The Veterans Choice Program (VCP): Program Implementation
Released: 2018-09-19T00:00:00

Introduction

In response to concerns about access to medical care at many Department of Veterans Affairs (VA) hospitals and clinics across the country in spring 2014, Congress passed the Veterans Access, Choice, and Accountability Act of 2014 (VACAA, P.L. 113-146 , as amended). On August 7, 2014, President Obama signed the bill into law. Since the VACAA was enacted, Congress has amended the act several times: P.L. 113-175 , P.L. 113-235 , P.L. 114-19 , P.L. 114-41 , P.L. 115-26 , P.L. 115-46 , P.L. 115-96 , and P.L. 115-182 . In addition, the VA has issued implementation regulations and guidance on several occasions in response to the changes to VACAA and challenges encountered during implementation of the law. Table 1 provides major highlights pertaining to the Veterans Choice Program (VCP)―a new, temporary program authorized by Section 101 of the VACAA that allows eligible veterans to receive medical care in the community.

On June 6, 2018, President Donald Trump signed the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Networks Act of 2018 (the VA MISSION Act of 2018) into law ( P.L. 115-182 ). Section 101 of this act established a new permanent Veterans Community Care Program (VCCP) that would replace VCP. This new program is expected to be operational around June 6, 2019. (The MISSION Act of 2018 stipulates that VCCP must be effective when the VA determines that 75% of the amounts deposited in the Veterans Choice Fund [VCF] have been exhausted, or when regulations are published by the VA, which is no later than one year after the date of enactment of the VA MISSION Act—June 6, 2019.)

This report provides details on how the VCP is being implemented. It is meant to provide insight into the execution of the current VCP program that is still functioning until the new VCCP program becomes operational sometime in June 2019.

Scope and Limitations

Information contained in this report is drawn from regulations published in the Federal Register , conference calls, numerous meetings with VHA staff, and briefing materials and other information provided by the VA Office of Congressional and Legislative Affairs (which may not be publicly available). This report does not discuss the new VCCP program established by Section 101 of the VA MISSION Act of 2018.

Medical Services Under VCP

Once an eligible veteran is authorized to receive necessary treatment, including follow-up appointments and ancillary and specialty medical services, under the VCP, a veteran may receive similar services that are offered through their personalized standard medical benefits package at a VA facility. VA's standard medical benefits package includes (but is not limited to) inpatient and outpatient medical, surgical, and mental health care; pharmaceuticals; pregnancy and delivery services; dental care; and durable medical equipment, and prosthetic devices, among other things. Currently, 81 categories of medical services and procedures are authorized to be provided under VCP. However, institutional long-term care and emergency care in non-VA facilities are excluded from the VCP. "It is important to note that the VCP does not provide guaranteed health care coverage or an unlimited medical benefit." These services are authorized and provided under separate statutory authorities outside the scope of VCP.

Eligibility

Generally, all veterans have to be enrolled in the VA health care system to receive care under the VCP. Once this initial criterion is met, a qualified veteran may choose to receive care through VCP. Veterans may become eligible for care under the VCP through one of four different pathways:

30-d ay w ait l ist (Wait-Time Eligible) : A veteran is eligible for care through the VCP when he or she is informed, by a local VA medical facility, that an appointment cannot be scheduled within 30 days of the clinically determined date of when the veteran's provider determines that he or she needs to be seen (this category also includes care not offered at the veteran's primary VA medical facility and a referral cannot be made to another VA medical facility or federal facility), or within 30 days of the date of when the veteran wishes to be seen. 40 miles or m ore d i stance (Mileage Eligible) : A veteran is eligible for care through the VCP when he or she lives 40 miles or more from a VA medical facility that has a full-time primary care physician. 40 m iles or l ess d istance (Mileage Eligible) : A veteran is eligible for care through the VCP when he or she resides in a location, other than one in Guam, American Samoa, or the Republic of the Philippines, and travels by air, boat, or ferry in order to seek care from his or her local VA facility; or incurs a traveling burden based on environmental factors, geographic challenges, or a medical condition. State or t erritory without a f ull- s ervice VA medical f acility: A veteran is eligible for care through the VCP when his or her residence is more than 20 miles from a VA medical facility and located in either Alaska, Hawaii, New Hampshire (excluding veterans who live 20 miles from the White River Junction VAMC), or U.S. territory (excluding Puerto Rico).

