You are enrolled in VA healthcare, but the VA clinic is far away, the wait for an appointment is long, or the VA does not offer the specific service you need. Can you see a local civilian doctor and have the VA pay for it? In many cases, yes — through VA Community Care. But there are rules, and understanding them before you try to use community care will save you from surprise bills and denied coverage.
What Is Community Care?
VA Community Care lets enrolled veterans receive healthcare services from approved civilian providers in their community, paid for by the VA. The program is managed through contractors — Optum and TriWest — who maintain networks of community providers and process claims on behalf of the VA.
When Can I Use Community Care?
You may be eligible for community care when the VA does not offer the service you need, the VA cannot schedule you within access standards (generally 20 days for primary care and mental health, 28 days for specialty care), the nearest VA facility offering that service is too far from your home (generally more than 30 minutes for primary care, 60 minutes for specialty care), you and your VA provider agree that community care is in your best medical interest, or the VA facility does not meet certain quality standards for the service you need.
How to Request Community Care
Talk to your VA healthcare team. Tell them the service you need and ask about community care options. Your VA provider and the community care office will evaluate your eligibility and, if approved, create a referral and authorization. The VA’s contractor will then connect you with a community provider and help schedule the appointment.
What You Cannot Do
You cannot simply walk into a civilian doctor’s office and use your VA enrollment for payment. Community care requires a VA authorization before the appointment. If you see a community provider without authorization, the VA will not pay, and you will owe the full cost of the visit.
What About Copays?
Community care copays are generally the same as what you would pay for the same service at a VA facility. Your copay amount depends on your priority group and the type of service. Some veterans have no copays at all.
Emergency Exception
If you have a medical emergency, go to the nearest emergency room — VA or civilian. The VA has provisions for covering emergency care at non-VA facilities for enrolled veterans in certain circumstances. After emergency treatment, contact the VA as soon as possible to report the emergency visit.
The Bottom Line
Community care is a real benefit, but it requires a VA referral and authorization first. Start with your VA healthcare team. Ask about community care. If you are eligible, the process works — and you get care closer to home from a provider you and the VA selected together.
Community care is a real benefit, but it requires a VA referral and authorization first. Start with your VA healthcare team. Ask about community care. If you are eligible, the process works — and you get care closer to home from a provider you and the VA selected together.
The MISSION Act and Your Access Standards
The VA MISSION Act of 2018 significantly expanded veteran access to community care. Under the MISSION Act, the VA established specific access standards that determine when you are eligible for community care. If the VA cannot provide the care you need within designated wait time standards (typically 20 days for primary care and mental health, 28 days for specialty care) or drive time standards (typically 30 minutes for primary care, 60 minutes for specialty care), you may be eligible to receive that care from a community provider. These standards are not suggestions — they are congressionally mandated requirements that give veterans the right to access care outside the VA when the VA cannot meet them. Understanding these standards empowers you to advocate for your own access when VA appointment availability does not meet the established criteria.
How Community Care Providers Get Paid
When you receive community care, you should not receive a bill from the community provider for VA-authorized services. The VA pays the community provider through the regional contractor (Optum or TriWest, depending on your location). If you receive a bill from a community provider for services that were authorized by the VA, contact the VA community care office at your VA medical center immediately. You are not responsible for paying bills that the VA authorized. However, if you received services that were not authorized by the VA, or if you went to a community provider without a VA authorization, you may be responsible for those costs. Always verify that you have an active community care authorization before receiving services from any non-VA provider.
What to Expect During a Community Care Visit
When you visit a community care provider, bring your VA community care authorization letter or reference number, your VA identification card, and a list of your current medications. The community care provider delivers your care and sends clinical documentation back to your VA medical center so your VA care team has a complete picture of all treatment you receive. You should not be asked to pay out of pocket for VA-authorized services — if a provider asks you to pay, explain that the service is authorized through VA Community Care and provide the authorization information. After your visit, follow up with your VA primary care team to ensure they received the community care provider documentation and to discuss any treatment recommendations from the community care visit.
Veterans who are new to community care should also know that not all community providers participate in the VA CCN network. When the VA authorizes community care, they will typically identify providers in the network. If you have a specific provider you want to see who is not in the network, discuss this with your VA community care coordinator — in some cases, the VA can authorize out-of-network providers, though the process may take longer.