§17.4600. Urgent care.
38 C.F.R. § 17.4600
Purpose. The purpose of this section is to establish procedures for accessing urgent care. Eligible veterans may obtain urgent care, in accordance with the requirements and processes set forth in this section, from qualifying non-VA entities or providers in VA's network that are identified by VA in accordance with paragraph (c)(2) of this section.
Definitions. The following definitions apply to this section.
Eligible veteran means a veteran described in 38 U.S.C. 1725A(b).
Episodic care means care or services provided in a single visit to an eligible veteran for a particular health condition, or a limited set of particular health conditions, without an ongoing relationship being established between the eligible veteran and qualifying non-VA entities or providers.
Longitudinal management of conditions means outpatient care that addresses important disease prevention and treatment goals and is dependent upon bidirectional communications that are ongoing over an extended period of time. For purposes of this section, the term “longitudinal management of conditions” and “longitudinal care” are synonymous.
Qualifying non-VA entity or provider means a non-VA entity or provider, including Federally-qualified health centers as defined in 42 U.S.C. 1396d(l)(2)(B), that has entered into a contract, agreement, or other arrangement with the Secretary to furnish urgent care under this section, or has entered into an agreement with a third-party administrator with whom VA has a contract to furnish such care.
Urgent care means services provided by a qualifying non-VA entity or provider, and as further defined in paragraphs (b)(5)(i) through (iv) of this section.
Urgent care includes service available from entities or providers submitting claims for payment as a walk-in retail health clinic (Centers for Medicare and Medicaid Services (CMS) Place of Service code 17) or urgent care facility (CMS Place of Service code 20);
Except as provided in paragraph (b)(5)(ii)(B) or (b)(5)(iv) of this section, urgent care does not include preventive health services, as defined in section 1701(9) of title 38, United States Code, dental care, or chronic disease management.
Urgent care includes immunization against influenza (flu shots), as well as therapeutic vaccines that are necessary in the course of treatment of an otherwise included service and screenings related to the treatment of symptoms associated with an immediate illness or exposure.
Urgent care may only be furnished as episodic care for eligible veterans needing immediate non-emergent medical attention, and it does not include longitudinal care. Veterans requiring follow-up care as a result of an urgent care visit under this section must contact VA or their VA-authorized primary care provider to arrange such care.
If VA determines that the provision of additional services is in the interest of eligible veterans, based upon identified health needs, VA may offer such additional services under this section as VA determines appropriate. Such services may be limited in duration and location. VA will inform the public through a Federal Register document, published as soon as practicable, and other communications, as appropriate.
Procedures.
Eligible veterans may receive urgent care under this section without prior approval from VA.
Eligible veterans must declare at each episode of care if they are using this benefit prior to receiving urgent care under this section.
VA will publish a website providing information on urgent care, including the names, locations, and contact information for qualifying non-VA entities or providers from which urgent care is available under this section.
In general, eligibility under this section does not affect eligibility for hospital care or medical services under the medical benefits package, as defined in § 17.38, or other benefits addressed in this title. Nothing in this section waives the eligibility requirements established in other statutes or regulations.
Urgent care furnished under this section must meet VA's standards for quality established under 38 U.S.C. 1703C, as applicable.
Copayment.
Except as provided in paragraphs (d)(2) through (4) of this section, an eligible veteran, as a condition for receiving urgent care provided by VA under this section, must agree to pay VA (and is obligated to pay VA) a copayment of $30:
After three visits in a calendar year if such eligible veteran is enrolled under § 17.36(b)(1) through (6), except those veterans described in § 17.36(d)(3)(iii) for all matters not covered by priority category 6.
If such eligible veteran is enrolled under § 17.36(b)(7) or (8), including veterans described in § 17.36(d)(3)(iii).
An eligible veteran who receives urgent care under paragraph (b)(5)(iv) of this section or urgent care consisting solely of an immunization against influenza (flu shot) is not subject to a copayment under paragraph (d)(1) of this section and such a visit shall not count as a visit for purposes of paragraph (d)(1)(i) of this section.
If an eligible veteran would be required to pay more than one copayment under this section, or a copayment under this section and a copayment under § 17.108 or § 17.111, on the same day, the eligible veteran will only be charged the higher copayment.
