[Federal Register Volume 74, Number 12 (Wednesday, January 21, 2009)]
[Proposed Rules]
[Pages 3535-3540]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-1024]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AN23


Expansion of Enrollment in the VA Health Care System

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend its 
regulations regarding enrollment in the VA health care system. In 
particular, it proposes to establish additional subpriorities within 
enrollment priority category 8 and provide that beginning on the 
effective date of the rule, VA would enroll priority category 8 
veterans whose income exceeds the current means test and geographic 
means test income thresholds by 10 percent or less.

DATES: Written comments must be received on or before February 20, 
2009.

ADDRESSES: Written comments may be submitted through http://www.Regulations.gov; by mail or hand-delivery to the Director, 
Regulations Management (02REG), Department of Veterans Affairs, 810 
Vermont Ave., NW., Room 1068, Washington, DC 20420; or by fax to (202) 
273-9026. Comments should indicate that they are submitted in response 
to ``RIN 2900-AN23--Expansion of Enrollment.'' Copies of comments 
received will be available for public inspection in the Office of 
Regulation Policy and Management, Room 1063B, between the hours of 8 
a.m. and 4:30 p.m., Monday through Friday (except holidays). Please 
call (202) 461-4902 for an appointment. In addition, during the comment 
period, comments may be viewed online through the Federal Docket 
Management System (FDMS) at http://www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Tony Guagliardo, Director, Business 
Policy, Chief Business Office (163), Veterans Health Administration, 
Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 
20420, (202) 461-1591. (This is not a toll free number.)

SUPPLEMENTARY INFORMATION: Public Law 104-262, the Veterans' Health 
Care Eligibility Reform Act of 1996, required VA to establish a 
national enrollment system to manage the delivery of inpatient hospital 
care and outpatient medical care, within available appropriated 
resources. It directed that the enrollment system be managed in such a 
way as ``to ensure that the provision of care to enrollees is timely 
and acceptable in quality,'' and authorized such subprioritization of 
the statutory enrollment categories ``as the Secretary determines 
necessary.'' The law also provided that starting October 1, 1998, most 
veterans had to enroll in the VA health care system as a condition for 
receiving VA hospital and outpatient care.
    In a document published in the Federal Register on January 17, 2003 
(68 FR 2670), VA published an interim final rule that amended 38 CFR 
17.36 to add two new subpriorities to both enrollment priority 
categories 7 and 8, for a total of four subpriorities in each category. 
It also announced that

[[Page 3536]]

beginning January 17, 2003, VA would enroll all priority categories of 
veterans except that those veterans in priority category 8 who were not 
in an enrolled status on January 17, 2003, or who requested 
disenrollment after that date, would not be eligible to be enrolled. 
The veterans in this priority category are those whose incomes exceed 
certain income limits and who do not qualify for enrollment in another 
priority category. Since then, VA has not enrolled veterans in priority 
category 8 unless they had been enrolled in another priority category 
and no longer qualified for enrollment in that category.
    This proposed rule would establish additional subpriorities within 
enrollment priority category 8 and would provide that beginning on the 
effective date of the rule, VA would enroll priority category 8 
veterans whose income exceeds the current means test and geographic 
means test income thresholds by 10 percent or less. These veterans 
would continue enrollment in these subpriority groups (even if their 
income exceeds the current tests by more than 10 percent) unless they 
become eligible for enrollment in a higher category or subpriority; a 
request for disenrollment is made; or a decision is made to disenroll 
their particular subpriority or category. This proposed rule would also 
amend the medical regulations by making a nonsubstantive change to 
reflect an alternative method to submit VA's Application for Health 
Care Benefits (VA Form 10-10EZ).

