[Federal Register Volume 83, Number 21 (Wednesday, January 31, 2018)]
[Proposed Rules]
[Pages 4452-4455]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-01865]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AP55


Medical Care in Foreign Countries and Filing for Reimbursement 
for Community Care Not Previously Authorized by VA

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend its 
medical regulations related to hospital care and medical services in 
foreign countries. We would amend the regulations to simplify and 
clarify the scope of these rules. We would address medical services 
provided to eligible veterans in the Republic of the Philippines, and 
remove regulations related to grants to the Republic of the Philippines 
that are no longer supported by statutory authority. VA also proposes 
to amend its medical regulations related to filing claims for 
reimbursement of medical expenses incurred for VA care not previously 
authorized.

DATES: Written comments must be received on or before April 2, 2018.

ADDRESSES: Written comments may be submitted through 
www.Regulations.gov; by mail or hand-delivery to the Director, 
Regulations Management (00REG), Department of Veterans Affairs, 810 
Vermont Ave NW, Room 1063B, Washington, DC 20420; or by fax to (202) 
273-9026. Comments should indicate that they are submitted in response 
to ``RIN 2900-AP55--Medical care in foreign countries and filing for 
reimbursement for community care not previously authorized by VA.'' 
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 (this is not a toll-free 
number). In addition, during the comment period, comments may be viewed 
online through the Federal Docket Management System (FDMS) at 
www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Joseph Duran, Director, Policy and 
Planning, Office of Community Care (10D1A1), Veterans Health 
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, 
Washington, DC 20420, (303) 372-4629. (This is not a toll-free number) 
or [email protected].

SUPPLEMENTARY INFORMATION: Section 1724 of title 38 United States Code 
(U.S.C.) prohibits VA from furnishing hospital care or medical services 
outside any State except under specific circumstances. VA is authorized 
under 38 U.S.C. 1724(b)(1) to furnish care and services to an eligible 
veteran outside any State if VA ``determines that such care and 
services are needed for the treatment of a service-connected disability 
of the veteran or as part of a rehabilitation program under chapter 31 
of this title.'' VA furnishes health care to eligible veterans in the 
Republic of the Philippines under this authority. In addition, 38 
U.S.C. 1724(c) provides that ``within the limits'' of the Veterans 
Memorial Medical Center at Manila, Republic of the Philippines, VA may 
enter into contracts to furnish necessary hospital care to a veteran 
for any non-service-connected disability if such veteran is unable to 
defray the expenses of necessary hospital care. VA may also operate an 
outpatient clinic in the Republic of the Philippines to furnish 
necessary medical services to a veteran who has a service-connected 
disability. 38 U.S.C. 1724(e).
    Several sections of title 38 Code of Federal Regulations (CFR) part 
17 address VA's authority to provide for hospital care and medical 
services for eligible veterans outside the United States, as well as 
submission of claims for reimbursement for services obtained from 
community care providers outside the United States. VA proposes to 
revise or amend these regulations to consolidate similar content, 
clarify provisions, and ensure that these regulations reflect current 
VA practice and statutory authority.

Sec.  17.35 Hospital Care and Outpatient Services in Foreign Countries

    Current Sec.  17.35 states that the Secretary may furnish hospital 
care and medical services to any veteran sojourning or residing outside 
the United States, without regard to the veteran's citizenship if 
necessary for treatment of a service-connected disability, or any 
disability associated with and held to be aggravating a service-
connected disability; or, if the care is furnished to a veteran 
participating in a rehabilitation program under 38 U.S.C. chapter 31 
who requires care for the reasons enumerated in 38 CFR 17.47(i)(2).
    We would revise Sec.  17.35 by simplifying the rule and adding a 
paragraph to address medical services provided to eligible veterans in 
the Republic of the Philippines. VA proposes to remove the phrase 
``sojourning or residing'' as it creates an unnecessary distinction. VA 
may furnish medical care and services to any veteran outside the United 
States, regardless of whether the veteran is sojourning (temporarily 
staying), has established residence outside of the United States, or in 
some other status that does not fit the broad definitions of either 
``sojourning or residing.'' In addition, the term ``sojourning'' is 
antiquated. While it remains a defined term in many dictionaries it is 
not commonly used by the public. We would also amend the introductory 
sentence to refer to VA rather than the Secretary of VA which is how VA 
is referred to in recently published rulemakings. We would designate 
the introductory sentence in this section as paragraph (a), and current 
paragraphs (a) and (b) as paragraphs (a)(1) and (2) respectively. 
Finally, we would change the references to ``medical services'' in the 
current regulation to ``outpatient services.'' The term ``outpatient 
services'' is similarly used in Sec.  17.38 and other VA regulations 
instead of ``medical services,'' and we believe it is more 
understandable to the reader.
    We would add a new paragraph (b) to address hospital care and 
outpatient services provided to eligible veterans in the Republic of 
the Philippines as authorized in 38 U.S.C. 1724. Paragraph (b) would 
state that under the VA Foreign Medical Program VA may furnish hospital 
care and outpatient services in the Republic of the Philippines to a 
veteran who meets the requirements of Sec.  17.35(a). VA may also 
provide outpatient services to a veteran in the VA outpatient clinic in 
Manila for the treatment of such veteran's service-connected conditions 
within the limits of the clinic. A veteran's non-service connected 
conditions may also be treated within the limits of the VA outpatient 
clinic in Manila, if the veteran has a service-connected disability.
    Paragraph (c) would provide guidance on which sections of part 17 
apply to claims for payment or reimbursement of services not previously 
authorized by the Foreign Medical Program. We would state that such 
claims are governed by Sec. Sec.  17.123-17.127 and 17.129-17.132. This 
is consistent with the requirements for claims for payment or 
reimbursement for medical services not previously authorized by VA 
provided within the United States.

