Veterans Integrated Services Network (VISN) 12 Map of Catchments
Information on Green Bay Vet Center
VHA Office of Community Care Ambulance Transportation Fact Sheet 2021
Basic Eligibility Information
If you served in the active military and were separated under any condition other than dishonorable, you may qualify for VA healthcare benefits. Current and former members of the Reserve or National Guard who were called to active duty (other than active duty for training) by a federal order and completed the full period for which they were called or ordered to active duty may be eligible for VA healthcare as well. Veterans who enlisted after September 7, 1980 or officers who 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. The minimum duty requirement may not apply to veterans who were discharged for a disability incurred or aggravated in the line of duty, for a hardship, or early out.
Enrollment is not automatic, there are determining factors for enrollment into VA healthcare. The first factor is based on service. The service requirements are
- a former Prisoner of War; or
- those in receipt of a Purple Heart; or
- a recently discharged Combat Veteran (within five years of discharge); or
- those discharged for a disability incurred or aggravated in the line of duty; or
- those receiving VA Service Connected disability (SCD) compensation; or
- those receiving VA pension; or
- those in receipt of Medicaid benefits; or
- those who served in Vietnam between January 9, 1962 and May 7, 1975; or
- those who served in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998; or
- those who served at least 30 days at Camp Lejeune between August 1, 1953 and December 31, 1987.
The second factor is based on income. Veterans who are below the annual income limits are eligible for healthcare. Co-pays will be based on income. Every year the VA will check with other federal agencies to determine income changes and if co-payment is required.
The third factor is for veterans who have a service connected disability but not compensable (SCD 0%). These veterans will receive medical treatment for the service connected disability only. However, if the veteran meets the requirements of the income test for the second factor he/she may be eligible for VA healthcare enrollment.
Finally, If an individual received a discharge “under other than honorable conditions,” he or she may still be eligible for treatment at a VA medical facility for disabilities determined to be service connected, unless the individual is subject to one of the statutory exemptions to benefits specified in 38 U.S.C. § 5303.
Veterans meeting the requirements above should call our office for an appointment. We will help fill out the required form and send it to the VA.
VA Health Care is not Health Insurance
VA healthcare is not medical/health insurance, it is health care provided in the VA healthcare system. Enrolled veterans can receive medical treatment from the VA Medical Center or VA Clinic to which they are assigned. This benefit is only for the veteran, not family members. VA healthcare will not pay for routine treatment at a non-VA medical facility unless pre-approval is authorized and provided to the veteran by VA. This is called “VA Care in the Community.” During a medical emergency, veterans should immediately seek care at the nearest medical facility. A medical emergency is an injury, illness, or symptom so severe that without immediate treatment, you believe your life or health is in danger. If this happens, ask the facility to bill the VA (although there is no guarantee VA will authorize payment). Remember, if you phone VA and speak to the nurse advise line and they advise you to seek emergency care, that is not an authorization for payment.
During a medical emergency, you should immediately seek care at the nearest medical facility. A medical emergency is an injury, illness or symptom so severe that without immediate treatment, you believe your life or health is in danger. If you believe your life or health is in danger, call 911 or go to the nearest emergency department right away.
You do not need to check with the VA before calling for an ambulance or going to an emergency department. During a medical emergency, you are encouraged to seek immediate medical attention without delay. A claim for emergency care will never be denied based solely on VA not receiving notification prior to seeking care.
It is, however, important to promptly notify the VA that you are receiving emergency care at a community emergency department. Notification should be made within 72 hours of admission, sooner is always better. You do not have to be the one to notify the VA, a family member or friend can notify them on your behalf. DO NOT assume the medical facility will contact the VA, even if they say they will, it is better to have someone contact the VA as well. This allows VA to assist you and/or the healthcare provider in coordinating necessary care or transfer, and helps to ensure that the administrative and clinical requirements for the VA to pay for the care are met.
Service-Connected Emergency Care
In general, the VA can pay for emergency medical care at a local emergency department (ED) for your service-connected condition, or if the care is related to your service-connected condition. Specifically, emergency medical care for your service-connected or related condition(s) is eligible for VA payment as long as the VA wasn’t reasonably available to provide the care.
In accordance with the following situations and requirements, the VA can pay emergency care costs for:
- A Veteran who receives emergency treatment of a service-connected, or adjunct condition* in a community emergency department; OR
- A Veteran who is Permanently and Totally disabled (P&T) as the result of a service-connected condition is eligible for emergency treatment of ANY condition; OR
- A Veteran who is participating in a VA Vocational Rehabilitation Program, and who requires emergency treatment to expedite their return to the program, is eligible for emergency treatment for any condition; AND(scenarios 1-3 must all meet #4)
- The emergency was of such a nature that the Veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy.
NOTE: A service-connected condition is one that has been adjudicated by the Veterans Benefits Administration (VBA) and a disability rating has been granted. An adjunct condition is one that, while not directly service-connected, is medically considered to be aggravating a service-connected condition. Legal authorities and payment methods for VA payment for emergency care for service-connected conditions are contained in Title 38 U.S.C. §1728, 38 CFR §17.120 and 38 CFR §17.132.
Nonservice-Connected Emergency Care
The VA can also pay for emergency medical care at a community ED for your nonservice-connected condition. However, there are several requirements and factors that affect the extent to which the VA can cover those services. Specifically, emergency medical care for your nonservice-connected condition(s) is eligible for VA payment when all of the following five elements are true:
- Care was provided in a hospital emergency department (or similar public facility held to provide emergency treatment to the public); AND
- The emergency was of such a nature that the Veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy; AND
- A VA medical facility or another Federal facility was not reasonably available to provide the care; AND
- The Veteran is enrolled and has received care within a VA facility during the 24 months before the emergency care; AND
- The Veteran is financially liable to the provider of emergency treatment.
There are limitations on the VA’s ability to provide coverage when you have other health insurance (OHI). If OHI does not fully cover the costs of treatment, the VA can pay certain costs for which you are personally liable. By law, the VA can pay coinsurance, deductibles (but not co-payments) that a Veteran may owe to the provider as required by their health insurance plan.
The VA is also legally prohibited from providing coverage for individuals covered under a health plan contract because of a failure by the Veteran or the provider to comply with the provisions of that health plan contract, e.g., failure to submit a bill or medical records within specified time limits, or failure to exhaust appeals of the denial of payment.
NOTE: Legal authorities and payment methods for VA payment for emergency care for nonservice-connected conditions are contained in Title 38 U.S.C. §1725 and 38 CFR §17.1000.
After Receiving Care
Once your immediate emergency medical care needs have been addressed, you, a family member, or friend should contact the nearest VA medical facility within 72 hours. Once notified, VA staff will assist you and/or your representatives in understanding eligibility and how eligibility relates to services rendered in the community. The VA staff will also ensure that, if desired, you are transferred to a VA medical center upon stabilization and that you are set up to receive additional care, post discharge, without interruption.
IMPORTANT: When you receive emergency medical care, notifying the VA as quickly as possible is always best. It ensures the maximum potential for VA coverage and assists the VA in providing you with the care you need.
Filing a Claim: Claims for emergency medical care should be submitted to the VA as soon as possible after care has been provided. The deadline for filing a claim depends on whether care was provided for a service-connected (24 months) condition or a nonservice-connected (90 days) condition. Here is a quick Video on filing a community care claim with the VA.
For more information on Emergency Medical Care click HERE.