Contents

• Introduction
• Scope and Limitations
• Medical Services under VCP
• Eligibility
• Choice of Care
• VCP Providers
• Program Administration
• Third-Party Administrators (TPAs)
• Community Care Provider Participation
• Consults/Referral Processes
• Unusual or Excessive Burden Determination
• Authorization of Care and an Episode of Care
• Appointment Scheduling
• Medication Process
• Processing Medical Claims
• Medical Services Not Previously Authorized
• Payments
• Veterans' Out-of-Pocket Costs
• Cost Shares for Veterans with Other Health Insurance (OHI)
• Provider Payment Methodologies

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.that enables eligible veterans to receive medical care in the community. (P.L. 115-26 eliminated the August 7, 2017, expiration date for the VCP and allowed the program to continue until the initial $10 billion deposited in the Veterans Choice Fund was expended. The VA Choice and Quality Employment Act of 2017, P.L. 115-46, authorized and appropriated an additional $2.1 billion to continue the VCP until funds were expended, and when these funds were also nearing its end, Division D of P.L. 115-96 appropriated an additional $2.1 billion to continue the VCP until funds are expended.) 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 (this category also includes care not offered at a veterans' primary VA facility and a referral cannot be made to another VA medical facility or other federal facility). 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 VCP 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 secondaryEnactment of P.L. 115-26 on April 19, 2017, allowed VA to become the primary payer when certain veterans with other health insurance (OHI) receive care for nonservice-connected conditions under VCP. —veterans would not have to pay a copayment under their OHI anymore. The VA would coordinate with a veteran's OHI and bill for any copayments that the veteran would be responsible for similar to what they would have paid had they received care within a VA medical facility. Participating community providers are reimbursed by their respective TPA, and VA pays the TPAs.

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The Veterans Choice Program (VCP): Program Implementation

Introduction

In response to concerns about access to medical care at many Department of Veterans Affairs (VA) hospitals and clinics across the country in spring 2014,¹ Congress passed the Veterans Access, Choice, and Accountability Act of 2014 (VACAA, P.L. 113-146, as amended). On August 7, 2014, President Obama signed the bill into law.² Since the VCAA was enacted, Congress has amended the act several times: P.L. 113-175, P.L. 113-235, P.L. 114-9,P.L. 114-41, P.L. 115-26, P.L. 115-46, and P.L. 115-96 and P.L. 114-41. In addition, the VA has issued implementation regulations and guidance on several occasions in response to the changes to VACAA and challenges encountered during implantation of the law. Table 1 provides major highlights pertaining to the Veterans Choice Program (VCP)―a new, temporary program that allows eligible veterans to receive medical care in the community authorized by section 101 of the VACAA.

The VCP supplements several already existing statutory authorities³ that allow the VA to provide care outside of its own health care system. These existing statutory authorities are briefly described in Table A-1. The Veterans Choice Program will end when the $10 billion in mandatory funding deposited in the Veterans Choice Fund (section 802 of P.L. 113-146, as amended) is exhausted, or no later than August 7, 2017Congress has continued to keep the VCP funded and authorized, and has indicated that it plans to continue the program, until a streamlined and permanent care in the community program is authorized to replace this temporary program.⁴ "It is important to note that the VCP does not provide guaranteed health care coverage or an unlimited medical benefit."⁵

This report provides details on how the VCP is being implemented. It is meant to provide insight into the execution of the current VCP program.

Scope and Limitations

Information contained in this report is drawn from regulations published in the Federal Register, conference calls and numerous meetings with VHA staff, and briefing materials and other information provided by the VA Office of Government Relations (which may not be publicly available). This report does not discuss the numerous issues that have arisen during the implementation of VCP or VA's plan to Congress that was submitted on October 30, 2015 (as required by P.L. 114-41) to streamline and improve the current VCP.

various legislative proposals currently under consideration in Congress to replace the VCP. ⁶

Medical Services under VCP

Once an eligible veteran is authorized to receive necessary treatment, including follow-up appointments and ancillary and specialty medical services, under the VCP, a veteran may receive similar services that are offered through their personalized standard medical benefits package at a VA facility. VA's standard medical benefits package includes (but is not limited to) inpatient and outpatient medical, surgical, and mental healthcare; pharmaceuticals; pregnancy and delivery services; dental care; and durable medical equipment, and prosthetic devices, among other things.⁶ 7 Currently, 81 categories of medical services and procedures are authorized to be provided under VCP.⁸ However, institutional long-term care and emergency care in non-VA facilities are excluded from the VCP. These services are authorized and provided under separate statutory authorities outside the scope of VCP (see Table A-1).

Eligibility

Generally, all veterans have to be enrolled in the VA health care system⁷9 to receive care under the VCP. Once this initial criterion is met, a qualified veteran may choose to receive care through VCP. Veterans may become eligible for care under the VCP through one of four different pathways:⁸

• 1030-day wait list (Wait-Time Eligible): A veteran is eligible for care through the VCP when he or she is informed, by a local VA medical facility, that an appointment cannot be scheduled
• within 30 days of the clinically determined date of when the veteran's provider determines that he or she needs to be seen (this category also includes care not offered at the veterans' primary VA medical facility and a referral cannot be made to another VA medical facility or federal facility),⁹11 or
• within 30 days of the date of when the veteran wishes to be seen.
• 40 miles or more distance (Mileage Eligible): A veteran is eligible for care through the VCP when he or she lives 40 miles or more from a VA medical facility that has a full-time primary care physician.
• 40 miles or less distance (Mileage Eligible): A veteran is eligible for care through the VCP when he or she resides in a location, other than one in Guam, American Samoa, or the Republic of the Philippines, and
• travels by air, boat, or ferry in order to seek care from his or her local VA facility; or
• incurs a traveling burden¹⁰12 based on environmental factors, geographic challenges, or a medical condition.¹¹
13
• State or territory without a full-service VA medical facility: A veteran is eligible for care through the VCP when his or her residence is more than 20 miles from a VA medical facility and located in either
• Alaska,
• Hawaii,
• New Hampshire (excluding veterans who live 20 miles from the White River Junction VAMC), or
• U.S. territory (excluding Puerto Rico).

