Eligibility for Health Care Programs - Military Service Pensioner

Purpose

This policy provides direction on health care eligibility for those individuals who are recognized as military service pensioners under the Veterans Health Care Regulations.

Policy

General

1. Under the Veterans Health Care Regulations, a military service pensioner means a former member or reserve force member who is entitled to a pension under the Pension Act for a disability related to military service that was not:
   1. active service in World War II,
   2. service in a theatre of operations (see section 2 of the Veterans Benefit Act), or
   3. special duty service.

Treatment Benefits (Pensioned Condition)

2. Military service pensioners are eligible to receive treatment benefits in Canada or elsewhere for a pensioned condition to the extent that the treatment benefits are not available to them as former members or reserve force members of the Canadian Armed Forces (see policy entitled Treatment for a Disability Benefits Entitled Condition).

Supplementary Benefits

3. Military service pensioners are eligible to receive supplementary benefits, including the cost of travel and escort fees (see policy entitled Health-related Travel), if they are in receipt of the following treatment benefits authorized by Veterans Affairs Canada:
   1. any medical, surgical or dental examination or treatment provided by a health professional; or
   2. the provision or maintenance of any surgical or prosthetic device or aid, or any home adaptations to accommodate the use of such a device or aid.

Treatment Allowances

4. Military service pensioners who are entitled to a pension under the Pension Act for a disability attributable to or incurred during military service are eligible to receive a treatment allowance for a period of acute care for a pensioned condition provided in a hospital or on an out-patient basis (see policy entitled Treatment Allowances).

Miscellaneous Benefits

5. Military service pensioners who are hospitalized are eligible to receive treatment benefits for any health condition, until such time as it is confirmed whether the hospitalization was in respect of a pensioned condition or was necessary for a condition unrelated to the pensioned condition (see policy entitled Treatment for a Disability Benefits Enittled Condition).
6. Military service pensioners are eligible to receive reimbursement of the cost associated with a medical examination, including the cost of travel incurred, if the medical examination is requested by Veterans Affairs Canada or the Veterans Review and Appeal Board (see policies entitled Costs Associated with Required Medical Examinations and Health-related Travel).
7. Military service pensioners who are transferred from one health care facility to another for medical reasons are eligible to receive the costs of transportation incurred in Canada, if they are:
   1. eligible to receive any part of the cost of intermediate care under the Veterans Independence Program; or
   2. eligible to receive any part of the cost of chronic care under the Long Term Care Program.
8. When a critically-ill military service pensioner receives intermediate care, chronic care, or acute care in a hospital and, in the attending physician's opinion, a visit by a family member or other designated person would be beneficial to the health of the military service pensioner, that family member or other designated person is eligible to receive the transportation costs incurred, in Canada, for the visit (see Health-related Travel policy).

Veterans Independence Program

9. Military service pensioners are eligible to receive Veterans Independence Program services of home care, ambulatory health care, and home adaptations, or intermediate care in a community bed, if:
   1. the services or care are not available to them as former members or reserve force members of the Canadian Armed Forces or, as an insured service under a provincial health care system, or if the cost of such services or care is not recoverable from a third party (see policies entitled Requirement to Access Provincial Programs and Costs Recoverable from Third Parties);
   2. they are resident in Canada;
   3. the provision of these services will assist them to remain self-sufficient at their principal residence or the provision of intermediate care is necessary for health reasons; and
   4. an assessment indicates one of the following:
      1. their pensioned condition impairs their ability to remain self-sufficient at their principal residence; or
      2. they meet the criteria of a frail pensioner (see paragraphs 32 to 35 of the Veterans Independence Program - Benefits at Home policy for more information).
          

Long Term Care – Pensioned Condition (Community Bed)

10. Military service pensioners are eligible to receive the cost to them of chronic care for a pensioned condition when an assessment shows that the care is an appropriate response to their health needs and:
    1. the care is received within Canada, in a community bed; or
    2. the care is received outside of Canada in a health care facility:
       1. if care is delivered in a health care facility that is of a standard equivalent to the care that would have been provided within a community facility in Canada; and
       2. provided that the cost of such care does not exceed the usual cost of chronic care in the jurisdiction in which the care is received.

Long Term Care – Frail Pensioner

11. A military service pensioner who requires chronic care for a non-pensioned condition (i.e. does not meet the eligibility outlined in paragraph 10 of this policy) may be eligible for financial support toward the cost of care if they meet the criteria of a frail pensioner as outlined in the Veterans Independence Program - Benefits at Home) policy. Those military service pensioners approved for Veterans Independence Program intermediate care (type II health needs) whose health needs increase to chronic care (type III health needs) continue to be eligible to receive reimbursement for Veterans Independence Program intermediate care, as type III health care needs encompasses type II needs (see paragraph 9 of the Community Facilities (Veterans Independence Program - Intermediate Care and Long-term Care)).
12. Military service pensioners referred to in paragraph 11 of this policy are responsible for the cost of chronic care beyond the limit established for Veterans Independence Program intermediate care. If applicable, they are also required to pay up to the maximum accommodation and meal rate (see policy entitled Accommodation and Meals Contribution).

References

Veterans Health Care Regulations

Pension Act

Treatment for a Disability Benefits Entitled Condition policy

Treatment Allowances policy

Costs Associated with Required Medical Examinations policy

Health-related Travel policy

Requirement to Access Provincial Programs policy

Costs Recoverable from Third Parties policy

Veterans Independence Program - Benefits at Home Policy

Community Facilities (Veterans Independence Program - Intermediate Care and Long-term Care) policy

Accommodation and Meals Contribution policy