Am I eligible for emergency care at a non-VA facility?
An eligible Veteran may receive emergency care at a non-VA health care facility at VA expense when a VA facility or other Federal health care facility with which VA has an agreement is unable to furnish economical care due to the Veteran’s geographical inaccessibility to a VA medical facility, or when VA is unable to furnish the needed emergency services.
Are there any payment limitations for non-VA emergency care?
Emergency care must be pre-authorized by VA. When the emergency care is not authorized in advance by VA, it may be considered as preauthorized care when the nearest VA medical facility is notified within 72 hours of admission, the Veteran is eligible and the care rendered is emergent in nature. Claims for non-VA emergency care not authorized by VA in advance of services being furnished must be timely filed. Because timely filing requirements differ by type of claim, you should contact the nearest VA medical facility as soon as possible to avoid payment denial for an untimely filed claim.
Payment may not be approved for any period beyond the date on which the medical emergency ended, except when VA cannot accommodate transfer of the Veteran to a VA or other Federal facility. An emergency is deemed to have ended at that point when a VA physician has determined that, based on sound medical judgment, a Veteran who received emergency hospital care could have been transferred from the non-VA facility to a VA medical center for continuation of treatment.
What type of emergency care can VA authorize in advance?
| Subject to eligibility and payment limitations described in “Emergency Care” in 5_Medical Benefits Package, VA may preauthorize and issue payment for non-VA emergency care when treatment is needed for: | Inpatient Care | Outpatient Care |
|---|---|---|
| The Veteran’s VA-rated service-connected disability, or for a nonservice condition that is associated with and aggravating the Veteran’s service-connected condition | √ | √ |
| A disability for which the Veteran was released from active duty | √ | √ |
| Any condition of a Veteran who is rated by VA as permanently and totally disabled due to a service-connected disability | √ | √ |
| Any condition of a Veteran who is an active participant in the VA Chapter 31 Vocational Rehabilitation and Employment Program, who needs treatment medically determined to make possible the Veteran’s entrance into a course of training or prevent interruption of a course of training that was interrupted due to such illness, injury or dental condition | √ | √ |
| Any condition for a Veteran who has a VA service-connected disability rating of 50% or greater | √ | |
| A condition for which the Veteran has been furnished VA hospital care, nursing home, domiciliary care or medical services and who requires medical services to complete treatment incident to such care or services | √ | |
| Any condition of a Veteran who is in receipt of increased VA pension, additional VA compensation or allowances based on the need for regular aid and attendance or by reason of being permanently housebound | √ | |
| A condition requiring emergency care that developed while the Veteran was receiving medical services in a VA facility or contract nursing home or during VA authorized travel | √ | √ |
| Any condition that will prevent the need for hospital admission for a Veteran in the state of Alaska or Hawaii and U.S. Territories, excluding Puerto Rico | √ | |
| Any condition for women Veterans | √ | |
| Any dental services, treatment and related dental appliances for Veterans who are former prisoners of war | √ |
Can VA pay for non-VA emergency care that is not preauthorized?
VA has limited payment authority when emergency care at a non-VA facility is provided without authorization by VA in advance of services being furnished or when notification to VA is not made within 72 hours of admission. VA may pay for unauthorized emergency care as indicated below. Since payment may be limited to the point your condition is stable for transfer to a VA facility, the nearest VA medical facility should be contacted as soon as possible for all care not authorized by VA in advance of the services being furnished.
| For service-connected | For nonservice-connected conditions |
|---|---|
| VA may only pay for emergency care provided in a non-VA facility for certain Veterans who are rated by VA with a service-connected disability. VA may pay for emergency inpatient or outpatient care when treatment is needed for: | VA may only pay for emergency care provided in a non-VA facility for treatment of a Nonservice- connected condition only if all of the following conditions are met: |
| The Veteran’s VA rated service-connected disability or for a nonservice-condition that is associated with and aggravating the Veteran’s service-connected condition | The episode of care cannot be paid as an unauthorized claim for service-connected Veterans |
| A VA facility was not considered feasibly available when the urgency of the Veteran’s medical condition, the relative distance of the travel involved or the nature of the treatment required makes it necessary or economically advisable to use public or private facilities | The Veteran is enrolled in the VHA health care system and received VA medical care within a 24-month period preceding the furnishing of the emergency treatment |
| VA may only pay for emergency care provided in a non-VA facility for certain Veterans who are rated by VA with a service-connected disability. VA may pay for emergency inpatient or outpatient care when treatment is needed for | VA may only pay for emergency care provided in a non-VA facility for treatment of a Nonservice-connected condition only if all of the following conditions are met |
| Any condition of a Veteran who is rated by VA as permanently and totally disabled due to a service connected disability | The Veteran is personally liable to the health care provider for the emergency treatment that meets the prudent layperson definition of an emergency |
| Any condition of a Veteran who is an active participant in the VA Chapter 31 Vocational Rehabilitation and Employment Program, who needs treatment medically determined to make possible the Veteran’s entrance into a course of training or to prevent interruption of a course of training that was interrupted due to such illness, injury or dental condition | The Veteran has no other contractual or legal recourse against a third party that would, in whole, extinguish the Veteran’s liability. The claim must be filed within 90 days from the date of discharge or the date the Veteran exhausted without success any actions to obtain payment from a third party |
| A prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health | A prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health |
| Once authorization for care is granted by VA the, authorization will be continued after admission only for the period of time required to stabilize or improve the patient’s condition to the extent that further care is no longer required to satisfy the purpose it was initiated | Once authorization for care is granted by VA, the authorization will be continued after admission or only for the period of time required to stabilize or improve the patient’s condition to the extent that further care is no longer required to satisfy the purpose it was initiated |
| The Veteran is not entitled to care or services under a health plan contract | |
| Treatment was provided in a hospital emergency room |
