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VA Benefit Urgent Care FAQs

• When should I go to an urgent care?

  When you are suffering from a minor injury or illness that doesn’t necessitate a visit to an emergency room, a trip to a local urgent care center may be the best option, particularly if your primary care provider isn’t available or you can’t get into see them. Urgent care centers diagnose and treat a wide array of healthcare conditions including the flu or common cold, immunizations (such as flu shots), symptoms including fever, headaches, cough, sneezing, and chills, sprains and fractures, and more. Additionally, many clinics offer after-hours care and often open their doors on weekends and holidays, making urgent care an accessible and affordable healthcare option for many consumers.

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• When should I go to the urgent care vs emergency room (ER)?

  Urgent care facilities are seen as a combination between an emergency room (ER) and a PCP (Primary Care Physicians), serving the instant and after hours requirements of neighboring patients. Most urgent care clinics even say that they can diagnose and treat up to seventy-five percent of the patients who visit an emergency room. The primary difference between an ER and Urgent care is the experience of the patient. The average waiting time in an ER is almost 2.5 hours while waiting time in urgent care is between 15 and 45 minutes. The cost of urgent care is usually a fraction of what you would pay in an emergency room. It is advisable to visit an emergency room in situations of medical emergency because urgent care clinics are meant for minor and non-emergent illnesses and injuries.

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• Can veterans use their VA Benefits at urgent care?

  Yes. Under the MISSION Act beginning June 6, 2019, veterans can go to a community healthcare provider, including urgent care, but with a few restrictions:

  • The urgent care provider must be part of the VA’s contracted network of community healthcare providers or the veteran may have to pay the full cost of care.
  • VA won’t pay your urgent care bill if you go for preventative care or dental services. The urgent care benefit is not intended to replace a normal doctor.
  • You must be enrolled in VA healthcare and received care through the VA within 24 months to be eligible for the urgent care benefit.
  • Only eligible veterans can use the benefit. Family members cannot use it.
  • You may be charged a copayment for your urgent care visit, based on how many times you’ve gone to urgent care and what your assigned veteran priority group is. Some may pay nothing for the first three visits, then $30 per visit to urgent care for the fourth and subsequent visit in a single calendar year. Others will pay $30 per visit regardless of number of visits. Flu shots at urgent care will never require a copay.
  • There is no limit on the number of times an eligible veteran can access urgent care.
  • Copayments are not paid by the veteran out-of-pocket. The VA will bill you separately.
  • VA also will pay for or fill prescriptions from urgent care, but if the medication is longer than a 14-day supply, the prescription must be submitted and filled by the VA. Some veterans may be required to pay a copay for medication.

  The Department of Veterans Affairs official site has a warning: “If an eligible Veteran goes to an out-of-network urgent care provider, they may be required to pay the full cost of care.”

• What is the MISSION Act?

  Signed into law on June 6, 2018 and replacing the expiring CHOICE Act, the VA MISSION Act of 2018, commonly referred to simply as the MISSION Act, is designed to improve VA healthcare for veterans, addressing in-network and non-VA healthcare. Endorsed by over 30 veteran service organizations (VSOs) and going into effect on June 6, 2019, the MISSION Act broadens healthcare access to veterans to include telehealth and community providers, including non-VA urgent care and walk-in clinics.

• Can Veterans go to an urgent care without a referral?

  The MISSION Act includes an update to the VA benefit policy for urgent care “for the treatment of minor injuries and illnesses, such as colds, sore throats, and minor skin infections.” This is offered “in addition to the opportunity to receive care from a VA provider,” since some same-day services are available at many VA facilities around the country.

  Veterans can go to a community urgent care without a referral if the clinic “is part of VA’s contracted network of community providers.” Veterans should know that VA payment for urgent care services is only possible if the care meets the following criteria:

  • The patient must be eligible for the healthcare benefit;
  • The urgent care provider is part of VA’s contracted network;
  • The services are not excluded under the benefit

• What’s the process for accessing urgent care with TRICARE?

  While a referral is not necessary for a veteran to access a community urgent care clinic, it is best to contact your nearest VA medical facility to check your eligibility for the urgent care benefits mentioned above. Following your urgent care visit, the clinic must file a claim with he VA in order to be paid and any follow-up medical documents must be sent to the veteran’s home VA medical facility.

• Will the VA cover all community urgent care visits?

  According to the Department of Veterans Affairs, urgent care options for veterans are available for “non-emergent symptoms” including flu-like symptoms, colds, coughs, wheezing, sore throats, ear pain, bumps, bruises, sprains, painful urination, and minor skin irritations. Additionally, some vaccines, x-rays, some lab testing, and some medications are also covered. If you are concerned about the complexity of your medical history, it is best to seek treatment from your primary care doctor at the VA rather than visiting an urgent care center.

  The Department of Veterans Affairs will pay for an urgent care visit and/or fill urgent care prescriptions but you cannot get routine or primary care through this benefit. A co-pay may be required in some cases, particularly for medication, in an urgent care capacity.

• Do TRICARE plans also allow for urgent care visits?

  While separate from the VA urgent care benefit, most TRICARE plans support urgent care visits. There are a variety of TRICARE plans covering veterans, each of which have their own stipulations relating to urgent care and other community healthcare providers. The three primary buckets including TRICARE Prime Plans, TRICARE Select plans, and the US Family Health Plan. Below is a summary of the urgent care benefits available within each plan type.

  TRICARE Prime Plans

  Urgent care without a referral is available from any TRICARE authorized urgent care center or network provider^[1] through the following:

  • Active duty family member
  • Retiree or retiree family member
  • Active duty service member enrolled in TRICARE Prime Remote

  If you are an active duty service member living in a TRICARE Prime Service Area, you should seek care at a military hospital or clinic when/where available, or contact the Nurse Advice Line for assistance.

  TRICARE Select and All Other TRICARE Plans

  Urgent care without a referral is available from any TRICARE authorized urgent care center or network provider^[2] through the following:

  • Active duty family member
  • Retiree or retiree family member

  US Family Health Plan

  Visit your designated provider’s web site for details

  Urgent Care Overseas

  If you are overseas, you don’t need a referral to visit an urgent care if you are enrolled in either a TRICARE plan stateside or in a TRICARE Overseas plan, but to ensure your urgent care visit is cashless and claimless, you must get prior authorization from the TRICARE overseas contractor. Otherwise, you may have to pay the provider up front and file a claim for reimbursement later.

  If you are enrolled in a TRICARE Overseas plan and traveling stateside, You don’t need a referral and you can get urgent care from any TRICARE authorized urgent care center or network provider.^[3][4]

  • [1] If you are a family member or retiree and seek urgent care from a non-network provider outside of a TRICARE authorized urgent care center, you will have to pay point-of-service option cost-shares.
  • [2] You will pay network or non-network copayments or cost-shares, depending on the type of provider you see.
  • [3] If you are enrolled in a TRICARE Prime plan and seek urgent care from a non-network provider outside of a TRICARE authorized urgent care center, you will have to pay point-of-service option cost-shares.
  • [4] Active Duty Service Members must follow up with their PCM when they receive care outside of a military hospital or clinic, in accordance with DoD and Service regulations.