§ 17.4010 - Veteran eligibility.
Section 1703(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) of this section. If VA determines that a covered veteran meets at least one or more of the conditions in paragraph (a) of this section and has provided information required by paragraphs (b) and (c) of this section, the covered veteran may elect to receive authorized non-VA care under § 17.4020.
(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) of the Veterans Access, Choice, and Accountability Act of 2014 (Pub. L. 113-146, sec. 101, as amended; 38 U.S.C. 1701 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) of this section, but received care or services under title 38 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.
(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, 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) of this section are subject to VA's clinical appeals process, and such decisions may not be appealed to the Board of Veterans' Appeals.