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01 December 2009



== VA Electronic Health Record [01] -------------------------------------------------- (VA/Kaiser Pilot Program)

== U.S. Cadet Nurse Corps --------------------------------------------------------------- (VA Recognition Sought)

== COLA 2011 --------------------------------------------------------------------------------- (0.1% OCT 09)

== Mobilized Reserve 24 NOV 09] ----------------------------------------------------- (9,082 Decrease)

== DFAS myPay System [07] ---------------------------------------------------------- (Personal Email Addees)

== Military Health Records --------------------------------------------------------------- (72,000 PDHRAs Missing)

== VA Blue Water Claims [08] --------------------------------------------------------- (H.R.2254 & S.1939)

== VA Emergency Care [04] ------------------------------------------------------------ (Non-VA Facilities)

== Combat Zone Tax Rules -------------------------------------------------------------- (IG Audit Uncovers Problems)

== Vet Pro Bono Assistance [01] ----------------------------------------------------- (Center for Vet Advancement)

== VA Women Vet Programs [08] ----------------------------------------------------- (4 Year Study)

== Tricare Regional Contracts [04] ---------------------------------------------------- (Health Net Protest Upheld)

== Veterans Corps [02] -------------------------------------------------------------------- (Vet Application Date)

== Veteran Employment [05] ------------------------------------------------------------ (SVAC Hearing 18 NOV)

== Medicare Reimbursement Rates 2010 [02] ------------------------------------ (TFL Impact)

== VA Family Caregiver Assistance [01] -------------------------------------------- (Senate Vet Package)

== SDVOSB Contract Fraud ------------------------------------------------------------- (Disabled Vet Program Abused)

== VA Nursing Homes [04] --------------------------------------------------------------- (Gold Star Parent Admission)

== VA Claim Denial [04] ------------------------------------------------------------------- (Appeal Process Legislation)

== VA Budget 2010 [05] ------------------------------------------------------------------- (Senate Action)

== Tricare Reserve Select [14] ---------------------------------------------------------- (Gray Area Entry Delay)

== Tricare Reserve Select [15] ---------------------------------------------------------- (2010 Enrollment)

== VA Thyroid Cancer Treatment ------------------------------------------------------- (Radiation Overdose)

== DoD to VA Transition [12] ------------------------------------------------------------ (DES Pilot Expansion)

== Aid & Attendance [03] ----------------------------------------------------------------- (2009)

== Mammograms ----------------------------------------------------------------------------- (New Guidelines)

== Cholesterol ---------------------------------------------------------------------------------- (Overview)

== Cholesterol [01] --------------------------------------------------------------------------- (Zetia Study)

== U.S. Savings Bonds [05] -------------------------------------------------------------- (Redemption Problems)

== South Dakota DVA ---------------------------------------------------------------------- (Stand Alone DVA Sought)

== Health Care Reform [16] --------------------------------------------------------------- (Vet Death Impact)

== Health Care Reform [17] --------------------------------------------------------------- (H.R.3962 Unintended Vet Harm)

== Health Care Reform [18] --------------------------------------------------------------- (FY09 Questionable Claim Pmts)

== Health Care Reform [19] --------------------------------------------------------------- (More Vet Assurances)

== Veterans' Court [03] --------------------------------------------------------------------- (New DPA Report)

== VA Prostrate Radiation Treatment [01] ------------------------------------------ (Few Sanctions)

== VA Prostrate Radiation Treatment [02] ------------------------------------------ (NRC Sanctions)

== VA Medical School Affiliations ------------------------------------------------------ (Strengthening Partnership)

== Arlington National Cemetery [07] --------------------------------------------------- (Cemetery Probe Ordered)

== Mission Serve ------------------------------------------------------------------------------ (Community Vet Integration)

== Pennsylvania GVOACs ----------------------------------------------------------------- (Governor Closing 5)

== VA Burial Benefit [08] ------------------------------------------------------------------- (Summary)

== Enlistment [04] ---------------------------------------------------------------------------- (Credit/Finance Criteria)

== Medicare Fraud [27] --------------------------------------------------------------------- (16-30 Nov 09)

== Medicaid Fraud [03] ---------------------------------------------------------------------- (16-30 Nov 09)

== Military History Anniversaries --------------------------------------------------------- (Dec 1-15 Summary)

== Tax Burden for Kansas Retirees ----------------------------------------------------- (2009)

== Veteran Legislation Status 29 Nov 09 ---------------------------------------------- (Where we stand)

== Have You Heard ---------------------------------------------------------------------------- (The hunting dog)




VA Electronic Health Record Update 01:      The Department of Veterans Affairs (VA) and Kaiser Permanente on 25 NOV announced a pilot program designed to improve care and services to our Nation's heroes.  VA and Kaiser Permanente are launching a program to exchange electronic health record (EHR) information using the Nationwide Health Information Network (NHIN) created by the Department of Health and Human Services. Starting late NOV, VA and Kaiser Permanente will send a joint letter to Veterans in the San Diego area who receive care from both institutions, to invite Veterans to participate in this first-ever pilot program.  Veterans, who respond and ask to participate, will enable their public and private sector health care providers and doctors to share specific health information electronically, safely, securely and privately.  This initial pilot is planned to begin in mid-December 2009. 


     "This partnership demonstrates the power of a large-scale EHR that safely connects several care systems.  Securely digitizing American's health care information is only the first step in realizing the cost saving and improved quality benefits possible with health care technology," said Andrew M. Wiesenthal, MD, associate executive director of The Permanente Federation. "The reality is that most people receive care from multiple providers.  Without the ability for caregivers and patients to have access to their data, all of the time, there is the possibility for wasted time and resources duplicating tests and procedures.  Exchange of current health record data at the point of treatment also improves quality, allowing medical decisions to be made quickly, with the relevant



     The pilot program connects Kaiser Permanente HealthConnect and the VA's electronic health record system, VistA, two of the largest electronic health record systems in the country. The program puts the highest priority on patient privacy and data security, and no exchange of information will occur without the explicit permission of the individual patient. Explicit policies and technologies to safeguard patient information are part of the NHIN. Patient

information will not be shared without first obtaining their consent. Veterans' access to care will in no way be affected at either institution if they choose not to participate.  Patients who do choose to participate will benefit by allowing their doctors at any one of the institutions to obtain key health record information from other participating institutions.  VA, DoD, and HHS have been working closely to create a system that will modernize the way health care is delivered and benefits are administered.  DoD will be included in the next phase of the pilot program in early 2010. [Source: VA Press Release 25 Nov 09 ++]




U.S. Cadet Nurse Corps:     Many surviving Nurse Corps members throughout the country, have been writing letters to President Obama, Congress members and their senators urging them to pass a bill that would recognize the service of the Corps members as active military service for purposes of laws administered by the Secretary of Veterans Affairs. A bill for the Corps 116,717 members to receive veteran status has been introduced several times to Congress by Nita M. Lowey (D-NY) starting in 1996. Testimony for the newest bill, The United States Cadet Nurse Corps Equity Act (H.R.1522), was presented to the Veterans Affairs subcommittee in March.    


      During World War II, there was an urgent need to train students ages 17 to 35 to help fill the gap left behind by nurses who had gone overseas to help with the war effort. New nurses were needed to keep the healthcare system running at home. President Roosevelt initiated the Corps in 1943 and launched a nationwide recruitment campaign that promised a free education and a monthly stipend of $15 plus room and board. Students took a pledge after completion of the program to go into a branch of the military. Corp members did all functions of a graduate nurse: went to class, worked 12 hour days performing tasks from bathing and treatments to obstetrics and pediatrics, and even custodial duties like keeping the labs clean because the men were overseas. Because of the Corps, nurse education improved, standards were higher and our country’s hospitals stayed intact. President Truman authorized the United States Public Health Service to become a military branch and oversee the Corps.


     Dubbed the “Forgotten Angels,” members of the United States Cadet Nurse Corps never received benefits for their service during World War II. However, many took their state board exams and became registered nurses after the war. The U.S. Cadet Nurse Corps induction pledge was: At this moment of my induction into the United States Cadet Nurse Corps of the United States Public Health Service:

•     I am solemnly aware of the obligations I assume toward my country and toward my chosen profession;

•     I will follow faithfully the teachings of my instructors and the guidance of the physicians with whom I work;

•     I will hold in trust the finest traditions of nursing and the spirit of the Corps;

•     I will keep my body strong, my mind alert, and my heart steadfast;

•     I will be kind, tolerant, and understanding;

•     Above all, I will dedicate myself now and forever to the triumph of life over death;

•     As a Cadet nurse, I pledge to my county my service in essential nursing for the duration of the war.

[Source: The Advertiser-News article 19 Nov 09 ++]




COLA 2011:      The Bureau of Labor Statistics announced that inflation rose 0.1% in OCT 09 due to slight increases in energy and new car prices. The CPI is the measure used to make annual cost-of-living adjustments to military retired pay, survivor benefits, Social Security and other federal pensions. However, cumulative inflation 1.8% in the hole for COLA calculation purposes, since inflation actually declined 1.9% last year. If the October inflation rate of 0.1% were to continue every month, it would take until DEC 2010 to get out of the “COLA hole.”  And that would mean no COLA until DEC 2011 (payable in the Jan 2012 check). That may turn out to be a pessimistic forecast, as inflation could well heat up in time to generate a small COLA in Dec 2010. [Source: MOAA Leg Up 24 Nov 09 ++]




Mobilized Reserve 24 NOV 09:     The Department of Defense announced the current number of reservists on active duty as of 24 NOV 09. The net collective result is 9,082 less reservists mobilized than last reported in the Bulletin for 8 SEP 09.  At any given time, services may activate some units and individuals while deactivating others, making it possible for these figures to either increase or decrease.  The total number currently on active duty from the Army National Guard and Army Reserve is 105,522; Navy Reserve, 6,482; Air National Guard and Air Force Reserve, 13,818; Marine Corps Reserve, 7,617; and the Coast Guard Reserve, 779.  This brings the total National Guard and Reserve personnel who have been activated to 134,218, including both units and individual augmentees.  A cumulative roster of all National Guard and Reserve personnel who are currently activated can be found at  [Source: DoD News Release No. 929-09 25 Nov 09 ++]




DFAS myPay System Update 07:     All existing Personal Email Addresses were deleted from myPay on 30 NOV 09.  If you want a Personal Email Address you may enter it as a Secure Personal Email Address.  It should be secure enough that sensitive information as well as general notifications may be sent to it and it may not match an existing email address on myPay. To add your Personal Email Address as your Secure Personal Email Address select the email address option located on your myPay main menu. You must enter the Secure Personal Email Address twice.  Questions regarding this myPay change may be directed to the Centralized Customer Support Unit at 1(888)-332-7411, commercial (216) 522-5096, Defense Switching Network (DSN) 580-5096 (07-1830 EST).  [Source: DFAS Nov 09 ++]




Military Health Records:     A congressional watchdog agency reported 19 NOV that the Defense Department cannot locate post-deployment health reassessments (PDHRA)) for more than 72,000 people — about 23% of service members who have returned from combat since 1 JAN 07, when the detailed assessments were supposed to be kept for anyone deployed for 30 days or longer. Missing questionnaires might be the result of returning service members deciding not to complete the form, which is supposed to detail any post-deployment health problems or concerns. But it is also possible that completed forms were lost, the Government Accountability Office says in a report to Congress. Whatever the cause, the absence of such a large percentage of records is significant because one purpose for collecting the information was to look for trends in health issues and to be able to track people with similar reports of minor problems to see if they become something larger. Defense officials acknowledge this is a serious issue. In a written response to the report, Ellen Embrey, the acting assistant defense secretary for health affairs, said, “We must be more aggressive.” Every service has problems, according to the report, but the Army and Air Force seem to be doing a better job than the Navy and Marine Corps in getting completed questionnaires to a central repository, the report says. Missing PDHRA by service are:

•     Army:  36,510 missing reports, the largest number of all of the services. But this represents just 19.6% of the people who have returned from Iraq and Afghanistan, the report says.

•     USAF:  8,162 missing reports, 15.8% of those who had returned from the combat theaters.

•     Navy:  5,938 which is the lowest number of missing reports, but the highest percentage gap at 44.3%, because it has deployed far fewer people than the other services.

•     USMC:  21,751 questionnaires, which represents 32.1% of the returning Marines.


     The Defense Department started using a post-deployment health assessment in 2005, with a goal of having everyone complete the form within 90 to 180 days of their return from Iraq or Afghanistan. Some of the current form is voluntary and some is mandatory. Service members must complete the demographic data identifying who they are, where they deployed and other information. The self-assessment about their health, including mental health, is voluntary. The form is electronic, and it is supposed to be submitted to a central repository when completed and a copy added to the service members’ medical records. The report notes that only about 1% of returning service members refuse to complete the health portion of the report, with the refusal rate being the greatest in the Air Force, where up to 5 percent don’t complete the health questions. Every form is supposed to be reviewed by a health professional, and service members who report problems are supposed to be given a chance to discuss them, the report says. Because everyone is supposed to fill out the form, the absence of so many questionnaires shows policy is not being followed, the report to Congress says. [Source: NavyTimes Rick Maze article 0 Nov 09 ++]




VA Blue Water Claims Update 08:    Legislation granting Air Force and Navy veterans a better shot at receiving disability benefits for Agent Orange-related illness now has 204 co-sponsors in the House of Representatives, 14 short of the number needed to guarantee passage. The bill, H.R.2254, is the Agent Orange Equity Act. It would grant people who served in the waters off Vietnam and the airspace above it the same presumptions as people who set foot there: that certain diseases are the result of exposure to the herbicide Agent Orange, widely used to defoliate jungle around U.S. bases and outposts. If enacted, the bill would cover veterans who had received a Vietnam Service Medal, Vietnam Campaign Medal or who served on Johnston Island, a Navy outpost, beginning 1 APR 72, and ending 30 SEP 77. Rep. Bob Filner (D-CA-51), the House Veterans Affairs Committee chairman who is the measures chief sponsor, said the bill goes a long way toward providing benefits to veterans whom the Veterans Affairs Department illogically refuses to acknowledge. Current law requires VA to provide care for service members exposed to Agent Orange by virtue of their boots on the ground, but ignores veterans that served in the blue waters and the blue skies of Vietnam, Filner said. His bill would provide the same presumptions to all combat veterans of the Vietnam War, regardless of where they served. Filner said he hopes Congress acts soon. Time is running out for these Vietnam veterans. Many are dying from their Agent Orange-related diseases, uncompensated for their sacrifice. Achieving the 218 votes needed to guarantee passage of a bill through the House does not guarantee the change will become law. There is a Senate version of the bill, S.1939, sponsored by Sen. Kirsten Gillibrand (D-NY) that has eight co-sponsors, far short of the 51 needed to guarantee passage. [Source: NavyTimes Rick Maze article 20 Nov 09 ++]




VA Emergency Care Update 04:     In 2001, the U.S. Congress provided VA with authorization (called the Mill Bill) to pay for emergency care in non-VA facilities for veterans enrolled in the VA health care system. The benefit will pay for emergency care rendered for non-service-connected conditions for enrolled veterans who have no other source of payment for the care. However, VA will only pay to the point of medical stability. There are very strict guidelines concerning these types of claims. Veterans and their non-VA providers should be aware that these claims must be filed with the VA within 90 days from the last day of the emergent care; otherwise, the claim will be denied because it was not filed in a timely manner. This benefit is a safety net for enrolled veterans who have no other means of paying a private facility emergency bill. If another health insurance provider pays all or part of a bill, VA cannot provide any reimbursement. Veterans who retired from the U.S. military are covered by Tricare/CHAMPUS insurance and cannot file a Mill Bill claim. To qualify, you must meet all of these criteria:


•     You were provided care in a hospital emergency department or similar facility providing emergency care; and

•     You are enrolled in the VA Health Care System, and

•     You have been provided care by a VA health care provider within the last 24 months (excludes C & P, Agent Orange, Ionized Radiation and Persian Gulf exams); and

•     You are financially liable to the provider of the emergency treatment for that treatment; and

•     You have no other form of health care insurance; and

•     You do not have coverage under Medicare, Medicaid, or a state program; and

•     You do not have coverage under any other VA programs; and

•     You have no other contractual or legal recourse against a third party (such as a Workman’s Comp Claim or a Motor Vehicle Accident) that will pay all or part of the bill; and

•     Department of Veterans Affairs or other federal facilities were not feasibly available at time of the emergency; and

•     The care must have been rendered in a medical emergency of such nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health.