Table 2 provides a breakdown of the unique number of veterans utilizing the VCP, by eligibility category, from November 2014 through August 28, 2018, unless otherwise noted.

A veteran who believes that he or she meets one of the eligibility criteria to receive care through the VCP is to have his or her eligibility status confirmed by local VA staff. A high-level overview of the eligibility process to access care through the VCP is illustrated in Figure 1 . Local VA facility staff members are to review clinical and administrative records of the veteran to determine the appropriate medical benefits package and clinical criterion. Confirmation of the veteran's eligibility status is generally determined within 10 business days from when the request for confirmation was submitted. Veterans who are found ineligible to participate in the VCP are to be given instructions, in their notification letters, on how to appeal the VA's decision. Also see Appendix A for a detailed high-level workflow of how care is obtained through VCP.

Choice of Care

Eligible veterans have two options for receiving health care services under the Veterans Choice Program (VCP). First, veterans may choose to receive their medical care from a VA provider. A veteran who chooses this option is to receive an appointment with a VA provider. The veteran may be offered a VA appointment that is more than 30 days out or at a facility that is more than 40 miles from the veteran's residence. If an offered appointment does not accommodate the veteran's clinical needs, the local VA staff may place the veteran on an electronic waiting list until an alternate appointment becomes available. At any time , the veteran (based on the availability of clinical appointments) may choose to receive his or her medical services from a VA community care provider.

The second option allows veterans to receive health care services from a VA community care provider (VCP provider) who accepts eligible VCP veterans. Veterans who choose this option are to have their names and medical authorization information sent to a VCP provider of their choice. At any time , veterans (based on the availability of clinical appointments) may choose to receive their medical services from a VA provider.

VCP Providers

Under the VCP, several entities and providers are eligible to provide care and services. These include, among others, federally qualified health centers, Department of Defense (DOD) medical facilities, Indian Health Service outpatient health facilities or facilities operated by a tribe or tribal organization, hospitals, physicians, and nonphysician practitioners or entities participating in the Medicare or Medicaid program, an Aging and Disability Resource Center, an area agency on aging, or a state agency or a center for independent living. VA employees are excluded from providing care or services under VCP, unless the provider is an employee of VA, and is not acting within the scope of such employment while providing hospital care or medical services through the VCP. Generally, VCP providers "must maintain at least the same or similar credentials and licenses as those required of VA's health care providers."

Program Administration

The Veterans Choice Program (VCP) is not a health insurance plan for veterans. Under the VCP, veterans are given the option of receiving care in their local communities instead of waiting for a VA appointment and/or enduring traveling burdens to reach a VA facility.

All veterans who are enrolled in the VA health care system are to be mailed a VCP card. The card lists relevant information about the VCP. Many veterans have attempted to use the VCP card as an insurance card. The VCP card may not be used to pay for medical services performed outside of or within the VA. Specifically, the VCP card does not

replace veterans' identification cards, guarantee eligibility under the VCP, or provide health insurance-like benefits (i.e., the VCP, like all VA health care, is not health insurance).

Third-Party Administrators (TPAs)

In September 2013, the VA awarded contracts to Health Net and TriWest to expand veterans' access to non-VA health care in the communities, under the Patient-Centered Community Care (PC3) initiative. Later, in November 2014, the VA modified those contracts to include support services under the Veterans Access, Choice, and Accountability Act of 2014 (VACAA, or the Choice Act). Under the Veterans Choice Program (VCP), Health Net and TriWest manage the appointments, counseling services, card distributions, and a call center. They also oversee VCP providers, medical services reporting and billing processes, and the coordination of care with private health insurers. As illustrated in Figure 2 , Health Net covers Regions 1, 2, and 4, and TriWest covers Regions 3, 5A, 5B, and 6.

