The following resources provide payment information related to payment under the Department of Veterans Affairs (VA) health system and payment under TRICARE.
For additional assistance with payment and reimbursement issues, contact APTA's Payment Policy & Advocacy department at 800/999-2782, ext 8511 or firstname.lastname@example.org.
VHA Versus TRICARE
The Veterans Health Administration (VHA), under the Department of Veterans Affairs (VA), covers only veterans—those who once served in the military but have now separated from active duty or retired veterans who also meet certain eligibility and health criteria.
TRICARE, under the Department of Defense, is a civilian network providing health care benefits for active duty service members, National Guard/reserve members, and their families when services cannot be provided at a military treatment facility. Military retirees and their families also are eligible for TRICARE.
VA Health System: Veterans' Care by Non-VA Providers
Under the Veterans Access, Choice, and Accountability (Choice) Act, medical care can be provided to eligible veterans outside of the Department of Veterans Affairs (VA) when VA medical facilities are not "feasibly available." If a veteran enrolled in the VA health care system is eligible for certain medical care, the local VA hospital or clinic should provide it as the first option. If it can't, then each local VA medical facility has criteria to determine whether non-VA care may be used.
Two non-VA provider programs are Patient-Centered Community Care (PC3) contracts and the Veterans Choice Program.
Patient-Centered Community Care (PC3) Contracts
When a veteran requires primary and specialty care that is not readily available at his or her VA health care facility (HCF), the HCF may use a Patient-Centered Community Care (PC3) contract to purchase the veteran's care. The HCF's clinical and Non-VA care teams coordinate to determine if the care is available at the HCF, a different nearby HCF, or another health care partner. If not, they will look to the PC3 contractor to buy the care.
VA's contract with third-party contractor Health Net Federal Services to administer the PC3 program in eastern regions of the country expired in September 2018. VA took over administration in October. The transition to VA from Health Net was automatic; no action is needed from providers or veterans who had been working with that contractor.
In October 2018, VA announced that TriWest Healthcare Alliance, the third-party contractor that administers the program in the western regions, will take over administration nationwide, expanding its services to help ensure Veterans in all regions have ready access to community care. TriWest expects to be fully operating in all regions by the end of January 2019. Until then, VA and Health Net will continue the transition of care and services.
Veterans Choice Program (VCP)
VCP complements PC3, by allowing more services to be covered and giving veterans more options in choosing to receive care—whether from the community or from VA itself.
Under the VCP, veterans must receive prior authorization from VA to receive care from one of VA's VCP network of community providers. The authorization is based on specific eligibility requirements and discussions with the veteran's VA provider. VA must authorize care that is needed beyond the scope of the first authorization. Veterans may be eligible to receive care through VCP based on 1 or more of the following conditions:
- VA can't provide the services the veteran needs.
- VA can't make an appointment for the veteran at the nearest VA medical facility within 30 days of the clinically indicated date (the date the veteran and his or her VA provider agree should be the next date the veteran is seen for care), or if VA can't determine this date, the date the Veteran prefers to be seen next.
- The veteran lives more than a 40-mile drive from the nearest VA medical facility with a full-time primary care physician.
- The veteran has to travel by air, boat, or ferry to get to the nearest VA medical facility.
- The veteran faces an excessive burden in traveling to the nearest VA medical facility (such as geographic challenges, environmental factors, or a health problem that makes it hard to travel).
Like PC3, as of October 1, 2018, VCP is administered by either VA or by TriWest Healthcare Alliance, depending on the veteran's geographic location. VA took over administration from third-party contractor Health Net Federal Services, whose contract expired and was not renewed. The transition to VA from Health Net was automatic; no action is needed from providers or veterans who had been working with that contractor. Also as with PC3, TriWest Healthcare Alliance will take over nationwide operations for the VCP. TriWest expects to be fully operating in all regions by the end of January 2019. Until then, VA and Health Net will continue the transition of care and services.
Eligible non-VA community care providers may become VCP providers. Providers who are interested in participating in the VCP may do so either through the Patient Centered Community Care (PC3) network or the Choice network. Community providers who are under the Choice network may only render authorized services to VCP-eligible veterans. Under the PC3 network, all veterans who are eligible for VA community care may be seen.
The reason is that there are two different statutory authorities for care delivered through VCP and PC3. Interested providers are required to contact TriWest to determine whether they qualify as a VA community care provider.
To qualify, providers must meet the following criteria:
- Have a full, current, and unrestricted state license and the same or similar VA credentials.
- Not be named on the Centers for Medicare and Medicaid Services exclusionary list.
- Meet all Medicare Conditions of Participation and Conditions for Coverage.
- Provide resources (services, facilities, and providers) that are in compliance with applicable federal and state regulatory requirements.
- Submit all medical records of rendered services to veterans to the third-party administrator (VA or TriWest) for inclusion in the veterans’ VA electronic medical records.
- PC3 providers: must establish an agreed-upon reimbursement amount for rendered services to veterans.
- VCP providers who do not wish to be PC3 providers: must accept Medicare rates.
Before rendering services, the PT completes an application on the administrator’s website (VA or TriWest) to receive authorization to provide care. To receive payment, the PT files a claim with the administrator, including a copy of the records for medical care and services provided to the veteran. Any additional care beyond what was authorized requires a secondary authorization from the administrator. This secondary authorization can last up to a year.
Additional Veterans Affairs Resources
The TRICARE program is administered by 2 separate contractors in 2 different regions: the East Region is administered by Humana Military. The West Region is administered by Health Net Federal Services.
PTAs and TRICARE: Update
June 6, 2018: The National Defense Authorization Act of 2017, signed on December 12, included a provision adding PTAs (and OTAs) as authorized providers under TRICARE. However, this change is not yet effective. The change to regulation will be implemented through the notice and comment rulemaking process. The proposed rule is expected in the fall of 2018 or spring of 2019. A 60-day comment period will follow the release of the proposed rule, after which the Department of Defense will review the comments and draft and publish the final rule.
Until the rule is finalized and published, TRICARE does not consider a PTA as an authorized provider, and the rule will not be retroactive.
APTA will keep members informed of the timeline for this changeover to the TRICARE system.
|Present (as of Summer 2018)
||Proposed rule to implement the law is under coordination by Department of Defense (DoD)
|Fall 2018 or Spring 2019
||Proposed rule is released to the Office of Management and Budget (OMB) for review
|+ 90 days
||Proposed rule is published in Federal Register for public comment
|+ 60 days
||Public comment period ends
|+ 30-90 days
||Draft of final rule is sent to DoD after Defense Health Agency addresses comments for potential revisions
|+ 45-60 days
||Final rule is cleared by DoD and White House staff and released to OMB for review
||Final rule is published in Federal Register
(by 2021 per
Additional TRICARE Resources
APTA Managed Care Contracting Toolkit: This can be a helpful resource when contracting with managed care contractors such as those that administer TRICARE.
TRICARE Information for Providers: The TRICARE website offers general information on rates and reimbursement.
TRICARE Program Manuals (2015 Edition): These manuals are applicable to the east and west regional managed care support contractors.
TRICARE Allowable Charges Tool: This interactive tool allows you to enter a zip code to find the maximum charges TRICARE is allowed to pay for the most frequently used procedures or services in a specific geographic area. These charges are tied by law to Medicare's allowable charges, and they do not reflect TRICARE beneficiary out-of-pocket cost shares, copayments, deductibles, or payments made by any other health plan coverages.