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VA Healthcare Eligibility & Copays

VA Healthcare Eligibility & Copays
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Enrollment in VA Healthcare

The Department of Veterans Affairs budget is decided by Congress each year.  The more money VA gets, the more veterans can enroll in VA healthcare.  And, of course, the opposite is true—less money, fewer enrollees.  For this reason, VA assigns every veteran an Enrollment Priority Group to make sure that certain groups of veterans are able to enroll before others.

When you apply for enrollment, VA will assign you a Priority Group and let you know whether you are eligible for VA healthcare in general.  Your Priority Group also determines whether you will be responsible for copayments for medications and different types of care at VA Medical Centers.

Below, you’ll find the types of veterans that fit into each Priority Group.  You can reference the graphic as a starting place for determining which Group you may fall into, but be aware that this is just an overview.  You may want to check out the specific language VA uses to describe each group.

If you meet the requirements for more than one Priority Group, VA will place you in the highest Priority Group for which you are eligible.

VA Healthcare Eligibility and Copayments - infographic - Priority Groups

[Click on image to zoom in]

TIP:  You can find out what this year’s geographically adjusted income limits are at this VA website.  The income limits are based on where you live and the number of dependents (children, spouse, etc.) you have.

 

Copayment for Each Priority Group

Under Medical Benefits Package, veterans in different priority groups typically have access to the same medical services (with some exceptions—see “Eyeglasses & Hearing Aids” below).  But each Priority Group has different rules regarding a veteran’s responsibility for copayments.  Below is an overview of the copay requirements for each Priority Group.

VA Healthcare Eligibility and Copayments - 2017 VA Copay Requirements at a Glance

[Click on image to zoom in]

Services Exempt from Inpatient and Outpatient Copayments

All of the following services do NOT require inpatient and outpatient copays, regardless of the veteran’s Priority Group:

  • Care related to a VA-rated service-connected disability
  • Special registry examinations offered by VA to evaluate possible health risks associated with military service (for example, the Agent Orange Registry exam)
  • Counseling and care for military sexual trauma
  • Compensation and Pension examinations 
  • Care that is part of a VA research project
  • Readjustment counseling
  • Care for cancer of the head or neck caused by nose or throat radium treatments received while in the military
  • Individual or group smoking cessation or weight reduction services
  • Hospice care

OEF/OIF/OND Combat Veterans

As shown in the graphic above, combat veterans discharged from active duty on or after January 28, 2003 are eligible for enrollment in Priority Group 6 for 5 years following discharge, unless they qualify for a higher group.  After the 5-year period ends, these veterans will be reassigned to the appropriate Priority Group and subject to copayment requirements, if applicable.

During the 5-year “enhanced eligibility” period, combat veterans in Priority Group 6 are, unlike other Group 6 members, responsible for copayments for care related to any conditions that are congenital or developmental (for example, scoliosis that existed before military service), or for specific ailments that began after service (for example, a common cold).

TIP: You can find this year’s copay amounts for different services at this VA website. 

 

Eyeglasses & Hearing Aids

VA healthcare covers routine vision and hearing exams and preventive tests, but generally does not cover eyeglasses or hearing aids.

However, VA will provide you with eyeglasses and/or hearing aids if you

  • receive compensation for a service-connected disability (of any kind),
  • receive increased pension for regular aid and attendance or for being permanently housebound,
  • are a former Prisoner of War (POW), or
  • received a Purple Heart medal.

There are a few other scenarios in which veterans may obtain eyeglasses or hearing aids from VA.  More information about VA’s eyeglasses and hearing aid policy is available at this VA website.

 

Dental Care

VA only offers dental care benefits to certain qualifying veterans, based on a “Class” system.  But veterans who do not qualify for VA dental care (and are enrolled in VA healthcare) may purchase dental insurance at a reduced cost through the VA Dental Insurance Program (VADIP).

To find out more about VADIP or the system used to determine eligibility for VA dental benefits, you can visit this VA website.

 

How do I enroll?

To enroll in VA’s Medical Benefits Package, you must apply (in most cases).  To apply, you must submit VA Form 10-10 EZ by mail, in person, or online.

If you submit the form by mail, you should send it to:

Health Eligibility Center
Enrollment Eligibility Center
2957 Clairmont Road, Suite 200
Atlanta, GA 30329-1647

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Category: Veterans Law

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