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When Does the VA Pay for Non-VA Medical Care?

Published on November 12th, 2019

The rules for determining when the VA will pay for the community care you receive from a private healthcare provider are changing. Last year, President Trump signed into law the VA MISSION Act, which went into effect on June 7, 2019. On that date, the Veterans Choice Program (VCP), which used to control non-VA treatment to veterans, was discontinued and a new system called VA community care took its place. Overall, the MISSION Act will make more veterans eligible for treatment at non-VA facilities. According to one estimate, the number of veterans eligible for community care will rise from 560,000 to 2.1 million.

The VA Is Expanding Access to Community Care for Veterans

Just as before the changes, veterans need to seek approval from the VA before obtaining care from a community provider. But now there’s an exception. You can go to a non-VA urgent care clinic or emergency room to receive treatment without having to get prior approval. This aspect of the program is available to anyone who is part of the VA health care system and has received VA medical care within the last two years. The only issue is that you will usually have to pay a co-payment, and if the provider or the treatment you receive are not part of the MISSION program, you may need to pay for the whole thing.

To receive non-urgent care from a a non-VA medical provider, you must meet one or more of the following criteria:

  • You need treatment that is not available at the VA facility. For example, if you are pregnant and need maternity care, you will need to find a health care provider because the VA does not provide maternity services.
  • You like in a part of the country that does not have a full service VA medical facility, which includes Alaska, Hawaii, New Hampshire, Guam, American Samoa, the Northern Mariana Islands, and the U.S. Virgin Islands.
  • You currently qualify for the Veterans Choice Program, and you continue to meet the criteria for eligibility.
  • You need to travel 30 minutes or more to receive primary care from the VA medical facility, or 60 minutes or more to receive secondary care.
  • The closest VA hospital cannot offer you an appointment for 20 days for primary care, or for 28 days for secondary care.
  • Your attending VA physician recommends that you seek treatment from a non-VA provider, usually because you require specialized treatment.
  • The VA has determined that your local VA facility does not meet its quality standards for treatment.

One of the most significant changes with the MISSION Act is the switch from driving distance to driving time for determining whether traveling to a VA healthcare facility is such a burden that you should be receiving community care. This is a big advantage for people who live in urban areas. Your VA hospital may only be a few miles from your home, but bad traffic conditions could mean that your average driving time now makes you eligible for community care.

Get Control of Your VA Benefits With the Help of a Lawyer

For many veterans, the process of applying for and receiving benefits goes smoothly. But others are not so lucky.  Instead, they are refused the benefits they should be receiving. If you have been denied access to veterans disability compensation, the veterans benefits lawyers of Jackson & MacNichol can help. Call us today at  800-524-3339 for a free consultation about getting the veterans benefits that you and your family deserve.


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