Eligibility for community care outside VA

Eligibility requirements

To be eligible for community care, you must meet the requirements listed here.

You must meet both of these basic requirements:

• You’re enrolled in or eligible for VA health care, and
• You have approval from your VA health care team before you get care from a community provider (except for certain cases like urgent or emergency care)

Keep reading for additional requirements based on where you live.

Additional requirements for most states

If you live in a state that isn’t considered low population density, you must meet the additional requirements listed here. (If you live in Alaska, Montana, North Dakota, South Dakota, or Wyoming, check the next section on this page for eligibility requirements for low-population-density states.)

At least one of these must be true:

• You need a service that we don’t provide at any VA health facility, or
• You live in a state or territory that doesn’t have a full-service VA health facility, or
• You and your VA provider agree that getting care from an in-network community provider is in your best medical interest, or
• We can’t provide the service you need in a way that meets our quality standards, or
• We can’t provide the care you need within our standards for drive and wait times (keep reading for designated access standards)

Designated access standards 

• For primary care, mental health, and extended outpatient care: 30-minute average drive time or 20-day wait time 
• For specialty care: 60-minute average drive time or 28-day wait time 

Additional requirements if you live in a low-population-density state

If you live in 1 of the 5 lowest population-density states (Alaska, Montana, North Dakota, South Dakota, or Wyoming), you must meet the additional requirements listed here.

Both of these must be true:

• You qualified under the 40-mile distance requirement on June 6, 2018, and

• You live in a location that would still make you eligible under these requirements

Examples of when you may be eligible for community care

Here are 6 examples of when you may be eligible for community care based on each requirement:

Example 1: A service we don’t provide

You need maternity care or in vitro fertilization (IVF) care. But we don’t provide maternity care or IVF at any of our facilities. So, you’re eligible to get these services from an in-network community provider. 

Example 2: No full-service VA health facility

You live in Alaska, Hawaii, New Hampshire, Guam, American Samoa, the Northern Mariana Islands, or the U.S. Virgin Islands. We don’t have a full-service VA health facility in your state or territory. So, you’re eligible to get care from an in-network community provider.

Example 3: Qualification under the 40-mile distance requirement

You previously qualified under the Veterans Choice Program’s 40-mile distance requirement on June 6, 2018, and you still live at the same address. And you live in Alaska, Montana, North Dakota, South Dakota, or Wyoming. So, you’re eligible to get care from an in-network community provider.

Example 4: Drive and wait time standards

For primary care or mental health

You need a primary care or mental health appointment, but the average drive time to your nearest VA clinic is longer than 30 minutes. This means you’re eligible to get primary or mental health care from an in-network community provider because the drive time exceeds the access standards.

You could also qualify if your drive time were within the standard but the soonest available appointment date is over 20 days away. 

For specialty care

You need an appointment for specialty care (such as cardiology care for a heart problem), but the soonest available appointment date is over 28 days away. This means you’re eligible to get specialty care from an in-network community provider because the wait time exceeds the access standards. 

You could also qualify if your appointment date is within 28 days, but your average drive to the nearest VA facility that offers cardiology is longer than 60 minutes.

Example 5: Your best medical interest

You’re getting recurring treatment for a condition and have medical issues that prevent you from getting to the VA facility that’s within our standards for drive time (such as nausea from recurring cancer treatments). Or you require recurring treatments that we can’t supply in a timely manner, even if they meet our wait time standards. If you and your VA provider agree that it’s in your best medical interest to get care from the community provider, you’re eligible for community care.

Example 6: Quality standards

You need cardiology care for a heart problem. But we’ve determined that your local VA health facility doesn’t provide cardiology care that meets our quality standards. You may be able to get cardiology care from an in-network community provider.

Learn how to get community care referrals and schedule appointments