The U.S. Department of Veterans Affairs launched the Community Care Program after the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act was signed into law in 2018. This was done to improve veterans’ timely access to healthcare nationwide.
It’s like an extension of the VA’s primary healthcare system, which provides long-term care for veterans. This includes annual checkups and physicals, among other things. But when the VA becomes backed up with millions of appointments, wait times can become frustrating if not dangerous.
With budget cuts and potential workforce reductions, the future of the Community Care Program is unclear. At the time of this story, the VA Office of Public Affairs has not responded to questions about how budget cuts will impact the program.
VA Primary Care
Veterans who receive their healthcare through the VA are assigned a primary care physician (PCP). They can be a Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), nurse practitioner, or physician’s assistant. They are the first point of contact when veterans are enrolled in the Veterans Health Administration (VHA).
Regardless of their title, the person handling your primary care establishes a long-standing relationship with you to track everything from your blood pressure to weight gain to your behaviors.
It’s a form of surveillance on your health, so if things start to change for the worse, like heart failure or dementia, they can address them early on — including early detection of cancer.
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Primary Care oversees the introduction of a veteran to the VHA’s “patient-centered medical home model,” the Patient Aligned Care Team (PACT). Your team includes family members, caregivers, a primary care provider, a registered nurse care manager, a licensed practical nurse or medical assistant, and a clerk.
This care team is set up to put the veteran at the center and address their needs. Should a specialty care team be needed, like oncology or orthopedics, your PACT will coordinate those appointments for you wherever the specialists are, sometimes requiring a veteran to be treated outside of the VHA.
The MISSION Act
The MISSION Act became law in 2018, bringing the VA’s previous Veterans Choice Program to an end and establishing the Community Care Program. The new eligibility created better access for veterans who face lengthy delays in care or are hindered by state-line prohibited telehealth appointments.
The MISSION Act criteria grants a veteran access to community care if:
- A veteran cannot get a primary or mental health care appointment within 20 days.
- The timeline for a specialty care appointment is more than 28 days.
- The location of a veteran’s primary or mental health care appointment is more than a 30-minute drive.
- Specialty care appointments require a drive longer than 60 minutes.
- The VA doesn’t have the services a veteran needs.
- Community care is in the best interest of the veteran.
The VA calculates the drive times via “geomapping software.” If you encounter an issue with your route, bring it to your care team immediately. An important note for all the stubborn veterans out there: you must communicate with your VA team to enter the community care program.
Another thing veterans should know is that they may qualify under the “grandfather provision” related to 40-mile distance eligibility under the Veterans Choice Program. The new criteria under the MISSION Act make healthcare access better for veterans.
But, with the Promise to Address Comprehensive Toxics Act, or PACT Act, signed into law, veterans have better healthcare access and treatment than ever before.
The Community Care Program covers primary, urgent, emergency, and specialty care for veterans. Some things covered through community care may surprise you, such as foreign medical care and in vitro fertilization.
A veteran must have enrolled in or be eligible for VA healthcare to receive authorization for community care. The exception is if a veteran needs urgent or emergency care. You’ll need to notify the VA of emergency care in the community within 72 hours, though there is built-in leniency on a case-by-case basis.
A veteran must go to an in-network urgent care clinic; otherwise, he or she may be fully liable for the medical bills that result from the visit. Regardless of the level of care, veterans need to meet the basic criteria of being registered or eligible for VA healthcare.
For a veteran to gain access to the community care program, further eligibility criteria must be met:
- The service needed is not provided at a VA health facility.
- Your state doesn’t have a full-service VA health facility, especially for 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.
- A veteran is “qualified under the 40-mile distance requirement on June 6, 2018, and live in a location that would still make you eligible under these requirements.”
- A veteran cannot receive care within the VA’s drive and wait times standards.
- A veteran and their VA provider agree care from in-network community providers is in their best medical interest.
- A veteran cannot get services in a way that meets the VA’s quality standards.
When the VA cannot provide the services a veteran needs or the wait times are too long, the community care network takes over, and the VA healthcare system stops. The CCN covers five regions.
New England to North Carolina is region one, the Midwest is region two, the Southeast and Puerto Rico are region three, the West, Southwest, Hawaii, and Western U.S. territories are region four, and Alaska is region five.
Two private companies act as third-party administrators for the VA through processing healthcare claims and signing up community providers for the CCN. Optum Serve covers regions one, two, and three, while TriWest Healthcare Alliance covers regions four and five.
The services provided by the CCN, after your VA healthcare team approves it, can range from routine medical care and surgeries to rehabilitation and nursing homes. Other services that may surprise veterans include hypnotherapy, massage therapy, and “Native American healing practices.”
Dental care can be covered through the CCN, but the criteria that qualify veterans for free dental care or a partially covered area are grey areas in the VA’s policies.
If you are wondering what you qualify for, it’s always best to contact your VA healthcare team to make sure you qualify for community care, what services are in-network, and what services are covered.
If you’re thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States. Reach the National Suicide Prevention Lifeline by calling or texting 988, and you’ll be connected to trained counselors.
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