115-26 , P.L. 115-46 , P.L. 115-96 , and P.L. 115-182 . Table 1 provides major highlights pertaining to the Veterans Choice Program (VCP)―a new, temporary program authorized by Section 101 of the VACAA that allows eligible veterans to receive medical care in the community. Section 101 of this act established a new permanent Veterans Community Care Program (VCCP) that would replace VCP. (The MISSION Act of 2018 stipulates that VCCP must be effective when the VA determines that 75% of the amounts deposited in the Veterans Choice Fund [VCF] have been exhausted, or when regulations are published by the VA, which is no later than one year after the date of enactment of the VA MISSION Act—June 6, 2019.) This report does not discuss the new VCCP program established by Section 101 of the VA MISSION Act of 2018. Veterans may become eligible for care under the VCP through one of four different pathways:
30-d ay w ait l ist (Wait-Time Eligible) : A veteran is eligible for care through the VCP when he or she is informed, by a local VA medical facility, that an appointment cannot be scheduled within 30 days of the clinically determined date of when the veteran's provider determines that he or she needs to be seen (this category also includes care not offered at the veteran's primary VA medical facility and a referral cannot be made to another VA medical facility or federal facility), or within 30 days of the date of when the veteran wishes to be seen. 40 miles or m ore d i stance (Mileage Eligible) : A veteran is eligible for care through the VCP when he or she lives 40 miles or more from a VA medical facility that has a full-time primary care physician. 40 m iles or l ess d istance (Mileage Eligible) : A veteran is eligible for care through the VCP when he or she resides in a location, other than one in Guam, American Samoa, or the Republic of the Philippines, and travels by air, boat, or ferry in order to seek care from his or her local VA facility; or incurs a traveling burden based on environmental factors, geographic challenges, or a medical condition. State or t erritory without a f ull- s ervice VA medical f acility: A veteran is eligible for care through the VCP when his or her residence is more than 20 miles from a VA medical facility and located in either Alaska, Hawaii, New Hampshire (excluding veterans who live 20 miles from the White River Junction VAMC), or U.S. territory (excluding Puerto Rico). VCP Providers

Under the VCP, several entities and providers are eligible to provide care and services. These include, among others, federally qualified health centers, Department of Defense (DOD) medical facilities, Indian Health Service outpatient health facilities or facilities operated by a tribe or tribal organization, hospitals, physicians, and nonphysician practitioners or entities participating in the Medicare or Medicaid program, an Aging and Disability Resource Center, an area agency on aging, or a state agency or a center for independent living. Third-Party Administrators (TPAs)

In September 2013, the VA awarded contracts to Health Net and TriWest to expand veterans' access to non-VA health care in the communities, under the Patient-Centered Community Care (PC3) initiative. Later, in November 2014, the VA modified those contracts to include support services under the Veterans Access, Choice, and Accountability Act of 2014 (VACAA, or the Choice Act). Under the Veterans Choice Program (VCP), Health Net and TriWest manage the appointments, counseling services, card distributions, and a call center. End of Contract with Health Net