Projections for Increasing Enrollment of Priority Category 8 Veterans 
Whose Income Exceeds the Current VA Means Test and Geographic Means 
Test Income Thresholds by 10 Percent or Less

    An existing regulation (38 CFR 17.36(c)) requires that the 
Secretary determine which categories of veterans are eligible to be 
enrolled and that the Secretary notify eligible enrollees of the 
determination by announcing it in the Federal Register. In making that 
determination, the Secretary must consider an array of factors 
including economic information such as available resources, projections 
of demand for enrollment, and the length of waiting times for 
appointments for care.
    The actual number of total enrollees who were enrolled at any time 
in 2003 was 7,120,347. The corresponding number in 2008 was 7,802,382. 
The increase in the veterans enrolled in the VA health care system 
between 2003 and 2008 is, therefore, 682,035.
    The 2009 Appropriations Act provided funding in VA's health care 
appropriation to increase priority category 8 enrollment. The Veterans 
Health Administration's (VHA) total FY 2009 medical care appropriation 
is $40.434 billion. This is supplemented by an additional $3.717 
billion from collections for copayments, third-party reimbursements for 
services, other revenue, and carry-over funds. The sum of these 
resources is $44.151 billion. The following table shows the projected 
enrollment for FY 2009 together with the projected expenditures that 
would be needed to provide the medical benefits package to enrollees 
under VA's current enrollment policy:

                          FY 2009 Projections Under VA's Current Enrollment Policy \1\
----------------------------------------------------------------------------------------------------------------
                                                                                                   Cumulative
                     Priority category                        Enrollment       Expenditures       expenditures
----------------------------------------------------------------------------------------------------------------
1.........................................................       1,079,852    $10,552,245,777    $10,552,245,777
2.........................................................         595,548      2,352,417,015     12,874,662,792
3.........................................................       1,090,376      3,517,387,015     16,392,050,361
4.........................................................         233,153      3,461,043,477     19,853,093,838
5.........................................................       2,361,166     11,513,021,012     31,366,114,850
6.........................................................         354,785        606,349,476     31,972,464,326
7.........................................................       1,056,733      2,041,244,267     34,013,708,592
8.........................................................       1,286,626      2,692,952,224     36,706,660,817
                                                           =================
    Total.................................................       8,058,238     36,706,660,817  .................
----------------------------------------------------------------------------------------------------------------
\1\ This table does not include projections regarding the impact of the proposed regulatory change.

    The following table shows the projected enrollment and expenditures 
for FY 2009 if the expanded enrollment as proposed in this document is 
implemented. The projections are based on reopening enrollment for 
Priority 8 veterans whose income exceeds the current VA means test 
(VMT) and geographic means test (GMT) income thresholds by 10 percent 
or less. The means tests are currently based on Calendar Year (CY) 2007 
income.
    Priority 8 veterans eligible to enroll under VMT/GMT+10 percent are 
assumed to enroll at higher rates than the average historical rates 
evidenced in the current Priority 8 enrollee population. Experience 
shows that veterans in the lower income ranges for Priority 8 veterans 
are more likely to enroll. The FY 2009 enrollment projections also 
reflect an expected surge in enrollment when the suspension is lifted 
and veterans who have not been able to enroll take advantage of this 
opportunity. The higher enrollment rates for VMT/GMT+10 percent 
veterans were increased by 17.5 percent for FY 2009 to reflect the 
expected surge. In absence of any data to support a different 
assumption, the projections for VMT/GMT+10 percent assume the new 
Priority 8 enrollees will have the same reliance and morbidity as 
current Priority 8 enrollees.

          FY 2009 Projections Under VA's Current Enrollment Policy Plus GMT/VMT 10 Percent Scenario \1\
----------------------------------------------------------------------------------------------------------------
                                                                                                   Cumulative
                     Priority category                        Enrollment       Expenditures       expenditures
----------------------------------------------------------------------------------------------------------------
1.........................................................       1,079,852    $10,552,245,777    $10,522,245,777
2.........................................................         595,548      2,352,417,015     12,874,662,792
3.........................................................       1,090,376      3,517,387,568     16,392,050,361
4.........................................................         233,153      3,461,043,477     19,853,093,838
5.........................................................       2,361,166     11,513,021,012     31,366,114,850

[[Page 3537]]

 
6.........................................................         354,785        606,349,476     31,972,464,326
7.........................................................       1,056,733      2,041,244,267     34,013,708,592
8.........................................................       1,545,331      3,178,199,353     37,191,907,945
                                                           -----------------------------------------------------
    Total.................................................       8,316,943     37,191,907,945  .................
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\1\ FY 2009 Projections in this table include projections under Current Enrollment Policy plus the impact of the
  proposed regulatory change.

