[Federal Register Volume 79, Number 185 (Wednesday, September 24, 2014)]
[Rules and Regulations]
[Pages 57409-57415]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-22637]



[[Page 57409]]

Vol. 79

Wednesday,

No. 185

September 24, 2014

Part V





Department of Veterans Affairs





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38 CFR Part 17





 Hospital Care and Medical Services for Camp Lejeune Veterans; Payment 
or Reimbursement for Certain Medical Expenses for Camp Lejeune Family 
Members; Final Rule

Federal Register / Vol. 79 , No. 185 / Wednesday, September 24, 2014 
/ Rules and Regulations

[[Page 57410]]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AO78


Hospital Care and Medical Services for Camp Lejeune Veterans

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: This document amends Department of Veterans Affairs (VA) 
regulations in order to implement a statutory mandate that VA provide 
health care to certain veterans who served at Camp Lejeune, North 
Carolina, for at least 30 days during the period beginning on January 
1, 1957, and ending on December 31, 1987. The law requires VA to 
furnish hospital care and medical services for these veterans for 
certain illnesses and conditions that may be attributed to exposure to 
toxins in the water system at Camp Lejeune. This rule does not 
implement the statutory provision requiring VA to provide health care 
to these veterans' family members; regulations applicable to such 
family members will be promulgated through a separate notice.

DATES: Effective Date: This rule is effective September 24, 2014.

FOR FURTHER INFORMATION CONTACT: Terry Walters, Deputy Chief 
Consultant, Post-Deployment Health, Office of Public Health (10P3A), 
Veterans Health Administration, 810 Vermont Avenue NW., Washington, DC 
20420, (202) 461-1017 (this is not a toll-free number).

SUPPLEMENTARY INFORMATION: On September 11, 2013, VA published a notice 
of proposed rulemaking setting forth proposed regulations to provide 
hospital care and medical services to certain veterans who served at 
Camp Lejeune for at least 30 days from January 1, 1957, to December 31, 
1987. 78 FR 55671-55675, Sept. 11, 2013. Interested persons were 
invited to submit comments on or before October 11, 2013. We received a 
total of 65 comments. All of the issues raised by the commenters that 
opposed at least one portion of the rule can be grouped together by 
similar topic, and we have organized our discussion of the comments 
accordingly. Based on the rationale set forth in the proposed rule and 
in this document, VA is adopting the proposed rule as a final rule with 
one change to 38 CFR 17.400(d)(2)(A).

Limitations on Retroactive Copayments

    In paragraph Sec.  17.400(d)(2)(A) of the proposed rule, we had 
stated that in order to receive retroactive reimbursement for care 
provided by VA for a condition or illness that was made copayment 
exempt, veterans must request Camp Lejeune status no later than 
September 11, 2015. We explained that we selected that date because it 
was two years after publication of the proposed rule. We received 
numerous comments on this provision.
    First, commenters misunderstood the effect of Sec.  
17.400(d)(2)(A). To be clear, it is not a deadline to enroll in VA as a 
Camp Lejeune veteran. Rather, as we explained in the proposed rule, 
Sec.  17.400(d)(2) establishes that VA would retroactively reimburse 
certain copayments paid by Camp Lejeune veterans for VA-provided health 
care. There is no deadline for a veteran to enroll in VA and be 
recognized as a Camp Lejeune veteran.
    Commenters were also concerned about the deadline for retroactive 
copayments. For example, one individual noted that a veteran could be 
treated for a period of time without being diagnosed with one of the 15 
conditions, and stated that in such a case the veteran's copayments 
should be returned to the veteran. Another commenter suggested that VA 
apply a deadline for retroactive copayment only after VA notifies the 
affected veteran of his or her eligibility for Camp Lejeune veteran 
status and the procedures to apply for retroactive reimbursement.
    We note that as soon as the law became effective, VA began an 
aggressive effort to notify veterans of the Camp Lejeune veteran 
status. VA does not hold or maintain the records of all individuals who 
served at Camp Lejeune, and has instead engaged in comprehensive 
outreach to all veterans. In addition, new enrollees in the VA 
healthcare system are now required to answer on the enrollment form, VA 
form 10-10EZ, whether they served at Camp Lejeune for the requisite 
time periods. VA has conducted, and will continue to conduct for at 
least the next two years, aggressive outreach to veterans through the 
Marine Corp registry and the Agency for Toxic Substances and Disease 
Registry (ATSDR) Community Action Panel, and will provide education to 
VA environmental health providers. VA has directly notified Veteran 
Service Organizations on the benefit that VA is providing to veterans. 
VA has used both print and digital methods to reach the largest 
possible number of veterans. Finally, VA clinicians are being trained 
to identify the 15 illnesses or conditions and ask whether veterans 
diagnosed as having one of them served at Camp Lejeune.
    Having a deadline after which VA will not accept retroactive claims 
for copayment reimbursement is necessary to ensure program integrity 
and reduce potential administrative burdens associated with retroactive 
reviews of old claims. It is also consistent with other retroactive 
payment authorities in part 17 of title 38, Code of Federal 
Regulations. See 38 CFR 17.129 and 17.1004. We do, however, accept the 
commenters' suggestions that more time is needed for veterans to learn 
about this program. We therefore adjust the deadline for submission of 
a request for Camp Lejeune status to obtain eligibility for retroactive 
reimbursement from September 11, 2015, to September 24, 2016. This will 
align the two-year deadline with the date that this rule takes effect, 
rather than the date that it was proposed.