In March 2018, the VA announced that the VCP contract with Health Net would end by September 30, 2018. Low volume of patients, customer service issues, and delayed payments to community providers were potentially some of the reasons for this decision. The contract with TriWest would continue. Second, a veteran may request a VA community care consult/referral (from his or her VA provider or local VA staff) in order to receive a medical service that is also timely. For urgent VA community care consults/referrals, VA providers are to coordinate the veteran's care directly with the VA Community Care Coordination staff. For nonservice-connected conditions, veterans may also be reimbursed for their out-of-pocket expenses, including those with other health insurance plans. The VA reimburses the TPAs for the care veterans obtain through the VCP, and the TPA then reimburses the community care providers in their networks. Since 2016, the VA has processed payments to the TPA on an aggregated basis known as "bulk payments." When veterans receive care at a VA facility, they do not pay copayments at the time of their medical appointments; copayment rates are determined by the VA after services are furnished—based on if the care was for a service-connected or nonservice-connected condition. Therefore, veterans' out-of-pocket costs under the VCP are the same as if they were receiving care and services from a VA provider in a VA facility—if a veteran does not pay any copayments at VA health care facilities, the veteran will not have to pay any copayments under the VCP. 115-26 , which amended P.L. This change went into effect on April 19, 2017. The VA would coordinate with a veteran's OHI and recover any costs, and bill the veteran for any copayments that the veteran would be responsible for similar to what they would have paid had they received care within a VA medical facility (see Figure 3 ).
Authorized under Section 101 of the Veterans Access, Choice, and Accountability Act of 2014 (VACAA), the Veterans Choice Program (VCP) is a temporary program that enables eligible veterans to receive medical care in the community. Since the program was first established by VACAA, it has been amended and funded several times. More recently, P.L. 115-26 eliminated the August 7, 2017, expiration date for the VCP and allowed the program to continue until the initial $10 billion deposited in the Veterans Choice Fund (VCF) was expended. P.L. 115-46 authorized and appropriated an additional $2.1 billion to continue the VCP until funds were expended, and when these funds were also nearing their end, Division D of P.L. 115-96 appropriated an additional $2.1 billion to continue the VCP until funds were expended. Lastly, Section 510 of the VA MISSION Act (P.L. 115-182), signed into law on June 6, 2018, authorized and appropriated $5.2 billion for VCP without fiscal year limitation, and Section 143 of this same act imposed a sunset date that is one year after the date of enactment (June 6, 2018) of the VA MISSION Act (i.e., June 6, 2019). Title 101 of the VA MISSION Act also authorized a permanent program known as the Veterans Community Care Program (VCCP), which is to replace VCP when VCCP is established by the Department of Veterans Affairs (VA) around June 2019 (when regulations are published by the VA no later than one year after the date of enactment [June 6, 2018] of the VA MISSION Act; that is, June 6, 2019, or when the VA determines that 75% of the amounts deposited in the VCF have been exhausted).
Eligibility and Choice of Care
Veterans must be enrolled in the VA health care system to request health services under the VCP. A veteran may request a VA community care consult/referral, or his or her VA provider may submit a VA community care consult/referral to the VA Care Coordination staff within the VA.
Veterans may become eligible for the VCP in one of four ways. First, a veteran is informed by a local VA medical facility that an appointment cannot be scheduled within 30 days of the clinically determined date requested by his or her VA doctor or within 30 days of the date requested by the veteran (this category also includes care not offered at a veteran's primary VA facility and a referral cannot be made to another VA medical facility or other federal facility). Second, the veteran lives 40 miles or more from a VA medical facility that has a full-time primary care physician. Third, the veteran lives 40 miles or less (not residing in Guam, America Samoa, or the Republic of the Philippines) and either travels by air, boat, or ferry to seek care from his or her local facility or incurs a traveling burden of a medical condition, geographic challenge, or an environmental factor. Fourth, the veteran resides 20 miles or more from a VA medical facility located in Alaska, Hawaii, New Hampshire (excluding those who live 20 miles from the White River Junction VAMC), or a U.S. territory, with the exception of Puerto Rico.
Once found eligible for care through the VCP, veterans may choose to receive care from a VA provider or from an eligible VA community care provider (VCP provider). VCP providers are federally qualified health centers, Department of Defense (DOD) facilities, or Indian Health Service facilities, and hospitals, physicians, and nonphysician practitioners or entities participating in the Medicare or Medicaid program, among others. A veteran has the choice to switch between a VA provider and VCP provider at any time.
Program Administration and Provider Participation
The VCP was administered by two third-party administrators (TPAs): Health Net and TriWest. At the end of September 2018, the VA has announced that it would end its contract with Health Net as a TPA because of low patient volume, customer service issues, and late payments to community providers in its network. TriWest would continue to be a TPA for the areas they manage. Generally, a TPA manages veterans' appointments, counseling services, card distributions, and a call center. The TPA contracts directly with the VA. Then, the TPA contracts with eligible non-VA community care providers interested in participating in the VCP.
Payments
Generally, a veteran's out-of-pocket costs under the VCP are equal to VHA out-of-pocket costs. Veterans do not pay any copayments at the time of their medical appointments. Copayment rates are determined by the VA after services are furnished. Enactment of P.L. 115-26 on April 19, 2017, allowed VA to become the primary payer when certain veterans with other health insurance (OHI) receive care for nonservice-connected conditions under VCP—veterans would not have to pay a copayment under their OHI anymore. The VA would coordinate with a veteran's OHI and bill for any copayments that the veteran would be responsible for similar to what they would have paid had they received care within a VA medical facility. Participating community providers are reimbursed by their respective TPA, and VA pays the TPAs on an aggregated basis, known as bulk payments.