Purchase Care Program

The Veterans Health Administration Office of Community Care (VHA OCC) operates two main service lines; Delivery Operations and Revenue Operations, that support medical care delivery and services for Veterans and their families. VHA OCC is also responsible for functions that support these service lines such as administration, planning, oversight and stakeholder relations. Delivery Operations manages all of the programs that allow Veterans and their family members to receive care and services through community providers outside of VA (i.e. Veterans Choice Program and traditional community care) and manages Veteran and family member programs that pay for care outside of VA (i.e. Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) and Foreign Medical Program (FMP)). Revenue Operations manages the centralized processes that allow VA to collect revenue from private health insurance carriers for non-service connected care provided to insured Veterans. Funds that are collected go back to VA medical facilities to provide health care services to Veterans. VHA OCC is mainly responsible for managing back-end revenue cycle processes that take place at the seven Consolidated Patient Account Centers (CPACs) located across the country. Other functions of VHA OCC support and strengthen the effectiveness of its business lines. These include strategy, policy and planning, budget, workforce management, performance improvement and oversight, data integration, communications and stakeholder relations. Taken together, VHA OCC works closely with Veterans and their families, community providers, and VA staff to ensure Veterans can get care from community providers when needed, administers VHA's beneficiary programs, and collects revenue from private health insurance carriers to provide additional financial support to VA medical facility operations.

What follows is not a comprehensive listing of eligibility requirements. For detailed eligibility requirements the USC and CFR's of each program should be consulted. For Veterans generally eligibility is established by evidence of service by DD Form 214 or through the Veterans Benefits Administration. Benefits provided are based on eligibility as established at 8 levels approved by the VHA Deputy Under Secretary for Health. For Non Veteran Beneficiaries eligibility is established by adjudication of the Sponsoring Veteran as Permanently and Totally disabled (P & T) (38 CFR 17.52(a)(1)(iii)) and that the Non Veteran Beneficiary is a dependant of the Veteran by the VBA and is eligible for Chapter 35 Benefits.

As stated above under Applicant Eligibility.

Military Discharge Certificate (DD Form 214), VBA Adjudication of disability rating for Veteran beneficiaries, VBA Adjudication of eligibility for Chapter 35 Benefits for Non Veteran Beneficiaries.

Uses generally cover medically necessary health care for eligible recipients. Restrictions are detailed in the underlying authority for each congressionally authorized program.

Once eligibility is established the benefit is available for the life of the Veteran Beneficiary. For Non Veteran Beneficiaries where eligibility is based on adjudication as a dependant the benefit is terminated if dependant status is not maintained. The full spectrum of benefits are immediately available upon adjudication of eligibility.

Awards are initiated and authorized from the VA Regional Office processing the benefits claim. All subsequent benefit administration refers to the VARO adjudication of eligibility or to the status of the Veteran or Non Veteran Beneficiary as established by the VBA.

Veterans initiate benefits eligibility claims through their serving VA Regional Office under the Veterans Benefits Administration. Where there is no disability claim involved the Veterans serving Veterans Administration Medical Center (VHA/VAMC) or Community Based Outreach Clinic (VHA/CBOC) establishes benefits eligibility through the VHA/CBO/Health Eligibility Center. Secondary validation of eligibility is performed for Non Veteran Beneficiary's by the administering Program Office.

There are no deadlines for award of eligibility. When adjudication of a disability establishes the disability at a date prior to the date of adjudication each program has in place mechanisms to provide retroactive benefits. For programs requiring additional adjudication beyond that of the VBA ~89% of all applications were approved within 30 days in FY09.

Appeals are available within each program beginning with local formal appeal, a second appeal process is provided by policy and upon adverse determination of a second appeal the final level of appeal is provided through the Board of Veterans Appeals.