How to Successfully Navigate the VA Community Care Program: My Experience Getting Cancer Treatment Outside the VA

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Hi Veterans, Brian Reese here, the VA Claims Insider!

Navigating the VA healthcare system can be challenging, especially for those dealing with complex health issues like cancer.

For many of us, including myself, the VA Community Care program provides a valuable alternative, allowing us to receive treatment from civilian doctors.

In this article, I’ll share my personal experience with getting cancer treatment approved outside the VA.

We’ll explore what VA Community Care is, how it works, the types of services covered and not covered, why your request might be approved or disapproved, and offer some tips and strategies for navigating the system effectively.

Let’s begin!

Summary of Key Points

• Eligibility and Approval: Veterans must be enrolled in or eligible for VA health care and receive approval from their VA health care team to use VA Community Care, which includes factors like VA provider availability, distance from VA facilities, and specific healthcare needs.

• Covered Services: VA Community Care covers a wide range of services, including urgent and emergency care, routine medical care, surgeries, dialysis, rehabilitation, and complementary health services, provided by in-network community providers with prior VA approval.

• Navigating the System: Effective navigation of VA Community Care requires proactive engagement, diligent follow-up, and advocacy. Veterans must coordinate between their VA primary care team, the VA’s community care office, and civilian care providers to ensure timely and appropriate care.

• Pros and Cons: The program offers access to specialized care and reduced wait times, but the approval process can be complex, and there may be potential for miscommunication between VA and community providers.

What is VA Community Care?

VA Community Care is a government program that allows eligible veterans to receive healthcare services from providers outside of the VA system.

This can be particularly beneficial for those who live far from a VA facility or need specialized care that is not readily available within the VA network.

How It Works:

• Eligibility: Veterans must meet certain eligibility criteria to qualify for VA Community Care. This includes factors such as distance from a VA facility, the availability of required services within the VA, and specific healthcare needs.

• Referral and Authorization: Once eligibility is determined, a VA provider or coordinator will refer the veteran to a community care provider. This step requires authorization from the VA, ensuring that the care is covered.

• Scheduling Appointments: After authorization, the veteran can schedule appointments with the approved community provider. The VA will handle the payment directly with the provider, so veterans do not need to worry about the upfront costs.

What Services Are Covered By VA Community Care?

The VA covers a wide range of care and services through Community Care, ensuring veterans receive the necessary medical attention both for immediate needs and long-term health management.

Here’s a breakdown of the types of care and services covered:

Immediate Care Needs:

• Urgent Care: Veterans can receive urgent care services from in-network community providers for immediate medical needs that are not life-threatening but require prompt attention.

• Emergency Care: Emergency care is covered until the veteran can be safely transferred to a VA facility. This ensures that veterans receive critical medical attention in emergency situations.

Routine Types of Care:

• Routine Medical Care: Routine medical care, including general check-ups and ongoing health management, is covered when approved by the VA health care team.

• Surgeries: Veterans can receive surgical procedures from in-network community providers with prior approval from their VA health care team.

• Dialysis: For veterans needing dialysis, this service is covered by in-network community providers, ensuring access to essential treatments.

• Vaccines: Vaccinations are covered to help veterans stay protected against various diseases.

• Rehabilitation: Rehabilitation services, including physical therapy and occupational therapy, are available from in-network community providers to aid in recovery and improve quality of life.

• Nursing Homes, Assisted Living, and Home Health Care: Long-term care options, such as nursing homes, assisted living, and home health care services, are covered to support veterans who require these types of care.

Specialty Medical Care:

• Cardiology: Treatment for heart-related conditions, including diagnostics, surgeries, and follow-up care.

• Oncology: Cancer treatments, including chemotherapy, radiation therapy, and surgery.

• Endocrinology: Care for hormone-related conditions, such as diabetes and thyroid disorders.

• Neurology: Treatment for neurological disorders, including stroke, epilepsy, and multiple sclerosis.

