---
kind: "range"
citation: "38 C.F.R. §§ 17.4000–17.4040"
title: "38"
from: "17.4000"
to: "17.4040"
count: 9
url: "https://uscodex.org/cfr/38/17.4000..17.4040"
---

# §17.4000. Purpose and scope.

- (a) **Purpose.** [Sections 17.4000 through 17.4040](/cfr/38/17.4000..17.4040.md) implement the Veterans Community Care Program, authorized by [38 U.S.C. 1703](/usc/38/1703.md).
- (b) **Scope.** The Veterans Community Care Program establishes when a covered veteran may elect to have VA authorize an episode of care for hospital care, medical services, or extended care services from an eligible entity or provider. [Sections 17.4000 through 17.4040](/cfr/38/17.4000..17.4040.md) do not affect eligibility for non-VA care under sections [1724](/usc/38/1724.md), [1725](/usc/38/1725.md), [1725A](/usc/38/1725A.md), or [1728](/usc/38/1728.md) of title 38, United States Code.

# §17.4005. Definitions.


For purposes of the Veterans Community Care Program under [§§ 17.4000 through 17.4040](/cfr/38/17.4000..17.4040.md):

Appointment means an authorized and scheduled encounter, including telehealth and same-day encounters, with a health care provider for the delivery of hospital care, medical services, or extended care services.

Covered veteran means a veteran enrolled under the system of patient enrollment in [§ 17.36](/cfr/38/17.36.md), or a veteran who otherwise meets the criteria to receive care and services notwithstanding his or her failure to enroll in [§ 17.37(a) through (c)](/cfr/38/17.37.md?p=a..c).

Eligible entity or provider means a health care entity or provider that meets the requirements of [§ 17.4030](/cfr/38/17.4030.md).

Episode of care means a necessary course of treatment, including follow-up appointments and ancillary and specialty services, which lasts no longer than 1 calendar year.

Extended care services include the same services as described in [38 U.S.C. 1710B(a)](/usc/38/1710B.md?p=a).

Full-service VA medical facility means a VA medical facility that provides hospital care, emergency medical services, and surgical care and having a surgical complexity designation of at least “standard.”

Note 1 to the definition of “full-service VA medical facility”: VA maintains a website with a list of the facilities that have been designated with at least a surgical complexity of “standard,” which can be accessed on VA's website.

Hospital care has the same meaning as defined in [38 U.S.C. 1701(5)](/usc/38/1701.md?p=5).

Medical services have the same meaning as defined in [38 U.S.C. 1701(6)](/usc/38/1701.md?p=6).

Other health-care plan contract means an insurance policy or contract, medical or hospital service agreement, membership or subscription contract, or similar arrangement not administered by the Secretary of Veterans Affairs, under which health services for individuals are provided or the expenses of such services are paid; and does not include any such policy, contract, agreement, or similar arrangement pursuant to title XVIII or XIX of the Social Security Act ([42 U.S.C. 1395](/usc/42/1395.md) et seq.) or chapter 55 of title 10, United States Code.

Residence means a legal residence or personal domicile, even if such residence is seasonal. A covered veteran may maintain more than one residence but may only have one residence at a time. If a covered veteran lives in more than one location during a year, the covered veteran's residence is the residence or domicile where they are staying at the time they want to receive hospital care, medical services, or extended care services through the Veterans Community Care Program. A post office box or other non-residential point of delivery does not constitute a residence.

Schedule means identifying and confirming a date, time, location, and entity or health care provider for an appointment in advance of such appointment.

Note 1 to the definition of “schedule”: A VA telehealth encounter and a same-day care encounter are considered to be scheduled even if such an encounter is conducted on an ad hoc basis.

VA facility means a VA facility that offers hospital care, medical services, or extended care services.

VA medical service line means a specific medical service or set of services delivered in a VA facility.