A veteran who believes that he or she meets one of the eligibility criteria to receive care through the VCP is to have his or her eligibility status confirmed by local VA staff. A high level overview of the eligibility process to access care through the VCP is illustrated in Figure 1. Local VA facility staff members are to review clinical and administrative records of the veteran to determine the appropriate medical benefits package and clinical criterion. Confirmation of the veteran's eligibility status is generally determined within 10 business days from when the request for confirmation was submitted. Veterans who are found ineligible to participate in the VCP are to be given instructions, in their notification letters, on how to appeal the VA's decision.¹²14

Figure 1. Eligibility Process to Access Care through the Veterans Choice Program (VCP)

Source: Figure prepared by CRS based on information from the Veterans Health Administration. Notes: * this category includes care not offered at the veterans' primary VA medical facility and a referral cannot be made to another VA medical facility or federal facility. Illustrated is a high level overview of the process to access care under the Veterans Choice Program (VCP). This figure does not specify (1) the criteria VA staff uses to determine veterans' eligibility statuses; (2) the interactions veterans will encounter throughout their processes to access care under the VCP; or (3) how local VA Medical Centers (VAMC) may enter into provider agreements with VA community care providers. This figure does not reflect the appeals process.

Choice of Care

Eligible veterans have two options for receiving health care services under the Veterans Choice Program (VCP). First, veterans may choose to receive their medical care from a VA provider. A veteran who chooses this option is to receive an appointment with a VA provider. The veteran may be offered a VA appointment that is more than 30 days out or at a facility that is more than 40 miles from the veteran's residence.¹³15 If an offered appointment does not accommodate the veteran's clinical needs, the local VA staff may place the veteran on an electronic waiting list until an alternate appointment becomes available. At any time, the veteran (based on the availability of clinical appointments) may choose to receive his or her medical services from a VA community care provider.

The second option allows veterans to receive health care services from a VA community care provider (VCP provider) who accepts eligible VCP veterans. Veterans who choose this option are to have their names and medical authorization information sent to a VCP provider of their choice.¹⁴16 At any time, veterans (based on the availability of clinical appointments) may choose to receive their medical services from a VA provider.

VCP Providers

Under the VCP several entities and providers are eligible to provide care and services. These include among others, federally-qualified health centers, Department of Defense (DOD) medical facilities, Indian Health Service outpatient health facilities or facilities operated by a tribe or tribal organization, hospitals, physicians, and non-physician practitioners or entities participating in the Medicare or Medicaid program, an Aging and Disability Resource Center, an area agency on aging, or a state agency or a center for independent living. VA employees are excluded from providing care or services under VCP, unless the provider is an employee of VA, and is not acting within the scope of such employment while providing hospital care or medical services through the VCP.¹⁵17 Generally, VCP providers "must maintain at least the same or similar credentials and licenses as those required of VA's health care providers."¹⁶

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Program Administration

The Veterans Choice Program (VCP) is not a health insurance plan for veterans. Under the VCP, veterans are given the option of receiving care in their local communities instead of waiting for a VA appointment and/or enduring traveling burdens to reach a VA facility.¹⁷19

All veterans who are enrolled in the VA health care system are to be mailed a VCP card. The card lists relevant information about the VCP. Many veterans have attempted to use the VCP card as an insurance card. The VCP card may not be used to pay for medical services performed outside of or within the VA. Specifically, the VCP card does not

• replace veterans' identification cards,
• guarantee eligibility under the VCP,¹⁸20 or
• provide health insurance-like benefits (i.e., the VCP, like all VA health care, is not health insurance).

Third-Party Administrators (TPAs)

In September 2013, the VA awarded contracts to Health Net¹⁹21 and TriWest²⁰22 to expand veterans' access to non-VA health care in the community, under the Patient-Centered Community Care (PC3) initiative.²¹23 Later, in November 2014, the VA modified those contracts to include support services under the Veterans Access, Choice, and Accountability Act of 2014 (VACAA, or the Choice Act). Under the Veterans Choice Program (VCP), Health Net and TriWest manage the appointments, counseling services, card distributions, and a call center.²²24 They also oversee VCP providers, medical services reporting and billing processes, and the coordination of care with private health insurers. As illustrated in Figure 2, Health Net covers Regions 1, 2, and 4, and TriWest covers Regions 3, 5A, 5B, and 6.

Figure 2. VCP Regions Covered by Third-Party Administrators

Source: Map prepared by CRS based on data from the Veterans Health Administration.

