, though they might be shifted to a lower-priority group and required to pay copayments.

Several groups of veterans who’ve been out longer also qualify for free care or medication. These include:

• Purple Heart and Medal of Honor recipients

• Former prisoners of war

• Those who served on the ground in Vietnam; in Southwest Asia during the Persian Gulf War or were exposed to radiation during service

• Single veterans who make less than $31,443 or married vets whose household income is less than $37,333

• Veterans with disabilities that the VA deems 50 percent debilitating or worse

You’ll see percentages like that come up a lot in the VA’s determinations for how much a veteran will pay for care, or be paid in compensation for service-connected disabilities. Here’s how the Los Angeles Times put it: “The VA uses a formula that combines a veteran’s conditions into a rating of 0% to 100% — in 10% increments. The higher the rating, the larger the monthly disability check.”

The Process

Veterans can enroll online, by phone, by mail or in person. Vets must divulge details on their separation from the service, financial information (so the VA can determine if they qualify for free care under the income threshold) and undergo a physical exam.

If they want to file a disability claim, veterans can head to the Veterans Benefits Administration office in Mission Valley for a so-called “compensation and pension” exam with a VA doctor, or take a Disability Benefits Questionnaire to a non-VA doctor. But filing a claim with the benefits office is a wholly separate process from VA health care.

While veterans wait for their applications to be approved, they can still receive emergency care.

If a veteran is accepted into the VA health care system, he or she is assigned an enrollment priority group.

Priority Groups

Once enrolled, veterans are classified in a hierarchy of need. It’s set up this way so Congress can start cutting from the bottom if funding becomes an issue.

Veterans in the Priority 1 group have service-connected disabilities the VA has deemed 50 percent or more disabling, or are considered unemployable because of their conditions. The group classifications get gradually less urgent from there. Veterans in the Priority 8 group are above the income threshold and have agreed to pay copays. You can check out the defined groups here.

What They Get

Aside from a fancy Veteran Health Identification Card, that is.

Every enrolled patient is assigned a team of health care professionals, called a Patient Aligned Care Team. These include a primary care provider, pharmacist, a registered nurse care manager, a licensed practical nurse or medical assistant and clerk.

VASDHS offers a pretty wide range of services. The La Jolla medical center alone has support for hearing loss, spinal injury, moderate traumatic brain injury, sexual trauma and mental health. Check out the full list of what’s available locally, and what’s included (and excluded) in the national VA’s medical care package.

Dental benefits aren’t available to many veterans. Veterans who have service-connected dental disabilities, are former prisoners of war or whose service-connected disabilities are deemed 100 percent disabling qualify for free dental care. For others, the VA offers the option of buying reduced-cost plans through Delta Dental and MetLife.

If veterans are enrolled, the VA might pay for emergency care at non-VA facilities as long as a veteran is transferred to a VA hospital as soon as it’s safe. VA hospitals must be notified within 72 hours of a veteran’s admission to a non-VA hospital. Not all non-VA emergency care will automatically be paid for – VA physicians review these requests.

What They Pay

Veterans who are able must pay copayments – $50 for specialty care and $15 for primary care. For $1,216, they can receive 90 days of inpatient care a year, and pay $10 for each day after. But that can change depending on priority group assignment. Check out the breakdown here.

A few services don’t require copays, including counseling and treatment for military sexual trauma, hospice care and mental health counseling as they adjust to civilian life.

There’s another income threshold to avoid paying copays for prescriptions – $12,652 for single veterans and $16,569 for households, with an additional $2,161 for each dependent.

Priority groups matter at the pharmacy counter, too. Depending on their group assignment, vets will pay $8 or $9 for each 30-day supply of medications not related to service-connected disabilities.

Also, an enrolled veteran can apply for financial hardship assistance if his or her income suddenly drops.

Filing a Claim

This is a whole other animal.

The process of filing a claim is cumbersome and finicky. Veterans don’t need to be enrolled in VA care to file one, but they do need to be prepared for rejection and red tape.

“Everyone knows it takes a while to file a disability claim – sometimes a long time … I think it’s standard that you have to file more than one time to get it to go through,” said Butler, of the VA.

But it’s worth the trouble if the claim goes through. Veterans with service-connected disabilities receive compensation, and coverage is life-long.

Veterans can submit claims by mail, in person or online.

The VA is responsible for gathering federal records or service medical records, but if veterans already have these, they can submit them to speed things up.

Each claimed disability needs to be evaluated by a physician, though veterans can have private health care providers fill out the benefits questionnaire and submit it with their claim.

There are a few types of claims. Service members can file a disability compensation claim before the end of their terms, and some disabilities developed before and after service may be eligible for compensation, if active duty aggravated the condition or an injury afterward was somehow caused by service.

Once it’s in the system, VA officials review the evidence and notify the veteran by mail. How long might that process take? In San Diego, about 189 days, according to the local VBA, though the average for data collected since October 2013 showed 264.5 days in San Diego, a hair under the national average of 264.7 days.

Source: Veterans Benefits Administration Reports, Department of Veterans Affairs
Source: Veterans Benefits Administration Reports, Department of Veterans Affairs

San Diego has a goal to get processing times under 125 days, a VA official said. According to the data above, the national VA is gunning for 80 days.

Who Pays for All This

VA health care is paid for through funds from Congress, patients’ copayments and reimbursements from a patient’s non-VA health insurance.

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