The following resources provide payment information related to payment under the Department of Veterans Affairs (VA) 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.
VA Versus TRICARE
The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) 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.
New Veterans Community Care Program on the Way
The VA Mission Act of 2018 consolidated VA’s community care programs, including the Veterans Choice Program, into a new Veterans Community Care Program designed to ensure that veterans choose VA for their health care by getting them the right care at the right time from the right provider. The program is expected to be operational around June 6, 2019.
Meanwhile, the current system for veterans’ health care is still in place—see Veterans’ Care by Non-VA Providers below for more information.
VA is developing the regulations and policies needed to implement the Mission Act, and is training its staff and awarding contracts to furnish care. However, community providers can expect continuity of operations for the time being as VA works to roll out the Veterans Community Care Program. For more information about the VA Mission Act and new program, see the following resources:
Check back to this page as VA rolls out more information about the new Veterans Community Care Program.
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) and the Veterans Choice Program (VCP). To better understand the differences between the 2 programs, see the provider fact sheet from the TriWest Healthcare Alliance: PC3 and VCP Comparison – All Regions.
Patient-Centered Community Care (PC3)
Patient-Centered Community Care (PC3) is a nationwide network of community providers that gives eligible Veterans access to primary care, inpatient and outpatient specialty care, mental health care, limited emergency care, and limited newborn care for enrolled female veterans.
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.TriWest Healthcare Alliance is the third-party contractor that administers the program nationwide to help that ensure Veterans across the country have ready access to community care. 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)
The Veterans Choice Program is one of several programs through which a veteran can receive care from a community provider, paid for by VA. For example, if a veteran needs an appointment for a specific type of care, and VA cannot provide the care in a timely manner, or the nearest VA medical facility is too far away or too difficult to get to, then the veteran may be eligible for care through VCP.
To use the Veterans Choice Program, veterans must receive prior authorization from VA to receive care from a provider that is part 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.
As with PC3, TriWest Healthcare Alliance administers the nationwide operations for the VCP.
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 (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.
APTA Partnering With VA
APTA and VA are partners under a memorandum of agreement (MOA) to leverage the strengths of both organizations for the good of veterans, physical therapists, and physical therapist assistants. In particular, the 2 organizations are working together to raise awareness of nonpharmacological treatment options for pain, VA’s efforts toward preventing suicide among this vulnerable population, the National Veterans Sports Programs and Special Events, and the VA Adaptive Sports Grants Program. Read more about the MOA.
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.
||Proposed rule to implement the law is under coordination by Department of Defense (DoD)
||Proposed rule is released to the Office of Management and Budget (OMB) for review
|December 20, 2018
||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.