• Pulmonology: Care for lung-related conditions, including asthma, COPD, and pulmonary fibrosis.

• Gastroenterology: Treatment for digestive system disorders, including Crohn’s disease, ulcers, and liver diseases.

• Urology: Care for urinary tract and male reproductive system issues.

• Orthopedics: Treatment for musculoskeletal conditions, including joint replacements, fractures, and arthritis.

Surgical Services:

• General Surgery: Procedures ranging from minor surgeries to more complex operations.

• Cardiothoracic Surgery: Heart and chest surgeries, including bypass surgeries and valve replacements.

• Vascular Surgery: Treatment for blood vessel conditions, including aneurysms and varicose veins.

• Neurosurgery: Surgical treatment for brain and spinal cord conditions.

• Ophthalmology Surgery: Eye surgeries, including cataract removal and corrective surgeries.

• ENT Surgery: Ear, nose, and throat surgeries, including sinus surgeries and tonsillectomies.

Rehabilitation Services:

• Physical Therapy: Treatment to improve mobility, strength, and overall physical function.

• Occupational Therapy: Assistance in improving daily living and working skills.

• Speech Therapy: Treatment for speech, language, and swallowing disorders.

• Audiology: Services for hearing-related issues, including hearing aids and cochlear implants.

Mental Health Services:

• Psychiatry: Treatment for mental health conditions, including medication management.

• Psychology: Therapy and counseling for mental health issues such as PTSD, depression, and anxiety.

• Substance Abuse Treatment: Programs for addiction treatment and recovery support.

• Group Therapy: Peer support and group counseling sessions for various mental health conditions.

Other Services:

• Pain Management: Comprehensive treatment plans for chronic pain, including medications, injections, and therapy.

• Dermatology: Treatment for skin conditions, including eczema, psoriasis, and skin cancer.

• Rheumatology: Care for autoimmune and inflammatory diseases, such as rheumatoid arthritis and lupus.

• Podiatry: Treatment for foot and ankle conditions, including diabetic foot care.

• Women’s Health: Specialized care for female veterans, including gynecological services and maternity care.

• Dental Care: Routine dental check-ups, cleanings, and necessary dental procedures for eligible veterans.

Complementary and Integrative Health Services:

• Biofeedback: A therapy that helps veterans learn how to control bodily processes that are typically involuntary, such as heart rate and muscle tension.

• Hypnotherapy: A guided relaxation technique that helps veterans address issues like pain management, stress, and anxiety.

• Massage Therapy: Therapeutic massage to relieve muscle tension and improve overall well-being.

• Native American Healing Practices: Traditional healing practices used by Native American communities, tailored to the needs of veterans.

• Relaxation Techniques: Techniques such as guided imagery and progressive muscle relaxation to reduce stress and promote relaxation.

• Tai Chi: A form of exercise that combines movement, meditation, and breathing techniques to improve physical and mental health.

What Services Are NOT Covered by VA Community Care?

While the VA Community Care program provides a broad range of services to eligible veterans, there are certain services that are not covered.

Here are some key services typically not covered by VA Community Care:

Non-Medically Necessary Services:

• Cosmetic Procedures: Surgeries or treatments performed solely for aesthetic purposes, such as facelifts or liposuction, are generally not covered.

• Elective Surgeries: Non-essential surgeries that are not medically necessary, including some types of bariatric surgery.

Experimental Treatments:

• Experimental or Investigational Procedures: Treatments that are not yet widely accepted as standard medical practice or are still under clinical trial.

• Unapproved Medications: Drugs that have not been approved by the FDA or are part of experimental treatment protocols.

Long-Term and Custodial Care:

• Long-Term Care: Extended care services in facilities such as nursing homes that are not related to rehabilitation or short-term medical treatment.

• Custodial Care: Non-medical care that helps with daily activities like bathing, dressing, and eating, especially when these services are not part of a treatment plan for a medical condition.