    The previous tables display 2009 projections based on the 2008 
Enrollee Health Care Projection Model, VA's health care actuarial 
model. The VA Enrollee Health Care Projection Model (the ``Model'') 
supports the VHA health care budget, projects the number of veterans 
who will be enrolled, the health care services they will choose to get 
from VHA, and the expenditures associated with that utilization for 20 
years. The utilization and expenditure projections are developed based 
on where enrollees live to support population-based long-term planning. 
Base year unit costs are based on FY 2007 unit cost data from VA's 
financial accounting system--Decision Support System (DSS). The base 
year unit costs are trended forward using health care cost trends and 
adjusted for the impact of enrollee aging and changes in VA's level of 
health care management over the 20-year projection period. The 
expenditures projected by this model reflected in these tables exclude 
services such as Long Term Care, Readjustment Counseling, Spina Bifida, 
Foreign Medical Programs, Non-Veteran Medical Care, and the Civilian 
Health and Medical Program of the Department of Veterans Affairs 
(CHAMPVA). Total expenditures for medical care not included in the 
model are projected to be $6.959 billion in FY 2009. The following 
tables show VA's projections for enrollment through 2019 under the 
current enrollment policy and how the proposed expansion of enrollment 
in priority category 8 would affect that.

                           Projected Priority Category 8 Enrollment: FY 2009-2019 \1\
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                                                                      Current
                           Fiscal year                              enrollment      GMT/VMT 10%        Total
                                                                    policy \2\     scenario \3\     enrollment
----------------------------------------------------------------------------------------------------------------
2009............................................................       1,286,626         258,705       1,545,331
2010............................................................       1,291,964         265,571       1,557,535
2011............................................................       1,294,969         271,755       1,566,724
2012............................................................       1,295,921         281,598       1,577,518
2013............................................................       1,293,672         295,772       1,589,444
2014............................................................       1,288,124         290,583       1,578,707
2015............................................................       1,280,054         294,617       1,574,671
2016............................................................       1,269,050         297,001       1,566,051
2017............................................................       1,258,489         299,393       1,557,882
2018............................................................       1,244,623         300,847       1,545,470
2019............................................................       1,228,603         300,798       1,529,401
----------------------------------------------------------------------------------------------------------------
\1\ The enrollment projections begin with VetPop data, 20-year projections of the veteran population that are
  produced by the VA Office of the Actuary. At this time, VetPop does not provide veteran projections by
  Priority Levels so VetPop data is combined with other data sources to create VetPop Proxy data, which provides
  veteran projections by Priority Level.
Historical enrollment data are analyzed to develop enrollment rates by Priority Level, Age Band, Geographic
  Area, and Special Conflict Status. The enrollment rates are then applied to the enrollment pool, which is
  VetPop minus the enrolled veteran population, to determine projected enrollees for any given year.
Mortality rates specific to age, gender, and Priority Level are then applied to the enrollee population, and the
  enrollment and potential enrollee pool are aged one year at the end of each fiscal year to arrive at the
  projections for the beginning of the next fiscal year. The process of applying enrollment and mortality rates
  then repeats for the duration of the enrollment projections.
The VA Enrollee Health Care [Projection Model (EHCPM) also accounts for geographic migration and enrollees who
  transition between enrollment Priority Levels.
\2\ FY 2009-2019 Projections under Current Enrollment Policy do not include the impact of the proposed
  regulatory change.
\3\ FY 2009-2019 Projections under GMT/VMT 10 percent represent the impact of the proposed regulatory change.