If an eligible veteran meets the definition of Indian or urban Indian, as defined in 25 U.S.C. 1603(13) and (28), they are exempt from copayments for all urgent care visits. To demonstrate that they meet the definition of Indian or urban Indian, the veteran must submit to VA any of the documentation described in paragraphs (d)(4)(i)(A) through (F) of this section:
Documentation issued by a federally recognized Indian Tribe that shows that the veteran is a member of the Tribe;
Documentation showing that the veteran, irrespective of whether they live on or near a reservation, is a member of a Tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member;
Documentation showing that the veteran is an Eskimo or Aleut or other Alaska Native;
Documentation issued by the Department of Interior (DOI) showing that the veteran is considered by DOI to be an Indian for any purpose;
Documentation showing that the veteran is considered by the Department of Health and Human Services (HHS) to be an Indian under that Department's regulations; or
Documentation showing that the veteran resides in an urban center and meets one or more of the following criteria:
(1) Irrespective of whether they live on or near a reservation, is a member of a Tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member;
(2) Is an Eskimo or Aleut or other Alaska Native;
(3) Is considered by DOI to be an Indian for any purpose; or
(4) Is considered by HHS to be an Indian under that Department's regulations.
After VA determines the submitted documentation meets paragraph (d)(4)(i) of this section and updates the veteran's record to reflect the veteran's status as an Indian or urban Indian, VA will reimburse eligible veterans exempt under paragraph (d)(4)(i) for any copayments that were paid to VA for urgent care visits provided on or after January 5, 2022, if they would have been exempt from making such copayments if paragraph (d)(4)(i) had been in effect.
Prescriptions. Notwithstanding any other provision of this part, VA will:
Pay for prescriptions written by qualifying non-VA entities or providers for eligible 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 urgent care no longer than 14 days.
Fill prescriptions for urgent care written by qualifying non-VA entities or providers for eligible veterans, including over-the-counter drugs and medical and surgical supplies, available under the VA national formulary system.
Pay for prescriptions written by qualifying non-VA entities or providers for eligible veterans that have an immediate need for durable medical equipment and medical devices that are required for urgent conditions (e.g., splints, crutches, manual wheelchairs).
Payments. Payments made for urgent care constitute payment in full and shall extinguish the veteran's liability to the qualifying non-VA entity or provider. The qualifying non-VA entity or provider may not impose any additional charge on a veteran or his or her health care insurer for any urgent care service for which payment is made by VA. This section does not abrogate VA's right, under 38 U.S.C. 1729, to recover or collect from a third party the reasonable charges of the care or services provided under this section.
Notes, amendments, and revision history
Amendments
[84 FR 26018, June 5, 2019, as amended at 88 FR 13034, Mar. 2, 2023; 88 FR 19873, Apr. 4, 2023; 88 FR 21478, Apr. 11, 2023]
Source
Source: Sections 17.4100 through 17.4135 appear at 84 FR 21678, May 14, 2019, unless otherwise noted.
Authority
