| Document
Title: Ryan White CARE Act and Veterans
August
19, 2004
HIV/AIDS
Bureau
Dear Ryan White CARE Act Grantee:
Enclosed
is the HIV/AIDS Bureau's (HAB) draft policy proposal developed
to clarify the provision of Ryan White Comprehensive AIDS
Resources Emergency (CARE) Act services to persons who are
veterans living with HIV and also eligible for Department
of Veterans Affairs (VA) health care benefits. CARE Act grantees
may not deny services, including prescription drugs, to a
veteran who is otherwise eligible for CARE Act services.
This
policy notice will explain how the coordination of care for
veterans who are eligible for CARE Act services can be maximized;
enhance CARE Act grantees understanding of the VA health care
system so that they can work to assure HIV-infected veterans
are provided with optimal access to care and treatment; clarify
the roles and responsibilities of the CARE Act and the VA
in providing HIV/AIDS care to veterans; and address the critical
misconceptions about veterans' eligibility for CARE Act services.
We invite
your review and comment of this draft policy within 45 days
or no later than Monday, October 4, 2004. Please distribute
this document for review to other organizations as deemed
appropriate.
In commenting
please refer to the "Ryan White CARE Act and Veterans
Draft Policy Notice" and address to:
Ms.
Alice Litwinowicz
Health Resources and Services Administration
HIV/AIDS Bureau/Office of Policy and Program Development
Parklawn Building, Room 7-18
5600 Fishers Lane
Rockville, Maryland 20857
You may
submit comments in one of three ways (no duplicates, please):
1. By mail. You may mail written comments to the address
above.
2. Electronically.
You may submit electronic comments and e-mail comments: alitwinowicz@hrsa.gov
(attachments should be in Microsoft Word or WordPerfect; however,
we prefer Microsoft Word).
3. By
facsimile (FAX) transmission. Fax comments to 301-443-5838.
Page
2 - Ryan White CARE Act Grantee
Please
include your name, title, name of organization, complete address,
and telephone number.
Thank
you for your attention to this important matter.
Sincerely,
/S/
Deborah
Parham Hopson, Ph.D., R.N.
RADM, USPHS
Associate Administrator
Enclosure
Draft
Policy Notice - 04-01 Ryan White CARE Act and Veterans
Introduction:
The HIV/AIDS
Bureau (HAB) has carefully examined the issues surrounding
the Ryan White Comprehensive AIDS Resources Emergency (CARE)
Act and HIV positive veterans who are eligible for care and
treatment by the Department of Veterans Affairs (VA). This
draft policy outlines how CARE Act grantees should address
the care and treatment of veterans who present at grantee
sites. This draft policy also requires that our grantees learn
more about the VA generally, and in their geographic area
and region, in particular.
Purpose:
The Bureau
developed this policy:
- To
explain how the coordination of care for veterans who are
eligible for CARE Act services can be maximized;
- To
enhance CARE Act grantees' understanding of the VA health
care system so that they can work to assure HIV- infected
veterans are provided with optimal access to care and treatment;
- To
clarify the roles and responsibilities of the CARE Act and
the VA in funding and providing HIV/AIDS care to veterans;
and
- To
address the critical misconceptions about veteran's eligibility
for CARE Act services.
Principles
that Guided the Framework for this Policy:
By law,
the CARE Act is the payer of last resort. As such, CARE Act
grantees are required to determine and verify an individual's
eligibility for services from all sources to ensure the individual
is provided the widest range of needed medical and support
services. This means a grantee must coordinate benefits and
ensure that the individual's eligibility for other private
or public programs is determined at the time of initial intake.
Eligibility needs to be reconfirmed periodically to determine
if your client's eligibility status for any other programs
has changed. Services that must be reimbursed by any private
or public payers should be determined before CARE Act funds
are used to pay for care. The CARE Act may pay for services
that fill the gaps in coverage of these other private or public
health care programs but the funds cannot be used for services
that should be reimbursed or paid by the other payers.
VA
Health Care
Like
most systems of health care in the U.S., the VA health care
system has changed significantly. In recent years, the Congress
made legislative changes that have dramatically enhanced veterans'
health care benefits as well as access to those benefits.
The VA administers its program through an annual patient enrollment
system. The enrollment system assigns veterans to priority
groups to ensure that health care benefits are available to
enrolled veterans. The eight (8) enrollment priority groups
can be found in Attachment 1.
Each
year, the Secretary of the VA makes a determination about
which of the eight priority groups will be allowed to enroll
for VA health care benefits. Since January 2003, for example,
the VA is accepting no new priority group eight veterans for
enrollment. Because these groups are subject to change, CARE
Act grantees should periodically visit the VA Web site to
confirm the current priority group categories.