                         Projected Total Priority Category 1-8 Enrollment: FY 2009-2019
----------------------------------------------------------------------------------------------------------------
                                                                                      Current
                                                                      Current       enrollment
                           Fiscal year                              enrollment     plus GMT/VMT     Change from
                                                                    policy \1\     10% scenario   current policy
                                                                                        \2\
----------------------------------------------------------------------------------------------------------------
2009............................................................       8,058,238       8,316,943         258,705
2010............................................................       8,173,270       8,438,842         265,578
2011............................................................       8,274,706       8,546,461         271,755
2012............................................................       8,341,713       8,623,310         281,598
2013............................................................       8,378,061       8,673,833         295,772
2014............................................................       8,384,127       8,674,710         290,583
2015............................................................       8,364,224       8,658,841         294,617
2016............................................................       8,318,496       8,615,497         297,001

[[Page 3538]]

 
2017............................................................       8,277,135       8,576,528         299,393
2018............................................................       8,231,823       8,532,671         300,847
2019............................................................       8,181,196       8,481,994         300,798
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\1\ FY 2009-2019 Projections under Current Enrollment Policy do not include the impact of the proposed
  regulatory change.
\2\ FY 2009-2019 Projections in this column include projections under Current Enrollment Policy plus the impact
  of the proposed regulatory change.

    As can be seen from the FY 2009 medical care appropriation and the 
tables above, VA projects that available resources to expand enrollment 
will be adequate to support the proposed expansion of enrollment of 
Priority 8 veterans.

Previous Interim Final Rules and Responses to Comments

    This document includes proposed changes in the provisions adopted 
in the interim final rule published in the Federal Register on January 
17, 2003 (68 FR 2669, RIN 2900-AL51). We received five comments on that 
interim final rule. All of the commenters expressed disagreement with 
VA's decision to suspend enrollment of additional veterans in priority 
category 8. Each of the commenters generally expressed the view that VA 
should provide care to all veterans seeking care because they had 
served their country. Thoughtful consideration was given to the 
comments received. However, as discussed in the preamble accompanying 
publication of the interim final rule, VA is required to assess 
available resources and determine the number of veterans it is able to 
enroll to ensure that medical services provided are both timely and 
acceptable in quality. An enrollment system is necessary because the 
provision of VA health care is discretionary and can be provided only 
to the extent that appropriated resources are available for that 
purpose. The enrollment decision made in January 2003 was based on 
available resources, and the comments do not suggest that VA's 
assessment of available resources was incorrect.

Unfunded Mandates

    The Unfunded Mandates Reform Act requires, at 2 U.S.C. 1532, that 
agencies prepare an assessment of anticipated costs and benefits before 
issuing any rule that may result in the expenditure by State, local, 
and tribal governments, in the aggregate, or by the private sector of 
$100 million or more in any given year. This rule would have no such 
effect on State, local, or tribal governments.

Paperwork Reduction Act

    This proposed rule contains no provisions constituting a new 
collection of information, but would change, merely by adding an option 
of a new method of submission, a collection of information that has 
been approved by the Office of Management and Budget (OMB) in 
accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521). 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. The information collection 
provisions affected by this proposed rule have been approved under 
control number 2900-0091.

Executive Order 12866 and Congressional Review Act

    This is an economically significant regulatory action under 
Executive Order 12866 and constitutes a major rule under the 
Congressional Review Act.
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, when regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety, 
and other advantages; distributive impacts; and equity). Executive 
Order 12866 classifies a ``significant regulatory action'' requiring 
review by OMB as any regulatory action that is likely to result in a 
rule that may: (1) Have an annual effect on the economy of $100 million 
or more, or adversely affect in a material way the economy, a sector of 
the economy, productivity, competition, jobs, the environment, public 
health or safety, or State, local, or tribal governments or 
communities; (2) create a serious inconsistency or interfere with an 
action taken or planned by another agency; (3) materially alter the 
budgetary impact of entitlements, grants, user fees, or loan programs 
or the rights and obligations of entitlement recipients; or (4) raise 
novel legal or policy issues arising out of legal mandates, the 
President's priorities, or the principles set forth in the Executive 
Order.
    VA has examined the economic, interagency, budgetary, legal, and 
policy implications of this proposed rule and has concluded that it is 
an economically significant regulatory action under Executive Order 
12866 because it is likely to result in a rule that may have an annual 
effect on the economy of $100 million or more and may raise novel legal 
or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in the Executive Order. This 
proposed rule is also a major rule under the Congressional Review Act 
because it is likely to result in an annual effect on the economy of 
$100 million or more.
    VA has attempted to follow OMB circular A-4 to the extent feasible 
in this analysis. The circular first calls for a discussion of the need 
for the regulation. The Consolidated Security, Disaster Assistance, and 
Continuing Appropriations Act, 2009 (Pub. L. 110-329) was enacted on 
September 30, 2008. The accompanying report language stated that 
funding was included to reopen priority category 8 enrollment. The 
preamble above discusses the need for the regulation in more detail. 
There are not any alternatives to publishing this proposed rule that 
will accomplish the stated provisions in the report language of the 
Consolidated Security, Disaster Assistance, and Continuing 
Appropriations Act, 2009 (Pub. L. 110-329).
    VA uses the Enrollee Health Care Projection Model (Model), a health 
care actuarial model, to project veteran demand for VA health care. To 
project enrollment and expenditures under this proposed regulatory 
change, VA first identified the number of non-enrolled veterans whose 
income exceeds the current VA means test and geographic means test 
income thresholds by 10

