[Federal Register Volume 63, Number 132 (Friday, July 10, 1998)]
[Proposed Rules]
[Pages 37299-37307]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-18302]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AJI8


Enrollment--Provision of Hospital and Outpatient Care to Veterans

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: This document proposes to amend VA's medical regulations. The 
Veterans' Health Care Eligibility Reform Act of 1996 mandates that VA 
implement a national enrollment system to manage the delivery of 
healthcare services. Accordingly, the medical regulations are proposed 
to be amended to establish provisions consistent with this mandate. 
Starting October 1, 1998, most veterans must be enrolled in the VA 
healthcare system as a condition of receiving VA hospital and 
outpatient care. Veterans would be allowed to apply to be enrolled at 
any time. They would be eligible to be enrolled based on funding 
availability and their priority status. In accordance with statutory 
provisions, the proposed rule also states that some categories of 
veterans would be eligible for VA hospital and outpatient care even if 
not enrolled. This document further proposes to establish a ``medical 
benefits package'' setting forth, with certain exceptions, the hospital 
and outpatient care that would be provided to enrolled veterans and 
certain other veterans.

DATES: Comments must be received on or before September 8, 1998.

ADDRESSES: Mail or hand-deliver written comments to: Director, Office 
of Regulations Management (02D), Department of Veterans Affairs, 810 
Vermont Ave., NW, Room 1154, Washington, DC 20420. Comments should 
indicate that they are submitted in response to ``RIN: 2900-AJ18.'' All 
written comments received will be available for public inspection at 
the above address in the Office of Regulations Management, Room 1158, 
between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday 
(except holidays).

FOR FURTHER INFORMATION CONTACT: Roscoe Butler, Health Administration 
Service, (10C3), Veterans Health Administration, Department of Veterans 
Affairs, 810 Vermont Avenue, NW, Washington, DC 20420, (202) 273-8302. 
(This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: This document proposes to amend VA's medical 
regulations at 38 CFR part 17. Public Law 104-262, the Veterans' Health 
Care Eligibility Reform Act of 1996, mandated that VA implement a 
national enrollment system to manage the delivery of healthcare 
services. Accordingly, the medical regulations are proposed to be 
amended to establish provisions consistent with this mandate. Starting 
October 1, 1998, most veterans must be enrolled in the VA healthcare 
system as a condition for receiving VA hospital and outpatient care. 
They would be allowed to apply to be enrolled at any time. In 
accordance with statutory provisions, the proposal also states that 
some categories of veterans would be eligible for VA hospital and 
outpatient care even if not enrolled. This document further proposes to 
establish a ``medical benefits package'' setting forth, with certain 
exceptions, the hospital and outpatient care that would be provided to 
enrolled veterans and certain other veterans.

National Enrollment System (Proposed Sec. 17.36)

    The proposed rule restates statutory provisions by announcing that 
certain veterans must be enrolled in the VA healthcare system as a 
condition for receiving VA hospital and outpatient care. Also, 
consistent with the mandate of Public Law 104-262, the proposed rule 
contains a mechanism for determining which categories of veterans are 
eligible to be enrolled. Moreover, the proposed rule includes 
procedures for applying for enrollment, continuation of enrollment, and 
disenrollment; and provides for notification to veterans of 
determinations regarding their enrollment status.
    The proposed rule also contains provisions for automatically 
enrolling veterans who were enrolled prior to October 1, 1998, in the 
VA healthcare system under the trial VA voluntary enrollment program 
that began on October 1, 1997, if they are in a funded priority 
category as explained below. This would help avoid duplicate 
decisionmaking and paperwork since the trial VA voluntary enrollment 
program used essentially the same procedures for enrollment as those 
set forth in the proposed rule.
    Consistent with the statutory mandate, the proposed rule provides 
that the Secretary will determine which categories of veterans are 
eligible to be enrolled based on the following order of priority:
    (1) Veterans with a singular or combined rating of 50 percent or 
greater based on one or more service-connected disabilities or 
unemployability.
    (2) Veterans with a singular or combined rating of 30 percent or 40 
percent based on one or more service-connected disabilities.
    (3) Veterans who are former prisoners of war; veterans with a 
singular or combined rating of 10 percent or 20 percent based on one or 
more service-connected disabilities; veterans who were discharged or 
released from active military service for a disability incurred or 
aggravated in the line of duty; veterans who receive disability 
compensation under 38 U.S.C. 1151; veterans whose entitlement to 
disability compensation is suspended pursuant to 38 U.S.C. 1151, but 
only to the extent that such veterans' continuing eligibility for 
hospital and outpatient care is provided for in the judgment or 
settlement described in 38 U.S.C. 1151; veterans whose entitlement to 
disability compensation is suspended because of the receipt of military 
retired pay; and veterans receiving compensation at the

