Implementation of the Veterans Choice Program (VCP)

Implementation of the Veterans Choice Program (VCP)

Updated July 12, 2017
Implementation of the Veterans Choice Program (VCP)
In response to wait time manipulation allegations and
VA Response to the Shortfall
access issues at many Department of Veterans Affairs (VA)
To prolong the funds for VCP, on June 12, 2017, the VA
hospitals across the country, Congress passed the Veterans
provided guidance to VA medical facilities on optimizing
Access, Choice and Accountability Act of 2014 (VACAA).
funding for VA community care. Among other things:
On August 7, 2014, the bill was signed into law (P.L. 113-
 Veterans who are eligible based on statutory criteria (see
146, as amended).
below) will continue to be eligible to use VCP.
Background Resources
 “Choice First” criteria—that is, care not offered at the

For wait time issues, see VA Office of Inspector General
veteran’s primary VA medical facility—will no longer
(OIG), Administrative Summaries of Investigation Regarding
apply. In May 2015, the VA provided guidance to VA
Wait Time (http://bit.ly/2gLEnAr)
medical facilities that VCP should be the primary

For a detailed provision-by-provision explanation of the
program to be used when patients are waiting for care or
act, see CRS Report R43704, Veterans Access, Choice, and
need care that cannot be provided at the veterans’
Accountability Act of 2014 (H.R. 3230; P.L. 113-146)
primary facility.