Issues Concerning Enrollment Procedures

    We received several comments about the enrollment process. Some 
commenters asked specific questions about how the regulation would be 
applied to their particular cases, or identified themselves as Camp 
Lejeune veterans and requested benefits. Whenever possible, based on 
identifying information provided in the comment, we have contacted 
these individuals privately to assist them. It is inappropriate to 
address individuals' claims with specificity in this notice; however, 
several commenters were concerned that the enrollment process would be 
burdensome, or that VA would require veterans to fill out forms or 
otherwise take actions that, in practice, VA does not require. To 
address these concerns, we assure the public that enrollment as a Camp 
Lejeune veteran will be as seamless and simple as possible. Veterans 
who identify themselves as Camp Lejeune veterans on VA Form 10-10EZ and 
whose status is confirmed will not need to re-enroll for VA care or 
take any further action in order to be copayment-exempt for future care 
related to their Camp Lejeune illness. Veterans also will generally not 
need to take any specific actions, once their status is verified, to 
receive retroactive reimbursement for copayments paid before their Camp 
Lejeune status was established (as long as the care was provided on or 
after August 6, 2012, the date that the legislation authorized VA to 
begin providing Camp Lejeune benefits). VA will pay retroactive 
copayments in accordance with paragraph (d)(2) of the regulation 
without requiring further action by such veterans. Only in 
extraordinary situations--for example, if

[[Page 57411]]

it is not immediately apparent that the claimant is a veteran--will VA 
require veterans to take additional action by providing more 
information or evidence related to their claims.
    One commenter was concerned that veterans will not remember the 
exact dates that they resided at Camp Lejeune. The commenter was also 
concerned, generally, that older veterans have difficulty filling out 
forms.
    We understand that some veterans may have difficulty completing 
VA's application for enrollment, VA Form 10-10EZ, which is available 
online at https://www.1010ez.med.va.gov/. VA offers resources at the 
local level in VA Medical Centers to assist veterans in filling out our 
forms. In addition, we operate a help line (1-877-222-VETS(8387)). 
Moreover, we note that veterans who are already enrolled need only 
identify themselves as Camp Lejeune veterans at their local facility or 
on the help line--or state that they believe they may qualify as a Camp 
Lejeune veteran--and VA will take appropriate action, without requiring 
that the veteran fill out a new form or remembering the specific dates 
they resided at Camp Lejeune. Finally, VA recently revised the VA Form 
10-10EZ in order to reduce the burden on veterans. VA will continue to 
provide veterans with assistance to complete applications, and provide 
Camp Lejeune veterans with specific guidance and help. However, we do 
not make any changes based on the above comments.