Community Care Provider Participation²³

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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.²⁴26 The reason is that there are two different statutory authorities for care delivered through VCP and PC3. Interested providers are required to contact Health Net and/or TriWest to determine whether they qualify as a VA community care provider.²⁵27 To qualify, providers must meet the following criteria:

• Have a full, current, and unrestricted state license and the same/similar VA credentials.
• Not be named on the Centers for Medicare and Medicaid Services (CMS) exclusionary list.²⁶
28
• Meet all Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs).²⁷
29
• Accept Medicare or Medicaid rates.
• 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 TPA for inclusion in veterans' VA electronic medical records.

After determining that a provider is eligible for participation, he or she may enroll (with Health Net and/or TriWest) as a VCP provider. At this time, the VA community care provider and respective third-party administrator (TPA) are to establish an agreed-upon reimbursement amount for rendered services to veterans. When Health Net or TriWest is unable to coordinate the delivery of health care services to veterans, local VA Medical Centers (VAMCs) may enter into VCP Provider Agreements with eligible VA community providers through the VAMCs Community Care Departments.²⁸

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Consults/Referral Processes²⁹

31

Consults and referrals, known as the VA community care consults/referrals, are initiated in two different manners.³⁰32 First, a VA physician may submit a VA community care consult/referral (through the Computerized Patient Record System [CPRS])³¹33 on behalf of a veteran when there is a clinical need for the veteran to receive timely medical services. Second, a veteran may request a VA community care consult/referral (from his or her VA provider or local VA staff) in order to receive a medical service that is also timely. Regardless of how the consult/referral is initiated, all VA community care consults/referrals are to be processed by the VA Community Care Coordination staff within the VA. VA community care consults/referrals are processed based on whether the veteran requires emergent or urgent care. For urgent VA community care consults/referrals, VA providers are to coordinate the veteran's care directly with the VA Community Care Coordination staff.

When a veteran's request for a VA community care consult/referral cannot be approved, the veteran's local VA facility staff are to notify the veteran. On behalf of the veteran, his or her VA provider is to continue coordinating the veteran's medical services within the VA. The veteran's provider might also explore other existing community care options (see Table A-1) offered by the Veterans Health Administration (VHA).

After a veteran's request is approved or the VA community care consult/referral is submitted by the veteran's provider, the VA Community Care Coordination staff are to confirm the veteran's eligibility status. A veteran may decline enrollment into the VCP. When a veteran declines enrollment, his or her respective third-party administrator (TPA) is to document the veteran's reason for opting out of the program. Then, on behalf of the veteran, his or her VA provider is to continue coordinating the veteran's medical services within the VA. The veteran's provider might also explore other existing community care options offered by the VHA.

If a veteran is found eligible to access care through the VCP, the VA Community Care Coordination staff is to then electronically upload the veteran's VA community care consult/referral and pertinent medical documentation in the Contractor Portal, which is visible to Health Net and TriWest. Once Health Net or TriWest receives the documentation, the respective TPA is to contact the veteran. During this contact, the eligible veteran is to be provided with an overview of VCP benefits and asked to confirm his or her choice to receive medical services under the VCP.

If a veteran reiterates his or her choice to receive medical care under the VCP, the veteran may select his or her VA community care provider and coordinate with a TPA to schedule an appointment. In addition, the veteran is to be asked to provide other health insurance information, if applicable, and is made aware of possible copayments and deductibles. A veteran with a clinical need for a service-connected and/or special authority condition³²34 (SC/SA) is to have his or her screening information reviewed by Revenue Utilization Review (R-UR)³³35 nurses. The veteran's appointment is then to be entered in the Contractor Portal so that it can be viewed by the VA Community Care Coordination staff. Daily, the VA Community Care Coordination staff is to check the Contractor Portal for appointment statuses and other updates. After the appointment is scheduled, the VA Community Care Coordination staff are to enter the appointment information into the Appointment Management system (within the VA) and update the veteran's status to "scheduled."

Unusual or Excessive Burden Determination³⁴36

Along with the environmental factors, geographic challenges, and medical conditions, veterans are assessed by

• the nature or simplicity of the hospital care or medical services the veteran requires,
• how frequently the veteran needs hospital care or medical services, and
• the need for an attendant for a clinical service.³⁵37

Authorization of Care and an Episode of Care

Prior to delivering medical services to veterans under the Veterans Choice Program (VCP), such services are to be authorized by the VA.³⁶38 If a veteran requires services beyond those authorized, his or her VCP provider may request another authorization. The delivery and usage of unauthorized medical services could result in non-reimbursement. Under the VCP, over 2 million authorizations have been validated by the third-party administrators (TPAs) Health Net and TriWest. These authorizations of care, shown in Table 2, were validated from November 5, 2014 to July 2016, unless otherwise noted. From November 2014 through June 2016, TPAs made over 2.3 million appointments for veterans to receive care through VCP.

December 22, 2017, unless otherwise noted.

The VA defines an episode of care (EOC) as "a necessary course of treatment, including follow-up appointments and ancillary and specialty services, which last no longer than one calendar year from the date of the first appointment with a non-VA health care provider."³⁷39 This one-year Choice EOC period of validity begins when the first appointment is scheduled. VA community care providers may request an authorization extension for a veteran's current EOC through the veteran's respective TPA.

Appointment Scheduling

Veterans and VCP providers verify eligibility status before scheduling medical appointments for clinical needs. Appointments are to be scheduled on the basis of clinical appropriateness.³⁸40 VCP-eligible veterans are to receive a call from their respective third-party administrator (TPA), Health Net or TriWest. The TPAs are to provide veterans with information about the organization and schedule their appointments. Once appointments are scheduled, the contractor is to inform the VA. Emergent or urgent care authorizations are to be done expeditiously (see text box below).