       If you are an eligible veteran, and a VA facility is not feasibly available when you believe your health or life is in immediate danger, report directly to the closest emergency room (ER). If your condition is stabilized by the ER but additional medical care is needed, proceed to the nearest VAMC. If hospitalization is required for your service or non-service-connected condition, you, your representative or the treating facility should contact the nearest VAMC’s Transfer Center within 24 hours to arrange a transfer to VA care. Veterans have a responsibility to ensure that the VA Transfer Center is notified immediately upon any hospital admission. Payment responsibility is as follows:

•     VA will reimburse health care providers for all medical services necessary to stabilize your condition up to the point you can be transferred to an approved VA health care facility or other federal facility. If you stay beyond that point, you will assume full responsibility for the payment of costs associated with treatment.

•     If you are hospitalized, and the VA is notified, the VA will be in regular contact with your physician at the private hospital. As soon as your condition stabilizes, the VA will assist the private facility with arrangements to transport you to a VA, or VA-designated facility.

•     If the VA accepts responsibility for the emergency room visit and/or admission, the ambulance will be paid from the scene of the incident to the first non-VA facility providing necessary care.

•     The VA is only authorized to pay for an ambulance to go from the scene of the incident to the first non-VA facility providing necessary care. The veteran is responsible for payment for an ambulance from the non-VA facility to a VA facility. Ambulance bills are considered unauthorized claims, and must be submitted to the VA in a timely manner.

•     The VA’s authority for reimbursement of pharmacy items to veterans from non-VA providers follows a strict set of guidelines. The veteran must be actively enrolled in a Fee Basis Program; the pharmacy item must be considered as urgent or emergent by the initiating physician; the pharmacy item cannot be reimbursed past a 10 day supply; and the prescription and receipts must be turned in to the Fee Basis Unit. The reimbursement is based upon the U.S. Government’s Red Book cost and no taxes can be reimbursed.

•     If you are billed for emergency care services, contact the nearest VAMC Hospital Fee Unit and a representative will assist you in resolving the issue. Under the law, payment from the VA is considered as "payment in full" for the dates authorized.


     Claims must be filed with the nearest VA Medical facility to where the services were rendered within 90 days of the discharge date of medical service; otherwise, the claim will be denied because it was not filed in a timely manner. You will need to provide to the VA the following documents from the Emergency Room/Hospital for them to pay for emergency care in a non-VA facility?

•     HCFA Form UB92 or other Approved Medicare Form (OCR) (pink and white Medicare Billing Form) from the Hospital Business Finance Office

•     Itemized Billing Statement from the Hospital Business Office.

•     A complete copy of All Medical Records pertaining to the admission through the date of discharge for this ER Visit/Hospitalization.

•     Ambulance Provider HCFA Form 1500 or other Approved Medicare Form (OCR) (pink and white Medicare billing form).

•     Ambulance Trip Ticket/Run Report.

•     ALL OTHER Provider/Physician Medicare HCFA Form 1500 or other Approved Medicare Form (OCR)

[Source: Nov 09 ++]




Combat Zone Tax Rules:    A recent audit found hundreds of thousands of troops and civilians who have served in combat zones may not have received all their earned tax benefits or have continued to receive benefits to which they are not entitled. According to the audit by the Treasury Inspector General for Tax Administration “active combat zone indicators” remained on the 2007 tax records of some 339, 027 taxpayers beyond the date of their departure from a combat zone. That was 40% of the total number of taxpayers with combat zone indicators on their records for that tax year. The IRS initially reversed the indicators for those taxpayers, based on the exit dates provided by the Pentagon in monthly reports to the IRS, but reactivated the indicators when those taxpayers annotated “combat zone” on their tax returns. Service members and civilians can self-identify as serving in a combat zone by annotating their tax return or calling or e-mailing the IRS.  The IRS has required no proof to support such claims. In addition, the IG said:


•     The IRS records on combat zone tax indicators do not differentiate between military and civilian taxpayers — which can result in civilians being granted tax relief benefits to which they are not entitled.

•     The wages of civilians supporting the military in war zones are not excluded from federal tax, but such civilians are entitled to other benefits such as extensions of time to file their tax returns.


•     The IRS cannot tell which member of a married couple filing a joint return is in the military, or if both are serving, which also results in inaccurate returns.

•     The IG’s review of tax year 2007 records found that 1,720 of 185, 685 combat zone transactions identified Social Security numbers that did not match an IRS tax account — possibly the result of first-time filers or data entry errors. As a result those records were not flagged with a combat zone indicator.


     J. Russell George, the Treasury inspector general for tax administration said, “This is not the first time we have reported these findings. The IRS must do its best to correct this problem, especially during wartime.” A 2005 audit found that more than 58% of 580, 000 taxpayer records with active combat zone indicators were incorrect, and that errors created during updates “were not resolved.” The errors ranged from missing information to mismatches between Social Security numbers and names.  The IRS undertook a “one-time cleanup” following that audit by identifying and reversing the indicators on 203,485 accounts with an entry date more than three years old and no exit date. In its response to the new report the IRS said:


•     It concurred with nine of the 10 recommendations made by the inspector general.

•     It wants to eliminate self-identification on tax returns, but not until it is sure that other means of identification are adequate

•     It will consider the option of a secure form for self-identification by e-mail for civilians. For service members the monthly Pentagon notification should suffice said Michael McKenney, assistant IG for audit.

•     It will work to identify which member of a married couple is serving in a combat zone, or if both are, especially if they file jointly.

•     It is working to ensure the accurate reversal of a combat zone indicator for joint filers when it receives Pentagon notification of an exit date.


     The IRS disagreed with one recommendation, saying it already has a process for distinguishing between military and civilian taxpayers. The IG countered that although the IRS can identify service members through the records the Pentagon provides, it uses the same indicator for both. Once entered onto a civilian taxpayer’s record, that “could allow the civilian taxpayers to inappropriately exclude income without action by the IRS because the IRS will not review accounts with unreported income if a combat zone indicator is present.” The IRS set up a task force to evaluate processing concerns for combat zone tax exclusions in NOV 087 that has produced some positive results,

 the inspector general said. Under federal tax law enlisted personnel pay no federal tax on income earned in a combat zone, while officers pay taxes only on income that is above the highest monthly enlisted pay, a provision that affects only senior officers. All troops in combat zones can postpone filing and paying taxes, enforcement activities and other tax actions. [Source: ArmyTimes William H. McMichael article 30 Oct 09 ++]




Vet Pro Bono Assistance Update 01:  A Los Angeles-based law organization on 11 NOV launched a program to provide free legal assistance to veterans who hit bureaucratic roadblocks when filing claims for federal medical and mental health benefits. Public Counsel, a pro bono law firm, will offer the free service throughout Southern California and in partnership with other volunteer attorneys in more than 25 states. "Many veterans who return home to their families are facing a system that routinely rejects their benefit claims," Los Angeles Mayor Antonio Villaraigosa said at a Veterans Day news conference to announce the effort. "That's absolutely unacceptable. We can and must do more for our nation's heroes." Public Counsel President Hernan D. Vera said the effort would help the 1.7 million troops deployed to Afghanistan and Iran, many of whom have been denied benefits for post-traumatic stress disorder depression, traumatic brain injury, and other combat-related injuries. The program also will help the tens of thousands of homeless veterans living on the nation's streets to collect government assistance. "The veterans' homeless population is skyrocketing. Nearly one out of every four homeless individuals we see on the streets of Los Angeles wore the uniform protecting our country. But only one in 10 receive the government services that they're entitled to," Vera said. The legal program, called the Center for Veterans Advancement (CVA), will provide free legal representation in court as well as for administrative proceedings with the Department of Veterans Affairs, the Social Security Administration, all branches of the military,  and with other local and national agencies. For additional info refer to Veterans seeking assistance can contact Public Counsel at:

•     Mailing Address: P.O. Box 76900, Los Angeles, CA 90076 Tel: (213) 385-2977

•     Office Address: 610 South Ardmore Avenue, Los Angeles, CA 90005 Fax: (213) 385-9089


     The CVA also provides training in VA representation and assists veterans in obtaining housing, employment, medical care, and supportive services. Public Counsel provides the opportunity for its volunteers to work on a wide variety of projects. Some of the casework is relatively simple, suitable for new attorneys seeking to develop new skills or more experienced attorneys seeking to expand their legal experience. Other cases are highly complex. In addition to work on litigation matters, Public Counsel volunteers can also assist with transactional and administrative matters as well as work in specialized areas such as bankruptcy and health care. Public Counsel’s speakers’ bureaus provide lawyers opportunities to educate their clients about the lawyer’s area of specialty. Volunteer opportunities are by no means limited to lawyers. Paralegals, legal assistants, law students, expert witnesses, and individuals employed in other professions are needed and welcomed (see Non-legal volunteer opportunities). For information about volunteering at Public Counsel, contact their volunteer coordinator, Ted Zepeda, at (213) 385-2977 x125 or The Center for Veterans Advancement is being sponsored by grants from the Safeway and Vons foundations, as well as Northrop Grumman, the Oder Family Foundation, the Bettingen Foundation and other private donors. It does not receive city funding.  


     Marine Corps veteran Aaron Huffman 27, who served in both Iraq and Afghanistan from 2000 to 2004, said he was forced to turn to Public Counsel last year when the Veterans Administration denied his claim for medical coverage after he injured his back when his Humvee hit a roadside bomb in Iraq. The Humvee flipped and loads of gear landed on Huffman, pinning him against the windshield. Huffman said he underwent spinal surgery for three herniated disks in his lower back. He said the Veterans Administration immediately denied his claim for compensation, telling him that he needed to provide more documentation that showed the injuries were suffered in combat. "When you're in the middle of combat, you don't always have time to pull over and say, 'Time out, I just got hurt, can you record this,' " Huffman said. "That's not the way combat works. That's some of the issues veterans are facing."  [Source: Los Angeles Times Phil Willon article 12 Nov 09 ++]




VA Women Vet Programs Update 08:    Secretary of Veterans Affairs Eric K. Shinseki announced the Department of Veterans Affairs (VA) is launching a comprehensive study of women Veterans who served in the military during the Vietnam War to explore the effects of their military service upon their mental and physical health. The study, which begins NOV 09 and lasts more than four years, will contact approximately 10,000 women in a mailed survey, telephone interview and a review of their medical records.  As women Vietnam Veterans approach their mid-sixties, it is important to understand the impact of wartime deployment on health and mental outcomes nearly 40 years later.  The study will assess the prevalence of post-traumatic stress disorder (PTSD) and other mental and physical health conditions for women Vietnam Veterans, and explore the relationship between PTSD and other conditions.


     VA will study women Vietnam Veterans who may have had direct exposure to traumatic events, and for the first time, study those who served in facilities near Vietnam.  These women may have had similar, but less direct exposures.  Both women Veterans who receive their health care from VA and those who receive health care from other providers will be contacted to determine the prevalence of a variety of health conditions. About 250,000 women Veterans served in the military during the Vietnam War and about 7,000 were in or near Vietnam.  Those who were in Vietnam, those who served elsewhere in Southeast Asia and those who served in the United States are potential study participants. The study represents to date the most comprehensive examination of a group of women Vietnam Veterans, and will be used to shape future research on women Veterans in future wars.  Such an understanding will lay the groundwork for planning and providing appropriate services for women Veterans, as well

as for the aging Veteran population today.


     Women Veterans are one of the fastest growing segments of the Veteran population.  There are approximately 1.8 million women Veterans among the nation's total of 23 million living Veterans.  Women comprise 7.8% of the total Veteran population and nearly 5.5% of all Veterans who use VA health care services.  VA estimates women Veterans will constitute 10.5% of the Veteran population by 2020 and 9.5% of all VA patients. In recent years, VA has undertaken a number of initiatives to create or enhance services for women Veterans, including the implementation of comprehensive primary care throughout the nation, staffing every VA medical center with a women Veterans program manager, supporting a multifaceted research program on women's health, improving communication and outreach to women Veterans, and continuing the operation of organizations like the Center for Women Veterans and the Women Veterans Health Strategic Healthcare Group. The study, to be managed by VA's Cooperative Studies Program, is projected to cost $5.6 million.  [Source: VA Press Release 19 Nov 09 ++]




Tricare Regional Contracts Update 04:    In what may reflect a flawed Department of Defense (DoD) contracting process, on 17 NOV, the Sacramento Business Journal reported that the U.S. Government Accountability Office (GAO) has upheld Health Net's bid protest regarding the DoD's award of the $2.8 billion annual Tricare contract for delivering services to active-duty military personnel, National Guard and Reserve, retirees and dependents in twenty East Coast and Midwest states (Tricare North) to Aetna. The GAO had earlier upheld the bid protest of Humana Military Healthcare Services after it lost a multibillion-dollar contract for the southern region (Tricare South) to UnitedHealth Group Inc. The Journal reported that GAO concluded that Aetna had hired a former high-level Tricare employee with access to proprietary information about Health Net Inc.'s performance that could have given Aetna a competitive edge in its bid for the lucrative military health care contract. It went on to report that the GAO detailed six flaws in the procurement process in documents posted online 17 NOV, with a recommendation that Aetna should be excluded from the competition. This would place Health Net "as the only viable awardee." The article reported that according to Michael Golden, GAO managing associate general counsel for the bid protest division, will send a letter to defense officials detailing the flaws and the recommendations. Defense officials have 60 days to respond, but that a decision against the GAO recommendation is "extremely rare." If DoD fails to respond, GAO could present the matter to Congress for action. Tricare services will continue as the bid protest process moves forward through DoD, and, if necessary, through Congress. [Source: NGAUS Leg Up 20 Nov 09 ++]




Veterans Corps Update 02:    On 18 NOV Nicola Goren, Acting CEO of the Corporation for National and Community Service was joined by U.S. Senator Mark Warner (D-VA) and Representative John Sarbanes (D-MD-03) on a national conference call to discuss new funding opportunities to support veterans service and military families. The conference call with Veterans Service Organizations (VSO) and other veterans groups covered the development of the Veterans Corps and new AmeriCorps funding for programs that leverage veterans' skills and expertise to help restore local communities and ease veterans' transition to civilian life.  Veterans Corps is led by the Corporation and was authorized by the Edward M. Kennedy Serve America as part of the AmeriCorps program to prioritize funding for veterans services. Presently, the plan encourages veterans to apply by 26 JAN 2010.  According to officials participating in the conference call notification of acceptance in to the program is scheduled for JUN 2010.  Veteran groups were also informed that depending on need veterans may be eligible to receive housing, medical care, training and an educational allowance upon completion of the program.  For more information refer to the Corporation for National and Community Service website .  [Source: NAUS Weekly Update 20 Nov 09 ++]




Veteran Employment Update 05:     The Senate Veterans' Affairs Committee held a hearing 18 NOV on improving veterans' employment support and opportunities focusing on the needs of veterans recently separated from active duty. Current statistics show the unemployment rate of returning veterans to be among the highest at 11.6%.  Raymond Jefferson, Assistant Secretary for Veterans Employment and Training (VETS), Department of Labor discussed current VETS initiatives to include its competitive grant programs and their role in the Transition Assistance Program (TAP). Committee members probed representatives from wounded warrior transition teams, Microsoft, and Oracle for ideas on how to improve current programs and transition services to veterans. U.S. Senator Daniel K. Akaka (D-HI) Chairman of the Veterans’ Affairs Committee, held a hearing today . In his opening statement Akaka said, "These are difficult times for many Americans, with an unemployment rate higher than it has been in more than twenty years.  Many Americans have given up looking for work because they believe none is available.  Many others are only able to find part-time employment.  The extent of our challenges is truly staggering.  For our Nation’s veterans, especially those who have recently separated from active duty, the search for a job can be particularly difficult.  Skills honed on the battlefield are not easily translated to a resume for the civilian job market.  The problem is compounded by the need for a period of readjustment to civilian life. Veterans who have been injured while on active duty, and especially those who are suffering the invisible wounds of war, face an even more daunting task when seeking to find a career.  For those thousands of veterans who are homeless, who may be bearing the burdens of drug or alcohol abuse, or are struggling with mental health issues, finding work can seem impossible.  Older veterans, and those from other conflicts, may lack the skills necessary to compete in an increasingly high tech job market.  Jobs that once were plentiful may simply no longer exist .... “I will continue to work with my colleagues and advocates to help veterans find and maintain rewarding jobs.” For more on the hearing or to view the live webcast visit the Senate VA website at  [Source: VFW Washington Weekly 20 Nov 09 ++]




Veteran Employment Update 05:     The Senate Veterans' Affairs Committee held a hearing 18 NOV on improving veterans' employment support and opportunities focusing on the needs of veterans recently separated from active duty. Current statistics show the unemployment rate of returning veterans to be among the highest at 11.6%.  Raymond Jefferson, Assistant Secretary for Veterans Employment and Training (VETS), Department of Labor discussed current VETS initiatives to include its competitive grant programs and their role in the Transition Assistance Program (TAP). Committee members probed representatives from wounded warrior transition teams, Microsoft, and Oracle for ideas on how to improve current programs and transition services to veterans.

