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Ryan White HIV/AIDS Program & Veterans

Policy Notice - 07- 07

Ryan White HIV/AIDS Program and Veterans (PDF - 390)

DATE: September 28, 2007

TO: All Ryan White HIV/AIDS Program Grantees

Attached is the HIV/AIDS Bureau’s (HAB) updated policy describing the Ryan White HIV/AIDS Program and Veterans. This policy was previously published as “Policy Notice 04-01” and was designed to clarify the provision of Ryan White HIV/AIDS Program services to veterans living with HIV who are also eligible for Department of Veterans Affairs (VA) health care benefits. This updated policy reflects the technical changes in Title XXVI of the Public Health Service Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (Ryan White HIV/AIDS Program) and establishes updated guidelines for Ryan White HIV/AIDS Program and Veterans. The previous policy has not undergone any substantive changes and is being re-issued to reflect the technical changes as a result of the newly reauthorized Ryan White HIV/AIDS Program.

The HRSA/HAB policy notice is clear: Ryan White HIV/AIDS Program grantees may not deny services, including prescription drugs, to a veteran who is otherwise eligible for Ryan White HIV/AIDS Program services. The updated Frequently Asked Questions (FAQs) clarify specific issues raised about the policy and provide information about resources available to veterans in the VA health care system and have also been included with the updated policy.

Many Ryan White HIV/AIDS Program grantees already have a long standing relationship with the VA, their local VA health care facility and enrollment office. If you do not, HRSA encourages you to meet with VA staff and providers, learn more about VA’s health care eligibility and enrollment, and services provided to HIV-infected veterans in order to have optimal Ryan White HIV/AIDS Program and veterans coordination.

For additional information about other VA benefits eligibility, including housing, education and training, vocational rehabilitation and employment benefits and services for homeless veterans check the Veterans Administration Web site or contact a VA benefits office at 1-877-222-VETS. Each year the VA publishes and updates the Federal Benefits for Veterans and Dependents pamphlet.

If you have any questions regarding the content of the HAB Policy Notice, please contact your project officer. Thank you for your attention to this important matter.

Deborah Parham Hopson, Ph.D., R.N.

Assistant Surgeon General
Associate Administrator

Policy Notice - 07-07: Ryan White HIV/AIDS Program and Veterans
The HIV/AIDS Bureau (HAB) has carefully examined the issues surrounding the Ryan White HIV/AIDS Program and HIV positive veterans who are eligible for care and treatment by the Department of Veterans Affairs (VA). This policy outlines how Ryan White HIV/AIDS Program grantees should address the care and treatment of veterans who present at grantee sites. This policy also requires that our grantees learn more about the VA generally, and in their geographic area and region, in particular.

The Bureau developed this policy:

  • To explain how the coordination of care for veterans who are eligible for Ryan White HIV/AIDS Program services can be maximized;

  • To enhance Ryan White HIV/AIDS Program 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 Ryan White HIV/AIDS Program and the VA in funding and providing HIV/AIDS care to veterans; and
  • To address the critical misconceptions about veteran’s eligibility for Ryan White HIV/AIDS Program services.
  1. Role of Ryan White HIV/AIDS Program Grantees with the VA:
  • Many Ryan White HIV/AIDS Program 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 Ryan White HIV/AIDS Program grantees with the VA and their health care facilities to ensure that veterans receive optimal care and treatment.
  • Ryan White HIV/AIDS Program grantees may not deny services, including prescription drugs, to a veteran who is otherwise eligible for Ryan White HIV/AIDS Program services. Ryan White HIV/AIDS Program grantees (case managers, others) must work to assure that veterans receive necessary support or other services funded by the Ryan White HIV/AIDS Program 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. Ryan White HIV/AIDS Program grantees are required to become familiar with their local VA care system, especially those with experienced HIV providers. Ryan White HIV/AIDS Program grantees can provide a valuable service in assisting veterans to establish care within the VA system by becoming familiar with enrollment procedures, eligibility requirements, and local VA contacts for coordination of HIV care.
  • Ryan White HIV/AIDS Program grantees or contractors may refer eligible veterans to the VA for services when appropriate and available. However, Ryan White HIV/AIDS Program grantees or contractors may not require that eligible veterans access VA care against their will.
  • If transitioning from a Ryan White HIV/AIDS Program-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. Ryan White HIV/AIDS Program grantees should work with veteran clients to ensure that such gaps do not jeopardize the veteran’s HIV treatment. Similarly, VA health systems should work with clients to assure that service gaps do not jeopardize the care of veterans who choose to leave the VA system.
  • Veterans may also be eligible for services from State-funded veterans programs, Veterans Service Organizations, or Vet Centers. Ryan White HIV/AIDS Program grantees should be familiar with these other resources.
  • Ryan White HIV/AIDS Program 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 Ryan White HIV/AIDS Program grantees or providers to provide HIV-related services for veterans that are not available at the veteran’s VA facility or clinic.
  1. Principles that Guided the Framework for this Policy:
    By law, the Ryan White HIV/AIDS Program is the payer of last resort. As such, Ryan White HIV/AIDS Program 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 clients’ eligibility status for any other programs has changed. Services that must be reimbursed by any private or public payers should be determined before Ryan White HIV/AIDS Program funds are used to pay for care. The Ryan White HIV/AIDS Program 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 a system of annual patient enrollment. 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.

