VA Healthcare Priority Groups
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Priority Groups and Their Access to Care
VA assigned priority groups are determined by three factors: your medical condition, your service experience and your income level. There are eight priority groups that can be assigned each having different levels of benefits available to the veteran.
- Priority Group 1 include those servicemembers deemed to have a service-connected disability with the rating of 50% or higher or those servicemembers who are said to be unemployable because of a service-connected disability.
- Priority Group 2 encompasses those veterans who have a 30% or 40% service-connected disability rating.
- Priority Group 3 includes any veterans with a 10% or 20% service-connected disability rating, any veteran who was rendered disabled in the line of duty which resulted in discharge, any veteran who became disabled as a result of VA treatments or participation in a VA vocational rehabilitation program or those servicemembers who received a Purple Heart or had been a POW.
- Priority Group 4 includes veterans who have been labeled catastrophically disabled by VA or those receiving aid and attendance or household benefits on pension from the VA.
- Priority Group 5 is for those veterans who are receiving VA pension benefits, those who are eligible for Medicaid programs and those with incomes and assets are less than the VA Means Test Thresholds
- Priority Group 6 includes all those veterans who are 0% service-connected but they are still receiving VA compensation, also those who experienced exposure to Ionizing Radiation either during atmospheric testing or during the occupation of Hiroshima and Nagasaki, World War I veterans and Project 112/SHAD participants.
- Priority Group 7 is for those veterans whose income and/or net worth is above the VA Income Threshold yet the income is below the Geographic Means Test Threshold and agrees to pay a specified co-pay. This group is further broken down into subpriority groups.
The first, Subpriority A is for those veterans that enrolled in the VA healthcare system on a specific date and have remained enrolled since then who are not compensable 0% service-connected.
The second subgroup is Subpriority C. This subgroup is for veterans enrolled in the VA healthcare systems on a specific date who are still enrolled since that date and are nonservice-connected.
- Priority Group 8 has had changes to the regulations which are allowing more veterans to be part of this group. In previous years those veterans with household incomes exceeding VA income thresholds were automatically denied enrollment. Now, as long as the household income does not exceed VA income thresholds but more than 10%, these veterans are eligible for benefits.
Also included in this group are veterans with income and/or net worth above the VA national income threshold and the VA national geographic income thresholds as long as they agree to co-pays
Non-compensable and 0% service-connected veterans are eligible for enrollment in this category, however, they are divided into subpriority categories
- Subpriority A for those enrolled as of January 16, 2003 and who have remained enrolled since that date or have been placed their due to eligibility status change.
- Subpriority B are those enrolled on or after June 15, 2009 with incomes greater than the current VA national income thresholds or VA National Geographic income thresholds by 10% or less.
- Subpriority C is for those veterans enrolled as of January 16, 2003 who remained enrolled since that date or place there due to the eligibility status change.
- Subpriority D is for those veterans enrolled on or after June 15, 2009 with incomes greater than the current VA national income thresholds or VA National Geographic income thresholds by 10% or less.
- The first is Subpriority E which are non-compensatable 0% service connected veterans.
- The second Subpriority G which are non-service connected veterans.
New enrollment restrictions have suspended enrolling new high income veterans paying for care after January 16, 2003. For this reason Priority Groups 8E and 8G are not eligible. The full range of VA healthcare benefits will still be available to those members enrolled in Priority Groups 8A or 8C.
Veterans who served in a combat location during active duty service after November 11, 1998 and have sense been discharged are eligible for free Healthcare Services for conditions possibly related to combat service for five years following separation. This refers to veterans currently enrolled and who are newly enrolled and discharged on or after January 20, 2003
How Private Health Insurance Affects VA Coverage
Veterans having private health insurance are able to apply for VA health benefits but they must provide full information of their health care coverage, even coverage coming from a spouses plan.
The veteran will not be responsible for any remaining unpaid portion of the VA bill not covered by private insurance. Any money paid will cover dollar for dollar any VA co-pays me apply.
Preference for Care
Those veterans in Priority Group 1 will be given preference when it comes to scheduling of care. Veterans were 50% or more disabled for service-connected conditions or unemployable due to service-connected conditions or receiving care for service-connected disabilities will be given preferential scheduling over other groups.
For those veterans seeking medical benefits who are not receiving disability compensation or pension from VA must take into account their gross annual household income and net worth as a determinant of priority grouping. Gross annual household income must be below financial thresholds that are adjusted annually for your geographic area. The following list covers in detail what must be included when reporting income: along with annual job income, retirement pay, Social Security, unemployment insurance, dividends and interest, workers’ compensation, black lung benefits and any other income sources must be reported. When considering net worth, the market value of any property owned that is not a primary residence, bonds, stocks, notes, retirement accounts, bank deposits, cash and savings accounts are all included. Necessity for a co-pay will be determined by your financial status.
Requirements for VA Co-pays
Those veterans belonging to Priority Group 7 whose income is above the means threshold but below the VA's geographical based income threshold must pay the following co-pays: for the first 90 days of inpatient care during a 365 day period starting the day the patient is first treated is 20% of the Medicare deductible, after that the veteran is responsible for 10% of the Medicare deductible for each additional 90 days of inpatient care. There is also a two dollar per day co-pay for hospital care.
For non-compensable 0% service-connected veterans or nonservice-connected veterans with a gross annual household income above the VA national and geographic income thresholds the following deductibles apply: for the first 90 days of inpatient care during a 365 day period the veteran is responsible for the full Medicare deductible, after that, for each additional 90 days of inpatient care the veteran is responsible for one half of the Medicare deductible. There's also a $10 per day hospital care co-pay.
If a veteran is interested in extended care, co-pays do apply, however, they are based on the financial situation of the veteran and determined at the time of application for the services.
Co-pays for medication are eight dollars for a 30 day supply if the prescription is not related to a service-connected condition and is provided free of charge if it is treating a service-connected condition.