Concerns Over Clinical Identification of Illnesses or Conditions

    Many commenters were concerned by Sec.  17.400(c), which states 
that VA will assume that one of the 15 illnesses or conditions are 
considered attributable to the veteran's active duty in the Armed 
Forces unless VA clinically determines under its clinical practice 
guidelines that the illness or condition is not attributable to the 
veteran's service. One commenter suggested that VA include a 
``preponderance of the evidence'' standard of proof for determining 
whether a Camp Lejeune veteran's illness or condition is attributable 
to a cause other than service at Camp Lejeune. Other commenters 
suggested that VA remove Sec.  17.400(c) entirely because, they assert, 
it is impossible to determine the cause of a specific illness or 
condition. We are not making any changes to the final rule based on 
these comments because the comments misconstrue the effect of the law 
and regulation.
    Under 38 U.S.C. 1710(e)(1)(F), VA is required to provide hospital 
care and medical services to a veteran who served at Camp Lejeune who 
has one of the 15 identified illnesses or conditions. VA does not, and 
cannot, require veterans to produce affirmative evidence of a 
connection between their illness or condition and exposure to 
contaminated water at Camp Lejeune. The only limitation on this 
requirement is that, under 38 U.S.C. 1710(e)(2)(B), VA is barred from 
providing such care to a veteran based solely on the veteran's status 
as a Camp Lejeune veteran if the veteran's illness or condition is 
found, in accordance with guidelines issued by the Under Secretary for 
Health, to have resulted from a cause other than exposure at Camp 
Lejeune. In other words, the burden is on VA to clinically determine 
that, in a particular veteran's case, his or her illness or condition 
resulted from something other than service at Camp Lejeune. Thus, VA 
practice will not be to require veterans to make an affirmative showing 
of a connection unless VA determines that an illness or condition is 
not connected to service at Camp Lejeune.
    Moreover, it is not VA's intent, nor has it been our practice, to 
attempt to disqualify Camp Lejeune veterans from receiving copayment-
free care for a listed condition or illness. We acknowledge that given 
current science, it may be difficult in many situations to determine 
the cause of a veteran's illness or condition. In these cases, VA will 
give the benefit of the doubt to the veteran.
    For example, one commenter stated that lung cancer, one of the 15 
listed illnesses or conditions, could be erroneously attributed to 
cigarette smoking rather than service at Camp Lejeune. Medical science 
cannot definitively distinguish clinically whether the origin of an 
individual's lung cancer is the result of service at Camp Lejeune or 
cigarette smoking. Therefore, VA would not be able to rule out the 
clinical possibility that the veteran's lung cancer was caused by 
service at Camp Lejeune, and such a veteran would receive his or her 
cancer treatments without being required to make a copayment. This 
would be true even if cigarette smoking were medically more likely than 
not the cause of the veteran's lung cancer.
    Some commenters questioned whether the proposed rule would cover 
secondary illnesses or conditions that arise from, or lead to the 
development of, one of the 15 listed illnesses or conditions. Once VA 
enrolls a Camp Lejeune veteran as a Priority Group 6 veteran, that 
individual receives comprehensive VA care; however, pursuant to 38 
U.S.C. 1710(e)(1)(F), VA may only waive copayments for hospital care 
and medical services provided for one of the 15 illnesses or 
conditions. Therefore, VA will determine clinically whether a separate 
condition or illness was caused by or resulted from one of the 15 
illnesses or conditions. VA will also determine clinically whether any 
prior treatment was provided for one of the 15 illnesses or conditions 
that was undiagnosed at the time that the hospital care or medical 
services were provided. If such a clinical nexus exists, then VA would 
waive or reimburse the copayment. If VA clinically determines that the 
illness or condition is not related to one of the 15 illnesses or 
conditions, then VA will assess a copayment. Similarly, VA cannot 
reimburse a copayment if VA clinically determines that the previously 
provided hospital care or medical services were not for one of the 15 
illnesses or conditions. This is consistent with the limited mandate to 
provide care in section 1710(e)(1)(F) and VA's provision of hospital 
care and medical services for other Priority Group 6 veterans. See 38 
CFR 17.108(d).
    One commenter provided an example of breast cancer, which is one of 
the 15 illnesses covered by the statute that metastasizes to the 
patient's brain. VA clinicians evaluate the unique needs of each 
patient, and will do so for Camp Lejeune veterans as well. We will use 
this same approach for determining the clinical progression of an 
illness or condition in each Camp Lejeune veteran. In this example, if 
a VA clinician determines that a Priority Group 6 Camp Lejeune 
veteran's breast cancer (one of the 15 listed illnesses) may have 
spread to his or her brain, and VA waives copayment for the breast 
cancer due to the connection to service at Camp Lejeune, then VA would 
also waive copayments for treatment of the brain cancer. If the VA 
clinician affirmatively identifies a clinical origin of the brain 
cancer other than the breast cancer, then VA will assess copayments for 
the treatment of the brain cancer.
    One commenter suggested that VA implement baseline screenings for 
all Camp Lejeune veterans. Once VA enrolls veterans in the healthcare 
system, regardless of their Priority Group level, veterans and their 
clinicians together determine what is appropriate for each individual's 
clinical needs. Screenings for one or more of the 15 illnesses or 
conditions may often be clinically indicated and medically appropriate. 
In such cases, VA would consider such screenings to be related hospital 
care or medical services, and Camp Lejeune veterans will not be charged 
a copayment.