[[Page 4453]]

Sec.  17.125 Where To File Claims

    Current Sec.  17.125 addresses where veterans must file claims for 
payment or reimbursement of medical expenses incurred for care not 
previously authorized in the United States, including the Territories 
and possessions of the United States, Puerto Rico, the Republic of the 
Philippines, and other foreign countries. Paragraph (a) focuses on 
medical care rendered in the U.S. and U.S. Territories or possessions 
other than Puerto Rico. Puerto Rico is addressed in a separate 
paragraph in current Sec.  17.125 since it is the only U.S. territory 
with a VA medical center. Paragraph (a) directs that claims should be 
filed with the Chief, Outpatient Service, or Clinic Director of the VA 
facility designated as a clinic or jurisdiction which serves the region 
in which the care or services were rendered.
    We would amend Sec.  17.125 by amending the prefatory statement to 
state that, generally, VA must preauthorize VA payment for health care 
services provided in the community when such care is provided in a 
State as that term is defined in 38 U.S.C. 101(20). This definition of 
``State'' encompasses each of the several States, Territories, and 
possessions of the United States, the District of Columbia, and the 
Commonwealth of Puerto Rico. Paragraph (a) would be amended to state 
that in those cases where VA payment for such services has not been 
authorized in advance, claims for payment for such health care services 
provided in a State should be submitted to the VA medical facility 
nearest to where those services were provided. We believe these changes 
would simplify the claims submission process. Under the current rule, a 
veteran must first determine which VA facility is designated as a 
clinic or jurisdiction which serves the region in which the care or 
services were rendered. This may not be the VA facility nearest to 
where community care was rendered, and that information is not always 
readily available. The proposed amendment would require only that the 
veteran determine which VA facility is geographically closest to where 
community care was rendered. In addition, the proposed change would 
simplify the rule, as there would be no separate paragraph addressing 
reimbursement for community care provided in Puerto Rico.
    Current Sec.  17.125 does not specifically address submission of 
claims for medical care provided in Canada. VA entered into a 
reciprocal agreement with Canada in 1956 which provides that Veterans 
Affairs Canada will furnish medical service and hospital care to U.S. 
veterans in Canada to the extent requested by VA. Medical services and 
hospital care furnished by Veterans Affairs Canada under this agreement 
is that authorized under VA's Foreign Medical Program. Consistent with 
that agreement, if a U.S. veteran obtains hospital or medical care in 
Canada which is authorized under 38 CFR 17.35, the veteran must submit 
the claim to Veterans Affairs Canada, a department of the government of 
Canada equivalent to VA. In turn, Canadian veterans who incur certain 
hospital or medical expenses in the United States must submit any claim 
for reimbursement to VA. Proposed paragraph (b) would state that claims 
for payment for health care services under proposed 38 CFR 17.35(a) 
that are provided in Canada must be submitted to the Foreign Countries 
Operations Unit of Veterans Affairs Canada. The Foreign Countries 
Operations Unit is the office designated by Veterans Affairs Canada to 
accept claims for reimbursement of medical expenses from U.S. veterans.
    Current paragraph (c) provides that claims for the expenses of care 
or services rendered in other foreign countries must be mailed to the 
Health Administration Center (HAC). The program office currently 
responsible for administering health care provided to veterans outside 
of the U.S. is the Foreign Medical Program, Office of Community Care. 
In proposed paragraph (c) we would state that all other claims for 
payment for health care services under proposed 38 CFR 17.35(a) that 
are provided outside a State must be submitted to the Foreign Medical 
Program, P.O. Box 469061, Denver, CO 80246-9061.