     U.S. Senator Daniel K. Akaka (D-HI), Chairman of the Veterans’ Affairs Committee, in his opening statement said, "These are difficult times for many Americans, with an unemployment rate higher than it has been in more than twenty years.  Many Americans have given up looking for work because they believe none is available.  Many others are only able to find part-time employment.  The extent of our challenges is truly staggering.  For our Nation’s veterans, especially those who have recently separated from active duty, the search for a job can be particularly difficult.  Skills honed on the battlefield are not easily translated to a resume for the civilian job market.  The problem is compounded by the need for a period of readjustment to civilian life. Veterans who have been injured while on active duty, and especially those who are suffering the invisible wounds of war, face an even more daunting task when seeking to find a career.  For those thousands of veterans who are homeless, who may be bearing the burdens of drug or alcohol abuse, or are struggling with mental health issues, finding work can seem impossible.  Older veterans, and those from other conflicts, may lack the skills necessary to compete in an increasingly high tech job market.  Jobs that once were plentiful may simply no longer exist .... I will continue to work with my colleagues and advocates to help veterans find and maintain rewarding jobs.” For more on the hearing or to view the live webcast visit the Senate VA website at  [Source: VFW Washington Weekly 20 Nov 09 ++]




Medicare Reimbursement Rates 2010 Update 02:    On 19 NOV the House of Representatives passed a bill that would stop the scheduled cut in Medicare physician payments rates scheduled for this coming January. The bill (H.R.3961) blocked the 21% physician cut required by the formula originally passed in 1997. The various scheduled cuts in the last decade have been delayed by Congress from going into effect. These Medicare payments are critically important to any military retiree who uses Tricare for Life, since both Medicare is first payer for TFL. If doctors stopped seeing Medicare patients due to the level of payments they could (and probably would) also stop seeing Tricare patients. The bill restructures the present payment formula in 2011, taking into account spending since 2009 “or, beginning in 2014, spending for the previous five years. It would provide two separate updates, one for evaluation, management and preventive services, and another for other services.”


     It is not at all clear whether the Senate will go along with this version. Last month the Senate rejected another House bill dealing with what is now called the “docs fix” in Washington because there is no offset. The CBO says this bill will cost $210 billion in 10 years and there is no offset in this proposal either. The day before the House passed its bill the Senate’s Minority Leader Senator Mitch McConnell (R-KY) said: “Senate Democrats recently tried to pass a so-called doc fix that would have forced seniors to pay higher premiums — on top of the half a trillion dollars they want to cut from Medicare. Fortunately, this bill was rejected by a wide bipartisan majority. While we all think this problem needs to be addressed, this is not the way to do it. And I’m confident that should a similar bill pass the House later this week, we’ll reject it again.” On the other hand everyone on both sides of the aisle thinks something must be done about the pending 21% cut. [Source: TREA Washington Update 20 Nov 09 ++]




VA Family Caregiver Assistance Update 01:    On 19 NOV the Senate passed Caregivers and Veterans Omnibus Health Services Act of 2009 (S.1963) an omnibus package of veterans bills. The bill had been held up for several days because of Senator Tom Coburn’s (R-OK) amendment calling for a cost offset. His amendment required an offset of the costs and would have ordered the State Department to transfer funds from its budget for supporting international organizations and peacekeeping activities. The amendment was defeated 32-66. The bill was then passed 98-0. It combined several different bills:


•     S.801: Family Caregiver Program Act of 2009. A bill to amend title 38, United States Code, to waive charges for humanitarian care provided by the Department of Veterans Affairs to family members accompanying veterans severely injured after September 11, 2001, as they receive medical care from the Department and to provide assistance to family caregivers, and for other purposes.

•     S.252: Veterans Health Care Authorization Act of 2009. A bill to amend title 38, United States Code, to enhance the capacity of the Department of Veterans Affairs to recruit and retain nurses and other critical health-care professionals, to improve the provision of health care veterans, and for other purposes.

•     S.597: Veterans Health Care Improvement Act of 2009. A bill to amend title 38, United States Code, to expand and improve health care services available to women veterans, especially those serving in operation Iraqi Freedom and Operation Enduring Freedom, from the Department of Veterans Affairs, and for other purposes.

•     S.498: Vet Dental Insurance. A bill to amend title 38, United States Code, to authorize dental insurance for veterans and survivors and dependents of veterans, and for other purposes.

•     S.246: Veterans Health Care Quality Improvement Act. A bill to amend title 38, United States Code, to improve the quality of care provided to veterans in Department of Veterans Affairs medical facilities, to encourage highly qualified doctors to serve in hard-to-fill positions in such medical facilities, and for other purposes.

•     S.772: Honor Act of 2009. A bill to enhance benefits for survivors of certain former members of the Armed Forces with a history of post-traumatic stress disorder or traumatic brain injury, to enhance availability and access to mental health counseling for members of the Armed Forces and veterans, and for other purposes.


    Among other things It authorizes approximately $3.7 billion for programs to help caregivers for veterans from the Iraq and Afghanistan wars, improve health care in rural areas, focus on women veterans health care, provide VA dental care for some veterans and their families and survivors. Senator Coburn’s failed amendment would have also expanded the bill to cover all veterans rather than just those from the present wars. His hold caused a dramatic confrontation. Veterans’ Affairs Chairman Daniel K. Akaka (D-HI) said: “The cost of veterans’ health care is a true cost of war and must be treated as such. The cost of the underlying bill does not need to be offset. The price has already been paid, many times over, by the service of the brave men and women who wore our nation’s uniform.” Senator Coburn’s statement was: “I don’t have any opposition to veterans’ care. We’re supposedly anti-veteran because we think maybe we ought to pay for some things that we do around here. . . . I apologize to no one for having put a hold on this bill for a very good reason.” [Source: TREA Washington Update 20 Nov 09 ++]




SDVOSB Contract Fraud:     Of more than 100 allegations of fraud and abuse, GAO audited 10 firms between OCT 08 and NOV 09 and found that ineligible companies improperly received millions of dollars in set-aside and sole source Service Disabled Veteran Owned Small Business (SDVOSB) contracts. The audited firms received approximately $100 million in SDVOSB contracts and another $300 million through other small business programs such as the 8(a) program for disadvantaged minority groups and the HUBZone program for firms located in historically underutilized business zones. According to the Small Business Administration, $6.5 billion in federal contracts were awarded to service-disabled veteran-owned small businesses in fiscal 2008. The firms GAO studied committed the fraud in several ways. One company owner was not a service-disabled veteran, another was owned by a service-disabled veteran, but he did not control the firm's daily operations, and several SDVOSBs were serving as pass-throughs for large and sometimes foreign corporations. In the case of a pass-through, a firm or team listed a service-disabled veteran as the majority owner, but all work was performed and managed by a nonservice disabled person or firm, in violation of program requirements.


     Gregory Kutz, GAO managing director of forensic audits and special investigations, told the House Small Business Committee on 19 NOV that the case studies show "significant control weaknesses" in the program, including effective fraud prevention by the Small Business Administration. "The SDVOSB program is essentially an eligibility-based program," Kutz said. "However, neither the SBA, except when responding to a protest, nor contracting officials are currently verifying the eligibility of firms claiming to be SDVOSBs." Neither SBA nor contracting agencies have processes in place to access Veterans Affairs Department records listing individuals who are valid service-disabled veterans, Kutz said. Contracting officers also are not required to validate a firm's eligibility before an award. And unlike the 8(a) or HUBZone programs, firms professing eligibility are not required to submit documents substantiating this claim. Perhaps most discouraging, Kutz said, was that in many fraud cases, federal contracting officials were "actively involved" in and aware of the misrepresentation. He cited an example of a contract for furniture at MacDill Air Force Base in Tampa, Fla., where the contract was awarded to a firm -- essentially a shell company -- owned by a full-time contract employee on the base. "The base director of business operations also told us that MacDill had about $14 million in service-disabled veteran-owned small business sole source and set-aside contracts in 2008, and 90% of firms that received these contracts were front companies for large businesses," Kutz told lawmakers.


     Committee members of both parties expressed outrage and disgust at the misuse of a program designed to help injured veterans. "Imagine being a veteran who is injured in Iraq or Afghanistan, yet despite your injuries you still manage to launch your own business. Then imagine finding out that you are losing out on contracts designated for veterans because a big company found out how to get around the rules," said Rep. Nydia Velazquez (D-NY). "What kind of message does that send to veterans in this country? We've got to stop it." Rep. Sam Graves (R-MO), said fraud alone would be problematic, but in this case it shuts out deserving individuals and firms from crucial opportunities. "The firms denied contracts are those owned by individuals who made a significant sacrifice in defending our country," Graves said. "That is simply unacceptable." Lawmakers and GAO both said at the hearing that there must be greater and swifter penalties for those violating the SDVOSB program. While Mills said SBA has recommended that the 10 firms GAO studied be investigated by the SBA inspector general, Kutz said many, if not all, could still be eligible to receive federal dollars. "It's important when they lie to us and cheat that we do something about it," Kutz said. "You can suspend someone without going through a lengthy three-year process of debarment."


     Administrator Karen Mills said SBA was working closely with Veterans Affairs to strengthen oversight of the program, but that primarily SBA is responsible for ensuring SDVOSBs were in fact small businesses, and VA is responsible for ensuring the owners are service-disabled veterans. "The culture of the SBA is that we will not be the agency of fraud, waste, abuse and mismanagement," Mills said. "We have an aggressive, new attitude towards this; it is explicitly one of our priorities." Kutz echoed the idea that this priority is relatively new for SBA. "SBA is good people, but the history of SBA has been as an advocacy organization, not an enforcement organization," he said. "Therefore, you're not going to have the right kind of people, necessarily, that are very good at this. But I would argue that if you're going to be an advocate for small businesses, you need to deal with the integrity of the programs, and today's hearing is a good start." [Source: Elizabeth Newell article 19 Nov 09 ++]




VA Nursing Homes Update 04:    Senator John Ensign’s amendment to expand access for Gold Star parents to Veterans Affairs Nursing Homes was included in the "2010 Military Construction and Veterans Affairs Appropriations “a bill that passed the Senate 17 NOV.   Ensign’s amendment will provide Gold Star parents with access to VA Nursing Homes even if they have not lost all of their children in combat. Ensign, said, “Our servicemen and –women make the ultimate sacrifice when they give their life for our country. However, Gold Star parents pay the ultimate price when they lose their child for the sake of our country and they are owed a great honor.  Current policy requires that these parents must face this loss for every one of their children before they gain admittance to VA Nursing Homes.  My legislation will help correct this injustice because one loss is more than should be required to receive VA Nursing Home care for Gold Star parents.” Currently, Gold Star parents may receive care in a VA home only if they have lost all of their children in service to our country.  This matter was brought to Senator Ensign’s attention by the Nevada Office of Veterans’ Services and the National Association of State Veterans’ Homes because they are currently in a situation where they must deny admission to Gold Star parents if they have any surviving children. [Source: KTVN-TV Reno NV article 18 Nov 09 ++]




VA Claim Denial Update 04:   A House subcommittee moved 18 NOV to reduce the amount of time it takes for a veteran to appeal a benefits decision, which can add two to five years to the wait for benefits. Approved by the disability assistance and memorial affairs subcommittee of the House Veterans’ Affairs Committee, the unnumbered draft bill, called the Veterans Appeals Improvement and Modernization Act of 2009, attempts to streamline both the administration appeals process within the Veterans Affairs Department and the judicial review process through the Court of Appeals for Veterans Claims. Included in the bill are procedural changes, such as allowing new information from a veteran whose claim is under appeal to be sent directly to the Board of Veterans Affairs, rather than to a regional office where it would have to work its way through the bureaucracy; and giving the Court of Appeals for Veterans Claims the power to review an entire claim, not just one part at a time. The change in the appeals court process is aimed at what veterans have come to call the “hamster wheel” of having a claim with multiple issues decided one at a time in a process that never seems to end as the claim is sent back and forth between the regional official and administrative board. Additionally, the bill tries to set the stage for more fundamental changes by creating an independent panel, the Veterans Judicial Review Commission, that would evaluate the disability and survivor benefits claims process and recommend changes. An interim report from the commission would be required by July 2010 with a final report by 30 DEC 2010. The report deadlines make it possible that some changes could be approved by Congress as early as next year, but major changes would not be considered until 2011. [Source: AirForceTimes Rick Maze article 18 Nov 09 ++]




VA Budget 2010 Update 05:    The Senate approved its version of the "2010 Military Construction and Veterans Affairs Appropriations" bill with a proposed budget of $133.9 billion on 17 NOV. The House version of the legislation was approved in July. The measure (HR 3082), passed 100-0, is now headed to conference committee, where negotiators will try to hammer out the differences between the Senate and House versions. Some items of interest to the veteran community in the Senate version include:


•     Both Senate and House bills include an information technology (IT) budget of $3.3 billion. However, the Senate bill puts hold on $1.1 billion in IT development funds until VA's Chief Information Officer Roger Baker completes a review of the department's IT systems and he and Secretary Eric Shinseki identify which projects should receive funding in fiscal 2010.

•     $3.2 billion nationally for health care and support services for homeless veterans, including $500 million in direct programs to assist homeless veterans.

•     $50 million for the VA to renovate unused, empty buildings on VA campuses to provide housing with supportive services, including rehabilitation and counseling, for homeless veterans.

