Eligibility for Health Care Programs

Issuing Authority

Director General, Policy and Research

Effective Date

6 January 2016

Document ID

1007

Care has been taken to ensure these policies accurately reflect the acts and regulations. Should any inconsistencies be found, the acts and regulations will prevail.

Purpose Policy General Treatment Benefits - Pensioned Condition Treatment Benefits - Any Health Condition Supplementary Benefits Treatment Allowances Miscellaneous Benefits Veterans Independence Program Long Term Care - Pensioned Condition (Community Bed)Long Term Care – Any Health Condition Long Term Care - Frail Pensioner References

Purpose

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

Policy

General

There are five distinct civilian groups including civilian, income-qualified civilian, overseas service civilian, income-qualified overseas service civilian, and civilian pensioner, each with its own eligibility policy. Under the Veterans Health Care Regulations, a civilian pensioner is defined as a person who is entitled to a pension under either the Civilian Government Employee (War) Compensation Order or Parts I to III or VI to X of the Civilian War-related Benefits Act, namely:
1. Canadian salt water fishers;
2. Auxiliary Services Personnel (including supervisors and helpers, and Overseas headquarters staff);
3. Newfoundland Overseas Forestry Unit;
4. Corps of (Civilian) Canadian Fire Fighters for Service in the United Kingdom;
5. Air raid precautions workers;
6. Injury during remedial treatment;
7. Members of the Voluntary Aid Detachment;
8. Overseas welfare workers; or
9. Civilian members of Ferry Command.

Treatment Benefits - Pensioned Condition

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

Treatment Benefits - Any Health Condition

Civilian pensioners are eligible to receive treatment benefits in Canada for any health condition if 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 civilian 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. meeting the criteria of an income-qualified civilian (see policy entitled Eligibility for Health Care Programs - Income-qualified Civilian);
4. meeting the criteria of an overseas service civilian (see policy entitled Eligibility for Health Care Programs - Overseas Service Civilian) and:
  1. 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; or
  2. has exceptional health needs;
5. 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:
  1. in response to a need arising from their war-related pensioned condition; or
  2. 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); or
6. in receipt of Long Term Care in a community bed (under section 22.1 of the Veterans Health Care Regulations), and the cost of their care reduces their income below the applicable War Veterans Allowance income factor (see War Veterans Allowance Act).

Supplementary Benefits

Civilian 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

Civilian pensioners are eligible to receive a treatment allowance in respect of 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

Civilian 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).
Civilian 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.)
Civilian 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).
Civilian 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. any part of the cost of intermediate care under the Veterans Independence Program; or
2. any part of the cost of chronic care under the Long Term Care Program.
When a critically-ill civilian pensioner receives intermediate care or chronic care or receives 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 civilian 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

Civilian 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 an insured service 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 additional information);
2. they are resident in Canada;
3. an assessment indicates that the provision of those services will assist the them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons; and
4. they qualify under one of the following:
  1. an assessment indicates that their war-related pensioned condition impairs their ability to remain self-sufficient at their principal residence;
  2. they are medium disabled;
  3. they are seriously disabled; or
  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).

Long Term Care - Pensioned Condition (Community Bed)

Civilian 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

Civilian pensioners are eligible to receive the cost to them of chronic care in Canada in a community bed, if:
1. the chronic care is not available to them as an insured service under a provincial
  health care system or, if the cost of such benefits and services is not recoverable from a third party;
2. an assessment shows that the care is an appropriate response to their health needs; and
3. they qualify under one of the following as:
  1. medium disabled;
  2. seriously disabled;
  3. an income-qualified civilian; or
  4. the cost of their care reduces their income below the applicable War Veterans Allowance income factor.
Civilian pensioners referred to in paragraph 14.c) iv. are required to pay the amount of their assessable income that exceeds the War Veterans Allowance income factor toward the cost of care. They are also required to pay up to the maximum accommodation and meals rate (see policy entitled Accommodations and Meals Contribution for more information).

Long Term Care - Frail Pensioner

A civilian 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 13 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 civilian 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).
Civilian pensioners referred to in paragraph 15 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).