# §17.4010. Veteran eligibility.


[Section 1703(d)](/usc/38/1703.md?p=d) of title 38, U.S.C., establishes the conditions under which, at the election of the veteran and subject to the availability of appropriations, VA must furnish care in the community through eligible entities and providers. VA has regulated these conditions under [paragraphs (a)(1) through (5)](#a-1..a-5) of this section. If VA determines that a covered veteran meets at least one or more of the conditions in [paragraph (a)](#a) of this section and has provided information required by paragraphs [(b)](#b) and [(c)](#c) of this section, the covered veteran may elect to receive authorized non-VA care under [§ 17.4020](/cfr/38/17.4020.md).

- (a) **The covered veteran requires hospital care, medical services, or extended care services and—**
  - (1) No VA facility offers the hospital care, medical services, or extended care services the veteran requires.
  - (2) **VA does not operate a full-service VA medical facility in the State in which the veteran resides.**
  - (3) The veteran was eligible to receive care and services from an eligible entity or provider under [section 101(b)(2)(B)](/cfr/38/101.md?p=b-2-B) of the Veterans Access, Choice, and Accountability Act of 2014 (Pub. L. 113-146, [sec. 101](/cfr/38/101.md), as amended; [38 U.S.C. 1701](/usc/38/1701.md) note) as of June 5, 2018, and continues to reside in a location that would qualify the veteran under that provision, and:
    - (i) Resides in Alaska, Montana, North Dakota, South Dakota, or Wyoming; or
    - (ii) Does not reside in one of the States described in [paragraph (a)(3)(i)](#a-3-i) of this section, but received care or services under [title 38](/cfr/38.md) U.S.C. between June 6, 2017, and June 6, 2018, and is seeking care before June 6, 2020.
  - (4) Has contacted an authorized VA official to request the care or services the veteran requires, but VA has determined it is not able to furnish such care or services in a manner that complies with designated access standards established in [§ 17.4040](/cfr/38/17.4040.md).
  - (5) The veteran and the veteran's referring clinician determine it is in the best medical interest of the veteran, for the purpose of achieving improved clinical outcomes, to access the care or services the veteran requires from an eligible entity or provider, based on one or more of the following factors, as applicable:
    - (i) The distance between the veteran and the facility or facilities that could provide the required care or services;
    - (ii) The nature of the care or services required by the veteran;
    - (iii) The frequency the veteran requires the care or services;
    - (iv) The timeliness of available appointments for the required care or services;
    - (v) The potential for improved continuity of care;
    - (vi) The quality of the care provided; or
    - (vii) Whether the veteran faces an unusual or excessive burden in accessing a VA facility based on consideration of the following:
      - (A) Excessive driving distance; geographical challenges, such as the presence of a body of water (including moving water and still water) or a geologic formation that cannot be crossed by road; or environmental factors, such as roads that are not accessible to the general public, traffic, or hazardous weather.
      - (B) **Whether care and services are available from a VA facility that is reasonably accessible.**
      - (C) **Whether a medical condition of the veteran affects the ability to travel.**
      - (D) Whether there is a compelling reason the veteran needs to receive care and services from a non-VA facility.
      - (E) The need for an attendant, which is defined as a person who provides required aid and/or physical assistance to the veteran, for a veteran to travel to a VA medical facility for hospital care or medical services.
  - (6) In accordance with [§ 17.4015](/cfr/38/17.4015.md), VA has determined that a VA medical service line that would furnish the care or services the veteran requires is not providing such care or services in a manner that complies with VA's standards for quality.
- (b) If the covered veteran changes his or her residence, the covered veteran must update VA about the change within 60 days.
- (c) A covered veteran must provide to VA information on any other health-care plan contract under which the veteran is covered prior to obtaining authorization for care and services the veteran requires. If the veteran changes such other health-care plan contract, the veteran must update VA about the change within 60 days.
- (d) **Review of veteran eligibility determinations.** The review of any decisions under [paragraph (a)](#a) of this section are subject to VA's clinical appeals process, and such decisions may not be appealed to the Board of Veterans' Appeals.