Alternative and Complementary Therapies:

• Unapproved Alternative Therapies: Some complementary and alternative therapies that are not recognized by mainstream medical practice, such as certain herbal treatments and homeopathy.

• Non-Evidence-Based Practices: Therapies that lack sufficient scientific evidence to support their effectiveness.

Services Outside the United States:

• International Care: Medical services received outside the United States are generally not covered, except in certain circumstances related to service-connected disabilities or under specific programs like the Foreign Medical Program (FMP).

Dental Services:

• Non-Essential Dental Services: While some dental care is covered for eligible veterans, non-essential or cosmetic dental procedures, such as teeth whitening or elective orthodontics, are not covered.

Personal Comfort Items:

• Non-Medical Personal Items: Items such as televisions, radios, and beauty or grooming services provided during hospital stays.

Over-the-Counter Medications and Supplies:

• Non-Prescription Drugs: Over-the-counter medications, supplements, and supplies unless prescribed by a VA or VA-authorized provider as part of a treatment plan.

Certain Mental Health Services:

• Non-Evidence-Based Mental Health Therapies: Some forms of therapy that do not have a strong evidence base or are not widely accepted within the mental health community.

Vision and Hearing Services:

• Elective Vision Procedures: Surgeries like LASIK that are not medically necessary.

• Non-Medical Hearing Devices: Devices and treatments for hearing improvement that are not medically necessary, such as high-end personal listening devices.

Pros Tips and Lessons Learned Navigating VA Community Care

Navigating VA Community Care requires proactive engagement and diligent follow-up.

Here are some key lessons I’ve learned from my own experience:

Take Initiative and Lead Communications:

I had to act and follow up almost daily, coordinating between my VA primary care team, the VA’s community care office, and my civilian care team at Texas Oncology. This proactive approach is crucial because no one will advocate for your care as passionately as you will.

You Must Sweat the Details:

Pay close attention to every detail of your care requests. Whether it’s paperwork, appointment scheduling, or follow-up calls, staying on top of these details can make a significant difference in the timeliness and quality of your care.

Advocate for Your Needs:

Remember, if you don’t ask, the answer is always no. Before my community care was approved, the VA’s community care office in Temple, TX called to schedule my first chemotherapy appointment with a VA oncologist. Knowing there was an 8-week wait time and the urgency of starting treatment, I questioned this approach. The community care team then asked if I’d prefer a civilian provider to handle my care. My immediate answer was YES! If I hadn’t spoken up, I’d probably still be waiting for my first chemotherapy appointment.

Getting Treatment Approved Through VA Community Care: My Experience

The Community Care Approval Process:

The process of getting cancer treatment approved through VA Community Care can be intricate and time-consuming.

Here are the steps I followed:

• Consult with Your VA Primary Care Provider: Discuss your health condition and treatment options with your VA healthcare provider. Express your interest in receiving treatment outside the VA. I used secure messenger to community with my VA primary care team about my cancer diagnosis and my desire for community care to handle my chemotherapy and radiation treatments.

• Request a VA Community Care Referral: Your VA provider will need to submit a referral for community care. Ensure that all necessary medical records and justifications for the referral are included. My initial referral was denied because my VA primary care provider didn’t provide the VA community care office with medical records to substantiate my diagnosis of Hodkin’s Lymphoma. However, the denial was quickly overturned once the medical records with diagnosis were sent to the VA community care office.

• Follow Up Often: Regularly check the status of your referral. This can be done through the VA’s patient portal or by contacting your VA Community Care Coordinator. I was calling the Temple VA’s Community Care hotline daily to follow-up for status. I also had Texas Oncology doing the same. You need to take decisive action and follow-up often.

• Approval and Authorization: Once your referral is approved, you will receive authorization for the specific services. Keep a copy of this authorization for your records. Note that your approval will include some services, but not others. I needed to get separate referrals approved for the chemo port placement surgery and radiation treatment.

