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Testimony:

Before the Subcommittee on Health, Committee on Veterans' Affairs, 
House of Representatives:

United States General Accounting Office:

GAO:

For Release on Delivery Expected at 1:30 p.m.

Thursday, May 22, 2003:

VA LONG-TERM CARE:

Veterans' Access to Noninstitutional Care Is Limited by Service Gaps 
and Facility Restrictions:

Statement of Cynthia A. Bascetta:

Director, Health Care--Veterans' Health and Benefits Issues:

GAO-03-815T:

GAO Highlights:


Highlights of GAO-03-815T, a testimony before the Subcommittee on 
Health, Committee on Veterans Affairs, House of Representatives 

Why GAO Did This Study:

With the aging of the veteran population, the Department of Veterans 
Affairs (VA) is likely to see a significant increase in long-term care 
need.  VA uses noninstitutional long-term care services, such as home 
health care and adult day health care, and institutional care to meet 
this need.  GAO identified limits in veterans access to six 
noninstitutional long-term care services and factors that contribute 
to these limitations in its report VA Long-Term Care:  Service Gaps 
and Facility Restrictions Limit Veterans Access to Noninstitutional 
Care (GAO-03-487, May 9, 2003).  The report is based, in part, on a 
survey of all 139 VA facilities.  Todays testimony discusses 
conclusions and highlights recommendations GAO made in the report to 
improve access to VA noninstitutional long-term care services.

What GAO Found:

Veterans access to the six noninstitutional services GAO reviewed is 
limited by service gaps and facility restrictions.  Of VAs 139 
facilities, 126 do not offer all six of these servicesadult day 
health care, geriatric evaluation, respite care, home-based primary 
care, homemaker/home health aide, and skilled home health care. 
Veterans have the least access to respite care, which is not offered 
at 106 facilities.  By contrast, skilled home health care is not 
offered at 7 facilities.  Veterans access is more limited than these 
numbers suggest, however, because even when facilities offer these 
services they often do so in only part of the geographic area they 
serve.  In fact, for four of the six services the majority of 
facilities either do not offer the service or do not provide access to 
all veterans living in their geographic service area.  Veterans 
access may be further limited by restrictions that individual 
facilities set for use of services they offer.  For example, at least 
9 facilities limit veterans eligibility to receive noninstitutional 
services based on their level of disability related to military 
service, which conflicts with VAs eligibility standards.  Many 
facilities restrict the number of veterans who receive services 
resulting in veterans at 57 of VAs 139 facilities being placed on 
waiting lists for noninstitutional services. 

[See PDF for image]

[End of figure]

VAs lack of emphasis on increasing access to noninstitutional long-
term care services has contributed to service gaps and individual 
facility restrictions that limit access to care.  Faced with competing 
priorities and little guidance from headquarters, field officials have 
chosen to use available resources to address other priorities.  While 
VA has implemented a performance measure for fiscal year 2003 that 
encourages networks to increase veterans use of five of the six 
noninstitutional services, it does not require networks to ensure that 
all facilities provide veterans access to noninstitutional services.

What GAO Recommends:

In its report GAO recommended that VA:

* ensure that facilities follow VAs eligibility standards when 
determining veteran eligibility for noninstitutional long-term care 
services, and  

* refine current performance measures to help ensure that all VA 
facilities provide veterans with access to required noninstitutional 
services. 

VA concurred with the recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-03-815T.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Cynthia A. Bascetta 
at (202) 512-7101.

[End of section]

Mr. Chairman and Members of the Subcommittee:

We are pleased to be here today to discuss the Department of Veterans 
Affairs (VA) noninstitutional long-term care services and how veterans' 
access to these services could be improved. Meeting the long-term care 
needs of veterans is growing in importance as the number of veterans 
most in need of these services--those 85 years old and older--is 
expected to increase from 640,000 to 1.3 million by 2012. To provide 
assistance to veterans with chronic illness or physical or mental 
disability, VA provides a continuum of noninstitutional and 
institutional services. Noninstitutional services are provided to 
veterans in their own homes or in community settings, and include 
specific services to meet the requirements of the Veterans Millennium 
Health Care and Benefits Act.[Footnote 1]

VA provides noninstitutional services directly through its own 
employees and by contracting for services. In fiscal year 2002, VA 
spent approximately $283 million on noninstitutional long-term care 
services and served an average daily census of about 24,000 veterans. 
By contrast, VA spent nearly $3 billion on institutional long-term care 
provided in nursing homes and other settings and had an average daily 
census of more than 43,000 veterans.