# §17.4015. Designated VA medical service lines.

- (a) VA may identify VA medical service lines that are underperforming based on the timeliness of care when compared with the same medical service line at other VA facilities and based on data related to two or more distinct and appropriate quality measures of VA's standards for quality when compared with non-VA medical service lines.
- (b) VA will make determinations regarding VA medical service lines under this section using data described in [paragraph (a)](#a) of this section, VA standards for quality, and based on factors identified in [paragraph (e)](#e) of this section.
- (c) VA will announce annually any VA medical service lines identified under [paragraph (a)](#a) of this section by publishing a document in the Federal Register. Such document will identify and describe the standards for quality VA used to inform the determination under [paragraph (a)](#a), as well as how the data described in [paragraph (a)](#a) and factors identified in [paragraph (e)](#e) of this section were used to make the determinations. Such document will also identify limitations, if any, concerning when and where covered veterans can receive qualifying care and services at their election in the community based on this section. Such limitations may include a defined timeframe, a defined geographic area, and a defined scope of services. VA will also take reasonable steps to provide direct notice to covered veterans affected under this section.
- (d) VA will identify no more than 3 VA medical services lines in a single VA facility under this section, and no more than 36 VA medical service lines nationally under this section.
- (e) In determining whether a VA medical service line should be identified under [paragraph (a)](#a) of this section, and to comply with [paragraph (c)](#c) of this section, VA will consider:
  - (1) Whether the differences between performance of individual VA medical service lines, and between performance of VA medical service lines and non-VA medical service lines, is clinically significant.
  - (2) **Likelihood and ease of remediation of the VA medical service line within a short timeframe.**
  - (3) **Recent trends concerning the VA medical service line or non-VA medical service line.**
  - (4) The number of covered veterans served by the medical service line or that could be affected by the designation.
  - (5) **The potential impact on patient outcomes.**
  - (6) **The effect that designating one VA medical service line would have on other VA medical service lines.**

