Veteran Community Care: Eligibility

Veteran Community Care: Eligibility


A Veterans eligibility for community care depends on their individual health care needs or
circumstances. There are six criteria that can qualify a
Veteran to receive community care, and a Veteran only needs
to meet one of these to be eligible. In consultation with
their care teams, a Veteran may be eligible for community care
in one of the following situations: 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 U.S. territory
without a full-service VA medical facility. 3. Veteran Qualifies Under the
“Grandfathered” 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, there
are two requirements that 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); and 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, a Veteran
meets specific access standards for
average drive time or appointment wait times. 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 care team, 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’s 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. 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 that 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, you 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. In addition to the six criteria, Veterans may also
be eligible for urgent care from a community provider who is part
of VA’s network. To be eligible for urgent care, Veterans must
be enrolled in the VA health care system and have received
care through VA from either a VA or community provider within the
past 24 months. Finally, 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 otherwise eligible for care. Eligibility
for community care is dependent upon a Veteran’s individual
health care needs or circumstances. And VA staff
members generally make all eligibility determinations. To
learn more about the eligibility for community care, and to find
out if you are eligible, please contact your local VA medical
facility, or visit VA.gov.

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