After receiving the notification, a veteran's local VA facility staff are to cancel his or her appointment at the VA. Veterans may also choose to schedule their own appointments after receiving an authorization of care under the VCP.³⁹41 If veterans choose to do so, they are asked to provide their appointment information to Health Net or TriWest.

Appointment information that is provided to the TPAs is to get uploaded into the Contractor's Portal, so that it can be viewed by the VA Community Care Coordination staff. Daily, the VA Community Care Coordination staff are to check the Contractor Portal for veterans' appointment statuses and other updates. After receiving the notification, the veteran's local VA facility staff are to cancel his/her appointment at the VA.

Medication Process

Veterans may have their prescriptions filled at their local VA pharmacies, non-VA pharmacies, and through the Consolidated Mail Outpatient Pharmacy (CMOP). If the VA is unable to fill a medication request within a prescribed timeframe or one that is not within the VA formulary, a non-VA pharmacy may fill the initial 14-day supply (without refills).⁴⁰42 For veterans who require prescriptions for more than 14 days, the VCP prescribing clinician is to have the remaining supply of medication filled at a VA pharmacy. Similar to the provisions of health care services under the VCP, medications filled at non-VA pharmacies will also require prior authorizations from the VA.

The VA is to reimburse veterans for out-of-pocket expenses related to the purchase of medications that treat service-connected conditions. For nonservice-connected conditions, veterans may also be reimbursed for their out-of-pocket expenses, including those with other health insurance plans.⁴¹43 To be reimbursed, veterans submit a copy of their prescriptions, authorizations, and original receipts to their local VA Community Care Office. The VA also allows non-VA pharmacies to process medication claims on a veteran's behalf.

Processing Medical Claims

Medical claims under the Veterans Choice Program (VCP) are processed through the veteran's respective third-party administrators (TAPs). Health Net and TriWest upload and manage veterans' medical claims through the Contractors Portal. Through this web portal, the VA Community Care Coordination staff are to retrieve a veteran's documentation of clinical need and upload it in the veteran's medical records.

The VA community care provider is to submit medical claims to a veteran's respective third-party administrator. After Health Net or TriWest receives the claim, the TPA is to submit it through its web portal. Subsequently, the VA is to retrieve the documentation from the TPA's web portal and upload it in the veteran's medical records.

The VA reimburses the TPAs for the care veterans obtain through the VCP, and TPAs then reimburses the community care providers in their networks.⁴⁴

Per Federal authority, VA is the primary and exclusive payer for medical care it authorizes. As such, non-VA medical care providers may not bill the Veteran or any other party for any portion of the care authorized by VA. Federal law also prohibits payment by more than one Federal agency for the same episode of care; subsequently any payments made by the Veteran, Medicare, or any other Federal agency must be refunded to the payer [from the VCP provider] upon acceptance of VA payment.⁴²

45

Medical Services Not Previously Authorized

Under the VCP, medical claims for unauthorized non-VA health care services may be submitted to the VA for payment consideration. Veterans, VA community care providers, and persons who paid for services on behalf of a veteran are required to submit to the VA the following documentation:

• a standard billing form,⁴³46 or an invoice (i.e., Explanation of Benefits [EOB]), and/or receipt of services paid and/or owed;
• an explanation of the circumstance that led to the veteran receiving unauthorized care outside of the VA;
• any statements and/or supporting documentation;⁴⁴47 and
• VA Form-10-583, Claim for Payment of Cost of Unauthorized Medical Services.⁴⁵48

Payments

Veterans' Out-of-Pocket Costs

Veterans who are enrolled in VA health care do not pay premiums,⁴⁶49 deductibles,⁴⁷50 or coinsurances⁴⁸51 for their medical services. However, they may be required to pay a fixed copayment amount (for nonservice-connected disabilities or conditions) as shown below. When veterans receive care at a VA facility, they do not pay copayments at the time of their medical appointments; copayment rates are determined by the VA after services are furnished—based on if the care was for a service-connected or nonservice-connected condition. Therefore, veterans' out-of-pocket costs under the VCP are the same as if they were receiving care and services from a VA provider in a VA facility—if a veteran does not pay any copayments at VA health care facilities, the veteran will not have to pay any copayments under the VCP.⁴⁹52 For example:

• A veteran could pay $50 copayments for a specialty care visit and $15 for a primary care visit for a nonservice-connected disability or condition.
• A veteran in Priority Groups 7 and2 thru 8 could pay a $9 copaymentcopayment between $5 and $11 per 30-day or less supply of medication.⁵⁰
53
• All veterans are exempt from paying copayments for services and medications that are related to a service-connected disability or condition.⁵⁴
Cost Shares for Veterans with Other Health Insurance (OHI)

The VA defines other health insurance (OHI) as commercial insurance. Commercial insurance, often referred to as private insurance, is not funded by federal and state taxes. This type of insurance is offered by companies such as Blue Cross and Blue Shield, Aetna, Cigna, and the Kaiser Foundation. Plans purchased through the state health exchanges are also considered as OHI. In addition, veterans who purchase commercial insurance plans agree to cost-sharing responsibilities. Such cost-sharing obligations include copayments, deductibles and coinsurance (e.g., 80/20 rule: 80% insurer responsibility/20% patient responsibility).