Sec. Sec.  17.140 and 17.141 Delegation of Authority

    Current Sec.  17.140 states that the VA medical facility with 
responsibility for the fee basis program in the region or territory 
(including the Republic of the Philippines) served by such medical 
facility has authority to adjudicate all claims for the payment or 
reimbursement of the expenses of services not previously authorized 
rendered in the region or territory. Current Sec.  17.141 states that 
HAC has authority to adjudicate claims for the payment or reimbursement 
of the expenses of services not previously authorized rendered in any 
foreign country except the Republic of the Philippines which will be 
referred to the VA Outpatient Clinic in Pasay City. We propose to 
remove Sec. Sec.  17.140 and 17.141 and mark those sections as reserved 
for future use. VA believes that these sections are no longer required 
as the subject matter would be covered by proposed revisions to Sec.  
17.125.

Sec. Sec.  17.350 through 17.370 Grants to the Republic of the 
Philippines

    Executive Order 11762 provides that the President has delegated 
authority to VA relating to grants-in-aid to the Republic of the 
Philippines for medical care and treatment of veterans under 38 U.S.C. 
1731 through 1734. Under 38 U.S.C. 1732(b) VA is authorized to provide 
grants to the Veterans Memorial Medical Center for the purpose of 
assisting the Republic of the Philippines in the replacement and 
upgrading of equipment and in rehabilitating the physical plant and 
facilities of such center. Grants under this section are for the 
purpose of providing effective care and treatment of United States 
veterans in the Veterans Memorial Medical Center, and the amount of 
such grants is limited to funds specifically appropriated for that 
purpose. Authority to provide grants under 38 U.S.C. 1732(b) extended 
only through September 30, 1990. VA published regulations at 38 CFR 
17.350 through 17.370 to administer these grants. As VA's authority to 
provide grants under 38 U.S.C. 1732(b) has expired, we propose to 
remove Sec. Sec.  17.350 through 17.370. VA still retains authority 
under 38 U.S.C. 1731 to assist the Republic of the Philippines in 
fulfilling its responsibility in providing medical care and treatment 
for Commonwealth Army veterans and new Philippine Scouts in need of 
such care and treatment for service-connected disabilities and non-
service-connected disabilities under certain conditions. Since 2002, 
under that separate authority, VA has provided several grants to the 
Republic of the Philippines to furnish, install and maintain medical 
equipment at the Veterans Memorial Medical Center.

Effect of Rulemaking

    The Code of Federal Regulations, as proposed to be revised by this 
proposed rulemaking, would represent the exclusive legal authority on 
this subject. No contrary rules or procedures would be authorized. All 
VA guidance would be read to conform with this rulemaking if possible 
or, if not possible, such guidance would be superseded by this 
rulemaking.

Paperwork Reduction Act

    This proposed rule contains no provisions constituting a collection 
of information under the Paperwork

[[Page 4454]]

Reduction Act of 1995 (44 U.S.C. 3501-3521).

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed regulatory 
amendment 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 rulemaking would not directly 
affect any small entities. Only VA beneficiaries and certain community 
care providers would be directly affected. Therefore, pursuant to 5 
U.S.C. 605(b), this amendment would be exempt from the initial and 
final regulatory flexibility analysis requirements of sections 603 and 
604.

Executive Orders 12866, 13563 and 13771

    Executive Orders (E.O.s) 12866 and 13563 direct agencies to assess 
all costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). E.O. 
13563 emphasizes the importance of quantifying both costs and benefits 
of reducing costs, of harmonizing rules, and of promoting flexibility. 
E.O. 12866, Regulatory Planning and Review, defines ``significant 
regulatory action'' to mean 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.''
    VA has examined the economic, interagency, budgetary, legal, and 
policy implications of this regulatory action, and it has been 
determined not to be a significant regulatory action under E.O. 12866. 
This proposed rule is not expected to be an E.O. 13771 regulatory 
action because this proposed rule is not significant under E.O. 12866.

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 expenditure by 
State, local, or tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any given year. This proposed rule would have no such 
effect on State, local, or tribal governments, or on the private 
sector.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance program number and title 
for this proposed rule are as follows: 64.008, Veterans Domiciliary 
Care; 64.009, Veterans Medical Care Benefits; 64.010, Veterans Nursing 
Home Care; 64.018, Sharing Specialized Medical Resources.

