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Coco CulhaneUrban Justice Center If you find this article helpful, you can learn more about the subject by going to www.pli.edu to view the on demand program or segment for which it was written. |
Understanding discharge status and how to advocate for VA eligibility.
Who is a veteran? The question is not as simple as it seems. For the purposes of the Department of Veterans Affairs, a veteran is “a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable.” 38 U.S.C. § 101(2); 38 C.F.R. § 3.1(d). Even that definition is deceptively simple because it is the threshold, the beginning of endless regulations that determine who the VA lets in the door. There are an estimated 560,000 veterans from the Vietnam era with less than honorable discharges. Since 2000, over 600,000 servicemembers have been given less-than-fully-honorable discharges, as well; about half of those discharges are lower than a General and preclude VA services.
Behavior that civilians may see as a bad habit may be punishable under the Uniform Code of Military Justice (UCMJ). Symptoms of brain injury and post-traumatic stress1 may be treated as misconduct. What was once called “soldier’s heart,” “shell-shock”, and “battle fatigue,” was not even recognized as a clinical diagnosis until 1980, when Post-Traumatic Stress Disorder was added to the Diagnostic and Statistics Manual of Mental Disorders (DSM-III).2 In addition to those who have been discharged for misconduct that is a direct result of physical and psychological wounds, there are approximately 100,000 LGBTQ veterans who were discharged for “homosexual acts,” or similar labels, before the repeal of “Don’t Ask, Don’t Tell.” These veterans need zealous advocacy to access the health care and benefits they earned.
A. | Military Separation Forms 1. | The Department of Defense Form 214 (DD214) is given to a servicemember any time they separate from active duty service. This document provides a summary of service, including dates, overseas time, awards, and the discharge characterization, narrative, and SPN code. It is important to remember that DD214s are sometimes missing information, such as medals. The document provides an outline of a person’s service; however, veterans may have more than one DD214 and there may be errors, so further investigation is always needed.a. | For many veterans the Characterization and Narrative Reason for Separation can be both psychologically and economically damaging. | b. | A veteran’s DD214 is presented everywhere from job interviews to school admission and DMV applications. |
| 2. | A DD Form 215 is used to correct errors on a DD214. | 3. | National Guard and Reservists only receive DD214s when they separate from active duty. a. | National Guard members receive a document upon completion of their service called NGB Form 22 (for one period, not necessarily the entire obligation). | b. | Members of the National Guard and Reserves receive DD Form 256, Honorable Discharge Certificate, upon final completion of their service. | c. | Members of the National Guard and Reserves receive DD Form 257, General Discharge Certificate, upon final completion of their service agreement |
| 4. | Records can be requested using a Standard Form 180. Depending on the branch and period of service, the form is sent to different locations that are listed on the form. | 5. | If a veteran does not have any service records, sometimes the National Personnel Records Center can produce NA Form 13038, Certification of Military Service. |
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B. | Types of Discharge Characterization & Status (informal definitions) 1. | Honorable: Service was excellent | 2. | General (Under Honorable Conditions): Service was good | 3. | Other Than Honorable, “OTH”: Service was marked by misconduct, possibly a failure to perform well or follow orders, one-time drug use, or other minor offenses. | 4. | Bad Conduct, “BCD”: This is a punitive discharge, meaning the servicemember went through a court-martial. | | | | 5. | Dishonorable: This is also a punitive discharge. DDs are rare in the modern era. Since 2001 less than 2,000 of these discharges have been given out. | 6. | Entry Level Separation, “ELS”: This is not a characterization. An ELS is given when a servicemember has been in less than 180 days. A characterization of service can be given but an ELS simply indicates: it didn’t work out. |
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C. | Eligibility Consequences 1. | There are exceptions to everything, so this is just a summary of basic eligibility correlations: a. | Honorable: all benefits, everything from health care to home mortgage guaranty to GI bill benefits. | b. | General: nearly all benefits, with the main exclusion being education benefits. Sometimes: “General (Under Honorable Conditions)” – this does not make it an Honorable Discharge. | c. | OTH: This is a gray area and often veterans are told they are not eligible, even by VA staff. In fact, the Veterans Benefits Administration (VBA) is supposed to review the entirety of the servicemember’s record and make a determination on the character of service, based on statutory and regulatory bars. i. | With a positive “Character of Discharge” (COD) determination, a veteran may receive a full medical package if otherwise eligible and any benefits he or she is entitled to, aside from those that require a fully Honorable discharge. | ii. | Some veterans barred from benefits may still receive health care for service-connected injury. | iii. | Older veterans may have an “Undesirable” discharge (UD), equivalent to today’s OTH. |
| d. | BCD: not entitled to health care unless the exception for insanity applies; disability benefits may be possible with a COD if discharged by special court-martial, not general. | e. | DD: no benefits, no medical, unless insanity exception applies. |
| | | | 2. | Insanity, 38 U.S.C. § 5303(b), 38 C.F.R. § 3.354: There is an insanity exception to the statutory and regulatory bars. See below, I.D.1.c. | 3. | A veteran can receive the health care and benefits for any period of active duty service that qualifies them. In other words, someone who served for four years and was given an Honorable discharge is eligible for health care and benefits for that service. If the person re-enlisted, for example, and served a second four year period and was given a Bad Conduct Discharge via general court-martial, an injury incurred during that period would not be compensable. |
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D. | Avenues of Advocacy 1. | VA Character of Discharge (COD) determination. The VA is bound by Department of Defense discharge characterizations but has some discretion within a statutory and regulatory framework when reviewing Other Than Honorable (OTH) and Bad Conduct (BCD) discharges. The VA uses “honorable” and “dishonorable” in their determinations, but these terms should not be confused with the DoD usage. For example, an OTH may be deemed “dishonorable for VA purposes” but this does not mean the veteran has a dishonorable discharge. a. | Statutory Bars, 38 U.S.C. §5303, 38 C.F.R. § 3.12 (b) and (c). i. | Discharge or dismissal by general court-martial | ii. | Conscientious objector who refused to perform duties, wear the uniform, or otherwise obey orders. | iii. | Deserter: absent without authority for 180 days or more, without compelling reason. | iv. | Resignation by an officer for the good of the service. | v. | Discharge by request as an alien during a period of hostilities | vi. | Certain upgrades granted by the president and DoD programs in the 1970s require the VA to review the veteran’s record on a “case-by-case” basis to determine eligibility. 38 U.S.C. §5303(e)(2). |
| | | | b. | Regulatory Bars in 38 C.F.R. § 3.12 i. | This regulation repeats the bars found in 38 U.S.C. §5303 (mainly in subsection (c)) and lays out further specifications for denial. | ii. | Subsection (d) identifies reasons for discharge that will be considered dishonorable: 1) | Acceptance of an undesirable discharge to escape trial by general court-martial. a) | Often there will be no evidence of the type of court-martial the servicemember would have faced. | b) | An advocate can present evidence that the court-martial would have been a special court-martial and not a general. |
| 2) | Mutiny or spying. | 3) | Offenses of moral turpitude. This generally includes felonies and crimes against the person. | 4) | Willful and persistent conduct. a) | Generally the VA views willful to mean that the conduct involved intentional wrongdoing or reckless disregard. | b) | It is unclear what constitutes “persistent”; there are more exceptions (such as onetime drug use, 38. C.F.R. § 3.301) than absolute designations.3 |
| 5) | Sexual acts involving aggravating circumstances (child molestation, prostitution, conduct between servicemembers of disparate rank, etc.). |
| | | | iii. | Some veterans who received discharge upgrades by presidential or DoD programs in the 1970 are specifically barred under 38 C.F.R. § 3.12(h). |
