New VA Choice Program rules effective Dec. 1

New VA Choice Program rules effective Dec. 1

The Department of Veterans Affairs (VA) has published and made effective its interim final rule that expands the VA Choice Program, which combines the agency’s existing private health-care programs into a single system with the goal of stopping gaps in veteran care.

VA Choice ProgramVetsHQ has analyzed these changes, which if implemented well and correctly, have an opportunity to be valuable and effective for veterans who are eligible for the program.

Changes to the Choice Program include:

  • Establishing an “Unusual or Excessive Burden” Standard for travel to the VA for health care
  • Veteran Eligibility expansion
  • Periods of Follow Up Care lengthened
  • Appointment Wait Time standard defined
  • Distance Requirements modified
  • Provider Eligibility expansion

The VA has established an “unusual or excessive burden” standard for travel to the VA for health care. Examples of circumstances under which a veteran’s travel to a VA medical facility is an “unusual or excessive burden”:

  • If veterans are only able to access a VA medical facility that is 40 miles or less from their residence via roads that are not accessible to the general public include roads through military bases or other restricted areas
  • Traffic or hazardous weather,  including special traffic congestion and patterns or weather conditions that make travel of a veteran to a VA medical facility 40 miles or less from their residence excessively or unusually burdensome
  • Geographical challenges, such as the presence of a body of water  or a geologic formation that cannot be crossed by road
  • A medical condition that affects the Veteran’s ability to safely travel for 40 miles or less to a VA medical facility, such as Veterans requiring a portable ventilator or an oxygen tank, who may be able to travel for a certain of amount of time (versus miles). Also, Veterans with spinal cord injuries or other serious conditions may require the use of assistive devices or may not be able to traverse over bumpier or windier roads.

Three additional factors have been added to the federal regulation, and are referred to as “other factors, as determined by VA”:

“(A) The nature or simplicity of the hospital care or medical services the veteran requires”;

Routine or simple tests or procedures, such an allergy test or an immunization do not justify traveling a longer distance to receive the care at the VA.

“(B) The frequency that such hospital care or medical services need to be furnished to the veteran”;

If a Veteran needs repeated appointments for a course of treatment, such as chemotherapy, the burden of travel could be lessened by receiving care close to home rather than travel to the VA.

and

“(C) The need for an attendant, which is defined as a person who provides required aid and/or physical assistance to the veteran, for a veteran to travel to a VA medical facility for hospital care or medical services.”

While these criteria are fully defined and newly implemented, the VA can make a case-by-case determination of other factors than create an unusual or excessive travel burden for the Veteran.

Veteran Eligibility, Periods of Follow Up Care, Appointment Wait Times,
Distance Requirements, and Provider Eligibility

Program changes:

  • cover all veterans enrolled in the VA health care system
  • remove the 60-day limit on an episode of care
    • The limitation is now 1 year, subject to the VA’s “clinical judgment to determine that ancillary and specialty care is actually needed”
    • Warning: The VA will authorize only the care that it deems necessary as part of a course of treatment. If a non-VA health care provider believes that a veteran needs additional care outside the scope of the authorized course of treatment, the health care provider must contact VA prior to administering such care to ensure that this care is authorized (i.e., will be paid for by the VA).  The VA will determine whether any additionally requested care means a new ‘episode of care’ on a case-by-case basis.
  • modify the wait-time and 40-mile distance eligibility criteria
    • 38CFR17.1510(b)(1)(ii) (newly added) —  the new wait-time criteria creates eligibility for the Program:

“The veteran attempts, or has attempted, to schedule an appointment with a VA health care provider, but VA is unable to schedule an appointment for the veteran within:

(i) The wait-time goals of the Veterans Health Administration; or

(ii) With respect to such care or services that are clinically necessary, the period VA determines necessary for such care or services if such period is shorter than the wait-time goals of the Veterans Health Administration.”

  • A “qualifying VA medical facility” is now defined to those facilities with at least a full-time primary care physician.
    • A ‘full-time primary care physician” is defined as “at least one individual physician whose workload, or multiple physicians whose combined workload, equates to a 0.9 full-time equivalent employee that works at least 36 clinical work hours per week.”

Previously, a Veteran living 10 miles from a VA-community based outpatient clinic (CBOC) (no full-time primary care physician), and 50 miles from another VA medical facility (with full-time primary care physician(s) on staff), the veteran would not be eligible for the Program because of their proximity to the CBOC. With the implementation of this interim final rule, this Veteran would be eligible for the Program. This change is based on the VA’s interpretation of Public Law 114-41, Section 4005(e) and their revision of federal regulation at 38CFR17.1505.

  • expand provider eligibility based on criteria as determined by the VA

The Program has expanded eligibility to Medicaid providers, increasing the VA’s ability to offer certain services, such as dental care and unskilled home health services.  This change does not constitute a change in services generally offered to Veterans.  This change does expand the services available under the Choice Program by expanding the number and type of authorized providers.  In all cases, the Veteran must be found eligible for the services, and the VA will determine the medical necessity.

The VA’s interim final rule on the VA Choice Program was published and became effective the same day — December 1, 2015.

Comments can still be submitted on or before March 30, 2016 at regulations.gov. To view the entire interim rule published in the Federal Register, go to https://federalregister.gov/a/2015-29865. The VA Choice Program is only authorized to run until August 7, 2017, or until funds expire.

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