Written by: Christian N. Horde, J.D., LL.M.

VA Health Care Enrollment

To receive any medical benefits under the VA you must first enroll in their VA Health Care system. You will need to fill out an Application for Health Benefits (VA Form 10-10EZ) and gather the documents listed below:

• Your most recent tax return
• Social Security numbers for yourself and your qualified dependents
• Account numbers for any current health insurance you already have (like Medicare, private insurance, or insurance from your employer)

You can apply in person or online here: https://www.va.gov/health-care/how-to-apply/. To find your closest VA health care office go here: https://www.va.gov/find-locations/.

After a completed application is filed, the VA determines which priority group the veteran will go to, and the veteran is notified of their enrollment status. The priory group assignment is based on multiple factors including the veteran’s income and unreimbursed medical expenses which is reported on the VA Form 10-10EZ. Each year, the VA determines what priority groups will be enrolled for the next cycle on health care. There are eight (8) categories, one (1) being the highest priority. The determination is based on the VA’s yearly budget and resources.

If the veteran’s priority group is chosen for enrollment for a particular year, the veteran should be able to receive various services under the VA medical benefits package, including extended care services. Described by law here: https://www.law.cornell.edu/cfr/text/38/17.38

Eligibility for VA Health Care

You may be able to get VA health care benefits if you served in the active military, naval, or air service and didn’t receive a dishonorable discharge. See more at https://www.va.gov/health-care/eligibility/.

If you enlisted after September 7, 1980, or entered active duty after October 16, 1981, you must have served 24 continuous months or the full period for which you were called to active duty, unless any of the descriptions below are true for you.

This minimum duty requirement may not apply if any of these are true. You:

Were discharged for a disability that was caused—or made worse—by your active-duty service, or

Were discharged for a hardship or “early out,” or

Served prior to September 7, 1980

If you’re a current or former member of the Reserves or National Guard, you must have been called to active duty by a federal order and completed the full period for which you were called or ordered to active duty. If you had or have active-duty status for training purposes only, you don’t qualify for VA health care.

Eligibility for Geriatrics and Extended Care

Once you are enrolled for VA Health Care and can receive your medical benefits package, the veteran can then use those benefits. The services available are dependent on that area’s resources.

At the Orlando VAMC level the extended care programs that are offered are listed here: https://www.orlando.va.gov/services/index.asp. Social Work Service manages the Community Nursing Home Program, Home Maker/ Home Health Aide Program, Community Adult Day Care Program, the Caregiver Program, Spinal Cord Injury Program, Women Veterans Program, Visual Impairment Services/Blind Rehabilitation Services, Former POW Advocate Program, Palliative Care Program, and Medical Foster Home Program.

When those services do become available the veteran may owe a copay.

Copays: When do I owe one?

1. Service-Connected Disability

Veterans with compensable service-connected disability, and veterans needing extended are with a service-connected disability do not owe a copay for extended care services.

2. Income under the VA MAPR

If a veteran has income under their Maximum Annual Pension Rate (MAPR), then they will not owe a copay. To determine your MAPR amount, visit: https://www.va.gov/pension/veterans-pension-rates/

3. All Other Veterans

All other veterans, including those with a service-connected disability that not compensable, will owe a copay for extended care services that are provided by the VA.

Copayments are set by law here: https://www.law.cornell.edu/cfr/text/38/17.111 and are currently:

(i) Adult day health care – $15.

(ii) Domiciliary care – $5.

(iii) Institutional respite care – $97.

(iv) Institutional geriatric evaluation – $97.

(v) Non-institutional geriatric evaluation – $15.

(vi) Non-institutional respite care – $15.

(vii) Nursing home care – $97.

Summary of Benefits

Below is a summary of the Geriatric and Extended Care benefits and the additional eligibility requirements for each benefit:

Home Based Primary Care (HBPC)

This benefit includes a team of providers who deliver primary care in the Veteran’s home. The team includes nurse practitioners, social workers, registered dieticians, physical therapists and a nurse. The HBPC also includes a physician and a clinical pharmacist who are involved in formulation of patient care plan but do not make home visits. This team serves the need of the home-bound Veteran who is physically and/or cognitively unable to keep his primary care clinic appointments although other admission criteria does apply. 

Eligibility: To be considered for this program, request should be made through your primary care provider.

Skilled Home Health Care

Skilled Home Health is health care services that can be provided to Veterans if they live far away from VA. The care is delivered by a community-based home health agency that has a contract with VA.

The program is for Veterans who need skilled services such as: skilled nursing, case management, physical therapy, occupational therapy, speech therapy, wound care, or IV antibiotics. Skilled Home Health Care can be used in combination with other Home and Community Based Services.

Eligibility: In order to receive this benefit, the veteran will need at least one of the following: intermittent, short-term, or long-term skilled nursing assessment, teaching, treatment services, or monitoring; intermittent, short-term, or transitional rehabilitative therapies, such as physical therapy, speech, and language pathology services, and occupational therapy; or intermittent, short-term, or transitional social work services.

Adult Day Health Care (ADHC)

Adult Day Health Care is a program Veterans can go to during the day for social activities, peer support, companionship, and recreation.

The program is for Veterans who need help with activities of daily living (ADLs). Examples include help with bathing, dressing, or fixing meals. This program is also for Veterans who are isolated or their caregiver is experiencing burden. Adult Day Health Care can be used in combination with other Home and Community Based Services.

Health services such as care from nurses, therapists, social workers, and others may also be available. Adult Day Health Care can provide respite care for a family caregiver and can also help Veterans and their caregiver gain skills to manage the Veteran’s care at home.

Eligibility: Veterans should meet one or more of the following: (1) dependent in three or more ADLs; or (2) experiences significant cognitive impairment; or (3) has two ADL dependencies and has two or more of the following conditions: (a) dependent in three or more instrumental ADLs; (b) recently discharged from a nursing home; (c) 75 years of age or older; (d) a high user of medical services; (e) clinical depression; or (f) lives alone in the community.

Respite Care

Respite care is a program that pays for care for a short time when family caregivers need a break, need to run errands, or need to go out of town for a few days. Respite Care can be helpful to Veterans of all ages, and their caregiver.

Eligibility: The veteran must meet all three of the following requirements: (1) the veteran has a diagnosed chronic disabling illness; (2) the veterans lives at home and requires assistance with ADLs in order to stay at home; and (3)

Medical Foster Care

Medical Foster Homes are private homes in which a trained caregiver provides services to a few individuals. Some, but not all, residents are Veterans. VA inspects and approves all Medical Foster Homes.

A Medical Foster Home can serve as an alternative to a nursing home. It may be appropriate for Veterans who require nursing home care but prefer a non-institutional setting with fewer residents.

Eligibility: To be eligible for a Medical Foster Home you need to be enrolled in Home Based Primary Care, and a Home needs to be available. The veteran must meet the nursing home level of care. The veteran must also: (1) be unable to live independently due to functional, cognitive, and/or psychological impairment, and (2) have complex medical conditions requiring care from a VA home health care team.

To learn more about VA benefits, contact The Elder Law Center of Kirson & Fuller today at 407-422-3017!