VA: Urgent Care Benefits

Thanks to the passage of the VA Mission Act of 2018, veterans who are eligible for VA health care benefits have expanded access to urgent care treatment as an option for minor medical issues. Updates to the program in 2019 allows veterans to access health services via “approved non-VA medical providers” according to the VA official site.

The Purpose Of The VA Mission Act

The VA Mission Act was signed into law in 2018 and provides for changes in the VA health care system including requirements that the VA “coordinate the furnishing of hospital care, medical services, and extended care services” to insure:

  • Scheduling of medical appointments in a timely manner.
  • Establishing a “mechanism to receive medical records from non-Department providers.”
  • Ensuring continuity of care and services.
  • Ensuring coordination “among regional networks if the covered veteran accesses care and services in a different network than the regional network in which the covered veteran resides.”
  • Establishing measures to prevent eligible veterans from having “a lapse in care resulting from errors or delays by the Department or its contractors or an unusual or excessive burden in accessing hospital care, medical services, or extended care services.”

The VA Mission Act, “subject to the availability of appropriations” must provide hospital care, medical services, and extended care services even if the VA itself “does not offer the care or services” a veteran needs under certain circumstances.

The availability of urgent care and walk-in care is one of the ways the Act has expanded the availability of care under the VA health care system.

Eligible Veterans can, thanks to the Act, receive care or treatment from an urgent care provider as long as that provider is a part of the VA network of authorized urgent care centers.

When The VA Will Pay For Urgent Care Services

Veterans who need urgent care may have that care paid for by the Department of Veterans Affairs when the following applies:

  • The medical care provided is not on the list of excluded services such as preventive medicine or dental care.
  • The Veteran is eligible for the urgent care benefit.
  • The care provider is part of VA’s contracted network of community providers.

Veterans who choose to use an urgent care facility that is not in the VA network should assume they will be required to pay the entire cost of such services.

VA Payment For Prescriptions Issued During An Urgent Care Visit

The Department of Veterans Affairs agrees to cover the cost of or fill the prescriptions given during an urgent care visit to a provider in the network.

Routine care prescriptions must be filled by the VA, and when prescribed medication with a supply of 14 days or less, eligible veterans are allowed to have the script filled at “a contracted pharmacy in the VA network or the prescription can be filled at a non-contracted pharmacy.”

In cases where a non-contracted pharmacy is used, the veteran is required to pay out of pocket and submit a claim to be reimbursed with a local VA medical facility. Prescription medication may or may not require a copay.

The Department of Veterans Affairs official site advises that an annual medication copayment cap applies for veterans in VA Priority Groups 2 through 8 (see below). The co-pay cap is $700 per calendar year. Veterans in VA Priority Group 1 have no medication copayment required.

How To Check If You Are Eligible For Urgent Care Under The VA Mission Act

The VA official site directs veterans to check with their local VA medical facility to check eligibility for these services and VA payment for them. Veterans who are eligible may locate an authorized urgent care facility near them by checking the VA provider locator tool on its official site.

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.

There Is A Difference Between Urgent Care And Emergency Care

The Department of Veterans Affairs notes a marked difference between urgent care and emergency care. The services offered for urgent care under the VA Mission Act include, according to the VA, “…minor injuries or illnesses that are not life threatening.”

Emergency care, which is not part of the scope of the Urgent Care benefit, is defined by the VA as any medical service required without delay to avoid threats to life or limb.

Urgent Care Services Provided Under The VA Mission Act

Qualifying veterans may seek urgent care from an in-network provider for “non-emergent symptoms” for conditions including flu, minor injuries such as sprained ankles or wrists, bruises, skin irritation, injuries that require splints or casts, earache, painful urination or related issues. Care may be given in two basic types of care centers in the VA network; Urgent and Retail.

The VA defines these two locations as follows:

  • Urgent care facilities may include locations “whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention” that is non-emergency care. Care at these locations may include splints, casts or other attention that may be more advanced than the services required from a Retail outlet.
  • Retail may be a walk-in clinic, pharmacy, or independent clinic. These may be inside a retail outlet such as WalMart or Target. The mention of these two retail chains does not imply they are actually part of the VA network-you will need to check with the VA to find authorized, in-network locations near you. Do not assume that WalMart or Target are authorized VA urgent care providers.

Remember, if you have a medical condition that is not well-understood or may be complicated to explain to a new care provider, it may be best to discuss treatment with your primary care provider first. Any situation that may be a threat to life or limb should not be dealt with using urgent care services; you may require emergency treatment instead depending on circumstances.

“Special Authority And Exposure”

In the above VA copayment rules for urgent care, there are certain exclusions (see above) for special authority and exposure cases. What does this mean? VA.gov defines “special authorities and exposure” as “those related to combat service and exposures.” This can include but may not be limited to:

  • Agent Orange
  • Military Sexual Trauma
  • Active duty at Camp Lejeune
  • Project Shipboard Hazard and Defense (SHAD/Project 112)
  • Southwest Asia Conditions)
  • Presumptions applicable to certain Veterans with psychosis and other mental illnesses
  • Exposure to ionizing radiation

VA Urgent Care Benefit Copayment Issues

You may be required to make a copayment for authorized VA urgent care services, and that co-pay may differ from other copayment requirements you have experienced under the VA health care system.

The nature and amount of the copayment you are responsible for depends on your VA priority group and the number of times you visit an in-network urgent care provider within the year.

  • Copayment Rules For VA Priority Groups 7-8: A modest copayment applies for each visit.
  • Copayment Rules For VA Priority Groups 1-5: No copayment for the first three visits during a calendar year. For all visits beyond the first three per year a modest copayment applies.
  • Copayment Rules For VA Priority Group 6: No copayment for the first three visits during a calendar year in cases where the visits are related to “special authority” or exposure. If the visit is not related to “special authority” or exposure, there is a modest copayment per any visit. For those who meet the “special authority” or exposure requirement, there is a modest co-pay for every visit after the third one.

For all VA priority groups, there is no copayment required for visits specifically for flu shots only. Furthermore, flu shot-only visits “do not count as a visit for the number of visits in a calendar year for eligible Veterans in priority groups 1-6” according to VA.gov.