| c. | Insanity, 38 U.S.C. § 5303(b), 38 C.F.R. § 3.354. While the VA definition of insanity seems quite broad and easy to apply, the more common criminal law standards seem to be what is actually used in a determination. i. | Definition. There are three prongs of the insanity definition and the Court of Appeals for Veterans Claims (CAVC) has held that the phrase “due to disease” applies to each (Zang v. Brown, 8 Vet. App. 246, 253 (1995)): 1) | Exhibits “prolonged deviation from his normal method of behavior” or | 2) | “Interferes with the peace of society” or | 3) | Has “so departed (become antisocial) from the accepted standards” of his community that he lacks the ability to adjust to social norms |
| ii. | Evidence. Generally, a veteran must show contemporaneous medical evidence. Gardner v. Shinseki, 22 Vet. App. 415 (2009). This can be difficult for veterans who did not seek medical treatment, particularly for Post-Traumatic Stress Disorder which did not exist as a diagnosis until after the Vietnam War, or for veterans who do not have copies of their service treatment records. The VA is supposed to base its decision on “all the evidence procurable relating to the period involved.” 38 C.F.R. §3.354(b). | iii. | Standard. The standard here is the same for other VA claims: more likely than not (“When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.” 38 U.S.C. §5107(b).) |
| d. | Process i. | A COD is treated like a claim within the VBA. Veterans can initiate the review by applying for health care (the Health Eligibility Center of VHA will send the file to VBA to make a determination) or by applying for benefits.1) | NOTE: veterans are often told by VA staff that they are not eligible and simply turned away. Many “frontline” staff are not aware of the COD process and thus do not inform veterans of their right to a determination. Veterans should always get a denial in writing, which can be appealed. |
| ii. | A predetermination hearing can be requested at a regional office. | iii. | A denial can be appealed and advocates should put together a statement in support of a positive COD (a brief) with evidence disputing any possible bars. If the VA cited one bar in the denial, do not assume that other bars should not be addressed. In addition to disputing the bars, the brief/statement for a veteran who was AWOL should point out how the veteran’s service was otherwise meritorious and a benefit to the nation. 38 C.F.R. §3.12(c)(6)(i). | iv. | If the claim is denied at the regional office, the appeal goes to the BVA, and is adjudicated from there. (See III.B.) |
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| 2. | DoD a. | Discharge Review Boards, DODI 1332.28, 10 U.S.C. §1553, 32 C.F.R. §§ 70.8, 70.9, DD Form 293. i. | What the boards can do: The board has the power to upgrade discharges except those awarded by general court-martial. 1) | Can upgrade the character and change the narrative reason for separation | 2) | Cannot change reenlistment codes or modify content of records |
| | | | ii. | Standard: 1) | The boards will assess on the basis of equity and propriety (fairness & legal/technical sufficiency) | 2) | Veteran must show: “substantial credible evidence” | 3) | The board must “review the case with liberal consideration to the former member that post-traumatic stress disorder or traumatic brain injury potentially contributed to the circumstances resulting in the discharge of a lesser characterization.” 10 U.S.C. §1553(d)(3)(A) (ii); National Defense Authorization Act for Fiscal Year 2017, Sect. 535; Public Law No: 114-328 (2016). |
| iii. | Statute of Limitations: 15 year statute of limitations begins to run from the date of separation. | iv. | Composition: The board is five officers. Applications for an upgrade must receive a majority vote. 1) | If a veteran has post-traumatic stress disorder or traumatic brain injury, due to combat or military sexual trauma, a clinical psychologist or psychiatrist, or physician with training on mental health issues must be voting member of board 10 USC § 1553(d). |
| v. | Form of Application: 1) | Documentary Review (a brief & evidence) a) | If documentary review is requested first and the veteran is denied, the veteran can strengthen a brief or evidence based on the decisional document, which will give the board’s reasoning, and resubmit/add to the application at the personal appearance. |
| 2) | Personal Appearance (“two bites of same apple”): a) | Better chance to receive the upgrade statistically | | | | b) | There is a right to appear | c) | In D.C. (Some branches are moving to telephonic/videoconference hearings. There used to be traveling boards and advocates are urging for their return. Travel cost is prohibitive for many, if not most, veterans.) |
| 3) | Appeal under APA, six years, 28 U.S.C. § 2401 |
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| b. | Board for Correction of Military/Naval Records, DoDI 1332.41, 10 U.S.C. § 1552, DD Form 149. i. | What the boards can do: Power to upgrade, change reenlistment codes, change discharge to medical/disability retirement, modify or add to contents of records—anything except overturn court-martial conviction. | ii. | Standard: boards assess veteran’s applications on the basis of injustice and error (unfairness & legal/procedural error) 1) | Unlike DRBs, BCMRs are bound by precedent. See Wilhelmus v. Geren, 796 F. Supp. 2d 157, 162 (D.D.C. 2011). |
| iii. | Statute of limitations: 3 year SOL from date of “discovery of alleged error or injustice” and can be waived “in the interest of justice” | iv. | Composition: Made up of high-ranking civilian employees | v. | Form of Application: 1) | Brief with evidence | 2) | Personal appearances may be granted but there is no right to appear (have not granted in many years) | 3) | Appeal under APA, 6 years, 28 U.S.C. § 2401 |
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Veterans must be enrolled in the Veterans Health Administration to be eligible for standard medical benefits. Enrolled means that a veteran has
applied and been assigned one of the priority groups by the Health Eligibility Center located in Atlanta. Title 38, Chapter 17, of the United States Code covers VA health benefits.
A. | Priority Groups, 38 U.S.C. § 1705(a), 38 C.F.R. § 17.36 (b). 1. | Group 1: Veterans with a singular or combined rating of 50 percent or greater based on one or more service-connected disabilities or unemployability. | 2. | Group 2: Veterans with a singular or combined rating of 30 percent or 40 percent. | 3. | Group 3: a. | Veterans with a singular or combined rating of 10 percent or 20 percent; | b. | Veterans who are former prisoners of war; | c. | Veterans awarded the Medal of Honor or Purple Heart; | d. | Veterans who were discharged or released from active military service for a disability incurred or aggravated in the line of duty; | e. | Veterans who receive disability compensation under 38 U.S.C. § 1151; and | f. | Veterans receiving rated 10 percent based on multiple noncompensable service-connected disabilities that clearly interfere with normal employability. |
| 4. | Group 4: Veterans who receive VA Pension based on their need for regular aid and attendance or by reason of being permanently housebound and other veterans who are determined to be catastrophically disabled by the Chief of Staff (or equivalent clinical official) at the VA facility where they were examined. | 5. | Group 5: Veterans not covered by groups 1-4 who receive VA Pension or who are eligible for Medicaid. | 6. | Group 6: a. | Veterans of the Mexican border period or of World War I; | b. | Veterans solely seeking care for a disorder associated with exposure to a toxic substance or radiation, for a disorder associated with service in the Southwest Asia theater of operations during the Gulf War (the period between August 2, 1990, and November 11, 1998), or 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 provided and limited in 38 U.S.C. § 1710(e); | c. | Camp Lejeune veterans pursuant to § 17.400; and | d. | Veterans with 0 percent service-connected disabilities who are nevertheless compensated, including veterans receiving compensation for inactive tuberculosis. |
| 7. | Group 7: Veterans who agree to a copayment if their income constitutes “low income” under the geographical income limits established by HUD, with additional prioritizations within this group based on enrolled status date. | 8. | Group 8: Veterans not included in priority category 4 or 7, who are eligible for care only if they agree to pay copayments determined under 38 U.S.C. §1710(f) and §1710(g). This category is further prioritized into the following subcategories: a. | Noncompensable zero percent service-connected veterans who were in an enrolled status on January 17, 2003, or who are moved from a higher priority category or sub-category due to no longer being eligible for inclusion in such priority category or subcategory and who subsequently do not request disenrollment; | b. | Noncompensable zero percent service-connected veterans not included in paragraph (b)(8)(i) of this section and whose income is not greater than ten percent more than the income that would permit their enrollment in priority category 5 or priority category 7, whichever is higher; | c. | Nonservice-connected veterans who were in an enrolled status on January 17, 2003, or who are moved from a higher priority category or subcategory due to no longer being eligible for inclusion in such priority category or subcategory and who subsequently do not request disenrollment; | d. | Nonservice-connected veterans not included in paragraph (b)(8)(iii) of this section and whose income is not greater than 10 percent more than the income that would permit their enrollment in priority category 5 or priority category 7, whichever is higher; | e. | Noncompensable 0 percent service-connected veterans not included in paragraph (b)(8)(i) or paragraph (b)(8)(ii) of this section; and | f. | Nonservice-connected veterans not included in paragraph (b)(8)(iii) or paragraph (b)(8)(iv) of this section. |
