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Dential Care Under Voc Rehab


jessie0054
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Question

Does a vet at 70 % get full dential care or only emergency care under Voc Rehab? My son went to the Dentist at Charleston SC this morning under an appointment set up for him by his Voc Counselor only to get there and they tell him he can only get emergency care. Is this right?

Thanks

Jessie

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10. ELIGIBILITY FOR DENTAL CARE

a. General

(1) VA Dental Services examine and treat eligible inpatient and outpatient beneficiaries. Eligibility for dental care is governed by statute and provided in accordance with the provisions of existing law and regulations as cited in United State Code., sections 1710© and 1712, and Title 38 Code of Federal Regulations (CFR) sections 17.160 through 17.166. Dental eligibility is determined in a different manner than medical eligibility. The Business Office, Health Eligibility Center, holds responsibility for verification of administrative aspects of dental eligibility. It is the responsibility of the Dental Service Chief to make determinations on all clinical aspects of dental eligibility.

(2) It is not the established mission of VA to provide dental care to all veterans or even to all those who are hospitalized. The extent of treatment is determined through an understanding of the patient's dental classification and the appropriate scope of dental care to be provided based on that classification.

b. Dental Classification. The laws and regulations mandate dental care as a benefit for defined veteran groups. Specific dental classifications have been established that further define patient groups and the appropriate scope of care based on that classification. The nuances of the VHA HANDBOOK 1130.01 December 24, 2008 4

classifications are addressed in the Inpatient, Outpatient and Long Term Care sections of this Handbook. Also see Appendix A for the Scope of Care Quick Reference Guide.

(1) The following patient groups are included in the defined dental classification scheme and are to be provided dental care in compliance with VHA regulations and Directives:

(a) Residents of VA Residential Rehabilitation Treatment Programs, including Domiciliaries.

(b VA Community Living Center (formerly known as Nursing Home Care Unit) residents.

© Inpatients with compelling medical need for dental treatment.

(d) Patients having a compelling medical need that requires completion of dental care initiated while an inpatient.

(e) Outpatient Dental Class I through VI beneficiaries.

(f) Outpatients with dental emergencies.

(2) The following patient groups are included in the defined dental classification scheme and may be provided dental care if clinic capacity is available.

(a) Hospitalized veterans whose dental conditions are not considered to be adjunct to their medical problems.

(b Inpatients without other dental entitlement who are active duty military personnel or military retirees.

© Specially designated inpatients and outpatients such as those provided for under approved sharing agreements.

c. Professional Considerations. VA is obligated to fulfill the requirements of the statutes enacted by Congress and to follow their intent. Every Dental Service has the responsibility to provide care on the basis of the patient's dental classification. A clearly defined and documented treatment plan, consistent with the appropriate scope of care for that patient's classification, will be developed for each episode of care.

(1) There is no authority to expand the scope of care beyond the veteran's level of entitlement in order to meet the demands of an educational program as a "teaching case." If a training program is dependent upon types of cases that are not available in sufficient numbers, the scope of that program should be reevaluated.

(2) The patient's ability to pay for the cost of private dental care should not be a factor in determining the extent or limitation of dental treatment that will be provided by VA. December 24, 2008 VHA HANDBOOK 1130.01 5

(3) Dental care provided for reasons of medical necessity should not exceed the scope necessary to resolve the condition that is complicating a medical problem. For example, a patient's medical problem may require only the removal of foci of infection. Even though VA may edentulate a patient to resolve the dental condition's impact on a medical problem, VA is not obligated to provide prostheses for this patient.