•     $29 million for medical care for veterans in highly rural areas  

•     $44.7 billion for VA healthcare in fiscal 2010, which started 1 OCT 09

•     $48.2 billion for VA medical services for 2011 to end the cycle of the VA getting its funding late every year as Congress wrangles over the federal budget.

•     Gold Star parent admission to VA nursing homes. 

•     An amendment that directs VA to study how it addresses combat stress in women vets.

•     A provision that requires the National Cemetery Administration (NCA) to look Into creating a national cemetery In Montana.

[Source: Various 19 Nov ++]




Tricare Reserve Select Update 14:    Gray area military retirees who were promised health care coverage under Tricare may have to wait a year or longer for benefits to begin, Tricare officials are warning. Reserve retirees, who have had to wait until age 60 before military health coverage begins, had been promised they could sign up for Tricare Reserve Select under a provision of the 2010 National Defense Authorization Act, which was signed by President Barack Obama on 28 OCT 09. Tricare coverage for the reserve retirees — called “gray area” retirees because they are eligible for, but not yet receiving, retirement benefits — was authorized effective 1 OCT, but everyone expected it would take six to eight months to implement, based on the amount of time it has taken for other Tricare changes. But military and veterans associations were surprised 17 NOV when a Tricare official said it could take 11 to 18 months before enrollment is allowed.


     One group thinks the delay might be driven by the budget. “I suspect the Pentagon is slowing implementation to coincide with the next generation of a Tricare contract to avoid change order costs,” said Marshall Hanson, a retired Navy captain who is legislative director for the Reserve Officers Association. Hanson’s group has launched an effort with other military associations to try to push the Defense Department to move faster by getting congressional leaders involved. Congressional aides working on military health care issues said they already have heard complaints about the slow implementation and were trying to determine the reason. The Tricare statement warning of the delay says the new program requires Tricare to come up with “complex operational procedures, negotiate significant modifications to existing contracts and introduce changes in the Code of Federal Regulations.” The statement from Thomas E. Broyles, a Tricare Management Activity spokesman, was sent to several military and veterans groups that were inquiring about when the new benefit would begin. [Source: MarineCorpsTimes Rick Maze article 18 Nov 09 ++]




Tricare Reserve Select Update 15:     By law, Tricare Reserve Select (TRS) Premiums are now based on the actual cost of delivering care to Guard and Reserve families. Previously, the Defense Department developed TRS premiums based on federal civilian health costs. When military associations and Congress questioned that, the Government Accountability Office did a study and determined that TRS premiums were significantly higher than actual costs would indicate. So Congress directed a substantial premium reduction, implemented in JAN 09, and required that 2010 premiums would be 28% of the average of actual cost of delivering care to Guard and Reserve eligibles in 2007 and 2008. The Defense Department has announced that:

•     The TRS member-only premium for 2010 will be $49.62 per month - a $2.11 (4.4%) increase from 2009.

•     The TRS family premium for 2010 will be $197.65 per month - a $17.48 (9.7%) increase.


     Current enrollment in the program is approximately 30% of those eligible. Enrolling in Tricare Reserve Select (TRS) is a 2-step process:

1.    Qualify - Log on to the Guard and Reserve Web Portal; Follow the instructions; Print and sign the TRS Request Form (DD Form 2896-1)

2.    Purchase - You may purchase the plan at any time throughout the year, there are no tiers or open seasons. Mail or fax your completed TRS Request Form along with the first month's premium payment to your regional contractor within the specified deadline.  [Source: NGAUS & MOAA Leg Up 20 & 24 Nov 09 ++]




VA Thyroid Cancer Treatment:     A thyroid cancer patient at the San Diego VA Medical Center recently received an unusually large dose of radiation after radioactive iodine became stuck in his feeding tube for nearly four days, federal regulators and the hospital’s officials said. Dr. Daniel Duick, a thyroid cancer expert in Phoenix and former president of the American Association of Clinical Endocrinologists, said he had never heard of such a case. “Why would (the iodine) have gotten lodged in the feeding tube?” he said. “It doesn’t make sense. There is something radically wrong here.” Doctors at the Veterans Affairs Medical Center in La Jolla said the patient wasn’t injured. “Any occurrence from radiation exposure we would have expected to see already,” said Dr. Ernest Belezzuoli, who heads the hospital’s nuclear medicine program. “The patient is doing well, with no adverse effects.” VA officials have reported the 21 SEP incident to the federal Nuclear Regulatory Commission and halted the practice of administering radioactive iodine through feeding tubes.


     Receiving radioactive iodine is a standard treatment for most thyroid cancer patients after they undergo surgery to remove the diseased gland. Patients typically swallow the liquid, which enters the bloodstream and gets absorbed by any remaining thyroid cells. Over two days, the radioactive material is excreted naturally from the body. While that’s happening, the patients are confined as doctors monitor their levels of radioactivity. In the VA hospital case, the patient, who lives outside of San Diego County, was supposed to be treated with 194 millicuries of I-131 sodium iodide. Because the man couldn’t swallow due to the recent surgery on his neck, physicians administered the liquid iodine through a feeding tube, Belezzuoli said. “We noticed in our standard monitoring that the radioactivity levels were not going down as expected,” Belezzuoli said. “When we realized the atypical nature of that, we had the feeding tube removed.”  A scan of the tube revealed 80 millicuries of iodine, according to a report the hospital filed with the Nuclear Regulatory Commission. Doctors estimated that less than half of the intended dose was absorbed by the patient’s body.


     Only a small number of thyroid cancer patients receive radioactive iodine therapy through a feeding tube. “Maybe one every five years” at the local VA hospital, Belezzuoli said. It’s unclear why the iodine became stuck in the recent case. Medical workers administering the treatment typically flush the tube with water to ensure the dose has been delivered properly, Duick said. In rare instances, some of the iodine becomes trapped in the patient’s intestines because of constipation, Belezzuoli said. “We may never know exactly the entire situation,” he said. “It could be an isolated equipment issue. It could be a process issue. It could just be retention in the patient.” Investigators for the Nuclear Regulatory Commission recently spent several days at the VA hospital, said commission spokeswoman Viktoria Mitlyng. They expect to issue a report on the iodine incident in the coming weeks. Duick said the case could draw the interest of other physicians who treat thyroid cancer patients. [Source: San Diego Union Keith Darcé article 16 Nov 09 ++]





DoD to VA Transition Update 12:     The Departments of Defense (DoD) and Veterans Affairs (VA) announced 16 NOV that beginning in JAN 2010, the Disability Evaluation System (DES) pilot will expand to an additional six installations across the country. The new locations will include: Fort Benning, Ga.; Fort Bragg, N.C.; Fort Hood, Texas; Fort Lewis, Wash.; Fort Riley, Kan.; and Portsmouth Naval Medical Center, Va. This expansion brings the total number of military facilities using the pilot to 27. “The decision to expand the pilot was based upon favorable reviews focusing on the program’s ability to meet timeliness, effectiveness, transparency, and customer and stakeholder satisfaction,” said Noel Koch, deputy under secretary of defense, Office of Wounded Warrior Care and Transition Policy. In NOV 07, the DoD and VA implemented the pilot test for disability cases originating at the three major military treatment facilities in the national capital region.  The pilot is a test of a new process design eliminating the duplicative, time-consuming, and often confusing elements of the two current disability processes of the departments.  Key features of the DES pilot include one medical examination and a single-sourced disability rating.   To date, more than 5,431 service members have participated in the pilot since NOV 07. In OCT 08, DoD and VA approved expansion of the DES pilot to 18 sites beyond the three initial national capital region sites. This process was successfully completed on 31 MAY 09. The estimated completion date for the new six site expansion is scheduled for 31 MAR 2010.  “This expansion encompasses an additional 20% of total service member population enrolled in the program to achieve 47% overall enrollments, which will allow us to gather and evaluate data from a diverse geographic area, prior to determining worldwide implementation,” said Koch. The pilot was authorized by the Defense Authorization Act of 2008 and stems from the recommendations from the reports of the Task Force on Returning Global War on Terrorism Heroes, the Independent Review Group, the President’s Commission on Care for America’s Returning Wounded Warriors (the Dole/Shalala Commission), and the Commission on Veterans’ Disability Benefits. [Source: DoD News Release No. 895-09 dtd 16 Nov 09 ++]




Aid & Attendance Update 03:   This Special Pension (part of the VA Improved Pension program) allows for Veterans and surviving spouses who require the regular attendance of another person to assist in eating, bathing, dressing, undressing or taking care of the needs of nature to receive additional monetary benefits.  It also includes individuals who are blind or a patient in a nursing home because of mental or physical incapacity.  Assisted care in an assisted living facility also qualifies. This most important benefit is overlooked by many families with Veterans or surviving spouses who need additional monies to help care for ailing parents or loved ones.  This is a "pension benefit" and is not dependent upon service-related injuries for compensation.  Most Veterans who are in need of assistance qualify for this pension.  Aid and Attendance can help pay for care in the home, nursing home or assisted living facility.  For 2009 a single veteran is eligible for up to maximum benefit of $1,645 per month ($19,736 annually), while a surviving spouse is eligible for up to $1,057 per month ($12,681 annually).  A couple is eligible for up to $1,950 per month ($23,396 annually).  To be eligible the veteran must have served during one of the following periods:

•     World War II: December 7, 1941 through December 31, 1946

•     Korean War: June 27, 1950 through January 31, 1955

•     Vietnam War: August 5, 1964 (February 28, 1961, for veterans who served “in country” before August 5, 1964), through May 7, 1975

•     Gulf War: August 2, 1990, through a date to be set by law of Presidential Proclamation


     The VA must determine that your net worth is such that it will probably not support you through the remainder of your life. The VA does not include primary residence or vehicles when determining net worth. To qualify you must have a “countable income” of less than the pension amount to be eligible for all or a portion of the pension. Countable Income is the amount of income a veteran or surviving spouse receives each year including rollover interest, AFTER deducting all unreimbursed, and recurring health care expenses. This includes assisted living costs, home health care, insurance & Medicare premiums, on-going pharmacy costs and more. If you have dependents, their health care costs can also be used to reduce your countable income. However, their income must also be added into the equation.  Refer to for additional details on the Aid & Attendance pension. Application to the VA for this benefit can be made by any of the following methods:

•     On line at; or 

•     At download and fill out VA Form 21-526, Veteran's Application for Compensation and/or Pension.  Send the completed application and any copies of other documents to the VA regional office that serves your area of residence. Make sure you download all parts of the application as well as the instructions for filling out the forms.  If available, attach copies of dependency records (marriage & children's birth certificates).

•     Contact a Veterans Service Officer (VSO) from a veterans service organization.    To locate call 1-800-827-1000, for the location of the nearest VSO nearest you.  Also, you can refer to for a list of the nationally recognized Veterans Service Organizations.


     There are three levels to the Improved Pension program: Basic Pension, Housebound, or Aid & Attendance. Each tier has its own level of benefits and qualifications.  If you or your loved one does not qualify for Aid and Attendance, you may want to check to see if you qualify for another level of the Pension. For example the following would apply for eligibility to receive the Basic Pension:

•     A veteran receives $14,000 per year from Social Security. His wife earns $9,000 per year. The veteran also earns $5,000 per year from a small company pension giving the couple a total annual income of $28,000, and;

•     The couple have $38,000 in net worth in CDs and savings (not enough to support them for the rest of their lives) and they still live in the home they bought in 1954, and;

•     The veteran pays $1,800 per month for his wife’s home health care, they each pay a monthly Medicare premium of $96.40 (x 2 = $192.80/mo), and he also pays $149 per month for supplemental insurance. Thus, their total medical monthly expenses come to $25,702 per annum.

•     When you subtract the medical expenses from their total income, you get a “countable income” of only $2,368. The maximum basic benefit amount of $15,493 minus the countable income amount of $2,298 equals $13,195 ($1100 per month) which would be paid by the VA if the veteran applies for it..

[Source: Various Nov 09 ++]



Mammograms:    A government panel's recommendation 16 NOV that women under the age of 50 do not need regular mammograms set off a furious debate about the importance of the routine screening tool, leaving many women confused about how best to protect their health. In issuing its guidelines, the U.S. Preventive Services Task Force concluded that risk of breast cancer is very low in women age 40 to 50 and that the risk of false positives and complications from biopsies and other invasive procedures is too high for the procedure to be used routinely. The current standard is mammograms every year or two for women 40 and older. Oncologists were nearly uniform in their disparagement of the guidelines, fearing the loss of a valuable cancer-prevention tool. Women in their 40s account for at least a quarter of breast cancer diagnoses. "I think it is unfortunate that they came to this conclusion," said Dr. Angela Sie, director of imaging at the Breast Center at Long Beach Memorial Hospital. "It would be a huge step backwards for women's health in this country." And other groups that issue guidelines about screening and prevention, such as the American Cancer Society, the National Cancer Institute and the American College of Obstetricians and Gynecologists, immediately attacked the federal panel's conclusion, saying that they would not change their guidelines and would continue to urge women to undergo the tests. Insurance companies and Medicare administrators, which normally follow the panel's guidelines closely, said they would continue to pay for the procedure -- although it is not clear how long they can resist the panel's influence.


     The argument is similar to the one recently surrounding men's screening for prostate cancer. Several studies have suggested that complications from false positives and biopsies in PSA (prostate-specific antigen) screening outweigh the potential benefits of the procedure. The government panel has not produced general guidelines for prostate testing. The cancer society and institute simply recommend that men consult with their doctors about the potential value of the test. That, in effect, is also what the panel is suggesting for mammograms. The U.S. Preventive Services Task Force was established by the U.S. Public Health Service in 1986 to assess the value of preventive medical techniques, such as mammography. It is now sponsored by the Department of Health and Human Services' Agency for Healthcare Research and Quality. Its recommendations are closely watched and are generally followed by insurance companies and Medicare, but adherence is not mandatory. The task force issued the new guidelines, an update to its 2002 recommendations in the journal Annals of Internal Medicine. "No one is saying that women should not be screened in their 40s," said Dr. Diana Petitti, vice chairwoman of the task force. "We're saying there needs to be a discussion between women and their doctors." The task force also advised women age 50 and older to get mammograms every two years instead of every year, and said evidence isn't sufficient to determine a course of action for women 75 and older.


