Veteran Community Care – Urgent Care VA MISSION Act of 2018 As part of implementing the VA MISSION Act of 2018, VA will offer an urgent care benefit that provides eligible Veterans with greater choice and access to timely, high-quality care. 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 sameday services. Eligible Veterans will be able 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). This benefit is expected to be available when final Federal regulations are published and effective, expected June 6, 2019. Important: Details about urgent care are not yet final. Process Overview 1. Find Provider Eligible Veteran finds and travels to in-network urgent care provider. 2. Confirm Eligibility Veteran states they are using VA benefit and urgent care provider confirms Veteran eligibility. 3. Receive Care Veteran receives covered urgent care services and medication is prescribed if needed. 4. Billing Urgent care provider bills VA Third Party Administrator (TPA), and VA may bill the Veteran the applicable copayment.

 

Eligibility Veterans will be eligible for the urgent care benefit if they are enrolled in VA health care and have received care through VA (from either a VA or community provider) within 24 months prior to receiving this care. Veterans can go to an urgent care provider in VA’s contracted network of community providers and receive covered services without prior authorization from VA. To check their eligibility once the urgent care benefit has started, Veterans should contact their local VA medical facility. Finding an Urgent Care Provider To find an available urgent care provider in VA’s contracted network of community providers, Veterans will be able to use VA’s provider locator on VA.gov (https://www.va.gov/find-locations/) or contact their local VA medical facility. VA staff can inform the Veteran of available in-network locations and offer to find the closest locations. Important: VA can only pay for care under this benefit if the veteran is eligible, the services are not excluded under the benefit, and the provider is part of VA’s contracted network of community providers and is identified as an urgent care provider. If an eligible Veteran goes to an out-of-network urgent care provider, they may be required to pay the full cost of care. By law, VA cannot pay claims for urgent care rendered to a Veteran from providers that are not part of VA’s network. Getting Urgent Care When arriving at an in-network urgent care provider, eligible Veterans must: • Ask and verify that the urgent care provider is part of VA’s contracted network of community providers. The urgent care provider may have a sign posted that indicates they are part of VA’s contracted network of community providers. • Inform the provider that they would like to use their VA urgent care benefit to receive care. Note: The urgent care provider will confirm the Veteran’s eligibility prior to furnishing care. If the provider is not part of VA’s network, eligible Veterans have several options: • Agree to pay potentially the full cost of care and receive care immediately • Go to a different urgent care provider that is part of VA’s contracted network of community providers • Go to the nearest VA medical facility • Go to the nearest emergency department if Veteran reasonably believes that delay in seeking immediate medical attention would be hazardous to their life or health.

 

Covered Services The urgent care benefit covers treatment of non-emergent symptoms such as flu-like symptoms (coughs and colds), wheezing, sprains, sore throats, painful urination, bumps and bruises, ear pain, and mild skin irritations, which are typically addressed by urgent care facilities and walk-in retail health clinics. Excluded from the benefit are preventive and dental services. Important: While urgent care is a convenient benefit for treatment of non-emergent symptoms, Veterans should always consider talking with or seeing their primary care provider if they are concerned that the community provider will not understand the complexities of their medical history or medications. Veterans should remember the following when considering urgent care: • If Veterans have a medical emergency, they should immediately seek care at the nearest emergency room. A medical emergency is an injury, illness, or symptom so severe that a prudent layperson reasonably believes that delay in seeking immediate medical attention would be hazardous to life or health. • If you believe your life or health is in danger, call 911 or go to the nearest emergency department right away. Important: VA can only pay for care an eligible Veteran receives from a community emergency department in certain circumstances and under specific conditions. Visit the following link for more information: https://www.va.gov/COMMUNITYCARE/programs/veterans/Emergency_Care.asp Differences Between Urgent Care and Emergency Care Urgent Care Emergency Care Urgent care consists of medical services provided for minor illnesses or injuries that are not lifethreatening such as strep throat, pink eye, or influenza. Emergency care consists of hospital care or medical services that a prudent layperson reasonably believes are necessary without delay to avoid hazards to life or health. Examples of conditions or symptoms that justify emergency care include severe chest pain; seizures or loss of awareness; severe headache; heavy uncontrollable bleeding; poisoning; moderate to severe burns, and large broken bones. The urgent care benefit also covers diagnostic services like X-Rays, some lab testing, and some medications (with limitations). However, not all facilities in VA’s network will be able to offer these services. Therapeutic vaccines are covered when these are required for the treatment of certain conditions covered under the urgent care benefit. For example, an eligible veteran seeking treatment for a wound caused by rusted metal requires treatment for the wound and may require a tetanus vaccine as part of the course of treatment. With the exception of a flu shot, vaccines and other preventive care services are not covered, and eligible Veterans should not manage their chronic conditions, or otherwise manage their care over the long term, through the urgent care benefit. Important: Urgent care is not a replacement for an eligible Veteran’s preventive health care. Eligible Veterans should work with their primary care provider for this type of care. If an eligible Veteran goes to an urgent care provider and receives services that are not covered by this benefit, they may be required to pay the full cost of care. Copayments Eligible Veterans may be charged a VA copayment for urgent care that is different from other VA medical copayments. VA copayments for urgent care depend on the eligible Veteran’s assigned priority group and the number of times they visit an in-network urgent care provider in a calendar year. Important: Copayment charges are not yet final pending publication of the final regulation. • Priority Groups 1-5. There is no copayment for the first three visits during a calendar year. For the fourth visit and all subsequent visits in a calendar year, the copayment is $30. • Priority Group 6. There is no copayment for the first three visits during a calendar year if the visit is related to special authority,* or exposure. For the fourth visit and all subsequent visits in a calendar year, the copayment is $30. If the visit is not related to special authority,* or exposure, the copayment is $30 per visit, regardless of which visit it is. • Priority Groups 7-8. The copayment is $30 per visit. • Priority Groups 1-8. No copayment for a flu shot-only visit. Visits consisting only of a flu shot do not count as a visit for the number of visits in a calendar year for eligible Veterans in priority groups 1-6. Priority Group(s) Copayment Amount 1-5 • First three visits (per calendar year): $0 • Fourth and greater visits (per calendar year): $30 6 • If related to a condition covered by a special authority: o First three visits (per calendar year): $0 o Fourth and greater visits (per calendar year): $30 • If not related to a condition covered by a special authority: o $30 per visit 7-8 • $30 per visit 1-8 • $0 copay for visit consisting of only a flu shot

