Eligibility for Health Care Programs - Seriously Disabled

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Issuing Authority

Director General, Policy and Research

Effective Date

January 06, 2016

Document ID

1034

Purpose

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

Seriously disabled is the term used to describe those Veteran pensioners or civilian pensioners whose extent of disability, in respect of the aggregate of all of their disability assessments under the Pension Act and the Veterans Well-being Act is equal to or greater than 78%. A portion of the disability assessment must be related to a disability incurred or aggravated while serving during World War II or the Korean War in order for the individual to be eligible for treatment benefits, the Veterans Independence Program and/or Long Term Care as seriously disabled.
Seriously disabled may also be used to describe those flying accident pensioners, Newfoundland Special Award pensioners, or Red Cross pensioners whose extent of disability is equal to or greater than 78%. These eligibility groups may access treatment and supplementary benefits; however, they are not eligible for Veterans Independence Program and/or Long Term Care.
Effective August 28, 2001, the Veterans Health Care Regulations were amended to provide access to health care benefits to those individuals whose extent of disability is equal to or greater than 78% (defined as seriously disabled). Health care benefit access for these seriously disabled pensioners is based on need; it is not a requirement that the need be related to a pensioned condition.

Pensioners, as described in paragraphs 1 and 2 of this policy, who satisfy the criteria to be recognized as seriously disabled are eligible to receive treatment benefits in Canada for any health condition, to the extent that such benefits and services are neither available to them under a provincial health care system; or if the cost of such benefits and services is not recoverable from a third party. See policies entitled Requirement to Access Provincial Programs and Costs Recoverable from Third Parties for more information.

Pensioners, as described in paragraphs 1 and 2 of this policy, who satisfy the criteria to be recognized as seriously disabled are eligible to receive supplementary benefits 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 the device or aid.

Veteran/civilian pensioners who satisfy the criteria to be recognized as seriously disabled are eligible to receive the services of home care, ambulatory health care, and home adaptations, or intermediate care in a community bed, to the extent that such services or care are not available to them under a provincial health care system, or if the cost of such benefits and services is not recoverable from a third party (see policies entitled Requirement to Access Provincial Programs and Costs Recoverable from Third Parties for more information), if:
1. they are resident in Canada; and
2. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Veteran/civilian pensioners who satisfy the criteria to be recognized as seriously disabled are eligible to receive the cost to them of chronic care received in Canada in a community bed, to the extent that the chronic care is not available to them under a provincial health care system, or if the cost of such care is not recoverable from a third party. See policies entitled Requirement to Access Provincial Programs and Costs Recoverable from Third Parties for more information.

Veteran/civilian pensioners who satisfy the criteria to be recognized as seriously disabled are not required to pay the cost of accommodation and meals while in receipt of adult residential care, intermediate care or chronic care when the cost of that care is payable, in whole or in part, under the Veterans Health Care Regulations.