Subscribe Blog RSS Feed. Since the law was passed May 5, 2010 as section of the Caregiver Act (Senate Bill S 1963), many medical centers have moved to stop collecting co-payments for either inpatient medical admissions or outpatient clinic visits for those designated as catastrophically disabled veterans. However BVA still gets some emails and phone calls from blinded veterans that are having problems.
Every Visual Impairment Service Team Coordinator VIST has been sent instructions on this and would recommend that if a veteran is having a local problem they talk with the VIST and your primary health care provider to ensure that your records document your blindness. There is a number listed below to call if a veteran needs assistance from the VA and link.
Department of Veterans Affairs VHA DIRECTIVE 2010-054
Veterans Health Administration
Washington, DC 20420 December 9, 2010
CATASTROPHICALLY DISABLED VETERAN EVALUATION, ENROLLMENT, AND CERTAIN COPAYMENT-EXEMPTIONS
1. PURPOSE: This Veterans Health Administration (VHA) Directive issues policy for the clinical evaluation, enrollment in Priority Group 4, and the discontinuation of inpatient, outpatient, and medication copayments of eligible Veterans who are catastrophically disabled.
2. BACKGROUND
a. Public Law 104-262,Section 104(a) of the “Veterans’ Health Care Eligibility Reform Act of 1996,” established a system of annual patient enrollment, in order of priority, for the provision of Department of Veterans Affairs (VA) hospital care or medical services (see Title 38 United States Code (U.S.C.) 1705. Under this system, VA must enroll in Priority Group 4, Veterans who are catastrophically disabled (see 38 U.S.C. §1705(4)).
b. This cohort of veterans was still, however, subject to copayment requirements applicable to their receipt of VA care. This requirement has changed with the enactment of Pub. L. 111-163 Section 511 of the “Caregivers and Veterans Omnibus Health Services Act of 2010,” which is codified in 38 U.S.C. 1730A. Section 511 prohibits VA from requiring Veterans who are catastrophically disabled from paying copayments for the receipt of hospital care or medical services. VA’s General Counsel (GC) has held that this statutory provision extends to copayment requirements that would apply to the receipt of prescription drugs (see subpar. 5g). In a separate opinion, the GC held that Section 511 does not, by operation of law, prohibit the collection of copayments applicable to the receipt of nursing home care (see subpar. 5h). Therefore, veterans with catastrophic disabilities must still pay applicable copayments for the receipt of nursing home care.
NOTE: Examples of extended care include: nursing home care, domiciliary care, respite care, geriatric evaluation, and adult day health care. Although these Veterans are still subject to applicable copayments for the receipt of nursing home care, certain extended care services (essentially “noninstitutional alternatives to extended care”) fall within the definition of “medical services” for purposes of 38 U.S.C. Chapter 17. As a result, Veterans with catastrophic disabilities are exempt from copayments applicable to the receipt of noninstitutional respite care, noninstitutional geriatric evaluation, noninstitutional adult day health care, Homemaker/Home Health Aide, Purchased Skilled Home Care, Home-based Primary Care, and any other noninstitutional alternative extended care services.
c. Veterans are considered to be catastrophically disabled if they have a permanent, severely disabling injury, disorder, or disease that compromises the ability to carry out the activities of daily living to such a degree that the individual requires:
(1) Personal or mechanical assistance to leave the home, or bed; or
(2) Constant supervision to avoid physical harm to self or others.
NOTE: This is met if the individual’s circumstances meet the terms of Title 38 Code of Federal Regulations (CFR) 17.36(e) (see Att. A).
d. An evaluation to determine whether a Veteran is catastrophically disabled, as defined by the Secretary, may be initiated at the request of the Veteran, the Veteran’s representative, or facility clinical staff. For all requests, facility staff must use and complete VA Form 10-0383, Catastrophically Disabled Veteran Evaluation & Approval (Fillable), which can be used for local reproduction. This form is available on the VA Forms Web site at http://vaww.va.gov/vaforms/. NOTE: This is an internal VA Web site not available to the public.
