Veterans Community Care Program: Eligibility, Copays, and Authorization

To qualify for the Veterans Community Care Program, you need to be enrolled in VA health care and meet at least one access-related condition, such as living more than a 30-minute drive from the nearest VA primary care facility or being unable to get an appointment within 20 days.¹ Your costs are the standard VA copays: $0 for service-connected care, $15 for a primary care visit in 2026, and $50 for specialty care, with tiered urgent care copays based on your priority group.² The program was created by the VA MISSION Act of 2018 and pays outside providers directly, so a community visit should never produce a bill at checkout.

Who Qualifies for Community Care

Two things are required: enrollment in (or eligibility for) VA health care, and at least one qualifying condition.³ Meeting a single condition is enough. You don’t have to satisfy all of them.

Drive Time and Wait Time Standards

The most-used pathway is the access standards test. For primary care, mental health, and extended care, you qualify if the nearest VA facility offering that care is more than a 30-minute average drive from your home. For specialty care, the threshold is 60 minutes.⁴

Wait times work the same way. If the VA cannot schedule your appointment within 20 days for primary care, mental health, or extended care, or within 28 days for specialty care, you can choose a community provider instead.⁴ The clock runs from the date you request the appointment, not from a later scheduling call. If the VA offers you a date beyond the window, push back.

Other Ways to Qualify

Even if the drive-time and wait-time tests don’t apply, other pathways may:

The service you need is not available at any VA facility. Maternity care and in vitro fertilization are common examples.⁵
No full-service VA medical center operates in the state where you live.¹
You and your VA provider agree community care is in your best medical interest, considering factors like the complexity of your condition and the distance to a VA specialist.¹
The VA service line that would treat you is not meeting the VA’s own quality benchmarks.⁶

Community care covers the same medically necessary services available inside the VA system, including primary care, specialty care, mental health, rehabilitation, and certain dental services, plus services the VA does not itself provide.³ Cosmetic procedures, experimental treatments, and anything not deemed medically necessary are excluded.

If the VA Says You Don’t Qualify

An eligibility denial counts as a clinical determination, so you can appeal through the VA’s clinical appeal process. File a written appeal with the Patient Advocate at your VA medical facility. The facility must decide within three business days.⁷

If that first appeal is denied, escalate to the Veterans Integrated Service Network (VISN) level by writing to the VISN Patient Advocate Coordinator. That office also has three business days to resolve community care eligibility appeals, and the VISN decision is final.⁷ These timelines are much faster than standard VA appeals.

What Community Care Costs You

Community care carries the same copayment structure as care at a VA facility. Service-connected care is free. For non-service-connected care, your copay depends on your priority group and the type of visit.⁸

2026 Copay Rates

Outpatient copays for 2026 are $15 per primary care visit and $50 per specialty care visit or specialty test.² Urgent care copays are tiered by priority group and by how many urgent care visits you’ve had in the calendar year:

Priority groups 1 through 5: no copay for the first three visits each year, then $30 per visit.
Priority group 6: no copay if the visit relates to a condition covered by a special authority; otherwise $30 per visit.
Priority groups 7 and 8: $30 per visit from the first visit onward.²

There is no annual cap on urgent care visits. To use the urgent care benefit at all, you must have received VA care within the previous 24 months.

What the Provider Can and Cannot Charge You

Community providers bill the VA or its third-party administrator directly. They cannot collect payment from you at the time of service. Any copay you owe comes later through the VA’s billing system. If a community provider tries to charge you at checkout, you can decline and direct them to the VA billing process.⁶

For emergency care, an extra protection kicks in: once the VA pays a provider under the emergency treatment provisions, that payment extinguishes your liability for the covered treatment, and the provider cannot bill you for any remaining balance.⁹

Other Insurance and Travel

If you have private insurance or Medicare, the VA may coordinate with your other insurer for non-service-connected care at non-VA facilities. You won’t owe any unpaid balance that your other insurance declines to cover, though you may still owe the VA copay for non-service-connected care based on your priority group.¹⁰

The VA reimburses mileage for travel to authorized community care appointments at 41.5 cents per mile, calculated round-trip using the shortest route from your home to the provider.¹¹ The care must have been pre-approved.

Getting Authorized Before You Go

Every community care visit requires advance authorization from the VA. Urgent and emergency care are the exceptions. Your VA provider or care coordinator submits a consult, the VA reviews it and confirms your eligibility, and then issues an authorization with a specific reference number.¹²

That authorization number is the most important piece of paperwork in the process. Your community provider needs it before treating you, and it must appear on any claim submitted to the VA. Show up without a valid authorization number and the VA can refuse to pay, leaving you responsible for the full bill. Confirm both the authorization number and that your provider is in the VA’s network before the appointment.

