Am I eligible for community care under the new criteria?
A Veteran is eligible for community care based on six eligibility criteria below:
1. Veteran needs a service that is not available at VA (e.g., maternity care, IVF)
2. Veteran resides in a U.S. state or territory without a full-service VA medical facility (Alaska, Hawaii, New Hampshire, and the U.S. territories of Guam, American Samoa, Northern Mariana Islands, and the U.S. Virgin Islands).
3. Veteran qualifies under the “Grandfather” provision meaning:
- Veteran was eligible under the 40-mile distance criteria under the Veterans Choice Program on the day before the VA MISSION ACT was enacted into law (June 6, 2018)
- Veteran continues to reside in a location that would qualify them under that criterion.
If both these requirements are met a Veteran may be eligible if one of the following is true:
- Veteran lives in one of the five states with the lowest population density (ND, SD, MT, AK, WY), or
- Veteran lives in another state, received care between June 6, 2017, and June 6, 2018 and requires care before June 6, 2020.
4. Veterans must meet specific access standards for average drive time or appointment wait times. The designated access criteria are not based on a Veteran’s “preferred” location, but instead are based on the wait times and average drive times to any VA facility that provides the service needed.
(Average drive times replaces the prior 40-mile limit in the Veterans Choice Program)
Average drive time to a specific VA medical facility:
- 30-minute average drive time for primary care, mental health, and non-institutional extended care services (including adult day health care).
- 60-minute average drive time for specialty care.
Appointment wait time at a specific VA medical facility:
- 20 days for primary care, mental health care, and non-institutional extended care services, unless the Veteran agrees to a later date in consultation with their VA health care provider.
- 28 days for specialty care from the date of request, unless the Veteran agrees to a later date in consultation with their VA health care provider.
5. Veteran and their referring clinician agree that it is in the Veteran’s best medical interest to be referred to a community provider.
6. Veteran needs care from a VA medical service line that VA determines is not providing care that complies with VA’s quality standards.
When did the new eligibility criteria go into effect?
The new eligibility criteria for community care were effective June 6, 2019.
How does VA determine if I am eligible for community care?
The Veterans VA provider and VA medical facility staff members work with the Veteran to determine if they are eligible for community care.
Does VA need to officially authorize the care I receive through a community provider?
Community care generally must be authorized in advance by VA before a Veteran can receive care from a community provider. The urgent care/walk-in care benefit does not require that the care be authorized in advance by VA.
What is changing with community care appointments?
Community care appointments will be scheduled directly by VA staff as VA implements its new Community Care Network (CCN) or, in some instances, Veterans will continue to be able to schedule their own appointment.
May I Go to any community provider I want?
If a Veteran is eligible for community care, they will be able to receive care from a community provider who is part of the VA network that is accessible to them.
Has the process for getting prescription medication changed?
There are no changes to how prescriptions are processed for Veterans receiving community care. As part of an authorized visit with a community provider, Veterans can receive a short-term supply of 14 or fewer days, urgent prescription medication in their community. Long-term prescription medications longer than a 14-day supply must be filled by VA.
Do I have to pay a copayment for community care?
Copayment charges are the same for community care as care at a VA medical facility. Usually, this means Veterans who are required to pay copayments will be charged a copayment for treatment of their non service-connected conditions. Copayment bills are sent by VA, not the community provider. For the urgent care benefit, Veterans may owe a copayment that would be different from their usual VA copayment, depending on their assigned Veteran priority group and the number of urgent care visits per calendar year.
Does VA pay beneficiary travel expenses if I am referred to a community provider?
If a Veteran is eligible for beneficiary travel, their eligibility does not change. Beneficiary travel is paid the same way whether the care is provided at a VA medical facility or through a community provider.
What rate does VA pay when a veteran is referred to a community provider for care?
Generally, VA pays Medicare rates, but there are several proposed exceptions to this rate that may apply, to be established through a contract or agreement.
Do the changes to community care under the VA Mission Act mean that VA is being privatized or that funds meant for VA medical facilities will be re routed to the private sector?
The Administration is making no efforts to privatize VA or shift resources away from VA medical facilities. Improvements to community care under the VA Mission Act are part of a larger effort to modernize the VA health care system and give Veterans greater choice over their health care.
What is the Community Care Network (CCN)?
CCN will serve as a high-performing network of community providers. VA is currently working to award contracts with Third Party Administrators (TPAs) to establish CCN nationwide.
What key information do community providers need to know about community care in the future?
To partner with VA to care for Veterans, most community providers will need to join VA’s Community Care Network (CCN). In addition, community providers must generally submit claims using electronic data interchange (EDI).