[[Page 3539]]

percent or less. VA then projected the number of those veterans who 
would enroll based on historical priority category 8 enrollment rates. 
The projected health care service utilization for these new enrollees 
was based on the historical morbidity and reliance rates of the current 
priority category 8 enrollee population. The projected expenditures 
represent the cost to provide the projected health care services to 
these new enrollees.
    Using the 2008 Model, VA projects that this proposed regulatory 
change would result in an additional 258,705 priority category 8 
enrollees in FY 2009. The projected increase in total health care 
service expenditures associated with this new enrollment is $485 
million in FY 2009. The revenues generated by the first- and third-
party collections are projected to be $121 million,\1\ resulting in a 
$364 million growth in net health service expenditures for FY 2009, and 
$375 million was provided in the Consolidated Security, Disaster 
Assistance, and Continuing Appropriations Act, 2009 (Pub. L. 110-329). 
VA's expenditures related to this proposed regulatory change are 
projected to be approximately $2.931 billion for five years.\2\ These 
expenditures exclude services such as Long Term Care, Readjustment 
Counseling, Spina Bifida, Foreign Medical Programs, Non-Veteran Medical 
Care and CHAMPVA.

    \1\ The first party collections are based on the projected 
health care service utilization of the new Priority 8 enrollees. In 
the base year (2007), we applied the appropriate co-payment to the 
projected services. We then balanced the resulting co-payment 
revenue projections to the actual collections for 2007 for four 
categories (inpatient, outpatient, residential rehabilitation, and 
pharmacy) and by Veterans Integrated Service Network (VISN) to 
account for the amount actually collected. The resulting first-party 
revenue per service developed for 2007 is applied to the projected 
services in future years to project the first-party revenue 
associated with health care utilization of the new Priority 8 
enrollees. Further, the pharmacy co-payment is increased over time 
based on the legislated Consumer Price Index (CPI) schedule.
    To develop the third-party collections, we calculated the 
percentage of third-party revenue collected in 2007 as a percent of 
2007 expenditures by VISN, priority level, and two age bands (under 
and over age 65). We then applied these percentages to the projected 
expenditures for the new Priority 8 enrollees in future years. For 
2010, the percentages were increased to reflect VHA's initiatives to 
increase third-party revenue collections.

                                         \2\ Five Year Projection Table
                               [Present value: (future value)/((1+i-[supcaret]n)]
----------------------------------------------------------------------------------------------------------------
          ($ in billions)             FY 2009      FY 2010      FY 2011      FY 2012      FY 2013       5 year
----------------------------------------------------------------------------------------------------------------
Future Value (FV).................       $0.485       $0.533       $0.580       $0.631       $0.702       $2.931
3% discount rate (i)..............        3.00%        3.00%        3.00%        3.00%        3.00%  ...........
7% discount rate (i)..............        7.00%        7.00%        7.00%        7.00%        7.00%  ...........
Number of Years (n)...............            0            1            2            3            4  ...........
Present Value (PV) at 3%..........       $0.485       $0.517       $0.546       $0.578       $0.624       $2.751
Present Value (PV) at 7%..........       $0.485       $0.498       $0.506       $0.515       $0.536       $2.540
----------------------------------------------------------------------------------------------------------------

    VA requests comments on all of these projections.