You can search for network providers using the VA’s locator at va.gov/find-locations, or ask your VA care coordinator to identify one and help schedule the appointment.¹³ Seeing an out-of-network provider without specific authorization creates payment problems that are hard to fix after the fact.

Emergency Care Follows Different Rules

Emergencies do not wait for authorization, and the VA recognizes that. But the notification rules for emergency care are strict and separate from standard community care eligibility.

To have your emergency treated as authorized, the VA must be notified within 72 hours of your arrival at the emergency department. The hospital or you can report the visit through the VA’s Emergency Care Reporting portal or by calling 844-724-7842.¹⁴ Missing that window doesn’t automatically mean denial, but it shifts your claim into the more restrictive “unauthorized emergency care” category with additional requirements.¹⁵

Baseline requirements apply either way: you must be enrolled in VA health care, no VA or federal facility could have provided the care fast enough, and a reasonable person would have believed that delaying care could endanger your life or health. The care must have been provided in an actual emergency department, not an urgent care clinic.¹⁵

For claims that fall into the unauthorized category, the rules tighten. Coverage for a service-connected condition requires showing that the emergency involved that condition, that you have a permanent and total disability rating, or that you needed the care to return to a VA vocational rehabilitation program. For a non-service-connected condition, you must have received VA care within the previous 24 months, the visit must have been to a hospital emergency department, and you and the provider must have exhausted other insurance options first.¹⁵

One more limit: the VA only covers non-VA emergency care until you can be safely transferred to a VA or federal facility. If the VA can accept a transfer and the community hospital doesn’t coordinate it, continued treatment may not be covered.

Prescriptions From a Community Provider

How your prescription gets filled depends on whether it came out of urgent care or ongoing treatment.

After an urgent care visit, the VA covers up to a 14-day supply filled at an in-network community pharmacy. For opioids, the limit is a seven-day supply or the state prescribing limit, whichever is less.¹⁶ The pharmacy must be in the same state where you received urgent care. Anything longer than 14 days has to go to your VA facility’s pharmacy.

Routine and maintenance prescriptions from any community provider also go to the VA pharmacy, sent electronically, by fax, or as a hard copy. VA pharmacies fill up to a 90-day supply for most medications, though controlled substances may be limited to 30 days or less, and no prescription can exceed 12 months of total therapy including refills.¹⁷ If the medication isn’t on the VA formulary, your community provider will need to submit a non-formulary request through the VA’s Community Care representative.

Fixing a Bill You Shouldn’t Have Gotten

Billing errors are common because the process involves the VA, a third-party administrator, and the provider. If you get a bill directly from a community provider for authorized care, contact the VA right away. The provider should not be billing you.

For VA copay charges you believe are wrong, dispute them in writing within 30 days of receiving the bill to avoid late charges. If you file within 90 days of when the charges first appeared on your statement, the VA will pause collection action until the dispute is resolved.¹⁸ You can submit disputes online through Ask VA, by mail to your nearest VA medical center’s business office, or in person.

If a billing problem has already hit your credit, the VA runs an Adverse Credit Helpline at 877-881-7618 for VA health care bills. You can also work with a Veterans Service Organization for free help with billing disputes, or hire an attorney or VA-accredited agent.¹⁸

1
Office of the Law Revision Counsel. 38 USC 1703 – Veterans Community Care Program
2
Veterans Affairs. Current VA Health Care Copay Rates
3
Veterans Affairs. Eligibility for Community Care Outside VA
4
Federal Register. Update to Access Standards Drive Time Calculations
5
Federal Register. Veterans Community Care Program
6
eCFR. 38 CFR Part 17 – Veterans Community Care Program
7
Department of Veterans Affairs. Appeal of Veterans Health Administration Clinical Decisions
8
Veterans Affairs. Your Health Care Costs
9
eCFR. 38 CFR 17.1008 – Balance Billing Prohibited
10
Veterans Affairs. VA Health Care and Other Insurance
11
Veterans Affairs. Reimbursed VA Travel Expenses and Mileage Rate
12
Department of Veterans Affairs. File a Claim for Veteran Care – Information for Providers
13
VA News. VA MISSION Act: Finding a Community Provider, Making Appointments, and Getting Care
14
Department of Veterans Affairs. Centralized Community Emergency Treatment Reporting and Care Coordination
15
Veterans Affairs. Getting Emergency Care at Non-VA Facilities
16
Veterans Affairs. Getting Prescriptions and Vaccines at a Non-VA Pharmacy
17
Department of Veterans Affairs. Pharmacy Requirements – Information for Providers
18
Veterans Affairs. Dispute Your VA Copay Charges