     Breast cancer specialists warned that the new recommendations could undermine advances in detecting and treating breast cancer early. Deaths from breast cancer have dropped 30% since 1990. Mammography "is one screening test that I recommend unequivocally, and would recommend to any woman 40 and over," Dr. Otis W. Brawley, chief medical officer of the cancer society, said in a statement. Brawley said the task force concluded that screening 1,300 women in their 50s to save one life is worth it, but that screening 1,900 women in their 40s to save one life is not. Brawley also noted that 17% of breast cancer deaths in 2006 were among women diagnosed in their 40s. Added Dr. Len Lichtenfeld, the cancer society's deputy medical officer: After a review of the evidence, "We see no reason at this point to alter our guidelines." Women in their 40s "have more aggressive cancers, have higher risks of death and recurrence, and more difficult cancers to treat," added Dr. Alice Chung, assistant director of the John Wayne Cancer Institute Breast Center in Santa Monica. "When you are weighing the benefits and risks for them, the benefits clearly outweigh the risks." More than 192,000 new cases of breast cancer are expected in the U.S. this year, and 40,000 deaths. Early detection is the best tool to prevent deaths, most oncologists agree. The task force also recommends against breast self-examinations, saying teaching women how to perform them doesn't save lives. Instead, experts say, women should make a point of noticing any changes in their breasts in the course of daily activities. [Source: Los Angeles Times Judith Graham & Thomas H. Maugh article 17 Nov 09 ++]




Cholesterol:    Cholesterol is a waxy substance in the bloodstream that plays a critical role in maintaining cell membranes and hormones in the body. It’s crucial to life, completely natural, yet somehow infamous in the minds of health conscious people worldwide. In general, the body is able produce all the cholesterol it needs by synthesizing it in the liver. However, it can also be ingested through food sources such as egg yolks, meat, and dairy products. Overconsumption is the primary cause of elevated cholesterol levels, the consequence of which is multiple associated health risks and a common source of anxiety for many individuals. Cholesterol is only partially water-soluble, which means it cannot dissolve and move through the bloodstream efficiently. Lipoproteins are specialized spherical proteins that encapsulate cholesterol and provide a soluble means of transportation. The density of these lipoproteins categorize cholesterol into four levels: very low density lipoprotein (VLDL), intermediate density lipoprotein (IDL), low density lipoprotein (LDL), and high density lipoprotein (HDL)


     LDL can sometimes leave deposits along the artery linings. These deposits, compounded over time, can narrow the arteries and reduce blood flow in a process called atherosclerosis. HDL can reverse the narrowing process by removing the deposits and delivering them to the liver, where cholesterol will be degraded or recycled. Therefore, it's important to maintain a healthy ratio of LDL and HDL cholesterol to minimize the risk of coronary heart disease. If your LDL cholesterol is too high, or your HDL cholesterol is too low, consider alternatives to foods high in saturated fat such as oatmeal and other complex carbohydrates that can trap LDL cholesterol and remove it from the body. Healthy eating and regular exercise will help you maintain a proper ratio, as well as numerous additional benefits. Bottom line cholesterol in moderation is healthy and necessary for life. So the next time someone speaks ill of it, remind them that even excessive water consumption can be hazardous to a person’s health. [Source: Nov 09 ++]



Cholesterol Update 01:    Results of a new study suggest that the cholesterol lowering drug Zetia, manufactured by Merck maybe dangerous. Millions of Americans take Zetia to control their cholesterol, but study results indicate that they maybe at increased risk of heart problems. In the study, researchers analyzed health records of people who took Zetia, comparing them to people taking a rival drug, Niaspan. Those people on the Merck drug did not see a reduction in their cholesterol build up and were also at a greater statistical risk of suffering a heart attack. Zetia “has been on the market for about seven years and we still haven’t proven that it improves clinical outcomes,” said Dr. Roger Blumenthal, preventive cardiology chief at Johns Hopkins University. The new results will be “very influential” in getting more doctors to turn to Niaspan, he said. The study will be published in the 16 NOV issue of the New England Journal of Medicine. [Source: Nov 09 ++]




U.S. Savings Bonds Update 05:     Holders of lost savings bonds dating back to World War II say it's not nearly as easy to track down the lost money as the U.S. Treasury Department claims in an ongoing lawsuit. The Bureau of the Public Debt counters that its process aims to make sure that only the legal owners of the old bonds are able to redeem them. Demanding requirements - which can include the Social Security number of long-dead original purchasers for a gift bond - are in place to make sure the money ends up in the right place, the agency said.  Anne Adams of Nashville, Tenn., doesn't believe it. She has spent months trying to recover lost bonds for her daughter and her husband. In both cases, she said the Treasury Department threw up insurmountable roadblocks to recovering the money. Her husband served in the Marines during the Vietnam War, she said, and had a large portion of his paycheck automatically sent into savings bonds. Adams said the Treasury Department required copies of the original paycheck stubs in order to track down the lost bonds. The family had no way of getting the old paystubs from the Marines. "It was a lot of money, probably half his paycheck for four years," Adams said.  For her daughter, Treasury is asking for the Social Security number of the now deceased family friend - from another state - who originally bought the $100 bond in the late 1970s. "It was a waste of money, it was a complete waste of money," Adams said of the bonds. "I am sure that money is going somewhere, but it is not to the people it was intended for."


     If she can't find the lost bond or the requested documentation, the Treasury Department doesn't have to send her the money. "I am starting to think that is what they were counting on," Adams said. Joyce Harris, with the Bureau of the Public Debt, said the agency needs to make sure that only the legal owners of the bonds can redeem them. "We want to make sure the rightful owner is getting the proceeds of the bond," she said. More than $16 billion worth of the bonds are unclaimed. Several states are suing the federal government, seeking the money back on behalf of their residents. Montana, New Jersey, North Carolina, Kentucky, Oklahoma and Missouri argue states are the legal repository for lost funds, and already have a system in place that makes it easy for people to reconnect with lost money. The federal government counters that the money isn't really lost. "It is not unclaimed property," said Harris, the Treasury spokeswoman. "It is unredeemed in our minds." A Web site  set up by the Treasury Department to help people track down lost bonds only searches back as far as the early 1970s - frustrating those who hold older bonds commonly bought much earlier during patriotic fundraising efforts. But Harris said older records were not computerized. And she noted earlier bonds were often bought with just names, and not listed under a Social Security number that can facilitate a computer search.


     Tom Boergadine of St. Louis said he has been trying to help his wife Gail track down a bond purchased in 1963. But he said the Treasury Department has been of little help, especially after it became clear the Internet search site was of no use to them. "It's obviously frustrating," he said. "There is no lost bond department that we know of." Boergadine said that the bond is not for a lot of money, perhaps $100. The relatively small sums of the bonds prompted many families to simply forget about them as time went on. The bonds date back to the unprecedented bond buying campaign of World War II. Most American families bought at least one bond at the time and many never cashed them in - thanks in part to a 40-year maturity in the bonds. And those same "Series E" war bonds continued to be sold by the federal government until 1980. Not everyone holding old, unredeemed bonds favors the lawsuit, which would transfer the money to the states. Bea Giusti said her 83-year-old husband bought bonds when he was a soldier in World War II. The California resident who lives north of San Francisco says she doesn't trust the state - caught in a financial meltdown - with the money. Giusti said the couple may simply pass the bonds on, unredeemed, to their grandchildren so they can be used later.  [Source: AP article 16 Nov 09 ++]




South Dakota DVA:      A coalition of veterans’ organizations that has tried for several years to convince South Dakota to create a separate Department of Veterans Affairs has gained new support on the issue. The veterans also want the director and employees of that department to be required to have had honorable discharges. About a dozen legislators joined Republican gubernatorial candidate and Senate Majority Leader Dave Knudson on 14 NOV in signing a pledge to split off Veterans Affairs from the state Department of Military Affairs and staff it only with people with honorable discharges. The legislators attended a lunch sponsored by the South Dakota Veterans Council, including the American Legion, Paralyzed Veterans of America, Retired Enlisted Association, Veterans of Foreign Wars and Disabled American Veterans. Legislators also agreed to support feasibility studies for an East River state veterans home and a state or national cemetery, and they promised to continue to support veterans preference in public, state and federal employment.


     American Legion Adjutant Denny Brenden pointed out that the House and Senate last year passed a concurrent resolution calling on the Legislative Research Council to study creating a new Veterans Affairs Department. But no study has been done. "The voices of South Dakota veterans are being ignored. This year we recommend a resolution to mandate a study," Brenden said. Rick Barg, VFW adjutant, said the 73,000 veterans in South Dakota create a powerful voting bloc. The pledge that legislators and gubernatorial candidates were asked to sign, which will be offered at three other events around the state, is a good voting guide to those veterans, he said. With the pledge, "we're telling them, 'This is how this guy feels about veterans,' " Barg said. "We're doing our homework before we get to Pierre. You're on our side, or you aren't with us." A Veterans Affairs Department separate from Military Affairs would fall in line with what a majority of states already recognize, that running a state National Guard and veterans programs present vastly different challenges, Murphy said. Twenty-seven states have separate Veterans Affairs Departments, and 17 states group Veterans Affairs with a department other than Military Affairs, according to Murphy. [Source: The Sioux-Falls Argus Peter Harriman article 15 Nov 09 ++]




Health Care Reform Update 16:     A report from Agence France Presse (AFP) indicates that the number of American veterans who died in 2008 because they didn't have healthcare, is 14 times higher than the military death toll in Afghanistan, for the entire year. Two Harvard medical researchers analyzed data, comparing U.S. combat-related deaths in Afghanistan, with the number of veterans who died because they lacked the ability to seek out adequate healthcare and access medical services. All of the veterans surveyed were under the age of 65. The study was released to coincide with the Veterans Day holiday, when those who died fighting overseas are honored and recognized. It clearly indicates that in spite of care from the Veterans Administration, many American veterans remain without coverage. The AFP report states that the analysis utilized census data to determine how many U.S. veterans lack both private health coverage and VA care. Associate Professor of Medicine at Harvard Medical School, David Himmelstein, is also the co-founder of Physicians for a National Health Program, which co-authored the study. He said the veterans represent a group of about 1.5 million people.


     Along with co-author Stephanie Woolhandler, who is also a Harvard medical professor, Himmelstein compared that figure with an additional study that examined the mortality rate that accompanies a lack of health insurance. He told AFP, "The uninsured have about a 40% higher risk of dying each year than otherwise comparable insured individuals. Putting that all together you get an estimate of almost 2,300 -- 2,266 veterans who die each year from lack of health insurance." He cites how some veterans in the U.S. have access to medical care through the VA, but that coverage, under the current system, breaks veterans down into 8 "priority groups" and this can lead to delays in treatment. "The priority eight group, the lowest priority, are veterans above the very poor group who have no other reason to be eligible and that group is essentially shut out of the VA," Himmelstein said. It is not clear how the study will affect the US Senate's decision on health care reform legislation. In the end, Himmelstein is clear that even current congressional proposals would still leave veterans out in the cold in terms of healthcare coverage. He says in the AFP article that he favors a national health care program similar to those in Britain and Canada.


     The Wall Street Journal’s columnist James Taranto’s opinion of what was reported above  is garbage in, garbage out. Even a reporter should be smart enough to realize that you can't derive a precise number like 2,266 from hazy ones like "about 1.5 million people" and "about a 40% higher risk." This is junk science with an obvious political agenda. [Source: Tim King article 15 Nov 09 ++]




Health Care Reform Update 17:     Two top Republicans warn that the national health care reform plan approved by the House of Representatives could end up hurting military retirees and veterans. Reps. Howard “Buck” McKeon of California, ranking Republican on the House Armed Services Committee, and Steve Buyer of Indiana, ranking Republican on the House Veterans’ Affairs Committee, said they fear the Affordable Health Care for America Act that passed the House by a 220-215 vote on 7 NOV would restrict options and possibly reduce coverage for veterans, retirees and their families. The bill is now headed to the Senate for debate that is likely to result in major changes in the bill. “I find it outrageous that the government would attempt to dictate where and how they obtain health care,” said Buyer, one of the lawmakers who helped create the Tricare for Life health benefit for Medicare-eligible military retirees. Specifically, Buyer said he opposes H.R.3962 because it “restricts veterans’ health care options and imposes a sweeping government takeover of our nation’s health care system.” The ability of the Defense and Veterans Affairs departments to fully control their own health care programs are jeopardized by the bill, he said, because these programs are not given autonomy from the larger federal health care czar position that would be created by the legislation.


     Democratic leaders, including the three committee chairman responsible for preparing H.R.3962, repeatedly have said there is nothing in the bill that interferes with military and veterans health coverage but McKeon and Buyer are talking mostly about unintended harm. The two key Republicans have the support of major veterans groups — including AmVets, Blinded Veterans of America and The Retired Enlisted Association — which share the same concerns, although perhaps not to the same fierce extent. Raymond Kelly, national legislative director AMVETS, said his concerns are based on a desire for clarity. “The intent of the bill is to allow veterans to have VA care and, if they qualify, to also be part of the insurance exchange to get care for themselves and their families,” Kelly said. “We support the intent, but we would like the bill to spell that out more directly.” Concessions were made in an effort to provide greater clarity, although McKeon and Buyer did not get everything they sought. At Buyer’s urging, the House bill includes a provision that would specifically exempt veterans enrolled in VA health care from having to pay a 2.5% penalty on their income if they don’t have private health insurance. [Source: ArmyTimes Rick Maze article 9 Nov 09 ++]




Health Care Reform Update 18:    A new federal report has found that the government paid $47 billion in questionable Medicare claims in fiscal year 2009, illustrating the challenges the government could face as it seeks to pay for health reform by reducing fraud. According to the report, the figure represents about 12.4% of spending in Medicare's fee-for-service program. It is unclear whether fraud is actually worsening because much of the increase in possible fraud over the last year is due to changes in HHS methodologies. The report indicates that from 2005 to 2008, the Bush administration reported that 4% of Medicare payments were improper -- or about $17 billion in 2008 alone. During that time, officials did not consider a payment improper if it lacked complete documentation or if the provider's signature was illegible -- even though these factors typically bar payment. Critics said that fraud figures during that period therefore were understated.


     For FY 2009, the Obama administration did count those claims as improper, but a complete tally could not be tabulated based on the new methodology. Using the new formula, the report officially lists a partial improper payment tally of 7.8% but noted that the unofficial 12.4% figure is more accurate. The federal government is hoping to reduce improper payments in the program to 9.5% next year, resulting in savings of $9.7 billion. The report also found that 9.6% of Medicaid claims, or about $18.1 billion, are improperly paid. President Obama is expected to announce new efforts to crack down on Medicare fraud, including a government Web site to provide a more comprehensive account of health care spending. CMS also is launching its own Web site next month that will allow users to track Medicare payments by state, diagnosis and hospital. CMS is coming under scrutiny because of records indicating that for three years, it ignored internal watchdog warnings of fraud in several programs. The records were provided to the press by Sen. Chuck Grassley (R-IA), ranking member of the Senate Finance Committee. HHS Secretary Kathleen Sebelius said the agency is implementing new processes for tracking warnings. [Source:  AP, Detroit Free Press, & Boston Globe articles 17 Nov 09 ++]




Health Care Reform Update 19:    The national health reform bill passed by the House last month and the Senate version to be debated in early DEC pose no threat to current health care benefits provided to military families, retirees or veterans, say advocates for these beneficiaries as well as congressional committee staffs. The Affordable Health Care for America Act (H.R.3962) states in Section 311 that "nothing" in the bill "shall be construed as affecting" authorities used by the departments of Defense and Veterans Affairs to provide Tricare programs or VA health care benefits. The Military Officers Association of America (MOAA), the Fleet Reserve Association of America, the American Legion and other veterans’ service organizations have studied the legislative language of both bills. Their own reviews, and assurances they’ve received from relevant committees, give them confidence that the bills won’t impact benefits or fees charged by Tricare or VA, nor will these beneficiaries be exposed to any new tax liabilities. "We have not talked to anybody — Republican, Democrat, anyone in the [Obama] administration or serving in Congress — who is trying to do anything to affect military people" as part of national health reform legislation, said Steve Strobridge, MOAA’s director of government relations.


     Confusing the issue for many beneficiaries has been an e-mail being passed among military retirees that warns falsely that the Congressional Budget Office has drafted legislation to attach new fees to Tricare for Life, the prized insurance supplement relied on by Medicare-eligible retirees. The e-mail is filled with misinformation.  CBO has no authority to draft legislation.  CBO did release a report last December presenting options for holding down federal health care costs; a few of those options would raise fees on military retirees and veterans.  But neither the Obama administration nor any members of Congress have embraced any of these ideas. Steve Robertson, legislative director for the American Legion, said he has assurances from the armed services committees, veterans’ affairs committees and congressional leaders including House Speaker Nancy Pelosi that health reform will not impact Tricare programs or VA health care. "My comfort level is pretty high," Robertson said. Strobridge noted that the Senate bill, the Patient Protection and Affordable Care Act (H.R.3590), doesn’t contain the same specific language that the House bill does to shield Tricare programs and VA health benefits. However, the Senate bill’s provision to allow an excise tax on "applicable employer-sponsored coverage" lists, among government plans, only the Federal Employees Health Benefits Plan for possible inclusion. Tricare and VA health care benefits are not named. Finance committee staffers have explained that this was intentional to shield these programs.


