If you’ve used the Department of Veterans Affairs (VA) healthcare benefit for any length of time, you know the health system has come a long way toward being more responsive to veteran needs. More flexible and timely scheduling options, increases in telehealth appointments, and the introduction of community care are just some of the services that have been implemented in recent years. Not long ago, the VA added another option: urgent care.
This benefit was added with the passage of the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 or MISSION Act, which went into effect in June of 2019. The act included provisions for VA’s suicide prevention efforts, prosthetic research, overhauling the VA’s electronic health records system, expanding assistance for caregivers, and other improvements. Additionally, the MISSION ACT replaces the previous VA Choice Program in defining VA’s Community Care program.
Recently, I had the opportunity to try out the new VA urgent care benefit. While there were some bumps in the process, here’s my overall impression:
-The benefit is fairly simple to use—though veterans should be aware of the rules to avoid significant fees
-Unlike some past benefits, the criteria and process for using the benefit is straightforward
-VA, as required by law, has put together useful materials that help veterans understand how to navigate the benefit
-Exploring the urgent care requirements and process online before you need to use it is recommended
If you find yourself in need of urgent care under the VA MISSION Act, here are the steps in the process, the misinformation I was given during the process, and where to find more information online.
Step 1: Confirm Eligibility for the Benefit
The first step in the process is to confirm your eligibility for the VA urgent care benefit.
I was originally told:
I needed to call the referral line before I could use urgent care.
This is incorrect—that’s only required for non-urgent community care visits.
Instead, the first step in the VA urgent care process is:
To confirm that you are eligible to receive care under the VA MISSION ACT.
Unlike most VA situations, these eligibility requirements are surprisingly simple.
You must be enrolled in VA healthcare. (If you’re not, you can enroll here.)
You must have used VA healthcare within the past 24 months.
You can call your local VA facility or 844-MyVA311 (844-698-2311) to confirm your eligibility. (Even though I use VA frequently, I still called to confirm my eligibility to be on the safe side.)
Ultimately, it’s up to VA to decide what constitutes urgent care but they generally define it as “minor injuries and illnesses that are not life-threatening.”
Also, be sure you are going for a true urgent need. Ultimately, it’s up to VA to decide what constitutes urgent care but they generally define it as “minor injuries and illnesses that are not life-threatening.” Examples they give include pink eye and strep throat (I went for a sinus infection, as my clinic isn’t making those type of appointments, especially with the COVID-related restrictions). Preventive care is not covered—those appointments should be made through your primary care doc—and emergency dental services are also not covered. You can find more details on eligibility, covered services, and FAQs in the Department of Veterans Affairs’ community care factsheet.
If you’re not sure, or you’d rather try to be seen at VA, you can try their same day services.
Step 2: Locate a VA-approved Facility
Locating a VA-approved urgent care facility was one area where I got good information about the process—mostly.
My VA facility gave me a number to call to locate a VA-approved urgent care provider.
They were able to provide me options based on my zip code. However, the first option they gave me wasn’t in the best part of town, so I asked for other options. They complied and gave me five more options before I was satisfied with my choices.
They also gave me a website where I could check approved locations.
Here’s what else you need to know about finding a VA-approved provider:
VA will only approve the care if you use a VA-approved provider.
The VA urgent care program is broken down into 6 regions, with 1-3 being the eastern portion and 4-6 being the western portion. The eastern and western portions have different numbers to call for locating an approved facility (see VA Region Map below).
The eastern and western portion also have different insurance providers—East is Optum and West is TriWest. (The eastern (1-3) regions switched insurance providers on 1 Sep 2020.) This means the approved urgent care locations in those regions may have changed as well. If you previously used urgent care in one of these regions and need to use it again, be sure to confirm that your chosen urgent care location is still on the approved list.