Regulatory Flexibility Act

    The Secretary hereby certifies that the adoption of this proposed 
rule would 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 rule would not directly affect 
any small entities. Only individuals could be directly affected. 
Therefore, pursuant to 5 U.S.C. 605(b), this rule is exempt from the 
initial and final regulatory flexibility analysis requirements of 
sections 603 and 604.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are 64.005, Grants to States for 
the Construction of State Homes; 64.007, Blind Rehabilitation Centers; 
64.008, Veterans Domiciliary Care; 64.009, Veterans Medical Care 
Benefits; 64.010, Veterans Nursing Home Care; 64.011, Veterans Dental 
Care; 64.012, Veterans Prescription Service; 64.013, Veterans 
Prosthetic Appliances; 64.014, Veterans State Domiciliary Care; 64.015, 
Veterans State Nursing Home Care; 64.016, Veterans State Hospital Care; 
64.018, Sharing Specialized Medical Resources; 64.019, Veterans 
Rehabilitation Alcohol and Drug Dependence; and 64.022, Veterans Home 
Based Primary Care.

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: January 13, 2009.
James B. Peake,
Secretary of Veterans Affairs.

    For the reasons set out in the preamble, VA proposes to amend 38 
CFR part 17 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, and as stated in specific 
sections.

    2. Amend Sec.  17.36 by revising paragraphs (b)(8), (c)(1), (c)(2), 
and (d)(1) and the authority citation to read as follows:


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

* * * * *
    (b) * * *
    (8) Veterans not included in priority category 4 or 7, who are 
eligible for care only if they 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 who were 
in an enrolled status on January 17, 2003, or who are moved from a 
higher priority category or subcategory due to no longer being eligible 
for inclusion in such priority category or subcategory and who 
subsequently do not request disenrollment;
    (ii) Noncompensable zero percent service-connected veterans not 
included in paragraph (b)(8)(i) of this section and whose income is not 
greater than ten percent more than the income that

[[Page 3540]]

would permit their enrollment in priority category 5 or priority 
category 7, whichever is higher;
    (iii) Nonservice-connected veterans who were in an enrolled status 
on January 17, 2003, or who are moved from a higher priority category 
or subcategory due to no longer being eligible for inclusion in such 
priority category or subcategory and who subsequently do not request 
disenrollment;
    (iv) Nonservice-connected veterans not included in paragraph 
(b)(8)(iii) of this section and whose income is not greater than ten 
percent more than the income that would permit their enrollment in 
priority category 5 or priority category 7, whichever is higher;
    (v) Noncompensable zero percent service-connected veterans not 
included in paragraph (b)(8)(i) or paragraph (b)(8)(ii) of this 
section; and
    (vi) Nonservice-connected veterans not included in paragraph 
(b)(8)(iii) or paragraph (b)(8)(iv) of this section.
    (c) * * *
    (1) It is anticipated that each year the Secretary will consider 
whether to change the categories and subcategories of veterans eligible 
to be enrolled. The Secretary at any time may revise the categories or 
subcategories of veterans eligible to be enrolled by amending paragraph 
(c)(2) of this section. The preamble to a Federal Register document 
announcing which priority categories and subcategories are eligible to 
be enrolled must specify the projected number of fiscal year applicants 
for enrollment in each priority category, projected healthcare 
utilization and expenditures for veterans in each priority category, 
appropriated funds and other revenue projected to be available for 
fiscal year enrollees, and projected total expenditures for enrollees 
by priority category. The determination should include consideration of 
relevant internal and external factors, e.g., economic changes, changes 
in medical practices, and waiting times to obtain an appointment for 
care. 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.
    (2) Unless changed by a rulemaking document in accordance with 
paragraph (c)(1) of this section, VA will enroll the priority 
categories of veterans set forth in Sec.  17.36(b) beginning [effective 
date of regulation], except that those veterans in subcategories (v) 
and (vi) of priority category 8 are not eligible to be enrolled.
    (d) * * *
    (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 or via an online submission at https://www.1010ez.med.va.gov/sec/vha/1010ez/.
* * * * *
(Authority: 38 U.S.C. 101, 501, 1521, 1701, 1705, 1710, 1722)

 [FR Doc. E9-1024 Filed 1-16-09; 8:45 am]
BILLING CODE 8320-01-P