     MOAA has urged senators to add three clarifying provisions to their bill. One of those would duplicate language of the House bill that nothing in the legislation alters health care program authorities for DOD and VA. Other language is sought to explicitly exclude Tricare, Tricare for Life and VA health care programs from any health reform bill excise tax on certain employer-provided plans.  Finally, MOAA wants language in the Senate bill calling for a study of national health reform's impact on veterans to include a study of the impact on Tricare and Tricare for Life. Military people who seek assurance that the Senate health reform bill won’t impact them negatively end up "looking for something that isn’t there," Strobridge said. The Senate, like the House, should make it clear, he said. The only real threat to military and veteran benefits posed by national health reform, he continued, is the likelihood that it will add to the annual federal budget deficit which was $1.4 trillion last year. That will increase political pressure, over time, to curb federal entitlements including military health care and retirement plans, said Strobridge. "There are lots of people out there who would like to raise military fees" on health benefits, Strobridge said. "But they are not trying to do it in this legislation. ... As far as we can see, everybody in Congress is trying to bend over backwards to protect the military. And that's true of both parties."


     Pressure on defense budgets already is enormous. "That's why Defense leaders have been saying for years ‘I don't what to pay this $10 billion for Tricare for Life that we put in the defense bill every year.  I want to shift more costs to the beneficiary.  That is what the Bush administration said the last three years," Strobridge said. "We haven't even started to talk about the effect of the baby boom generation on Medicare and Social Security" on future budgets, he added. Given that pressure, MOAA has been pressing Congress to define in law that military members and retirees have earned through service certain unassailable rights to promised retirement and health care benefits. "What we're concerned about is that budget pressure will drive arbitrary decisions.  That is what has hurt us in the past," said Strobridge.  Congress should take steps to spell out what military folks have earned. "If you don't have any rules to rely on," he said, "when the budget tidal wave comes it will sweep you away."  [Source: Military Update Tom Philpott article 28 Nov 09 ++]




Veterans' Court Update 03:     A new report by the Drug Policy Alliance (DPA) exposes practices and policies that for decades have unjustly resulted in large numbers of psychically injured and addicted veterans landing in U.S. prisons and jails. The report reflects a year's worth of outreach to veterans and veterans' advocates across the country and a distillation of their most creative, innovative and optimistic responses to the problem. Gen. Steven Xenakis, M.D., special adviser to the Joint Chiefs of Staff for warrior and family support, brought a message of official support to a teleconference announcing the release of the report: "250,000 soldiers is a large number of soldiers, Marines, sailors and airmen who have been affected," he said. "It is so important that people are made aware of the issues and that we follow up with the best action plans we can find. … We in this country have a responsibility to assist and support them." The report recommends changes in state and federal statutes that now prioritize punishment over treatment for veterans who commit nonviolent drug-related offenses as a result of their addictions and other mental health issues. "Courts, as a way of dealing with large numbers of people with substance-abuse problems, are a very slow and expensive way to go," Dan Abrahamson, the Drug Policy Alliance's director of legal affairs, explained. "You need a courtroom and a judge and all the players, from prosecutors to defense attorneys. Providing treatment straight up requires far fewer resources and far less investment for far greater returns."


     The report also calls for the adoption of overdose-prevention programs and the expansion of veterans' access to medication-assisted therapies to treat opioid dependence. Overdose is an ongoing problem among veterans, as are other self-destructive behaviors that inflate the official and unofficial tally of suicides among active-duty troops and veterans. (Veterans, often compromised by alcohol or drugs, are an astonishing 148% more likely to die in a motorcycle crash than civilians of comparable age, race and sex.) Guy Gambill, a longtime veteran’s advocate who was instrumental in shaping the report, reminded the teleconference participants that "one of the hallmark symptoms of PTSD is the tendency to self-medicate. In the aftermath of Vietnam, self-medication and its collateral behaviors landed tens of thousands of veterans in prison," Gambill said. "This time, let's be smarter than the problem...So who do we have room to help? People with drug-offense charges. In cases where a veteran has combat-related psychological trauma and nonviolent drug offenses, there is a lot of political will to give these guys a break."  A great litmus test for that political will would be the immediate repeal of the 2002 Veterans Administration directive barring treatment for incarcerated veterans. This almost incomprehensibly myopic policy is, as the report states, "a missed opportunity for the VA to provide critical services and support for veterans to recover from the psychological wounds that caused their criminal activity in the first place


     Currently, the most successful mechanism for diverting veterans from incarceration and into treatment was conceived by Judge Robert Russell. His veterans' court in Buffalo, N.Y., is a hybrid version of the drug and mental health courts that since the 1980s have had a dramatic impact on the conversation about who and under what circumstances should be sent to prison. Russell's court was the first in the country to cater specifically to the needs of veterans with addiction disorders and/or mental illness who are charged with nonviolent criminal offenses. After almost two years, Russell's court boasts an astonishing recidivism rate of zero, compared to the 60 to 70% national average. Such courts are now springing up across the country, but they are seriously limited by their abilities to attract and process large numbers of cases. Last year, Russell's court processed under a hundred cases. Tom Tarantino, a legislative associate with Iraq and Afghanistan Veterans of America, pointed out the whole problem, is of an entirely unknown magnitude. "We don't really know how many veterans are in jail right now. The numbers cited in the DPA report are from a survey done in 2004. In 2004, there were over a million fewer veterans of Iraq and Afghanistan than there are today... The Department of Defense has lists of people who have been in the military, and the Department of Justice quarterly collects lists of people who have been arrested. We just need them to compare lists."


     But even armed with that data, there are only about a dozen veterans courts in operation or in the planning stages in the entire country. Even if more troops and veterans can be persuaded to make use of them, there are hardly enough courts to handle the daunting wave of new veterans expected to run afoul of the law. The consequences of an arrest and conviction can be devastating, the report explains, including denial of employment, housing or public benefits. And an estimated 585,000 veterans are denied the right to vote because of felony convictions. The DPA report is more interested in interventions that can occur before veterans become entangled in the criminal justice system. It emphasizes "front-end diversion practices," or ways keep veterans out of prison in the first place. Gambill noted some encouraging experimental programs in Chicago and Los Angeles that make use of veterans who are specifically trained to ride along with police when they get disturbance calls. Some of the suggestions made in the report will require the coordinated efforts and funds of multiple agencies. But some are so simple and obvious, even cheap, that it is sort of mind-boggling that they even warrant discussion. For example Tricare, the Defense Department's health insurance plan for active-duty service members, will not pay for methadone and other medication therapies for addicted veterans. It simply excludes maintenance treatment. No explanation. It just says, we don't pay for it.


     Untreated combat-related mental-health injuries are predictive of substance abuse, and untreated substance abuse is predictive of encounters with the criminal justice system. And the door predictably revolves. For many service members the vicious cycle begins while they are still under military jurisdiction. "It was really alarming how many combat soldiers were given prescription drugs with little or no supervision," he reported. "To be really blunt, I know crack dealers who are more discriminating with issuing drugs than some of the clinics that I saw in Iraq." Many of those drugs have serious known side effects, including suicide. And many of them, drugs to help soldiers sleep and drugs to help them stay awake, are seriously addictive. "The ease of obtaining prescription drugs in the combat zone," Tarantino explains, "is not mirrored back in garrison. When soldiers come home, their reliance on those same drugs can create severe problems." This report highlights the gross injustice of holding service members and veterans entirely responsible for drug reliance that is facilitated, if not encouraged, when it serves military purposes. That injustice is aggravated when it is used as an excuse to kick people out of the military, thereby denying them benefits. It is further aggravated when treatment is withheld, both for their injuries and for their addictions, and aggravated further still when it is punished with incarceration. [Source:  AlterNet News Penny Coleman article 11 Nov 09 ++]




VA Prostrate Radiation Treatment Update 01:     More than a year after the Philadelphia VA Medical Center said it had given substandard care to nearly 100 veterans with prostate cancer, the list of sanctions is sparse: One physician accepted a three-day suspension. A radiation safety official got a letter of reprimand. And the University of Pennsylvania doctor who performed most of the poor procedures lost his job when the Philadelphia VA closed the program. Newly obtained documents shed more light on the program, showing that the mistakes began with the earliest cases, starting in 2002, and that the hospital missed numerous opportunities to catch them. Yet no program-wide review ensued, and the brachytherapy treatments continued for five more years. The timeline of events was:

•     FEB 02: The first prostate-cancer patient is treated.

•     FEB 03: In the ninth patient treated, more than half the seeds land in the bladder.

•     OCT 05: A patient, 86, gets half the seeds put in his bladder.

•     MAY 08: A dosing error triggers a full program review.

•     JUN 08: The program is shut down. Director Gary Kao stops treating patients at the Philadelphia VA Medical Center and the University of Pennsylvania.

•     SEP 08: Veterans Affairs' Administrative Board of Investigation recommends disciplinary action against several key people.

•     JUN 09: Articles in the New York Times and The Inquirer detail a troubled program. Kao takes a leave from Penn research position. The first congressional hearing is held.

•     AUG 09: Radiation oncologist Richard Whittington is suspended for three days.

•     OCT 09: Radiation safety officer Mary E. Moore receives a letter of reprimand.


The Nuclear Regulatory Commission (NRC) reviewed several of the worst Philadelphia cases but failed to stop the procedures.  From FEB 02 to JUN 08, the month the implant program was closed, 98 of 114 veterans treated got incorrect doses of radiation. Federal investigators have found that 63 were under dosed and that 35 got too much radiation to tissue near their prostates.  Ten veterans have had a recurrence of their prostate cancer, according to the VA. And nine others show signs of a possible return. The mistakes led to internal investigations, congressional scrutiny, and probes by the NRC and the VA's inspector general. At least five veterans have filed claims seeking compensation from the VA. The number is expected to rise since the VA has advised all the veterans of their rights to pursue legal action.


     Gerald Cross, acting undersecretary for health at the Veterans Health Administration, and other officials ascribed delays to giving employees due process. "Perhaps there were some missed opportunities" early on, Cross said, but he added that the agency had responded quickly when it identified a problem. "We found it. We reported it. We took action" to stop the program, he said last month on his third visit to the medical center this year. Cross said the VA was carefully monitoring the patients to ensure everything possible was being done for them. Much of that may have been avoided if someone at the Philadelphia VA had been monitoring the quality of the implants performed by its team. Several members of Congress said the long delays and weak consequences set a bad precedent. Rep. Joe Sestak (D-PA) said, "Unless they are taking the recommendations and acting upon them, particularly if it means disciplinary action, then a message is being sent that it is OK. A lack of accountable leadership is the source of the real problem here. Fixing it isn't just about putting better systems in place. It is also making sure that the culture of accountability is ingrained, and that is what is wrong with not taking these recommendations and acting upon them."  Some lawmakers who have investigated the cases said that the DVA actions were both anemic and late, and that the agency had acted only after prominent newspaper articles appeared in the summer, detailing radiation overdoses and underdoses. Sen. Arlen Specter (D-PA) said, "They ought not have to wait for a front-page newspaper article or a Senate committee hearing to do what they should have done on their own. I think that it is regrettably necessary to keep pressure on them to follow up." [Source: Philadelphia Inquirer Josh Goldstein Article 15 Nov 09 ++]




VA Prostrate Radiation Treatment Update 02:     The Nuclear Regulatory Commission on 17 NOV found the Philadelphia Veterans Affairs Medical Center in violation of multiple regulations regarding the surgical placement of radiation seeds in the treatment of prostate cancer patients. The findings resulted from a special inspection NRC conducted at the medical center after a physicist there determined a prostate cancer patient had received an incorrect radiation dose in May 08. That discovery triggered multiple investigations by NRC and VA, which ultimately identified 98 medical errors out of 116 treatments for 114 veterans at the Philadelphia center between 2002 and 2008. All the patients were undergoing brachytherapy, a complicated treatment that involves implanting iodine-125 seeds in the prostate to destroy cancer cells. Dozens of patients were found to have seeds erroneously implanted in other organs. VA suspended the center's program in JUN 08. "My professional medical opinion is that the prior brachytherapy program did not remotely meet current medical standards," said Dr. Ronald Goans, the medical consultant NRC hired to examine the records and health outcomes of prostate cancer patients treated at the center.


     Goans extensively analyzed the records of 30 patients who were most seriously underdosed or overdosed and found a number experienced symptoms that could be related to the errors, including inflammation and damage to the colon, rectal bleeding and in at least one case, a recurrence of cancer. In his report to NRC, Goans said the program's past performance "is quite puzzling and shows considerable inconsistency in seed placement." Brachytherapy at the Philadelphia VA center was performed under a contract with the University of Pennsylvania School of Medicine, and many of the errors were found in surgeries performed by Dr. Gary Kao, a radiation oncologist at the university who played a key role in implementing the center's brachytherapy program in 2002. In JUN 08, Kao suspended his clinical practice at the school's request, according Dr. Stephen Hahn, chairman of the university's radiation oncology department, in a statement submitted to the House Veterans' Affairs Committee in July.


     The NRC inspection found that the Philadelphia center lacked adequate procedures to ensure patients received treatments according to the physician's prescription and failed to instruct personnel in reporting requirements for medical events. Inspectors also cited the center for incomplete record-keeping and failing to notify NRC no later than the next calendar day after discovery of a medical event. NRC is considering a range of enforcement actions against the Philadelphia medical center, from a notice of violations to thousands of dollars in fines. Regulators are scheduled to meet with VA officials on Dec. 17 to discuss the issue further. Any enforcement decisions likely will be made early next year, said NRC spokeswoman Viktoria Mitlyng. Despite the program's shortcomings, Goans praised staff at the center for their efforts to address the problems: "I continue to be impressed with the efforts of the current VA oncology department staff and would not foresee a recurrence of the situation seen in the time frame 2002 to 2008.  The Philadelphia Inquirer is reporting that injured veterans and their spouses have filed 31 claims seeking $58 million in damages over botched prostate cancer care at the Philadelphia VA Medical Center. [Source: Katherine McIntire Peters articles 19 Nov 09 ++]




VA Medical School Affiliations:       To ensure Veterans receive 21st century care, Secretary of Veterans Affairs Eric K. Shinseki has vowed to strengthen the partnership between the Department of Veterans Affairs (VA) and the schools that train the nation's health care professionals. Secretary Shinseki said, "Schools of medicine and other institutions of higher education for health care professionals have been essential partners with VA in caring for Veterans for over 60 years. VA is strengthening that relationship to ensure it provides accessible, world-class health care for the men and women who have served this nation in uniform." Shinseki's remarks came in response to a report by a blue-ribbon panel appointed to advise VA on strengthening relationships with medical schools and other colleges and universities for health care professionals. Two key recommendations from that report, which are among the 50 for which Shinseki said VA will have an implementation plan by January, are:

•     Formation of a standing, federally-chartered advisory committee to help VA realize the full potential of its partnerships with health professional schools; and

•     Examination and streamlining of policies and procedures that impede those partnerships.


The report reaffirms the vital importance of academic affiliations and calls for VA to strengthen its partnerships with the academic community to enhance health care for Veterans. 