For a more in-depth discussion on implementation of the
VCP, see CRS Report R44562, The Veterans Choice
 Veterans who do not qualify for VCP because their
Program (VCP): Program Implementation
required care is not offered at the veteran’s primary VA
medical facility will be referred to another VA medical
Section 101 of VACAA authorized the Veterans Choice
facility or a federal facility such as a Department of
Program (VCP) ―a temporary program that provides
Defense medical facility, Indian Health Service (IHS),
veterans the flexibility to receive medical care in the
or Tribal Health Facility, or to other community care
community if that is their preference. The VCP generally
providers not participating in VCP.
covers all medical care services, including diagnostic and
laboratory tests, among others. Emergency care, dialysis
VCP Eligibility
care, and long-term nursing home care are not covered.
To participate in the VCP, a veteran must be enrolled in the
VA health care system and meet one of the following
The VCP is in addition to several existing statutory
criteria:
authorities that allow the VA to provide care outside of its
health care system. Generally, these statutory authorities
 the veteran cannot schedule an appointment within 30
fall into three broad categories: (1) contracts to purchase
days of the veteran’s preferred date or a date determined
care, (2) non-contracted medical care purchased on a fee for
clinically appropriate by a VA provider; or
service basis from providers in the community, and (3)
 the veteran resides more than 40 miles from his or her
emergency care when delays may be hazardous to a
veteran’s life or health
closest VA medical facility with a full-time primary care
.
provider; or
Unexpected Shortfall in the Veterans Choice Fund
 the veteran resides 40 miles or less from a VA medical
The VCP was to end either when the $10 billion in
facility and faces an unusual or excessive burden in
mandatory funding included in VACAA was fully obligated
accessing such a facility due to geographical challenges;
or no later than August 7, 2017. Enacted on April 19, 2017,
or
P.L. 115-26 eliminated the sunset date of August 7 and
 the veteran resides in a state without a full-service VA
authorized the VA to continue the VCP until the $10 billion
medical facility that provides hospital care, emergency
was fully obligated. At the time of enactment of P.L. 115-
services, and surgical care and resides more than 20
26, the VA had indicated to Congress that about $1 billion
miles from such a facility (this criterion applies only to
of the funding for VCP could remain unobligated by
veterans residing in three states: Alaska, Hawaii, and
August 7. However, in mid-June 2017, VA notified
New Hampshire).
Congress that due to the increased authorization of
appointments, there had been higher rate of usage of VCP
How Is VCP Administered?
funds, and VCP would not be able to continue past August
The VACAA provided 90 days from the date of enactment
15, 2017, since all the remaining funds for VCP would be
to establish the temporary VCP. VA awarded contracts to
fully obligated by then. As of June 9, 2017, $9.2 billion of
two existing VA contractors—Health Net Federal Services,
VCP funds had been obligated and $7.1 billion had been
LLC and TriWest Healthcare Alliance Corporation—to
expended. According to the VA, at least $3.5 billion in new
serve as third-party administrators (TPA) of the VCP. In
mandatory budget authority would be needed to continue
their TPA role, TriWest serves the western United States
VCP through FY2018. (The VA estimates that
and mid-South regions; Health Net serves the remainder of
approximately $252 million per month is obligated for
the country.
VCP.)
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Implementation of the Veterans Choice Program (VCP)
What Is the Process to Obtain Care?
because of inappropriate or delayed VCP billing. With the
Generally, the VA determines a veteran’s eligibility for
enactment of P.L. 115-26, veterans will not have to pay a
VCP. Once a veteran is eligible for VCP under wait time
copayment under their other health insurance plans.
criteria (cannot obtain the care at a VA facility within 30
Furthermore, community care providers will only bill the
days or less), the VA sends the referral to the TPA and the
VA and not the veteran’s other health insurance plans. The
TPA contacts the veteran. The TPA explains the program,
VA will coordinate and bill the veteran’s health insurance
ensures that the veteran understands any out-of-pocket
for non-service connected care.
expenses he or she may incur, and obtains the veteran’s
preference for an appointment and schedules it with a VCP
Some Potential Issues for Congress
participating provider. After the veteran is seen by a
 Overlapping and sometimes contradictory eligibility
provider, the TPA follows up with the provider and
requirements among the various non-VA care statutory
provides the clinical records to the VA.
authorities have caused numerous challenges to
If a veteran is eligible under the distance criteria (resides 40
veterans and providers. Currently, various policy
miles or more), a veteran can directly call the TPA (1-866-
proposals are being discussed to consolidate and
606-8198). The TPA will confirm eligibility for VCP via
streamline all non-VA community care programs. A
VA-provided eligibility information. Once eligibility is
proposed new program known as Veterans CARE
confirmed, the TPA explains the program, ensures that the
(Coordinated Access & Rewarding Experiences)
veteran understands any out-of-pocket expenses he or she
Program was discussed at a hearing on June 7, 2017.
may incur, and obtains the veteran’s preference for an
Briefly, under this proposal, the veteran will be
appointment and schedules it with a VCP participating
authorized to receive care in the community based on
provider. After the scheduled appointment with a VCP
clinical determination. Under the Veterans CARE
participating provider, the TPA will follow the same
Program, the VA would develop an integrated
process as described for those who qualify under the wait
community network that would include the Department
time criteria.
of Defense, the Indian Health Service, Tribal Health
Under both processes, urgent care appointments are
Programs, Federally Qualified Health Centers (FQHCs),
required to be scheduled and take place within two days,
academic affiliates, and other private providers.
and routine care appointments must be scheduled within 5
Veterans who have urgent care needs would have access
days and occur within 30 days. If TPAs cannot meet these
to a networks of walk-in clinics.
requirements, the requests are returned to the VA medical
 Both long- and short-term considerations for new
center, and the VA could utilize other non-VA care
budgetary resources exist. While Congress may
authorities (see Figure 1).
consider proposals to fund the VCP shortfall through
FY2018, it is unclear how long-term funding for a
VA as the Primary Payer for VCP
proposed new community care program would be
Enacted on April 19, 2017, P.L. 115-26 required VA to be
structured. Currently, there are two different funding
the primary payer for care for veterans with nonservice-
streams for VCP and other non-VA community care
connected conditions. Prior to the enactment of P.L. 115-
programs. While the VCP is funded as a mandatory
26, the VA was the secondary payer for care provided for a
appropriation, other community care programs are
nonservice-connected disability if the veteran had another
funded as discretionary appropriations. The VA has
health-insurance plan. This change arose because some
testified that having two different streams has created
veterans had to pay higher out-of-pocket costs under VCP
numerous challenges in administering these programs
than under other non-VA care statutory authorities. This
and responding to variances in demand for care in the
had resulted in veterans facing debt collection issues
community during the fiscal year.
Figure 1.High-Level Patient Flow for VCP

Source: Congressional Research Service based on VA information. Note: TPA= Third Party Administrator; VCP=Veterans Choice Program.

IF10563
Sidath Viranga Panangala, Specialist in Veterans Policy

https://crsreports.congress.gov

Implementation of the Veterans Choice Program (VCP)

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