Health Benefits
Frequently Asked Questions - Health Care Benefits Overview
Where can I find more information?
Call VA Health Benefits toll-free help line at 1-877-222-VETS (8387) Monday through Friday between 8 a.m. and 8 p.m. ET. Information is also available at www.va.gov/healthbenefits.
How can I verify my enrollment?
Once your enrollment is confirmed, you will receive a Veterans Health Benefits Handbook from us notifying you of the status of your enrollment. You may also call us toll free to verify your enrollment at 1-877-222- VETS (8387) Monday – Friday between 8 a.m. and 8 p.m. ET.
If enrolled, must I use VA as my exclusive health care provider?
There is no requirement that VA become your exclusive provider of care. If you are a Veteran who is receiving care from both VA and a local provider, it is important for your health and safety that your care is coordinated, resulting in one treatment plan (co-managed care).
I am moving to another state. How do I transfer my care to a new VA health care facility?
If you want to transfer your care from one VA health care facility to another, contact your PACT. Your PACT will work with the Traveling Veteran Coordinator for assistance in transferring your care and establishing an appointment at the new facility.
How do I choose a preferred facility? How do I change my preferred facility?
When you apply for enrollment, you will be asked to choose a preferred VA facility. This will be the VA facility where you will receive your primary care. You may select any VA facility that is convenient for you.
If the facility you choose cannot provide the health care that you need, VA will make other arrangements for your care based on administrative eligibility and medical necessity. If you do not choose a preferred facility, VA will choose the facility that is closest to your home. You may change your preferred facility at any time.
Can I cancel my VA health care coverage?
You may request to dis-enroll from VA health care, commonly referred to as cancel/decline, at any time. To request to be dis-enrolled, you must submit a signed and dated document requesting to be dis-enrolled from VA health care to a VA Medical Center or you may mail the request to:
Health Eligibility Center
Enrollment & Eligibility Division
2957 Clairmont Road, Suite 200
Atlanta, GA 30329-1647
Cancelling your VA health care coverage may impact your health care coverage requirements under the Affordable Care Act if you do not have other qualifying health care.
You may reapply for enrollment at any time by completing a new VA Form 10-10EZ, “Application for Health Benefits,” online at www.vets.gov, by calling toll free 1-877-222-VETS (8387) or by visiting your local VA health care facility. Please note that you will be considered a new applicant and eligibility for enrollment will be based upon eligibility requirements in place at that time.
Where can I find the new income limits?
Because VA income limits may change each year, they are not published in this booklet; however, the income limit for the previous year can be viewed online at 2021 VA National and Priority Group 8 Relaxation Income Thresholds
What is a geographic income limit?
Recognizing the cost of living can vary significantly from one geographic area to another, Congress added income limits based on geographic locations to the existing VA income limits for financial assessment purposes. Veterans whose income falls between the VA income limit and the geographic income limit for the Veteran’s locale will have their inpatient medical care copayments reduced by 80%.
Geographic income limits for the previous year can be found at https://www.va.gov/healthbenefits/apps/explorer/AnnualIncomeLimits/LegacyVAThresholds?FiscalYear=2021.
What happens if at the end of the process my income is verified to be higher than the income limits?
Your copay status will be changed from copay exempt to copay required, which may result in disenrollment due to enrollment restrictions for Veterans whose income exceeds the income limits. VA facilities involved in your care will be notified of your change in status and to initiate billing for services provided during that income year. Your enrollment priority status may be changed if your financial status is adjusted by the income verification process. If your enrollment status is changed, you will be notified by mail.
Does VA have access to my income tax return?
No, VA does not have access to your tax return. The IRS and the SSA share earned and unearned income data reported by employers and financial institutions.
I am a recently discharged combat Veteran. Must I pay VA copayments?
Veterans who qualify under this special eligibility are not subject to copays for conditions potentially related to their combat service; however, unless otherwise excused, combat Veterans may be subject to appropriate copay rates for care or services VA determines are unrelated to their military service.