• Schedule Your Treatment: Contact the approved community care provider to schedule your appointments. Ensure that they have received the necessary authorization from the VA. I communicate with my civilian Oncologst team at Texas Oncology 2-3 times per week. This has been critical to ensure timely scheduling of appointments.

Why Your Request Might Be Disapproved

There are several reasons why a request for community care might be disapproved:

• Eligibility Issues: If you do not meet the eligibility criteria, your request will be denied.

• Service Availability: If the VA can provide the necessary services within their network, they may deny the request. Note: the community care office attempted to schedule me with a VA doctor even though there was an 8-week wait time (way past their standard 4-week window for approving community care). I had to advocate for community care so I didn’t have to wait that long.

• Incomplete Documentation: Missing or incomplete medical records and referral justifications can result in disapproval. This happened to me the first time.

• Administrative Errors: Sometimes, administrative errors or miscommunication between the VA and the community provider can lead to disapproval.

The Pros and Cons of VA Community Care

Pros:

• Access to Specialized Care: Community care provides access to specialists and treatments that may not be available within the VA system.

• Convenience: Veterans living far from VA facilities can receive care closer to home.

• Timeliness: In some cases, community care can reduce wait times for treatments.

Cons:

• Complex Approval Process: The process of getting approved for community care can be lengthy and complicated.

• Potential for Miscommunication: Coordination between the VA and community providers can sometimes be problematic.

• Coverage Limitations: Not all treatments and services may be covered under community care.

Final Thoughts

Navigating the VA Community Care program can be daunting, especially when dealing with a serious health conditions like cancer.

However, with persistence and the right strategies, it is possible to access the care you need from civilian providers.

My journey through this process taught me the importance of being proactive, staying informed, and leveraging all available resources.

For veterans considering VA Community Care, I hope my experience provides valuable insights and encouragement to pursue the best possible healthcare options available.

VA Care in the Community: Frequently Asked Questions (FAQs)

What is VA Community Care?

VA Community Care is a program that allows eligible veterans to receive health care from civilian providers outside the traditional VA healthcare system. This can include specialists, primary care providers, and other medical professionals who are part of the VA’s network of community care providers. Click here to search for approved VA community care providers.

What are the eligibility requirements for VA Community Care?

To be eligible for VA Community Care, you must be enrolled in or eligible for VA health care and have approval from your VA health care team before receiving care from a community provider. Additionally, you must meet one of several specific conditions, such as needing a service the VA doesn’t provide, living in a state or territory without a full-service VA facility, or not being able to receive care within the VA’s drive and wait time standards.

How do I get approval for VA Community Care?

Approval for VA Community Care typically comes from your VA health care team. Your primary care provider or specialist will assess your medical needs and determine if community care is necessary. They will then initiate a referral to the VA’s community care office, which will handle the approval process and coordinate your care with an in-network community provider.

What is the VA Community Care phone number?

The VA Community Care national phone number is 877-881-7618. Agents are available Monday through Friday, 8:00 a.m. to 9:00 p.m. eastern time. This number can be used for general inquiries, scheduling, and coordination of care with community providers. For specific questions regarding your care or eligibility, it is often best to contact your local VA medical center or community care office directly.

Can I use VA Community Care for services not available at VA facilities?

Yes, you can use VA Community Care if the VA doesn’t provide the specific service you need at any of its facilities. For instance, if you require dialysis and the VA does not offer dialysis services, you can receive treatment from an in-network community provider.

What if there is no full-service VA health facility in my state or territory?

If you live in a state or territory without a full-service VA health facility, such as Alaska, Hawaii, New Hampshire, Guam, American Samoa, the Northern Mariana Islands, or the U.S. Virgin Islands, you are eligible to receive care from an in-network community provider.

How does the 40-mile distance requirement affect my eligibility?