Authority: 38 U.S.C. 501, and as noted in specific sections. Section 17.30 also issued under 38 U.S.C. 1701. Section 17.32 also issued under 38 U.S.C. 7331-7334. Section 17.35 is also issued under 38 U.S.C. 1724. Section 17.37 is also issued under 38 U.S.C. 101, 1701, 1705, 1710, 1720J, 1721, 1722. Section 17.38 is also issued under 38 U.S.C. 1701 and 1703. Section 17.43 also issued under 38 U.S.C. 109, 1784, 8111, and 8153. Section 17.44 also issued under E.O. 10122, 15 FR 2173, 3 CFR, 1949-1953 Comp., p. 313, E.O. 10400, 17 FR 8648, 3 CFR, 1949-1953 Comp., p. 900, and E.O. 11733, 38 FR 20431, 3 CFR, 1971-1975 Comp., p. 792. Section 17.46 is also issued under 38 U.S.C. 1710. Section 17.47 is also issued under 38 U.S.C. 1701, 1710, 1721, 1722, 1729, 3104(a)(9), 7333, Pub. L. 99-272; 42 U.S.C. 1396 et seq. Section 17.52 is also issued under 38 U.S.C. 1701, 1703, 1710, 1712, and 3104. Section 17.55 is also issued under 38 U.S.C. 513, 1703, and 1728. Section 17.56 is also issued under 38 U.S.C. 1703 and 1728. Sections 17.61 through 17.74 are also issued under 38 U.S.C. 1730. Section 17.86 also issued under 38 U.S.C. 1785. Section 17.101 is also issued under 38 U.S.C. 101, 1701, 1705, 1710, 1721, 1722, 1729. Section 17.102 also issued under 38 U.S.C. 109, 1711, 1729, 1784, 1784A, 1785, 8111, 8153. Section 17.105 is also issued under 38 U.S.C. 501, 1721, 1722A, 1724, and 1725A. Section 17.108 is also issued under 38 U.S.C. 501, 1703, 1710, 1725A, 1720J, and 1730A. Section 17.110 is also issued under 38 U.S.C. 501, 1703, 1710, 1720D, 1720J, 1722A, and 1730A. Section 17.111 is also issued under 38 U.S.C. 101(28), 501, 1701(7), 1703, 1710, 1710B, 1720B, 1720D, 1722A, and 1730A. Section 17.125 is also issued under 38 U.S.C. 7304. Sections 17.156 and 17.157 are also issued under 38 U.S.C. 3901 and 3902. Section 17.158 is also issued under 38 U.S.C. 3902 and 3903. Section 17.169 is also issued under 38 U.S.C. 1712C. Sections 17.243 through 17.248 are also issued under 38 U.S.C. 7302 note. Sections 17.270, and 17.272 through 17.277 are also issued under 38 U.S.C. 1781. Section 17.271 is also issued under 38 U.S.C. 1720G(a)(7)(A) and 1781. Section 17.278 is also issued under 38 U.S.C. 1781 and 42 U.S.C. 2651. Section 17.279 is also issued under 5 U.S.C. 552 and 552a; 38 U.S.C. 1781, 5701, and 7332. Sections 17.380, 17.390 and 17.412 are also issued under sec. 260, Pub. L. 114-223, 130 Stat. 857, and sec. 236, Public Law 115-141, 132 Stat. 348, and sec. 236, div. J, Pub. L 115-141, 132 Stat. 348. Section 17.395 is also issued under 38 U.S.C. 1788. Section 17.410 is also issued under 38 U.S.C. 1787. Section 17.415 is also issued under 38 U.S.C. 7301, 7304, 7402, and 7403. Section 17.417 also issued under 38 U.S.C. 1701 (note), 1709A, 1712A (note), 1722B, 1730C, 7301, 7306, 7330A, 7331, 7401-7403, 7405, 7406, 7408. Section 17.419 also issued under 38 U.S.C. 1701 (note), 7301, 7306, 7330A, 7401-7403, 7405, 7406, 7408). Section 17.450 is also issued under 38 U.S.C. 1703E. Sections 17.525 through 17.531 are also issued under 38 U.S.C. 7691 through 7697. Sections 17.545 through 17.553 are also issued under 38 U.S.C. 7698, 7699, 7699A, and 7699B. Sections 17.600 through 17.612 are also issued under 38 U.S.C. 7601-7619, 7633, 7634, 7636, and sec. 104(a), div. V, Public Law 117-328. Sections 17.613 through 17.618 are also issued under Pub. L. 115-182, sec. 304. Sections 17.640 and 17.647 are also issued under sec. 4, Pub. L. 114-2, 129 Stat. 30. Sections 17.641 through 17.646 are also issued under 38 U.S.C. 501(a) and sec. 4, Pub. L. 114-2, 129 Stat. 30. Section 17.655 also issued under 38 U.S.C. 501(a), 7304, 7405. Sections 17.1200 through 17.1230 are also issued under 38 U.S.C. 1720J. Section 17.3200 also issued under 38 U.S.C. 1162, 1701, 1707, 1710, 1714, 1717, 3901. Section 17.3210 also issued under 38 U.S.C. 1701, 1710. Section 17.3220 also issued under 38 U.S.C. 1701(6)(F), 1710. Section 17.3230 also issued under 38 U.S.C. 1701(6)(F), 1710, 1714(a). Section 17.3250 also issued under 38 U.S.C. 1701, 1710, 1725, 1728. Section 17.3500 is also issued under Pub. L. 102-139 sec. 101. Sections 17.4000 through 17.4040 also issued under 38 U.S.C. 1703, 1703B, and 1703C. Section 17.4100 et seq. is also issued under 38 U.S.C. 1703A. Section 17.4600 is also issued under 38 U.S.C. 1725A and 1730A.
Amendments
[84 FR 26018, June 5, 2019, as amended at 88 FR 13034, Mar. 2, 2023; 88 FR 19873, Apr. 4, 2023; 88 FR 21478, Apr. 11, 2023]