What is a VA service-connected rating, and how do I establish one?
A service-connected rating is an official ruling by VA that your illness or condition is directly related to your active military service. To obtain more information or to apply for any of these benefits, contact your nearest VA Regional Office at 1-800-827-1000, or visit us online at www.ebenefits.va.gov or www.va.gov.
What if I receive a bill and cannot pay?
If you are unable to pay your bill, you should discuss the matter with the Patient Billing Office at the VA health care facility where you received your care. See “ VA Has Options That Can Help Veterans Pay Copayments” on pages 15 and 16.
What is the Affordable Care Act?
The Affordable Care Act, also known as the health care law, was created to expand access to affordable health care coverage to all Americans, lower costs and improve quality and care coordination. For more information, see “Coverage Under The Affordable Care Act”on page 12 or visit www.va.gov/health/aca/.
If I am enrolled in VA Health care, do I meet the requirements for health care coverage?
Yes. If you are enrolled in any of VA’s programs below, you have coverage under the standards of the health care law:
- VA health care program
- CHAMPVA
- Spina Bifida Health Care Benefits Program
When do I begin declaring health care coverage to IRS?
U.S. taxpayers need to declare their health coverage on their federal tax forms.
When did VA begin notifying the IRS of a Veteran’s enrollment in the VA health care system?
In 2015, VA began sending the IRS, Veterans and eligible beneficiaries forms that provide details of the health coverage provided by VA. These forms are used for the income tax process.
What if I do not receive this form?
VA annually sent IRS Form 1095-B to Veterans who were enrolled in the VA health care system at any time the previous calendar year. If you did not receive a Form 1095-B from VA explaining your health care coverage for each year you are or have been enrolled, call 1-877-222-VETS (8387) Monday through Friday from 8 a.m. until 8 p.m. ET. This form is for your records only and should not be sent to the IRS or returned to VA.
What is a Patient Aligned Care Team (PACT)?
A Patient Aligned Care Team (PACT) includes the Veteran, his or her family or caregivers and a group of health care professionals who work together to plan that individual’s whole-person care and life-long health and wellness. It focuses on:
- Partnerships with Veterans
- Access to care using diverse methods
- Coordinated care among team members
- Team-based care with Veterans as the center of their PACT
How does a PACT function?
A PACT uses a team-based approach. You are the center of the care team that also includes your family members, caregivers and health care professionals – primary care provider, nurse care manager, clinical associate and administrative clerk. When other services are needed to meet your goals and needs, another care team may be called in. For more information, visit www.patientcare.va.gov/primarycare/PACT.asp.
Am I eligible for dental care?
VA is authorized to provide extensive dental care, while in other cases, treatment may be limited. The chart below describes dental eligibility criteria and contains information to assist Veterans in understanding their eligibility for VA dental care. The eligibility for outpatient dental care is not the same as for most other VA medical benefits and is categorized into classes. For instance, if you are eligible for VA dental care under Class I, 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: | |
|---|---|---|
| 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 II(C) |
| 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. 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 from a period of active duty (under conditions other than dishonorable) of 90 days or more during the Persian Gulf War era | One-time dental care if your DD 214, “Certificate of Release or Discharge from Active Duty,” does not indicate that a complete dental examination and all appropriate dental treatment had been rendered prior to discharge.* | Class II |
| 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 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 |
| Actively engaged in a 38 USC Chapter 31 Vocational Rehabilitation and Employment Program |
Dental care to the extent necessary as determined by a VA dental professional to:
|
Class V |
| Receive 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 |
| An enrolled Veteran who is homeless and receiving care under VHA Directive 2007039 | 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: Outpatient emergency dental care may be provided as a humanitarian service to individuals who do not have established dental eligibility. Dental treatment is limited to that necessary to address acute pain or a dental condition which is determined to be endangering life or health.
