[Federal Register Volume 83, Number 92 (Friday, May 11, 2018)]
[Rules and Regulations]
[Pages 21893-21897]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-10054]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AP60


Expanded Access to Non-VA Care Through the Veterans Choice 
Program

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

-----------------------------------------------------------------------

SUMMARY: The Department of Veterans Affairs (VA) adopts as final, with 
no change, an interim final rule revising its medical regulations that 
implement section 101 of the Veterans Access, Choice, and 
Accountability Act of 2014, as amended, (hereafter referred to as ``the 
Choice Act''), which requires VA to establish a program (hereafter 
referred to as the ``Veterans Choice Program'' or the ``Program'') to 
furnish hospital care and medical services through eligible non-VA 
health care providers to eligible veterans who either cannot be seen 
within the wait-time goals of the Veterans Health Administration (VHA) 
or who qualify based on their place of residence or face an unusual or 
excessive burden in traveling to a VA medical facility. Those revisions 
contained in the interim final rule, which is now adopted as final, 
were required by amendments to the Choice Act made by the Construction 
Authorization and Choice Improvement Act of 2014, and by the Surface 
Transportation and Veterans Health Care Choice Improvement Act of 2015. 
VA published an interim final rule on December 1, 2015, implementing 
those regulatory revisions, and we received seven public comments. This 
final rule responds to those public comments and does not make any 
further regulatory revisions.

DATES: Effective date: This rule is effective on May 11, 2018.

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.)

SUPPLEMENTARY INFORMATION: The Choice Act, Public Law 113-146, was 
enacted on August 7, 2014. Further amendments to the Choice Act were 
made by Public Laws 113-175, 113-235, 114-19, 114-41, and 115-26. Under 
these authorities, VA established the Veterans Choice Program and 
published regulations at 38 CFR 17.1500 through 17.1540. This final 
rule revises VA regulations in accordance with the amendments to the 
Choice Act made by Public Laws 114-19 and 114-41. Public Law 114-19, 
the Construction Authorization and Choice Improvement Act, amended the 
Choice Act to define additional criteria that VA may use to determine 
that a veteran's travel to a VA medical facility is an ``unusual or 
excessive burden.'' Public Law 114-41, the Surface Transportation and 
Veterans Health Care Choice Improvement Act of 2015, amended the Choice 
Act to expand eligibility for the Veterans Choice Program to all 
veterans enrolled in the VA health care system, to remove the 60-day 
limit on an episode of care, modify the wait-time and 40-mile distance 
eligibility criteria, and expand provider eligibility based on criteria 
as determined by VA. VA published an interim final rule on December 1, 
2015, to implement these amendments to the Choice Act. 80 FR 74991. We 
received seven comments on the interim final rule and respond to those 
comments in the discussion below. We are adopting as final the interim 
final rule with no revisions.
    Comments regarding changes in Public Law 114-19 related to the 
``unusual or excessive burden'' standard.
    Section 3(a)(2) of Public Law 114-19 amended section 
101(b)(2)(D)(ii)(II) of the Choice Act by defining additional criteria 
that could be the basis for finding that a veteran faced an ``unusual 
or excessive burden'' in traveling to receive care in a VA medical 
facility, including environmental factors such as roads that are not 
accessible to the general public, traffic, or hazardous weather; a 
medical condition that affects the ability to travel; or other factors, 
as determined by the Secretary. The interim final rule revised Sec.  
17.1510(b)(4)(ii) to include environmental factors such as roads that 
are not accessible to the general public, traffic, or hazardous 
weather, or a medical condition that affects the ability to travel. The 
interim final rule also added three ``other factors'' to Sec.  
17.1510(b)(4)(ii)(A) through (C): The nature or simplicity of the 
hospital care or medical services the veteran requires; how frequently 
the veteran needs such hospital care; or medical services, and the need 
for an attendant, which is defined as a person who provides required 
aid and/or physical assistance to the veteran, for a veteran to travel 
to a VA medical facility for hospital care or medical services. VA 
received one positive comment in support of the revisions to Sec.  
17.1510(b)(4)(ii), and we thank the commenter for this feedback. VA did 
not receive any comments that suggested changes to the revisions to 
Sec.  17.1510(b)(4)(ii), and therefore does not make further regulatory 
revisions.
    Comments regarding changes in Public Law 114-41 related to veteran 
eligibility, periods of follow up care, wait times, distance 
requirements, and provider eligibility.
    Section 4005(b) of Public Law 114-41 amended section 101 of the 
Choice Act to remove the August 1, 2014, enrollment date restriction, 
thereby making all veterans enrolled in the VA health care system under 
Sec.  17.36 potentially eligible for the Program if they meet its other 
eligibility criteria. Section 17.1510 was therefore revised in the 
interim final rule to codify this expanded eligibility for the Program. 
VA implemented this change ahead of the Sec.  17.1510 revision, as this 
change was not subject to notice and comment because it had an 
immediate effective date and VA did not need to interpret the language 
of the public law to give it effect. VA also did not receive any 
comments on this revision, and does not make any further regulatory 
revisions.
    Section 4005(a) of Public Law 114-41 amended section 101(h) of the 
Choice Act by removing the 60-day limitation on an ``episode of care.'' 
Sec. 4005(a), Public Law 114-41, 129 Stat. 443. The definition of 
``episode of care'' in Sec.  17.1505 was therefore revised in the 
interim final rule by removing the