Step 3: Checking in at the VA-approved Facility
Unfortunately, I wasn’t given any information about what I needed to provide to check-in at the VA-approved facility. However, I was given the fax number to my local VA facility and told to provide it to the urgent care center so they could release my records to my VA primary care provider. I ended up showing them my VA ID card and told them VA was my insurer and that was sufficient.
Here’s what VA says you need to do when you check in:
Tell them you are using your VA urgent care benefit
Provide them a government-issued ID
Confirm they are a contracted provider
There may be costs associated with your visit. What to know about the costs veterans may incur when using the VA urgent care benefit:
You won’t have to pay anything at the urgent care facility; VA will send you a bill for anything you owe.
Copays vary depending on your VA priority group, what you are being seen for, and how many urgent care visits you have in a calendar year. Here’s a VA graphic that shows the breakout.
Note that you don’t have a co-pay if the only reason you are using one of these providers is to get your annual flu shot.
Don’t forget to contact your local VA facility for the fax number to release your records, so that any notes from your visit make it into your VA file.
VA has created a handy assistance card for both veterans and providers that explains the basic process of using urgent care and provides websites and phone numbers for getting assistance if you get stuck along the way. Given my experiences with misinformation along the way, I highly recommend you print the assistance cards for your region (both veteran and provider) and store them in your car or purse/wallet, so you have them handy should you need them. You can download the cards for your region here.
Step 4: Filling VA Urgent Care Prescriptions
I was told conflicting information regarding getting and filling prescriptions written by the VA-approved urgent care provider.
First, I was told to ask about a VA formulary, because that would let the provider know I was using VA pharmacy benefits.
Then I was told I needed to tell the provider to “activate” my pharmacy benefits by calling one of two numbers, the VA pharmacy or an automatic recording number.
The provider then argued with me and said he didn’t need to do either (I finally convinced him to call, just in case).
Finally, I was given a prescription and opted to take it to a VA-approved pharmacy, only to be told by the pharmacist that my VA ID card was “worthless” to him and he couldn’t fill my prescription.
Another pharmacist finally told him they could fill it, but only 7 days-worth.
So, what’s the truth about VA urgent care pharmacy benefits?
VA can pay for up to 14-day worth of medication, with the exception of opiates, which are limited to up to 7-days-worth, as stipulated by state law.
Urgent care prescriptions can be filled:
- At a VA pharmacy (copay may apply),
- An in-network pharmacy (copay may apply), or
- At an out-of-network pharmacy (at the veteran’s expense and the veteran can then file a claim to be reimbursed).
They must be filled in the same state as the facility that wrote the prescription.
All prescriptions must adhere to VA’s Urgent/Emergent Formulary list.
Step 5: Follow-up with Your VA Primary Care Provider
Once I’d completed my visit, I followed up with my VA primary care provider. Which turned out to be a good thing, because I’d forgotten to sign the release at the urgent care clinic and she wasn’t aware of my visit! Also, because she was familiar with my file (I have an awesome VA care provider who reads my file in-depth before our visits), she wanted to supplement what the urgent care provider had done and add additional tracking measures to be sure the medications weren’t interfering with my chronic health conditions.
Here are other reasons you should follow up with your VA provider after your urgent care visit:
Any follow-up care has to be completed in a VA clinic or using an updated VA community care referral to a VA-approved provider—meaning, you can’t just keep going to urgent care for the same condition or VA won’t pay for it.
To ensure prescribed medication doesn’t conflict with any of your other medications (even though that should already be the case, mistakes can happen!)
In case your medical records don’t make it into the VA system and what happened at urgent care impacts your long-term care in any way.
VA Urgent Care Benefit is Easy to Use, If You Follow the Rules
As VA processes go, using the VA urgent care program under the MISSION Act is relatively easy, as long as you follow the rules. Also, VA has done extensive work to put together materials that explain the process every step of the way and I highly recommend looking through them before you need the service so that, if you run into any of the issues I did, you know what to do next.
You can start your own research on their urgent care page. Or on their MISSION ACT page.
© 2020, Sarah Maples LLC. All rights reserved.
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