(4) Appropriate dental authorization for outpatient dental care for veterans that have other rated, compensable service connected conditions of the head and neck area is sometimes confusing. Conditions such as loss of soft tissue, scarring or cranial nerve involvement may have significant impact on oral function even though there may be no physical trauma to the dental structures, per se. These non-dental conditions are not rated in the 9900 series of the Schedule for Rating Disabilities (See Appendix bb and are considered medical conditions. The decision as to whether or not dental care will be authorized as adjunctive care (either as Class III or Class VI) will be determined by the Chief, Dental Service, or designee and based on the same criteria as for other medical conditions.

d. Scope of Dental Care. Once a patient's dental classification has been properly established, the appropriate scope of care for that patient must be determined. The scope of dental care to be provided can be categorized as Comprehensive, Focused or Emergent/Urgent. The intent of these categories is to facilitate a consistent standard of care throughout all VA dental facilities.

(1) Comprehensive Dental Care. Patients eligible for Comprehensive Dental Care receive any dental treatment that is reasonably necessary and clinically determined by the treating dentist to meet the patient's dental needs. A recall program should be established for those patients who are eligible for comprehensive and repeat dental care. The goal of care is to attain and sustain oral health and function including prosthetic rehabilitation as indicated.

(2) Focused Dental Care. Focused dental care is intended to resolve a specific dental condition dependent upon, and consistent with the patient's classification. Treatment may include relief of pain, elimination of infection, or improvement of speech or esthetics. It also includes treatment of adjudicated non-compensable service connected teeth (i.e. Class II and Class IIa.) The goal of care is to provide a specific improvement of the oral conditions that directly impact the medical condition (Class III and VI), assist in vocational rehabilitation (Class V), or to provide dental care professionally determined to be medically and functionally appropriate to their status for those in a VA Community Living Center or extended care facility.

(a) Consultation requests, when applicable, from non-dental providers must identify the medical condition being aggravated or the management of which is compromised by the dental problem. The Dental Service Chief, or designee, will review the consult and make a final determination based on dental eligibility and scope of care.

(b Dental treatment is generally limited and may include supportive periodontal therapy, endodontic therapy, restorative dentistry, and oral surgical procedures. VHA HANDBOOK 1130.01 December 24, 2008 6

© Treatment may also include the fabrication of removable and complete dentures as indicated in the approved treatment plan. Once the episode of care has been completed, subsequent treatment is the responsibility of the patient.

(3) Emergent/Urgent Dental Care. Outpatient emergency dental care is provided as a humanitarian service to individuals who do not have established dental eligibility. Dental treatment is limited to that necessary to address acute pain, significant infection, uncontrolled bleeding, or any dental condition that is determined to be a serious threat to health or endangering life. The goal of treatment is to eliminate symptoms and/or remove foci of infection. Dental care is generally limited to one time palliative procedures and appropriate pharmacological therapy.

(a) The provision of emergency dental treatment does not entitle the patient to subsequent or follow-up care unless the individual is eligible under some other provision.

(b Individuals who are not eligible for VA dental care, but who are provided outpatient emergency dental treatment will be processed in accordance with VA policy and procedures as follows:

1. Veterans presenting at VA medical facilities requesting treatment for acute pain, significant infection or uncontrolled bleeding of oral origin should initially be seen for administrative processing and triage. Triage will include, if applicable, verification of any medical condition for which there is a potential for adjunct (Class III or VI) dental care.

2. If the patient is not eligible or has limited eligibility for outpatient dental care, the patient must be informed of this fact and advised that if emergency treatment is provided for which there is no eligibility, the patient will be billed for treatment. The eligibility clerk or designee will complete and sign the statement of ineligibility on VA Form 10-2570g, Dental Outpatient Emergency Referral and Treatment Record. The applicant will sign the statement of understanding related to the emergency dental care and billing prior to referral to the Dental Service.

3. Dental Service personnel will examine the patient to determine the appropriate course of treatment based on the following options:

a. If the condition requires hospitalization, the patient will be returned to the admitting area with the necessary documents for admission.

b. If the dental condition can be treated on an outpatient basis and does not require immediate attention, the patient will be referred to community resources at their expense.

c. If the dental condition is considered emergent, appropriate care will be provided and documented.

