Montana VA Health Care System
VA MISSION Act of 2018
Tuesday, May 28, 2019Veteran Community Care - General Information
Under the VA MISSION Act, Veterans can expect a variety of improvements to community care. Eligibility criteria will be different, a new urgent care benefit will be provided, and customer service will be better.
The process for receiving community care will be improved, including the following steps:
1. VA confirms Veteran’s eligibility for community care under the new criteria.
2. A VA staff member assists the Veteran with scheduling the appointment or the Veteran schedules the appointment with their preferred community provider within the VA network.
3. Veteran receives care from a community provider in the VA network.
4. Community provider sends a claim to a Third Party Administrator or VA for payment.
In addition to new eligibility criteria, there are a variety of improvements under the VA MISSION Act that will make community care work better for Veterans:
- Single community care program. Existing programs will be combined into one single community care program. The Veterans Choice Program is coming to an end but some of its elements are being adopted into the new program. With one program and a single set of rules and processes, there is less complexity and likelihood of errors and problems.
- Better customer service. VA is implementing redesigned, streamlined internal processes, with improved education and communications resources for Veterans, our Veterans Service Organization (VSO) partners, and VA employees involved in community care operations. This will make administering community care easier and support excellent customer service for Veterans.
- New urgent care benefit. A new benefit will provide eligible Veterans with access to non-emergency care for certain conditions in the VA network of community providers. Veterans can go to any urgent care or walk-in care provider in VA’s network without prior authorization from VA. There may be copayments associated with this benefit depending on a Veteran’s assigned priority group and the number of times the benefit is used. Important: Details about the new urgent care benefit are not yet final.
- New Community Care Network. VA is establishing a new Community Care Network (CCN) of community providers that will be set up and administered through Third Party Administrators (TPAs). Once CCN is implemented, VA will directly coordinate with Veterans to schedule community care appointments (and in some instances continue to be able to schedule their own appointments) and support care coordination. VA’s TPAs will also be required to make timely payments to community providers.
- Modern IT systems. VA is modernizing its information technology (IT) systems to replace a patchwork of old technology and manual processes that slowed down the administration and delivery of community care. Once in place, the new IT systems will speed up all aspects of community care—eligibility, authorizations, appointments, care coordination, claims, payments—while improving overall communication between Veterans, community providers, and VA staff members.
The new community care program will start when VA publishes final, effective regulations, expected June 6, 2019. At that time, VA’s traditional community care program and the Veterans Choice Program will end, the new program will start, and the new eligibility criteria will go into effect. The urgent care benefit is also expected to be available starting June 2019.
A complete rollout of all six regions of the Community Care Network (CCN) is expected by Upgraded IT systems are also being implemented, with some expected to be completed in 2019 and others in 2020.
Frequently Asked Questions
Will I be eligible for community care under the new criteria? Under the proposed Federal regulation, a Veteran could be eligible for community care based on the 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 was eligible under the distance criteria under the Veterans Choice Program on the day before the VA MISSION Act was enacted into law (June 6, 2018), lives in one of the five states with the lowest population (ND, SD, MT, AK, WY) or continues to meet the distance criteria, received care between June 6, 2017, and June 6, 2018, and requires care before June 6, 2020.
4. Veteran meets specific access standards for average drive time or appointment wait-times (Important: Access standards are not yet final).
- Average drive time to a specific VA medical facility:
- 30-minute average drive time for primary care, mental health, and noninstitutional 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.
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 do the new eligibility criteria go into effect? The new eligibility criteria for community care will go into effect when the regulations are published and effective, expected June 6, 2019.
How will VA determine if I am eligible for community care based on the new criteria? The Veteran’s VA provider and VA medical facility staff members will work with the Veteran to determine if they are eligible under the new criteria.
- Will VA still 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. VA has proposed an exception to this when a Veteran receives emergency care from an in-network entity or provider and VA is notified within 72 hours, if certain additional conditions are met. The requirement for care to be authorized in advance by VA does not apply to the urgent care/walk-in care benefit that VA is establishing.
- 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 appointments.
- Will I be able to 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.
- Will the process for getting prescription medication change? 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 will be able to get a short-term, urgent prescription medication in their community, while long-term prescription medications will be filled by VA.
- Will 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 nonservice-connected conditions. Copayment bills are sent by VA, not the community provider. For the new 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.
- Will VA pay beneficiary travel expenses if I am referred to a community provider? If a Veteran is eligible for beneficiary travel, their eligibility will 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 will pay Medicare rates, but there are several proposed exceptions to this rate that may apply, to be established through a contract or agreement.
- What is the difference between the Veterans Choice Program and the VA MISSION Act? The Veterans Choice Program is the name of a Federal program started in 2014 to quickly expand access to care for Veterans. The VA MISSION Act is the name of a Federal law that establishes a new, single community care program, among other provisions. Some of these other provisions affect other types of VA benefits for Veterans beyond community care.
- 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 rerouted 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 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 new Community Care Network. In addition, community providers will generally be required to submit claims using electronic data interchange (EDI), and providers must submit claims within 180 days of providing care. Important: Details about claim filing requirements are not yet final.