[[Page 37300]]

10 percent rating level based on multiple noncompensable service-
connected disabilities that clearly interfere with normal employability
    (4) Veterans who receive increased pension based on their need for 
regular aid and attendance or by reason of being permanently housebound 
and other veterans who otherwise would be included in paragraphs (5) or 
(6) of this section but who are determined to be catastrophically 
disabled by the Chief of Staff (or equivalent clinical official) at the 
VA facility where they were examined.
    (5) Veterans not covered by paragraphs (1) through (4) who are 
determined to be unable to defray the expenses of necessary care under 
38 U.S.C. 1722(a).
    (6) Veterans of the Mexican border period or of World War I; 
veterans solely seeking care for a disorder associated with exposure to 
a toxic substance or radiation or for a disorder associated with 
service in the Southwest Asia theater of operations during the Gulf 
War, as provided in 38 U.S.C. 1710(e); and veterans with 0 percent 
service-connected disabilities who are nevertheless compensated, 
including veterans receiving compensation for inactive tuberculosis.
    (7) Veterans who agree to pay to the United States the applicable 
copayment determined under 38 U.S.C. 1710(f) and 1710(g).
    We also propose to establish the following subcategories for 
priority category 7:
    (i) Noncompensable zero percent service-connected veterans;
    (ii) Catastrophically disabled veterans; and
    (iii) All other priority category 7 veterans.

In our view, this would provide an equitable system for further 
prioritizing the enrollment of priority category 7 veterans if VA were 
able to provide care for only a portion of priority category 7 
veterans.
    Priority category 4 includes veterans who are ``catastrophically 
disabled.'' We have included a detailed definition of this term in 
proposed Sec. 17.36(e). We believe this is consistent with the 
Congressional intent.
    In connection with the Secretary's determination regarding which 
categories of veterans would be eligible for hospital and outpatient 
care, the proposed rule states that the Secretary will publish in the 
notice section of the Federal Register on or before October 1, 1998, a 
document announcing which categories of veterans are eligible to be 
enrolled. The proposed rule also states that thereafter, it is 
anticipated that the Secretary would publish in the notice section of 
the Federal Register on or before August 1 of each year the 
determination of which categories of veterans are eligible to be 
enrolled. It is likely that the Secretary would have sufficient 
information by August 1 of each year to make an appropriate 
determination. However, because of the possibility that the initial 
determination may require modification, the proposed rule would allow 
the Secretary to revise the determination by publication in the notice 
section of the Federal Register as necessary at any time. The proposed 
rule also includes criteria for determining which priority categories 
will be eligible to be enrolled.
    Veterans may appeal VA decisions regarding enrollment and 
disenrollment under the existing VA procedures, which include the right 
to appeal to the Board of Veterans' Appeals and the Court of Veterans 
Appeals.

Enrollment Not Required for Certain Categories of Veterans 
(Proposed Sec. 17.37)

    Consistent with the provisions of Public Law 104-262, the proposed 
rule states that certain categories of veterans, including veterans 
rated for service-connected disabilities at 50 percent or greater, are 
not required to be enrolled in the VA healthcare system as a condition 
for receiving VA care.
    Under Public Law 104-262, the list of veterans not required to be 
enrolled includes veterans ineligible to be enrolled but who need care 
based on ``compelling medical reasons.'' Based on our view of the 
statutory intent, the proposed rule indicates that this covers those 
cases when it is necessary to complete a course of treatment started 
when the veteran was enrolled in the VA healthcare system.
    Further, we note that we do not believe that the authority for 
providing hospital and outpatient care for ``compelling medical 
reasons'' was intended to cover the provision of care as a humanitarian 
service in emergency cases. VA has separate and long-standing authority 
to provide care to individuals such as non-enrolled veterans in medical 
emergencies subject to charges set by VA.