[[Page 57412]]

    Some commenters stated that Camp Lejeune veterans who have been 
diagnosed with at least one of the 15 illnesses or conditions should be 
able to continue to see their private physicians in order to ensure 
continuity of care. Some also suggested that VA reimburse veterans, 
either prospectively or retroactively, for care obtained from private 
physicians. We noted in the proposed rule that 38 U.S.C. 1710 only 
authorizes VA to provide direct hospital care and medical services to 
certain veterans. 78 FR 55672, Sept. 11, 2013. Section 1710 does not 
authorize VA to provide payment or reimbursement for care that VA did 
not provide to the veteran. Referral for non-VA medical care once 
enrolled is for preauthorized care. VA will authorize non-VA care for 
Camp Lejeune veterans in the same manner that VA authorizes such care 
for all Priority Group 6 veterans. In general, VA is a direct care 
provider, but may preauthorize non-VA care for certain veterans based 
on a variety of circumstances, such as the urgency of an individual's 
medical condition, the relative distance of the travel involved, or the 
nature of the treatment required, in accordance with our authority in 
38 U.S.C. 1703 and 8153 Subject to the provisions of Sec.  
17.400(d)(2), VA will reimburse Camp Lejeune veterans for copayments 
made for preauthorized non-VA hospital care and medical services that 
VA furnished on or after August 6, 2012. Commenters also inquired about 
reimbursement for costs incurred by Camp Lejeune veterans for hospital 
care and medical services that veterans obtained from non-VA providers 
prior to acquiring Camp Lejeune veteran status. Although, as noted 
above, VA does preauthorize non-VA hospital care and medical services 
when clinically appropriate, this law does not authorize VA to pay for 
hospital care and medical services that have already been provided to 
the veteran from a non-VA provider.
    Similarly, one commenter stated that he is a Camp Lejeune veteran 
who obtains his care locally, and that by doing so, rather than 
travelling to the nearest VA facility, he was saving VA ``thousands of 
dollars.'' He requested reimbursing veterans for local care when the 
veteran lives more than one hour away from the closest VA hospital that 
can provide care. VA understands that there are instances where 
geography is a vital factor in determining the best course of treatment 
or care. As noted above, VA preauthorizes non-VA care based on a 
variety of circumstances, including geographic location, and will make 
the same determinations for Camp Lejeune veterans.
    In addition, veterans enrolled in Priority Group 6, which includes 
Camp Lejeune veterans, may be eligible for travel benefits associated 
with their care in accordance with 38 CFR part 70--although eligibility 
as a Camp Lejeune veteran does not independently establish eligibility 
for travel benefits. We do not make any changes based on this comment.
    A commenter requested that VA add ``and symptoms arising therefrom 
prior to diagnosis'' to Sec.  17.400(c) in order to ensure that VA 
exempts veterans from copayments for hospital care and medical services 
provided for symptoms that existed before the appropriate diagnosis was 
made. We note that when issues of copayments are connected to clinical 
determinations, VA defers to the expertise of the clinical provider. VA 
conducts the same review process for veterans receiving treatment in 
connection to exposure to Agent Orange. First, the veteran requests a 
review of his copayments by calling the VA call center at 1-877-222-
VETS(8387). The call center will then refer the request to VA 
Utilization nurses who manually review the claim and the veteran's 
medical records. The nurses also contact the providers. If the 
veteran's provider determines that the hospital care and medical 
service provided prior to the diagnosis of one of the 15 conditions or 
illnesses were attributable to the veteran's service at Camp Lejeune, 
then the provider will update the veteran's progress notes and VA will 
manually process a refund of the copayment. Camp Lejeune veterans will 
be able to request the same review of copayments made for hospital care 
and medical services furnished by VA prior to the diagnosis of one of 
the 15 illnesses or conditions. We therefore make no changes to the 
rule based on the above comments.
    One commenter asked whether VA would require veterans to repay 
copayments waived or reimbursed for care for one of the 15 illnesses or 
conditions if VA later determines that the veteran's illness or 
condition resulted from a cause other than his or her service at Camp 
Lejeune. VA would assess a copayment for such hospital care or medical 
services, but we note that those instances would be rare. See 38 CFR 
17.102(a) (authorizing VA to recoup payment when care is provided in 
error). VA would attempt to make the clinical determination about the 
origin of an illness or condition at the time that the veteran either 
enrolls, or if enrolled, the time that the veteran notifies VA of his 
or her service at Camp Lejeune during the relevant time periods. Any 
veteran who self-identified as a Camp Lejeune veteran and received care 
from VA for one of the 15 illnesses or conditions, may be subject to 
copayments for care provided prior to the publication of this final 
rule if VA determines that the illness or condition resulted from a 
cause other than service at Camp Lejeune.
    A commenter suggested that VA recruit doctors who specialize in one 
or more of the 15 listed illnesses or conditions, and that those 
doctors be in the U.S. Military, or be veterans. We note that VA 
currently employs clinicians who specialize in each of the 15 illnesses 
or conditions. Though VA proudly employs a great number of veterans, it 
is not our view that one's status as a veteran or member of the armed 
forces has any bearing on an individual's ability to serve as a VA 
clinician. VA seeks to recruit well-qualified clinicians and will 
continue to do so utilizing existing hiring practices.