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B. | Copays: Veterans in Priority Group 1 (service-connected at 50 percent or more) are not required to make any copayments. Some veterans in Priority Groups 2 and 3 may have copayments for medications that are not for a service-connected condition. If a veteran is in receipt of VA Pension or has income below the pension threshold, he or she will not have to make copayments. For those veterans who are required to make copayments, Primary care is $15 and Specialty care is $50. Medication ranges from $5 to $11, depending on the tier of the medication; for some veterans there are annual caps ranging from $700 to $960. Geriatric care ranges from $5 per day up to $97 depending on the type of service. For a more detailed look at the many rules and exceptions, see Appendix A, 2017 Copayment Requirements at a Glance, U.S. Department of Veterans Affairs, Veterans Health Administration, (January 2017). |
C. | Standard Medical Benefits Package. 38 C.F.R. § 17.38. 1. | Medical Care a. | Preventive Care, nutrition education, immunization, inherited disease counseling, screenings; mental health care, including in-patient and out-patient programs, military sexual trauma services and counseling related to combat/trauma, readjustment, and harassment. | b. | Inpatient services for surgery, mental health, dialysis, acute care; access to intensive care, transplant services, spinal cord injury, traumatic brain injury, and polytrauma centers. | c. | Other services include geriatrics, telehealth, domiciliary, hospice, homelessness services, and more. | d. | Dental: Dental care is so limited that it should almost go under the Exclusions section below. Veterans can receive dental care if the need is service-connected or if they are rated at 100% service connected. For more detail, see Appendix B, Dental Benefits for Veterans, U.S. Department of Veterans Affairs, Veterans Health Administration, IB 10-442, February 2014. | e. | Emergencies: Medical emergencies can turn into an administrative nightmare at a time that is already extremely stressful. While the VA will pay for emergency care at another facility if a VA facility cannot provide care, the rules around this are detailed and transfer is expected quickly. Reimbursement is governed by 38 U.S.C. § 1725. The payment standards for “not previously authorized” services are strict. 38 C.F.R. §17.20(b). i. | A veteran is expected to be transferred to a VA facility (or one the VA contracts with) as soon as they are stable. “An emergency is deemed to have ended at the point when a VA provider has determined that, based on sound medical judgment, you should be transferred from the non-VA facility to a VA medical center.” | ii. | As an alternative to quoting extensive sections of the law here, the VA summarizes the conditions under which they will pay for emergency care for a non-service-connected condition on their website: | • | “The episode of care cannot be paid under another VA authority, and | | • | Based on an average knowledge of health and medicine (prudent layperson standard) you reasonably expected that delay in seeking immediate medical attention would have been hazardous to your life or health, and | | • | A VA or other Federal facility/provider was not feasibly available, and | | • | You received VA medical care within a 24-month period preceding the non-VA emergency care, and | | • | You are financially liable to the health care provider for the emergency care, and | | | | | • | The services were furnished by an Emergency Department or similar facility held out to provide emergency care to the general public, and | | • | You have no other coverage under a health plan (including Medicare, Medicaid and Worker’s Compensation), and | | • | You have no contractual or legal recourse against a third party that would, in whole, extinguish your liability” |
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| 2. | Non-Medical Services: Travel reimbursement (for those who qualify; see 38 U.S.C. §111, 38 C.F.R. §§ 70.1 – 70.50); Care-giver Support, which includes a hotline (1-855-260-3274), peer support groups, and lists of resources for the veteran care-receiver (If a veteran served after 9/11 there are money benefits available to his or her caregiver. Congress has proposed the expansion of these benefits to include elderly veterans’ care-givers but the estimated $3 billion cost has prevented any measure from passing.); canteen; and more. | 3. | Specific Exclusions: a. | Abortion and/or abortion counseling | b. | Plastic surgery that is not medically necessary | c. | Gender reassignment | d. | In-vitro fertilizations unless a veteran is combat-wounded and struggling with fertility as a result (in Fall 2016 a law was passed that allows VA to cover adoption and infertility treatment for two years). | e. | Non-FDA approved medicine unless part of a formal clinical trial | f. | Medical care for a veteran who receives care from another government entity required to provide it by law (i.e., an incarcerated veteran). |
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D. | Programs for Elderly Veterans 1. | General a. | Geriatrics Program i. | GeriPACT (Geriatric Patient Aligned Care Team): A primary care physician and specialists create multi-disciplinary teams that work together to optimize a veteran’s independence and well-being. The team may include doctors, nurses, social workers, and connects with community resources. (Standard VHA teams are called PACTs.) These teams are for a veteran who has more than one chronic illness and declining capabilities. VA website: 1) | More than one complex chronic disease | 2) | Dementia or cognitive decline | 3) | Geriatric syndromes (e.g., frailty, falls, incontinence, memory loss, taking lots of medicines, age 85 or older) |
| ii. | A Geriatric Assessment can be done to determine what services a veteran may need. This can be done in the home or at a community living center. | iii. | Dementia/Alzheimer’s Care: included in medical care package |
| b. | Home Based & Community Services i. | Adult Day Health Care | ii. | Home Based Primary Care | iii. | Homemaker and Home Health Aide Care | iv. | Hospice Care | v. | Palliative Care | vi. | Respite Care | vii. | Skilled Home Health Care | viii. | Telehealth Care | ix. | Veteran-Directed Care |
| c. | Residential Care & Nursing Homes: Except for Community Living Centers, which are rarely for long-term care, and some nursing homes, the other facilities and homes in this list are not paid for by the VA. Veterans can receive Home and Community Based Services while in these locations, if there is a clinical need for them.i. | Community Residential Care: NOT paid for by the VA. “CRC” is for veterans who do not have family or friends to assist them but do not need the full services of a nursing home. CRC can take place in a private home or a facility. Veterans can choose from approximately 1,300 VA approved facilities/settings, including “Assisted Living facilities, Personal Care Homes, Family Care Homes, Group Living homes, and Psychiatric Community Residential Care Homes” | ii. | Medical Foster Homes: NOT paid for by the VA, but veterans receive Home Based Primary Care services (see II.C.1.b.ii.) in a private home with a trained caregiver and up to several other individuals receiving care. The veterans VA social worker can assist a veteran in finding a medical foster home if they need this level of services but do not want an institutional setting. | iii. | Adult Family Homes: NOT paid for by the VA but the VA will pay for a nurse to/health professional to provide extra necessary services not provided by the trained caregiver working in the home. | iv. | Assisted Living: NOT paid for by the VA. | v. | Community Living Centers (VA Nursing Home— but not to be confused with state-run VA nursing homes): There are 132 of these facilities and they are mostly used for rehabilitative care, mental health recovery, respite, palliative and hospice care for end of life. Different centers provide different services so it is important to have a Geriatric Assessment of a veteran’s needs. The centers base eligibility on clinical need, service