VA's 2003 Enrollment Decision Q&A

If this is the largest increase in VA history, why are you suspending enrollment for some veterans? President Bush has given us a record fiscal year 2004 budget request in a time of heavy and competing demands throughout the government. His record request enables VA to improve health care access for its higher-priority core constituency - veterans with service-related disabilities, with low incomes and with special health care needs.

Even with the record budgetary increase, the large number of higher-income, non-disabled veterans expected to seek VA care would prevent VA from focusing on its core constituency. The suspension will allow VA to protect the quality of care and reduce waiting times.

The Secretary of Veterans Affairs is required by law to make an annual enrollment decision, and his decision to suspend enrollment for new Priority Group 8 veterans preserves access to health care for its core constituency.

Is it true that VA is no longer accepting new higher income veterans for enrollment? Yes, a veteran who applies for enrollment on or after January 17, 2003, and is assigned to Priority Group 8, will not be accepted for enrollment. Under the decision, Priority Group 8 veterans already enrolled in VA's health care system can continue to receive care. No veteran already enrolled will be affected.

Which veterans make up the Priority Group 8? Veterans in Priority Group 8 have no compensable service-connected disability or other status making them eligible for a higher priority category and have annual incomes above both national and geographic means tests.

Veterans in this Priority Group have incomes that exceed $24,644 in 2003 for a single veteran and $29,576 for a veteran with a single dependent) and that also exceed a geographically based income threshold set by the U.S. Department of Housing and Urban Development (HUD) for public housing benefits. Information about the HUD threshold is available at http://www.hud.gov/renting/phprog.cfm.

Why did VA make this decision? The decision ensures that VA can provide timely, high quality care to veterans with service-connected disabilities, lower incomes and special needs. VA has been unable to provide all enrolled veterans with timely access to health care services because of the tremendous growth in the number of veterans seeking VA health care. Between October 2001 and September 2002, VA enrolled 830,000 new veterans. This unprecedented surge in demand for VA health care is expected to continue in the future, exceeding VA's primary and specialty care capacity. This decision will help alleviate this situation and prevent further erosion of VA's capacity to provide needed health care services to veterans in a timely and medically appropriate manner.

Isn't VA reneging on the government's promise to provide health care for veterans? The law allows VA to provide care to the extent that resources are available. PL 104-262 requires the Secretary of Veterans Affairs to determine annually whether VA has sufficient resources to enroll veterans. The law gives the Secretary the responsibility to suspend enrollment when there are insufficient resources to provide quality health care. The Secretary's decision to suspend enrollment of veterans in the lowest priority group established by Congress (Priority Group 8) implements this legal responsibility.

What alternatives have been considered? Over the last several years, VA has implemented management efficiencies to partially offset the increasing demand. Past efficiencies included improved standardization policies in procurement of supplies, pharmaceuticals, equipment, and other capital purchases as well as other operational efficiencies including increasing third party collections. Additional management efficiencies are planned for FY 2004.

Another alternative is to continue placing veterans on waiting lists, which have been estimated at almost 236,000 veterans as of January 2003. This will greatly increase both the number of veterans waiting for care and increase the length of time they will wait for appointments. This alternative is unacceptable as it negatively affects quality and timely patient care.

What are the effects of this action?

• VA will continue to enroll veterans in Priority Groups 1 through 7. VA expects to enroll another 380,000 in Priority Groups 1 through 7, an increase of 6.6 percent from last year, and treat 4.6 million veterans at its medical facilities this year.
• Suspending enrollment of Priority Group 8 veterans on January 17 affects an estimated 164,000 veterans for the remainder of the fiscal year (January 15-September 30, 2003). Continuation of this suspension of enrollment will affect an estimated 360,000 veterans by the end of FY 2004 and 522,000 veterans by the end of FY 2005, based on demand expectations from this enrollee group.
• Without this action, demand would continue to exceed our capacity, in terms of staff and resources. The future year effect of this demand is a multiple billion-dollar shortfall. This enrollment action will begin to bring demand in line with capacity and reduce the number of veterans on waiting lists. In concert with other policy initiatives and management efficiencies included in the FY 2004 budget, demand and resources will once again be on parallel tracks.
• This regulation provides the Secretary more flexibility to effect enrollment actions by establishing four subcategories within Priority Groups 7 and 8. These subcategories are based on maintaining priority for those who have enrolled in the VA system over those who have not enrolled. Currently, this enrollment decision only affects Priority group 8 veterans who have not yet enrolled in VA's health care system.