My remarks are based on a recent report and other issued work.[Footnote 
2] We surveyed each of VA's 139 medical facilities to obtain data on 
the availability of six noninstitutional long-term care 
services,[Footnote 3] and identified any limits in access and reasons 
for these limitations. These services included three VA provides to 
meet the requirements of the Millennium Act--adult day health care, 
noninstitutional geriatric evaluation, and noninstitutional respite 
care--in addition to home-based primary care, skilled home health care, 
and homemaker/home health aide. We also interviewed VA officials and 
examined documents related to these issues.

In summary, we found that veterans' access to the six noninstitutional 
services we reviewed is limited by the lack of service availability and 
restrictions on their use. Of VA's 139 facilities, 126 do not offer all 
six services. Veterans have the least access to noninstitutional 
respite care, which is not offered by 106 VA facilities. By contrast, 
skilled home health care is not offered by 7 facilities but is provided 
by the remaining 132. Veterans' access to care is more limited, 
however, because even when facilities offer these services they often 
do so in only parts of the geographic area they serve. More than half 
of VA facilities do not offer four of the six servicesnoninstitutional 
respite care, home-based primary care, adult day health care, and 
noninstitutional geriatric evaluationat all, or only offer such 
services in parts of the geographic areas they serve. Veterans' access 
may be further limited by restrictions that individual facilities place 
on the services they offer. For example, we found that 9 facilities, in 
conflict with VA's eligibility standards, limited veterans' access to 
noninstitutional services based on their level of disability related to 
military service. In addition, restrictions placed by many facilities 
on the number of veterans who can receive these noninstitutional 
services have resulted in veterans at 57 of VA's 139 facilities being 
placed on waiting lists for noninstitutional services.

VA's lack of emphasis on increasing access to noninstitutional long-
term care services and a lack of guidance on the provision of these 
services have contributed to service gaps and individual facility 
restrictions. VA headquarters has not emphasized increasing access to 
these services by establishing measurable performance goals as it has 
for other priorities such as maintaining workloads in VA nursing homes. 
Without such performance measures, field officials faced with competing 
priorities have chosen to use available resources to address other 
priorities. VA has implemented a performance measure for fiscal year 
2003 that encourages networks to increase veterans' use of five of the 
six noninstitutional services, but it does not require networks to 
ensure that all network facilities provide veterans access to 
noninstitutional services. Moreover, VA has not provided facilities 
with adequate guidance on the provision of noninstitutional respite 
care, even though most have had little experience in providing the 
service. Some networks and facilities are confused about how to provide 
noninstitutional respite care and as a result some are not providing 
the service. VA has also not provided adequate guidance on which 
noninstitutional services are required. In particular, VA has not 
specified whether the home health services requirement includes one, 
all, or some combination of home-based primary care, homemaker/home 
health aide, and skilled home health care. In the absence of VA 
headquarters guidance on what home health services are required, VA 
facilities vary in their interpretations of what services they must 
provide.

To help ensure that veterans have access to noninstitutional long-term 
care services and that such services are offered uniformly throughout 
VA, we are recommending that VA take actions to increase emphasis on 
provision of these services, provide adequate guidance on their 
provision, and ensure that VA's eligibility standards are used to 
determine eligibility. Specifically, we are recommending that VA (1) 
ensure that facilities follow VA's eligibility standards when 
determining veteran eligibility for noninstitutional long-term care 
services, (2) define and provide guidance on noninstitutional respite 
care, (3) specify in VA policy whether home-based primary care, 
homemaker/home health aide, and skilled home health care are to be 
available to all enrolled veterans, and (4) refine current performance 
measures to help ensure that all VA facilities provide veterans with 
access to required noninstitutional services. In commenting on a draft 
of our report, VA concurred with our recommendations, discussed 
preliminary actions it plans to take, and stated that it will provide a 
detailed action plan to implement our recommendations.