Appeals

    One commenter suggested that the rule ``should include provisions 
that provide for notice of a denial, the provision of the research 
forming the basis for the denial, and the opportunity to challenge the 
denial before a judicial body'' and provide the ``ability of Camp 
Lejeune veterans to challenge the clinical practice guidelines and the 
denial of medical assistance.''
    Veterans are given the same appeal rights for Camp Lejeune benefits 
as for other benefits administered by VA. Along with the written 
explanation for the denial of benefits, the veteran receives a form 
explaining the appeals process (VA Form 4107VHA for VHA decisions). 
Part 20 of title 38, CFR, gives the Board of Veterans' Appeals 
jurisdiction over questions of law and fact that affect the provision 
of VA benefits. The Board's jurisdiction also extends to questions of 
eligibility for health care benefits administered by the Veterans 
Health Administration, which would include eligibility as a Camp 
Lejeune Veteran. See 38 CFR 20.101(b). The clinical practice guidelines 
provide factors for clinicians to consider when determining whether an 
illness or condition is attributable to a cause other than the 
veteran's residence at Camp Lejeune. The guidelines explain such 
clinical indications, evolve over time, and encourage clinicians to 
consider the veteran's full history in order to make the best possible 
clinical determination. The clinical practice guidelines will serve as 
a resource to VA clinicians and will not require that VA clinicians 
take specific actions. Therefore, we do not

[[Page 57413]]

make any changes based on the above comment.