End of Contract with Health Net

In March 2018, the VA announced that the VCP contract with Health Net would end by September 30, 2018. Low volume of patients, customer service issues, and delayed payments to community providers were potentially some of the reasons for this decision. The contract with TriWest would continue. The VA has issued guidance to veteran patients, community providers, and local VA medical center staff regarding next steps after the contract with Health Net ends in September 2018. These documents have been reproduced in their entirety in Appendix B . Activities previously undertaken by Health Net, such as VCP authorizations, care coordination, and billing and payments, will now be managed directly between local VA medical centers and community care providers.

Community Care Provider Participation24

Eligible non-VA community care providers may become VCP providers. Providers who are interested in participating in the VCP may do so either through the Patient Centered Community Care (PC3) network or the Choice network. Community providers who are under the Choice network may only render authorized services to VCP-eligible veterans. Under the PC3 network, all veterans who are eligible for VA community care may be seen. The reason is that there are two different statutory authorities for care delivered through VCP and PC3. Interested providers are required to contact TriWest to determine whether they qualify as a VA community care provider. To qualify, providers must meet the following criteria:

Have a full, current, and unrestricted state license and the same/similar VA credentials. Not be named on the Centers for Medicare and Medicaid Services (CMS) exclusionary list. Meet all Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs). Accept Medicare or Medicaid rates. Provide resources (services, facilities, and providers) that are in compliance with applicable federal and state regulatory requirements. Submit all medical records of rendered services to veterans to the TPA for inclusion in veterans' VA electronic medical records.

After determining that a provider is eligible for participation, he or she may enroll (with TriWest) as a VCP provider. At this time, the VA community care provider and respective third-party administrator (TPA) are to establish an agreed-upon reimbursement amount for rendered services to veterans. When TriWest is unable to coordinate the delivery of health care services to veterans, local VA Medical Centers (VAMCs) may enter into VCP Provider Agreements with eligible VA community providers through the VAMCs' Community Care Departments.

Consults/Referral Processes30

Consults and referrals, known as the VA community care consults/referrals, are initiated in two different manners. First, a VA physician may submit a VA community care consult/referral (through the Computerized Patient Record System [CPRS]) on behalf of a veteran when there is a clinical need for the veteran to receive timely medical services. Second, a veteran may request a VA community care consult/referral (from his or her VA provider or local VA staff) in order to receive a medical service that is also timely. Regardless of how the consult/referral is initiated, all VA community care consults/referrals are to be processed by the VA Community Care Coordination staff within the VA. VA community care consults/referrals are processed based on whether the veteran requires emergent or urgent care. For urgent VA community care consults/referrals, VA providers are to coordinate the veteran's care directly with the VA Community Care Coordination staff.

When a veteran's request for a VA community care consult/referral cannot be approved, the veteran's local VA facility staff are to notify the veteran. On behalf of the veteran, his or her VA provider is to continue coordinating the veteran's medical services within the VA. The veteran's provider might also explore other existing community care options offered by the Veterans Health Administration (VHA).

After a veteran's request is approved or the VA community care consult/referral is submitted by the veteran's provider, the VA Community Care Coordination staff are to confirm the veteran's eligibility status. A veteran may decline enrollment into the VCP. When a veteran declines enrollment, his or her respective third-party administrator (TPA) is to document the veteran's reason for opting out of the program. Then, on behalf of the veteran, his or her VA provider is to continue coordinating the veteran's medical services within the VA. The veteran's provider might also explore other existing community care options offered by the VHA.

If a veteran is found eligible to access care through the VCP, the VA Community Care Coordination staff is to then electronically upload the veteran's VA community care consult/referral and pertinent medical documentation in the Contractor Portal, which is visible to TriWest. Once TriWest receives the documentation, the respective TPA is to contact the veteran. During this contact, the eligible veteran is to be provided with an overview of VCP benefits and asked to confirm his or her choice to receive medical services under the VCP.

If a veteran reiterates his or her choice to receive medical care under the VCP, the veteran may select his or her VA community care provider and coordinate with a TPA to schedule an appointment. In addition, the veteran is to be asked to provide other health insurance information, if applicable, and is made aware of possible copayments and deductibles. A veteran with a clinical need for a service-connected and/or special authority condition (SC/SA) is to have his or her screening information reviewed by Revenue Utilization Review (R-UR) nurses. The veteran's appointment is then to be entered in the Contractor Portal so that it can be viewed by the VA Community Care Coordination staff. Daily, the VA Community Care Coordination staff is to check the Contractor Portal for appointment statuses and other updates. After the appointment is scheduled, the VA Community Care Coordination staff are to enter the appointment information into the Appointment Management system (within the VA) and update the veteran's status to "scheduled."

