Transcript vacaa--the choice program

Veterans Access, Choice and Accountability Act of 2014 (VACAA)
The Choice Program
Background
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Public Law (P.L.) 113-146, 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. 113-175), 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. 113-146 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
17.108, 17.110, and 17.111 of title 38 of the Code of Federal Regulations (CFR) and
establishes new regulations at 38 CFR 17.500 through 17.1540 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.
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Eligibility
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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.
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Eligibility (continued)
Step 2:
 Have an appointment greater than 30 days of clinically indicated date (CID) or
desired date (DD) in absence of CID
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 reside more than 40 miles from the nearest VA medical facility regardless of
services offered-straight line calculation
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Choice Card Production / Distribution
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Instruction letter accompanied card
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Veterans Choice Program – 40+ Miles
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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 113-146
 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
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Veteran Choice Program – 30+ Days
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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 1-800 number for the TPA
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VCL list data is transmitted to TPA 3 times each week
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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)
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If Veteran selects to use Choice Program
– TPA uses consult to determine what services are to be scheduled
– TPA schedules appointment with veteran
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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
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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
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Resources
Website for information and eligibility check: http://www.va.gov/opa/choiceact
TPA for our region is HealthNet: 1-866-606-8198
Salisbury VAMC Fee Basis Pharmacy FAX for providers: 704-638-3808
Salisbury VAMC NON-VA care department coordinating CHOICE: 704-638-9000 ext
2022
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Reminder: Contents of this Presentation are …
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Questions
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