[[Page 21894]]

phrase ``which lasts no longer than 60 days from the date of the first 
appointment with a non-VA health care provider,'' and the 60-day 
limitation was replaced with a 1-year limitation, consistent with VA's 
authority in section 101(c)(1)(B)(i) of the Choice Act to establish a 
timeframe for authorization of care. VA received one comment in support 
of this change, but this comment also suggested that VA make exceptions 
to the 1-year limitation, particularly for chronic conditions, to avoid 
the possibility of the unnecessary cessation of care due to 
reauthorization requirements. The comment further suggested that VA 
should provide more specific information regarding what a community 
provider would need to submit to VA to obtain a broader authorization 
beyond 1-year, and that VA should provide more details on the process 
community providers may follow to ``provide additional care outside the 
scope of the authorized course of treatment.'' We agree that veterans 
should not experience cessations of treatment for an ongoing condition 
if they require care beyond one year; the regulations do therefore 
allow reauthorization for additional episodes of care as needed. 
However, we believe that it is important that VA reauthorize an episode 
of care annually even in those instances where it is apparent at the 
time of the initial authorization that the condition is chronic and 
care will be required for greater than one year. A chronic medical 
condition may change over time, resulting in a need to reexamine the 
authorized scope of care. Annual reauthorization of an episode of care 
provides an opportunity for VA to review the scope of the episode of 
care with the healthcare provider and make necessary revisions to meet 
the needs of the veteran. Care may only be provided within the scope of 
the authorized episode of care, as defined in Sec.  17.1505 as a 
``necessary course of treatment, including follow-up appointments and 
ancillary and specialty services'' for identified health care needs. If 
a community provider believes that a veteran needs additional care 
outside the scope of the authorized course of treatment, the health 
care provider must contact VA prior to administering such care to 
ensure that this care is authorized and therefore will be paid for by 
VA. Details regarding what specific information must be submitted or 
what processes must be followed to obtain authorizations for additional 
episodes of care, or for an authorization to provide care not 
authorized as part of the episode of care, is too specific for a 
regulation, but information is available from the contractors that 
administer the Choice program and from VA when the care is authorized 
under a Choice provider agreement. VA continually works with the 
contractors and with community providers to improve education and 
processes under the Program. VA does not make any further regulatory 
revisions based on this comment.
    Section 4005(d) of Public Law 114-41 amended section 101(b)(2)(A) 
of the Choice Act to create eligibility for veterans that are unable to 
be scheduled for an appointment within ``the period determined 
necessary for [clinically necessary] care or services if such period is 
shorter than'' VHA's wait time goals. Section 4005(d), Public Law 114-
41, 129 Stat. 443. This new wait-times based criterion was added as 
paragraph (b)(1)(ii) of Sec.  17.1510, and created eligibility when a 
veteran is unable to schedule an appointment within a period of time 
that VA determines is clinically necessary and which is shorter than 
VHA's wait time goals. VA received one positive comment in support of 
this revision, and we thank the commenter for this feedback. VA did not 
receive any comments that suggested changes to this revision, and 
therefore does not make further regulatory revisions.
    Section 4005(e) of Public Law 114-41 amended section 101(b)(2)(B) 
of the Choice Act to modify the 40-mile distance eligibility criterion 
to provide that veterans may be eligible if they reside more than 40 
miles from ``(i) with respect to a veteran who is seeking primary care, 
a medical facility of the Department, including a community-based 
outpatient clinic, that is able to provide such primary care by a full-
time primary care physician; or (ii) with respect to a veteran not 
covered under clause (i), the medical facility of the Department, 
including a community-based outpatient clinic, that is closest to the 
residence of the veteran.'' VA found that it would be impracticable and 
not veteran centric to apply a ``seeking primary care'' eligibility 
criterion, and therefore did not revise the general 40-mile requirement 
in Sec.  17.1510(b)(1) in the interim final rule to reflect such a 
strict reading of the public law. However, VA did revise Sec.  17.1505 
to add a definition of ``full-time primary care physician,'' as well as 
amend the definition of ``VA medical facility'' to require that such a 
facility have a full-time primary care physician, so that for purposes 
of determining distance-related eligibility for the Program, VA 
considered a qualifying VA medical facility to include only those 
facilities with at least a full-time primary care physician. VA 
received one positive comment in support of this revision, and we thank 
the commenter for this feedback. VA did not receive any comments that 
suggested changes to this revision, and therefore does not make further 
regulatory revisions.
    Section 4005(c) of Public Law 114-41 amended sections 101(a)(1)(B) 
and 101(d) of the Choice Act to permit VA to expand provider 
eligibility beyond those providers expressly listed in section 
101(a)(1)(B) of the Choice Act, in accordance with criteria as 
established by VA. In the interim final rule, VA revised Sec.  
17.1530(a) to refer to a new paragraph (e) that established eligibility 
for these other providers, and added a new paragraph (e) to Sec.  
17.1530 to list these providers specifically. VA also revised Sec.  
17.1530(d) to reorganize current requirements and add new requirements 
for these providers, in accordance with section 101(d)(5) of the Choice 
Act. VA received two positive comments in support of this revision, and 
we thank the commenters for this feedback. VA received one comment that 
inquired whether, given the expansion of eligible providers, such 
providers were required to be Medicare- participating providers. We 
clarify that eligible providers in the Program include but are not 
limited to Medicare-participating providers, as established in Sec.  
17.1530(a) and (e). With this clarification, and because VA did not 
receive any comments that suggested changes to this revision, we 
therefore do not make further regulatory revisions.

