VA MISSION ActBy RON HOLLINGSWORTH,
Under the VA MISSION Act, Veterans will have better access and greater choice in health care either at VA or a community provider through improved eligibility criteria. The new eligibility criteria are projected to go into effect in June 2019 after final regulations are published and effective. These criteria are not yet final. Key aspects of community care eligibility are noted below:
1. Veterans must receive approval from VA prior to obtaining care from a community provider in most circumstances.
2. 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.
3. Eligibility for community care will continue to be dependent upon a Veteran’s individual health care needs or circumstances.
4. VA staff members generally make all eligibility determinations.
5. Veterans will usually have the option to receive care at a VA medical facility regardless of their eligibility for community care.
6. 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.
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.
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 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.
Example: If you are a Veteran living in Guam, you would be eligible for community care because you reside in a State without a full-service VA medical facility.
3. 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, 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
Example A: 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.
Example B: If you are a Veteran who lives in Wyoming and you qualified under the 40-mile criterion under the Veterans Choice Program on June 5, 2018, you would be eligible for community care.
4. VA Cannot Furnish Care within Certain Designated Access Standards. To be eligible under this criterion, Veteran meets specific access standards for average drive time or appointment wait-times.
The specific access standards are described below. (Important: Access standards are proposed and not yet final).
•Average drive time to a specific VA medical facilityo30-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
Note: Average drive times are calculated by VA using geo-mapping software that uses inputs such as traffic to calculate the average driving time.
•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 provider or 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.
Example A: 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.
Example B: If you live an average drive time of 25 minutes from the nearest VA medical facility and need a primary care appointment, but cannot be scheduled for one for 25 days, you would be eligible for community care.
Example C: If you live an average drive time of 50 minutes from a VA hospital, but that hospital doesn’t offer the specialty care or service you need, and the closest VA facility that does offer that care or service is a 75-minute drive away, 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 their best medical interest to see a community provider.
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 specialist for that type of cancer, you could be eligible for community care if the clinician and patient agree that this treatment should be furnished 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.
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.