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Patrick Jolly

Patrick Jolly

Veterans who are enrolled in VA health care may now be able to use local care providers under the new Community Care Program.

There are two main components that became active on June 6, 2019 – the Urgent Care Program and the Community Care Network.

The Urgent Care Program was established to allow eligible veterans to receive urgent care from an urgent care provider that is part of VA’s contracted network of community providers without prior authorization from VA. VA can pay for an urgent care claim only if:

  • The veteran is eligible for the benefit;
  • The urgent care provider is part of VA’s contracted network of community providers; and
  • The services are not excluded under the benefit (excluded services include preventive services and dental services).

To be eligible, a veteran must be actively enrolled in the VA health care system, and been seen within the previous 24 months at a VA facility.

A list of qualified medical providers for urgent care is online at va.gov/find-locations/. Veterans can also call their local VA clinic for information.

With urgent care, Veterans have a new option for care for the treatment of minor injuries and illnesses, such as colds, sore throats, and minor skin infections. The benefit is offered in addition to the opportunity to receive care from a VA provider, as VA also offers same day services.

VA will pay for or fill prescriptions for urgent care. For routine prescription medication, the prescription must be submitted to VA to be filled. For urgent prescription medication of a 14 day or fewer supply, Veterans can either fill the prescription at a contracted pharmacy in the VA network or the prescription can be filled at a non-contracted pharmacy. If a non-contracted pharmacy is used, Veterans must pay for the prescription and then file a claim for reimbursement with their local VA medical facility.

Eligible veterans may have a co-payment of $30. For veterans in VA Health Care Priority Groups 1-5, the first three visits each calendar year are free.

The other new component is the Community Care Network.

Veterans may be eligible for care through a provider in their local community depending on their health care needs, and if they meet specific eligibility criteria. Even if a Veteran is eligible for community care, they generally still have the option of choosing to receive care from a VA medical facility.

Veterans must be enrolled in VA health care. In most cases, Veterans must receive approval from VA before receiving care from a community provider to avoid being billed for the care. VA staff members generally make all eligibility determinations for community care.

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If prescription medication is needed, the prescription should usually be sent to and filled by the nearest VA pharmacy. Veterans can receive short-term prescription medication for a 14-day or fewer supply that can be filled at a non-VA pharmacy. A prescription for more than a 14-day supply must be filled by VA.

Both of these programs became active on June 6, 2019. Both programs require that the community care provider be part of the VA network of providers.

Unfortunately, as of the writing of this column there are few providers in Napa County that could be used for community care, and no urgent care clinics. Napa County is working with the VA Community Care office to develop a process. Napa County falls geographically under the VA Medical Center in San Francisco.

Health care professionals and urgent care clinics that would be interested in becoming part of the VA network should go to the TriWest Healthcare Alliance provider’s website at joinournetwork.triwest.com.

There is a third category of service that is not new – emergency care. Veterans who are active in the VA health care system (seen within the last 24 months) may be eligible for this benefit.

During a medical emergency, Veterans should immediately seek care at the nearest medical facility. A medical emergency is an injury, illness or symptom so severe that without immediate treatment, you believe your life or health is in danger. If you believe your life or health is in danger, call 911 or go to the nearest emergency department right away.

Veterans do not need to check with VA before calling for an ambulance or going to an emergency department. During a medical emergency, VA encourages all Veterans to seek immediate medical attention without delay. A claim for emergency care will never be denied based solely on VA not receiving notification prior to seeking care.

It is, however, important to promptly notify VA after receiving emergency care at a community emergency department. Notification should be made within 72 hours of admission to a community medical facility. This allows VA to assist the Veteran in coordinating necessary care or transfer, and helps to ensure that the administrative and clinical requirements for VA to pay for the care are met.

In general, VA can pay for emergency medical care at a local emergency department for a Veteran’s service-connected condition, or if the care is related to a Veteran’s service-connected condition. Specifically, emergency medical care for a Veteran’s service-connected or related (adjunct) condition(s) is eligible for VA payment as long as the VA wasn’t reasonably available to provide the care.

VA can also pay for emergency medical care at a community emergency medical care for a Veteran’s nonservice-connected condition. However, there are several requirements and factors that affect the extent to which VA can cover those services. Specifically, emergency medical care for a Veteran’s nonservice-connected condition(s) is eligible for VA payment when all of the following five elements are true:

  • Care was provided in a hospital emergency department (or similar public facility held to provide emergency treatment to the public); AND
  • The emergency was of such a nature that the Veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy; AND
  • A VA medical facility or another Federal facility was not reasonably available to provide the care; AND
  • The Veteran is enrolled and has received care within a VA facility during the 24 months before the emergency care; AND
  • The Veteran is financially liable to the provider of emergency treatment.

The Napa County Veterans Service Office can answer questions and help veterans and their dependents apply for the many benefits that are available. We have a one-hour orientation to benefits every Tuesday afternoon at 1:30, and host the Vet Connect program linking vets to benefits on the second Thursday of each month from 9 – noon. We’re located at 650 Imperial Way in Napa, and can be reached by phone at 707-253-4558 or email vets@napavets.com. Please visit us on the web at www.napavets.com.

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