Eligibility for community care outside VA

Eligibility requirements

To be eligible for community care, you must meet the requirements listed here.

You must meet both of these requirements:

• You’re enrolled in or eligible for VA health care, and
• You have approval from your VA health care team before you get care from a community provider (except for certain cases like urgent or emergency care)

And you must meet at least 1 of these requirements:

• You need a service that we don’t provide at any VA health facility, or
• You live in a state or territory that doesn’t have a full-service VA health facility, or
• You live in Alaska, Montana, North Dakota, South Dakota, or Wyoming, or
• You qualified under the 40-mile distance requirement on June 6, 2018, and live in a location that would still make you eligible under these requirements, or
• We can’t provide the care you need within our standards for drive and wait times, or
• You and your VA provider agree that getting care from an in-network community provider is in your best medical interest, or
• We can’t provide the service you need in a way that meets our quality standards

Examples of when you may be eligible for community care

Here are 6 examples of when you may be eligible for community care based on each requirement:

Example 1: A service we don’t provide

You need dialysis. But we don’t provide dialysis at any of our facilities. So, you’re eligible to get dialysis from an in-network community provider.

Example 2: No full-service VA health facility

You live in Alaska, Hawaii, New Hampshire, Guam, American Samoa, the Northern Mariana Islands, or the U.S. Virgin Islands. We don’t have a full-service VA health facility in your state or territory. So, you’re eligible to get care from an in-network community provider.

Example 3: Qualification under the 40-mile distance requirement

You previously qualified under the Veterans Choice Program’s 40-mile distance requirement on June 6, 2018, and you still live at the same address. And you live in Alaska, Montana, North Dakota, South Dakota, or Wyoming. So, you’re eligible to get care from an in-network community provider.

Example 4: Drive and wait time standards

For primary care or mental health

You need a primary care or mental health appointment. And your provider and you agree that you need that appointment within 20 days. But we can’t schedule an appointment for you at a VA health facility that’s within the next 20 days and within a 30-minute average drive from your home. This means you’re eligible to get primary or mental health care from an in-network community provider.

For specialty care

You need an appointment for specialty care (such as cardiology care for a heart problem). But we can’t schedule an appointment for you at a VA health facility that’s within a 60-minute average drive from your home. And we can’t schedule an appointment within the next 28 days. This means you’re eligible to get specialty care from an in-network community provider.

Example 5: Your best medical interest

You’re getting recurring treatment for a condition and have medical issues that prevent you from getting to the VA facility that’s within our standards for drive time (such as nausea from recurring cancer treatments). Or you require recurring treatments that we can’t supply in a timely manner, even if they meet our wait time standards. If you and your VA provider agree that it’s in your best medical interest to get care from the community provider, you’re eligible for community care.

Example 6: Quality standards

You need cardiology care for a heart problem. But we’ve determined that your local VA health facility doesn’t provide cardiology care that meets our quality standards. You may be able to get cardiology care from an in-network community provider.