     VA manages the largest medical education and health professions training program in the United States.  VA facilities are affiliated with 107 medical schools, 55 dental schools and more than 1,200 other schools for health care professionals.  Each year, 100,000 health professionals are trained in VA medical centers.  About two-thirds of the physicians practicing in the United States have had some of their professional education in the VA health care system.  "We welcome this opportunity to build even stronger bonds that will benefit not only the Veterans we serve, but also the tens of thousands of health professional trainees who receive some of their professional education in VA facilities," said Shinseki.  The Blue Ribbon Panel on VA-Medical School Affiliations, which included members from within and outside VA, was chartered under the Federal Advisory Committee Act in 2006.  It was led by Dr. Jordan Cohen, professor of medicine and public health at George Washington University and president emeritus of the Association of American Medical Colleges. [Source: VA News release 16 Nov 09 ++]




Arlington National Cemetery Update 07:    Secretary of the Army John McHugh announced 13 NOV that he has ordered an investigation into allegations of lost accountability of some graves, poor record keeping and other issues at Arlington National Cemetery. “As the final resting place of our nation’s heroes, any questions about the integrity or accountability of [the cemetery’s] operations should be examined in a matter befitting their service and sacrifice,” McHugh said after signing an order directing the Army Inspector General to begin investigating allegations regarding cemetery operations. McHugh’s order comes amid revelations that cemetery workers inadvertently buried cremated remains at a gravesite that was already in use. The error was discovered in MAY 08 and cemetery officials took immediate corrective measures, moving the cremated remains to another gravesite and remarking the original grave. Since then, questions have been raised over whether cemetery officials used proper procedures to correct the mistake, including notifying the next of kin.


     The investigation ordered by McHugh follows a separate internal investigation by the Military District of Washington (MDW) over the discovery of an unmarked grave. “Cemetery records, the MDW investigation and the non-invasive geophysical analysis of the gravesites strongly indicate that a husband and wife, who died years apart and should have been buried in the same gravesite, were instead buried in adjacent graves,” MDW spokesman Col. Dan Baggio said in a statement. New grave markers have been ordered for the site, and the couple’s family members have decided against exhuming the remains and conducting DNA tests. The unmarked grave was first discovered in 2003 but cemetery officials took no action until this year. McHugh is now directing the IG to examine accountability and policy issues in that case. The IG also is in the middle of a management review of the cemetery, started under McHugh’s predecessor Pete Geren, to make overall recommendations on how to better operate the facility. “A thorough investigation and transparency in its results can help correct whatever may be wrong and ensure America’s confidence in the operation of its most hallowed ground,” McHugh said in a statement. “We will take appropriate action as the facts dictate.” For a PDF copy of the Article 15-6 investigation by MDW refer to  .  [Source: ArmyTimes Michelle Tan article 16 Nov 09 ++]




Mission Serve:     On Veterans Day, First Lady Michelle Obama announced the launch of Mission Serve, a network that links veterans to community service groups, calling upon Americans to commit themselves to volunteering. The initiative, part of the public-service group Service Nation, aims to help veterans better integrate themselves in their communities. The Christian Science Monitor reports that only 13% of veterans report that their transition back to civilian life is going smoothly. Mission Serve comes at a time where the unemployment rate of veterans is rising and nearly 2 out of 3 veterans report that they feel their skills are not being sought out by their community. The idea of Mission Serve is to join groups already engaged in community service programs with veterans who have a desire to perform public service. A former Marine, for example, could have leadership skills to volunteer or work at a high school. A retired soldier could work with troubled youth. But there is no organized group bringing the skills to the need. Mission Serve also wants civilians to engage with veterans in community service that benefits the needs of the military community, whether it be working on a free summer camp for military kids or offering veterans vocational, educational training and support. For more info on Mission Serve and/or how to participate in the program refer to .  [Source: Huffington Post article 13 Nov 09 ++]




Pennsylvania GVOACs:     The state of Pennsylvania is quietly shutting down a program nearly 3 decades old that aids veterans statewide, mostly in rural areas. The Rendell administration is closing the state's five Governor's Veterans Outreach and Assistance Centers (GVOAC) which were started by Gov. Dick Thornburgh in 1981. The centers help veterans with paperwork for health claims, job placement, education and other services at locations outside the usual Veterans Affairs and veteran service organization offices across the state. The offices -- including branches in Erie and Greensburg -- are set to close by the end of DEC 09, though some have been shuttered already. State officials say the centers duplicate services already available in government offices in each of the state's 67 counties, not to mention those offered by the American Legion and other service groups. Many of those working in the five outreach offices are not officially certified to file the complicated forms necessary for obtaining federal benefits, meaning the paperwork has to be reviewed a second time after a veteran files them at the outreach centers. It is still a layer of help that veterans will miss, especially in bad economic times, American Legion leaders said 11 NOV. "If it helps veterans, it doesn't matter who is guiding them" to the aid said Kit Watson, Pennsylvania Department of the American Legion adjutant. "You're eliminating aid to veterans by closing these offices, especially with an influx coming back from Afghanistan and Iraq," said Steve Dennison, service officer for the Legion's Pittsburgh office.


     The state "is not cutting services to veterans. Our mission is to provide work force services that allow veterans to access education, training and employment programs," said Troy Thompson, spokesman for the state Department of Labor and Industry, which oversees veterans services. Employment aid can be better administrated by the state's CareerLink locations, he added, which have experts in veterans services. While Rendell administration officials downplayed any negative effects from closing the veterans center, state Rep. Douglas Reichley (R-Lehigh) was upset. He said he understands "strains on the state budget," but he also favors using state revenues "for funding certain vital services," such as those for veterans. "Countless veterans have come to my district office to consult with GVOAC officers to apply for veterans benefits, obtain service records or to apply for lost medals and recognitions," he said, adding that veterans should "contact the governor or their state legislators to demand that this vital service be restored."


     Chuck Ardo, a spokesman for the House Democratic Campaign Committee, retorted that Republicans "are all for less taxes and smaller government until the painful cuts needed to meet their demands are made." State Sen. Lisa Baker (R-20) who chairs the Senate panel on veterans affairs, plans to take a wait-and-see approach to eliminating the outreach centers. She and other legislators plan to meet with groups such as the American Legion

 the Veterans of Foreign Wars and Disabled American Veterans "to review what kind of hole this [elimination of GVOAC] will put in veterans' programs and how it will affect some of the rural, underserved areas." She said the program used $900, 000 in federal funds, but that loss will be offset by the use of $1.68 million in state funds for veterans’ services. She wants "outreach services to veterans to move forward. We can't remember veterans just on Veterans Day. We have to remember them every day." [Source: Pittsburgh Post-Gazette Timothy McNulty & Tom Barnes article 12 NOV 09 ++)




VA Burial Benefit Update 08:    VA offers the following benefits and services to honor our Nation's deceased Veterans.  For detailed information about all VA benefits and services, refer to


•     Headstones and Markers: VA can furnish a monument to mark the grave of an eligible Veteran.

•     Presidential Memorial Certificate (PMC): VA can provide a PMC for eligible recipients.

•     Burial Flag: VA can provide an American flag to drape an eligible Veteran's casket.

•     Reimbursement of Burial Expenses: Generally, VA can pay a burial allowance of $2,000 for Veterans who die of servicer elated causes. For certain other Veterans, VA can pay $300 for burial and funeral expenses and $300 for a burial plot.

•     Burial in a VA National Cemetery: Most Veterans and some dependents can be buried in a VA national cemetery.

•     Time Limits: There is no time limit to claim reimbursement of burial expenses for a service related death. In other cases, claims must be filed within two years of the Veteran's burial.

[Source: VA Pamphlet 21-00-1 JUL 09 ++]




Enlistment Update 04:    If you have unpaid loans which are significantly overdue and/or in collection, you can expect to be denied enlistment until you resolve the problem. A history of bad credit could also affect your security clearance eligibility, which could make many military jobs unavailable to you. Some recruits will have to show that they will be able to meet their current financial obligations upon enlistment. This includes recruits who are married (or who have ever been married), recruits who require a dependency waiver, recruits with a history of collection accounts, bankruptcy, closed uncollected accounts or bad credit. For the Air Force, it also includes any recruit who is at least 23 years of age. In general, the services are attempting to ensure that the recruit can meet current financial obligations on military active duty pay. For example, the Air Force uses the "40% rule." Any recruit who's monthly consumer debts (not counting debts which can be deferred, such as student loans) exceeds 40% of his/her anticipated military pay is ineligible for enlistment.


     The Navy policy examines total indebtness, rather than monthly payments. The Navy Recruiting Regulation States: No person may be selected who has a history of bad checks (unless through bank error), repossessions, cancelled or suspended charge accounts, or indebtedness exceeding half the annual salary of the paygrade at which the person is being recruited. If indebtedness includes a long-term mortgage, total indebtedness must not exceed 2 ½ times the annual salary. The Marines use the same Financial Eligibility Determination forms that the Navy uses. However, the Marines only do a Financial Eligibility Determination when the individual requires a Dependency Waiver. As part of the Dependency Waiver approval process, the applicant is interviewed by the Recruiting Commander (or his/her representative), who ensures, as part of the interview/review process that the recruit would be able to meet their current financial obligations on military pay.  Like the Marines, the Army only does a Financial Eligibility Determination when a Dependency Waiver is required. [Source: U.S. Military Rod Powers article 19 Sep 09 ++]




Medicare Fraud Update 27: 

•     Miami FL:  Alejandro Gonzalez, Roberto Rodriguez, and Manuel Camacho, all of Miami, were sentenced for their participation in a Medicare fraud scheme. Manuel Camacho was sentenced today to 18 months’ imprisonment, to be followed by two years of supervised release. Roberto Rodriguez was sentenced on 3 NOV to 102 months’ imprisonment, to be followed by 3 years of supervised release, and was ordered to pay restitution of $9,555,269. Alejandro Gonzalez was sentenced on 1 OCT to 96 months’ imprisonment, to be followed by 3 years of supervised release, and was ordered to pay restitution of $11,935,761.76. Defendant Camacho previously pled guilty to one count of money laundering conspiracy, and defendants Rodriguez and Gonzalez pled guilty to one count of conspiracy to commit mail fraud. According to documents filed with the court, between NOV 03 and NOV 06, defendants Gonzalez and Rodriguez established medical clinics in South Florida, purportedly to administer infusion therapies for the treatment of AIDS patients. In fact, however, no treatments were rendered and patients received a kickback for signing-in at the clinic. In this way, the defendants billed Medicare for millions of dollars for treatments that were not rendered, and, in fact, were not medically necessary. In sum, the defendants billed Medicare for approximately $40 million, of which Medicare paid about $12 million. Court documents reflect that defendant Camacho was recruited by his coconspirators to be the nominee owner of one of the clinics and was listed on the clinic’s bank accounts. Camacho wrote checks and purchased boats and luxury automobiles as directed by Gonzalez and Rodriguez to launder the proceeds of the Medicare fraud. He was involved in laundering more than $1 million on behalf of his co-defendants.

•     Hammond IL:  Dr. Adolph Yaniz faces charges of taking kickbacks in a Medicare and Medicaid fraud scheme and of illegally giving out prescriptions for painkillers and anxiety pills. Yaniz is charged with conspiracy to defraud the U.S. government, aiding and abetting in health care fraud, taking kickbacks and conspiracy to distribute controlled substances. On top of the fraud allegations, the indictment also claims that Yaniz gave three patients prescriptions for hydrocodone, also known as Vicodin, and alprazolam, also known as Xanax, and gave another patient a prescription for OxyCodone, even though none of them were medically needed. It also says Yaniz had 20,000 pills of hydrocodone that he intended to illegally distribute.

•     Miami FL:  A Miami man accused of bilking Medicare out of millions of dollars has been arrested in Ecuador two years after he allegedly fled. Federal authorities found Fermin Rey, a Santeria high priest, last week in Quito. He was indicted in 2007 as the owner of clinics that bilked Medicare out of $5.2 million in bogus medical equipment claims. Rey fled shortly after the indictment. Rey's case is among those that have caused judges to rethink bond for Medicare fraud suspects in South Florida because it is easy to flee. Of South Florida's 50 fugitives in health care fraud, authorities say dozens have fled to Cuba. Rey's trial is scheduled for MAR 09.

•     Virginia Beach VA: A federal court jury on 17 NOV found Dr. Ronald Poulin guilty of 28 counts of health care fraud, ruling that he bilked Medicare and Tricare out of $1.2 million. The prosecutors documented hundreds of occasions where Poulin billed for greater quantities of chemotherapy drugs than were actually administered to patients, charging for patient office visits that never occurred, and splitting vials of the anemia drug Procrit between two patients and then billing the insurance as if each patient had received a full vial. He also billed for vials of Procrit when patients brought in their own medicine. He faces up to 20 years in prison on the most serious charge of altering records, up to 10 years on the health care fraud count and up to five years on each of 26 false statement counts.

•     Elizabeth, N.J:  The United States has entered into a settlement with a New Jersey hospital and filed a motion to intervene in a lawsuit against a New York hospital involving allegations that the hospitals defrauded Medicare, the Justice Department recently announced. U.S is also seeking to intervene in a lawsuit brought against Brookhaven Memorial Hospital in East Patchogue, N.Y. Both of the hospitals are defendants in a suit brought by a whistleblower,Tony Kite, in 2005. The lawsuit involved allegations that the hospitals fraudulently inflated their charges to Medicare patients to obtain enhanced reimbursement from Medicare. In addition to its standard payment system, Medicare provides supplemental reimbursement, called "outlier payments," to hospitals and other health care providers in cases where the cost of care is unusually high. Congress enacted the supplemental outlier payments system to ensure that hospitals possess the incentive to treat inpatients whose care requires unusually high costs. The lawsuit alleged that the hospitals inflated their charges to obtain supplemental outlier payments for cases that were not extraordinarily costly and for which outlier payments should not have been paid. Kite brought his suit under the qui tam or whistleblower provisions of the False Claims Act, which permit private citizens with knowledge of fraud against the government to bring a lawsuit on behalf of the United States and to share in any recovery. Under the civil settlements announced, Kite will receive roughly $679,000, plus interest, out of the total recovery against Trinitas Regional Medical Center.

[Source:  Fraud News Daily reports 16-30 Nov -09 ++]




Medicaid Fraud Update 03: 

•     Washington D.C.:  For three years, the federal agency in charge of preventing Medicare fraud repeatedly ignored internal watchdog warnings about swindlers stealing millions of dollars by scamming several programs, documents show. The Centers for Medicare and Medicaid Services received roughly 30 warnings from inspectors over three years during the Bush and Obama administrations but didn't respond to half of them, even after repeated letters, according to records provided to The Associated Press by U.S. Sen. Charles Grassley's office. A JUL 08 warning said organized crime had infiltrated the system and was costing more than $1 million dollars for each phony Medicare provider license the crooks obtained. The letter got no response, Grassley said. He and other critics said lack of oversight in the federally administered program is part of an estimated $60 billion a year in Medicare fraud. "There's no good answer for why the bureaucracy turned a blind eye, and it's a breach of the public trust," said Grassley, an Iowa Republican and ranking member of the Senate Finance Committee. Fighting the fraud is key for the Obama administration, which hopes to pay for a large chunk of its proposed national health care overhaul by cracking down on those who cheat Medicare. Despite the lapses, Obama's Health and Human Services Secretary Kathleen Sebelius said the Centers for Medicare and Medicaid Services typically responds to fraud warnings promptly, and has investigated more than 300 since 2006. She was not satisfied that all fraud alerts were receiving sufficient responses and her office is implementing a new process for tracking the red flags. Grassley wants the agency to respond to future fraud warnings within two months and Sebelius agreed. "If the department quickly responds to them, there is the opportunity to save significant taxpayer dollars," Grassley said.