4. Upon treatment completion, a brief description of the emergency treatment provided will be recorded, signed by the treating dentist and returned to the VA office responsible for billing. December 24, 2008 VHA HANDBOOK 1130.01 7

e. Refusal to Accept Dental Services. In those instances when patients refuse to accept Dental Service's recommendations or do not cooperate in receiving treatment, a statement of the facts will be entered into a progress note for consideration and appropriate disposition by the Chief, Dental Service, or designee.

f. Treatment Continuation for Patients Who Relocate to Another Geographic Area. A key objective of VA Dentistry is to provide a consistent standard of dental care throughout VA dental facilities. If, however, a patient has a plan of treatment for a scope of care inconsistent with their dental classification, the receiving facility is not obligated to provide care beyond that which is justified. The Dental Service at the new facility will perform an evaluation, update the treatment plan and communicate any changes to the patient.

g. Patient Responsibility in Making and Keeping Dental Appointments. Any veteran eligible for dental treatment on a one-time completion basis only and who has not received such treatment within 3 years after filing the application shall be presumed to have abandoned the claim for dental treatment. (38 CFR 17.164)

11. OUTPATIENT DENTAL PROGRAM

a. Overview. The goal of VA Dental Services is to provide high quality, cost-effective dental treatment to eligible veterans. All VA dentists will be knowledgeable regarding the scope of care to be provided that is consistent with the patient's dental classification.

b. Persons Eligible for Outpatient Dental Care. Statutory eligibility for outpatient dental care is granted to veteran beneficiaries and is provided in accordance with existing law and regulations. Classes of eligible dental outpatients are as follows:

(1) Class I.

(a) Veterans having a compensable (10% or greater), service connected dental disability or condition (combat or non-combat related) rated under the 9900 series of the Schedule for Rating Disabilities (See Appendix b are eligible for any necessary dental care to maintain or restore oral health and masticatory function, including repeat care.

(b Appropriate dental authorization for outpatient dental care for veterans that have other rated, compensable service connected conditions of the head and neck area is sometimes confusing. Conditions such as loss of soft tissue, scarring or cranial nerve involvement may have significant impact on oral function even though there may be no physical trauma to the dental structures, per se. These non-dental conditions are not rated under the 9900 series, are considered medical conditions and are not eligible under Class I. The decision as to whether or not dental care will be authorized as adjunctive care (either as Class III or Class VI) will be determined by the Chief, Dental Service, or designee and based on the same criteria as for other medical conditions.

(2) Class II. Veterans having a noncompensable, service connected dental disability shown to have been in existence at the time of discharge or release from active duty may be provided VHA HANDBOOK 1130.01 December 24, 2008 8

any treatment as reasonably necessary for the one-time correction of the noncompensable, service connected dental disability if all of the following criteria are met:

(a) They are discharged or released from active duty under conditions other than dishonorable, from a period of active military service of not less than 180 days. In the case of Gulf War Era, Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, they are discharged or released from active duty under conditions other than dishonorable from a period of active military service of not less than 90 days.

(b Application for dental treatment is made within 180 days of discharge or release from active duty.

© The certificate of discharge or release certifies that the veteran was not provided, within the 90 day period immediately before discharge or release, a complete dental examination (including dental radiographs) and all appropriate dental treatment indicated by the examination was completed. This certification is found on the DD214, line 17.

(d) Scope of care for Class II.

1. One Episode of Class II Care. When Class II eligibility for a one-time episode of dental care has been exhausted by satisfactory completion of the authorized treatment, no further care will be provided. Class II dental beneficiaries who (through no fault of the VA) have not completed authorized treatment within 3 years after filing the application shall be presumed to have abandoned the claim for dental treatment.

2. Dental Prostheses and Implants Provided by VA. Class II dental beneficiaries are not entitled to long term maintenance of fixed or removable dental prostheses or dental implants. Once adjustments are satisfactory, the episode of prosthetic care is considered to be complete and subsequent treatment is the responsibility of the patient.