Background:

Changes in VA's eligibility standards have resulted in an increase in 
the number of veterans who are eligible to receive VA health care, 
including noninstitutional long-term care services. The Veterans' 
Health Care Eligibility Reform Act of 1996[Footnote 4] authorized VA to 
provide health care services not previously available to veterans 
without service-connected disabilities or low incomes.[Footnote 5] As 
required by the act and due to an anticipated increase in demand for VA 
health care from these changes in eligibility, VA has eight priority 
categories for enrollment, with higher priority given to veterans with 
service-connected disabilities, lower incomes, or other recognized 
statuses such as former prisoners of war. If sufficient resources are 
not available to provide care that is timely and acceptable in quality 
for all priority groups, the act requires VA to limit enrollment 
nationally, consistent with the eight priority groups. If needed, 
enrollment restrictions would begin with the lowest priority category. 
On January 17, 2003, VA announced that it would no longer enroll 
priority 8 veterans, those in the lowest priority category, for the 
duration of the year.[Footnote 6]

VA long-term care includes a continuum of services for the delivery of 
care to veterans needing assistance due to chronic illness or physical 
or mental disability. Assistance with veterans' needs takes many forms 
and is provided in varied settings, including institutional care in 
nursing homes or home and community-based noninstitutional care. Long-
term care also includes respite care services that temporarily relieve 
a caregiver from the burden of caring for a chronically ill and 
disabled veteran in the home.

VA's long-term care infrastructure, including nursing homes it 
operates, was developed when the concentration of veteran population 
was distributed differently by region. When VA developed its long-term 
care infrastructure, it relied more on nursing home care and less on 
home and community-based services than current practice. To help update 
VA's long-term care policy, the Federal Advisory Committee on the 
Future of VA Long-Term Care recommended in 1998 that VA meet the 
growing demand for long-term care by greatly expanding home and 
community-based service capacity while maintaining its nursing home 
capacity at the level of that time.[Footnote 7]

VA has delegated decision making regarding financing and service 
delivery for long-term care and other health care services to its 21 
health care networks. VA allocates resources for health care to each of 
the 21 networks, including resources used for long-term care. In turn, 
VA's networks have budget and management responsibilities that include 
allocating resources received from headquarters to facilities within 
their networks--including resources used to provide long-term care 
services.

Veterans' Access Is Limited by Gaps in Service Availability and 
Facility Restrictions on Service Use:

Veterans' access to the six noninstitutional services in our 
reviewadult day health care, geriatric evaluation, respite care, home-
based primary care, homemaker/home health aide, and skilled home health 
care--is limited due to gaps in availability and facility restrictions 
on use of the services. Of VA's 139 facilities, 126 do not offer all 
six noninstitutional services. Facilities that do offer a service do 
not always offer the service to veterans in the entire geographic area 
they serve. Further, veterans' access to the six noninstitutional 
services may be limited by restrictions that individual VA facilities 
place on service use. Some of these facility restrictions conflict with 
VA eligibility standards which state that most services are to be 
available to all enrolled veterans regardless of priority group.

Access to Care Is Limited by Service Gaps Across VA:

Access to care is limited because many VA facilities do not offer the 
six noninstitutional services in our review. Of VA's 139 facilities, 
126 did not offer all of the six noninstitutional services in fall 2002 
with little progress made in expanding the availability of services 
from fall 2001. (See fig. 1.) The least commonly available service of 
the six we reviewed in 2001 and 2002 was noninstitutional respite care. 
This service was not available at 110 facilities in fall 2001, and as 
of fall 2002, noninstitutional respite care was not available at 106 
facilities. In contrast, the most widely available service we reviewed 
was skilled home health care, which was offered at all but 7 
facilities.

Figure 1: Noninstitutional Long-Term Care Services at VA's 139 Medical 
Facilities:

[See PDF for image]

Note: Includes services provided directly by facilities or through 
contracts with other providers as of fall 2001 and fall 2002.

[End of figure]

Veterans' access to these services is further limited because among 
facilities that offer services, many do so in only parts of the 
geographic area they serve. Our fall 2002 survey showed that for four 
of the six servicesnoninstitutional respite care, home-based primary 
care, adult day health care, and noninstitutional geriatric 
evaluationthe majority of the facilities either did not offer one or 
more of the services or did not offer them in the entire geographic 
area they serve. As shown in figure 2, 42 facilities did not offer 
adult day health care and an additional 76 facilities did not offer 
adult day health care in their entire geographic service area. As a 
result, where veterans live in a facility's geographic service area 
determined whether they had access to the services offered by the 
facility. The remaining 21 facilities reported that they offered adult 
day health care in all parts of their geographic service areas.

Figure 2: Noninstitutional Long-Term Care Services, Based on Geographic 
Areas, at VA's 139 Medical Facilities:

[See PDF for image]

Note: Includes services provided directly by facilities or through 
contracts with other providers as of fall 2002.

