Notable VA Updates: How New Veterans Eligibility Requirements Impact Your Hospital

Posted August 3, 2021 by Jason Smartt, Esq., CRCR

Veterans who receive care outside the Department of Veteran Affairs (“VA”) hospitals saw their eligibility requirements change drastically in the past 20 years. Originally, the VA restricted veterans from visiting non-VA affiliated facilities for any type of treatment. Veterans could only go to VA hospitals if they wanted their treatment covered by their benefits. Now veterans can access non-VA affiliated facilities through multiple eligibility routes to receive treatment. Today, we examine how the VA changed eligibility requirements over the last two decades.  

Before 2001, the VA restricted veterans by requiring them to receive treatment from only VA hospitals regardless of condition, distance, or time to receive care. This out-right directive led to several issues the VA would slowly begin to tackle over the next 20 years. Starting in 2001, President Bush signed into law the Veterans Millennium Health Care and Benefits Act (38 CFR 3.22). The new law was a monumental step in the right direction as the Act allowed Veterans to receive treatment at non-VA facilities for emergency care when certain conditions occurred.

In 2013, the VA determined Veterans needed additional access to care across communities throughout the nation, resulting in the VA establishing the Patient Centered Community Care (“PC3”) network. This network allowed Veterans to receive treatment under any one of the three following conditions:

  • Wait list was longer than 30 days,
  • Services not available in their state, or
  • The nearest VA facility was not easily accessible

In 2014, President Obama signed the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146). This Act created the Veterans Choice Program (“VCP”), which allowed Veterans to seek treatment if the nearest VA facility was 40 miles or more away from their home. These exceptions essentially broke down the walls and allowed Veterans to seek treatment from sources they never thought possible. However, after several scandals and issues (where the VA all but admitted that they failed their veterans), Congress took matters into their own hands. Congress, through multiple hearings and speaking with Veteran groups, concluded that they needed to ease the restrictions even more, allowing veterans additional opportunities to seek treatment outside the VA.

On June 6, 2018, President Trump signed the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (aka MISSION Act) with overwhelming bipartisan approval from Congress. The MISSION Act consolidates all the programs into the Community Care Network (“CCN”) and allow veterans even more freedom to seek treatment from sources outside the VA. On June 6, 2019, the MISSION Act went into effect, effectively ending the VCP and replacing it with the CCN. Unfortunately, even the best laid plans sometimes hit a snag. Contained within the MISSION Act, Congress mandated that the VCP would end on the same day MISSION went into effect. However, due to various reasons such as complications with funding, a significant number of veterans still receiving coverage under the VCP, and eventually the pandemic, Congress extended the program funding for another two years ending on June 1st, 2021.

In addition, Congress extended the PC3 funding through March 31st, 2021, for the same reasons. For those next two years, hospitals, physicians, and veterans juggled three eligibility programs for veteran care and claims. With the addition of a new program, a new regional map for the entire country, and a new payer, complications occurred. Hospitals did not know where to file a claim, who to garner an authorization from, or whether the Veteran qualified for coverage.  

As of June 1, 2021, things finally settled down, as the CCN is the only program that exists and operates for Veteran Health Benefits. As veteran eligibility is concerned, the CCN is the best of both worlds. Now that the VCP and PC3 no longer exist, a Veteran can qualify for treatment under one of the following five conditions that the CCN provide:

  • Veterans can go to non-VA hospitals when the services they require are not offered in the state they live,
  • Veterans can go to non-VA hospitals if the VA does not operate in that state, 
  • Veterans who live in Alaska, North Dakota, South Dakota, Montana, or Wyoming received grandfathered coverage with their VACA Benefits from 2014,
  • If the VA cannot furnish the services needed to a Veteran in a timely manner – which is defined as 30 days or lifesaving,
  • Veterans can receive treatment at a non-VA facility if it is in the best medical interest of the Veteran – which the VA balances against distance, time, frequency, continuity of care, and if the Veteran faces an unusual burden

While this has been a difficult time for hospitals in learning the new eligibility requirements, EnableComp continues to stay on top of current developments. Our team is committed to ensuring our clients are up to date with the latest VA changes, improvements, and any new challenges they may encounter with VA claims.  Our VA expertise and knowledge allows us to assist our clients in locating gaps, refining processes, and establishing best practices to capture Veteran qualifications under CCN coverage or those that require further follow up with Fee Basis.

If you have additional questions related to your VA claims, let us know. If you are considering a partner to manage this entire process for you, look no further. Our team is currently seeing a 41% decrease in time to collect with an average increase of 25% – 40% in VA collections in 98 days or less.