Miscellaneous Comments

    The remaining five comments do not specifically pertain to the 
regulatory changes in the interim final rule, and are addressed here in 
turn.
    One commenter requested that the end date of August 7, 2017, for 
the Choice Act be removed and the program made permanent. The Choice 
Act, which was enacted on August 7, 2014, in Public Law 113-146, 
specifically prescribed that the Choice Program would be temporary, 
operating for 3 years or until the funding was exhausted, whichever 
came first. The 3-year sunset date was removed by Public Law 115-26, 
and so the Choice Program is authorized until the amounts appropriated 
in the Choice Fund are exhausted. Current regulations do not discuss 
the termination date of the Program, and VA does not make any 
regulatory changes based on Public Law 115-26 or this comment.
    Another commenter expressed a generalized concern that the Choice

[[Page 21895]]

Program created additional barriers to access healthcare as well as 
expressed specific concerns about the Choice Program. To address the 
commenter's generalized concern related to barriers to access, we 
acknowledge the difficulties that some veterans have experienced and 
expressed since the inception of the Choice Program in August 2014, and 
we are similarly sympathetic to the commenter's expressed experiences. 
Congress mandated that VA implement the Choice Program in 90 days, and 
implementing such an unprecedented program in terms of VA care in the 
community on a nationwide basis, in 90 days, resulted in growing pains 
for veterans, community providers, and VA. During the initial year of 
the Choice Program, VA met with veterans, community providers, leading 
healthcare experts, and staff across the country to hear concerns and 
identify solutions. In order to immediately implement changes to the 
Choice Program, VA brought in new leadership to oversee all Community 
Care Programs. Under this new leadership, VA quickly began to improve 
the Choice Program and laid out a plan to drive towards a future that 
delivers the best of VA and the community. VA has earnestly tried to 
implement the Choice Program in accord with legal requirements while 
being mindful of veteran concerns and administrative realities, and VA 
will continue to strive to reduce any barriers communicated to us by 
veterans. VA does not make any regulatory changes to address the 
commenter's generalized concerns about the Choice Program.
    As to the commenter's specific concerns, the commenter stated that 
there are no clear channels for resolution of complaints or problems 
when authorization for care has been delayed. The commenter further 
elaborated that it is difficult to access the Choice Program call 
centers and, once contact is made with the call center, it is difficult 
to receive answers from the employees working in the call centers. The 
commenter suggested that a process be put in place to address complaint 
resolution. We interpret these concerns to be limited to issues that 
arise administratively when the veteran is already enrolled in the 
Choice Program, such as delays in authorization, and not concerns 
regarding eligibility to participate in the Choice Program or concerns 
with clinical decisions throughout the course of treatment. Therefore, 
we further interpret these concerns to relate to the internal processes 
relating to administration of the program and do not make any 
regulatory changes. However, we describe below processes and 
improvements that both VA and the contractors that administer the 
Choice Program have undertaken and which we believe obviate the need 
for more formal processes in regulation.
    VA has taken affirmative steps to decrease administrative burdens 
such as delays in authorization and has improved access to VA staff 
through the VA call centers and the internet. For instance, VA has 
reduced the administrative burden for medical record submission for 
community providers by streamlining the documents required. We also 
have strived to improve veterans' experience with the call centers 
throughout the past year. More specifically, in May 2015, it took 
approximately 11 days to contact the veteran, obtain their provider and 