[End of figure]

The Millennium Act and VA policy also allow facilities to make 
available to veterans the services required as a result of the 
Millennium Actadult day health care, noninstitutional respite care, 
and noninstitutional geriatric evaluationthrough other providers or 
payers while still overseeing the care delivered using a case 
management approach.[Footnote 8] In these cases, VA could arrange for 
these services from non-VA sources but would not pay for them. However, 
VA headquarters has neither issued guidance on the use of case 
management to meet this requirement under the Millennium Act nor has it 
monitored the extent to which facilities use this option. Further, the 
benefit of VA case management in assisting veterans to access these 
three services is limited to those veterans who have some other sources 
to pay for the care. That is, if veterans are not eligible for care 
covered by another payer, such as Medicaid, or cannot pay themselves, 
case management assistance is not likely to result in access to the 
three services.

Veterans' Access to Care Is Further Limited by Individual Facility 
Restrictions:

Some facilities limit access to services based on veterans' service-
connected disability levels. For example, we found that nine VA 
facilities imposed their own eligibility restrictions on access to 
noninstitutional services based on veterans' service-connected 
disabilities. Because we did not systematically ask in our survey if 
facilities had restrictions based on service-connected disabilities, it 
is possible that additional facilities may impose similar eligibility 
restrictions. Such restrictions conflict with VA eligibility standards 
and result in inequitable access for veterans enrolled at these 
facilities. VA's eligibility standards state that most services are to 
be available to all enrolled veterans, regardless of priority 
group.[Footnote 9]

Many facilities also limit the number of veterans who may receive a 
service at a particular time. As a result, when more veterans need 
service than the established facility limit, these veterans have to 
wait for service until space or resources become available. In our 
survey, 57 of VA's 139 facilities reported that veterans are on waiting 
lists for one or more of the six noninstitutional services we reviewed 
as a result of restrictions placed on the number of veterans who may 
receive a service.

We are recommending that VA ensure that its facilities follow VA's 
eligibility standards when determining eligibility for 
noninstitutional long-term care services. The examples we found clearly 
point out the need for VA to take such action to ensure that facilities 
follow VA eligibility standards so that similarly situated veterans 
have access to similar care across the country. VA concurred with this 
recommendation and stated that the Veterans Health Administration will 
add eligibility sections in each new directive and handbook concerning 
Home and Community Based Care Programs. In addition, VA stated that it 
will provide a detailed action plan to implement this and other 
recommendations we made on VA's noninstitutional long-term care 
services.

Lack of Emphasis and Inadequate Guidance Contribute to Limited Access:

A lack of VA emphasis on increasing access to noninstitutional long-
term care services and inadequate VA guidance on providing these 
services have contributed to limited access for veterans. Until fiscal 
year 2003 VA had not provided measurable standards for the provision of 
these services or oversight to monitor their provision as it had for 
high-priority services. VA guidance on the provision of 
noninstitutional long-term care services has left unclear to some 
facilities how noninstitutional respite care service is to be defined 
and provided and whether all of the home health services in our review 
are a part of what VA requires be made available to veterans who need 
them.

VA Has Not Emphasized Increased Access to Noninstitutional Long-Term 
Care Services:

VA network and facility officials told us that VA headquarters has not 
emphasized increased access to noninstitutional long-term care services 
but emphasized other priorities. As a result, these officials said they 
use their resources for the priorities VA headquarters emphasizes 
rather than noninstitutional services. For example, officials in 9 of 
VA's 21 networks told us that VA headquarters' emphasis on the 
performance measure that requires networks to maintain workload in VA 
nursing homes has led them to devote resources to nursing home care 
that they might otherwise have used to provide noninstitutional 
services. One network director told us that the "pressure" from VA 
headquarters to maintain nursing home utilization is much greater than 
that to offer noninstitutional services. In another network, an 
official at a VA facility not offering three of the services in our 
study told us that these services were "victims of competition for 
resources." In other words, the facility had not funded these three 
noninstitutional services because facility officials had chosen to 
devote resources to other services. Another network director told us 
that, if forced to choose between funding different services, the 
network would allocate resources to services included in a performance 
measure.

One way VA emphasizes services is through performance measures, which 
VA establishes to monitor network officials' progress toward meeting 
certain VA strategic goals, such as increasing veterans' access to 
services. VA has demonstrated that requiring network officials to meet 
measurable performance standards can promote change. For example, since 
their inception in fiscal year 1996 VA has included a performance 
measure for providing immunizations to prevent pneumonia to veterans 
age 65 and older and those at high risk of the disease. VA increased 
the percentage of such veterans who received the immunization from 26 
percent in fiscal year 1996 to 81 percent in fiscal year 2002.