3. Periodontal Conditions. Specific treatment authorized for periodontal conditions of Class II beneficiaries is expected to provide maximum benefit by the time that episode of care is completed. When that treatment is satisfactorily completed as authorized, VA will not furnish any further treatment or follow-up for the periodontal condition.

4. Impacted Teeth. Impacted teeth are a developmental condition. Consideration for surgical extraction should be based on sound professional judgment to resolve existing disease or symptoms.

5. Malposed Teeth. Malposed teeth are considered a developmental abnormality and a pre-existing condition. VA will not provide orthodontic care in this circumstance. For cases in which trauma incurred in the line of duty resulted in malalignment of the teeth or when restorative procedures for which the patient is eligible require orthodontic intervention, orthodontic care may be provided.

6. Veterans with Orthodontic Appliances. When veterans arrive at VA facilities with orthodontic appliances for the purpose of correcting developmental malocclusion and have not December 24, 2008 VHA HANDBOOK 1130.01 9

had their treatment completed by the military prior to discharge, they need to be instructed to contact the dental clinic at their last active duty military assignment to arrange for completion of the care. If the military does not complete the orthodontic treatment, VA is not obligated to assume the responsibility of any phase of the orthodontic care unless directly related to rehabilitation of combat trauma to the maxillofacial region.

7. Service Connection of Dental Conditions for Treatment Purposes. Veterans Benefits Administration (VBA) may, upon request, provide documentation to the Dental Service defining service connection of specific teeth for dental treatment purposes. (38 CFR 3.381). The regulation provides for identification of teeth treated during military service, and applies only to Class II beneficiaries who have met the criteria as specified in Para. 11 b.(2)(a-c). The Chief or designee can use the document to assist in development of appropriate treatment recommendations.

(3) Class IIA. Those veterans having a noncompensable, service connected dental disability adjudicated as resulting from combat wounds or service trauma are eligible for repeat care and maintenance or replacement of the involved tooth/teeth. A Dental Trauma Rating (VA Form 10-564-D) or VA Regional Office Rating Decision letter (VA Form 10-7131) identifies the tooth/teeth eligible for care. Public Law 83, 84th Congress, Chapter 52, H.R. 5100, Approved June 16, 1955 invalidates old dental ratings and eligibility letters dated before 1955. Prior to 1955, teeth that received routine dental care while the veteran was on active duty were listed as "service connected". Patients with these dental ratings are not eligible for repeat care for the listed "service connected" teeth.

(4) Class IIC. Veterans who were Prisoners of War (POWs) are eligible for any needed dental care, including repeat care.

(5) Class III. Veterans with a dental condition professionally determined by VA to be aggravating or complicating the management of a service connected medical condition under active treatment are eligible for care to treat the dental condition. The goal is to provide focused care to treat only the oral conditions that directly impact the management of the service-connected medical condition. Eligibility for each episode of dental care must be predicated on referral (consult), followed by a new dental evaluation.

(6) Class IV. Veterans whose service connected disabilities have been rated at 100 percent (total) or who are receiving the 100 percent rate by reason of individual unemployability are eligible for any needed dental care, including repeat care, with the following exception: a veteran awarded a temporary total disability rating by the Veterans Benefits Administration is not eligible for comprehensive outpatient dental services based on an opinion by VA General Counsel (023) to the Under Secretary for Health (16), February 24, 2006, VAOPGCADV 2-2006. Determination of temporary status is the responsibility of the eligibility section of the Business Office.

(7) Class V

(a) A veteran who is actively engaged in a Chapter 31 vocational rehabilitation program is entitled to dental care to the extent needed to meet any of the following goals listed: VHA HANDBOOK 1130.01 December 24, 2008 10

1. make possible his or her entrance into a rehabilitation program,

2. achieve the goals of the veteran's vocational rehabilitation program,

3. prevent interruption of a rehabilitation program,

4. hasten the return to a rehabilitation program of a veteran in interrupted or leave status,

5. hasten the return to a rehabilitation program of a veteran placed in discontinued status because of a dental condition,

6. secure and adjust to employment during the period of employment assistance, or

7. enable the veteran to achieve maximum independence in daily living.

