[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
[[Page 37304]]
[GRAPHIC] [TIFF OMITTED] TP10JY98.002
[[Page 37305]]
[GRAPHIC] [TIFF OMITTED] TP10JY98.003
BILLING CODE 8320-01-C
[[Page 37306]]
(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
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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