appointment preference, and work with the community provider to 
schedule an appointment; by May 2016, the average number of days to 
accomplish those tasks decreased to only 6. The Choice Program call 
centers have also continued to improve with a call abandon rate of less 
than 2 percent; a call hold time of no more than 7 seconds; and first-
time call resolution over of 96 percent. In addition, Veterans are able 
to contact VA directly through this website that is available to the 
public: http://www.va.gov/opa/choiceact/. The website contains 
information about the program, a phone number that veterans can call in 
order to speak to a person directly, and also contains a live chat 
option that is available to veterans Monday through Friday from 8 a.m. 
to 8 p.m., eastern standard time. The vendors who administer the Choice 
Program additionally have processes in place for veterans who 
experience delays when receiving care in the community. The complaints 
and grievance processes for the contractors, TriWest and Health Net, 
are available at their public websites, respectively: http://www.triwest.com/globalassets/documents/veteran-services/complaint-grievance_form.pdf and https://www.hnfs.com/content/hnfs/home/va/provider/resources/resources/grievances.html.
    The commenter next expressed the specific concern that rural 
veterans are disproportionately negatively impacted by barriers created 
by the Choice Act and VA and that such veterans' feedback is not heard 
by VA as a result of their disability status and geographic location. 
We first clarify that VA strives to gain feedback from all veterans, 
including those who live in rural areas, about their experiences with 
the Choice Program. To obtain feedback from all veterans, regardless of 
their geographic location, VA developed a Survey of Healthcare 
Experiences of Patients (SHEP) for veterans to complete after receiving 
Choice care. We further acknowledge that there are unique problems that 
affect rural veterans and that it may be more difficult for rural 
veterans to obtain health care near their residence. In this regard, 
the 40-mile distance criterion in the Choice Program regulations at 
Sec.  17.1510(b)(2) is designed to address accessibility issues that 
affect rural Veterans. Particularly, the 40-mile criterion has been 
interpreted by VA to consider driving distance and not straight line 
distance (see 80 FR 22906, April 24, 2015), and to further interpret 
that this distance must be from a Veteran's residence to a VA medical 
facility that has at least one full time equivalent primary care 
physician (see 80 FR 74991, December 1, 2015). Both of these 
interpretations we believe increase the number of rural veterans 
eligible for the program, and VA otherwise actively seeks and documents 
the concerns of rural veterans that participate in the Choice program 
with its SHEP survey as described above. Therefore, we make no 
regulatory changes based on this comment.
    The commenter also stated that the Choice Program has created 
coordination of care issues for non-VA providers who administer health 
care for veterans. The commenter did not elaborate on what those issues 
are or how the Choice Program created them, or whether the interim 
final rule exacerbated the issues, and the commenter also did not 
suggest any changes to alleviate the issues. We do acknowledge that 
there may have been difficulty with coordination of care at the 
inception of the Choice Program, and, to enhance coordination of care 
for veterans, we have embedded Choice contractor staff with VA staff at 
14 VA facilities, and continue to increase the number of embedded 
Choice contractor staff locations. As the commenter did not provide 
enough specificity for suggested regulatory changes, and we believe VA 
has undertaken efforts to mitigate coordination of care issues, we do 
not make any regulatory revisions based on this comment.
    Finally, the commenter explained that it was easier to seek care 
prior to the Choice Program and that, even though the Program is 
voluntary, veterans are being told that they must use the Choice 
Program over VA care and other VA care in the community permitted by 
legal authorities other than the Choice Act. We first clarify that the 
Choice Program

