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The Veterans Administration Healthcare system provides comprehensive health care to qualifying Servicemembers in over 300 facilities around the country. Most of these clinics and hospitals are capable of carrying out any medical service or procedure a Veteran requires. However, it happens on occasion that a patient requires medical services that are not available in his local VA facility, or perhaps the Veteran lives too far away to reasonably access these needed services. The VA Community Care program provides care to Veterans through community services when the VA cannot.
What is VA Community Care?
The purpose of VA Care in the Community is to guarantee that service members receive the necessary care from the VA under all circumstances. The local VA system shouldn’t force VA recipients to forgo necessary care because it’s not available at a VA facility. Should the necessary care be accessible in civilian facilities, the Servicemember can avail of these services, with the VA shouldering the financial cost of the care. This also extends to the Veteran’s family members and dependents through the Civilian Health and Medical Program of the Department of Veteran Affairs, depending on specific Community Care Veterans Affairs eligibility requirements, which can vary based on the program.
Eligibility for VA Care in the Community
On a regular basis, a recipient of VA healthcare benefits must receive medical care in designated VA clinics and hospitals, while Community Care Veterans Affairs allows for care outside of VA facilities. With the resolution of many past issues, the quality of care in a VA facility now matches that of a civilian provider. VA Community Care does not cover medical care outside of the VA facility if it is simply that the Veteran prefers civilian care. To qualify, the Veteran must establish that the local VA facility is not a reasonable place to obtain the medical care and also meet the following eligibility requirements:
1. Veterans must receive approval from the VA prior to obtaining care from a community provider.
2. To be eligible, veterans must enroll in VA Healthcare; they do not need to enroll in a separate program.
3. Eligibility depends on the Veteran’s individual circumstances.
4. It must be determined that the Veteran needs a service not available at a VA medical facility, such as a female Veteran in need of maternity care not provided at a local clinic.
5. The Veteran must live in the United States or a territory without access to a full-service VA medical facility (Alaska).
6. The care provider in the civilian arena must meet the designated access standards of the VA.
7. It is determined that the VA care in the community is in the Veteran’s best medical interest, and it is determined that the care in the VA service line would not meet certain quality standards otherwise.
8. You reside more than 40 miles from a facility that provides care.
Before assuming civilian care will be covered, always consult with your Community Care Veterans Affairs expert.
Services Provided Through VA Community Care
To provide services and benefits to Veterans, the VA CCN relies on partnerships with civilian resources and private providers. You can quickly explore the Community Care Network at this link to see the services offered in your region and state. However, the VA CCN typically provides the following services and benefits:
- Urgent care
- Emergency services, until you can be transferred to a VA facility
- Certain specialized surgeries, like cardiac or organ transplants
- Dialysis
- Rehabilitation
- Nursing, assisted-living, and home healthcare
- Some forms of dental care not provided in VA facilities, such as bone grafts for implants or other oral surgery.
Community Care Network (CCN)
The VA Community Care Network is comprised of five regional networks that operate as the contract vehicle for the Veterans Administration to purchase care from the community for Veterans and their families. The VA CCN provides the list of approved providers for important and necessary services if a Veteran is seeking a specific type of medical care. Third-party administrators, such as Optum and TriWest, administer the CCN of providers. Optum Veterans Affairs operates in regions one, two, and three, while TriWest operates in regions four and five. Optum Veterans Affairs, as part of United Health Group Inc., serves as a third-party administrator for its regions. TriWest HealthCare Alliance also performs the service for its own regions. These two administrators assist the VA in providing Veterans with compensation for the healthcare they receive in private and civilian medical facilities.
Veterans Retirement Home and Long-Term Care Options
The VA itself operates many long-term care facilities and Veterans retirement homes for elderly, sick, and disabled veterans, many of which include 24/7 nursing and medical care, physical therapy, help with daily tasks, pain management, and support for caregivers. However, compared to VA medical facilities and clinics, these facilities are relatively few in number.
Sometimes, Veterans prefer nursing homes and assisted-living centers or their own homes with caregivers over moving to a VA retirement home facility, which might be in another state. The Community Care Network allows the VA to pay for some of the private care services. Recently, legislation was passed that allowed for services at home and in the community to be part of the VA standard medical benefits package, and all enrolled Veterans are eligible for the services. However, similar to other VA Community Care benefits, you must demonstrate a clinical need for the service, ensure it meets VA standards, and confirm its availability in your location. Some of the services include:
- Geriatric evaluation to assess care needs
- Adult daycare
- Home health aide
- Respite care
- Skilled in-home care
Residential settings and nursing homes have different eligibility requirements, and the VA does not pay for room and board in assisted living or nursing homes. However, you still qualify for services at home and in the community while living in a residential setting. Learn more at this link, or speak with your local Community Care Veterans Affairs representative.
Frequently Asked Questions
Look up your local Community Care phone number at this link to speak with an expert or apply online. All individuals who receive VA benefits are automatically eligible for Community Care benefits. Typically, your VA health care team only needs to refer you to the community provider for services. The VA then reviews the request for eligibility and contacts you with the decision.
Look up your local Community Care phone number at this link to speak with an expert or apply online. All individuals who receive VA benefits are automatically eligible for Community Care benefits. Typically, your VA health care team only needs to refer you to the community provider for services. The VA then reviews the request for eligibility and contacts you with the decision.
Your local VA clinic or medical facility will have a list of approved providers in the area should you need services through the Community Care Network. You can also look online at this link, based on your region, for a list of approved providers.
VA Healthcare provides services to Veterans inside VA clinics and facilities. When care is not available within the VA facility, VA care in the community provides care to Veterans through community providers and private providers. VACC is part of VA Healthcare.
VA Community Care provides long-term care to Veterans in the form of adult daycare, home health aides, respite care, and in-home healthcare. It does not provide reimbursement for residential settings and private nursing homes, although it does pay for Services at Home within the assisted living facility.
Talk to your VA healthcare provider about the medical care you require and whether the VA facility provides it. If it is not, or if services are more than 40 miles away, your VA provider will issue a referral to a private provider within the Community Care Network. A VA medical provider must carry out this task.
Click on this link to see the phone number for your regional provider or call the phone number 866–400-1238 for general information.
The Veteran Community Care Billing and Payment Fact Sheet at this link outlines what co-payments and reimbursements are available through the Community Care Network. If you need help resolving a billing dispute, you can call 866–400-1238 on Monday through Friday, 8 AM to 8 PM Eastern time. You can also contact a local BSO representative, attorney, or claims agent or dispute online within 120 days for an appeal.
