VA Priority Groups

[LindaT]

I received a letter from the VA confirming my husband's enrollment in the VA system and to notify him of his priority group.
It reads "You are currently enrolled in Priority Group 5" and a fact sheet that really did not give much info was included.
It seems from talking to others here he should be Category (is that the same as Priority?) group 4.
Is there a difference as far as cost and benefit when it comes to travel and equipment when he is referred to the SCI hub?
When I first spoke to the local VA and again at his first appointment last week I asked about Category 4 and they said it was up to the business office.
Should I pursue this? Where would I begin?

[skippy13]

If he is in group five then he is eligible for travel pay and care through the VA even though there are medicine co-pays. I think they are 8 dollars for a thirty day supply. I do not know if there is a co-pay on DME or anything else.

The only reason he has been put into category five is because of his eligibility for medicare. I think that they are hoping you will use medicare rather than the VA for cost savings for the VA. They cannot bill medicare, so what you use through medicare does not show up on the VA's budget. FILE A NOTICE OF DISAGREEMENT (NOD). A letter stating 'If you disagree with this decision...' should be in the same letter they sent you with his 'award' of eligibility. Use that information to file the NOD as soon as possible.

It is a best interests of the patient issue as far as I'm concerned and should not be a decision made by the stinkin' business office.

He should be in category (priority) group FOUR. He has a catastrophic injury. You don't get much more catastrophic than his injury.

Call the SCI coordinator at the MPLS VAMC and ask for help with eligibility issues or Gary Goldish, MD, Chief, SCI/D Service, Minneapolis VA. Remember, SCI is a specialty even in the VA. They do their best.

[airart1]

i wasnt eligable for travel pay in group 5, but they changed it this year to group 4, well first of 2011, and it does affect what you pay, you'll have to pay co-pays and such for equipment/medicines, yes you should pursue it to get it changed, but u can also fill out a form at the center your going to once a year and if you have a low income they'll waive the co-pays........

[skippy13]

I know that some of you guys and gals have been categorised incorrectly in the past. How did you correct that and can you help Linda and Dave?

[skippy13]

i wasnt eligable for travel pay in group 5, but they changed it this year to group 4, well first of 2011, and it does affect what you pay, you'll have to pay co-pays and such for equipment/medicines, yes you should pursue it to get it changed, but u can also fill out a form at the center your going to once a year and if you have a low income they'll waive the co-pays........


Category Five also has income limits. That is probably why you were not eligible for travel pay. If you meet the income limits in cat 5, you can get travel pay.

Air art; How did you get re-categorized? Any info to help Linda is needed.

[Semper Fi]

You need to push for the change to 4. If the VA gets in money problems you could get a benefits reduction. Which VA area do you go to? Your doctor can have input as to the classifcation.
Good luck.

[SCI-Nurse]

This is not difficult. I am disappointed your PVA NSO did not take care of this paperwork for you when helping you with eligiblity applications.

A VA physician must see him and complete the form for priority group category 4. It is not difficult, and is a 1 page form. Insist that the local SCI clinic physician get this done for you. The SCI Coordinator (Social worker) at the clinic should be taking care of this. Tell her Dr. Hammond's office (Chief Consultant for SCI for the whole VA) has instructed all SCI coordinators to be sure that those veterans with SCI get correctly rated as category 4. It makes a big difference in a number of benefits, including travel and co-payments.

(KLD)

[LindaT]

Thanks everyone. I'm going to call the coordinator tomorrow and start there.

[airart1]

skip, they did it on their own, but i did fill out the paperwork for the waiver of the co-pays, i wondered why and asked the spinal nurse at the SCI clinic Memphis and she said they were doing it for all wheelchair people but it took sometimes a couple of years to get the qualification, but a friend just signed up last year, 2011, and he is a five and the PVA chick is getting it recategorized as a 4.....i thought they were blowing smoke, but its definitely got its privileges as a 4 and the therapists like you, what i don't get is there is no consistency in the whole of the VA system, each spinal unit has to get something approved in a different way, a friend in Dallas can get stuff that i can't get and visa-versa, doesn't make any sense to me........

[skippy13]

skip, they did it on their own, but i did fill out the paperwork for the waiver of the co-pays, i wondered why and asked the spinal nurse at the SCI clinic Memphis and she said they were doing it for all wheelchair people but it took sometimes a couple of years to get the qualification, but a friend just signed up last year, 2011, and he is a five and the PVA chick is getting it recategorized as a 4.....i thought they were blowing smoke, but its definitely got its privileges as a 4 and the therapists like you, what i don't get is there is no consistency in the whole of the VA system, each spinal unit has to get something approved in a different way, a friend in Dallas can get stuff that i can't get and visa-versa, doesn't make any sense to me........

