Veterans Access, Choice and Accountability Act of 2014 (VACAA) The Choice Program

VETERANS HEALTH ADMINISTRATION Background Public Law (P.L.) , the Veterans Access, Choice, and Accountability Act of 2014, which was enacted on August 7, 2014, and amended through the Department of Veterans Affairs Expiring Authorities Act of 2014 (P.L ), improves the access of eligible Veterans to health care through non-VA entities and providers. The law establishes the Veterans Choice Program, new documentation and reporting requirements, and the Veterans Choice fund. P.L did not change the eligibility requirements for enrollment in the VA health care system and did not modify VA’s existing authorities to furnish non- VA care. On November 5, 2014, the Department of Veterans Affairs (VA) published an interim final rulemaking, AP24, that amends sections , , and of title 38 of the Code of Federal Regulations (CFR) and establishes new regulations at 38 CFR through to implement the Choice Program. The Choice Program covers hospital care and medical services under the Medical Benefits Package (see 38 CFR 17.38), which includes pharmacy and other benefits, such as beneficiary travel. For programs that have specific eligibility criteria, such as dental care, the specific eligibility criteria still applies. All care under the Choice Program must be pre-authorized. The Choice Program does not include Nursing Home Care or unscheduled (emergency) non-VA care. 1

VETERANS HEALTH ADMINISTRATION Eligibility Any Veteran who meets the eligibility criteria for the Choice Program is eligible to receive hospital care and medical services under the Medical Benefits Package, including medications or prosthetic devices (see 38 CFR 17.38). For programs that have specific eligibility criteria, such as dental care, the specific criteria still apply. VA will apply a two-step process to establish a Veteran’s eligibility. A Veteran must meet at least one of the criteria in step 1 and at least one of the criteria in step 2. Step 1:  enrolled in the VA health care system as of August 1, 2014, or  a combat Veteran who served on active duty in a theater of combat operations during a period of war after the Persian Gulf War, or in combat against a hostile force, and is within 5 years of separation. 2

VETERANS HEALTH ADMINISTRATION Eligibility (continued) Step 2:  Have an appointment greater than 30 days of clinically indicated date (CID) or desired date (DD) in absence of CID OR  reside more than 40 miles from the nearest VA medical facility regardless of services offered-straight line calculation 3

VETERANS HEALTH ADMINISTRATION Choice Card Production / Distribution Instruction letter accompanied card 4

VETERANS HEALTH ADMINISTRATION Veterans Choice Program – 40+ Miles TPA (Third Party Administrator) is provided list of eligible Veterans that reside more than 40 miles from VA facility – Distance is calculated by address on record – This list is updated monthly Veteran is notified of their eligibility through mailings Veteran can choose to contact TPA and coordinate ALL care ⁻Veteran is seen by Non-VA Choice Provider ⁻Choice provider submits claim, Explanation of Benefits (EOB) (if applicable) and clinical documentation to TPA ⁻Clinical documentation is sent to VA to add to veteran record ⁻TPA processes payment to Choice Provider ⁻TPA submits claim, EOB and clinical document to VA (CBOPC) for payment ⁻Consolidated Patient Account Centers (CPAC) staff will determine VA copayment and bill Veteran appropriately ⁻Care Provided is paid by CBO (Central Business Office) with funding authorized in PL  Ex: Vet needs hip replacement, all related care, i.e. workup, surgery and rehab considered episode of care. Approval for episode of care is only authorized for 60 days and must be renewed 5

VETERANS HEALTH ADMINISTRATION Veteran Choice Program – 30+ Days 30 day clock starts ticking based on “clinically indicated date” (CID) or patient desired date in absence of CID Veteran is added to VCL and made aware that they are eligible to use Choice Program and provided the number for the TPA VCL list data is transmitted to TPA 3 times each week Veteran contacts TPA for information and/or use of Choice Program – TPA notifies VAMC through web-based portal – NVCC communicates with TPA regarding authorization (upload consult/notes or inform of ineligibility) If Veteran selects to use Choice Program – TPA uses consult to determine what services are to be scheduled – TPA schedules appointment with veteran 6

VETERANS HEALTH ADMINISTRATION Veteran Choice Program – 30+ Days (continued) – TPA notifies VAMC of appointment – NVCC staff cancels existing VA appointment – Veteran is seen by Choice Provider – Choice provider submits claim, Explanation of Benefits (EOB) (if applicable) and clinical documentation to TPA – Clinical documentation is sent to VA to add to veteran record – TPA processes payment to Choice Provider – TPA submits claim, EOB and clinical document to VA CBOPC (Central Business Office for Purchased Care) for payment – Consolidated Patient Account Centers (CPAC) staff will determine VA copayment and bill Veteran appropriately 7

VETERANS HEALTH ADMINISTRATION Copayments and Secondary Payers VA Copayments Draft regulation eliminates VA copayment at time of service and allows it to be charged to the Veteran after care provided and coordination of benefits processed Other Health Insurance (OHI) Cost Shares/Copayments/Deductibles Requires Veterans with OHI to provide info to VA if selecting Choice Program Declining to provide OHI results in loss of this benefit OHI cost shares will be due by the Veteran to the provider or the OHI – VA does not have authority to interfere with health plan requirements VA can only pay up to the Medicare rate minus the cost of care provided – If the total of the cost of care plus the cost shares exceed the Medicare rate, Veteran may be left owing some portion of cost share Care for service connection or those without OHI will not incur additional expense 8

VETERANS HEALTH ADMINISTRATION Resources Website for information and eligibility check: TPA for our region is HealthNet: Salisbury VAMC Fee Basis Pharmacy FAX for providers: Salisbury VAMC NON-VA care department coordinating CHOICE: ext

VETERANS HEALTH ADMINISTRATION Reminder: Contents of this Presentation are … 10

VETERANS HEALTH ADMINISTRATION Questions 11