In October 2002, VA introduced a performance measure for 
noninstitutional long-term care which requires all networks to provide 
noninstitutional services to a portion of their enrolled veterans 
needing such services.[Footnote 10] The fiscal year 2003 goal for this 
measure will require the majority of networks to increase utilization 
of their noninstitutional services. The performance measure includes 
five of the services in our review but does not include 
noninstitutional geriatric evaluation. However, the performance 
measure does not require networks to ensure that veterans have access 
to noninstitutional long-term care services at all network facilities. 
Instead, network performance targets can be achieved if networks 
increase utilization at facilities that already offer noninstitutional 
services.

We are recommending that VA refine current performance measures to help 
ensure that all VA facilities provide veterans with access to required 
noninstitutional services. Without refinements that include individual 
facility performance, existing measures will not hold networks 
accountable for providing required services at each facility. VA 
concurred with this recommendation and stated that the Veterans Health 
Administration will develop performance measures to underscore the 
importance VA places on its noninstitutional long-term care programs. 
In addition, VA stated that it will provide a detailed action plan to 
implement this and other recommendations we made on VA's 
noninstitutional long-term care services.

VA Has Provided Inadequate Guidance on the Provision of 
Noninstitutional Respite Care:

VA headquarters has provided inadequate guidance to networks and 
facilities on the provision of noninstitutional respite care to address 
confusion in the field about what this service is and how it should be 
provided. This confusion exists, in part, because VA has limited 
experience with noninstitutional respite care and VA traditionally 
provided respite care in institutions such as nursing homes. 
Noninstitutional respite care, by contrast, is provided only in 
noninstitutional settings, such as a veteran's own home.

Although noninstitutional respite care has been required by VA for over 
a year, VA has not issued adequate guidance on the provision of 
noninstitutional respite care and VA staff told us they were unsure how 
to develop a noninstitutional respite care service. VA issued a 
directive in October 2001 that requires all facilities to provide 
noninstitutional respite care to veterans in need of the service yet it 
inadequately defines noninstitutional respite care and does not provide 
facilities with information regarding how to provide the service. For 
example, the directive states that noninstitutional respite care may be 
provided in a home or other noninstitutional settings. However, it does 
not specify which noninstitutional settings may be used for the purpose 
of respite care. In fact, officials in 6 of the 21 networks indicated 
that there was confusion in their networks about how to establish 
noninstitutional respite care programs and 1 of these networks reported 
this was the reason facilities in the network were not providing the 
service. Further, in our survey, six facilities reported that they 
offer noninstitutional respite care in community nursing homes, which 
are institutional settings, thus not meeting the requirement for 
noninstitutional respite care. VA headquarters officials said they are 
developing a handbook that will define and provide guidance on the 
provision of noninstitutional respite care.

We are recommending that VA define and provide guidance on 
noninstitutional respite care so that facilities can be clear on what 
noninstitutional respite care is and how and where it is to be 
provided. VA concurred with this recommendation and stated that it will 
provide a detailed action plan to implement this and other 
recommendations we made on VA's noninstitutional long-term care 
services.

VA Guidance Does Not Specify Which Home Health Services Are Required:

VA requires that facilities offer a home health services benefit as 
part of its medical benefits package.[Footnote 11] VA headquarters 
officials told us that the home services benefit includes home-based 
primary care, homemaker/home health aide, and skilled home health care. 
However, VA policy does not specify whether one, some combination, or 
all three home health services are required under the home health 
services benefit. Currently 138 out of VA's 139 facilities offer at 
least one of these three home health services, 59 facilities offer two 
of the three services, and 66 facilities offer all three. Without clear 
guidance to facilities on what services they must make available in 
order to fulfill the home health services benefit, facilities vary in 
their interpretation of what is included in the benefit and 
headquarters cannot ensure that veterans have access to the services to 
which they are entitled.

Because facilities and networks vary in their interpretation of what is 
included in the home health services benefit, facilities do not 
uniformly offer the same home health services. For example, at one 
facility we visited, an official told us that the facility interpreted 
the home health services benefit to mean that veterans must have access 
to skilled home health care--which the facility made available to all 
veterans. The facility restricted veterans' access to its homemaker/
home health aide and home-based primary care services because facility 
officials did not believe these services were required under VA's home 
health benefit. Similarly, in another network an official told us that 
the network interpreted the home health services benefit to include all 
three home care serviceshome-based primary care, homemaker/home health 
aide, and skilled home health care. As a result, access to these three 
services varies according to facility interpretation of what is 
required.

