CCN Next Gen - Eligibility_Enrollment Slides.pdf
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- Q503--CCN Next Gen - Dental Network
- Solicitation number
- 36C10G26R0004
About this file
This is an informational presentation document from the VHA Office of Integrated Veteran Care outlining community care eligibility criteria for the Veterans Health Administration as of February 2026.
Community care eligibility is governed by 38 USC 1703(d) and 38 CFR 17.4010 and requires that veterans meet four basic criteria: enrollment in VA or exemption from enrollment, a need for care or services, VA approval for community care, and satisfaction of one of six eligibility criteria. The six eligibility pathways are: (1) no VA facility offers the needed care; (2) VA lacks a facility in the veteran's residence location; (3) the veteran is grandfathered from the CHOICE Act; (4) VA cannot meet designated access standards for wait time and drive time; (5) the veteran and VA provider agree community care is in the veteran's best medical interest; and (6) VA does not meet internal quality standards for care. VA's designated access standards specify that primary care, mental health care, and non-institutional extended care services must be available within 20 days and 30-minute average drive time from the veteran's residence, while specialty care must be available within 28 days and 60-minute average drive time. VA must determine eligibility and confirm medical necessity and clinical appropriateness, though veterans may appeal denials through the Clinical Appeals process. Exceptions to eligibility determination requirements exist for in-network urgent care, emergency care, acute suicidal crises under the COMPACT Act, and potential future legislative changes. Veterans retain the option to receive care at VA medical facilities regardless of community care eligibility and may select specific in-network community providers or defer provider selection to VA.
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Text version
Community Care Eligibility
February 2026
VHA Office of Integrated Veteran Care
Basic Eligibility Requirements
Community care eligibility requirements are established in law and defined in VA regulation: 38 USC 1703(d) and 38 CFR 17.4010.
Veteran must be enrolled – or exempt from enrollment
Veteran requires care or services.
Must receive VA approval for community care
Meet one of the following six eligibility criteria
Eligibility Criteria
Eligibility Criteria
No VA facility offers the care needed
VA doesn’t have a facility where the Veteran resides
Veteran is grandfathered from CHOICE Act
Eligibility Criteria
Eligibility Criteria contd.
VA can’t meet wait time and drive time standards
Veteran and VA provider agree it’s in their Best Medical Interest to use community care
VA doesn’t meet internal quality standards for care
VA’s Designated Access Standards
Primary Care, Mental Health Care, and Non-Institutional Extended Care Services Appointment available within 20 days Appointment available within a 30-minute average drive time from the Veteran’s listed residence
Specialty Care
Appointment available within 28 days Appointment available within a 60-minute average drive time from the Veteran’s listed residence
If VA cannot offer an appointment that meets both the wait time and drive time standards, the Veteran would be community care eligible.
Note, we don’t count telehealth availability toward meeting the designated access standards.
Notes About Community Care Eligibility
VA must determine eligibility and ensure that care is medically necessary and clinically appropriate.
Veterans may appeal denials via the Clinical Appeals process.
Veterans are required to update VA regarding changes in residential address and must provide VA information on other health-care plan coverage.
Eligibility is defined in law; VA must offer a community care option if eligibility criteria is met.
Veterans will usually have the option to receive care at a VA medical facility regardless of community care eligibility.
A Veteran may elect to select a specific in-network community provider, or defer the choice to the VA.
Exceptions
An eligibility determination or prior authorization is not needed in certain circumstances:
In-Network Urgent Care Emergency Care
Acute Suicidal Crisis (COMPACT Act)
Potential future changes with legislation
Eligibility
Thank you
| Community Care Eligibility |
| Basic Eligibility Requirements |
| Eligibility Criteria |
| Eligibility Criteria |
| VA’s Designated Access Standards |
| Notes About Community Care Eligibility |
| Exceptions |
| Eligibility |
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