Comments Suggesting Expanding VA's Authority

    A number of commenters raised specific concerns with the statute 
authorizing the provision of hospital care and medical services.
    Many commenters suggested other conditions or illnesses that should 
be covered. Other commenters stated that the dates of eligible service 
at Camp Lejeune, January 1, 1957, to December 31, 1987, should be 
expanded to cover veterans who served at Camp Lejeune before or after 
such dates. Regardless of the merit of these comments, VA is without 
legal authority to provide benefits other than those authorized by 
statute. We do not make any changes based on these comments.
    Some commenters suggested that veterans be compensated in 
connection to their service at Camp Lejeune. Several suggested that 
they had been unable to conceive a child, and believed that this 
inability was directly due to exposure at Camp Lejeune, and asked to be 
compensated accordingly. VA cannot expand our authority through 
regulation beyond what Congress authorizes us to provide in law. 
Section 1710(e)(1)(F) of title 38, U.S.C., authorizes VA only to 
provide health care; it is not a compensation program. We lack 
authority to provide compensation under this law; however, if the 
commenter believes that they have a service-connected disability due to 
their exposure at Camp Lejeune, they should file a disability 
compensation claim with the Veterans Benefits Administration.
    One commenter suggested that VA furnish hospital care and medical 
services for individuals who served at Camp Lejeune while on active 
duty for training. We are legally barred from doing so because 38 
U.S.C. 1710(e)(1)(F) requires VA to furnish hospital care and medical 
services to Camp Lejeune veterans who ``served on active duty.'' Active 
duty is defined, as a matter of law, in 38 U.S.C. 101(21)(A), as full-
time duty in the Armed Forces, other than active duty for training.
    Some commenters raised issues of the validity of the studies relied 
on by Congress in enacting this law. VA cannot expand benefits beyond 
those granted by statute, even if the commenters believe that science 
does not support certain limitations in the law. Therefore, we do not 
make any changes based on the above comments.

Comments Related to VA Claims Backlog

    Commenters requested that VA improve its claims backlog for veteran 
benefits. We note that this issue is outside the scope of this 
rulemaking and VA will therefore not respond to those comments here.

Comments Related to Family Members

    A number of commenters raised issues related to VA's furnishing of 
hospital care and medical services to the family members of Camp 
Lejeune veterans. As we noted in the proposed rule, VA will publish a 
separate rulemaking concerning the family members of Camp Lejeune 
veterans. Such comments are outside the scope of this rulemaking and no 
changes will be made to this rule based on those comments.

Effect of Rulemaking

    Title 38 of the Code of Federal Regulations, as revised by this 
rulemaking, represents VA's implementation of its legal authority on 
this subject. Other than future amendments to this regulation or 
governing statutes, no contrary guidance or procedures are authorized. 
All existing or subsequent VA guidance must be read to conform with 
this rulemaking if possible or, if not possible, such guidance is 
superseded by this rulemaking.

Administrative Procedure Act

    In accordance with 5 U.S.C. 553(d)(3), the Secretary of Veterans 
Affairs finds good cause to issue this final rule with an immediate 
effective date. This rule is necessary to provide clarity regarding 
VA's duty to provide health care to veterans who may have been exposed 
to toxic substances due to their service at Camp Lejeune. Section 102 
of Public Law 112-154 requires VA to provide hospital care and medical 
services to Camp Lejeune veterans for the listed conditions and 
illnesses as of August 6, 2012. Many of the 15 listed conditions or 
illnesses are life-threatening and require immediate medical care. VA 
is capable of treating Camp Lejeune veterans for such illnesses or 
conditions immediately, which may lead to improved health outcomes for 
many veterans. However, this rule provides VA with the necessary 
framework to immediately implement this statutory requirement.
    This rule clearly defines how VA proposes to identify and integrate 
Camp Lejeune veterans into its enrollment system so VA can provide 
necessary health care to these veterans. For example, Public Law 112-
154 requires VA to provide hospital care and medical services to ``a 
veteran who served on active duty in the Armed Forces at Camp Lejeune, 
North Carolina, for not fewer than 30 days during the period beginning 
on January 1, 1957, and ending on December 31, 1987.'' The legislation, 
however, does not define the scope of who should be considered a Camp 
Lejeune veteran. This rule at Sec.  17.400(b) in the definition for 
``Camp Lejeune veteran'' explains that a veteran served at Camp Lejeune 
if he or she was stationed at Camp Lejeune, or traveled to Camp Lejeune 
as part of his or her professional duties. The regulation also explains 
that the 30-day minimum service requirement may be ``consecutive or 
nonconsecutive'' days. Without this regulation, VA would not be able to 
clearly identify all the veterans who should be provided the necessary 
health care as a result of their service at Camp Lejeune. Because of 
this final rule, VA will be able to identify those individuals who 
should be considered Camp Lejeune veterans and conduct outreach to the 
identified class of veterans. Although we expect most Camp Lejeune 
veterans to seek VA medical care for treatment of their illness or 
condition regardless of this rule, there may be some veterans who may 
go without treatment if they are not identified as a Camp Lejeune 
veteran, and their illness or condition does not result in eligibility 
for enrollment. Because many of the 15 listed conditions or illnesses 
are life-threatening and require immediate medical care, this rule with 
an immediate effective date is necessary to allow VA to provide medical 
care to all individuals identified as Camp Lejeune veterans.
    Furthermore, under the provisions of this rule, VA will be able to 
reimburse veterans for copayments that certain veterans may have 
already paid for illnesses or conditions identified in this rule. An 
immediate effective date will allow VA to reimburse copayments to 
alleviate this financial hardship for some of these veterans.
    For these reasons, the Secretary has concluded that ordinary 
effective-date procedures would be impracticable and contrary to the 
public interest and is accordingly issuing this final rule with 
immediate effective date.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 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