We are recommending that VA specify in VA policy whether home-based 
primary care, homemaker/home health aide, and skilled home health care 
are to be available to all enrolled veterans. VA concurred with this 
recommendation and VA stated that it will provide a detailed action 
plan to implement this and other recommendations we made on VA's 
noninstitutional long-term care services.

Mr. Chairman, this concludes my prepared remarks. I will be pleased to 
answer any questions you or other members of the subcommittee may have.

Contact and Acknowledgements:

For further information regarding this testimony, please contact me at 
(202) 512-7101. James C. Musselwhite also contributed to this 
testimony.

[End of section]

Related GAO Products:

VA Long-Term Care: Service Gaps and Facility Restrictions Limit 
Veterans' Access to Noninstitutional Care. GAO-03-487. Washington, 
D.C.: May 9, 2003.

Department of Veterans Affairs: Key Management Challenges in Health and 
Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003.

Long-Term Care: Availability of Medicaid Home and Community Services 
for Elderly Individuals Varies Considerably. GAO-02-1121. Washington, 
D.C.: September 26, 2002.

VA Long-Term Care: The Availability of Noninstitutional Services Is 
Uneven. GAO-02-652T. Washington, D.C.: April 25, 2002.

VA Long-Term Care: Implementation of Certain Millennium Act Provisions 
Is Incomplete, and Availability of Noninstitutional Services Is Uneven. 
GAO-02-510R. Washington, D.C.: March 29, 2002.

Veterans' Affairs: Observations on Selected Features of the Proposed 
Veterans' Millennium Health Care Act. GAO/T-HEHS-99-125. Washington, 
D.C.: May 19, 1999.

FOOTNOTES

[1] In November 1999, the Congress passed the Veterans Millennium 
Health Care and Benefits Act, which required that VA provide veterans 
access to three servicesadult day health care, geriatric evaluation, 
and respite care. VA chose to meet the Millennium Act requirements by 
issuing a directive in October 2001 requiring that facilities provide 
adult day health care, noninstitutional geriatric evaluation, and 
noninstitutional respite care to veterans in need of such services. 

[2] U.S. General Accounting Office, VA Long-Term Care: Service Gaps and 
Facility Restrictions Limit Veterans' Access to Noninstitutional Care, 
GAO-03-487 (Washington, D.C.: May 9, 2003). Also see Related GAO 
Products.

[3] Although VA has 172 medical centers, in some instances 2 or more 
medical centers have consolidated into health care systems. Counting 
health care systems and individual medical centers that are not part of 
a health care system as single facilities, VA has 139 facilities.

[4] Pub. L. No. 104-262  101, 104, 110 Stat. 3178-79, 3182-83 (1996).

[5] A service-connected disability is an injury or disease that was 
incurred or aggravated while on active military duty. VA classifies 
veterans with service-connected disabilities according to the extent of 
their disability. These classifications are expressed in terms of 
percentages--for example, the most severely disabled such veteran would 
be classified as having a service-connected disability of 100 percent. 
Percentages are assigned in increments of 10 percent. 

[6] Priority 8 veterans are primarily veterans with no service-
connected disabilities who have incomes above established limits for 
geographic regions set by the U.S. Department of Housing and Urban 
Development to reflect regional costs of living. Priority 8 veterans 
enrolled prior to January 17, 2003, remain enrolled to receive VA 
health care benefits. 

[7] VA Long-Term Care At The Crossroads: Report of the Federal Advisory 
Committee on the Future of VA Long-Term Care (Washington, D.C.: June 
1998).

[8] Case management includes assessment of the veteran's care needs, 
care planning and implementation, referral coordination, monitoring, 
and periodic reassessment of the veteran's care needs. 

[9] Although VA issued a regulation on September 17, 2002, granting 
priority for appointments to veterans with service-connected 
disabilities of at least 50 percent and veterans needing care for a 
service-connected disability, the regulation does not change other 
veterans' eligibility to receive services. 

[10] According to VA, when it plans for noninstitutional services it 
assumes that the vast majority of veterans will choose to use their 
Medicare benefits for home health care. 

[11] The medical benefits package is the set of services to be 
available to all enrolled veterans.