Due to various issues related to primary payment responsibility and veterans therefore experiencing adverse credit reporting to credit bureaus or debt collections by collections agencies, Congress enacted P.L.115-26, which amended P.L. 113-146 and made VA the primary payer for veterans with OHI who seek care for nonservice-connected conditions through the VCP. This change went into effect on April 19, 2017. The VA would coordinate with a veteran's OHI and recover any costs, and bill the veteran for any copayments that the veteran would be responsible for similar to what they would have paid had they received care within a VA medical facility (see Figure 3). Community care providers or the TPAs are no longer required to collect copays, cost-shares, or deductibles from veterans with OHI. Medicare, Medicaid, or TRICARE are not considered OHI plans under the VCP.
Figure 3. Coordination and Billing for Nonservice-Connected Care for Veterans with Other Health Insurance (OHI)

(This process is applicable to medical claims for all services performed after April 19, 2017).

Source: Figure prepared by CRS based on information from the Veterans Health Administration.

Notes: VHA is Veterans Health Administration. TPA is Third-Party Administrators (Health Net Federal Services and TriWest Healthcare Alliance).

Provider Payment Methodologies Guidance on rates for the delivery of care is outlined in Table 3. As stated before, first, the Veterans Choice Program providers are to receive their reimbursements from either Health Net or TriWest. Then the VA is to reimburse the third-party administrator.⁵⁵ Eligible VA community care providers who decide to participate under the PC3 network (rather than the Choice network) may incur reimbursement rates lower than those of Medicare.⁵⁶ If these providers move to the Choice network, they may negotiate for a similar rate as contracted under the PC3 Network. Table 3
• All veterans are exempt from paying copayments for services and medications that are related to a service-connected disability or condition.⁵¹

Under the VCP, veterans with Medicare, Medicaid, or TRICARE who are authorized care in the community are not required to pay any deductibles, coinsurances, or copayments for nonservice-connected medical care—even if Medicare, Medicaid, or TRICARE requires certain level cost sharing under those plans.⁵²

VCP providers bill private health insurers for medical care, supplies, and prescriptions provided to veterans for their nonservice-connected conditions.⁵³ As stated in the final rule on the VCP:

[The] veteran may owe some copayment, cost share, or deductible amount from their other health insurance to the provider. VA is unable to completely eliminate any potential copayment liability because under the Program [VCP], VA is a secondary payer while under other non-VA care, we [VA] are the primary payer, and our payment to the non-VA health care provider is payment in full.⁵⁴

Responsibilities of payer and cost-sharing obligations for veterans are categorized by service-connected care and nonservice-connected care (see Table 3).

Cost Shares for Veterans with Other Health Insurance (OHI)

The VA defines other health insurance (OHI) as commercial insurance. Commercial insurance, often referred to as private insurance, is not funded by federal and state taxes. This type of insurance is offered by companies such as Blue Cross and Blue Shield, Aetna, Cigna, and the Kaiser Foundation. Plans purchased through the state health exchanges are also considered as OHI. In addition, veterans who purchase commercial insurance plans agree to cost-sharing responsibilities. Such cost-sharing obligations include copayments, deductibles and coinsurance (e.g., 80/20 rule: 80% insurer responsibility/20% patient responsibility).

When veterans receive health care services for nonservice-connected conditions/diseases and have OHI, they may have to share the cost of the rendered services with the OHI company. Furthermore, veterans who receive VA community care services and have an OHI plan may also incur cost-sharing responsibilities.^55,56 However, veterans may have their copayment responsibilities paid by the VA.

After [the] VA has paid for the non-VA care under Choice, and if there are funds available to reimburse the veteran, VA will apply a dollar-for-dollar offset to the Veteran's applicable VA copayment responsibility. In addition, VA can reimburse the Veteran for any payments made by the veteran to cover the cost of copayments, deductibles, or cost shares required by their OHI. Unless an exception applies, the VA payment is capped at the Medicare (or other allowable) rate. If the OHI payment does not completely satisfy the veteran's VA copayment responsibility, VA will bill the veteran for the remainder of the VA copayment amount.⁵⁷

As stated previously Medicare, Medicaid, or TRICARE are not considered "other health insurance" plans under the VCP. Therefore, veterans with these plans will not incur any deductibles, coinsurances, or copayments costs.

Provider Payment Methodologies

Guidance on rates for the delivery of care is outlined in Table 4. First, the Veterans Choice Program providers are to receive their reimbursements from either Health Net or TriWest. Then the VA is to reimburse the third-party administrator.⁵⁸ Eligible VA community care providers who decide to participate under the PC3 network (rather than the Choice network) may incur reimbursement rates lower than those of Medicare.⁵⁹ If these providers move to the Choice network, they may negotiate for a similar rate as contracted under the PC3 Network.

Veterans and VA community care providers may call the Community Care Call Center⁶⁰57 to discuss billing issues. These issues range from the need to resolve a debt collection to inappropriately billed services.

Appendix. VA Care in the Community

Table A-1 summarizes the existing major statutory authorities that allow the VA to provide care to veterans in the community utilizing non-VA providers.

Author Contact Information

Acknowledgments

[author name scrubbed], CRS analyst in Health Policy, Domestic Social Policy Division, was a co-author of a previous version of this report.

[author name scrubbed], Visual Information Specialist, provided assistance with the figures in this report

.

The author wishes to thank the staff of the Department of Veterans Affairs, Office of Government Relations, for their assistance in obtaining information.