What are the effects of not taking this action? Past enrollment growth has exhausted VA's capacity. The projected growth for FY 2003 and beyond exceeds both VA's primary and specialty care capacity. As of January 2003, VA estimates that there are almost 236,000 veterans who have been unable to schedule an appointment or have an appointment scheduled more than 6 months from the desired date. If enrollment is not limited, over 520,000 new enrollees will enter the system in FY 2003. This would increase the number of veterans on the waiting list and adversely affect quality of care and patient safety for veterans who are currently enrolled. The suspension of new enrollments is necessary to prevent further erosion of VA's capacity to provide needed health care services to veterans in a timely and medically appropriate manner.

How will VA document that enrollment applications, VA Form 10-10EZ, have been completed and submitted to VA or postmarked prior to the effective date of the decision? If a decision is based on the postmark date of a mail-in application, the envelope will be a critical piece of information in the outcome of the appeal. Medical center staff will implement procedures to ensure this information is safeguarded and properly filed in the veteran's consolidated health record.

If a veteran cannot be enrolled, will he or she still be eligible for VA hospital and outpatient care? A veteran who is not enrolled will still be eligible for hospital and outpatient care for:

• Conditions related to military sexual trauma;
• Head or neck cancer related to nose or throat radium treatment while in the military;
• Readjustment counseling services;
• Treatment related to service-connected conditions.

Veterans should contact their local VA health care facility to learn if any other exceptions apply to them.

What happens if a veteran who is not enrolled in the VA health care system requests VA medical care? If VA determines a veteran has a condition requiring immediate treatment, VA will provide medical treatment on a humanitarian basis. VA must charge a fee for such care.

What if a veteran is catastrophically disabled? Catastrophically disabled veterans will be assigned to Priority Group 4. To request an evaluation, veterans can contact the enrollment office at their local VA health care facility.

Are there any special benefits for recently discharged combat veterans? Yes, recently discharged veterans who served in combat locations can receive health care for conditions potentially related to their service for two years after their release from service. VA is still developing computer enhancements to support this new benefit. Veterans should contact the Enrollment Coordinator at the nearest VA health care facility for more information.

Who should a veteran contact with questions concerning enrollment priority or eligibility for VA health care? For more information about enrollment and eligibility for VA health care, veterans can contact your local VA health care facility, or call VA's Health Benefits Service Center toll-free at 1-877-222-VETS (8387). Information is available on the Internet at http://www.va.gov/elig.

What is the Geographic Means Test used for Priority Group 8 veterans? Congress wanted to grant relief from making VA copayments for some veterans with marginal incomes, recognizing that income alone is not always a fair measure of one's standard of living because of sometimes large differences in the cost of living in different areas of the country. Congress modified VA's system of determining veterans' ability to pay for health care by creating a geographically-based income limit and reducing inpatient copayments for those veterans whose income falls below these new geographic income thresholds. The new geographic income thresholds are adjusted for all standard metropolitan statistical areas (SMSAs) and are updated periodically to reflect economic changes within the SMSAs. The geographic means tests are based upon the geographically based income threshold set by the U.S. Department of Housing and Urban Development (HUD) for public housing benefits. Information about the HUD threshold is available at http://www.hud.gov/renting/phprog.cfm.

Placed on Veteransinfo.net on 2/11/03