The Secretary of the VA makes a determination about the level at which VA will enroll the eight priority groups. Since January 2003, for example, the VA is accepting no new Priority Group 8 veterans for enrollment. Because these groups are subject to change, Ryan White HIV/AIDS Program grantees should periodically visit the VA Web site to confirm the current priority group categories that VA is currently enrolling.

Veterans receiving care through the VA are eligible for VA's medical benefits package which includes:

  • Preventive Care Services [immunizations, physical examinations (includes eye and hearing), health care assessments, screening tests, health education programs)];
  • Ambulatory (Outpatient) Diagnostic and Treatment Services (emergency outpatient care in VA facilities, medical, surgical, chiropractic care, mental health, bereavement counseling, substance abuse);
  • Hospital (Inpatient) Diagnostic and Treatment Services (emergency inpatient care in VA facilities, medical, surgical, mental health, substance abuse);
  • Medications and Supplies (prescription medications, over-the-counter medications, medical and surgical supplies); and
  • Some health care benefits are offered only to certain veterans or to veterans under special situations.

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 meet other criteria, such as being so severely visually impaired that eyeglasses are necessary to permit them to participate in their care. 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. 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 HIV/AIDS Program 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. VA’s general treatment authority (38 U.S.C. §1710) 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 non-service-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.

Ryan White HIV/AIDS Program and Veterans:
All enrolled 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 HIV/AIDS Program . To ensure that veterans have full access to all possible services, and to ensure that veterans are obtaining their preferred services, Ryan White HIV/AIDS Program grantees and contractors 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. Ryan White HIV/AIDS Program grantees are required to work with their local VA HIV/AIDS coordinators who are available for coordination, enrollment, and questions. Ryan White HIV/AIDS Program grantees may obtain the name and contact information of their local VA facility HIV/AIDS Coordinators from Ms. Donna Wells (donna.wells-taylor@va.gov or (202) 461-7250).

Ryan White HIV/AIDS Program grantees or contractors may not deny services, including prescription drugs, to a veteran who is otherwise eligible for Ryan White HIV/AIDS Program services. Ryan White HIV/AIDS Program grantees may not cite the “payer of last resort” language in Section 2605(a)(6), 2617(b)(7)(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. Services can be refused on the same basis as decisions of refusal for non-veterans.

Some VA facilities do not have infectious disease specialists or HIV/AIDS experienced providers. Ryan White HIV/AIDS Program providers are required to be familiar with the VA facilities in their local areas that have this expertise and which ones do not. Ryan White HIV/AIDS program providers need to determine where the VA facilities are located; referrals to VA facilities that are located outside an acceptable range are not required.

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
  • Veterans determined by VA to be unemployable due to service-connected conditions

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 Medal
  • 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 payments from VA
  • Veterans who have been determined by VA to be catastrophically disabled

Priority Group 5:

  • Non-service-connected veterans and 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 programs

Priority Group 6:

  • World War I veterans
  • Mexican Border War veterans
  • Compensable 0% service-connected veterans
  • Veterans solely seeking care for disorders associated with:
  • Exposure to herbicides while serving in Vietnam
  • Exposure to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki
  • Service in the Gulf War
  • Illness possibly related to participation in Project 112/SHAD
  • Service in combat after the Gulf War or during a period of hostility after November 11, 1998 are eligible for VA health care for two years following discharge from military service for combat related conditions

Priority Group 7:

  • Veterans with income and/or net worth above the VA income threshold and income below the geographic income threshold who agree to pay co-pays
  • 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:

  • Veterans with income and/or net worth above the VA income threshold and the geographic income threshold who agree to pay co-pays
  • 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: Veterans assigned to Priority Groups 8e or 8g are not eligible for enrollment as a result of the enrollment restriction which suspended enrolling new high-income veterans who apply for care after January 16, 2003. Veterans enrolled in Priority Groups 8a or 8c will remain enrolled and eligible for the full-range of VA health care benefits.

[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.]

For more information from the Veterans Administration, please look at the VA web site

For information on enrollment in VA’s health care system, including co-payments and both the geographic means test thresholds and Veterans Health Administration means test thresholds.

Specific questions can be answered by your local VA health care facility’s enrollment office or the Veterans Health Benefits Service Center at 1-877-222-VETS (1-877-222-8387).