Medical Benefits Package (Proposed Sec. 17.38)

    This document also proposes to set forth provisions explaining what 
care would and would not be provided to veterans enrolled in the VA 
healthcare system. The Secretary has authority to provide healthcare as 
determined to be medically needed. In our view, medically needed 
constitutes care that is determined by appropriate healthcare 
professionals to be needed to promote, preserve, or restore the health 
of the individual and to be in accord with generally accepted standards 
of medical practice. The care included in the proposed ``medical 
benefits package'' is intended to meet these criteria.
    The proposed regulations also explain that a veteran may receive 
certain types of VA care not included in the ``medical benefits 
package'' if authorized by statute or other sections of 38 CFR (e.g., 
humanitarian emergency care for which the individual will be billed, 
compensation and pension examinations, dental care, domiciliary care, 
nursing home care, readjustment counseling, care as part of a VA-
approved research project, seeing-eye or guide dogs, sexual trauma 
counseling and treatment, special registry examinations).

Technical Changes

    The proposed rule also proposes to make a number of technical 
amendments to the medical regulations for purposes of consistency.

OMB

    This document has been reviewed by the Office of Management and 
Budget OMB under Executive Order 12866.

Paperwork Reduction Act of 1995

    OMB has determined that proposed 38 CFR 17.36 would contain 
collections of information under the Paperwork Reduction Act of 1995 
(44 U.S.C. 3501-3520). Accordingly, under section 3507(d) of the Act, 
VA has submitted a copy of this rulemaking action to OMB for its review 
of the collections of information.
    OMB assigns a control number for each collection of information it 
approves. VA may not conduct or sponsor, and a person is not required 
to respond to, a collection of information unless it displays a 
currently valid OMB control number.
    Comments on the proposed collections of information should be 
submitted to the Office of Management and Budget, Attention: Desk 
Officer for the Department of Veterans Affairs, Office of Information 
and Regulatory Affairs, Washington, DC 20503, with copies mailed or 
hand-delivered to: Director, Office of Regulations Management (02D), 
Department of Veterans Affairs, 810 Vermont Ave., NW, Room 1154, 
Washington, DC 20420. Comments should indicate that they are submitted 
in response to ``RIN 2900-AJ18.''

[[Page 37301]]

    Title: Initial Application for Health Benefits.
    Summary of collection of information: Under the provisions of 
proposed Sec. 17.36(d)(1), a veteran who wishes to be enrolled must 
apply by submitting a VA Form 10-10EZ to a VA medical facility. 
Veterans applying based on inclusion in categories 1, 2, 3, 4, 6, and 7 
do not need to complete section II, but must complete the rest of the 
form. Veterans applying based on inclusion in priority category 5 must 
complete the entire form. VA Form 10-10EZ is set forth in full at 
proposed Sec. 17.36(f).
    Description of the need for information and proposed use of 
information: This information would be needed to determine whether a 
veteran would be eligible to be enrolled in the VA healthcare system 
and, consequently, whether the veteran would be eligible for VA 
hospital and outpatient care.
    Description of likely respondents: Veterans wishing to be enrolled 
in the VA healthcare system for the first time in order to receive VA 
hospital and outpatient care.
    Estimated number of respondents: 1,000,000.
    Estimated frequency of responses: 1.
    Estimated total annual reporting and recordkeeping burden: 333,333 
hours.
    Estimated annual burden per collection: 20 minutes.
    Title: Yearly Re-application for Health Benefits.
    Summary of collection of information: Under the provisions of 
proposed Sec. 17.36(d)(4)(iii), veterans enrolled based on inclusion in 
priority category 5 would be mailed a Form 10-10EZ on a yearly basis. 
They would be requested to complete the form and return the form to the 
address on the return envelope. VA Form 10-10EZ is set forth in full at 
proposed Sec. 17.36(f).
    Description of the need for information and proposed use of 
information: This information would be needed to determine whether a 
veteran would be eligible to continue to be enrolled in the VA 
healthcare system, and, consequently, whether the veteran would be 
eligible to continue to receive VA hospital and outpatient care.
    Description of likely respondents: Veterans in priority category 5 
wishing to continue to be enrolled in the VA healthcare system in order 
to receive VA hospital and outpatient care.
    Estimated number of respondents: 1,372,766.
    Estimated frequency of responses: 1.
    Estimated total annual reporting and recordkeeping burden: 343,192 
hours.
    Estimated annual burden per collection: 15 minutes.
    Title: Voluntary disenrollment.
    Summary of collection of information: Under the provisions of 
proposed Sec. 17.36(d)(4)(i), a veteran wishing to disenroll and forgo 
VA hospital and outpatient care would submit to a VA medical center a 
signed document stating that the veteran no longer wishes to be 
enrolled.
    Description of the need for information and proposed use of 
information: This information is needed to determine the identity of 
those veterans wishing to disenroll and forgo VA hospital and 
outpatient care. This will help VA determine how to allocate available 
funding for hospital and outpatient care.
    Description of likely respondents: Veterans no longer wishing to 
receive VA hospital and outpatient care.
    Estimated number of respondents: 100.
    Estimated frequency of responses: 1.
    Estimated total annual reporting and recordkeeping burden: 8.3 
hours.
    Estimated annual burden per collection: 5 minutes.
    The Department considers comments by the public on proposed 
collections of information in--
     Evaluating whether the proposed collections of information 
are necessary for the proper performance of the functions of the 
Department, including whether the information will have practical 
utility;
     Evaluating the accuracy of the Department's estimate of 
the burden of the proposed collections of information, including the 
validity of the methodology and assumptions used;
     Enhancing the quality, usefulness, and clarity of the 
information to be collected; and
     Minimizing the burden of the collections of information on 
those who are to respond, including responses through the use of 
appropriate automated, electronic, mechanical, or other technological 
collection techniques or other forms of information technology, e.g., 
permitting electronic submission of responses.
    OMB is required to make a decision concerning the collections of 
information contained in this proposed rule between 30 and 60 days 
after publication of this document in the Federal Register. Therefore, 
a comment to OMB is best assured of having its full effect if OMB 
receives it within 30 days of publication. This does not affect the 
deadline for the public to comment on the proposed rule.