If you live in Alaska, Montana, North Dakota, South Dakota, or Wyoming and qualified under the Veterans Choice Program’s 40-mile distance requirement as of June 6, 2018, you remain eligible for community care. This means you can receive care from an in-network community provider due to the significant distance from VA facilities.

What are the VA’s drive and wait time standards for community care eligibility?

For primary care or mental health appointments, if the VA cannot schedule an appointment within a 30-minute average drive from your home or within 20 days, you are eligible for community care. For specialty care, if the VA cannot schedule an appointment within a 60-minute average drive or within 28 days, you are also eligible for community care.

What does “best medical interest” mean in terms of community care eligibility?

If you and your VA provider agree that it is in your best medical interest to receive care from a community provider, you can be eligible for community care. This might be the case if the VA provider lacks experience with your specific health condition and a nearby community provider specializes in it.

Can I get community care if my local VA facility doesn’t meet quality standards?

Yes, if the VA determines that your local VA health facility does not provide care that meets its quality standards, you may be eligible to receive care from an in-network community provider. For example, if your local VA facility cannot provide adequate cardiology care, you can seek treatment from a community provider.

How do I know if a community provider is in-network?

The VA’s community care office will provide you with a list of in-network community providers once your referral is approved. You can choose from this list to ensure that your care is covered by the VA and to avoid any billing issues.

What should I do if my community care request is denied?

If your request for community care is denied, you should first seek clarification from your VA health care team or the community care office. They can explain the reason for the denial and help you address any issues. You can also appeal the decision if you believe the denial was unjustified.

Are there situations where I can get community care without prior VA approval?

Yes, in certain urgent or emergency situations, you may receive community care without prior VA approval. However, you must notify the VA within 72 hours of receiving emergency care to coordinate coverage and ensure the VA will cover the costs. The VA’s 72-hour emergency notification phone number is 844-724-7842.

Can I switch back to VA care after receiving community care?

Yes, you can switch back to VA care after receiving community care. It’s important to ensure that all medical records and treatment details are shared with your VA primary care team to maintain continuity of care.

How do I ensure my medical records are transferred between the VA and the community provider?

After receiving care from a community provider, make sure that all medical records and treatment details are sent to your VA primary care team. This can usually be coordinated through the VA’s community care office and the civilian provider’s administrative team.

Can I appeal a decision if my community care request is denied?

Yes, you have the right to appeal a decision if your community care request is denied. Contact your VA health care team or the community care office for guidance on the appeals process and to discuss your options.

What if the VA cannot provide timely appointments for my condition?

If the VA cannot provide timely appointments for your condition, you may be eligible for community care. For example, if you need a mental health appointment and the VA cannot schedule it within 20 days or within a 30-minute drive from your home, you can receive care from an in-network community provider.

How do I handle billing issues with community providers?

If you encounter billing issues with community providers, contact the VA’s community care office immediately. They can help resolve billing problems and ensure that the VA covers the cost of approved care. Keep records of all communications and documents related to your care and billing.

What if I prefer a specific community provider?

While you cannot choose any provider, you can select from the list of in-network community providers provided by the VA. If you have a preference, discuss it with the community care office to see if they can accommodate your choice.

Can I use community care for mental health services?

Yes, community care is available for mental health services if the VA cannot provide the necessary care within a reasonable timeframe or distance. The same eligibility criteria apply as for other types of care.

How does VA Community Care work for specialty treatments?

For specialty treatments, such as cardiology or oncology, if the VA cannot schedule an appointment within a 60-minute average drive or within 28 days, you are eligible for community care. Your VA provider will coordinate the referral to an in-network community provider who can offer the specialized care you need.

How do I get updates on my community care request?

Stay in regular contact with your VA health care team and the community care office to get updates on your request. Keeping detailed records of your communications and being proactive can help ensure that your care is coordinated effectively and without unnecessary delays.

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