connected disability, and income. VA Form 10-10EC, Application for Extended Care Benefits, can be used for these facilities. | | | | vi. | Community Nursing Homes: The VA contracts with nursing homes and determines payment eligibility based on clinical need, service connected disability, and income. See 38 U.S.C. § 1710– Eligibility for Hospital, Nursing Home, and Domiciliary Care and 38 U.S.C. § 1710A – Required Nursing Home Care. Under Section 1710(a)(1) the Secretary must provide medical care to veterans who need it for a service-connected disability and to veterans who need it and have a service connected disability of 50% or more. Under Section 1710(a)(2) and (a)(3) certain veterans with disability ratings less than 50% are eligible for nursing home care, as well (including those who were awarded a Purple Heart, were Prisoners of War, who were exposed to radiation or Agent Orange, who are low-income, etc.). §1710 (a)(2)(A-G). Under Section 1710(a)(3), certain veterans may also receive these benefits if they share the cost, per §1710(f). Under Section 1710A(a), which is in effect depending on Congress, the Secretary must provide nursing home care to veterans who need it for a service connected disability and to veterans who need it and have a service-connected disability rated at 70% or more; just as with priority groups, the extension of nursing home care benefits depend on the appropriations for the year. See §1710 (a)(4). Section 1710 is long and detailed; these few notes are in no way comprehensive. For transfers from VA facilities to nursing homes see 38 U.S.C. §1720, which describes short-term coverage in addition to the above long-term determinations. For even more detail on eligibility see 38 C.F.R. §§ 17.43 – 17.60, and then find an expert to make sense of it! Again, the citations in this outline are just a few sections among many rules. | vii. | State Veterans Nursing Homes: these are state-run nursing homes that are certified by the federal VA but that is the extent of the VA’s involvement. If a veteran qualifies for nursing home care, a state-run veterans nursing home may be chosen and payments will be made in accordance with 38 U.S.C. § 1745. Every state has its own eligibility criteria around clinical need. Some states allow non-veteran spouses and parents of veterans who died in combat (“gold star parents”). |
| d. | Veterans Choice Program: In the wake of the waitlist scandals that erupted in 2014, Congress passed legislation that made it possible for veterans to receive care outside of the VA. The basic eligibility requirements are either (1) that the veteran cannot get an appointment with the VA within 30 days or (2) the veteran lives more than 40 miles from the VA facility that could provide care. |
| 2. | Specific Era Risks/Diseases: The hazards of war and service include serious health issues that often present years after operations are over. The VA has registries that offer veterans health exams, information on potential disease, and the opportunity to detail illness, symptoms, or concerns. The VA then tracks these populations and the data. Benefits may also be available depending on the exposure (type of hazard) and disease or symptom. It is important to note that a registry does not mean that associated conditions are presumptively service-connected or compensable. (In addition, a veteran must file a claim for compensation, separate from a registry evaluation.) In the case of Agent Orange, it took extensive advocacy before the VA compensated veterans and their families. 38 U.S.C. §1116. After over a decade of litigation against the private companies that produced the herbicides, veterans were offered settlements that many felt were extremely inadequate. In 1991, twenty years after the government had ceased tactical herbicide usage, Congress passed a law that recognized certain medical conditions and illnesses as presumptively “linked” to exposure, authorizing the VA to provide health care and compensation. The list of presumptive conditions is long and debate continues about where a veteran may have been exposed. In recent years advocacy has focused on expanding the “boots on the ground” presumption requirement that excludes veterans exposed in the coastal areas of Vietnam or those who transported the barrels containing the herbicides on planes.Below are some of the hazards and resulting conditions related to certain periods. For a list of presumptive service-connected diseases and conditions, see 38 C.F.R. §§ 3.307 -3.309. Presumptions are based on statutorily defined time frames, locations, and “risk activities,” so a veteran who may not believe they qualify (because they were not in a war zone/period) should still inquire. For example, in the case of ionizing radiation exposure, a veteran may have been exposed during testing after World War II. Prisoners of war are also entitled to presumptive service-connection for a number of conditions. As with Agent Orange, presumptive diseases may be added to the regulations over the years. This means that a condition that was not compensable in the past may now be. Registering does not require enrollment in VA health care. It is recommended that veterans register in order to receive care and updates but, again, registering is not the same as filing a claim for a condition. a. | Registries: i. | Agent Orange Registry | ii. | Airborne Hazards and Open Burn Pit Registry | iii. | Gulf War Registry (includes Operations Iraqi Freedom & New Dawn) | iv. | Ionizing Radiation Registry | v. | Depleted Uranium Follow-Up Program | vi. | Toxic Embedded Fragments |
| b. | Hazards By War/Operation (this list is not comprehensive): i. | World War II: Ionizing radiation (servicemembers sometimes referred to as “Atomic Veterans”), resulting radiogenic diseases, mustard gas exposure, and more. | ii. | Cold War Era: Ionizing radiation, herbicides, mustard gas, biological weapons, asbestos, and more. | iii. | Korean War: cold-related problems including sensitivity, skin cancer in frost bite scars, peripheral vascular disease; ionizing radiation and radiogenic diseases, and more. | iv. | Vietnam Veterans: Agent Orange Exposure. Diabetes, prostate cancer, Hepatitis C, and many more. In addition to benefits for veterans, their biological children who were born with spina bifida may be eligible for compensation (parents must have served in Vietnam or the Korean DMZ during specific time frames). | v. | Gulf War: “Gulf War Syndrome” (a grouping of unexplained illnesses and symptoms), Fibromyalgia, Oil well fires, pesticides, and more. | vi. | Camp Lejeune: Veterans and their families may have been exposed to water contaminants at this Marine Corps base in North Carolina. For veterans who spent at least 30 days at Camp Lejeune from 1953 through 1987, certain conditions are presumptively service-connected as of March 2017. See 38 C.F.R. §§ 3.307 and 3.309. Health care is provided for a list of conditions that were established by law in 2012. See 38 C.F.R. §17.400. Family members may be eligible for reimbursement of their medical expenses. |
| c. | General Categories of Presumptions (§§ 3.307 – 3.309) i. | Radiation exposure | ii. | Tropical disease | iii. | Chronic disease | iv. | Diseases specific to former prisoners of war | v. | Exposure to certain herbicides |
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E. | Health Advocacy 1. | Patient Advocate: Each VA medical center (VAMC) has a Patient Advocate. If a veteran disagrees with any medical coverage or has concerns regarding care, this is the first person to contact. | 2. | Reconsideration: Veterans can express a disagreement with a doctor’s decision and request reconsideration by writing to the director of the VAMC within one year of the decision by the provider. (If the decision is from a clinic, the director of the corresponding VAMC that oversees the clinic is the appropriate place to address the request.) The request should outline why the veteran believes the doctor’s decision is wrong. In addition to requesting reconsideration in writing, veterans have a right to meet with the supervisor of the doctor/provider they disagree with; the meeting will be on the record (taped). The supervisor is the person who will conduct the reconsideration and will issue a decision in writing to the veteran. See 38 C.F.R. § 17.133 (b). | 3. | Clinical Appeal: If the clinical disagreement is not resolved at the VAMC level, a written request can be sent to the VISN level (VHA divides the country into regions, Veterans Integrated Service Networks, commonly called “viz-uhns”). At this stage, the process expands and may include an external review. The VISN Director will render a decision within 30 days of receiving the complaint/request; if an independent external review is conducted the director has 45 days. For more information, see the newly revised procedures set out in VHA Directive 1041, Appeal of VHA Clinical Decisions, October 24, 2016. | 4. | Other Appeals: Certain decisions—that involve things such as copays or reimbursement for travel—can be adjudicated before the Board of Veterans’ Appeals like a benefits claim. 38 C.F.R. §17.133(a). | 5. | MyVA: The new vision for the VA providing patient-centric care. The plan includes simplifying veterans’ access to information, claims, and care. | 6. | myHealtheVet: the online system where veterans can manage appointments, prescriptions, and access their medical records. |