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed rule will not 
have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. This proposed rule would affect only individuals. 
Accordingly, pursuant to 5 U.S.C. 605(b), this proposed rule is exempt 
from the initial and final regulatory flexibility analysis requirements 
of Secs. 603 and 604.
    The Catalog of Federal domestic assistance numbers for the programs 
affected by this rule are 64.005, 64.007, 64.008, 64,009, 64.010, 
64.011, 64.012, 64.013, 64.014, 64.015, 64.016, 64.018, 64.019, 64.022, 
and 64.025.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Alcohol abuse, Alcoholism, 
Claims, Day care, Dental health, Drug abuse, Foreign relations, 
Government contracts, Grant programs health, Grant programs-veterans, 
Health care, Health facilities, Health professions, Health records, 
Homeless, Medical and dental schools, Medical devices, Medical 
research, Mental health programs, Nursing homes, Philippines, Reporting 
and record-keeping requirements, Scholarships and fellowships, Travel 
and transportation expenses, Veterans.

    Approved: May 12, 1998.
Togo D. West, Jr.,
Secretary.
    For the reasons set out in the preamble, 38 CFR part 17 is proposed 
to be amended as set forth below:

PART 17--MEDICAL

    1. The authority citation for part 17 continues to read as follows:

    Authority: 38 U.S.C. 501, 1721 unless otherwise noted.


Sec. 17.34  [Amended]

    12. The first sentence of Sec. 17.34 is amended by removing ``When 
an application'' and adding, in its place, ``Subject to the provisions 
of Secs. 17.36 through 17.38, when an application''.
    2. An undesignated center heading and Sec. 17.36 are added to read 
as follows:

Enrollment Provisions and Medical Benefits Package


Sec. 17.36  Enrollment--provision of hospital and outpatient care to 
veterans.

    (a) Enrollment requirement for veterans. (1) Except as otherwise 
provided in Sec. 17.37, a veteran must be enrolled in the VA healthcare 
system as a condition for receiving VA hospital and outpatient care.

    Note to paragraph (a)(1): A veteran may apply to be enrolled at 
any time. (See Sec. 17.36(d)(1).)


[[Page 37302]]