e. Veterans whose medical conditions involve permanent severely disabling injuries, described above, should be encouraged to seek or undergo the Catastrophic Disability Evaluation. NOTE: To request a Catastrophically Disabled Veteran Evaluation, Veterans may call 1-877-222-VETS (8387) or the Enrollment Coordinator at their local VA medical facility. Positive determinations will enable them to enroll in VA’s health care system (particularly if they would otherwise be ineligible to enroll in VA’s health care system due to an existing administrative enrollment restriction, e.g., certain Priority Group 8’s). Currently enrolled veterans who are similarly clinically situated need to be encouraged to seek or receive the Catastrophic Disability Evaluation in order to elevate their enrollment status to Priority Group 4 and thus receive the benefits of enhanced enrollment, and more specifically, the copayment exemptions applicable to catastrophically disabled Veterans. As explained in VA’s regulation, some evaluations may involve only a pertinent medical records review.
3. POLICY: It is VHA policy to provide, upon request, a Catastrophically Disabled Veteran Evaluation within 30 days. Veterans determined to be catastrophically disabled, are placed in priority group 4, unless qualified to be enrolled in a higher priority group, and are exempt from copayments for hospital care, outpatient medical care and medications prescribed on an outpatient basis.
4. ACTION
a. Office of the Assistant Deputy Under Secretary for Health (10A5). The Office of the Assistant Deputy Under Secretary for Health is responsible for collecting Catastrophically Disabled Veteran Evaluation data for reporting and analysis purposes. The data is to be posted quarterly at: http://vaww4.va.gov/vhaopp/cdvet_eval.htm. NOTE: This is an internal VA Web site not available to the public. Using appropriate VA Form 10-0383, Veterans Health Information and Technology Architecture (VistA) entries, and the following data, which is to be collected; the:
(1) Number of new catastrophically disabled evaluations completed, both by record review and clinical examination;
(2) Number of cumulative catastrophically disabled evaluations completed, both by record review and clinical examination; and
(3) Number of total estimated or potential catastrophically disabled evaluations.
b. Medical Center Director. Each Medical Center Director is responsible for ensuring:
(1) VA health care facility staff initiates Catastrophically Disabled Veteran Evaluations for known Veteran- groups whose conditions reasonably indicate potential eligibility for this enhanced enrollment status, such as Veterans participating in Spinal Cord Injury Programs, in Traumatic Brain Injury Programs, in blinded Veterans programs, etc.
(2) Appropriate staff involved in the Catastrophically Disabled Veteran Evaluation is properly trained and knowledgeable in the following process:
(a) Upon request, the facility Enrollment Coordinator, or designee, must initiate a VA Form 10-0383, for each Veteran requesting such evaluation or on whose behalf such a request is made.
(b) The Enrollment Coordinator, or designee, must obtain all relevant VA clinical records or non-VA medical records provided by the Veteran, or obtained for the Veteran by VA staff, and have them reviewed by the Veteran’s clinician.
1. If sufficient documentation is available from the health records to determine the Veteran is catastrophically disabled, the clinician is to complete VA Form 10-0383, front and back, and make a recommendation as to whether the Veteran is or is not catastrophically disabled (as defined by 38 CFR 17.36(e). The clinician forwards the complete package to the Chief of Staff, or equivalent clinical representative, for approval or disapproval of the recommendation.
2. If the medical record information is not available or sufficient to make a determination of catastrophic disability, the Enrollment Coordinator, or designee, must request a Catastrophic Disability Examination be performed consistent with the medical center policy on conducting Catastrophic Disability evaluations. Upon completion of the evaluation, the examining clinician must complete and return VA Form 10-0383 to the Enrollment Coordinator, or designee, who is responsible for forwarding the completed package to the Chief of Staff, or equivalent clinical representative, for approval or disapproval of the recommendation. The data is then forwarded to the Veterans Integrated Service Network (VISN) within the timeframes established by the VISN.
BVA will continue to follow this implementation process and this legislation was one of our highest priorities in the past two years.
Thomas Zampieri Ph.D.
Director Government Relations
Blinded Veterans Association
477 H. Street NW
Washington DC 20001
Direct Office 202-355-9525
Cell 301-204-3291
BVA 202-371-8880
tzampieri@bva.org
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BVA’s Legislative Alerts Group
