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Community Care

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Community Care

Veterans may be eligible for care through a provider in their local community depending on their health care needs or circumstances, and if they meet specific eligibility criteria. Even if a Veteran is eligible for community care, they generally still have the option to receive care from a VA medical facility.

In most cases, Veterans must receive approval from VA before receiving care from a community provider to avoid being billed for the care. VA staff members generally make all eligibility determinations for community care.

Process Overview

1. Eligibility   

VA confirms a Veteran’s eligibility to receive community care.

2. Appointments  

Veteran or a VA staff member schedules appointment with a provider in VA’s network.

3. Getting Care   

Veteran receives care from a community provider in the VA's network.

4. Billing

Community provider sends the claim to a Third Party Administrator (TPA) or VA for payment.

Eligibility

A Veteran’s eligibility for community care depends on his/her individual health care needs or circumstances. Please note the following about eligibility for community care:

  • 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.

There are six criteria that can qualify a Veteran to receive community care. Veterans only need to meet one of these to be eligible.

1. 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.

For example, if you are a female Veteran and need maternity care, you would be eligible for community care because VA does not provide maternity care in any of its medical facilities.

2. 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 applies to Veterans living in:.

U.S. States

  • Alaska
  • Hawaii
  • New Hampshire

U.S. Territories

  • Guam
  • American Samoa
  • Northern Mariana Islands
  • U.S. Virgin Islands

For instance, if you are a Veteran living in Guam, you would be eligible for community care because you reside in a state or territory without a full-service VA medical facility.

3. Veteran qualifies under the “Grandfather” provision related to distance eligibility for VCP

For this element, there are a few different ways that a Veteran could be eligible for community care. Initially, there are two requirements that must be met in every case:

  1. 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), and
  2. Veteran 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, or
  • Veteran:
    • lives in another state,
    • received care between June 6, 2017, and June 6, 2018, and
    • requires care before June 6, 2020.

For example, if you are a Veteran who has lived in Kansas since 2012, your home is 41 miles driving distance to the nearest VA medical facility with a full-time primary care physician, and you received VA care between June 6, 2017, and June 6, 2018, you would be eligible for community care until June 6, 2020.

4. VA cannot provide care within certain designated access standards

In this situation, VA is unable to schedule an appointment that is within both average driving time standards and wait time standards. For average drive time to a specific VA medical facility, the access standards are:

  • 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

For appointment wait times at a specific VA medical facility, the access standards are:

  • 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

For instance, if you are a Veteran and live 10 miles from the nearest VA primary care provider, but it takes you over an hour to drive there on average due to heavy traffic, you would be eligible for community care.

5. 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 the best medical interest to see a community provider.

For example, if you are a Veteran with a certain type of ovarian cancer that your VA oncologist is not experienced in treating, and you live close to a community medical facility where there is a specialist for that type of cancer, you could be eligible for community care if the clinician and patient agree that this treatment should be provided by the community medical facility.

6. A VA 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 under certain limitations.

For example, if VA has identified that the cardiology service line at a local VA medical facility is not providing care that meets VA’s standards for quality, the Veteran may be able to elect to receive your cardiology care in the community. However, there may be limits on when, where, and what is available under this criterion.

For additional information and frequently asked questions (FAQs), refer to the Veteran Community Care – Eligibility fact sheet.

Appointments and Getting Care

Veterans eligible for community care generally have the option of choosing to receive care from a VA medical facility or community provider. For Veterans who choice to receive community care, a VA staff member will discuss with them their preferences for getting care from a community provider.

Finding a Community Provider

Veterans can either choose their preferred community provider or a VA staff member can help select one. The selected community provider must be part of VA’s network.

To find a community provider, please use the VA Facility Locator.

If there is a specific community provider a Veteran would like to see that is not in VA’s network, VA may be able to add them to its network. In some cases, a VA staff member will work with the Veteran to find other options when:

  • A community provider cannot be found that meets the Veteran's health care needs
  • A community provider was, but is no longer part of VA’s network
  • An existing community provider is no longer available

Once a community provider is selected, an appointment can be scheduled based on the Veteran's preferences and the community provider’s availability.

Scheduling Appointments

Before scheduling an appointment, it is important for the Veteran to confirm with a VA staff member that they are eligible and authorized for community care.

Once authorized to receive community care, they have several options for scheduling an appointment with a community provider, depending on the type of care they need. A Veteran may be able to:

  • Directly schedule an appointment and inform a VA staff member about the appointment
  • Use VA Online Scheduling to request an appointment for certain types of routine services
  • Have a VA staff member schedule the appointment
  • Have VA's Third Party Administrator (TPA) schedule the appointment

VA will send the Veteran and the selected community provider a referral. VA will also send the Veteran's medical documentation to the community provider to ensure proper care coordination between their VA care team and the community provider.

Getting Care

When a Veteran arrives for the appointment, the community provider should have the appointment, VA referral, and medical documentation on file. If a Veteran needs a follow-up appointment, the community provider should check to make sure VA has authorized additional care before scheduling the appointment.

Prescription Medication

If prescription medication is needed, the prescription should usually be sent to and filled by the nearest VA pharmacy. Veterans can receive short-term prescription medication for a 14-day or fewer supply that can be filled at a non-VA pharmacy. A prescription for more than a 14-day supply must be filled by VA.

Billing and Payments

After receiving care from a community provider, Veterans may have to pay a copayment for nonservice-connected care, just as the Veteran would if care was received at a VA medical facility. For urgent care, copayments depend on the Veteran's assigned priority group and the number of times the Veteran visits an urgent care provider in a calendar year.

Community providers cannot bill or collect a VA copayment directly from Veterans, including for urgent care. All VA copayments are billed as part of VA’s billing process.

VA may also bill insurance companies for care that is nonservice-connected. More information about VA Veteran copayments and health insurance is available in the links below:

CopaymentsHealth InsuranceBilling and PaymentsFinancial Hardship

Veterans experiencing adverse credit reporting or debt collection resulting from inappropriately billed Choice Program claims can call the Community Care Call Center for assistance.

Community Care Call Center: 877-881-7618 (9 a.m. 5 p.m. Eastern Standard Time)

Sunset of Veterans Choice Program (VCP)

Veterans are no longer eligible for community care under specific VCP eligibility criteria due to the expiration of the program. Veterans who were eligible for community care under VCP should speak with their VA care team or a VA staff member at their local VA medical facility about their eligibility for community care.

Resources

General Information

Sunset of Choice Program

Eligibility

Billing and Payments

Contacts

For more information, please contact your local VA medical facility.