    (2) Except as provided in paragraph (a)(3) of this section, a 
veteran enrolled under this section is eligible for VA hospital and 
outpatient care as provided in the ``medical benefits package'' set 
forth in Sec. 17.38.
    (3) A veteran enrolled based on having a disorder associated with 
exposure to a toxic substance or radiation, or having a disorder 
associated with service in the Southwest Asia theater of operations 
during the Gulf War, as provided in 38 U.S.C. 1710(e), is eligible for 
VA hospital and outpatient care provided in the ``medical benefits 
package'' set forth in Sec. 17.38 for the disorder.
    (b) Categories of veterans eligible to be enrolled. The Secretary 
will determine which categories of veterans are eligible to be enrolled 
based on the following order of priority:
    (1) Veterans with a singular or combined rating of 50 percent or 
greater based on one or more service-connected disabilities or 
unemployability.
    (2) Veterans with a singular or combined rating of 30 percent or 40 
percent based on one or more service-connected disabilities.
    (3) Veterans who are former prisoners of war; veterans with a 
singular or combined rating of 10 percent or 20 percent based on one or 
more service-connected disabilities; veterans who were discharged or 
released from active military service for a disability incurred or 
aggravated in the line of duty; veterans who receive disability 
compensation under 38 U.S.C. 1151; veterans whose entitlement to 
disability compensation is suspended pursuant to 38 U.S.C. 1151, but 
only to the extent that such veterans' continuing eligibility for 
hospital and outpatient care is provided for in the judgment or 
settlement described in 38 U.S.C. 1151; veterans whose entitlement to 
disability compensation is suspended because of the receipt of military 
retired pay; and veterans receiving compensation at the 10 percent 
rating level based on multiple noncompensable service-connected 
disabilities that clearly interfere with normal employability.
    (4) Veterans who receive increased pension based on their need for 
regular aid and attendance or by reason of being permanently housebound 
and other veterans who otherwise would be included in paragraphs (5) or 
(6) of this section but who are determined to be catastrophically 
disabled by the Chief of Staff (or equivalent clinical official) at the 
VA facility where they were examined.
    (5) Veterans not covered by paragraphs (1) through (4) of this 
section who are determined to be unable to defray the expenses of 
necessary care under 38 U.S.C. 1722(a).
    (6) Veterans of the Mexican border period or of World War I; 
veterans solely seeking care for a disorder associated with exposure to 
a toxic substance or radiation or for a disorder associated with 
service in the Southwest Asia theater of operations during the Gulf 
War, as provided in 38 U.S.C. 1710(e); and veterans with 0 percent 
service-connected disabilities who are nevertheless compensated, 
including veterans receiving compensation for inactive tuberculosis.
    (7) Veterans who agree to pay to the United States the applicable 
copayment determined under 38 U.S.C. 1710(f) and 1710(g). This category 
is further prioritized into the following subcategories:
    (i) Noncompensable zero percent service-connected veterans;
    (ii) Catastrophically disabled veterans; and
    (iii) All other priority category 7 veterans.
    (c) Federal Register notification of eligible enrollees. The 
Secretary will publish in the notice section of the Federal Register on 
or before October 1, 1998, a document announcing which categories of 
veterans are eligible to be enrolled. Thereafter, it is anticipated 
that the Secretary will publish in the notice section of the Federal 
Register on or before August 1 of each year a document announcing which 
categories of veterans are eligible to be enrolled. As necessary, the 
Secretary at any time may revise the determination by publication in 
the notice section of the Federal Register. A Federal Register document 
published under this paragraph must specify the total amount of 
appropriated funds and other revenue projected to be available for VA 
hospital and outpatient care for veterans eligible to be enrolled, 
specify the average amount of cost projected for a veteran in each 
priority category, and specify the projected utilization of VA hospital 
and outpatient care by veterans eligible to be enrolled for each 
priority category (based on experience from past years). The 
determination should include consideration of relevant internal and 
external factors, e.g., economic changes, changes in medical practices. 
Consistent with these criteria, the Secretary will determine which 
categories of veterans are eligible to be enrolled based on the order 
of priority specified in paragraph (b) of this section.
    (d) Enrollment and disenrollment process--(1) Application for 
enrollment. A veteran may apply to be enrolled in the VA healthcare 
system at any time. A veteran who wishes to be enrolled must apply by 
submitting a VA Form 10-10EZ to a VA medical facility. Veterans 
applying based on inclusion in priority categories 1, 2, 3, 4, 6, and 7 
do not need to complete section II, but must complete the rest of the 
form. Veterans applying based on inclusion in priority category 5 must 
complete the entire form. VA Form 10-10EZ is set forth in paragraph (f) 
of this section and is available from VA medical facilities.

    Note to paragraph (d)(1): To remain enrolled based on inclusion 
in priority category 5, a veteran annually must return to VA 
information on a VA Form 10-10EZ as provided in paragraph 
(d)(4)(iii) of this section and otherwise meet the requirements for 
enrollment.