Footnotes

9. 45. 56.

1.	Department of Veterans Affairs, Office of Inspector General, Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System, 14-02603-267, August 26, 2014. For a summary of wait-time issues at a VA medical facility, by state, see Department of Veterans Affairs Office of Inspector General, Administrative Summaries of Investigation Regarding Wait Times, http://www.va.gov/oig/publications/administrative-summaries-of-investigation.asp. Accessed on December 27, 2016November 14, 2017.
2.	P.L. 113-146 as amended by P.L. 113-175, P.L. 113-235, P.L. 114-9, and P.L. 114-41. For a detailed provision-by-provision explanation of the act, see CRS Report R43704, Veterans Access, Choice, and Accountability Act of 2014 (H.R. 3230; P.L. 113-146), by [author name scrubbed] et al.
3.	For a complete summary of the VA Care in the Community programs, see,CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by [author name scrubbed].
4.	38 U.S.C. §1701 note. For more information about the veterans choice fund see, CRS Report R44301, Veterans' Medical Care: FY2016 Appropriations, by [author name scrubbed]. "Department of Homeland Security Blue Campaign Authorization Act of 2017," Remarks by Representative David P. Roe, Congressional Record, vol. 163 (December 21, 2017), p. H10399.
5.	Letter from Veterans Health Administration, Chief Business Office Purchased Care to Veteran, Eligible Choice 30-Day Wait Recipient, September 25, 2015.
6.	For a complete summary of the VA's standard medical benefits package, see CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by [author name scrubbed]; and 38 C.F.R. §17.38.
7On November 3, 2017, the VA Care in the Community Act, 2017 (H.R. 4242) was introduced, and the measure was marked up and ordered to be reported as amended on December 19. On November 29, 2017, the Senate Committee on Veterans' Affairs marked up a draft measure, and it was reported to the Senate on December 5, 2017, titled Caring for our Veterans Act of 2017 (S. 2193).
7.	For a complete summary of the VA's standard medical benefits package, see CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by [author name scrubbed]; and 38 C.F.R. §17.38.
8.	The 81 categories of medical services and procedures covered in the community under the VCP are acupuncture; allergy and immunology; audiology; biofeedback; cardiology catheterization; cardiology imaging; cardiology rehabilitation; cardiology stress test; cardiology tests, procedures, studies; chemotherapy; chiropractic; colonoscopy; dental; dermatology; dermatology tests, procedures, studies; endocrinology; endocrinology tests, procedures, studies; ear, nose, and throat; gastroenterology; gastroenterology tests, procedures, studies; genetic testing/counseling; gynecology; gynecology tests, procedures, studies; hematology/oncology; Hepatitis C; homemaker home health aid; hospice; hyperbaric therapy; infectious disease; interventional radiology; intravenous therapy (IV)/ infusion, clinic; lab and pathology; medicine; mental health; nephrology; neurology; neurology tests, procedures, studies; neuropsych testing; neurosurgery; newborn care; non-institutional IV/infusion care; non-institutional skilled home care; non-institutional skilled nursing care; non-institutional spinal cord care; nuclear medicine; nutrition/dietitian services; obstetrics; occupational therapy; ophthalmology; ophthalmology tests, procedures, studies; optometry; orthopedic; orthopedic tests, procedures, studies; pain management; physical therapy; plastic surgery; podiatry; primary care; pulmonary; pulmonary rehabilitation; pulmonary tests, procedures, studies; radiation therapy; radiology; radiology CT scan; radiology DEXA scan; radiology mammogram; radiology MRI/MRA; radiology PET scan; radiology ultrasound; rehabilitation medicine; respiratory therapy; rheumatology; sleep study/polysomnography; surgery general; thoracic surgery; urology; urology tests, procedures, studies; vascular; vascular tests, procedures, studies; veteran directed home and community based services; and wound care (Source: Department of Veterans Affairs, FY2018 Congressional Budget Submission, Medical Programs and Information Technology Programs, vol. 2 of 4, May 2017, pp. VHA-319-VHA- 320 ).
For general enrollment procedures, see CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by [author name scrubbed].
810.	Department of Veterans Affairs, "Expanded Access to Non-VA Care through the Veterans Choice Program," 80 Federal Register 74991-74996, December 1, 2015 (codified at 38 C.F.R.§17.1510).
911.	Department of Veterans Affairs, VA Care in the Community (Non-VA Purchased Care) and use of the Veterans Choice Program, Memorandum from Acting Principal Deputy Under Secretary for Health to Veterans Integrated Service Network (VISN) Directors, May 12, 2015, and amended on October 1, 2015.
1012.	Local VA staff decides whether or not the burden is unusual or excessive and likely to exist "at least 30 days or more from the date of the determination." Staff are to document the decision on VA Form 119, Report of Contact, which includes the date of determination, expected duration of travel burden, and reason(s) behind the decision. Notification is to be sent in a letter by mail to the veteran. Department of Veterans Affairs, Veterans Health Administration, Veterans Choice Program - Unusual or Excessive Burden Determination, September 11, 2015.
1113.	A local VA provider or the facility's Primary Care Patient Aligned Care Team (PACT) determines whether or not a veteran is facing an unusual or excessive travel burden due to a medical condition. The duration of the burden is also assessed.
