Citation Nr: A25052257 Decision Date: 06/13/25 Archive Date: 06/13/25 DOCKET NO. 240220-419542 DATE: June 13, 2025 ORDER The appeal for entitlement to placement in priority group 1 in the Department of Veterans Affairs (VA) healthcare system is granted. FINDING OF FACT The Veteran has a combined rating in excess of 50 percent based on one or more service connected disabilities. CONCLUSION OF LAW The criteria for eligibility for copay exempt status under Priority Group 1 within the VA health care system have been met. 38 U.S.C. § 1710; 38 C.F.R. § 17.36. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from March 1969 to March 1971. In the February 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. In filing his VA Form 10182, the Veteran stated he was appealing a "Medical Health Care Benefit, Area of Disagreement: disability evaluation, service connection." In order to seek additional clarification, the Board sent correspondence to the Veteran in April 2025 in an attempt to determine the issue the Veteran was appealing. The Board advised the Veteran it was construing his February 2024 VA Form 10182 as a disagreement with the priority group assigned. The Board also advised the Veteran he is currently enrolled in priority group 1 and there is no higher priority group available. The letter gave the Veteran two options to proceed. Option one stated that if he agreed with the Board's interpretation, he could do nothing or submit correspondence agreeing with the Board's interpretation. The other option was to complete a Statement in Support of Claim to clarify his intent regarding the issues on appeal. The Board did not receive any response to the April 2025 correspondence. As such, the Board's interpretation of the VA Form 10182 will move forward and be adjudicated. Generally, VA outlines eligibility for enrollment into the VA health care system in 38 U.S.C. § 1710. Following an application for enrollment, Veterans are placed in priority groups. See 38 U.S.C. § 1722; 38 C.F.R. § 17.36; see generally https://www.va.gov/health-care/eligibility/priority-groups/ (last accessed June 11, 2025). Such priority group placement may affect factors such as how soon a Veteran receives health care benefits, and whether the Veteran is subject to certain copayment requirements for hospital care and medical services. See 38 C.F.R. §§ 17.36, 17.108. VA determines which categories of veterans are eligible to be enrolled, based upon enumerated priorities; with veterans who do not have any service-connected disabilities assigned the lowest priority. 38 C.F.R. § 17.36 (b). VA manages the enrollment of veterans in accordance with the following priority categories, in the order listed: (1) Veterans with a singular or combined rating of 50 percent or greater based on one or more service-connected disabilities or unemployability; and veterans awarded the Medal of Honor. (2) Veterans with a singular or combined rating of 30 percent or 40 percent based on one or more service-connected disabilities. (3) Veterans who are former prisoners of war (POWs); veterans awarded the Purple Heart; veterans with a singular or combined rating of 10 percent or 20 percent based on one or more service-connected disabilities; veterans who were discharged or released from active military service for a disability incurred or aggravated in the line of duty; veterans who receive disability compensation under 38 U.S.C. § 1151; veterans whose entitlement to disability compensation is suspended pursuant to 38 U.S.C. § 1151, but only to the extent that such veterans' continuing eligibility for that care is provided for in the judgment or settlement described in 38 U.S.C. § 1151 ; veterans whose entitlement to disability compensation is suspended because of the receipt of military retired pay; and veterans receiving compensation at the 10 percent rating level based on multiple noncompensable service-connected disabilities that clearly interfere with normal employability. (4) Veterans who receive increased 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) Veterans who are not covered under categories 1 through 4 but are unable to defray the expenses of necessary care as determined under 38 U.S.C. § 1722 (a). (6) Veterans of the Mexican border period or of World War I; 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); Camp Lejeune veterans pursuant to §17.400; and veterans with 0 percent service-connected disabilities who are nevertheless compensated, including veterans receiving compensation for inactive tuberculosis. (7) Veterans who agree to pay to the United States the applicable copayment determined under 38 U.S.C. § 1710 (f) and 1710(g) if their income for the previous year constitutes "low income" under the geographical income limits established by the U.S. Department of Housing and Urban Development for the fiscal year that ended on September 30 of the previous calendar year. For purposes of this paragraph, VA will determine the income of veterans (to include the income of their spouses and dependents) using the rules in §§3.271, 3.272, 3.273, and 3.276. After determining the veterans' income and the number of persons in the veterans' family (including only the spouse and dependent children), VA will compare their income with the current applicable "low-income" income limit for the public housing and section 8 programs in their area that the U.S. Department of Housing and Urban Development publishes pursuant to 42 U.S.C. 1437a (b)(2). In the event the veteran's income is below the applicable "low-income" income limits for the area in which the veteran resides, the veteran will be considered to have "low income" for purposes of this paragraph. To avoid a hardship to a veteran, VA may use the projected income for the current year of the veteran, spouse, and dependent children if the projected income is below the "low income" income limit referenced above. This category has additional subcategories. (8) Veterans not included in the above priority may be eligible for care but only if they agree to pay to the United States the applicable copayment determined under 38 U.S.C. §§ 1710 (f) and 1710(g). This required copayment category has additional subcategories. The evidence of record reflects the Veteran had a combined rating of 60 percent, effective May 13, 2014, as of a November 2022 rating decision (of note, there is a later rating decision that was issued after the AOJ decision on appeal; that is outside of the period on appeal and not for Board review in this decision). Priority group 1 requires Veterans to have a singular or combined rating of 50 percent or greater based on one or more service-connected disabilities or unemployability; and veterans awarded the Medal of Honor. The Veteran therefore meets the criteria for priority group 1. The evidence of record provided by Health Eligibility Center (HEC) reflects HEC assigned the Veteran to priority group 1. There is no higher level priority group available, the Veteran is already assigned to the highest priority group possible. 38 C.F.R. § 17.36. Contradictory information was provided by HEC, noting the last income year reviewed was 2009 and HEC reported the Veteran was categorized as "GMT Copay Required" and "Non-Exempt" for pharmacy co-pay status. However, based on the evidence of record, the Veteran is enrolled in priority group 1 and the Board is hereby granting entitlement to priority group 1. As noted above, the Veteran is already enrolled in priority group 1, there is no higher priority group available. Accordingly, entitlement to enrollment in priority group 1 is warranted. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Mouzakis, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.