    (2) Action on application. Upon receipt of a completed VA Form 10-
10EZ, a VA network or facility director will accept a veteran as an 
enrollee upon determining that the veteran is in a priority category 
eligible to be enrolled as announced in the applicable Federal Register 
notice. Upon determining that a veteran is not in a priority category 
eligible to be enrolled, the VA network or facility director will 
inform the applicant that the applicant is ineligible to be enrolled.
    (3) Automatic enrollment. Notwithstanding other provisions of this 
section, veterans who were notified by VA letter that they were 
enrolled in the VA healthcare system under the trial VA enrollment 
program prior to October 1, 1998, automatically will be enrolled in the 
VA healthcare system under this section if determined by a VA network 
or facility director that the veteran is in a priority category 
eligible to be enrolled as announced in the applicable Federal Register 
notice. Upon determining that a veteran is not in a priority category 
eligible to be enrolled, the VA network or facility director will 
inform the veteran that the veteran is ineligible to be enrolled.
    (4) Disenrollment. A veteran enrolled under paragraph (d)(2) or 
(d)(3) of this section will be disenrolled only if:
    (i) The veteran submits to a VA medical center a signed document 
stating that the veteran no longer wishes to be enrolled;
    (ii) A VA network or facility director determines that the veteran 
is no longer in a priority category eligible to be enrolled, as 
announced in the applicable Federal Register notice; or
    (iii) A VA network or facility director determines that the veteran 
has been enrolled based on inclusion in priority category 5; determines 
that the veteran was sent by mail a VA Form 10-10EZ; and determines 
that the veteran failed to return the completed form to the address on 
the return envelope within

[[Page 37303]]

60 days from receipt of the form. VA Form 10-10EZ is set forth in 
paragraph (f) of this section.
    (5) Notification of enrollment status. Notice of a decision by a VA 
network or facility director regarding enrollment status will be 
provided to the affected veteran by letter and will contain the reasons 
for the decision. The decision will be based on all information 
available to the decisionmaker, including the information contained in 
VA Form 10-10EZ.
    (e) Catastrophically disabled. For purposes of this section, 
catastrophically disabled means to have a permanent severely disabling 
injury, disorder, or disease that compromises the ability to carry out 
the activities of daily living to such a degree that the individual 
requires personal or mechanical assistance to leave home or bed or 
requires constant supervision to avoid physical harm to self or others. 
This definition is met if an individual has been found by the Chief of 
Staff (or equivalent clinical official) at the VA facility where the 
individual was examined to have a condition specified in paragraph 
(e)(1) of this section or to meet one of the conditions specified in 
paragraph (e)(2) of this section.
    (1) Quadriplegia and quadriparesis (ICD-9 Code 344.0x), paraplegia 
(ICD-9 Code 344.1), blindness (ICD-9 Code 369.4), unspecified 
hemiplegia (ICD-9 Code 342.90), persistent vegetative state (ICD-9 Code 
780.03), or a condition resulting from two of the following procedures 
(ICD-9 Code 84.x) provided the two procedures were not on the same 
limb:
    (i) Amputation through hand (procedure code 84.03);
    (ii) Disarticulation of wrist (procedure code 84.04);
    (iii) Amputation through forearm (procedure code 84.05);
    (iv) Disarticulation of elbow (procedure code 84.06);
    (v) Amputation through humerus (procedure code 84.07);
    (vi) Shoulder disarticulation (procedure code 84.08);
    (vii) Forequarter amputation (procedure code 84.09);
    (viii) Lower limb amputation not otherwise specified (procedure 
code 84.10);
    (ix) Amputation of toe (only if accompanied by V49.71 code for 
amputated great toe) (procedure code 84.11);
    (x) Amputation through foot (procedure code 84.12);
    (xi) Disarticulation of ankle (procedure code 84.13);
    (xii) Amputation through malleoli (procedure code 84.14);
    (xiii) Other amputation below knee (procedure code 84.15);
    (xiv) Disarticulation of knee (procedure code 84.16);
    (xv) Above knee amputation (procedure code 84.17);
    (xvi) Disarticulation of hip (procedure code 84.18); and
    (xvii) Hindquarter amputation (procedure code 84.19).
    (2)(i) Dependent in 4 or more Activities of Daily Living (eating, 
dressing, bathing, toileting, transferring, incontinence of bowel and/
or bladder), with at least 4 of the dependencies being permanent, using 
the Katz scale.
    (ii) A score of 10 or lower using the Folstein Mini-Mental State 
Examination.
    (iii) A score of 14 or higher on the Activities of Daily Living 
Index using Resource Utilization Group III.
    (iv) A score of 2 or lower on at least 4 of the 13 motor items 
using the Functional Independence Measure.
    (v) A score of 30 or lower using the Global Assessment of 
Functioning.
    (f) VA Form 10-10EZ. [insert actual photocopy of VA Form 10-10EZ]

BILLING CODE 8320-01-P

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[GRAPHIC] [TIFF OMITTED] TP10JY98.003



BILLING CODE 8320-01-C

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(Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, 1721, 1722)

    3. A new Sec. 17.37 is added to read as follows:


Sec. 17.37  Enrollment not required--provision of hospital and 
outpatient care to veterans.