Unusual or Excessive Burden Determination35

Along with the environmental factors, geographic challenges, and medical conditions, veterans are assessed by

the nature or simplicity of the hospital care or medical services the veteran requires, how frequently the veteran needs hospital care or medical services, and the need for an attendant for a clinical service.

Authorization of Care and an Episode of Care

Prior to delivering medical services to veterans under the Veterans Choice Program (VCP), such services are to be authorized by the VA. If a veteran requires services beyond those authorized, his or her VCP provider may request another authorization. The delivery and usage of unauthorized medical services could result in nonreimbursement. Over 5.9 million authorizations have been made under the VCP. These authorizations of care, shown in Table 3 , were authorized from November 5, 2014, to August 28, 2018, unless otherwise noted.

The VA defines an episode of care (EOC) as "a necessary course of treatment, including follow-up appointments and ancillary and specialty services, which last no longer than one calendar year from the date of the first appointment with a non-VA health care provider." This one-year Choice EOC period of validity begins when the first appointment is scheduled. VA community care providers may request an authorization extension for a veteran's current EOC through the veteran's respective TPA.

Appointment Scheduling

Veterans and VCP providers verify eligibility status before scheduling medical appointments for clinical needs. Appointments are to be scheduled on the basis of clinical appropriateness. VCP-eligible veterans are to receive a call from their respective third-party administrator (TPA). The TPAs are to provide veterans with information about the organization and schedule their appointments. Once appointments are scheduled, the contractor is to inform the VA. Emergent or urgent care authorizations are to be done expeditiously (see text box below).

After receiving the notification, a veteran's local VA facility staff are to cancel his or her appointment at the VA. Veterans may also choose to schedule their own appointments after receiving an authorization of care under the VCP. If veterans choose to do so, they are asked to provide their appointment information to the TPA.

Appointment information that is provided to the TPA is to get uploaded into the Contractor Portal, so that it can be viewed by the VA Community Care Coordination staff. Daily, the VA Community Care Coordination staff are to check the Contractor Portal for veterans' appointment statuses and other updates. After receiving the notification, the veteran's local VA facility staff are to cancel his/her appointment at the VA.

Medication Process

Veterans may have their prescriptions filled at their local VA pharmacies, non-VA pharmacies, and through the Consolidated Mail Outpatient Pharmacy (CMOP). If the VA is unable to fill a medication request within a prescribed timeframe or one that is not within the VA formulary, a non-VA pharmacy may fill the initial 14-day supply (without refills). For veterans who require prescriptions for more than 14 days, the VCP prescribing clinician is to have the remaining supply of medication filled at a VA pharmacy. Similar to the provisions of health care services under the VCP, medications filled at non-VA pharmacies will also require prior authorizations from the VA.

The VA is to reimburse veterans for out-of-pocket expenses related to the purchase of medications that treat service-connected conditions. For nonservice-connected conditions, veterans may also be reimbursed for their out-of-pocket expenses, including those with other health insurance plans. To be reimbursed, veterans submit a copy of their prescriptions, authorizations, and original receipts to their local VA Community Care Office. The VA also allows non-VA pharmacies to process medication claims on a veteran's behalf .

Processing Medical Claims

Medical claims under the Veterans Choice Program (VCP) are processed through the veteran's respective third-party administrator (TPA). TriWest uploads and manages veterans' medical claims through the Contractor Portal. Through this web portal, the VA Community Care Coordination staff are to retrieve a veteran's documentation of clinical need and upload it in the veteran's medical records.

The VA community care provider is to submit medical claims to a veteran's respective third-party administrator. After TriWest receives the claim, the TPA is to submit it through its web portal. Subsequently, the VA is to retrieve the documentation from the TPA's web portal and upload it in the veteran's medical records. The VA reimburses the TPAs for the care veterans obtain through the VCP, and the TPA then reimburses the community care providers in their networks. Since 2016, the VA has processed payments to the TPA on an aggregated basis known as "bulk payments."

