Chapter 10 Care Outside the VA System: What VA Covers

VA may refer enrolled Veterans to a non-VA provider in the community for a portion of care, under certain limited circumstances.

Pre-Authorized Non-VA Care

Non-emergency health care provided in non-VA facilities at VA expense (such as Fee Basis care) must always be pre-authorized. That is, VA must authorize in advance the services being furnished. VA may pre-authorize health care at a non-VA facility, or other Federal facility with which VA has an agreement.

However, VA may authorize non-VA emergency care — even though it was not authorized in advance — when (a) the nearest VA medical facility is notified within 72 hours of admission; (b) the care rendered is for a medical emergency; (c) VA or other Federal facilities are not feasibly available; (d) and the Veteran meets the eligibility requirements.

Emergency Care

A medical emergency is generally defined as a condition of such a nature that a prudent layperson would reasonably expect that delay in seeking immediate medical attention would be hazardous to life or health.

An enrolled Veteran may receive emergency care at a non-VA health care facility at VA expense when a VA facility (or other Federal health care facility with which VA has an agreement):

Cannot furnish economical care due to the patient’s distance from the facility; or

When VA is unable to furnish the needed emergency services.

VA Payment for Emergency Care of Service-Connected Conditions Without Prior Authorization

Since payment may be limited to the point when a condition is stable enough for travel to a VA facility, an enrolled Veteran needs to contact the nearest VA medical facility as soon as possible. An emergency is deemed to have ended at the point when a VA provider has determined that, based on sound medical judgment, the patient should be transferred from the non-VA facility to a VA medic center.

VA Payment for Emergency Care of Nonservice-connected Conditions Without Prior Authorization

VA may pay for emergency care provided in a non-VA facility for treatment of an enrolled Veteran’s Nonservice-connected condition only if all of the following conditions are met:

The episode of care cannot be paid under another VA authority, and

Based on an average knowledge of health and medicine (prudent layperson standard) there was a reasonable expectation that delay in seeking immediate medical attention would have been hazardous to life or health, and

A VA or other Federal facility/provider was not feasibly available, and

VA medical care has been received within a 24-month period preceding the non-VA emergency care, and

The Veteran is financially liable to the health care provider for the emergency care, and

The services were furnished by an Emergency Department or similar facility held out to provide emergency care to the general public, and

There is no other coverage under a health plan (including Medicare, Medicaid and Worker’s Compensation), and

There is no contractual or legal recourse against a third party that would, in whole, extinguish the Veteran’s liability, and

There is a 90 day timely filing limit.

Veterans Who are Living or Traveling in a Foreign Country

VA will pay for medical services for treating Service-connected disabilities, or any disability that is associated with and aggravates a Service-connected disability, for enrolled Veterans who live or travel outside the United States. This
program will also reimburse you for certain treatment of medical services while outside the United States, if needed as part of the VA-approved vocational rehabilitation program.

For more information, call the Foreign Medical Program
Office at 1-877-345-8179