The short answer
VA can designate a specific service at a VA facility, like cardiology at one medical center, as not meeting its quality standards. Veterans who need that service can then qualify for Community Care, within the time, place, and service limits VA sets. VA announces these designations in the Federal Register.
How does the quality-standard rule work?
It's one of the six ways to qualify for Community Care. Under 38 CFR 17.4010(a)(6), you qualify if you need care from a VA medical service line that VA has found isn't meeting its quality standards.
A "medical service line" is a specific service at a VA facility, like orthopedics at one medical center or cardiology at another. The rule is about that service, not the whole hospital.
VA's eligibility page gives this example: a Veteran needs cardiology care, and the local VA's cardiology care doesn't meet VA's quality standards, so the Veteran may be able to use an in-network community provider.
How does VA decide a service line is underperforming?
38 CFR 17.4015 sets the process. VA compares the service line on two things:
- Timeliness, compared with the same service at other VA facilities.
- Quality, using at least two separate quality measures, compared with non-VA providers.
VA also weighs:
- whether the differences are clinically significant;
- how likely and how quickly the problem can be fixed;
- recent trends;
- how many Veterans use the service or would be affected;
- the possible effect on patient outcomes; and
- how a designation would affect other VA services.
Are there limits?
Yes, several:
- Number: No more than 3 service lines at one facility and no more than 36 nationwide.
- Public notice: VA announces designations each year in the Federal Register and explains how it decided.
- Scope: The notice can limit Community Care under this rule to a certain time period, geographic area, or set of services.
- Notice to you: VA has to take reasonable steps to tell affected Veterans directly.
So this rule only works when VA has actually designated the service you need, at the facility you'd use, and only within the notice's limits.
How is this different from best medical interest?
| Quality-standard rule | Best medical interest | |
|---|---|---|
| Who decides | VA, nationally, through a public notice | You and your VA clinician |
| Looks at | How a VA service performs overall | Your individual situation |
| Covers | Everyone who needs that designated service, within limits | Only you, for this care |
| Rule | 17.4010(a)(6) and 17.4015 | 17.4010(a)(5) |
If you have concerns about the quality of care you're getting at VA but no designation applies, quality is still one of the best medical interest factors. You can raise it with your clinician. See Best Medical Interest.
How do I find out if a designation applies to me?
- Ask your facility's Community Care office whether any VA service lines at your facility are currently designated under 38 CFR 17.4015.
- Search the Federal Register for VA notices about designated medical service lines.
- Watch for a letter from VA, since it must try to notify affected Veterans.
If a designation applies, tell your care team you want Community Care under that rule and ask for a referral.