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A. | Benefits: There are so many benefits available to veterans and their family members that, each year, the VA publishes a small book as a guide to navigate the services and compensation by category. This list only highlights some of the most commonly used benefits that may be pertinent to elderly veterans. 1. | Disability Compensation, 38 U.S.C. § 101(16), 38 U.S.C. §§ 1101 – 1163, 38 C.F.R. §3.4. a. | There are three main components to a claim: i. | In-service incident, injury, illness, or aggravation of an existing condition (evidence of this may require military records, medical records, and lay statements known as “buddy statements”); | ii. | Current disability (medical evaluation by VA; medical evidence from private doctors can be used); and | iii. | A nexus between the current disability and the in-service event (a doctor’s statement that the current condition is “as likely as not”4 caused by the in-service event). |
| b. | Ratings: i. | Examinations for disability ratings and benefits are called “C&Ps” for Compensation and Pension exams. It is important that veterans attend the exam and vocalize all health concerns and complaints, even those they are not experiencing that day. | ii. | The VA schedule for rating disabilities can be found in Chapter 1, Part 4, of Title 38 of the Code of Federal Regulations. 1) | Sections 4.1 through 4.31 govern the policies of rating. | 2) | Sections 4.40 through 4.150 provide the ratings criteria for conditions, grouped by categories of disabilities. | 3) | There are many similarities between the VA and Social Security Administration disability assessments. However, they are not interchangeable and many veterans who may not be considered disabled by SSA will receive a rating from VA. |
| | | | iii. | Understanding a rating: Veterans receive a rating of 0 to 100 percent at 10 percent intervals; a veteran with a rating of 30 percent or higher receives additional compensation for dependents. 1) | A 0 percent rating is valuable because it means that the VA recognizes the disability as service-connected: if the condition worsens, the veteran will not have to prove the service-connected nexus anew. | 2) | Ratings are determined by applying the percentages one at a time, starting with the most disabling, to each subsequent result; in other words, they are not cumulative. a) | A veteran with a condition rated at 60 percent disabling and another condition at 30 percent disabling has a combined rating of 70 percent, not 90. First apply 60 percent and you have 40 percent remaining; then apply 30 percent to that 40 remaining and you have 12 percent. Add the two amounts (60 and 12 percent disabling) and you have 72 percent. This is then rounded down to the nearest 10 percent, which equals 70. | b) | Percentages ending in 5 get rounded up (55 becomes 60, e.g.). |
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| c. | Compensation: In 2017, for a single veteran with no dependents, monthly compensation ranges from $133.57 for 10 percent to $2,915.55 for 100 percent. i. | A veteran at 30 percent or greater may have additional amounts added for spouses and dependent children and parents. | ii. | There are other monetary benefits, for things such as the need for home care, that may augment total monthly compensation. | iii. | Disability compensation is not taxable. 38 U.S.C. 5301(a). |
| | | | d. | If a veteran is eligible for both service-connected and non-service connected disability benefits, the VA will pay the one that is greater. 38 U.S.C. § 1521(i). | e. | Total Disability, Individual Unemployability (TDIU or IU), gives a veteran the equivalent of a 100 percent rating. 38 C.F.R. §4.16. i. | At least one service-connected disability rated at 60 percent or two or more service-connected disabilities with at least one rated at 40 percent and with a combined rating of 70 percent or more AND | ii. | Unable to maintain “substantially gainful employment” as a result of service-connected disability. |
| f. | Special Monthly Compensation: This is a benefit added to the compensation for percentage ratings. It is for veterans with the loss of specific organs or body parts. 38 C.F.R. §3.350. |
| 2. | VA Pension, 38 U.S.C. §§ 1501 – 1525, 38 C.F.R. §3.3. a. | “Pension” may be confusing since some individuals have pensions from other employment; a pension may be referred to as “VA disability,” “non service-connected,” etc. These terms can also then be confused with service-connected disability compensation. | b. | Eligibility, 38 C.F.R. § 3.3(a)(3). Must have all three: i. | Served 90 consecutive days with at least 1 day in a period of war, as defined by statute. See 38 U.S.C. 101, 38 U.S.C. § 1521 (j), and 38 C.F.R. § 3.2. 1) | If the individual served after September 8, 1980, for enlisted and after October 16, 1981, for officers, the minimum service requirement is 24 continuous months or the full period called to active service (active duty orders under Title 10). 38 U.S.C. § 5303A, 38 C.F.R. § 3.12a. |
| ii. | Disabled OR over 65, 38 U.S.C. § 1513, 38 C.F.R. §§ 3.3(a)(3)(vi), 3.342. | | | | iii. | Low income 1) | Veterans and their family/household must fall below the Maximum Annual Pension Rate – “MAPR”. a) | If a veteran’s medical expenses are over 5 percent of the MAPR, they can be deducted from countable income. I) | Countable income is defined in 38 C.F.R. § 3.271. | II) | Exclusions are defined in 38 C.F.R. §3.272; medical expenses are outlined in §3.271(g). |
| b) | The current MAPR is a little $12,907 per year for a single veteran with no dependents.) 38 U.S.C. §1521 (b) – (j),§ 1542; 38 C.F.R. §3.3(3)(v), §3.23. |
| 2) | Must meet the net worth requirements outlined in 38 C.F.R. §§ 3.274, 3.275. |
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| c. | Compensation: In 2017, the rate for a single veteran with no income is $1,075 per month (more with dependents). i. | Increases in Pension amounts are tied to increases in Social Security cost of living adjustments (COLAs), as determined by Congress. | ii. | Increases take effect on December 1st of the year. |
| d. | The Pension is extremely useful in assisting veterans over income for the benefit but in need of home care or a nursing home, since those expenses can be deducted from income. | e. | If a veteran is eligible for both service-connected and non-service connected disability benefits, the VA will pay the one that is greater. 38 U.S.C. § 1521(i). |
| 3. | Aid & Attendance is paid in addition to Pension for those who need assistance in performing every day functions (bathing, dressing, etc.). The benefit can be for the veteran or other a spouse. 38 C.F.R. §§ 3.351, 3.352. | | | | 4. | Housebound is an increased benefit paid to those who: a. | are confined to their home because of permanent disability or | b. | those who have a permanent disability rated at 100 percent and another disability independently rated at 60 percent. 38 C.F.R. §3.351(d). |
| 5. | Survivors’ benefits a. | Dependency and Indemnity Compensation (“DIC”), 38 U.S.C. §§ 1301 – 1323, 38 C.F.R. §3.5, 3.7 i. | What: Benefit provided to certain survivors of a veteran who died while on active duty or whose death resulted from a service-connected disability or whose death was from a non-service-connected disability that was rated as totally disabling for the ten years immediately prior to death or… this goes on and is very detailed. Advocates should read the citations and seek assistance from an accredited representative. | ii. | Who: Eligibility is complicated; it is based on marriage (date of remarriage, length of marriage), cohabitation or shared children, etc. A spouse, children, and surviving parents are potentially eligible. There are increased rates for children (normally included in payment to a spouse), aid and attendance or housebound status, and other considerations. |
| b. | Survivors’ Pension5, 38 U.S.C. §§ 1541 – 1543, 38 C.F.R. §3.3(b)(4). i. | What: Benefit for certain survivors of a deceased veteran who was receiving or had qualifying service to receive a VA Pension or who was receiving retired pay for a service-connected disability from a period of war. | | | | ii. | Who: for the spouse or children of a deceased veteran if they meet the income/net worth requirements (MAPR). 1) | A child is defined as under age 18 or under age 23 if attending a VA approved school or incapable of self-support due a disability determined before age 18. | 2) | A child who is not in custody of a surviving spouse is eligible for pension, per 38 C.F.R. §3.24. |