# §17.4020. Authorized non-VA care.

- (a) **Electing non-VA care.** Except as provided for in [paragraph (d)](#d) of this section, a covered veteran eligible for the Veterans Community Care Program under [§ 17.4010](/cfr/38/17.4010.md) may choose to schedule an appointment with a VA health care provider, or have VA authorize the veteran to receive an episode of care for hospital care, medical services, or extended care services from an eligible entity or provider when VA determines such care or services are clinically necessary.
- (b) **Selecting an eligible entity or provider.** A covered veteran may specify a particular eligible entity or provider. If a covered veteran does not specify a particular eligible entity or provider, VA will refer the veteran to a specific eligible entity or provider.
- (c) **Authorizing emergency treatment.** This [paragraph (c)](#c) applies only to emergency treatment furnished to a covered veteran by an eligible entity or provider when such treatment was not the subject of an election by a veteran under [paragraph (a)](#a) of this section. This [paragraph (c)](#c) does not affect eligibility for, or create any new rules or conditions affecting, reimbursement for emergency treatment under section [1725](/usc/38/1725.md) or [1728](/usc/38/1728.md) of title 38, United States Code.
  - (1) Under the conditions set forth in this [paragraph (c)](#c), VA may authorize emergency treatment after it has been furnished to a covered veteran. For purposes of this [paragraph (c)](#c), “emergency treatment” has the meaning defined in [section 1725(f)(1)](/usc/38/1725.md?p=f-1) of title 38, United States Code.
  - (2) VA may only authorize emergency treatment under this [paragraph (c)](#c) if the covered veteran, someone acting on the covered veteran's behalf, or the eligible entity or provider notifies VA within 72-hours of such care or services being furnished and VA approves the furnishing of such care or services under [paragraph (c)(3)](#c-3) of this section.
  - (3) VA may approve emergency treatment of a covered veteran under this [paragraph (c)](#c) only if:
    - (i) **The veteran is receiving emergency treatment from an eligible entity or provider.**
    - (ii) The notice to VA complies with the provisions of [paragraph (c)(4)](#c-4) of this section and is submitted within 72 hours of the beginning of such treatment.
    - (iii) The emergency treatment only includes services covered by VA's medical benefits package in [§ 17.38](/cfr/38/17.38.md).
  - (4) **Notice to VA must—**
    - (i) Be made to the appropriate VA official at the nearest VA facility or by using the centralized notification process (information on the centralized notification process is accessible through VA's website at https://www.va.gov/resources/getting-emergency-care-at-non-va-facilities/ or successor website);
    - (ii) Identify the covered veteran; and
    - (iii) **Identify the eligible entity or provider.**
- (d) **Organ and bone marrow transplant care.**
  - (1) In the case of a covered veteran described in [paragraph (d)(3)](#d-3) of this section, the Secretary will determine whether to authorize an organ or bone marrow transplant for the covered veteran through an eligible entity or provider.
  - (2) The Secretary will make determinations under [paragraph (d)(1)](#d-1) of this section, and the primary care provider of the veteran will make determinations concerning whether there is a medically compelling reason to travel outside the region of the Organ Procurement and Transplantation Network in which the veteran resides to receive a transplant, in consideration of, but not limited to, the following factors:
    - (i) **Specific patient factors.**
    - (ii) Which facilities meet VA's standards for quality, including quality metrics and outcomes, for the required transplant.
    - (iii) The travel burden on covered veterans based upon their medical conditions and the geographic location of eligible transplant centers.
    - (iv) **The timeliness of transplant center evaluations and management.**
  - (3) This [paragraph (d)](#d) applies to covered veterans who meet one or more conditions of eligibility under [§ 17.4010(a)](/cfr/38/17.4010.md?p=a) and:
    - (i) Require an organ or bone marrow transplant as determined by VA based upon generally-accepted medical criteria; and
    - (ii) Have, in the opinion of the primary care provider of the veteran, a medically compelling reason, as determined in consideration of the factors described in [paragraph (d)(2)](#d-2) of this section, to travel outside the region of the Organ Procurement and Transplantation Network in which the veteran resides, to receive such transplant.

# §17.4025. Effect on other provisions.

- (a) **General.** No provision in this section may be construed to alter or modify any other provision of law establishing specific eligibility criteria for certain hospital care, medical services, or extended care services.
- (b) **Prescriptions.** Notwithstanding any other provision of this part, VA will:
  - (1) Pay for prescriptions no longer than 14 days written by eligible entities or providers for covered veterans, including over-the-counter drugs and medical and surgical supplies, available under the VA national formulary system to cover a course of treatment for an urgent or emergent condition.
  - (2) Fill prescriptions written by eligible entities or providers for covered veterans, including over-the-counter drugs and medical and surgical supplies, available under the VA national formulary system.
  - (3) Pay for prescriptions written by eligible entities or providers for covered veterans that have an immediate need for durable medical equipment and medical devices that are required for urgent or emergent conditions (e.g., splints, crutches, manual wheelchairs).
  - (4) Fill prescriptions written by eligible entities or providers for covered veterans for durable medical equipment and medical devices that are not required for urgent or emergent conditions.
- (c) **Copayments.** Covered veterans are liable for a VA copayment for care or services furnished under the Veterans Community Care Program, if required by § [17.108(b)(4)](/cfr/38/17.108.md?p=b-4) or [(c)(4)](/cfr/38/17.108.md?p=c-4), [§ 17.110(b)(4)](/cfr/38/17.110.md?p=b-4), or [§ 17.111(b)(3)](/cfr/38/17.111.md?p=b-3).

