ELIGIBILITY AND PRIORITY FOR DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SERVICES
The VA serves 8.76 million veterans per year at more than 1,700 health care sites throughout the United States (VA, 2015e). Not all veterans, however, are eligible for care through the VA. Veterans may be eligible for health care services if they
The VA has minimum duty requirements for eligibility for health care services. For example, most veterans who enlisted after September 7, 1980, or entered active duty after October 16, 1981, must have served 24 continuous months or the full period for which they were called to active duty in order to be eligible (VA, 2015c). A number of exceptions to the minimum duty requirements exist and, therefore, veterans must apply for health care services to determine eligibility. An enhanced eligibility status exists for any veteran who falls into one or more of the following categories:
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Veterans must apply for VA health care services, and then the VA reviews the application and makes a determination on eligibility for enrollment. Once a veteran is enrolled, the veteran is assigned an enrollment priority group (see Box 6-1). Priority groups are used because Congress annually allocates funds for VA and, given the limited funds it must work with, the agency needs a way to prioritize who should receive health care services. The priority groups range from 1 to 8, with those in group 1 receiving the highest priority. On the basis of eligibility and income, some veterans may have to pay a copay when using services.
Veterans who served in a combat theater after November 11, 1998, and were discharged from active duty on or after January 28, 2003, are eligible for comprehensive VA health care services for 5 years following their discharge under the “combat veteran” authority in the National Defense Authorization Act of 2008. Veterans in this group would include veterans serving in combat theaters in support of OEF/OIF/OND (unless they were discharged before January 28, 2003). During the 5 years, veterans are allowed to enroll for health care services without first establishing their priority group. After 5 years, these veterans are assigned to a priority group based on their income and degree of disability due to their service-related condition at that time (IOM, 2014). Combat veterans who did not enroll within the 5-year window of eligibility and were discharged from service between January 1, 2009, and January 1, 2011, were granted 1 additional year of eligibility under the Clay Hunt Suicide Prevention for American Veterans Act in 2015.1
In general, the VA does not provide health care services or coverage to spouses or dependents. However, with the Program of Comprehensive Assistance for Family Caregivers, veterans’ family members caring for seriously injured veterans, including veterans who have mental health conditions, are eligible for certain VA services including caregiver training, a financial stipend, mental health services and counseling, and access to health insurance (VA, 2017f).
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Legal veteran status is earned by individuals who complete at least 2 consecutive years of active-duty military service and are discharged or separate from service under conditions other than dishonorable.2 Under VA regulations (although not mandated by federal law), individuals who receive an other-than-honorable (OTH) discharge are not eligible to receive VA medical care, including mental health care (Commission on Care, 2016). This includes veterans who received an OTH discharge because of actions or behavior that resulted from a health condition (such as a traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], or substance use) that may have been caused or aggravated by their service. Individuals with OTH discharges have some level of misconduct on their records, but no court martial convictions. Nearly 7 percent of OEF/OIF/OND veterans have received an OTH discharge (Swords to Plowshares, 2016). A recent Government Accountability Office report (GAO, 2017) found that of the 91,764 service members who received a misconduct separation between fiscal years (FY) 2011 and 2015, 62 percent (57,141) were diagnosed with PTSD or a TBI within 2 years of their separation. Of the 57,141, 23 percent (12,283) received an OTH discharge, making them potentially ineligible to receive VA health care services. This finding is consistent with findings of a 2016 report by the congressionally appointed Commission on Care, which reported that many former service members who received an OTH discharge as a result of a regulatory bar (which could be the result of behavioral misconduct related to a service-connected mental health condition) are legally veterans, but are routinely denied health care unless they request, receive, and prevail in eligibility adjudication with the Veterans Benefits Administration (VBA) that their discharge was not dishonorable (Commission on Care, 2016). However, very few veterans who request eligibility adjudication receive it. For those veterans who are granted adjudication proceedings, the process can take about 4 years to complete (Swords to Plowshares, 2016). The Commission on Care recommends that the VA eliminate the regulation that automatically prohibits veterans with an OTH discharge from receiving health care from the VA. Furthermore, it recommends that the VA award tentative eligibility for services to individuals with OTH discharge who have completed substantial honorable service, including (but not limited to) serving in a combat theater. Finally, it recommends that the VA should provide an opportunity to recognize that misconduct that leads to the OTH discharge may itself be related to a service-connected condition (Commission on Care, 2016). As mentioned in Chapter 4, in 2017 VA Secretary David Shulkin announced that the VA would offer emergency mental health care to veterans with an OTH discharge status as part of its ongoing efforts to prevent veteran suicides (VA, 2017e). Under this initiative, veterans with OTH discharges will be eligible to seek treatment at a VA emergency department, Vet Center, or contact the Veterans Crisis Line. The VA will provide a full array of mental health services for up to 90 days. The VA estimated that 30,000 to 50,000 OTH veterans per year (out of the total 505,000) would use emergency mental health services, requiring an estimated 150,000 to 240,000 additional bed days of inpatient care as well as approximately 375 to 675 full-time equivalent provider-years of outpatient mental health services (VA, 2017d).
In FY 2016, 9,040,675 veterans of all eras were enrolled in the VA health system and assigned to priority groups 1-8 (see Box 6-1).3 Of those, 1,024,330 are OEF/OIF/OND veterans (that is, veterans who served in the U.S. Armed Forces after September 2001), and 8,016,345 are veterans of other eras. Figure 6-1 shows the distribution of enrolled OEF/OIF/OND veterans and other-era veterans among the priority groups. Priority groups 1, 6, and 8 have the highest numbers of OEF/OIF/OND veterans enrolled; priority groups 1, 5, and 8 have the highest numbers of veterans of other eras. Of the 1,024,330 OEF/OIF/OND veterans who are enrolled in VA health care, 604,871 of them used VA health care services in FY 2016. Figure 6-2 shows the distribution among the priority groups of OEF/OIF/OND veterans who are enrolled in VA health care and also use the health care services. Not all enrolled veterans actively use the health care services. The highest number of OEF/OIF/OND enrollees and users are in priority groups 1, 2, and 3. About 60 percent of OEF/OIF/OND enrollees use VA health services. This number is lower than the number of other-era enrollees who use VA health services, which is about 72 percent.
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