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| 6. | Burial Benefits, 38 U.S.C. §§ 2301 - 2308, 38 C.F.R. §§ 3.1600 – 3.1612. a. | Expense: i. | Service Related Death: VA will pay up to $2,000 for burial expenses (for a death after September 11, 2001) and may pay some of or all of the cost to transport the veteran to a VA national cemetery. | ii. | Non-service Related Death: 1) | Death in a VA hospital: VA will pay up to $749 for burial and funeral expenses. | 2) | Death not in a VA hospital: VA will pay up to $300 for burial and funeral expenses. | 3) | VA will pay $749 plot interment allowance if the veteran is not being buried in a national cemetery. |
| iii. | There are a number of conditions that must be met in order to receive burial allowance. For more information, see Appendix D, Dependents and Survivors Burial and Plot Interment Allowance. |
| b. | VA cemetery: i. | Burial in a national cemetery means that there will be a headstone/marker, perpetual care of the site, a Presidential Memorial Certificate, and a burial flag. | ii. | Eligibility: 1) | Minimum active duty requirement met | | | | 2) | Veteran had a discharge other than dishonorable (meaning the VA has to deem the service honorable). |
| iii. | Spouses and dependents may also be buried with the veteran, even if they pre-decease the veteran. |
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| 7. | Special Monthly Compensation: SMC is an additional cash amount for a specific disability such as loss of limb, certain organs, etc. 38 U.S.C. §1114. 38 C.F.R. § 3.350. | 8. | Benefits for children of Vietnam Veterans, 38 U.S.C. §§ 1801 – 1834. a. | Children of veterans who were in Vietnam between January 9, 1962, to May 7, 1975, who have spina bifida are entitled to special benefits. Children with certain birth defects may be included and children of certain Korean service veterans born with spina bifida are also entitled. | b. | These children are entitled to benefits, health care (or reimbursement for health care), and vocational rehabilitation. |
| 9. | Aid and Attendance, Housebound: these benefits are also available to certain survivors receiving Pension or DIC. See above, III.A.3., III.A.4. |
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B. | Overall structure of adjudication 1. | VARO, VA Regional Office a. | All claims begin at the regional level. The process includes optional informal hearings, a decision from a rater, and if there is a denial the veteran files a Notice of Disagreement and can request de novo review by a DRO (decision review officer) before appealing to the next level. There are time limits on all of these steps—for the veteran and not the VA. | b. | It is important to note that the VA has new requirements on how applications for benefits are submitted. “Informal claims” (a veteran just writing a letter to the VA, for example) are no longer accepted. Veterans can now initiate a claim by filing a VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC, or by calling the VA. The claimant then has one year to submit the claim in order to preserve that date. | c. | The VA must give the claimant “the benefit of the doubt.” 38 U.S.C. 5107(b), 38 C.F.R. §3.102. | d. | VA must: i. | Assist a veteran in obtaining records, 38 U.S.C. §5103A(b). | ii. | Notify a veteran of evidence or information required to prove the claim; what information is needed and what information the VA will attempt to obtain, 38 U.S.C. §5103; | iii. | Provide a medical examination when necessary for a claim, 38 U.S.C. §5103A(d); | iv. | Consider all legal theories upon which a claim could be granted, 38 C.F.R. §3.103(a). |
| e. | An individual must be accredited by the VA to represent a veteran before the Department of Veterans Affairs. Veteran Service Organizations (VSOs) are congressionally chartered to assist veterans with their claims at no cost. | f. | Veterans can file a Notice of Disagreement (NOD) at this stage to begin the appeals process. VA Form 21-0958, Notice of Disagreement. i. | Claimants can request a traditional appellate review to have the VARO consider your arguments and any new evidence. | ii. | Claimants can request a DRO, Decision Review Officer, who is a senior rater at the VARO who will consider the claim and any new evidence de novo. |
| g. | If the VA affirms their decision they will issue a Statement of the Case (SOC) with a summary of evidence reviewed in the claim file, the reason for the denial, and all of the relevant law cited. | h. | Veterans who do not elect to appeal a denial may reopen a claim with new and material evidence at any time. |
| | | | 2. | BVA, Board of Veterans Appeals a. | Once a claimant receives an SOC, the veteran can appeal to the BVA with VA Form 9, Substantive Appeal. i. | The Form 9 must be submitted within 60 days from the SOC. | ii. | The veteran must specifically state what they disagree with from the VARO decision. |
| b. | The board is in Washington, D.C., and veterans can request a hearing and either travel there, opt for a videoconference, or wait for a traveling board. In nearly all cases, for all options, the wait will be years. | c. | Claims will be considered de novo and may be remanded for further development of the evidence. | d. | The BVA is not bound by its own decisions. |
| 3. | CAVC, Court of Appeals for Veterans Claims, 38 U.S.C. §§ 7101 – 7907. a. | The court was created by the Veteran Judicial Review Act of 1998. It is an Article I court based in Washington, D.C., and has exclusive jurisdiction to review BVA decisions. 38 U.S.C. § 7252(a). | b. | Veterans can appeal to the CAVC after exhaustion, but the BVA cannot—though the chairman of the BVA can request reconsideration. 38 U.S.C. § 7266(a). i. | A veteran appeals by filing a Notice of Appeal to the court. | ii. | The notice must be filed within 120 days of the BVA final decision. |
| c. | CAVC decisions are binding on the BVA and VAROs. |
| 4. | Federal Circuit: The Federal Circuit has exclusive jurisdiction for review of VA rules and regulations. 38 U.S.C. §§ 502, 7292. a. | The Federal Circuit “may not review factual determination, it may review the application of law to facts if a constitutional issue is implicated.”6 38 U.S.C. §7292 (d)(2). | b. | The Veterans Judicial Review Act also precludes federal courts from reviewing any “questions of law and fact necessary to a decision by the Secretary.” 38 U.S.C. § 511(a). |
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A. | The VA Fiduciary Program was created to protect veterans who may not be able to handle their financial affairs. It has been marked by scandal over the years and advocates have been vocal about reform.7 Careful oversight is recommended. |
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B. | Process 1. | If a veteran seems to be unable to manage finances, the VA may propose the veteran (or other beneficiary) needs a fiduciary. a. | An appointment can also be requested and supporting evidence will be considered, in particular medical documentation or court order. | b. | Something as simple as a doctor’s note in a C&P exam can trigger the VA’s proposal. |
| 2. | A field examination will be conducted to assess the veteran’s situation. The VA notes on their website that a veteran should have the following ready for the examiner: | • | Photo identification. | | • | The source and amount of all monthly bills, recurring expenses (annual, bi-annual, quarterly, etc.), and income. | | • | A list of all assets, to include bank accounts, owned property, stocks, bonds, life insurance, burial plans, etc. | | • | A list of all current medications. | | • | Name, phone number, and address of your primary care doctor. | | • | Name, phone number, and address of your next of kin. |
| 3. | Decision: the VA will make a decision and notify the veteran/beneficiary in a letter. a. | The VA defines mental incompetency as a “person is one who because of injury or disease lacks the mental capacity to contract or to manage his or her own affairs, including disbursement of funds without limitation.” 38 C.F.R. 3.353 (a). | b. | A finding of incompetency requires a medical opinion that is “clear, convincing and leaves no doubt.” 38 C.F.R. 3.353(c). The individual has 60 days to submit evidence as to why they should not have a fiduciary (aside from the traditional appeals process). If the VA affirms their decision an appointment will be made. |
| 4. | Fiduciary Appointment a. | The VA determines who will be a veteran’s fiduciary. i. | Veterans can request a family member or specific person, but their appointment is not guaranteed. | ii. | Family can also email the VA to apply. Along with contact information, the veteran’s name and file number should be included. VA_Fiduciary@va.gov |
| b. | An investigation of the individual will be done that may include credit reports, character witnesses, and criminal background check, depending on the individual. (There are professional fiduciaries and the VA has had serious difficulties with appointments. Again, careful oversight is recommended.) |
