VA MISSION Act: VA’s new urgent care benefit for Veterans

Note: This article is part of a series on VA’s progress implementing the VA MISSION Act of 2018.

Sometimes a quick trip to a local walk-in retail health clinic or urgent care facility is a convenient alternative for minor injuries and illnesses.

As part of implementing the VA MISSION Act of 2018, VA will offer an urgent care benefit that provides eligible Veterans with greater choice and access to timely, high-quality care.

With urgent care, Veterans have a new option for care for the treatment of minor injuries and illnesses, such as colds, sore throats, and minor skin infections. The benefit is offered in addition to the opportunity to receive care from a VA provider, as VA also offers same-day services.

Eligible Veterans will be able to receive urgent care from an urgent care provider that is part of VA’s contracted network of community providers without prior authorization from VA. VA can pay for an urgent care claim only if:

• The Veteran is eligible for the benefit;
• The urgent care provider is part of VA’s contracted network of community providers; and
• The services are not excluded under the benefit (excluded services include preventive services and dental services).

This benefit will be available when final Federal regulations are published and effective, on June 6, 2019.

Eligibility

To check their eligibility once the urgent care benefit has started, Veterans should contact their local VA medical facility.

To find an available urgent care provider in VA’s contracted network of community providers, Veterans will be able to use VA’s provider locator on VA.gov (https://www.va.gov/find-locations/) or contact their local VA medical facility. VA staff can inform the Veteran of available in-network locations and offer to find the closest locations. 

VA can only pay for care under this benefit if the Veteran is eligible, the services are not excluded under the benefit, and the provider is part of VA’s contracted network of community providers and is identified as an urgent care provider. If an eligible Veteran goes to an out-of-network urgent care provider, they may be required to pay the full cost of care.

Covered Services

The urgent care benefit covers treatment of non-emergent symptoms such as flu-like symptoms (coughs and colds), wheezing, sprains, sore throats, painful urination, bumps and bruises, ear pain, and mild skin irritations, which are typically addressed by urgent care facilities and walk-in retail health clinics. Excluded from the benefit are preventive and dental services.

Important: While urgent care is a convenient benefit for the treatment of non-emergent symptoms, Veterans should always consider talking with or seeing their primary care provider if they are concerned that the community provider will not understand the complexities of their medical history or medications.

In addition, if you believe your life or health is in danger, call 911 or go to the nearest emergency department right away.

Urgent care is not a replacement for an eligible Veteran’s preventive health care. Eligible Veterans should work with their primary care provider for this type of care. If an eligible Veteran goes to an urgent care provider and receives services that are not covered by this benefit, they may be required to pay the full cost of care.

Copayments

Eligible Veterans may be charged a VA copayment for urgent care that is different from other VA medical copayments. VA copayments for urgent care depend on the eligible Veteran’s assigned priority group and the number of times they visit an in-network urgent care provider in a calendar year.

• Priority Groups 1-5. There is no copayment for the first three visits during a calendar year. For the fourth visit and all subsequent visits in a calendar year, the copayment is $30.
• Priority Group 6. There is no copayment for the first three visits during a calendar year if the visit is related to special authority* or exposure. For the fourth visit and all subsequent visits in a calendar year, the copayment is $30. If the visit is not related to special authority* or exposure, the copayment is $30 per visit, regardless of which visit it is.
• Priority Groups 7-8. The copayment is $30 per visit.
• Priority Groups 1-8. No copayment for a **flu shot-only visit. Visits consisting only of a flu shot do not count as a visit for the number of visits in a calendar year*.

*Special authorities include those related to combat service and exposures (e.g. agent orange, active duty at Camp Lejeune, ionizing radiation, Project Shipboard Hazard and Defense (SHAD/Project 112), Southwest Asia Conditions) as well as Military Sexual Trauma, and presumptions applicable to certain Veterans with psychosis and other mental illnesses.

When the benefit starts, Veterans can contact the VA Health Resource Center (HRC) for questions related to urgent care copayments at 1-877-222-VETS (8387). Veterans will also be able to contact their local VA medical facility for more information about urgent care copayments.

Prescription Medication

VA will pay for or fill prescriptions for urgent care. For routine prescription medication, the prescription must be submitted to VA to be filled.

For urgent prescription medication of a 14 day or fewer supply, Veterans can either fill the prescription at a contracted pharmacy in the VA network or the prescription can be filled at a non-contracted pharmacy. If a non-contracted pharmacy is used, Veterans must pay for the prescription and then file a claim for reimbursement with their local VA medical facility.

Some Veterans may be required to make a copayment for medication. Information about copayments can be found at https://www.va.gov/COMMUNITYCARE/revenue_ops/copays.asp.

Going Forward

This benefit will be available when final Federal regulations are published and effective, on June 6, 2019. The new urgent care benefit is consistent with President Trump’s commitment to provide Veterans with more choices and greater access to healthcare they’ve earned through their service to our country.

Resources

• Fact Sheet – Veteran Community Care – Urgent Care (VA MISSION Act of 2018)
• Fact Sheet – Veteran Community Care – Eligibility (VA MISSION Act of 2018)
• Fact Sheet – Veteran Community Care – General Information (VA MISSION Act of 2018)

*Special authorities include those related to combat service and exposures (e.g. agent orange, active duty at Camp Lejeune, ionizing radiation, Project Shipboard Hazard and Defense [SHAD/Project 112], Southwest Asia Conditions) as well as Military Sexual Trauma, and presumptions applicable to certain Veterans with psychosis and other mental illnesses.

**Free flu shots are currently only available through VA’s partnership with Walgreens, but will be available more widely in the future as part of the urgent care benefit.

Written by VHA Office of Community Care