The Veterans Affairs Department finalized a rule spelling out which veterans are eligible for the new, expanded Community Care program mandated by Congress last year.
It also issued a final rule granting veterans coverage for urgent care outside VA facilities, without prior VA approval but with a copayment.
Under the Community Care rule issued Tuesday, veterans must be enrolled in the VA healthcare system and meet at least one of six conditions to be eligible for VA-paid care outside the VA system. There were no significant changes from the proposed rule issued in February.
Among other criteria, veterans are eligible for outside care if the Veterans Health Administration does not offer care or services needed by the veteran; if it's not able to provide services to the veteran in a way that meets the VA's quality or timeliness standards; or if the veteran and referring clinician agree that receiving care outside the VA would be in the veteran's best medical interest.
The new Veterans Community Care program, mandated by the VA Mission Act enacted last year, starts Thursday. The agency received more than 23,000 comments on the proposed rule.
"President Trump promised to give veterans greater choice," VA Secretary Robert Wilkie said in a written statement. "We are honoring that promise by making sure veterans have access to timely, high-quality care, whether from our VA facilities or our community providers."
Provider and veterans groups hope the program will roll out without major glitches, unlike when the VA hastily launched the Veterans Choice program in 2014. But they worry that the 9.2 million veterans eligible for VA-paid healthcare will continue having trouble accessing timely, high-quality care outside of VHA hospitals and clinics.
Under the new rule, veterans would be eligible for community care if they must drive 30 minutes or more to a VA facility for primary care or mental health services, or 60 minutes or more for specialty care.
They'd also be eligible for private care if they have to wait 20 days or more for primary care or mental healthcare, or 28 days or more for specialty care.
The agency said it would issue a separate rule establishing competency standards and requirements for provision of care by non-VA providers in clinical areas where the VA has developed special expertise.
That grows out of concerns about whether private providers will be held to the same standards of quality and levels of familiarity with veterans' health issues that VA providers must meet. This is a particular worry for mental health screening and treatment.
Non-VA providers hope the program will improve their ability to share patient data with VA facilities and receive timely payment for serving veterans. Those have been major problems for the previous Veterans Choice program, which ends when the new program begins.
Under the Mission Act, the VA will consolidate seven existing programs that pay for veterans' care outside the VA system, including Veterans Choice, into one.
The 2018 law was designed to remedy long waits for care and payment under Choice, which itself was created by Congress to address excessive waits for care.
But experts question whether the VA has underestimated the number of patients who will take advantage of the broader eligibility rules to seek care outside VA facilities, draining dollars needed to keep the huge veterans' healthcare system strong.
In the new rule, the VA acknowledged those budgetary concerns and noted that use of private care is voluntary for veterans under the program. The Community Care program does not diminish the VA's obligation to directly provide care and continue improving its services, the agency said.
Gayle Lee, director of physician payment and quality for the Association of American Medical Colleges, said her organization will be monitoring the program rollout closely to see if the VA takes necessary steps to improve claims processing and administrative processes. That would encourage more providers to participate in the VA's community care networks.
Robyn Bash, vice president of government relations at the American Hospital Association, said her organization was pleased with the final rule. The law's requirement that the VHA adopt an electronic claims system should make a big difference in timely payment of claims, she said.
Still, she expressed caution about whether the VHA is ready to launch the Community Care program without hitches, noting that the agency is still working through the contracting process for fiscal intermediaries in several regions around the country.
TriWest will continue as interim administrator for the Choice program while the new contractors, including Optum Public Sector Solutions, ramp up their networks and processes over the coming year.
"They've been working hard on getting all those contracts awarded, but we'll have to see on the rollout," Bash said.
Carlos Fuentes, director of legislative services for the Veterans of Foreign Wars, worried that the VA is setting veterans up for disappointment in promising short waits for appointments with private providers.
"We would have preferred the VA not use wait time in the Community Care eligibility criteria," he said. "That's setting an expectation they won't be able to meet, and veterans won't be happy."
In the final rule, the VA acknowledged receiving comments that the drive-time and wait-time access standards were not realistic. But it said other public health insurance programs such as Tricare and state Medicaid plans use similar standards, and it was reasonable to follow those criteria.
"They say they have training in place to implement everything smoothly," Fuentes said. "We doubt that's the case. We'll be working with the VA to address issues that arise, so that veterans aren't negatively impacted."