*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 the Veteran Benefits Administration (VBA) dated before 1955, in which VBA determined the dental conditions to be non-compensable, is 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.
For more information about eligibility for VA medical and dental benefits, call toll-free 1-877-222-VETS (8387) or visit https://www.va.gov/health-care/.
What is Community Care?
VA provides health care for Veterans from providers in your local community outside of VA. Veterans may be eligible to receive care from a community provider when VA cannot provide the care needed. This care is provided on behalf of and paid for by VA.
Community care is available to Veterans based on certain conditions and eligibility requirements, and in consideration of a Veteran’s specific needs and circumstances. Community care must be first authorized by VA before a Veteran can receive care from a community provider.
Do I qualify for routine health care at community facilities at VA expense?
To qualify for routine health care at community facilities at VA’s expense, you must first be given a written referral. Included among the factors in determining whether such care will be authorized is your medical condition and the availability of VA services within your geographic area. VA copayments may be applicable.
Are there any payment limitations for community emergency care?
Claims must be timely filed for community emergency care not authorized by VA in advance of services being furnished. Because timely filing requirements differ by type of claim, you should contact the nearest VA medical facility as soon as possible to avoid payment denial for an untimely filed claim. (See “Emergency Care” on page 29 for specific rules.)
Payment may not be approved for any period beyond the point of stability, except when VA cannot accommodate transfer of the Veteran to a VA or other federal facility. An emergency is deemed to have ended at the point of stability when a VA physician has determined that, based on sound medical judgment, a Veteran who received emergency hospital care could have been transferred from the community facility to a VA medical center for continuation of treatment.
What type of emergency care can VA authorize in advance?
| Subject to eligibility and payment limitations described in “Emergency Care” on page 22, VA may preauthorize and issue payment for community emergency care when treatment is needed for: | Inpatient Care | Outpatient Care |
|---|---|---|
| The Veteran’s VA-rated service-connected disability, or for a nonservice condition that is associated with and aggravating the Veteran’s service-connected condition |
Yes |
Yes |
| A disability for which the Veteran was released from active duty |
Yes |
Yes |
| Any condition of a Veteran who is rated by VA as permanently and totally disabled due to a service-connected disability |
Yes |
Yes |
| Any condition of a Veteran who is rated by VA as permanently and totally disabled due to a service-connected disability Any condition of a Veteran who is an active participant in the VA Chapter 31 Vocational Rehabilitation and Employment Program and who needs treatment that is medically determined to make possible the Veteran’s entrance into a course of training or prevent interruption of a course of training that was interrupted due to such illness, injury or dental condition |
Yes |
Yes |
| Any condition for a Veteran who has a VA service-connected disability rating of 50% or greater. (Note: A service-connected disability rated at 50 percent or more is for one disability, not as a result of combining multiple disabilities.) |
No |
Yes |
| A condition for which the Veteran has been furnished VA hospital care, nursing home, domiciliary care or medical services and who requires medical services to complete treatment incident to such care or services |
No |
Yes |
| Any condition of a Veteran who is in receipt of increased VA pension, additional VA compensation or allowances based on the need for regular aid and attendance or by reason of being permanently housebound |
No |
Yes |
| A condition requiring emergency care that developed while the Veteran was receiving medical services in a VA facility or contract nursing home or during VA authorized travel |
Yes |
Yes |
| Any condition that will prevent the need for hospital admission for a Veteran in the state of Alaska or Hawaii and U.S. Territories, excluding Puerto Rico |
Yes |
Yes |
| Any condition for women Veterans |
Yes |
No |
| Any dental services, treatment and related dental appliances for Veterans who are former prisoners of war |
No |
Yes |
| Hospital care or medical services while in authorized travel status |
Yes |
Yes |
| For any disability of a Veteran receiving VA contract nursing home care, and in need of emergency treatment |
Yes |
Yes |
Can VA pay for non-VA emergency care that is not preauthorized?