[[Page 21896]]

is voluntary and veterans are provided the option of obtaining care 
solely at VA medical facilities. Significantly, the Choice Program is 
designed to respect and guarantee a veteran's choice to see a VA 
provider or a non-VA provider if they meet Choice Program criteria. In 
fact, if an eligible veteran elects to receive covered care through the 
Choice Program, VA is required by the Choice Act to furnish the care 
through the Program. In addition, the Choice Act authorized VA to 
purchase care through Choice provider agreements, which gives VA 
greater flexibility when furnishing care through the Choice Program. VA 
recognizes that some veterans faced administrative barriers and hurdles 
while seeking care through the Choice Program and that some veterans 
may have found it was easier in the past to seek VA care in the 
community under legal authorities other than the Choice Act. To ensure 
the Choice Program provides high quality and accessible care, VA has 
made and will continue to make improvements by working with Congress, 
our community providers, our Choice Program contractors and within VA. 
Therefore, we do not make any further regulatory revisions based on 
this comment.
    The final three comments are beyond the scope of the interim final 
rule and we will not make any regulatory changes based on the comments. 
One commenter expressed concern about the recertification process to 
become a vendor and contract with VA through ``vetbiz.gov.'' The 
process of vendorization on vetbiz.gov does not apply for clinical 
providers under the Choice Act. As the commenter did not otherwise 
reference the interim final rule or the Choice Program regulations 
generally, nor did the commenter state how the ability to recertify as 
a vendor was affected by the interim final rule or Choice regulations, 
we find that the comment is beyond the scope of the rulemaking.
    Another commenter supported the interim final rule because it would 
enable the commenter to access community care near the commenter's 
residence in Panama. Care under the Choice Program is not provided 
outside of the United States. VA's only authority to provide care 
abroad is through the foreign medical care provisions in 38 U.S.C. 
1724, and the Choice Act did not affect this limitation.
    Another commenter expressed a concern over the potentially 
burdensome nature of the administrative requirements to participate in 
the Choice Program. Specifically, the commenter requested that VA be 
mindful that an overly complicated process to apply to participate in 
the Choice Program may deter people who are eligible and entitled to 
participate in the Program. The commenter did not specify what these 
burdens are or if they were made worse by revisions in the interim 
final rule. Therefore, we interpret the comment to be general in scope. 
Although the interim final rule and the Choice regulations contain 
eligibility criteria, they do not contain any requirements or guidance 
for how to apply to participate in the Choice Program. Therefore, we 
find that the comment is not within the scope of the rulemaking and we 
will not make any regulatory changes based on this comment.

Effect of Rulemaking

    Title 38 of the Code of Federal Regulations, as confirmed by this 
final rule, 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.