| 5. | Ongoing duties and rules8 a. | A fiduciary must decide how to spend the beneficiary’s money in way that looks out for his/her wellbeing and keeps the individual in the same standard of living as those with similar resources. i. | Ensure housing is secure and grocery needs met, and arrange for medical care, and mental health treatment if necessary, for the beneficiary and any dependents. | ii. | Have all the beneficiary’s bills sent to the fiduciary and pay them on time; mange taxes, insurance needs, and any debts owed the beneficiary; make reasonable, safe investments. | iii. | Keep separate financial accounts in federally insured banks or credit unions, unless the fiduciary is a spouse, state or local entity, or health care facility. 1) | All transactions must be made by check or electronic transfer; ATM withdrawals and checks made payable to cash are not allowed. | 2) | Surplus funds must be invested in line with VA regulations. 38 C.F.R. §§ 13.103, 13.105, 13.106. |
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| | | | b. | The fiduciary must notify the VA if there is any change in circumstance and must reply to VA communications regarding an accounting, information for benefits verification, etc. i. | An accounting may be requested by the VA on an annual basis. The fiduciary has 30 days to produce all records over the accounting period and use VA Form 21P-4706b, Federal Fiduciary’s Account. |
| c. | The fiduciary must report changes in their own contact information and may alert the VA if they would like to withdraw due to illness, safety, felony convictions, etc. |
| 6. | A VA fiduciary has control only over VA benefits—not others. So it is not a solution for someone who needs financial management of other resources as well. Other means may be used to establish this financial/legal authority (court appointment, legal custody, etc.). If the fiduciary manages other funds for the beneficiary/veteran then reports on these funds must be made to the VA as well. | 7. | Once a Fiduciary has been appointed: a. | A veteran can request to be re-evaluated. 38 C.F.R. § 3.327(a). | b. | A veteran can request a different fiduciary be appointed. |
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C. | Firearms 1. | The VA reports individuals who have been appointed a fiduciary under this program to the FBI and the name will be added to the National Instant Criminal Background Check System. | 2. | Under the Brady Handgun Violence Prevention Act, 18 U.S.C. 924(a)(2), an individual who has been “adjudicated as a mental defective or been committed to a mental institution” cannot purchase, possess, receive or transport a firearm or ammunition.9 | | | | 3. | A veteran/beneficiary can apply to the VA to be relieved from this prohibition. |
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D. | Getting Rid of a Fiduciary Appointment 1. | There are several stages to object to a fiduciary appointment: when the VA has notified of the intent (60 days to submit evidence objecting), within one year of the VA’s decision of a fiduciary appointment, and any time after that. 38 C.F.R. § 3.103. a. | If it is within a year of the decision, like a benefits claim, the beneficiary/veteran should submit an NOD (Notice of Disagreement). | b. | If it has been more than a year, a beneficiary/veteran can request a reevaluation. 38 C.F.R. § 3.327(a). This is like the initial appointment process and a new decision will be issued. Then the beneficiary proceeds with an NOD. |
| 2. | NOD a. | The beneficiary should explain exactly what they disagree with and why, and provide evidence as to why the fiduciary is not necessary (a medical opinion is important evidence). | b. | The disagreement goes to the regional Fiduciary Hub (or the VARO— send documents to the address on the correspondence from the VA). |
| 3. | If the VARO does not agree, a veteran has the right to appeal to the Board of Veterans’ Appeals in Washington, D.C. a. | The case proceeds similar to a benefits claim appeal. | b. | Only the beneficiary, usually a veteran, has the right to appeal. However, if someone has been appointed by a court or has some other legal authority, that person can appeal on behalf of the beneficiary. |
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2017 Copayment Requirements at a Glance
| | Inpatient Care ($10 per day + $1,316 for first 90 days and $658 after 90 days – based on 365-day period). | Outpatient Care ($15 Primary Care; $50 Specialty Care; $0 for x-rays, lab, immunizations, etc.) | Outpatient Medication ($8 per 30-day supply PG 2-6 Calendar Year cap - $960) ($9 per 30-day supply PG 7-8 No Calendar Year cap) | Extended Care Services Institutional NHCU, Respite, Geriatric Eval - $0-97 per day. Non-Institutional Respite, Geriatric Eval, ADHC - $15 Domiciliary - $5 |
Priority Group 1 (SC 50% or more) | No | No | No | No |
*Priority Groups 2, 3 (SC 10% - 40%) No medication copayment for SC condition, former POWs, or Catastrophically Disabled Veterans **former POWs not exempted | No | No | Yes* | No |
**Priority Group 4 | No | No | No** | Yes |
Priority Group 5 No medication copayment if in receipt of VA pension or income below applicable pension threshold | No | No | Yes | Yes |
Priority Group 6 (Combat Veteran, SHAD, SC 0% compensable, ionization radiation, Agent Orange exposure, Southwest Asia service, stationed at Camp Lejeune August 1, 1953 - December 31, 1987) ***Copay rules apply if care or service provided is unrelated to VA’s exposure treatment authorities. | No**** | No**** | No**** | No**** |
Priority Group 7 Inpatient copay is reduced 80% of full rate | Yes | Yes | Yes | Yes |
Priority Group 8 Unless income is below applicable pension threshold for medication and extended care services copayment | Yes | Yes | Yes | Yes |
No extended care copayment when income is below pension single rate threshold.
*Copayment Free Care and Medication for treatment of Service-Connected (SC) disabilities, SC 50% or more, former POWs, Catastrophically Disabled Veterans, VA pensioners, and those under Special Authorities (e.g. PG 6, military sexual trauma, nasopharyngeal radium irradiation).
**Copayment for extended care services for former POWs when care provided is for a NSC condition.
***Veterans determined by VA to be Catastrophically Disabled (CD) are exempted from inpatient, outpatient and prescription copayments. CD Veterans are also exempt from copayments applicable to the receipt of non-institutional respite care, non-institutional geriatric evaluation, non-institutional adult day health care, Homemaker/Home Health Aide, Purchased Skilled Home Care, Home based Primary Care, and any other non-institutional alternative extended care services. Co-payment for other extended care services (ex. Nursing Home Care) not mentioned still apply.
***A&A and HB – For Veterans who are not in receipt of a VA Pension, but requires the aid and attendance (A&A) of another person or is permanently housebound (HB),the income limits for determining the exemption from outpatient medication copayment requirements and the eligibility for beneficiary travel benefits will be based on the maximum annual rate of pension as Identified in VHA Fact Sheet IB10-497.
****Exposure Treatment Authorities: Care authorized under 38 U.S.C. 1710(e) for Vietnam-era herbicide exposed Veterans, radiation-exposed Veterans, Gulf War Veterans, post-Gulf War combat exposed Veterans or Camp Lejeune Veterans.
OEF/OIF/OND Combat Veterans Enhanced Eligibility for Health Care Benefits
Combat Veterans discharged from active duty on or after January 28, 2003, are eligible for enrollment in Priority Group (PG) 6 for 5 years following discharge unless eligible for a higher enrollment priority (PG 1-5). After the special eligibility period ends, these Veterans will be reassigned to appropriate PG and subject to copayments, if applicable.
Copayments only applicable for PG 6 Combat Veteran enrollees for care related to a condition that is congenital or developmental e.g., scoliosis existed before military service (unless aggravated by combat service) or has a specific ailment that began after military service, such as a common cold, etc.
Comprehensive Medical Benefits Package
All enrolled Veterans have a comprehensive medical benefits package, which VA administers through an annual patient enrollment system. The enrollment system is based on priority groups to ensure health care benefits are readily available to all enrolled Veterans. Enrollment in the VA health care system provides Veterans with the assurance that comprehensive health care services will be available when and where they are needed during that enrollment period.
Dental Benefits for Veterans
Dental benefits are provided by the Department of Veterans Affairs (VA) according to law. In some instances, VA is authorized to provide extensive dental care, while in other cases treatment may be limited. This Fact Sheet describes dental eligibility criteria and contains information to assist Veterans in understanding their eligibility for VA dental care.
Outpatient Dental Program
The eligibility for outpatient dental care is not the same as for most other VA medical benefits and is categorized into classes. If you are eligible for VA dental care under Class I, IIA, IIC, or IV you are eligible for any necessary dental care to maintain or restore oral health and masticatory function, including repeat care. Other classes have time and/or service limitations.
