What Is VA Community Care? When Veterans Can Use Care Outside VA

Quick answer

VA Community Care is a way for VA to arrange and pay for eligible care from non-VA providers when the applicable Community Care requirements are met. It is part of the Veteran's VA health care benefit; it is not a separate commercial insurance plan and it is not permission to see any civilian provider without VA involvement.

Under 38 U.S.C. § 1703, the Veterans Community Care Program can furnish hospital care, medical services, and extended care services to covered Veterans through eligible providers. 38 CFR § 17.4000 describes the program as the framework for when a covered Veteran may elect to have VA authorize an episode of care from an eligible community provider.

For most routine, non-emergency care, three separate questions need to line up:

1. Are you enrolled in or otherwise eligible for VA health care?
2. Do you meet a Community Care eligibility pathway for the care you need?
3. Has VA approved the specific community care before you receive it?

VA's current guidance says Veterans generally need approval from their VA health care team before receiving routine care from a community provider. Urgent and emergency care have separate rules.

What VA Community Care does

VA normally delivers care through VA medical centers, clinics, and other VA services. Community Care is the system VA uses when qualifying care is furnished outside VA.

VA describes Community Care as care provided on behalf of VA and paid for by VA when the Veteran meets the applicable requirements. Federal law also directs VA to coordinate community care, including timely scheduling, receipt of medical records from non-VA providers, continuity of care, and coordination when a Veteran uses care across regional networks.

In practice, Community Care can involve several different steps:

• determining whether the Veteran qualifies for community care for the needed service;
• issuing a referral or authorization;
• identifying an eligible community provider;
• scheduling the appointment;
• defining the authorized episode or scope of care;
• exchanging records and coordinating follow-up; and
• paying the community provider through the applicable VA arrangement.

For what happens after eligibility is established, see VA Community Care Referrals, Authorizations, and Continued Care.

What kinds of care can it include?

The statute and regulation use three broad categories: hospital care, medical services, and extended care services.

That means Community Care is not limited to one specialty or to mental health. The exact service still has to fit the Veteran's eligibility, clinical need, provider arrangement, and authorization.

When can a Veteran use Community Care?

VA's current eligibility guidance says a Veteran must generally be enrolled in or otherwise eligible for VA health care and have VA approval before receiving routine community care. The Veteran must also meet at least one applicable Community Care criterion.

Current VA examples include situations where:

• VA does not offer the required service at any VA facility;
• the Veteran lives in a qualifying area without a full-service VA medical facility;
• the Veteran and VA clinician determine that community care is in the Veteran's best medical interest under the applicable rule;
• VA cannot furnish the needed service in a way that meets applicable quality standards;
• a protected legacy eligibility pathway applies; or
• VA cannot provide the needed care within designated drive-time or wait-time access standards.

The exact pathway matters. Qualifying for one service does not create an unlimited authorization for unrelated future care.

See VA's current Community Care eligibility guidance for the detailed criteria and access standards.

Eligibility is not the same as authorization

A Veteran can meet a Community Care eligibility criterion and still need VA to approve the specific care before a routine community appointment is covered.

VA's referral guidance says that before scheduling routine care with a non-VA provider in the Community Care Network, the Veteran must get a referral and the VA health care team must approve the care.

A useful way to separate the steps is:

• VA health care eligibility — the Veteran's underlying access to VA health care.
• Community Care eligibility — whether the needed care qualifies to be furnished outside VA.
• Referral or authorization — VA approval of the particular community care.
• Provider/network status — whether the provider can furnish care under an arrangement VA can use.
• Scheduling — the actual appointment with the provider.

Confusing those steps is a common reason a Veteran can be told they “qualify for Community Care” but still not have a usable community appointment.

Community Care is not the same as CCN

The Veterans Community Care Program is the eligibility and authorization framework. The Community Care Network (CCN) is VA's main contracted network of community providers used to deliver much of that authorized care.

A provider being in CCN does not, by itself, make a Veteran eligible for Community Care or authorize a visit.

See VA Community Care vs. the Community Care Network (CCN) for the full distinction.

How it relates to care delivered directly by VA

Qualifying for Community Care does not mean a Veteran has left VA health care or must stop using VA facilities.

VA states that a Veteran who is eligible for Community Care can still choose care at a VA health facility. A Veteran may receive some services directly from VA and other authorized services in the community.

Which pathway applies can differ by service, location, timing, clinical need, and the particular authorization.

What Community Care does not mean

Community Care does not generally mean:

• you can make any civilian appointment and bill VA afterward;
• every provider who says they “take VA” can automatically treat you under Community Care;
• meeting an access standard creates an open-ended authorization for unrelated services;
• eligibility for one Community Care service makes every future service eligible; or
• CCN participation replaces the Veteran-specific referral or authorization.

A practical process for routine Community Care

1. Start with the care need. Tell your VA care team what service or follow-up you need.
2. Confirm Community Care eligibility for that care. Ask which eligibility pathway applies if VA is arranging outside care.
3. Confirm the referral or authorization. Do not rely only on a verbal statement that you “qualify.”
4. Confirm the provider and scope. Check the intended provider, specialty or service, and authorization dates.
5. Schedule the appointment. Confirm that the community provider has received the referral.
6. Check continued-care requirements. If the community clinician recommends additional treatment, do not assume it is automatically included in the original authorization.

If the process stalls after approval, use the referrals and authorizations guide to determine whether the problem is eligibility, referral entry, authorization, scheduling, or continued care.

What about urgent or emergency care?

Urgent and emergency care have separate eligibility, authorization, notification, and payment rules. The routine Community Care referral process should not be used as a reason to delay emergency treatment.

If you believe your life or health is in danger, seek emergency care. For the separate rules after a non-VA emergency visit, see Non-VA Emergency Care for Veterans.

Before a routine community appointment

Confirm:

• VA has approved the specific care;
• the provider has the referral or authorization;
• the authorized dates and services cover the planned appointment; and
• you know whom to contact if the provider has not received the authorization.

That short check can prevent many Community Care problems before treatment occurs.