VA Community Care Program: Accessing Non-VA Healthcare

The VA Community Care Program provides eligible Veterans with access to non-VA health care providers when the Department of Veterans Affairs (VA) cannot readily provide the necessary care or it is not suitable. This program ensures Veterans can receive a wide range of medical, mental health, and specialty services from community providers.

What is the VA Community Care Program?

Community care is medical care from an approved provider outside the VA system. For planned appointments, you need eligibility for VA health care and approval from your care team before treatment. The written authorization establishes which services, provider, and dates are covered.

When can you request community care?

You must be enrolled in or eligible for VA health care. At least one access or clinical reason must apply: an unavailable service, no full-service VA facility in your state or territory, your best medical interest, unmet quality standards, a protected former distance qualification, or drive or wait times beyond access standards.

The usual standards are a 30-minute average drive or 20-day wait for primary care, mental health, and extended outpatient care; specialty care uses 60 minutes or 28 days. Eligibility for one service does not approve every outside appointment. Ask the care team to assess the needed service and available appointment.

What You Can Get

The VA Community Care Program covers a wide range of medical, mental health, and specialty care services. These services are provided by authorized community providers, rather than directly by the VA. The program's primary benefit is access to these non-VA health care providers when VA care is not readily available or suitable. Specific dollar amounts for services are not provided directly to the Veteran; instead, the VA typically covers the cost of authorized care from community providers. The extent of coverage is determined by the specific authorization provided by the VA for each Veteran's care.

How to Apply — Step-by-Step

Applying for the VA Community Care Program involves a discussion with your VA provider. The process typically follows these steps:

1. Discuss Your Needs with Your VA Provider: Begin by talking to your current VA health care provider about your medical needs and any challenges you face in receiving care directly from the VA.
2. Eligibility Determination: Your VA provider will assess your situation against the established eligibility criteria for community care, such as distance from a VA facility, wait times, or the availability of specific services.
3. Referral if Appropriate: If your VA provider determines you are eligible, they will make a referral for you to receive care from a community provider.
4. VA Authorization: It is critical that VA must authorize planned appointments and services in advance. Receiving care without prior VA authorization may result in the Veteran being responsible for the cost.
5. Scheduling and Receiving Care: Once authorized, you will typically work with the VA or a third-party administrator to schedule your appointment with an approved community provider.

For planned care, start with your VA provider or facility community care office. Confirm the authorization number, provider, services, and dates before the visit. If additional tests or visits fall outside that approval, ask the office to arrange the needed authorization.

Common Mistakes & Pitfalls

Navigating the VA Community Care Program can sometimes lead to misunderstandings. To help ensure a smooth experience, consider avoiding these common pitfalls:

• Not Getting Prior Authorization: A critical mistake is receiving care from a community provider without prior authorization from the VA. Planned appointments require authorization before the services can be covered.
• Assuming Eligibility: Eligibility is not automatic and must be determined by a VA provider based on specific criteria. Do not assume you qualify without a VA assessment.
• Self-Referral to Community Providers: Veterans cannot typically self-refer to community providers under this program. All referrals must come from your VA provider.
• Not Communicating with Your VA Provider: Failing to clearly communicate your healthcare needs or any issues with accessing VA care to your VA provider can hinder the referral process.
• Ignoring VA Communication: It's important to respond promptly to any communications from the VA regarding your community care referral or authorization.
• Not Understanding Covered Services: Ensure you understand what specific services have been authorized by the VA. Care outside of the authorized scope may not be covered.

Frequently Asked Questions

Can family members or dependents use the VA Community Care Program?

No, the VA Community Care Program is specifically for eligible Veterans. The VA does provide health care to Veterans’ family members and dependents through separate programs, such as the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). Eligibility for these programs varies and is distinct from Veteran community care.

Is prior authorization always required for community care?

Planned care requires prior approval. Urgent and emergency care have separate rules. Eligible veterans can use in-network urgent care without a referral if enrolled and treated by VA or an in-network provider within the past 24 months. Confirm network participation first. In a medical emergency, call 911 or go to the nearest emergency department; do not wait for a referral. Ask the provider to notify VA within 72 hours through the emergency care reporting portal. Notice alone does not guarantee payment, and missed notice does not automatically rule out all reimbursement.

What types of care are covered by the program?

The VA Community Care Program covers a wide range of medical, mental health, and specialty care services. The specific type of care authorized will depend on the Veteran's individual medical needs and the determination by their VA provider that community care is appropriate and necessary.

What if I live far from a VA facility but still want to receive care there?

You can choose available VA care even when eligible for community care. Using outside care does not require you to give up your VA care team.

If a referral stalls, is denied, or you receive a bill

Contact the facility community care office with your referral date and authorization details. Ask whether eligibility, scheduling, or the scope of approval is unresolved. For a treatment denial, ask the patient advocate about a Clinical Appeal; this differs from a disability compensation appeal.

If a provider bills you, send the office the bill, date of service, and authorization number. Some bills reflect billing errors; applicable VA copays and authorization limits still matter. A provider accepting VA patients is not proof that your particular visit was approved.

Find your care office

Use the facility locator to contact your medical center and ask for its community care office or patient advocate. The locator also searches for in-network urgent care. For enrollment help, call 877-222-8387.