# §17.4030. Eligible entities and providers.


To be eligible to furnish care and services under the Veterans Community Care Program, entities or providers:

- (a) Must enter into a contract, agreement, or other arrangement to furnish care and services under the Veterans Community Care Program under [§§ 17.4000 through 17.4040](/cfr/38/17.4000..17.4040.md).
- (b) **Must either—**
  - (1) Not be a part of, or an employee of, VA; or
  - (2) If the provider is an employee of VA, not be acting within the scope of such employment while providing hospital care, medical services, or extended care services through the Veterans Community Care Program under [§§ 17.4000 through 17.4040](/cfr/38/17.4000..17.4040.md).
- (c) **Must be accessible to the covered veteran.** VA will determine accessibility by considering the following factors:
  - (1) The length of time the covered veteran would have to wait to receive hospital care, medical services, or extended care services from the entity or provider;
  - (2) The qualifications of the entity or provider to furnish the hospital care, medical services, or extended care services from the entity or provider; and
  - (3) **The distance between the covered veteran's residence and the entity or provider.**

# §17.4035. Payment rates.


The rates paid by VA for hospital care, medical services, or extended care services (hereafter referred to as “services”) furnished pursuant to a procurement contract or an agreement authorized by [§§ 17.4100 through 17.4135](/cfr/38/17.4100..17.4135.md) will be the rates set forth in the terms of such contract or agreement. Such payment rates will comply with the following parameters:

- (a) Except as otherwise provided in this section, payment rates will not exceed the applicable Medicare fee schedule (including but not limited to allowable rates under [42 U.S.C. 1395m](/usc/42/1395m.md)) or prospective payment system amount (hereafter “Medicare rate”), if any, for the period in which the service was provided (without any changes based on the subsequent development of information under Medicare authorities).
- (b) With respect to services furnished in a State with an All-Payer Model Agreement under section 1814(b)(3) of the Social Security Act ([42 U.S.C. 1395f(b)(3)](/usc/42/1395f.md?p=b-3)) that became effective on or after January 1, 2014, the Medicare payment rates under [paragraph (a)](#a) of this section will be calculated based on the payment rates under such agreement.
- (c) Payment rates for services furnished in a highly rural area may exceed the limitations set forth in paragraphs [(a)](#a) and [(b)](#b) of this section. The term “highly rural area” means an area located in a county that has fewer than seven individuals residing in that county per square mile.
- (d) Payment rates may deviate from the parameters set forth in [paragraphs (a) through (c)](#a..c) of this section when VA determines, based on patient needs, market analyses, health care provider qualifications, or other factors, that it is not practicable to limit payment for services to the rates available under [paragraphs (a) through (c)](#a..c).
- (e) Payment rates for services furnished in Alaska are not subject to [paragraphs (a) through (d)](#a..d) of this section and will be set forth in the terms of the procurement contract or agreement authorized by [§§ 17.4100 through 17.4135](/cfr/38/17.4100..17.4135.md), pursuant to which such services are furnished. If no payment rate is set forth in the terms of such a contract or agreement pursuant to which such services are furnished, payment rates for services furnished in Alaska will follow the Alaska Fee Schedule of the Department of Veterans Affairs.

# §17.4040. Designated access standards.

- (a) The following access standards have been designated to apply for purposes of eligibility determinations to access care in the community through the Veterans Community Care Program under [§ 17.4010(a)(4)](/cfr/38/17.4010.md?p=a-4).
  - (1) **Primary care, mental health care, and non-institutional extended care services.** VA cannot schedule an appointment for the covered veteran with a VA health care provider for the required care or service:
    - (i) Within 30 minutes average driving time of the veteran's residence; and
    - (ii) Within 20 days of the date of request unless a later date has been agreed to by the veteran in consultation with the VA health care provider.
  - (2) **Specialty care.** VA cannot schedule an appointment for the covered veteran with a VA health care provider for the required care or service:
    - (i) Within 60 minutes average driving time of the veteran's residence; and
    - (ii) Within 28 days of the date of request unless a later date has been agreed to by the veteran in consultation with the VA health care provider.
- (b) For purposes of calculating average driving time from the veteran's residence in [paragraph (a)](#a) of this section, VA will use geographic information system software.