    Even if not enrolled in the VA healthcare system:
    (a) A veteran rated for service-connected disabilities at 50 
percent or greater will receive VA hospital and outpatient care 
provided for in the ``medical benefits package'' set forth in 
Sec. 17.38.
    (b) A veteran who has a service-connected disability will receive 
VA hospital and outpatient care provided for in the ``medical benefits 
package'' set forth in Sec. 17.38 for that service-connected 
disability.
    (c) A veteran who was discharged or released from active military 
service for a disability incurred or aggravated in the line of duty 
will receive VA hospital and outpatient care provided for in the 
``medical benefits package'' set forth in Sec. 17.38 for that 
disability for the 12-month period following discharge or release.
    (d) When there is a compelling medical need to complete a course of 
VA treatment started when the veteran was enrolled in the VA healthcare 
system, a veteran will receive that treatment.
    (e) Subject to the provisions of Sec. 21.240, a veteran 
participating in VA's vocational rehabilitation program described in 
Secs. 21.1 through 21.430 will receive VA hospital and outpatient care 
provided for in the ``medical benefits package'' set forth in 
Sec. 17.38.
    (f) A veteran may receive VA hospital and outpatient care based on 
factors other than veteran status (e.g., a veteran who is a private-
hospital patient and is referred to VA for a diagnostic test by that 
hospital under a sharing contract; a veteran who is a VA employee and 
is examined to determine physical or mental fitness to perform official 
duties; a Department of Defense retiree under a sharing agreement).
    (g) For care not provided within a State, a veteran may receive VA 
hospital and outpatient care provided for in the ``medical benefits 
package'' set forth in Sec. 17.38 if authorized under the provisions of 
38 U.S.C. 1724 and 38 CFR 17.35.
    (h) Commonwealth Army veterans and new Philippine Scouts may 
receive hospital and outpatient care provided for in the ``medical 
benefits package'' set forth in Sec. 17.38 if authorized under the 
provisions of 38 U.S.C. 1734 and 1735.
    (i) A veteran may receive certain types of VA hospital and 
outpatient care not included in the ``medical benefits package'' set 
forth in Sec. 17.38 if authorized by statute or other sections of 38 
CFR (e.g., humanitarian emergency care for which the individual will be 
billed, compensation and pension examinations, dental care, domiciliary 
care, nursing home care, readjustment counseling, care as part of a VA-
approved research project, seeing-eye or guide dogs, sexual trauma 
counseling and treatment, special registry examinations).

(Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, 1721, 1722)

    4. A new Sec. 17.38 is added to read as follows:


Sec. 17.38  Medical benefits package.