[[Page 57414]]

private sector, of $100 million or more (adjusted annually for 
inflation) in any one year. This final rule has no such effect on 
State, local, and tribal governments, or on the private sector.

Paperwork Reduction Act

    This final rule contains no new provisions constituting a 
collection of information under the Paperwork Reduction Act of 1995 (44 
U.S.C. 3501-3521). However, we note that veterans would apply for 
hospital care and medical services as a Camp Lejeune veteran under 
Sec.  17.400 by completing VA Form 10-10EZ, ``Application for Health 
Benefits,'' which is required under 38 CFR 17.36(d) for all hospital 
care and medical services. The Office of Management and Budget (OMB) 
approved the collection of information for VA Form 10-10EZ and assigned 
OMB control number 2900-0091. As discussed in a separate notice (78 FR 
39832, July 2, 2013), we requested approval from OMB to amend this form 
to include a specific checkbox for individuals to identify themselves 
as meeting the requirements of being a Camp Lejeune veteran. OMB 
approved the amended collection. This particular amendment to the form 
will have no appreciable effect on the reporting burden for the revised 
VA Form 10-10EZ. We also do not anticipate a significant increase in 
the total number of applications filed because most Camp Lejeune 
veterans likely would have applied for VA medical care for treatment of 
their illness or condition regardless of this rule.

Regulatory Flexibility Act

    The Secretary hereby certifies that this final 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. 601-12. 
This final rule will directly affect only individuals and will not 
affect any small entities. Therefore, pursuant to 5 U.S.C. 605(b), this 
rulemaking is exempt from the initial and final flexibility analysis 
requirements of 5 U.S.C. 603 and 604.

Executive Order 12866 and Executive Order 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
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 effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
Executive Order 12866 (Regulatory Planning and Review) defines 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 otherwise 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 recipients thereof; or (4) Raise novel legal 
or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in this Executive Order.
    The economic, interagency, budgetary, legal, and policy 
implications of this regulatory action have been examined, and it has 
been determined to be a significant regulatory action under Executive 
Order 12866. VA's impact analysis can be found as a supporting document 
at http://www.regulations.gov, usually within 48 hours after the 
rulemaking document is published. Additionally, a copy of the 
rulemaking and its impact analysis are available on VA's Web site at 
http://www1.va.gov/orpm/, by following the link for ``VA Regulations 
Published.''

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this rule are 64.007, Blind Rehabilitation 
Centers; 64.008, Veterans Domiciliary Care; 64.009, Veterans Medical 
Care Benefits; 64.010, Veterans Nursing Home Care; 64.012, Veterans 
Prescription Service; 64.013, Veterans Prosthetic Appliances; 64.014, 
Veterans State Domiciliary Care; 64.015, Veterans State Nursing Home 
Care; and 64.022, Veterans Home Based Primary Care.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Jose D. 
Riojas, Chief of Staff, approved this document on June 18, 2014, for 
publication.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Alcohol abuse, Alcoholism, 
Claims, Day care, Dental health, Drug abuse, Health care, Health 
facilities, Health professions, Health records, Homeless, Medical 
devices, Medical research, Mental health programs, Nursing homes, 
Veterans.

    Dated: September 18, 2014.
William F. Russo,
Acting Director, Office of Regulation Policy & Management, Office of 
the General Counsel, U.S. Department of Veterans Affairs.