Paperwork Reduction Act

    Although this action contains provisions constituting collections 
of information, at 38 CFR 17.1530(d), under the Paperwork Reduction Act 
of 1995 (44 U.S.C. 3501-3521), no new or proposed revised collections 
of information are associated with this final rule. The information 
collection requirements for Sec.  17.1530(d) are currently approved by 
the Office of Management and Budget (OMB) and have been assigned OMB 
control number 2900-0823.

Executive Orders 12866, 13563, and 13771

    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,'' which requires review by the Office 
of Management and Budget (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 that this is an economically significant regulatory 
action under Executive Order 12866. VA's regulatory 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 regulatory impact 
analysis are available on VA's website at http://www.va.gov/orpm/, by 
following the link for ``VA Regulations Published From FY 2004 Through 
Fiscal Year to Date.'' 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 website 
at http://www.va.gov/orpm by following the link for VA Regulations 
Published from FY 2004 through FYTD. This rule is not subject to the 
requirements of E.O. 13771 because this rule results in no more than de 
minimis costs.

Congressional Review Act

    This regulatory action is a major rule under the Congressional 
Review Act, 5 U.S.C. 801-08, because it may result in an annual effect 
on the economy of $100 million or more. Although this regulatory action 
constitutes a major rule within the meaning of the Congressional Review 
Act, 5 U.S.C. 804(2), it is not subject to the 60-day delay in 
effective date applicable to major rules under 5 U.S.C. 801(a)(3) 
because the Secretary finds that good cause exists under 5 U.S.C. 
808(2) to make this regulatory action effective on the date of 
publication, consistent with

[[Page 21897]]

the reasons given for the publication of the interim final rule. In 
accordance with 5 U.S.C. 801(a)(1), VA will submit to the Comptroller 
General and to Congress a copy of this regulatory action and VA's 
Regulatory Impact Analysis.

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 
private sector, of $100 million or more (adjusted annually for 
inflation) in any 1 year. This final rule will have no such effect on 
State, local, and tribal governments, or on the private sector.

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-
612. This final rule will not have a significant economic impact on 
participating eligible entities and providers who enter into agreements 
with VA. To the extent there is any such impact, it will result in 
increased business and revenue for them. We also do not believe there 
will be a significant economic impact on insurance companies, as claims 
will only be submitted for care that will otherwise have been received 
whether such care was authorized under this Program or not. Therefore, 
pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial 
and final regulatory flexibility analysis requirements of 5 U.S.C. 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 as follows: 64.008--Veterans 
Domiciliary 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; 64.024--VA Homeless Providers Grant and Per Diem Program; 
64.026--Veterans State Adult Day Health Care; 64.029--Purchase Care 
Program; 64.035--Veterans Transportation Program; 64.038--Grants for 
the Rural Veterans Coordination Pilot; 64.039--CHAMPVA; 64.040--VHA 
Inpatient Medicine; 64.041--VHA Outpatient Specialty Care; 64.042--VHA 
Inpatient Surgery; 64.043--VHA Mental Health Residential; 64.044--VHA 
Home Care; 64.045--VHA Outpatient Ancillary Services; 64.046--VHA 
Inpatient Psychiatry; 64.047--VHA Primary Care; 64.048--VHA Mental 
Health Clinics; 64.049--VHA Community Living Center; 64.050--VHA 
Diagnostic Care.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Alcohol abuse, Alcoholism, 
Claims, Day care, Dental health, Drug abuse, Government contracts, 
Grant programs-health, Grant programs-veterans, Health care, Health 
facilities, Health professions, Health records, Homeless, Mental health 
programs, Nursing homes, Reporting and recordkeeping requirements, 
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 Janaury 12, 2018, for publication.

    Dated: May 8, 2018.
Consuela Benjamin,
Regulations Development Coordinator, Office of Regulation Policy & 
Management, Office of the Secretary, Department of Veterans Affairs.

PART 17--MEDICAL

0
Accordingly, the interim rules amending 38 CFR part 17 which were 
published at 80 FR 74991 on December 1, 2015, and 81 FR 24026 on April 
25, 2016, are adopted as final without change.
[FR Doc. 2018-10054 Filed 5-10-18; 8:45 am]
BILLING CODE 8320-01-P