The new eligibility criteria will be a major improvement over existing criteria in terms of making things simpler: currently, eligibility criteria vary between VA’s community care programs. When the new criteria go into effect, Veterans can expect better access and greater choice in their health care, whether at VA or through a community provider.
The eligibility criteria are projected to go into effect in June 2019 after final regulations are published and effective, so the criteria are not yet final. In addition, key aspects of community care eligibility include the following:
- Veterans must receive approval from VA prior to obtaining care from a community provider in most circumstances.
- Veterans must either be enrolled in VA health care or be eligible for VA care without needing to enroll to be eligible for community care.
- Eligibility for community care will continue to be dependent upon a Veteran’s individual health care needs or circumstances.
- VA staff members generally make all eligibility determinations.
- Veterans will usually have the option to receive care at a VA medical facility regardless of their eligibility for community care.
- Meeting any one of six eligibility criteria listed below is sufficient to be referred to a community provider—a Veteran does not have to meet all of them to be eligible. (Real-world examples of when a Veteran would be eligible for community care are included in the eligibility fact sheet linked at the end of the article).
Veteran Needs a Service Not Available at a VA Medical Facility
In this situation, a Veteran needs a specific type of care or service that VA does not provide in-house at any of its medical facilities.
Veteran Lives in a U.S. State or Territory Without a Full-Service VA Medical Facility
In this scenario, a Veteran lives in a U.S. State or territory that does not have a full-service VA medical facility. Specifically, this would apply to Veterans living in Alaska, Hawaii, New Hampshire, and the U.S. territories of Guam, American Samoa, the Northern Mariana Islands, and the U.S. Virgin Islands.
Veteran Qualifies under the “Grandfather” Provision Related to Distance Eligibility for the Veterans Choice Program
For this element, there are a few different ways that a Veteran could be eligible for community care. Initially, the following two requirements must be met in every case:
Veteran was eligible under the 40-mile criterion under the Veterans Choice Program on the day before the VA MISSION Act was enacted into law (June 6, 2018), andVeteran continues to reside in a location that would qualify them under that criterion.
If both of these requirements have been met, a Veteran may be eligible if one of the following is also true:
Veteran lives in one of the five States with the lowest population density from the 2010 Census: North Dakota, South Dakota, Montana, Alaska, and Wyoming, orVeteranlives in another State,received care between June 6, 2017, and June 6, 2018, andrequires care before June 6, 2020
VA Cannot Furnish Care within Certain Designated Access Standards
To be eligible under this criterion, VA would have to be unable to schedule a VA appointment for a Veteran at a facility within a specific average drive time to a VA medical facility and within a certain number of days (wait-time). If VA could not schedule an appointment that is within both the average driving time standards and the wait-time standard, then the Veteran would be eligible for community care.
The specific access standards are described below. (Important: Access standards are proposed and not yet final).
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 provider28 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
It Is in the Veteran’s Best Medical Interest
In this situation, a Veteran may be referred to a community provider when the Veteran and the referring clinician agree that it is in their best medical interest to see a community provider.
A VA Medical Service Line Does Not Meet Certain Quality Standards
In this scenario, if VA has identified a medical service line is not meeting VA’s standards for quality based on specific conditions, Veterans can elect to receive care from a community provider with certain limitations.
What is described above should be taken as a preview of what the final eligibility criteria may be, because it is not yet final. The new criteria are expected to go into effect in June 2019, after final regulations are published and effective.
Fact Sheet – Veteran Community Care – Eligibility (VA MISSION Act of 2018)Fact Sheet – Veteran Community Care – General Information (VA MISSION Act of 2018)