Brian Reinhart Health Systems Specialist September, 2015 Veterans Access, Choice and Accountability Act of 2014 (VACAA) The Choice Program and the Choice Card Brian Reinhart Health Systems Specialist September, 2015

VACAA – The Choice Program / Choice Card Fast Facts Overview Background: Major element of Public Law 113-146, passed Aug. 7, 2014 Funded at $10 billion Temporary 3-year program to bridge gap while VA expands capacity, access Approximately 600,000 Veterans immediately eligible: 40 miles / 30 days 9 million enrolled Veterans to receive a Choice Card Program to be run by a contracted third party administrator Rolled out on Nov. 5 2014. Dependent upon OMB approval of VA-proposed regulations and establishment of TPA contracts – thus, all information in this presentation is subject to change!

Third Party Administrator – Health Net TPA to provide most business processes: Card distribution Provider management Call centers Appointment management Reporting Billing

Choice Card Production / Distribution TPA contract to include Choice Card production and distribution Instruction letter accompanied card Phased distribution

Choice Program Eligibility VA CHOICE PROGRAM 40 Mile Geo-Burden Choice-First Choice

Veterans Choice Program – 40+ Miles TPA is provided list of eligible Veterans that reside more than 40 miles from VA facility Distance is calculated by address in VistA This list is updated monthly Veterans is notified of their eligibility through mailings Veteran can choose to contact TPA and coordinate ALL care Care is pre-authorized by VA based on eligibility and clinical criteria is determined by TPA using InterQual standards Care Provided is paid by CBO with funding authorized in PL 113-146 Ex: Vet needs hip replacement, all related care, i.e. workup, surgery and rehab considered episode of care. Approval for episode of care is only authorized for 60 days and must be renewed

Veterans Choice Program – 40+ Miles (continued) VA will own the Electronic Health Record (EHR) – even if the Veteran is never seen in a VA facility Veteran is seen by Non-VA Choice Provider Choice provider submits claim, Explanation of Benefits (EOB) (if applicable) and clinical documentation to TPA TPA processes payment to Choice Provider

Choice – 30+ Days Clock starts ticking based on “clinically indicated date” (CID) If no clinically indicated date, patient preferred date is used If we KNOW that community wait is longer than VA wait, we should inform the Veteran, who can then make an informed choice about care When Veteran is added to VCL, VA schedules appointment Veteran is made aware that they are eligible to use Choice Program and provided the 1-800 number for the TPA Veteran contacts TPA for information and/or use of Choice Program

Choice – 30+ Days (continued) If Veteran decided NOT to use Choice for this episode of care TPA and/or patient notifies VAMC Veteran keeps appointment at VA If Veteran selects to use Choice Program TPA gathers information from Veteran VA uploads documentation to the portal TPA provides Veteran with list of approved Choice providers

Choice Program – 30+ Days (continued) TPA schedules appointment for Veteran with selected provider TPA provides appointment information to VAMC VA staff cancel existing appointment VA staff documents information in CPRS Veteran is seen by Choice Provider Choice provider submits claim, Explanation of Benefits (EOB) (if applicable) and clinical documentation to TPA TPA processes payment to Choice Provider, payment is at Medicare rate or other specific rates identified in regulation when Medicare rates do not exist

VA Choice-First This program is for services that the VA Medical Center does not offer, or offer very little of. All requests have to be approved by Chief of Staff or designated individual. We reach out to the patient and inform them of this and upload appropriate documentation to Health Net. From this point forward the Choice-First process is handled very similar to regular Choice.

Third Party Administrator VA pays no more than Medicare rate Providers are either part of the TPA network or have a Choice Provider Agreement which meet requirements of the Choice Act TPA will schedule Veterans community appointment OR send back to VA Responsible to provide clinical documentation to VA Notifies VA if/when community appointment scheduled Coordinates other health insurance (OHI) information with provider and responsible to provide Explanation of Benefit (EOB) to VA TPA is Health Net

Third Party Administrator (continued) TPA will provide list of approved providers to Veteran to choose from If desired provider is not on list – TPA will coordinate getting agreement with provider If provider refuses agreement they are not available for the Choice Program TPA will schedule appointment with selected provider TPA sends through portal appointment information to primary facility NVCC office will enter into FBCS in preparation of receipt of claim If Veteran is Service Connected TPA will contact CBO to obtain SC/NSC determination If for NSC condition AND Veteran has insurance TPA will notify provider they must bill OHI first

Challenges Coordinating Pre and Post care (prosthetics, therapy, etc.). Medications. The retrieval of medical documentation from TPA. Coordinating communication between TPA and Veterans.

The VACAA Intranet Page – Your “Hub” for Choice Program Information, Resources: VA Choice Information available at: Public: http://www.va.gov/opa/choiceact/ VA Employees (intranet): http://vaww.va.gov/CHOICE/Tool_Kit.asp Information Toolkits Fact Sheets FAQs News Releases More added regularly

Reminder: Contents of this Presentation are …