(b Requests for dental care will be forwarded to the Dental Service by the Chapter 31 Vocational Rehabilitation Program on VA Form 28-8861. This form needs to be provided for each episode of care requested. Dental care should not be provided beyond the anticipated rehabilitation date as specified on the form.

(8) Class VI

(a) Any veteran scheduled for admission or who is receiving outpatient care under 38 U.S.C. may receive dental care if the dental condition is clinically determined to be complicating the non-service connected medical condition currently under VA treatment. Eligibility for each episode of dental care will be predicated on referral and consultation, followed by a decision based upon clinical judgment. The goal is to provide focused care to treat only the oral conditions that directly impact the management of the non-service connected medical condition.

(b Certain homeless and other enrolled veterans also are eligible for a one-time course of dental care per VHA policy, Public Law 107-95 and Title 38 United States Code (U.S.C.) § 2062. Dental workload for veterans participating in this program is recorded under the Class VI dental outpatient classification.

(9) Other Beneficiaries. Other beneficiaries who may be eligible for dental care in VA dental clinics on an outpatient basis, subject to and consistent with the provision of existing laws, VA regulations, and the availability of VA resources are:

(a) Armed Forces Personnel on Active Duty. Authority from the Commanding Officer of the military installation should accompany the request for dental treatment. However, if extenuating circumstances are present, treatment of the emergent dental condition may be accomplished prior to the receipt of authority. Emergency dental treatment for members of the Armed Forces on active duty will be limited to such treatment as is found necessary for the relief of pain and control of acute infection, trauma or hemorrhage. December 24, 2008 VHA HANDBOOK 1130.01 11

(b Armed Forces Personnel in VA Polytrauma Centers. Active duty military personnel with spinal cord injury, traumatic brain injury or blindness who are receiving treatment in a VA polytrauma center are eligible to receive dental care under a direct resource sharing agreement in accordance with Department of Veterans Affairs and Department of Defense Memorandum of Agreement regarding referral of active duty military personnel with effective date January 1, 2007. Dental services will be billed at the interagency rate, where one exists, or at actual cost as appropriate.

© VA Employees. VA employees may be provided emergency dental treatment only to the extent necessary to permit the employee to remain on duty. Provision of care is predicated on referral from the employee health program. Employees with emergent conditions that may require follow-up care will be advised to seek private care at their expense. Injuries incurred in the performance of duty may receive necessary emergency treatment.

(d) Beneficiaries of Sharing Agreements. Treatment provided will be dependent on the specific language of the agreement.

(10) Disability Evaluation Examinations for Compensation and Pension Rating Purposes. Requests for an oral examination are submitted to the Dental Service at the request of the Regional Office. Examination findings must be accurately and comprehensively reported and the patient coded as a Category 20. Examinations must be completed within the timeframe required by VBA.

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Thanks for the reply Pete992.

Looks like i'm going to have to do some reading and hopefully understand.

Thanks again

Jessie

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Putting this all in a nut shell, have your son talk with his VOC Reh Counselor and have the counselor write a statement of the dental work that he needs. Then have your son take it to the dental clinic and see what they say, if they can not do it ask them for dental fee basis to get the dental work done. The Voc Reh Counselor should be able to tell the dentist what your son needs. Basically, the dental clinic will provide limited amount of work, teeth cleaning, maybe extractions, gum care and some bridges. The dental clinic does not provide braces or whitening, they will try their best to do as little as possible, but again the Voc Reh counselor should know the help that your son needs. Your son must be actively in the program and the dental clinic should verify this before any treatment.

Hope the Best

Edited by pacmanx1
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Thanks again Pete992:

You putting it in the nutshell helps alot!!

I'll send your post to my son, Hope it helps. he left the Va this morning not in a good mode.

Jessie

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  • HadIt.com Elder

While enrolled in Voc Rehab a Veteran is entitled to full dental service and anything they start has to be finished.

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