VA has limited payment authority when emergency care at a community facility is provided without authorization by VA in advance of services being furnished or when notification to VA is not made within 72 hours of admission. VA may pay for unauthorized emergency care as indicated below. Since payment may be limited to the point your condition is stable for transfer to a VA facility, the nearest VA medical facility should be contacted as soon as possible for all care not authorized by VA in advance of the services being furnished.
Additional requirements for retroactive payment approval for unauthorized emergency treatment for service-connected Veterans can be found in (Title 38 U.S.C. §1728): In addition to the General Eligibility requirements, for payment to be retroactively approved for emergent care under Title 38 U.S.C. §1728, one of the following criteria must also be met:
Emergency treatment of a service-connected*, or adjunct condition* in a community
emergency department; OR
- A Veteran who is permanently and totally disabled (P&T) as the result of a service-connected
condition is eligible for emergency treatment of ANY condition; OR
- A Veteran who is participating in a VA Vocational Rehabilitation Program and requires
emergency treatment to expedite their return to the program is eligible for emergency
treatment for any condition
VA may also pay for unauthorized nonservice-connected emergency care, indicated below, are contained in Title 38 U. S. C. §1725 and Title 38 CFR § 17.1000: In addition to the General Eligibility requirements, for payment to be retroactively approved for emergent care under Title 38 U.S.C. §1725, all of the following 5 criteria must also be met:
Care was provided in a hospital emergency department (or similar public facility held to provide
emergency treatment to the public); AND
- The Veteran has received care within a VA facility during the 24 months before the emergency
care; AND
- The Veteran is financially liable to the emergency treatment provider; AND
- If the treatment was due to an injury or accident, the claimant has exhausted, without success,
all liability claims and remedies reasonably available to the Veteran or provider against a third
party for payment of such treatment, and the Veteran has no contractual or legal recourse for
extinguishing, in whole, the Veteran’s liability to the provider; AND
- The Veteran is not eligible for reimbursement under Title 38 U.S.C. §1728 for the emergency
treatment.
For more information about emergency care, visit www.va.gov/communitycare/
Does VA offer compensation for travel expenses to and from a VA facility?
Yes, but not all Veterans qualify. If you meet specific criteria (see “Medically Related Travel Benefits” on page 24), you are eligible for travel benefits.
I already provided financial information on my initial VA application. Why is it necessary to complete a separate financial assessment for long-term care?
Your application for initial enrollment is based on your previous year income. The long term care financial assessment (VA Form 10-10EC, Application for Extended Care Services) is designed to assess your current financial status, including current expenses. This in-depth analysis provides the necessary monthly income/expense information to determine whether you qualify for free, long-term care or a significant reduction from the maximum copayment charge.
Once I submit a completed VA Form 10-10EC, who notifies me of my long-term care copay requirements?
The social worker or case manager involved in your long-term care placement will provide you with an annual projection of your monthly copayment charges based on available resources.
Assuming I qualify for nursing home care, how is it determined whether the care will be provided in a VA facility or a private nursing home at VA expense?
Generally, if you qualify for indefinite nursing home care, that care will be furnished in a VA facility. Care may be provided in a private facility under VA contract when there is compelling medical or social need.
If you do not qualify for indefinite care, you may be placed in a community nursing home, generally not to exceed six months, following an episode of VA care. The purpose of this short-term placement is to provide assistance to you and your family while alternative, long-term arrangements are explored.
For Veterans who do not qualify for indefinite VA Community Living Center care at VA expense, what assistance is available for making alternative arrangements?
When the need for nursing home care extends beyond the Veteran’s eligibility, our social workers will help family members identify possible sources for financial assistance. Our staff will review basic Medicare and Medicaid eligibility and direct the family to the appropriate sources for further assistance, including possibly applying for additional VA benefit programs.