1214.	Veterans may appeal the decision of their local facility to the Board of Veterans Appeals (BVA). First, veterans would send a notice of disagreement to their facility. Then the facility is to generate a statement of case (SOC). Lastly, the facility is to process the appeal and forward it to the BVA for processing. Department of Veterans Affairs, Veterans Health Administration, Veterans Choice Program - Unusual or Excessive Burden Determination, September 11, 2015, p. 3.
1315.	Department of Veterans Affairs, "Expanded Access to Non-VA through the Veterans Choice Program," 79 Federal Register 65577, November 5, 2014 (codified at 38 C.F.R. §17.1515).
1416.	38 C.F.R. §17.1515.
1517.	38 C.F.R. §17.1530 .
1618.	38 C.F.R. §17.1530.
1719.	Secretary Robert A. McDonald, An Open Letter to America's Veterans, Department of Veterans Affairs, Veterans Health Administration, 2014, http://www.va.gov/opa/choiceact/documents/Open-Letter-to-Veterans.pdf. Accessed on December 29, 20162017.
1820.	Department of Veterans Affairs, Veterans Choice Program, Leadership Toolkit for VA Facilities, p. 16.
1921.	Health Net Federal Services, Company InformationOverview of Health Net Federal Services' VA Programs, https://www.hnfs.com/content/hnfs/home/company/company-information/va.html. Accessed on December 29, 2016. 2017
2022.	TriWest Healthcare Alliance, About TriWest, http://www.triwest.com/en/about-triwest/.Accessed on December 29, 2016veteran-services/veterans-choice-program-vcp/. Accessed on January 2, 2018.
2123.	The Patient-Centered Community Care (PC3) initiative evolved from the Project on Healthcare Effectiveness through Resource Optimization (Project HERO) pilot program. Under the PC3 program, VA provides contracted inpatient and outpatient specialty care and mental health care to eligible veterans when VA medical facilities cannot provide services such as when there is a lack of medical specialists, or long wait times, or there is an extraordinary long distance from the veteran's residence.
2224.	Veterans Health Administration, Choice Champion Call, November 10, 2015, p. 31.
2325.	Major portions of this section are adapted from, Department of Veterans Affairs, Veterans Health Administration, How to become a Veterans Choice Program and/or Patient-Centered Community Care Provider, VA Community Care Fact Sheet for Interested Providers, March 14, 2016, p. 2, http://www.va.gov/PURCHASEDCARE/docs/pubfiles/factsheets/VHA-FS_How-to-become-a-Provider.pdf. Accessed on December 29, 2016.
24May 24, 2017 p. 2. https://www.va.gov/opa/choiceact/documents/How_to_Become_VA_Provider_05242017_508.pdf. Details on how providers could participate in VCP are available at https://www.va.gov/opa/choiceact/for_providers.asp. Accessed on January 2, 2018. 26.	Under the PC3 program, VA provides contracted inpatient and outpatient specialty care and mental health care to eligible veterans when VA medical facilities cannot provide services such as when there is a lack of medical specialists, or long wait times, or there is an extraordinary long distance from the veteran's residence.
2527.	Health Net may be contacted by phone (1-866-606-8198; press Option 2) or email (HNFSProviderRelations@Healthnet.com). For additional information about Health Net, see, https://www.hnfs.com/content/hnfs/home/va/provider.html[email address scrubbed]). Accessed on December 29, 2016January 2, 2018. TriWest may be contacted by phone (1-866-284-3743) or email ([email address scrubbed]). For additional information about TriWest, see https://www.triwest.com/provider. Accessed on December 29, 2016January 2, 2018.
2628.	The Centers for Medicare and Medicaid Services manages the Medicare Exclusion Database (MED) which contains a list of excluded providers and their sanctions and reinstatement files. For additional information about the MED, see https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MED/Overview-MED.html. Accessed on December 29, 2016January 2, 2018.
2729.	To determine if a provider or entity is required to meet the Conditions of Participations (CoPs) and Conditions for Coverage (CfCs), see https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/index.html. Accessed on December 29, 2016January 2, 2018.
2830.	Veterans Choice Program (VCP) Provider Agreements may be authorized between local VA Medical Centers (VAMCs) and out-of-network VA community care providers only after Health Net or TriWest is unable to process a veteran's authorization request and/or schedule an appointment, within a timely manner, for the veteran.
2931.	Major portions of this section are adapted from, Department of Veterans Affairs, Veterans Health Administration, VHA Chief Business Office, Veterans Choice Program, Unusual or Excessive Burden Determination (Other Factors) Process, December 2015.
3032.	Generally, a veteran who becomes eligible under the VCP through the "30-day wait list" or "40 miles or more distance" pathway, may not have to go through the entire VA community care consult/referral process.
3133.	The Computerized Patient Record System (CPRS) is the electronic system VA providers use to input consults/referrals for VA community care. Once entered, the VA community care consult/referral is to alert a clinical reviewer who is to examine the veteran's medical need and confirm that the requested services are not available at a local VA health care facility.
3234.	Special authority conditions include those that are eligible for service-connection under Priority Group 6 (combat veterans, ionization radiation, Agent Orange exposure, Southwest Asia service, veterans stationed at Camp Lejeune between August 1, 1953 to December 31, 1987, and Project 112/ SHAD), military sexual trauma, nasopharyngeal radium irradiation, etc.