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.

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. Gina S. 
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs, 
approved this document on August 25, 2017, for publication.

    Dated: January 26, 2018.
Janet Coleman,
Chief, Office of Regulation Policy & Management, Office of the 
Secretary, Department of Veterans Affairs.

    For the reasons stated in the preamble, the Department of Veterans 
Affairs proposes to amend 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.
    Section 17.35 is also issued under 38 U.S.C. 1724.
    Section 17.38 is also issued under 38 U.S.C. 101, 501, 1701, 
1705, 1710, 1710A, 1721, 1722, 1782, and 1786.
    Section 17.125 is also issued under 38 U.S.C. 7304.
    Section 17.169 is also issued under 38 U.S.C. 1712C.
    Sections 17.380 and 17.412 are also issued under sec. 260, 
Public Law 114-223, 130 Stat. 857.
    Section 17.410 is also issued under 38 U.S.C. 1787.
    Section 17.415 is also issued under 38 U.S.C. 7301, 7304, 7402, 
and 7403.
    Sections 17.640 and 17.647 are also issued under sec. 4, Public 
Law 114-2, 129 Stat. 30.
    Sections 17.641 through 17.646 are also issued under 38 U.S.C. 
501(a) and sec. 4, Public Law 114-2, 129 Stat. 30.

0
2. Revise Sec.  17.35 to read as follows:


Sec.  17.35  Hospital care and outpatient services in foreign 
countries.

    (a) Under the VA Foreign Medical Program, VA may furnish hospital 
care and outpatient services to any veteran outside of the United 
States, without regard to the veteran's citizenship:
    (1) If necessary for treatment of a service-connected disability, 
or any disability associated with and held to be aggravating a service-
connected disability;
    (2) If the care and services are furnished to a veteran 
participating in a rehabilitation program under 38 U.S.C. chapter 31 
who requires care and services for the reasons enumerated in 38 CFR 
17.47(i)(2).
    (b) Under the Foreign Medical Program, the care and services 
authorized under paragraph (a) of this section are available in the 
Republic of the Philippines to a veteran who meets the requirements of 
paragraph (a) of this section. VA may also provide outpatient services 
to a veteran referenced in paragraph (a)(1) in the VA outpatient clinic 
in Manila for the treatment of such veteran's service-connected 
conditions within the limits of the clinic. Non-service connected 
conditions of a veteran who has a service-connected disability may be 
treated within the limits of the VA outpatient clinic in Manila.
    (c) Claims for payment or reimbursement for services not previously 
authorized by VA under this section are governed by Sec. Sec.  17.123-
17.127 and 17.129-17.132 of this title.
0
3. Revise Sec.  17.125 to read as follows:


Sec.  17.125  Where to file claims.

    Generally, VA must preauthorize VA payment for health care services 
provided in the community when such

[[Page 4455]]

care is provided in a State as that term is defined in 38 U.S.C. 
101(20).
    (a) Where VA payment for such services has not been authorized in 
advance, claims for payment for such health care services provided in a 
State should be submitted to the VA medical facility nearest to where 
those services were provided.
    (b) Claims for payment for hospital care and outpatient services 
authorized under section 17.35(a) of this title and provided in Canada 
must be submitted to Veterans Affairs Canada, Foreign Countries 
Operations Unit, 2323 Riverside Dr., 2nd Floor, Ottawa, Ontario, Canada 
K1A OP5.
    (c) All other claims for payment for hospital care and outpatient 
services authorized under section 17.35(a) of this title and provided 
outside a State must be submitted to the Foreign Medical Program, P.O. 
Box 469061, Denver, CO 80246-9061.


Sec.  17.140  [Reserved]

0
4. Remove Sec.  17.140 and the undesignated center heading 
``Delegations of Authority'', immediately preceding it.


Sec.  17.141  [Reserved]

0
5. Remove Sec.  17.141.
0
6. Add an undesignated center heading, ``Delegation of Authority'' 
immediately preceding Sec.  17.142.


Sec.  Sec.  17.350-17.370  [Reserved]

0
7. Remove the undesignated center heading, ``Grants to the Republic of 
the Philippines'', immediately preceding Sec.  17.350.
0
 8. Remove Sec. Sec.  17.350 through 17.370.

[FR Doc. 2018-01865 Filed 1-30-18; 8:45 am]
 BILLING CODE 8320-01-P