The
U.S. Department of Veterans Affairs (VA) offers a variety of options for short-term and long-term/extended care nursing facility services. The VA may enter into agreements with certain community providers to care for veterans when they are not part of the VA contracted community care network. These agreements are known as
Veterans Care Agreements (VCA) and are intended to be used in situations where contracted services through the VA community care network are either not provided or not sufficient to ensure veterans can get the care they need. VA may only purchase care for veterans through these contract vehicles, such as the Patient-Centered Community Care (PC3) network or the Community Care Network (CCN), or by establishing a VCA. A VCA agreement covers veterans who either require short stays (1-100 days) or extended care services (101+ days).
In 2022, the VA transitioned the VCA reimbursement model to align with the Medicare Skilled nursing Facility Prospective Payment System (SNF PPS) Patient-Driven Payment Model (PDPM). The VCA
VA Community Nursing Home (CNH) Fee Schedule generally follows the Prospective Payment System (PPS) billing requirements found in Medicare Claims Processing Manual, Chapter 6–Skilled Nursing Facility (SNF) Inpatient Part A Billing and SNF Consolidated Billing with some exceptions as listed below.
AHCA developed a
2023 VA VCA Pricing Comparison Tool to assist providers in identifying the adequacy of the geographic-adjusted offered VCA PDPM rates for SNF short-stays (days 1-100) or long-stays (days 101+).
AHCA also developed a
2023 VA Fee Schedule for those PT, OT, and SLP services furnished days 100+ and transportation escort services that are excluded from the bundled PDPM per-diem payment rate.
AHCA members may contact
Dan Ciolek with questions related to the AHCA VA VCA 2023 pricing tools.
Exceptions:
- VA will use the Patient Driven Payment Model-based (PDPM) pricing software using the following specifications:
- CNH day 1-100: multiply physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), nursing, and non-case-mix components by 0.6 in addition to any other adjustment factors.
- CNH day 101+: remove PT, OT, and SLP components (or set adjustment factor to 0). Multiply nursing and non-case-mix components by 0.9.
- The non-therapy ancillary component will follow PDPM (3.0 for the first three days and 1.0 for all remaining days).
- No special service pricing exists outside of VA PDPM-based PPS for services such as bed hold, memory care, behavioral, HIV/AIDS, respite, ventilator, tracheostomy, and isolation/private room.
- VA covers some services under CNH authorizations that are not considered part of the nursing home PPS, listed below. Nursing homes are required to submit separate claims for these services.
- Physician Services: Providers delivering federally mandated or separately authorized services shall bill fee-for-service. The services will be reimbursed at the lesser of billed charges or the Medicare Physician Fee Schedule.
- PT, OT and SLP: When PT, OT or SLP therapy is required during days 101+ of a Veteran’s stay, providers must get prior authorization from VA. When care is delivered on days 101+ of a Veteran’s stay, providers will bill fee-for-service using the following procedure codes: G0151, G0152, G0153, G0157, G0158, G0159, G0160, G0161. The services will be reimbursed at the lesser of billed charges or the VA Fee Schedule.
- Escort services: When an escort to a medical appointment is indicated, providers must get prior authorization from VA. Providers will bill fee-for-service using the following procedure code: G0156. The services paid will be the lesser of billed charges or the VA Fee Schedule.