The short answer
You qualify if you're enrolled in VA health care and meet at least one of six rules: VA doesn't offer the care, your state has no full-service VA facility, you're grandfathered under the old 40-mile rule, VA can't meet its wait or drive-time standards, it's in your best medical interest, or the VA service doesn't meet quality standards.
What are the six ways to qualify?
You need to meet just one. They come from 38 CFR 17.4010(a) and VA's eligibility page.
| Rule | What it means | Who decides |
|---|---|---|
| 1. Service not available | No VA facility offers the care you need | VA |
| 2. No full-service VA facility | Your state or territory has no VA hospital with emergency and surgical care | Based on where you live |
| 3. Grandfathered 40-mile rule | You qualified under the old Choice rule and still meet its conditions | Based on your history and residence |
| 4. Access standards | VA can't schedule you within its wait-time or drive-time limits | Based on VA's earliest appointment and your drive time |
| 5. Best medical interest | You and your VA provider agree outside care is better for you | You and your provider |
| 6. Quality standards | VA has designated the VA service you need as not meeting its standards | VA, through a public notice |
Before any of these apply, you need to be a covered Veteran, which usually means enrolled in VA health care.
1. VA doesn't offer the service
If no VA facility offers the care you need, you qualify. The rule says "any" VA facility, so a service offered at another VA, even far away, can mean this rule doesn't apply. In that case, look at the drive-time standard or best medical interest instead.
Examples that sometimes fit: certain specialized procedures, or services VA doesn't provide in-house.
2. No full-service VA medical facility in your state
If you live in a state or U.S. territory without a full-service VA medical facility, you qualify. 38 CFR 17.4005 defines full-service as a VA facility that provides hospital care, emergency care, and surgery, with a surgical complexity rating of at least "standard." VA publishes the list of these facilities on its website.
This rule looks at your state, not your distance. A Veteran living near the border of a state without one may qualify even if a full-service VA is close by in the next state.
3. Grandfathered under the old 40-mile rule
This protects some Veterans who qualified under the Veterans Choice Program's 40-mile distance rule as of June 5, 2018. You qualify if you still live where that rule would apply, and either:
- you live in Alaska, Montana, North Dakota, South Dakota, or Wyoming; or
- you live elsewhere and got VA care between June 6, 2017, and June 6, 2018. Under the regulation, this second group could only use it for care sought before June 6, 2020, so it has largely ended.
Today, this rule mostly helps Veterans in those five states.
4. VA can't meet its access standards
This is the rule most Veterans use. You qualify if VA can't schedule your care within these limits, from 38 CFR 17.4040:
- Primary care, mental health, and non-institutional extended care: within 20 days of your request and within a 30-minute average drive.
- Specialty care: within 28 days and within a 60-minute average drive.
The wait-time clock starts when you ask for the care, unless you agree to a later date with your VA provider. Details: Wait-Time and Drive-Time Standards.
5. Best medical interest
You and your referring VA clinician can agree that outside care is in your best medical interest. You don't have to fail the wait or drive standards for this. The factors include distance, the type of care, how often you need it, timeliness, continuity of care, quality, and unusual travel burden. See Best Medical Interest.
6. A VA service line doesn't meet quality standards
VA can designate a specific VA service, like cardiology at one medical center, as underperforming. Veterans who need that service can then use Community Care within the limits VA sets. VA announces these designations in the Federal Register under 38 CFR 17.4015. See Community Care When a VA Service Line Falls Short.
What else do I need to do?
Two things the rule requires:
- Report a move within 60 days. Your residence affects drive-time and state-based eligibility, under 38 CFR 17.4010(b).
- Tell VA about other health insurance before the care is authorized, and report changes within 60 days, under 38 CFR 17.4010(c). See Other Health Insurance and Community Care.
If I qualify, do I have to use Community Care?
No. Under 38 CFR 17.4020(a), you choose: a VA appointment or Community Care. You can also name a specific eligible provider you want VA to use. VA authorizes outside care when it's clinically necessary.
How do I ask?
Tell your VA care team what care you need and ask: "Do I qualify for Community Care for this, and under which rule?" If the answer is no and you think you qualify, ask them to explain in writing. See What to Do If Your Referral Is Delayed or Stuck.
Eligibility decisions can be appealed through VA's clinical appeals process, not the Board of Veterans' Appeals, under 38 CFR 17.4010(d). See Appealing a Community Care Denial.