 

* Special authorities include those related to combat service and exposures (e.g. agent orange, active duty at Camp Lejeune, ionizing radiation, Project Shipboard Hazard and Defense (SHAD/Project 112), Southwest Asia Conditions) as well as Military Sexual Trauma, and presumptions applicable to certain Veterans with psychosis and other mental illnesses. In addition, please note the following about urgent care copayments and visits: • There is no limit on the number of times an eligible Veteran can access urgent care. • Copayments are not paid out-of-pocket at the time the eligible Veteran receives care at the urgent care provider. Eligible Veterans are billed separately by VA as part of VA’s normal billing process. When the benefit starts, Veterans can contact the VA Health Resource Center (HRC) for questions related to urgent care copayments at 1-877-222-VETS (8387). Veterans will also be able to contact their local VA medical facility for more information about urgent care copayments. Prescription Medication VA will pay for or fill prescriptions for urgent care. For urgent care prescription medication longer than a 14-day supply, 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. Some Veterans may be required to make a copayment for medication. Information about copayments can be found at https://www.va.gov/COMMUNITYCARE/revenue_ops/copays.asp. Support For questions and support, Veterans should contact their local VA medical facility. To find the nearest VA medical facility, use VA’s facility locator on VA.gov at https://www.va.gov/find-locations/. Community Providers Community providers must be part of VA’s contracted community care network to provide urgent care to Veterans and be reimbursed by VA. There are no exceptions. This means community providers must enter into a contract with one of VA’s Third Party Administrators (TPAs). Once a community provider is part of VA’s network, they can begin providing the urgent care benefit to Veterans.

 

 In-network community providers will be provided with a list of services that VA cannot reimburse (not pay for) by the TPA assigned to their region. When a Veteran presents at an urgent care provider in VA’s community care network: • The community provider must check a Veteran’s eligibility for the urgent care benefit before providing care. • This is accomplished by confirming with the TPA assigned to their region or by calling the local VA medical facility. After urgent care is provided to a Veteran: • The community provider must file a claim with the TPA assigned to their region. The TPA will adjudicate and pay the claim on behalf of VA. • Follow-up medical documentation must be sent to the Veteran’s home VA medical facility via an approved method such as Veterans Health Information Exchange (VHIE) or fax. For reference, an eligible Veteran’s home VA medical facility address will be provided in the daily eligibility file. Frequently Asked Questions Q1. What specific services are covered by the urgent care benefit? Individual health conditions are complex and unique to each Veteran. As a result, and to encourage eligible Veterans to seek care when and where they need it, VA does not publish a specific list of covered services for urgent care. VA does exclude from the urgent care benefit preventive services and dental services, as well as other items that are not included in the medical benefits package. Q2. Will VA reimburse beneficiary travel for urgent care? VA will reimburse beneficiary travel (BT) for eligible Veterans that travel to receive community care. Payment will be made for the distance to either the nearest VA or community medical facility that could have provided the care or services. Payment will only be made on a oneway basis (e.g. not round-trip) for unscheduled care. Q3. Are urgent care services provided at an emergency department covered by VA? If the emergency department is part of VA’s contracted network and has agreed to furnish urgent care services in accordance with the contract requirements, VA can pay for these services for eligible Veterans under this benefit. Q4. How do Veterans get more information about the urgent care benefit? Veterans can call their local VA medical facility for more information after the benefit starts, expected June 2019. A VA staff member can advise the Veteran on available urgent care providers and may be able to advise them on whether they will be charged a copayment for the care. Q5. Can the urgent care benefit be used by a Veteran’s family member? Only eligible Veterans can use this benefit. The benefit does not extend to family members and is non transferrable

 

Q6. How are VA copayments handled? Eligible Veterans will not be charged a VA copayment at the time of their visit. VA copayments, if applicable for the eligible Veteran, are billed by VA separately