Veterans
receiving care through the VA are eligible for "Acute
Care Benefits," or what the VA refers to as "Standard
Benefits" including:
- Preventative
Care Services [immunizations, physical examinations (includes
eye and hearing), health care assessments, screening tests,
health education programs)];
- Ambulatory
(Outpatient) Diagnostic and Treatment Services (medical,
surgical, mental health, substance abuse);
- Hospital
(Inpatient) Diagnostic and Treatment Services (medical,
surgical, mental health, substance abuse);
- Other
health care benefits are available on a limited basis (partial
listing) and may have special eligibility criteria: ambulance
services, dental care, durable medical equipment, eyeglasses,
hearing aids, home health care, homeless programs, maternity
and parturition services (usually provided in non-VA contracted
hospitals at VA expense and care is limited to the mother),
non-VA health care services, orthopedic, prosthetic and
rehabilitative devices, rehabilitative services, readjustment
counseling, and sexual trauma counseling; and
- Prescription
Drugs (when prescribed by a VA physician).
Veterans
must meet certain eligibility criteria for some services.
For example, to qualify for eyeglasses a veteran must have
a VA service-connected disability rating of 10 percent or
more or qualify with other specific veteran criteria, such
as being a participant in a VA vocational rehabilitation program.
Even with these limitations for certain services, the VA provides
comprehensive direct care for veterans. A veteran may select
any VA health care facility to serve as their primary treatment
facility. However, the Congress added geographically-based
means testing in addition to the existing VA national income
thresholds for financial assessment purposes, effective October
1, 2002 (See Attachment 1 for the VA Web site that contains
the current means test thresholds).
While
many veterans qualify for enrollment and cost-free health
care services based on a compensable service-connected condition
or other qualifying factor, most veterans will be asked to
complete a financial assessment as part of their enrollment
application process. Co-payments for outpatient medical care
and/or pharmaceuticals may be required from veterans in some
priority groups, primarily those without service connected
disability and higher income levels.
Because
the VA, like the Ryan White CARE Act and other programs, depends
primarily on annual Congressional appropriations, the VA encourages
veterans to retain any health care coverage they may already
have, especially those veterans in the lower enrollment priority
groups. There is no guarantee that Congress will appropriate
sufficient funds for VA to provide care for all enrollment
priority groups. The VA statute does not include payer of
last resort language and VA health care is not an entitlement
program. Veterans with private health insurance or with federally-funded
coverage through the Department of Defense (TRICARE), Medicare,
or Medicaid, may choose to use these sources of coverage as
a supplement to or an alternative to their VA benefits.
By law,
the VA bills health insurers for services provided to treat
nonservice-connected conditions. To ensure that current insurance
information is on file, including coverage through employment
or through a spouse, the VA asks about the veteran's health
insurance coverage during each patient visit.
CARE
Act and Veterans
All eligible
veterans may choose to receive their care from the VA health
care system. However, even if enrolled for VA health care,
a veteran does not have to use the VA as their exclusive health
care provider. Veterans are never required to access their
health care services from the VA, but rather they are always
free to obtain their health care services from the provider
of their choice. Veterans with private health insurance may
elect to use those benefits in seeking services from non-VA
providers as a supplement to their VA care. VA is not, however,
an insurance plan or an entitlement program and the VA authority
to pay for services from individual non-VA providers is extremely
limited.
In addition,
veterans may enroll in other private or public programs including
Medicare, Medicaid, and may receive services paid for by the
Ryan White CARE Act. To ensure that veterans have full access
to all possible services, and to ensure that veterans are
obtaining their preferred services, CARE Act grantees should
inform HIV-infected veterans of the benefits, services, and
physical location of the VA in their area. Many veterans have
not enrolled or used a VA facility and may not know what the
current requirements are for the eight priority groups. CARE
Act grantees are required to work with their local VA HIV/AIDS
coordinators who are available for coordination, enrollment,
and questions. CARE Act grantees may obtain the name and contact
information of their local VA facility HIV/AIDS Coordinators
from Ms. Donna Wells (donna.wells@hq.med.va.gov
or (202) 273-8205).
CARE
Act grantees may not deny services, including prescription
drugs, to a veteran who is otherwise eligible for CARE Act
services. CARE Act grantees may not cite the "payer of
last resort" language in Section 2605(a)(6), 2617(b)(6)(F),
or 2664(f) of the Public Health Service Act to force an HIV-infected
eligible veteran to obtain services from the VA health care
system or refuse to provide services.
Some
VA facilities do not have infectious disease specialists or
HIV/AIDS experienced providers. CARE Act providers are required
to be familiar with the VA facilities in their local areas
that have this expertise and which ones do not. CARE Act providers
need to determine where the VA facilities are located; referrals
to VAs that are located outside an acceptable range are not
required.
Updated Role of CARE Act Grantees with the VA
Many
CARE Act grantees currently collaborate with the VA to ensure
that eligible veterans receive care under the appropriate
program. This policy emphasizes and requires a collaborative
role for CARE Act grantees with the VA and their health care
facilities to ensure that veterans receive optimal care and
treatment.
- CARE
Act grantees may not deny services, including prescription
drugs, to a veteran who is otherwise eligible for CARE Act
services.
