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DSO Corner

Q: How does The Choice Act and getting emergency care outside the VA work?

A. VA’s Veterans Choice Program covers hospital care and medical services under the Medical Benefits Package, including pharmacy and other benefits, such as beneficiary travel. All care under the Choice Program must be pre-authorized. 
To be eligible, a veteran must meet either of the following criteria. Criteria 1: be enrolled in the VA health-care system as of Aug. 1, 2014, or be a combat veteran who served on active duty in a combat theater during a war period after the Persian Gulf War, or in combat against a hostile force, and also be within five years of separation.
Criteria 2: Have an appointment greater than 30 days from the desired appointment date (i.e. The primary care provider asks to see you again in two weeks and your appointment is scheduled within 30 days after the two-week mark), or reside more than 40 miles from a VA facility, measured in shortest driving distance, regardless of services offered. Distance is calculated by address on record.
The Choice Program does not include nursing home care or unscheduled (emergency) non-VA care. In the event that non-VA care is sought for emergency, all of the following criteria must be met in order to claim VA reimbursement: (1) You were provided emergency care in a hospital emergency department or similar facility. (2) You are enrolled in the VA health-care system. (3) You have been provided care by a VA health-care provider within the last 24 months. (4) You are financially liable to the care provider for the emergency treatment. (5) You have no other health insurance. (6) You do not have Medicare, Medicaid or a state care program. (7) You do not have coverage under any other VA programs. (8) You have no contractual or legal right to reimbursement from a third party for the bill. (9) VA or other federal facilities were not feasibly available at time of the emergency. (10) The care must have been rendered in a medical emergency in which a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. (11) VA must be notified of the care within 72 hours.
For further assistance, consult a Legion-accredited service officer.

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