Eligibility for Health Care Programs - Veteran Pensioner

Purpose

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

Policy

General

Treatment Benefits - Pensioned Condition

2. Veteran pensioners are eligible to receive treatment benefits in Canada or elsewhere in respect of a war-related pensioned condition (see policy entitled Treatment in Respect of a Pensioned or Awarded Condition).

Treatment Benefits - Any Health Condition

3. Veteran pensioners are eligible to receive treatment benefits in Canada for any health condition when those benefits and services are not available to them under a provincial health care system, or if applicable, from the Canadian Armed Forces as a member or former member, 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 additional information), when Veteran pensioners qualify under one of the following, as:
   1. medium disabled (sum of all their disability assessments is equal to or greater than 48%, but less than 78%);
   2. seriously disabled (sum of all their disability assessments is greater than 78%, of which at least 1% of the disability must relate to service in World War II or the Korean War);
   3. in receipt of (or eligibility has been established for) services and/or care under the Veterans Independence Program, specifically home care, ambulatory health care, or intermediate care that is:
      1. in response to a need arising from their war-related pensioned condition; or
      2. due to having exceptional health needs; or
      3. for meeting the criteria of a frail pensioner (see paragraphs 25 and 26 of the Eligibility of Pensioners (Veterans Independence Program) policy for more information);
      4. NOTE: Veterans Independence Program transportation services and home adaptations do not open up eligibility to health care coverage.
   4. in receipt of adult residential care (type I care), intermediate care (type II care) or chronic care (type III care) in a contract bed; or
   5. in receipt of Long Term Care in a community bed, and the cost of care reduces their income below the applicable War Veterans Allowance income factor.

Supplementary Benefits

4. Veteran 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 any aid, or any home adaptations to accommodate the use of such a device or aid.

Treatment Allowances

5. Veteran pensioners are eligible to receive a treatment allowance in respect of a period of acute care for a war-related pensioned condition provided in a hospital or on an out-patient basis (see policy entitled Treatment Allowances).

Miscellaneous Benefits

6. Veteran 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 in Respect of a Pensioned or Awarded Condition).
7. Veteran 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. (Refer to the policies entitled Health-related Travel and Costs Associated with Requested Medical Examinations.)
8. Veteran pensioners whose pensioned condition is one that requires an escort may, when travelling in Canada, have the cost of commercial transportation (other than by automobile) paid for an escort when on annual vacation or other travel approved by Veterans Affairs Canada (see policy entitled Health-related Travel).
9. When a critically ill Veteran pensioner receives intermediate or 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 Veteran 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.)
10. Veteran 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 eligible to receive:
    1. care in a contract bed; or
    2. any part of the cost of intermediate care under the Veterans Independence Program; or
    3. any part of the cost of chronic care under the Long Term Care Program.

Veterans Independence Program

11. Veteran pensioners are eligible to receive Veterans Independence Program services for 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 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 for additional information);
    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. the Veteran pensioner undergoes an assessment which indicates one of the following:
       1. it is a war-related pensioned condition which impairs the ability to remain self-sufficient at the principal residence;
       2. they are medium disabled;
       3. they are seriously disabled;
       4. they meet the criteria of a frail pensioner (see paragraphs 25 and 26 of the Eligibility of Pensioners (Veterans Independence Program) policy for more information); or
       5. they have exceptional health care needs that require Veterans Independence Program services and/or care, and have insufficient income to enable them to pay for those services or that care (refer to policy entitled Exceptional Health Needs).
12. Veteran pensioners described in paragraph 11.d)v are required to pay the amount of their assessable income that exceeds the applicable War Veterans Allowance income factor toward the cost of their Veterans Independence Program services. Those receiving intermediate care may be required to pay a monthly contribution toward the cost of their care up to the maximum accommodation and meals rate (see policy entitled Accommodations and Meals Contribution for more information). 

Long Term Care Program - Contract Bed

13. Veteran pensioners are eligible to receive intermediate care or chronic care in a contract bed, when an assessment indicates that the contract bed is an appropriate response to their health needs.

Long Term Care Program - Pensioned Condition (Community Bed)

14. Veteran pensioners are eligible to receive the cost to them of chronic care in a community bed, in respect of a war-related pensioned condition (see policy entitled Treatment in Respect of a Pensioned or Awarded Condition) when an assessment shows that the care is an appropriate response to their health needs and the care is received:
    1. in Canada; or
    2. outside Canada if:
       1. the care is received in a health care facility that is of a standard equivalent to the care that would have been provided in Canada; and
       2. 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 - Any Health Condition

15. Veteran pensioners are eligible to receive financial support toward the cost of chronic care in respect of any health condition to the extent that it 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 additional information), if:
    1. an assessment shows that the care is an appropriate response to their health needs;
    2. the care is provided in a community bed within Canada; and
    3. they meet one of the following criteria as:
       1. medium disabled;
       2. seriously disabled;
       3. insufficient income in that the cost of care reduces their income below the applicable War Veterans Allowance income factor (eligible for chronic care).
16. Veteran pensioners who are eligible to receive financial support toward the cost of chronic care as a result of having insufficient income (i.e. those who satisfy the criteria in 15 c) iii) are required to pay the amount of their assessable income that exceeds the applicable War Veterans Allowance income factor toward the cost of their care. They are also required to pay up to the maximum accommodation and meal rate (see policy entitled Accommodation and Meals Contribution).

Long Term Care - Frail Pensioner

17. A Veteran pensioner who requires chronic care under the Long Term Care program for a non-pensioned condition, but does not meet the eligibility outlined in paragraph 15 of this policy, may be eligible for financial support toward the cost of care if he/she meets the criteria of a frail pensioner as outlined in the Eligibility of Pensioners (Veterans Independence Program) policy. Those Veteran 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).
18. Veteran pensioners referred to in paragraph 17 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

Treatment in Respect of a Pensioned or Awarded Condition policy

Pension Act

Civilian Government Employees (War) Compensation Order

Requirement to Access Provincial Programs policy

Treatment Allowances policy

Health-related Travel policy

Exceptional Health Needs policy

Costs Associated with Requested Medical Examinations policy

Costs Recoverable from Third Parties policy

Eligibility of Pensioners (Veterans Independence Program) policy

Accommodation and Meals Contribution policy

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