- CARE
Act grantees (case managers, others) must work to assure
that veterans receive necessary support or other services
that the VA health care system does not provide. This may
vary by geographic location, given both the regional differences
across the VA's system and variations in local operation
of veteran's facilities. CARE Act grantees are required
to become familiar with their local VA facilities care,
especially those with experienced HIV providers. CARE Act
grantees can provide a valuable service in assisting veterans
establish care within the VA system by becoming familiar
with enrollment procedures, eligibility requirements, and
local VA contacts for coordination of HIV care.
- If
transitioning from a CARE Act funded provider or other community-based
care to VA-based HIV care, enrolled veterans may experience
wait times for initial appointments or other delays that
can result in interruptions of medical or pharmaceutical
care. CARE Act grantees should work with veteran clients
to ensure that such gaps do not jeopardize the veteran's
HIV treatment.
- Veterans
may also be eligible for services from State-funded veterans
programs, Veterans Service Organizations, or Vet Centers.
CARE Act grantees should be familiar with these other resources.
- CARE
Act grantees may contract with the VA to provide services
to HIV-infected veterans for HIV-related services that are
not covered by the VA. Alternatively, the VA can contract
with CARE Act grantees or providers to provide HIV-related
services for veterans that are not available at the veteran's
VA facility or clinic.
ATTACHMENT
1
VA
Health Care Enrollment Priority Groups
Upon
receipt of a completed application (must include signature
and date), the veteran's eligibility will be verified. Based
on his/her specific eligibility status, he/she will be assigned
to one of the following VA priority groups. The groups range
from 1 through 8 with Priority Group 1 being the highest priority
and Priority 8 the lowest.
Priority
Group 1
- Veterans
with service-connected disabilities rated 50% or more disabling
Priority
Group 2
- Veterans
with service-connected disabilities rate 30% or 40% disabling
Priority
Group 3
- Veterans
who are former Prisoners of War (POWs)
- Veterans
awarded the Purple Heart
- Veterans
whose discharge was for a disability that was incurred or
aggravated in the line of duty
- Veterans
with service-connected disabilities rated 10% or 20% disabling
- Veterans
awarded special eligibility classification under Title 38,
United States Code (U.S.C.), Section 1151, "benefits
for individuals disabled by treatment or vocational rehabilitation"
Priority
Group 4
- Veterans
who are receiving aid and attendance or housebound benefits*
Veterans who have been determined by VA to be catastrophically
disabled
* Note:
"attendance" is the VA's enrollment priority group
terminology
Priority
Group 5
- Nonservice-connected
veterans and noncompensable service-connected veterans rated
0% disabled whose annual income and net worth are below
the established VA Means Test thresholds
- Veterans
receiving VA pension benefits
- Veterans
eligible for Medicaid benefits
Priority
Group 6
- Compensable
0% service-connected veterans
- World
War I veterans
- Mexican
Border War veterans
- Veterans
seeking care solely for disorders associated with: exposure
to herbicides while serving in Vietnam; or exposure to ionizing
radiation during atmospheric testing or during the occupation
of Hiroshima and Nagasaki; or for disorders associated with
service in the Gulf War; 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
Priority
Group 7
- Veterans
who agree to pay specified copayments with income and/or
net worth ABOVE the VA Means Test threshold and income BELOW
the geographically-based threshold for their locality
Subpriority a: Noncompensable 0% service-connected veterans
who were enrolled in the VA health care system on a specified
date and who have remained enrolled since that date
Subpriority c: Nonservice-connected veterans who were enrolled
in the VA health care system on a specified date and who
have remained enrolled since that date
Subpriority e: Noncompensable 0% service-connected veterans
not included in Subpriority a above
Subpriority g: Nonservice-connected veterans not included
in Subpriority c above
Priority
Group 8 (Note: As of January 17, 2003, the VA is not accepting
new Priority Group 8 veterans for enrollment.)
Veterans
who agree to pay specified copayments with income and/or net
worth ABOVE the VA Means Test threshold and income ABOVE the
geographically-based threshold for their locality
Subpriority a: Noncompensable 0% service-connected veterans
enrolled as of January 16, 2003 and who have remained enrolled
since that date
Subpriority c: Nonservice-connected veterans enrolled as of
January 16, 2003 and who have remained enrolled since that
date
Subpriority e: Noncompensable 0% service-connected veterans
applying for enrollment after January 16, 2003
Subpriority g: Nonservice-connected veterans applying for
enrollment after January 16, 2003
Note:
Priority Groups 7 and 8 both have subpriority groups, a, c,
e, and g that are in descending order based on highest to
lowest priority. They deliberately were not placed in consecutive
order. Since these designations are used exclusively for internal
VA tracking purposes, the VA reserved b, d, and f for future
use in the event of additional changes in the priority groups.
VA
Web site information and toll free telephone number:
Source
for Attachment information: VA web site http://www.va.gov
To locate
a VA facility or clinic in your area: http://www1.va.gov/health_benefits/
For information
on enrollment in VA's health care system including copayments
and both the geographic means test thresholds and Veterans
Health Administration means test thresholds: http://www1.va.gov/Elig/page.cfm?pg=35
Additionally,
specific questions can be answered by your local VA health
care facility's enrollment office or the Veterans Health Benefits
Service Center: 1-877-222-VETS (8387)
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