Veterans Choice Act – Getting Care through the Choice Act

Getting Care Through the Veterans Choice Act

 

We have had a lot of questions come our way in regard to how to get care through the Veterans Choice Act and what’s covered and when it’s covered.  We want to provide all of you with guidance, what to make sure you have done, and what pitfalls to avoid and be aware of.

The Veterans Choice Act care is an optional alternative to getting care at an outside medical facility if you qualify for it.  It is not mandatory to use Choice Act for care – you can choose to wait until the next appointment is available, but you do have to inform the VA that you are waiving this option.

 

How Do I Get Authorized to Use the Choice Act?

  • The local VA Facility will inform you if you are authorized for Choice Act coverage based one of these qualifiers:
    • Told that you have to wait longer than 30 days for an appointment for care, OR
    • Live more than 40 miles from the closest VA Facility, OR
    • Unusual or Excessive Burdon
      • Geographic Challenges – A Veteran needs to travel around a large body of water, over a mountain, or needs to navigate a similar geographic barrier.
        • The Veteran resides in a location other than Guam, American Samoa, or the Republic of the Philippines and needs to travel by air, boat, or ferry to the VA medical facility closest to his/her home.
        • The Veteran faces an unusual or excessive burden traveling to a VA medical facility based on geographic challenges, environmental factors, or a medical condition. Staff at the Veteran’s local VA medical facility will work with him/her to determine if he/she is eligible for any of these reasons.
        • The Veteran resides in a State or a United States Territory without a full-service VA medical facility that provides hospital care, emergency services and surgical care having a surgical complexity of standard, and resides more than 20 miles from such a VA facility.
        • NOTE: This criterion applies to Veterans residing in Alaska, Hawaii, New Hampshire, Guam, American Samoa, Commonwealth of the Northern Mariana Islands and the U.S. Virgin Islands. Also note that some Veterans in New Hampshire reside within 20 miles of White River Junction VAMC and are therefore not eligible for the Choice Program.
      • Environmental Factors – A Veteran’s trip to the closest VA medical facility is blocked by traffic conditions such as a road that is inaccessible to the general public, or a prolonged road closure, or by hazardous weather conditions.
      • Medical Conditions – A Veteran has a medical condition, as confirmed by the local medical facility’s Primary Care Patient Aligned Care Team (PACT Team), that impacts his or her ability to travel.
      • Other Factors – A Veteran could be determined eligible based on the nature, simplicity, or frequency of the care he or she needs. This includes instances where a Veteran’s VA medical provider confirms that he or she requires an attendant to accompany him or her to a medical appointment either because of a medical condition or the type of procedure needed.

 

  • When the VA Facility calls to inform you of your eligibility, they inform you to wait for a phone call from the Veterans Choice Act in order to set up care. Each VA Facility has a Choice Act Coordinator that you can contact if you do not hear from the facility in a few days after being notified on your eligibility for Choice Act coverage.
  • The local VA Facility will then send the referral to the company running the Choice Act in your region:
    • Health Net Federal Services covers VA Veteran Integrated Service Networks (VISN) 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 19, & 23 (Regions 1, 2, & 4)
    • TriWest covers VA Veteran Integrated Service Networks (VISN) 9, 15, 16, 17, 18, 20, 21, 22 (Regions 3, 5A, & 5B)
  • After the request from the local VA facility is received, The Choice Act Contractor will contact the Veteran directly to arrange the authorization for care at a private medical facility. The will need the following information:
    • Verify your address
    • Collect any Other Health Insurance (OHI) information if you have any
      • Your OHI will be billed as the Primary Insurance and Choice Act will be billed as the Secondary Insurance.
    • Your availability for an appointment based on your schedule
    • Help you in identifying a provider close to your home
      • NOTE: The Choice Act will tell you that any provider that accepts Medicare rates for care can be set up as a Choice Act provider. However, we recommend talking with the Choice Act personnel to find out who is already registered as a Choice Act provider, as the provider is not required to accept Choice Act patients.  Doing this will avoid headaches and limit problems down the road.
    • The Choice Act will then reach out to the provider to schedule your appointment based on your availability. Once it is scheduled, the Choice Act will contact you to verify your appointment time.
      • NOTE: The provider may contact you as well to get information from you ahead of your appointment time, or send you paperwork to have filled out before your first appointment, so be on the lookout for correspondence from the provider

 

Now I have Care through Choice Act – Now What?

  • Do NOT go to an appointment for care before you have an authorization or before the start date of your authorization. If you do not follow the timelines, you can be held responsible for the costs of the visit(s) or services.
    • Some Veterans have been asked to do lab testing before the first appointment, but if the lab draw is before the start date of the authorization, it will not be covered. If your provider requests testing before the start date, have them contact the Choice Act Contractor BEFORE services are done so your authorization can be modified.
  • When you go to your first appointment with the Choice Act provider, be sure to bring your identification (Driver’s License, State ID Card) and your Choice Act Card.
  • Copays – There are no up-front copays that you will be responsible for at the time of your appointment. Any copays will be billed to you by the VA if they apply after services are completed.  The copays rules you are subject to at the VA is also they copay rules that apply to your Choice Act providers.  If you are VA copayment exempt then you will not be required to make the VA copayment under the Choice Program.
    • If the Choice Act provider tries to bill you for services, refer them to the Choice Act for billing issues. You are not responsible for paying the Choice Act provider.
  • Additional Services at Request of Choice Act Provider
    • If your Choice Act Provider wants to request additional visits or additional testing, they must submit a Request for Additional Services in order to be covered for the expenses.

 

As long as you keep on top of things, you should have no problems using a Choice Act Provider.

 

Let us know what your experience has been using the Veterans Choice Act – we want to share people’s experiences with everyone so we can all use it to the best of its ability and function.

 

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