VA Mission Act Goes into Effect

CCK Law: Our Vital Role in Veterans Law

The VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act, or VA Mission Act, was fully implemented on June 6, 2019.

About the VA Mission Act of 2018

The VA Mission Act was signed by the President on June 6, 2018.  This $52 billion bill overhauls veterans’ access to private healthcare, including urgent care and caregiver benefits, nationwide.  Specifically, the VA Mission Act expands private healthcare access for veterans who experience long wait times at their VA provider or are too far away from their VA healthcare provider to conveniently receive care at those facilities.

The VA Mission Act also expands VA’s Program of Comprehensive Assistance for Family Caregivers.  The Caregiver Program was implemented in 2011 in an effort to provide benefits to caregivers (i.e. spouses or family members who end up leaving jobs to care for a veteran full-time due to the extent or nature of his or her disability) of post-9/11 disabled veterans.  Under the VA Mission Act, the Caregiver Program will provide benefits to caregivers of pre-9/11 veterans in addition to post-9/11 veterans, and provide oversight for underperforming VA facilities.  This expansion of benefits will include eligible veterans from all eras of service will be implemented over the course of several years, mainly in two phases.  VA reports that caregiver benefits will first become available to veterans who were injured on or before May 7, 1975, with further expansion to include veterans injured between 1975 and 2001 occurring two years later.

Reasons for the VA Mission Act

The VA Mission Act is part of VA’s effort to innovate, upgrade, and pursue new ways to deliver the highest quality of care and service to veterans.  In a recent statement, VA Secretary Wilkie emphasized that “the Mission Act will enable VA to consolidate the Department’s community care efforts into a single, simple-to-use program that will empower veterans with the ability to choose the healthcare providers they trust.”  He further stated that on June 6, 2019, veterans can expect “less red tape, more satisfaction and predictability for patients, more efficiency for clinicians, and better value for taxpayers.”  Overall, the VA Mission Act strengthens VA’s ability to deliver trusted, easy to access, high quality care at VA facilities, virtually through telehealth, and in veterans’ communities thereby allowing veterans to get the care and services they need, where and when they need them.

Eligibility Criteria for Community Care

In conjunction with the Mission Act, VA also implemented new eligibility criteria for veterans seeking community care.  VA Secretary Wilkie asserts that the new eligibility criteria will make things simpler for veterans while providing better access and greater choice in their healthcare.  Key aspects of community care eligibility include the following:

• Veterans must receive approval from VA prior to obtaining care from a community provider in most circumstances (does not apply to urgent care)
• Veterans must either be enrolled in VA healthcare or be eligible for VA care without needing to enroll to be eligible for community care
• Eligibility for community care will continue to be dependent upon a veteran’s individual healthcare needs or circumstances
• VA staff members generally make all eligibility determinations
• Veterans will usually have the option to receive care at a VA medical facility regardless of their eligibility for community care.

Importantly, meeting any one of the six eligibility criteria listed below is sufficient to be referred to a community provider.  Veterans do not have to meet all criteria in order to be eligible:

1. Veteran needs a service not available at a VA medical facility
2. Veteran lives in a U.S. state or territory without a full-service VA medical facility
3. Veteran qualifies under the “grandfather” provision related to distance eligibility for the Veterans Choice Program
4. VA cannot furnish care within certain designated access standards
5. It is in the veteran’s best medical interest
6. A VA medical service line does not meet certain quality standards

Community Access Standards

VA published a proposed rule regarding the criteria for determining when covered veterans may elect to receive care and services through community healthcare entities or providers, as well as other parameters of the program, on February 22, 2019.  The eligibility criteria and final standards are based on an analysis of all the best practices in both the government and in the private sector, and then tailored to the needs of veteran patients.  As of June 6, 2019, the new access standards are as follows:

• Access standards are based on average drive time and appointment wait times
• 30-minute average drive time standard for primary care, mental health, and non-institutional extended care services,
• 60-minute average drive time standard for specialty care
• 20-day wait-time standard for primary care, mental health care, and non-institutional extended care services
• 28-day wait-time standard for specialty care form the date of request with certain exceptions

Eligible veterans who cannot access care within the above-mentioned standards are now able to choose between eligible community care providers and care at a VA medical facility.  The final regulations published on June 6^th also provide eligible veterans with access to urgent care.  Specifically, 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.  Importantly, while emergency appointments will require a copayment from veterans, VA will cover the bulk of the costs.

Comments in Response to Community Access Standards

In response to the initial proposal of the new community access standards on February 22^nd, VA received 23,557 comments.  While many comments expressed strong support for the overall rulemaking, others generally opposed both the drive-time and wait time access standards as proposed.  Such opposition was based primarily on assertions that the access standards were arbitrary because they were not realistic, feasible, or sustainable, and VA did not conduct enough research of all existing access models to properly propose its own access standards.  To address these concerns, VA reiterated that the drive-time and wait time standards were derived from specific analyses and data collection.  VA received additional comments and suggestions regarding aspects of the VA Mission Act related to the transition from the Veterans Choice Program, claims adjudication and payments, information technology and information sharing, and more.  However, upon review of this feedback, VA determined that no modifications were needed.  As such, no changes were made to the proposed rules, which have since been promulgated through the final regulations.