The US Department of Veterans Affairs (VA) released final rules related to a completely retooled program that allows veterans more choice in health care providers, but some of the provisions will apply only to certain regions (for now), and other interpretations of the new rule—including whether physical therapists (PTs) will be considered primary care providers—will be made as needs arise.
The final rules released this week are related to implementation of the VA Mission Act of 2018, which consolidates VA’s community care programs into a new community care program known as the Veterans Community Care Program. Among programs being consolidated is VA Choice, the program created in 2014 to increase access and reduce wait times for VA patients by allowing greater use of non-VA providers. The VA Choice Program will continue to provide care to veterans until the new program is fully operational.
Community Care Eligibility Criteria
The Veterans Community Care Program final rule provides the nuts-and-bolts guidance on the operation of the new Community Care Network, the centerpiece of the Mission Act, and specifically on 2 of the central features of the Mission Act: how and when veterans might qualify for receiving covered non-VA care, and who can provide it. The new community care provisions will apply only to certain regions of the country upon rollout and will expand incrementally.
When it comes to which veterans would qualify for non-VA care, the rule includes a long list of criteria, including the inability of a VA facility to provide the type of care the veteran requires, as well as factors including treatment frequency, geographical proximity of an appropriate VA facility, the veteran's ability to travel, and a "compelling reason" for the veteran to receive non-VA services, among others.
Entities who want to be included as eligible non-VA providers will need to enter into a contract with VA, and either not be a part of (or employee of) VA or not provide the same services provided within the VA. The provider must also be accessible to the veteran, which includes a reasonable wait time to receive services. The rule also states that VA will announce quality standards through a separate document but predicts that "quality comparisons will generally be based on care that is locally available and not on national averages." In its comments on the proposed rule, APTA asked VA to clarify how it would define types of care, including primary and specialty care, and whether physical therapy would be considered primary care. The VA responded by taking a wait-and-see approach, writing that "we believe in a majority of cases that it will be clear what standard should be applied to what care."
For now, the new system is being rolled out in states in Regions 1, 2, and 3 of VA’s new Community Care Network, which includes mid-Atlantic, southern, and Midwestern states: Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Iowa, Kansas Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, US Virgin Islands, Vermont, Virginia, Washington DC, West Virginia, and Wisconsin. The program isn’t expected to be operational everywhere until the end of 2019 at the earliest.
In another rule, VA clarified policies and procedures around covering veteran access to urgent care from non-VA providers without prior approval from VA. Qualifying facilities would include urgent care and walk-in retail health clinics.
As in the community care rule, qualifying non-VA providers would need to enter into a contract or agreement with VA. Veterans could in turn go to those facilities to seek a range of urgent care, including flu shots, vaccines, certain screenings, and other services, so long as the care isn't emergent or based on care over an extended period of time. In the rule, VA states it will provide veterans with information on participating urgent care providers.
In its comments on the proposed rule, APTA asked VA about whether follow-up care related to a covered urgent care visit would need separate VA authorization. VA responded by stating that follow-up care must be coordinated by VA.
APTA regulatory affairs staff continues to monitor the implementation of the Mission Act and will post resources and information on its Veterans Affairs and TRICARE webpage.