Eligibility for Health Care Programs - Special Duty Service Pensioner

Purpose

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

Policy

General

1. A special duty service pensioner is defined in the Veterans Health Care Regulations as a former member or reserve force member who is entitled to a pension under the Pension Act for a disability attributable to or incurred during special duty service, as defined in subsection 3(1) of the Pension Act.

Treatment Benefits - Pensioned Condition

2. Special duty 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).

Treatment Benefits - Any Health Condition

3. Special duty service pensioners are eligible to receive treatment benefits in Canada for any health 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, if:
   1. the treatment benefits are not available to them as insured services under a provincial health care system, or the cost of such benefits are not recoverable from a third party (see policies entitled Requirement to Access Provincial Programs and Costs Recoverable from Third Parties); and
   2. they are eligible to receive or in receipt of Veterans Independence Program services, specifically home care, ambulatory health care, or intermediate care (transportation services and home adaptations do not open up eligibility to health care coverage):
      1. in response to a need arising from a pensioned condition related to their special duty service; or
      2. as a frail pensioner (Veterans Independence Program - Benefits at Home Policy for more information).

Supplementary Benefits

4. Special duty 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 the device or aid.

Treatment Allowances

5. Special duty service pensioners who are entitled to a pension under the Pension Act for a disability attributable to or incurred during special duty 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 for more information).

Miscellaneous Benefits

6. Special duty 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 for a pensioned condition or was necessary for a condition unrelated to the pensioned condition (see policy entitled Treatment for a Disability Benefits Entitled Condition).
7. Special duty service pensioners are eligible to receive reimbursement associated with a medical examination, including the cost of travel, when a 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).
8. Special duty service 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. Special duty 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 eligible to receive any part of the cost of intermediate care under the Veterans Independence Program or chronic care under the Long Term Care program.
10. When a critically-ill special duty 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 special duty service pensioner, that family member or other designated person is eligible to receive the transportation costs incurred, in Canada, for the visit (see policy entitled Health-related Travel).

Veterans Independence Program

11. Special duty 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, if applicable, as an insured service under a provincial health care system, or if the cost of such services or care are 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 care is necessary for health reasons; and
    4. an assessment indicates that:
       1. their war-related pensioned condition impairs their ability to remain self-sufficient at their principal residence without those services; or
       2. they meet the criteria as a frail pensioner (Veterans Independence Program - Benefits at Home Policy policy for more information). 

Long Term Care – Pensioned Condition (Community Bed)

12. Special duty service pensioners are eligible to receive the cost to them of chronic care for a pensioned condition (see policy entitled Treatment for a Disability Benefits Entitled 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 Canada in a health care facility 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 – Frail Pensioner

13. A special duty service pensioner who requires chronic care under the Long Term Care program for a non-pensioned condition (i.e. does not meet the eligibility outlined in paragraph 12 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 Veterans Independence Program - Benefits at Home Policy policy. Those special duty 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).
14. Special duty service pensioners referred to in paragraph 13 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