VA Navigation Program

Intro
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
Veteran Needs a Service Not Available at VA Medical Facility
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.
Veteran Lives in a US State or Territory Without a Full Service VA Medical Facility
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.
VA Cannot Provide Care Within Certain designated Access Standards
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
Its in the Veterans 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
Its Not in the Veterans Best Medical Interest
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.