[Federal Register Volume 74, Number 93 (Friday, May 15, 2009)]
[Rules and Regulations]
[Pages 22832-22835]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-11400]
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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: Final rule.
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SUMMARY: This document amends the Department of Veterans Affairs (VA)
medical regulations regarding enrollment in the VA health care system.
In particular, it establishes additional sub-priorities within
enrollment priority category 8 and provides that beginning on the
effective date of the rule, VA will begin enrolling priority category 8
veterans whose income exceeds the current means test and geographic
means test income thresholds by 10 percent or less.
DATES: Effective date: This final rule is effective June 15, 2009.
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: In a document published in the Federal
Register (74 FR 3535) on January 21, 2009, we proposed amendments to 38
CFR 17.36 regarding enrollment of veterans for purposes of VA hospital
and outpatient care. This document adopts as a final rule, without
change, those proposed amendments.
This final rule amends regulations implementing Public Law 104-262,
the Veterans' Health Care Eligibility Reform Act of 1996, which
required VA to
[[Page 22833]]
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
sub-prioritization of the statutory enrollment categories ``as the
Secretary determines necessary.'' The law also provided that starting
on October 1, 1998, most veterans had to enroll in the VA health care
system as a condition for receiving VA hospital and outpatient care.
We provided a 60-day comment period, which ended on February 20,
2009. We received comments from one individual who essentially
expressed concern about VA's evaluation of his service-connected
disability and recommended that VA amend the current means test for VA
medical care to provide certain unspecified exceptions. However, we did
not propose to amend any of the disability evaluation regulations in 38
CFR part 3 or how VA administers the current means test for VA medical
care in 38 CFR 17.47(d) through (f). Accordingly, the comments are not
within the scope of this rulemaking and we will not make any changes
based upon the comments.
Previous Interim Final Rule and Responses to Comments
The proposed rule also noted that the amendments would modify
provisions adopted in the interim final rule published in the Federal
Register on January 17, 2003 (68 FR 2669), which limited enrollment of
veterans for VA medical care under priority category 8. We received
five comments concerning that interim final rule. All of the commenters
expressed disagreement with VA's decision to suspend enrollment of
additional veterans in priority category 8. In that regard, each of the
commenters would support the extension of priority 8 coverage in this
final rule.
Each of the commenters also generally expressed the view that VA
should provide care to all veterans because they served their country.
However, as discussed in the preambles to the 2003 interim final rule
and 2009 proposed 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 decisions made in the interim final rule and this final rule
were based on an assessment concerning available resources, and we did
not receive any comments regarding either rule suggesting that VA's
assessment was incorrect.
Based on the rationale in the proposed rule, we are adopting the
provisions of the proposed rule as a final rule without change.
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 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 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 rule and has concluded that it is an
economically significant regulatory action under Executive Order 12866
because it 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 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 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 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
[[Page 22834]]
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 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 $2.931 billion for five years.\2\ These
expenditures exclude services such as Long Term Care, Readjustment
Counseling, Spina Bifida, Foreign Medical Programs, Non-Veteran Medical
Care and CHAMPVA.
\1\ The first party collections are based on the projected
health care service utilization of the new Priority 8 enrollees. In
the base year (2007), we applied the appropriate co-payment to the
projected services. We then balanced the resulting co-payment
revenue projections to the actual collections for 2007 for four
categories (inpatient, outpatient, residential rehabilitation, and
pharmacy) and by Veterans Integrated Service Network (VISN) to
account for the amount actually collected. The resulting first-party
revenue per service developed for 2007 is applied to the projected
services in future years to project the first-party revenue
associated with health care utilization of the new Priority 8
enrollees. Further, the pharmacy co-payment is increased over time
based on the legislated Consumer Price Index (CPI) schedule.
To develop the third-party collections, we calculated the
percentage of third-party revenue collected in 2007 as a percent of
2007 expenditures by VISN, priority level, and two age bands (under
and over age 65). We then applied these percentages to the projected
expenditures for the new Priority 8 enrollees in future years. For
2010, the percentages were increased to reflect VHA's initiatives to
increase third-party revenue collections.
\2\ Five Year Projection Table
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($ in billions):
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
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Regulatory Flexibility Act
The Secretary hereby certifies that the adoption of this 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 rule will not directly affect any small entities.
Only individuals will be directly affected. Therefore, pursuant to 5
U.S.C. 605(b), this rule is exempt from the final regulatory
flexibility analysis requirements of section 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 recordkeeping requirements, Scholarships and fellowships, Travel
and transportation expenses, Veterans.
Approved: April 15, 2009.
John R. Gingrich,
Chief of Staff, Department of Veterans Affairs.
0
For the reasons set out in the preamble, the Department of Veterans
Affairs amends 38 CFR part 17 as follows:
PART 17--MEDICAL
0
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.
0
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 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
[[Page 22835]]
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. E9-11400 Filed 5-14-09; 8:45 am]
BILLING CODE 8320-01-P