3335.	"R-UR, under the auspices of the CBO, is the systematic evaluation and analytical review of clinical information in order to maximize reimbursement from third-party payers. In 2003, guidance was established standardizing the clinical review functions with third-party reimbursement responsibilities at VA medical facilities. R-UR in this context operates to promote improvements in patient care and to maximize the potential for the recovery of funds due VA for the provision of health care services to Veterans, dependents, and others using the VA health care system." For more information, see Department of Veterans Affairs, Veterans Health Administration, Utilization Management Program, VHA Directive 1117, Washington, DC, July 9, 2014, p. 8, http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3018. Accessed on December 29, 2016January 2, 2018.
3436.	Major portions of this section are adopted from Department of Veterans Affairs, Veterans Health Administration, VHA Chief Business Office, Veterans Choice Program, Unusual or Excessive Burden Determination (Other Factors) Process, December 2015.
3537.	An attendant for clinical services is a person who provides essential aid and/or physical assistance to the veteran so that the veteran can travel to a VA medical facility to have hospital care or medical services rendered. 38 C.F.R. §17.1510(b)(4)(ii)(A)-(C).
3638.	VA community care providers may call the Operation Center for Choice at [phone number scrubbed] to request prior authorization from either Health Net or TriWest prior to delivering medical services to veterans. Failure to obtain preauthorization prior to rendering health services may result in uncompensated services.
3739.	38 C.F.R. §17.1505.
3840.	Ibid.
3941.	Department of Veterans Affairs, "Expanded Access to Non-VA Care Through the Veterans Choice Program," 80 Federal Register 66424, October 29, 2015.
4042.	Veterans Health Administration, Ten Things to Know About the Choice Program, 2015, http://www.va.gov/HEALTH/newsfeatures/2015/July/10-Things-to-Know-About-Choice-Program.asp. Accessed on December 29, 2016January 2, 2018.
4143.	Department of Veterans Affairs, Veterans Health Administration, Prescription Reimbursement Associated with VACC Delivered under the Choice Program, VA Care in the Community (VACC) Program Reference Sheet, October 27, 2015. Department of Veterans Affairs, "Expanded Access to Non-VA Care Through the Veterans Choice Program," 79 Federal Register 65572, November 5, 2014.
4244.	Department of Veterans Affairs, VA Office of Inspector General, Veterans Health Administration, Audit of Timeliness and Accuracy of Choice Payments Processed Through the Fee Basis Claims System, 15-03036-47, December 21, 2017, p. 6.	Department of Veterans Affairs, Veterans Health Administration, Working with the Veterans Health Administration: A Guide for Providers, October 2014, p. 3, http https://www.va.gov/PURCHASEDCARECOMMUNITYCARE/docs/pubfiles/programguides/NVC_Providers_Guide.pdf. Accessed on December 29, 2016January 2, 2018.
4346.	The standard billing forms for reimbursement include the UB-04 CMS-1450 or CMS-1500.
4447.	38 C.F.R. §17.124.
4548.	VA Form 10-583, Claim for Payment of Cost of Unauthorized Medical Services, at http://www.va.gov/vaforms/form_detail.asp?FormNo=583. Accessed on June 2, 2016January 2, 2018.
4649.	An amount paid, by an enrollee or by an employer or a combination of both parties, to an insurer for a beneficiary to enroll in a health insurance plan.
4750.	An amount a beneficiary must pay out of pocket before the health insurance plan begins paying for services.
4851.	A specified percentage a beneficiary pays out of pocket to a provider after meeting any deductible requirements.
4952.	Only veterans in Priority Group 1 (those who have been rated 50% or more service-connected) and veterans who are deemed catastrophically disabled by a VA provider are never charged a copayment, even for treatment of a nonservice-connected condition. For more information, see Department of Veterans Affairs, "Criteria for a Catastrophically Disabled Determination for Purposes of Enrollment," 78 Federal Register 72576-72579, December 3, 2013.
5053.	The VA categorizes veterans into eight Priority Groups, based on factors such as service-connected disabilities and income (among others). For a detailed summary of eight Priority Groups, see CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by [author name scrubbed].
5154.	38 C.F.R. §§17.108, 17.110, 17.111.
52.	Veterans Health Administration, Non-VA Medical Care Program and Provider Fact Sheet, p. 2, http://www.manchester.va.gov/documents/123014-VACAA-ProviderFactSheet.pdf. Accessed on June 2, 2016.
53.	CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by [author name scrubbed].
54.	Department of Veterans Affairs, "Expanded Access to Non-VA Care Through the Veterans Choice Program," 80 Federal Register, 66426, October 29, 2015.
55.	Department of Veterans Affairs, Veterans Health Administration, Veterans Choice Program Other Health Insurance and Copayment Responsibility, August 12, 2015, p. 1.
56.	Veterans Health Administration, Choice Champion Call, January 12, 2016, p. 23.
57.	Ibid., p. 2, and 38 C.F.R. §§17.1520(b), 17.1535(b).
58.	Ibid., p. 33.
5955.	Department of Veterans Affairs, VA Office of Inspector General, Veterans Health Administration, Audit of Timeliness and Accuracy of Choice Payments Processed Through the Fee Basis Claims System, 15-03036-47, December 21, 2017, p. 6.	Department of Veterans Affairs, "Expanded Access to Non-VA Care Through the Veterans Choice Program," 80 Federal Register 66425, October 29, 2015.
6057.	Veterans may call the Community Call Center at 1-877-881-7618 from 9 am to 5 pm EST. (https://www.va.gov/HEALTHBENEFITS/cost/disputes.asp). Accessed on January 2, 2018.