    (a) Subject to paragraphs (b) and (c) of this section, the 
following hospital and outpatient care constitutes the ``medical 
benefits package'' (basic care and preventive care):
    (1) Basic care.
    (i) Outpatient medical, surgical, and mental healthcare, including 
care for substance abuse.
    (ii) Inpatient hospital, medical, surgical, and mental healthcare, 
including care for substance abuse.
    (iii) Prescription drugs, including over-the-counter drugs and 
medical and surgical supplies available under the VA national formulary 
system.
    (iv) Emergency care in VA facilities; and emergency care in non-VA 
facilities in accordance with sharing contracts or if authorized by 
Secs. 17.52(a)(3), 17.53, 17.54, 17.120-132.
    (v) Bereavement counseling as authorized in Sec. 17.98.
    (vi) Comprehensive rehabilitative services other than vocational 
services provided under 38 U.S.C. chapter 31.
    (vii) Consultation, professional counseling, training, and mental 
health services for the members of the immediate family or legal 
guardian of the veteran or the individual in whose household the 
veteran certifies an intention to live, if needed to treat:
    (A) The service-connected disability of a veteran; or
    (B) The nonservice-connected disability of a veteran where these 
services were first given during the veteran's hospitalization and 
continuing them is essential to permit the veteran's release from 
inpatient care.
    (viii) Durable medical equipment and prosthetic and orthotic 
devices, including eyeglasses and hearing aids as authorized under 
Sec. 17.149.
    (ix) Home health services authorized under 38 U.S.C. 1717 and 
1720C.
    (x) Reconstructive (plastic) surgery required as a result of 
disease or trauma, but not including cosmetic surgery that is not 
medically necessary.
    (xi) Respite, hospice, and palliative care.
    (xii) Payment of travel and travel expenses for veterans eligible 
under Sec. 17.143 if authorized by that section.
    (2) Preventive care, as defined in 38 U.S.C. 1701(9), which 
includes:
    (i) Periodic medical exams.
    (ii) Health education, including nutrition education.
    (iii) Maintenance of drug-use profiles, drug monitoring, and drug 
use education.
    (iv) Mental health and substance abuse preventive services.
    (v) Immunizations against infectious disease.
    (vi) Prevention of musculoskeletal deformity or other gradually 
developing disabilities of a metabolic or degenerative nature.
    (vii) Genetic counseling concerning inheritance of genetically 
determined diseases.
    (viii) Routine vision testing and eye-care services.
    (ix) Periodic reexamination of members of high-risk groups for 
selected diseases and for functional decline of sensory organs, and the 
services to treat these diseases and functional declines.
    (b) Provision of the ``medical benefits package''. Care referred to 
in the ``medical benefits package'' will be provided to individuals 
only if it is determined by appropriate healthcare professionals that 
the care is needed to promote, preserve, or restore the health of the 
individual and is in accord with generally accepted standards of 
medical practice.
    (1) Promote health. Care is deemed to promote health if the care 
will enhance the quality of life or daily functional level of the 
veteran, identify a predisposition for development of a condition or 
early onset of disease which can be partly or totally ameliorated by 
monitoring or early diagnosis and treatment, and prevent future 
disease.
    (2) Preserve health. Care is deemed to preserve health if the care 
will maintain the current quality of life or daily functional level of 
the veteran, prevent the progression of disease, cure disease, or 
extend life span.
    (3) Restoring health. Care is deemed to restore health if the care 
will restore the quality of life or daily functional level that has 
been lost due to illness or injury.
    (c) In addition to the care specifically excluded from the 
``medical benefits package'' under paragraphs (a) and (b) of

[[Page 37307]]

this section, the ``medical benefits package'' does not include the 
following:
    (1) Abortions and abortion counseling.
    (2) Drugs, biologicals, and medical devices not approved by the 
Food and Drug Administration unless the treating medical facility is 
conducting formal clinical trials under an Investigational Device 
Exemption (IDE) or an Investigational New Drug (IND) application, or 
the drugs, biologicals, or medical devices are prescribed under a 
compassionate use exemption.
    (3) Gender alterations.
    (4) Hospital and outpatient care for a veteran who is either a 
patient or inmate in an institution of another government agency if 
that agency has a duty to give the care or services.
    (5) Infertility services.
    (6) Membership in spas and health clubs.
    (7) Pregnancy and delivery.
    (8) Reproductive sterilization, unless medically necessary.
    (9) Surgery to reverse voluntary sterilization.
    (10) Surgical implantation of penile prostheses.

(Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, 1721, 1722)


Sec. 17.43  [Amended]

    5-6. In Sec. 17.43, paragraph (a) is removed and paragraphs (b) 
through (e) are redesignated as paragraphs (a) through (d), 
respectively.


Sec. 17.47  [Amended]

    7. In Sec. 17.47, paragraph (h) is removed; paragraphs (i) through 
(l) are redesignated as paragraphs (h) through (k), respectively; and 
newly redesignated paragraph (h) is amended by removing ``hospital or'' 
and by removing ``or hospital care in a Federal hospital under 
agreement,''.


Sec. 17.93  [Amended]

    8. In Sec. 17.93, paragraph (a)(2) is amended by removing ``Medical 
services'' and adding, in its place, ``Subject to the provisions of 
Secs. 17.36 through 17.38, medical services''.


Sec. 17.99  [Removed]

    9. Section 17.99 is removed.


Sec. 17.100  [Amended]

    10. In Sec. 17.100, the third sentence is amended by removing ``a 
new application is filed, and''.

[FR Doc. 98-18302 Filed 7-9-98; 8:45 am]
BILLING CODE 8320-01-P