The rules are very specific and are very concise and available to anyone who is supposed to know them. The only difference between offices and in the system is that some of the workers have actually taken the time to read all of the rules that apply to their job administration. Some don't even know that they exist.

More than once I have printed out the rules and guidelines and taken them to my appointment. Whatever I brought was news to them most of the time. They try to train people and as you know information is power. Most of the time they were simply not aware. I will let them know that I am aware of the rules when I have to.

Get to know the Title 38 Code of federal regulations.

Get to know the raters tables and also there are handbooks for almost anything that you need to know about. For example, the one covering an annual care eval through the VA is VHA Handbook 1176.1.

There is a handbook for everything. Do a little digging.

[cheesecake]

This is not difficult. I am disappointed your PVA NSO did not take care of this paperwork for you when helping you with eligiblity applications.

A VA physician must see him and complete the form for priority group category 4. It is not difficult, and is a 1 page form. Insist that the local SCI clinic physician get this done for you. The SCI Coordinator (Social worker) at the clinic should be taking care of this. Tell her Dr. Hammond's office (Chief Consultant for SCI for the whole VA) has instructed all SCI coordinators to be sure that those veterans with SCI get correctly rated as category 4. It makes a big difference in a number of benefits, including travel and co-payments.

(KLD)


Ugh, Linda I am sorry for this SNAFU. Yes, he should be a catagory 4!!! I had this occur with another veteran and the NSO took care of correcting it. Both KLD and Skippy have given you excellent advice, follow it and good luck.

[LindaT]

I spoke with our local coordinator this morning and she is working on it. We were impressed with her when we met her last week, so will start there.
I'm unsure if she knew exactly what I was talking about, but I was armed with the info you all have given me and relayed it to her in a tactful manner.

[cheesecake]

I spoke with our local coordinator this morning and she is working on it. We were impressed with her when we met her last week, so will start there.
I'm unsure if she knew exactly what I was talking about, but I was armed with the info you all have given me and relayed it to her in a tactful manner.
Keep us posted Linda. Every co-pay saved helps.

[airart1]

i got that book, thanks anyway, skippy........

[POPO367]

Linda,
If your husband is a patient in SCI he will be placed in either Priority Group 1 or 4. Every SCI center has been mandated to switch over all their non service connected SCI/D patients to Group 4. If you are service connected for SCI/D you will be in Priority Group 1 which doesn't have co-pays either. Priority Group 1 is higher on the pecking order than Group 4.

Each center is doing it different. Here in Long Beach we switched most of our patients a couple of months after we were mandated. Other SCI centers have been switching them as the Vets have come into the center for their annual physical. If the Vet was switched over late then they will get a refund of all the co-pays they paid after the switch was mandated last year.

I believe when I first applied through the VA, 5 years ago I was denied treatment and the SCI Coordinator had told me that was going to happen. Soon after I was denied they were able to get me into the SCI center, the denial was part of the process to get me into the system since I wasn't service connected. Your facility might have a different way of getting Vets into their facility. Don't be surprised if it takes a couple of months to kick in as far as you switching over to Group 4, so you might have to pay a few copays which will be refunded once the switch occurs.

[skippy13]

So, I made some calls on the 20th of this month to get more info about the priority groups.

I only heard back from them today. 6 days later. Wow. Too long in my opinion to wait for critical information.

How is it going Linda? Any Progress?

[LindaT]

GREAT NEWS!
I got a call today from the business office of the local VA telling me the doctor's form came through and Dave will definitely be changed from Priority 5 to Priority 4.
She was sending a letter out and wanted to make sure we knew what it meant.

Thank you everyone for all of the info.

[SCI-Nurse]

GREAT NEWS!
I got a call today from the business office of the local VA telling me the doctor's form came through and Dave will definitely be changed from Priority 5 to Priority 4.
She was sending a letter out and wanted to make sure we knew what it meant.

Thank you everyone for all of the info.

Great, and thank your husband for his service for us all. He earned this.

(KLD)

[t8burst]

GREAT NEWS!
I got a call today from the business office of the local VA telling me the doctor's form came through and Dave will definitely be changed from Priority 5 to Priority 4.
She was sending a letter out and wanted to make sure we knew what it meant.

Thank you everyone for all of the info.

That is awesome news Linda! Plus it is friday so Lockup is on. As the saying goes "the sun shines on a dogs ass every once in a while".