If you: | You are eligible for: | Through |
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Have a service-connected compensable dental disability or condition. | Any needed dental care | Class I |
Are a former prisoner of war. | Any needed dental care. | Class IIC |
Have service-connected disabilities rated 100% disabling, or are unemployable and paid at the 100% rate due to service-connected conditions. | Any needed dental care. [Please note: Veterans paid at the 100% rate based on a temporary rating, such as extended hospitalization for a service-connected disability, convalescence or pre-stabilization are not eligible for comprehensive outpatient dental services based on this temporary rating]. | Class IV |
Apply for dental care within 180 days of discharge or release (under conditions other than dishonorable) from a period of active duty of 90 days or more during the Persian Gulf War era. | One-time dental care if your DD214 certificate of discharge does not indicate that a complete dental examination and all appropriate dental treatment had been rendered prior to discharge.* | Class II |
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Have a service-connected noncompensable dental condition or disability resulting from combat wounds or service trauma. | Any dental care necessary to provide and maintain a functioning dentition. A Dental Trauma Rating (VA Form 10-564-D) or VA Regional Office Rating Decision letter ( VA Form 10-7131) identifies the tooth/teeth/condition(s) that are trauma rated. | Class IIA |
Have a dental condition clinically determined by VA to be associated with and aggravating a service-connected medical condition. | Dental care to treat the oral conditions that are determined by a VA dental professional to have a direct and material detrimental effect to your service connected medical condition. | Class III |
Are actively engaged in a 38 USC Chapter 31 vocational rehabilitation program. | Dental care to the extent necessary as determined by a VA dental professional to: | • | Make possible your entrance into a rehabilitation program | | • | Achieve the goals of your vocational rehabilitation program | | • | Prevent interruption of your rehabilitation program | | • | Hasten the return to a rehabilitation program if you are in interrupted or leave status | | • | Hasten the return to a rehabilitation program of a Veteran placed in discontinued status because of illness, injury or a dental condition, or | | • | Secure and adjust to employment during the period of employment assistance, or enable you to achieve maximum independence in daily living. |
| Class V |
Are receiving VA care or are scheduled for inpatient care and require dental care for a condition complicating a medical condition currently under treatment. | Dental care to treat the oral conditions that are determined by a VA dental professional to complicate your medical condition currently under treatment. | Class VI |
Are an enrolled Veteran who may be homeless and receiving care under VHA Directive 2007-039. | A one-time course of dental care that is determined medically necessary to relieve pain, assist you to gain employment, or treat moderate, severe, or complicated and severe gingival and periodontal conditions. | Class IIB |
* Note: Public Law 83 enacted June 16, 1955, amended Veterans’ eligibility for outpatient dental services. As a result, any Veteran who received a dental award letter from VBA dated before 1955 in which VBA determined the dental conditions to be noncompensable are no longer eligible for Class II outpatient dental treatment.
Veterans receiving hospital, nursing home, or domiciliary care will be provided dental services that are professionally determined by a VA dentist, in consultation with the referring physician, to be essential to the management of the patient’s medical condition under active treatment.
VETERANS FORMS—A SHORT LIST
| • | 21-0966, Intent to File: this form preserves a claim date and gives the veteran one year to complete the claim. |
| • | 21-4138, Statement in Support of Claim: used as a catch-all for anything really. Ex: Veteran can request a copy of c-file on this form (VBA) |
| • | 21-5345, Request for and Authorization To Release Medical Records (VHA) [VA version of a HIPAA release] |
| • | 3288, Request for and Consent to Release of Information: used to request documents from a claimant’s file (VBA) |
| • | 21-0845, Authorization to Disclose Personal Information to a Third Party: allows agent to speak to VA (VBA) |
| • | 10-10EZ, Application for Health Benefits |
| • | 10-10EC, Application for Extended Care |
| • | 21-22a, Appoint a Representative: this will cut off any prior representative’s access with no notice, so be extremely careful or the veteran’s claim will get sent to the beginning of the process again. Also note: VA Form 21-22 is the VSO version. |
| • | 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder |
| • | 9, Notice of Disagreement: this informs the VA Regional Office that you want to appeal a decision to the BVA |
| • | SF-180, Request Pertaining to Military Records: use this to get DD214s, Service Treatment Records (medical), and OMPF (Official Military Personnel File) |
| • | 21-526, Veteran’s Application for Compensation and/or Pension: VSO should assist veteran |
| • | 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs: use this form to authorize providers to send info to the VA as evidence for a claim |
| • | DBQ: this is a type of form that serves as a medical evaluation/survey document that a doctor can use to support a claim. For a list: http://www.benefits.va.gov/compensation/dbq_listbydbqformname.asp |
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| • | 21-530, Application for Burial Allowance |
| • | 40-10007, Application for Pre-Need Determination of Eligibility for Burial in a VA National Cemetery |
WHAT ARE VA BURIAL ALLOWANCES?
VA burial allowances are flat-rate monetary benefits that are generally paid at the maximum amount authorized by law for an eligible Veteran’s burial and funeral costs. A VA regulation change in 2014 simplified the program to pay eligible survivors quickly and efficiently. Eligible surviving spouses of record are paid automatically upon notification of a Veteran’s death, without the need to submit a claim. VA may grant additional benefits, including the plot or interment allowance and transportation allowance, if it receives a claim for these benefits.
If the burial benefit has not been automatically paid to the surviving spouse, VA will pay the first living person to file a claim of those listed below:
| • | The Veteran’s surviving spouse, OR |
| • | The survivor of a legal union* between the deceased Veteran and the survivor, OR |
| • | The Veteran’s children, regardless of age, OR |
| • | The Veteran’s parents or surviving parent, OR |
| • | The executor or administrator of the estate of the deceased Veteran |
The Veteran must have been discharged under conditions other than dishonorable. In addition, at least one of the following conditions must be met:
| • | The Veteran died as a result of a service-connected disability, OR |
| • | The Veteran was receiving VA pension or compensation at the time of death, OR |
| • | The Veteran was entitled to receive VA pension or compensation, but decided to receive his or her full military retirement or disability pay, OR |
| • | The Veteran died while hospitalized by VA, or while receiving care under VA contract at a non-VA facility, OR |
| • | The Veteran died while traveling under proper authorization and at VA expense to, or from, a specified place for the purpose of examination, treatment, or care, OR |
| • | The Veteran had an original or reopened claim for VA compensation or pension pending at the time of death and would have been entitled to benefits from a date prior to the date of death, OR |
| • | The Veteran died on, or after, October 9, 1996, while a patient at a VA-approved state nursing home. |
If the Veteran died on or after September 1, 2001, the maximum service-connected burial allowance is $2,000. If the Veteran died before September 11, 2001, the maximum service-connected burial allowance is $1,500. If the Veteran is buried in a VA national cemetery, VA may reimburse some or all of the costs of transporting the deceased Veteran’s remains.
Non Service-Connected Death
| • | If the Veteran died on or after October 1, 2016, VA will pay a $300 burial allowance and $749 for a plot. |
| • | If the Veteran died on or after October 1, 2015, but before October 1, 2016, VA will pay a $300 burial allowance and $747 for a plot. |
| • | If the Veteran died on or after October 1, 2014, but before October 1, 2015, VA will pay $300 for burial allowance and $745 for a plot. |
Effective October 1, 2011, there are higher non-service-connected death rates payable if the Veteran was hospitalized by VA at the time of his or her death.
| • | If the Veteran died on or after October 1, 2016, VA will pay a $749 burial allowance and $749 for a plot. |
| • | If the Veteran died on or after October 1, 2015, but before October 1, 2016, VA will pay a $747 burial allowance and $747 for a plot. |
| • | If the Veteran died on or after October 1, 2014, but before October 1, 2015, VA will pay a $745 burial allowance and $745 for a plot. |
If the death occurred while the Veteran was properly hospitalized by VA, or under VA contracted nursing home care, some or all of the costs for transporting the Veteran’s remains may be reimbursed.
Note: If the Veteran dies while traveling at VA expense for the purpose of examination, treatment, or care, VA will pay burial and plot allowances and transportation expenses.
If a Veteran dies and their remains are unclaimed, the entity responsible for the burial of the Veteran would be entitled to a $300 burial allowance. If the Veteran is buried in a VA national cemetery, VA may reimburse the cost of transporting the deceased Veterans remains. VA may also reimburse for the cost of a plot.
You can apply by completing VA Form 21P-530 Application for Burial Benefits. You should attach a copy of the Veteran’s military discharge document (DD Form 214 or equivalent) and a death certificate. If you are claiming transportation expenses, please attach a receipt for the expenses paid.
You can call us toll-free within the U.S. by dialing 1-800-827-1000. If you are located in the local dialing area of a VA regional office, you can also call us by checking your local telephone directory. For the hearing impaired, our TDD number is 711.
You should mail your application to the VA regional office located in your state. You can obtain the mailing address for VA regional offices by accessing our locations site. The address is also located in the government pages of your telephone book under “United States Government, Veterans.”
VA National Cemetery Burials / Headstones, Markers and Medallions / Presidential Memorial Certificates / Burial Flags