The Veterans Choice Program (VCP): Program Implementation

Summary

Authorized under Section 101 of the Veterans Access, Choice, and Accountability Act of 2014 (VACAA), the Veterans Choice Program (VCP) is a new, temporary program (the VCP is set to expire in August 2017 or whenever funds in the Veterans Choice Fund are exhausted) that enables eligible veterans to receive medical care in the community. It supplements several existing statutory authorities that allow the Veterans Health Administration (VHA) to provide health care services to veterans outside of the Department of Veterans Affairs (VA) facilities. Generally, all medical care and services (including inpatient, outpatient, pharmacy, and ancillary services) are provided through the VCP—institutional long-term care and emergency care in non-VA facilities are excluded from the VCP and are provided under different authorities. The VCP is not a health insurance plan for veterans, nor does it guarantee health care coverage to all veterans.

Eligibility and Choice of Care

Veterans must be enrolled in the VA health care system to request health services under the VCP. A veteran may request a VA community care consult/referral, or his or her VA provider may submit a VA community care consult/referral to the VA Care Coordination staff within the VA.

Veterans may become eligible for the VCP in four ways. First, a veteran is informed by a local VA medical facility that an appointment cannot be scheduled within 30 days of the clinically determined date requested by his or her VA doctor or within 30 days of the date requested by the veteran. Second, the veteran lives 40 miles or more from a VA medical facility that has a full-time primary care physician. Third, the veteran lives 40 miles or less (not residing in Guam, America Samoa, or the Republic of the Philippines) and either travels by air, boat, or ferry to seek care from his or her local facility or incurs a traveling burden of a medical condition, geographic challenge, or an environmental factor. Fourth, the veteran resides 20 miles or more from a VA medical facility located in Alaska, Hawaii, New Hampshire (excluding those who live 20 miles from the White River Junction VAMC), or a U.S. territory, with the exception of Puerto Rico.

Once found eligible for care through the VCP, veterans may choose to receive care from a VA provider or from an eligible VA community care provider (VCP provider). VCP providers are federally-qualified health centers, Department of Defense (DOD) facilities, or Indian Health Service facilities, and hospitals, physicians, and non-physician practitioners or entities participating in the Medicare or Medicaid program, among others. A veteran has the choice to switch between a VA provider and VCP provider at any time.

Program Administration and Provider Participation

The Veterans Choice Program is administered by two third-party administrators (TPAs): Health Net and TriWest. Generally, Health Net and TriWest manage veterans’ appointments, counseling services, card distributions, and a call center. The TPAs contract directly with the VA. Then, Health Net or TriWest will contract with eligible non-VA community care providers interested on participating in the VCP.

Payments

Generally, a veteran’s out-of-pocket costs under the VCP are equal to VHA out-of-pocket costs. Veterans do not pay any copayments at the time of their medical appointments. Copayment rates are determined by the VA after services are furnished. Usually, the VHA becomes the secondary payer when certain veterans with other health insurance (OHI) receive care for nonservice-connected conditions under VCP. Participating community providers are reimbursed by their respective TPA, and VA pays the TPAs.