•     Long Island NY:  The mastermind behind a Medicaid fraud scheme that robbed the state of more than $1 million will serve 3 to 9 years for his crime, a Nassau judge ruled 13 NOV. David L. Williams, 48, of North Hills, former vice president of People's Choice Surgical Supplies in Hempstead, pleaded guilty earlier this year to second-degree grand larceny on charges that he, his wife and two employees falsely billed Medicaid for more than $1 million that had not been ordered by doctors. A spokesman for the NY Attorney General said People's Choice, which was the largest medical supply company on Long Island based on its quantity of Medicaid billing, stole physicians' identities and submitted false claims without their knowledge and permission. Williams also illegally used the ID numbers of Medicaid recipients - sometimes by paying them cash for their information - and then used those numbers to falsely bill Medicaid for medical equipment products that were neither necessary nor ordered by a doctor. The products included diabetic supplies, diapers and Ensure nutritional supplements, among other things. Just three years ago, People's Choice Surgical Supplies was considered a promising local company, having been approved for more than $1 million in assistance from the Nassau Industrial Development Agency and publicly lauded by County Executive Thomas Suozzi. The company abruptly closed in 2006 when the attorney general's probe began, county officials said. David Williams' wife, Cynthia Williams, 46, previously pleaded guilty to third-degree grand larceny and was sentenced to 6 months in jail. Two People's Choice employees pleaded guilty to petty larceny. One was sentenced to probation and the other is awaiting sentencing.

•     Merrillville IN:  A Merrillville physician and the operator of a diagnostic laboratory have been indicted with conspiracy to commit health care fraud. Dr. Adolph Yaniz, 49, of Merrillville, and Munir Chaudhry, doing business as Medway Diagnostic Laboratories, were each charged with one count of conspiracy to defraud health care programs and four counts of substantive health care fraud violations. Yaniz was also charged with one count of receiving kickbacks, four counts of dispensing drugs without legitimate medical purposes, and one count of conspiracy to distribute Vicodin; while Chaudhry was separately charged with one count of paying kickbacks and one count of providing false information to federal agents, the U.S. Attorney said. Yaniz and Chaudhry were taken into custody on 13 NOV. The indictment was the result of “an extensive investigation by the Drug Enforcement Administration, the Federal Bureau of Investigation, the Food and Drug Administration, and the Indiana Attorney General-Medicaid Fraud Control Unit.

•     New Orleans:  A New Orleans woman has been sentenced to five years in prison for her role in a scheme to bill the Medicaid program for nearly $4 million in fraudulent claims. U.S. District Judge Mary Ann Vial Lemmon also on 17 NOV ordered 36-year-old Akasia Lee to pay about $3.9 million in restitution and a $1 million fine. Lee owned and operated A New Beginning of New Orleans Inc., which billed for providing personal care services to children who were Medicaid recipients. Federal prosecutors say Lee and four others who worked at A New Beginning conspired to forge and falsify prescriptions, time sheets and other documents in claims for Medicaid payments.

[Source:  Fraud News Daily reports 16-30 Nov -09 ++]




Military History Anniversaries:  

•     Dec 01 1918 - WWI: An American army of occupation enters Germany

•     Dec 01 1969 - Vietnam:  America’s first draft lottery since 1942 is held.

•     Dec 02 1944 - WWII: General George S. Patton’s troops enter the Saar Valley and break through the Siegfried line. 

•     Dec 03 1950 - Korea: The Chinese close in on Pyongyang, Korea, and UN forces withdraw southward.  Pyongyang falls 2 days later.

•     Dec 03 1942 - WWII: U.S. planes make the first raids on Naples, Italy.

•     Dec 06 1941 - WWII: President Franklin D. Roosevelt issues a personal appeal to Emperor Hirohito to use his influence to avoid war.

•     Dec 07 1917 - WWI: The United States declares war on Austria-Hungary with only one dissenting vote in Congress. 

•     Dec 07 1941 - WWII: Japanese attack Pearl Harbor without a declaration of war and land forces in Northern Borneo.

•     Dec 07 1942 - WWII: The U.S. Navy launches USS New Jersey, the largest battleship ever built.

•     Dec 08 1861 - Civil War: CSS Sumter captures the whaler Eben Dodge in the Atlantic. The American Civil War is now affecting the Northern whaling industry.

•     Dec 08 1941 - WWII: Roosevelt declares war on Japan noting the previous day’s events mark it as a date that will live in infamy.

•     Dec 08 1943 - WWII: U.S. carrier-based planes sink two cruisers and down 72 planes in the Marshall Islands.

•     Dec 08 1944 - WWII: The United States conducts the longest, most effective air raid on the Pacific island of Iwo Jima.

•     Dec 09 1950 - Cold War: Harry Gold gets 30 years imprisonment for passing atomic bomb secrets to the Soviet Union during World War II.

•     Dec 09 1992 - Operation Restore Hope: U.S. Marines land in Somalia to ensure food and medicine reaches the deprived areas of that country.

•     Dec 10 1898 - Spanish American War: The U.S. and Spain sign the Treaty of Paris, ending the war and ceding Spanish possessions, including the Philippines, to the United States.

•     Dec 10 1941 - WWII: Japanese troops invade the Philippine island of Luzon.

•     Dec 11 1862 - Civil War: Union General Ambrose Burnside occupies Fredericksburg and prepares to attack the Confederates under Robert E. Lee.  The battle ends two days later with the bloody slaughter of onrushing Union troops at Marye's Heights.

•     Dec 11 1941 - WWII: Germany and fascist Italy declare was on America. The U.S. reciprocates.

•     Dec 12 1863 - Civil War: Orders are given in Richmond, Virginia, that no more supplies from the Union should be received by Federal prisoners.

•     Dec 13 1775 - The Continental Congress authorizes the building of 13 frigates.

•     Dec 13 1774 - Mass militiamen successfully attacked arsenal of Ft. William and Mary

[Source:  Various Nov 09 ++]



Tax Burden for Kansas Retirees:     Many people planning to retire use the presence or absence of a state income tax as a litmus test for a retirement destination.  This is a serious miscalculation since higher sales and property taxes can more than offset the lack of a state income tax. The lack of a state income tax doesn’t necessarily ensure a low total tax burden. Following are the taxes you can expect to pay if you retire in Kansas:

State Sales Tax:  5.3% (prescription drugs exempt); Cities and counties may add another 3%.  Residents with income less than $30,300 and meet other qualifications can receive a sales tax refund on food.


Fuel & Cigarette Tax:

•     Gasoline Tax: 25 cents/gallon

•     Diesel Fuel Tax: 27 cents/gallon

•     Cigarette Tax: 79 cents/pack of 20


Personal Income Taxes

Tax Rate Range: Low - 3.5%; High - 6.45%

Income Brackets: 3. Lowest - $15,000; Highest - $30,000. For joint returns, the taxes are twice the tax imposed on half the income.

Personal Exemptions: Single - $2,250; Married - $4,500; Dependents - $2,250

Standard Deduction: Single - $3,000; Married filing jointly - $6,000. Also;

•     An additional $850 can be claimed if you are 65 years or older. 

•     An additional $850 can also be claimed if you are blind. 

•     If your spouse is 65 years or older, you can claim an additional $850. 

•     An additional $850 can also be claimed if your spouse is blind. 

•     If both you and your spouse are 65 years or older and blind, your standard deduction would be $8,800.


Medical/Dental Deduction: Federal amount. Up to $800 per contract, per taxpayer can be deducted if you have a long term care insurance contract.

Federal Income Tax Deduction: None

Retirement Income Taxes: Military, civil service, state/local government pensions are exempt.  Out-of-state government pensions are fully taxed.  Railroad retirement is fully exempt.  Social Security is exempt for residents with a federal adjusted gross income of $75,000 or less (2008) will be exempt from any state tax on their Social Security benefits.

Retired Military Pay: Not taxed.

Military Disability Retired Pay: Retirees who entered the military before Sept. 24, 1975, and members receiving disability retirements based on combat injuries or who could receive disability payments from the VA are covered by laws giving disability broad exemption from federal income tax. Most military retired pay based on service-related disabilities also is free from federal income tax, but there is no guarantee of total protection.

VA Disability Dependency and Indemnity Compensation: VA benefits are not taxable because they generally are for disabilities and are not subject to federal or state taxes.

Military SBP/SSBP/RCSBP/RSFPP: Generally subject to state taxes for those states with income tax. Check with state department of revenue office.


Property Taxes

Taxable property is assessed at its fair market value. Homeowners 55 and older who earn $29,700 or less are eligible for a refund of up to $700 under the Homestead Property Tax Refund Act.  You must also meet one of the following requirements: Be 55 years of age or older, or be blind or disabled, or have a dependent child under 18 who lived with you all year whom you claim as a personal exemption.  Additionally, 50% of Social Security benefits will be excluded from the definition of income for the purposes of qualifying for the program, resulting in additional property tax relief for seniors. A property tax refund is available for homeowners 65 or older with a household income of $16,800 or less.  The refund is 45% or the property taxes paid.  Those who claim this refund cannot claim a Homestead refund. 

The effective property tax burden for renters is 15% of total rent.  A homeowner with a residence valued at more than $350,000 or more is prohibited from participating in the program.  Call 877-526-7738 or 785-296-2365 for property tax details or refer to   


Inheritance and Estate Taxes

The Iowa inheritance tax ranges from 1% to 15% depending on the amount of the inheritance and the relationship of the recipient to the decedent.  If all the property of the estate has a value of less than $25,000, no tax is due. The surviving spouse's share, regardless of the amount, is not subject to tax. Currently annual gifts in the amount of $12,000 or less are not taxable.  For details refer to .  Iowa estate tax is not applicable for deaths on or after 1 JAN 05 due to changes in the IRS Code which replaced the state death tax credit with a state death tax deduction.


For further information, visit the Iowa Department of Revenue site   or call 515-281-3114. [Source:  Nov 09 ++]




Veteran Legislation Status 28 NOV 09:   For or a listing of Congressional bills of interest to the veteran community that have been introduced in the 111th Congress refer to the Bulletin’s Veteran Legislation attachment.  Support of these bills through cosponsorship by other legislators is critical if they are ever going to move through the legislative process for a floor vote to become law.  A good indication on that likelihood is the number of cosponsors who have signed onto the bill. Any number of members may cosponsor a bill in the House or Senate. At  you can review a copy of each bill’s content, determine its current status, the committee it has been assigned to, and if your legislator is a sponsor or cosponsor of it.  To determine what bills, amendments your representative has sponsored, cosponsored, or dropped sponsorship on refer to 

     Grassroots lobbying is perhaps the most effective way to let your Representative and Senators know your opinion. Whether you are calling into a local or Washington, D.C. office; sending a letter or e-mail; signing a petition; or making a personal visit, Members of Congress are the most receptive and open to suggestions from their constituents. The key to increasing cosponsorship on veteran related bills and subsequent passage into law is letting legislators know of veteran’s feelings on issues.  You can reach their Washington office via the Capital Operator direct at (866) 272-6622, (800) 828-0498, or (866) 340-9281 to express your views. Otherwise, you can locate on  your legislator’s phone number, mailing address, or email/website to communicate with a message or letter of your own making.  Refer to  for dates that you can access your legislators on their home turf.  [Source: RAO Bulletin Attachment 28 Nov 09 ++] 




Have You Heard?  The hunting dog


In the Blue Ridge Mountains , there was a retired sailor who was reputed to have the best hunting dog ever, by the name of "Chief"


Three Admirals went-up into the mountains and wanted to rent him. The old sailor said good hunting dog,...gonna cost ya $50.00 a day." They agreed and three days later came back with the limit.


The next year they came back. "Chief" got better, gonna cost you $75.00 a day," again they agreed, and 2 days later they came back with the limit.


The third year they came back and told the old sailor they had to have "Chief" even if it cost $100.00 a day. The old sailor replied, "You can have the worthless mutt for $5.00 a day, and I'm overcharging you $4.00!!"


The bewildered Admirals asked, "But we don't understand, what happened to him?"


"Well, a crew from the Navy base in Norfolk came up and rented him. One of the idiots called him Master Chief, and he's just been sitting on his ass barkin' ever since..."



VETERAN WEB LINKS: The following is an alphabetical reference list of Veteran National Service links for you to use the next time you want to research the latest on your veteran related questions:

Board of Veterans’ Appeals 

CARES Commission 

CARES Draft National Plan  

Center for Minority Veterans 

Center for Women Veterans 

Center for Veterans Enterprise 

Clarification on the changes in VA healthcare for Gulf War Veterans

Classified Records - American Gulf War Veterans Assn

Compensation Rate Tables, 12-1-03

Department of Veterans Affairs Home Page 

Directory of Veterans Service Organizations

Disability Examination Worksheets Index, Comp

Electronic Code of Federal Regulations

Environmental Agents

Environmental Agents M10

Establishing Combat Veteran Eligibility

Evaluation Protocol for Gulf War & Iraqi Freedom Veterans with Potential Exposure to Depleted Uranium (DU)

Evaluation Protocol For Non-Gulf War Veterans With Potential Exposure To Depleted Uranium (Du)

Fee Basis, Priority For Outpatient Medical Services & Inpatient Hospital Care

Federal Benefits for Veterans and Dependants 2005

Forms and Records Request

Geriatrics and Extanded Care 

Guideline for Chronic Pain and Fatigue MUS-CPG

Guide to Gulf War Veterans’ Health

Gulf War Subject Index

Gulf War Veterans’ Illnesses Q&As

Homeless Veterans

HSR&D Home

Ionizing Radiation

Iraqi Freedom/Enduring Freedom Veterans VBA

M10 for spouses and children

M10 Part III Change 1

M21-1 Table of Contents

Mental Health Program Guidelines

Mental Illness Research, Education and Clinical Centers

MS (Multiple Sclerosis) Centers of Excellence

My Health e Vet

NASDVA.COM Ë National Association of State Directors

National Center for Health Promotion and Disease Prevention

OMI (Office of Medical Inspector

Online VA Form 10-10EZ

Persian Gulf Registry

Persian Gulf Registry Referral Centers

VA Annual Report To Congress, Persian Gulf Veterans’ Illnesses Research 1999’_Illnesses_Appendices.doc

VA Annual Report To Congress, Persian Gulf Veterans’ Illnesses Research 2002

Phase I PGR

Phase II PGR

Policy Manual Index

Project 112 (Including Project SHAD) Prosthetics Eligibility

Public Health and Environmental Hazards Home Page

Public Health/SARS 

Publications: Manuals

Publications and Reports

Records Center and Vault Homepage

Records Center and Vault Site Map

Request For And Consent To Release Of Information From Claimant’s Records

Research Advisory Committee on Gulf War Veterans Illnesses April 11, 2002

Research Advisory Committee on Gulf War Veterans Illnesses

Research and Development

The Service Officers Corner

U.S. Court of Appeals for Veterans Claims

VA Annual Report To Congress, Persian Gulf Veterans’ Illnesses Research 1999’_Illnesses_Appendices.doc

VA Annual Report To Congress, Persian Gulf Veterans’ Illnesses Research 2002

VA Fact Sheet

VA Health Care Eligibility

Veterans Legal and Benefits Information VA Life Insurance Handbook: Chap 3

VA Loan Lending Limits and Jumbo Loans

VA MS Research

VA National Hepatitis C Program

VA Office of Research and Development



VAOIG Hotline Telephone Number and Address

Vet Center Eligibility - Readjustment Counseling Service

Veterans Benefits Administration Main Web Page

VHA Forms, Publications, Manuals

VHA Programs - Clinical Programs & Initiatives

VHA Public Health Strategic Health Care Group Home Page

VHI Guide to Gulf War Veteran’s Health

Vocational Rehabilitation

VONAPP online

WARMS - 38 CFR Book C

War-Related Illness and Injury Study Center - New Jersey

Welcome to the GI Bill Web Site

What VA Social Workers Do

WRIISC Patient Eligibility     [Source: CT American Legion Dept email 4 Nov 05]


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