    For the reasons set forth in the supplementary information of this 
rulemaking, 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, and as noted in specific sections.


Sec.  17.36  [AMENDED]

0
2. Amend Sec.  17.36(b)(6) by removing ``38 U.S.C. 1710(e);'' and 
adding, in its place, ``38 U.S.C. 1710(e); Camp Lejeune veterans 
pursuant to Sec.  17.400;''.


Sec.  17.108  [AMENDED]

0
3. Amend Sec.  17.108(e)(2) by removing ``or post-Gulf War combat-
exposed veterans;'' and adding in its place ``post-Gulf War combat-
exposed veterans, or Camp Lejeune veterans pursuant to Sec.  17.400;''.


Sec.  17.110  [AMENDED]

0
4. Amend Sec.  17.110(c)(4) by removing ``or post-Persian Gulf War 
combat-exposed veterans.'' and adding in its place ``post-Persian Gulf 
War combat-exposed veterans, or Camp Lejeune veterans pursuant to Sec.  
17.400.''.


Sec.  17.111  [AMENDED]

0
5. Amend Sec.  17.111(f)(5) by removing ``or post-Persian Gulf War 
combat-exposed veterans.'' and adding in its place ``post-Persian Gulf 
War combat-exposed veterans, or Camp Lejeune veterans pursuant to Sec.  
17.400.''.

0
6. Add an undesignated center heading and Sec.  17.400 to read as 
follows:
Hospital Care and Medical Services for Camp Lejeune Veterans and 
Families


Sec.  17.400  Hospital care and medical services for Camp Lejeune 
veterans.

    (a) General. In accordance with this section, VA will provide 
hospital care

[[Page 57415]]

and medical services to Camp Lejeune veterans. Camp Lejeune veterans 
will be enrolled pursuant to Sec.  17.36(b)(6).
    (b) Definitions. For the purposes of this section:
    Camp Lejeune means any area within the borders of the U.S. Marine 
Corps Base Camp Lejeune or Marine Corps Air Station New River, North 
Carolina.
    Camp Lejeune veteran means any veteran who served at Camp Lejeune 
on active duty, as defined in 38 U.S.C. 101(21), in the Armed Forces 
for at least 30 (consecutive or nonconsecutive) days during the period 
beginning on January 1, 1957, and ending on December 31, 1987. A 
veteran served at Camp Lejeune if he or she was stationed at Camp 
Lejeune, or traveled to Camp Lejeune as part of his or her professional 
duties.
    (c) Limitations. For a Camp Lejeune veteran, VA will assume that 
illnesses or conditions listed in paragraph (d)(1)(i) through (xv) of 
this section are attributable to the veteran's active duty in the Armed 
Forces unless it is clinically determined, under VA clinical practice 
guidelines, that such an illness or condition is not attributable to 
the veteran's service.
    (d) Copayments. (1) Exemption. Camp Lejeune veterans are not 
subject to copayment requirements for hospital care and medical 
services provided on or after August 6, 2012, for the following 
illnesses and conditions:
    (i) Esophageal cancer;
    (ii) Lung cancer;
    (iii) Breast cancer;
    (iv) Bladder cancer;
    (v) Kidney cancer;
    (vi) Leukemia;
    (vii) Multiple myeloma;
    (viii) Myleodysplasic syndromes;
    (ix) Renal toxicity;
    (x) Hepatic steatosis;
    (xi) Female infertility;
    (xii) Miscarriage;
    (xiii) Scleroderma;
    (xiv) Neurobehavioral effects; and
    (xv) Non-Hodgkin's Lymphoma.
    (2) Retroactive Exemption. VA will reimburse Camp Lejeune veterans 
for any copayments paid to VA for hospital care and medical services 
provided for one of the illnesses or conditions listed in paragraph 
(d)(1) of this section, if the following are true:
    (i) The veteran requested Camp Lejeune veteran status no later than 
September 24, 2016; and
    (ii) VA provided the hospital care or medical services to the Camp 
Lejeune veteran on or after August 6, 2012.

    Authority: 38 U.S.C. 1710.

[FR Doc. 2014-22637 Filed 9-23-14; 8:45 am]
BILLING CODE 8320-01-P