Per Federal authority, VA is the primary and exclusive payer for medical care it authorizes. As such, non-VA medical care providers may not bill the Veteran or any other party for any portion of the care authorized by VA. Federal law also prohibits payment by more than one Federal agency for the same episode of care; subsequently any payments made by the Veteran, Medicare, or any other Federal agency must be refunded to the payer [from the VCP provider] upon acceptance of VA payment.

Medical Services Not Previously Authorized

Under the VCP, medical claims for unauthorized non-VA health care services may be submitted to the VA for payment consideration. Veterans, VA community care providers, and persons who paid for services on behalf of a veteran are required to submit to the VA the following documentation:

a standard billing form, or an invoice (i.e., Explanation of Benefits [EOB]), and/or receipt of services paid and/or owed; an explanation of the circumstance that led to the veteran receiving unauthorized care outside of the VA; any statements and/or supporting documentation; and VA Form-10-583, Claim for Payment of Cost of Unauthorized Medical Services.

Payments

Veterans' Out-of-Pocket Costs

Veterans who are enrolled in VA health care do not pay premiums, deductibles, or coinsurances for their medical services. However, they may be required to pay a fixed copayment amount (for nonservice-connected disabilities or conditions) as shown below. When veterans receive care at a VA facility, they do not pay copayments at the time of their medical appointments; copayment rates are determined by the VA after services are furnished—based on if the care was for a service-connected or nonservice-connected condition. Therefore, veterans' out-of-pocket costs under the VCP are the same as if they were receiving care and services from a VA provider in a VA facility—if a veteran does not pay any copayments at VA health care facilities, the veteran will not have to pay any copayments under the VCP. For example

A veteran could pay $50 copayments for a specialty care visit and $15 for a primary care visit for a nonservice-connected disability or condition. A veteran in Priority Groups 2 thru 8 could pay a copayment between $5 and $11 per 30-day or less supply of medication. All veterans are exempt from paying copayments for services and medications that are related to a service-connected disability or condition.

Cost Shares for Veterans with Other Health Insurance (OHI)

The VA defines other health insurance (OHI) as commercial insurance. Commercial insurance, often referred to as private insurance , is not funded by federal and state taxes. This type of insurance is offered by companies such as Blue Cross and Blue Shield, Aetna, Cigna, and the Kaiser Foundation. Plans purchased through the state health exchanges are also considered as OHI. In addition, veterans who purchase commercial insurance plans agree to cost-sharing responsibilities. Such cost-sharing obligations include copayments, deductibles, and coinsurance (e.g., 80/20 rule: 80% insurer responsibility/20% patient responsibility).

Due to various issues related to primary payment responsibility and veterans therefore experiencing adverse credit reporting to credit bureaus or debt collections by collections agencies, Congress enacted P.L. 115-26 , which amended P.L. 113-146 and made VA the primary payer for veterans with OHI who seek care for nonservice-connected conditions through the VCP. This change went into effect on April 19, 2017. The VA would coordinate with a veteran's OHI and recover any costs, and bill the veteran for any copayments that the veteran would be responsible for similar to what they would have paid had they received care within a VA medical facility (see Figure 3 ). Community care providers or the TPAs are no longer required to collect copays, cost-shares, or deductibles from veterans with OHI. Medicare, Medicaid, or TRICARE are not considered OHI plans under the VCP.

Provider Payment Methodologies

Guidance on rates for the delivery of care is outlined in Table 4 . As stated before, first, the Veterans Choice Program providers are to receive their reimbursements from the TPA. Then the VA is to reimburse the third-party administrator. Eligible VA community care providers who decide to participate under the PC3 network (rather than the Choice network) may incur reimbursement rates lower than those of Medicare. If these providers move to the Choice network, they may negotiate for a similar rate as contracted under the PC3 Network.

Veterans and VA community care providers may call the Community Care Call Center to discuss billing issues. These issues range from the need to resolve a debt collection to inappropriately billed services.

Appendix A. Veterans Choice Program (VCP) High-Level Work Flow

Appendix B. VA Information Pertaining to the End of the Contract with Health Net