[Federal Register Volume 84, Number 21 (Thursday, January 31, 2019)]
[Proposed Rules]
[Pages 627-633]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-00277]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 17
RIN 2900-AQ47
Urgent Care
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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SUMMARY: The Department of Veterans Affairs (VA) is proposing to amend
its regulations that govern VA health care. This rule would grant
eligible veterans access to urgent care from qualifying non-VA entities
or providers without prior approval from VA. This rulemaking would
implement the mandates of the VA MISSION Act of 2018 and increase
veterans' access to health care in the community.
DATES: Comments must be received on or before March 4, 2019.
ADDRESSES: Written comments may be submitted through http://www.Regulations.gov; by mail or hand-delivery to: Director, Regulation
Policy and Management (00REG), Department of Veterans Affairs, 810
Vermont Avenue, North West, Room 1063B, Washington, DC 20420; or by fax
to (202) 273-9026. (This is not a toll-free telephone number.) Comments
should indicate that they are submitted in response to ``RIN 2900-AQ47
Urgent Care.'' 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 telephone number.) In addition, during the comment
period, comments may be viewed online through the Federal Docket
Management System (FDMS) at http://www.Regulations.gov.
FOR FURTHER INFORMATION CONTACT: Joseph Duran, Director of Policy and
Planning. 3773 Cherry Creek North Drive, Denver, CO 80209.
[email protected]. (303) 370-1637. (This is not a toll-free number.)
[[Page 628]]
SUPPLEMENTARY INFORMATION: On June 6, 2018, section 105 of Public Law
115-182, the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson
VA Maintaining Internal Systems and Strengthening Integrated Outside
Networks Act of 2018, or the VA MISSION Act of 2018, amended title 38
of the United States Code (U.S.C.) by adding a new section 1725A,
Access to walk-in care. The new section 1725A was further amended
through the Department of Veterans Affairs Expiring Authorities Act of
2018 (Pub. L. 115-251). This benefit is intended to offer eligible
veterans convenient care for certain, limited, non-emergent health care
needs. Section 1725A(a) and (g) direct the Secretary to establish
procedures and regulations to ensure eligible veterans are able to
access such care from qualifying non-VA entities or providers to ensure
their access to care when minor injury or illness arises. VA is
required to develop procedures to ensure eligible veterans are able to
access this care from qualifying non-VA entities or providers. Eligible
veterans would include any enrolled veteran who has received care under
chapter 17 of title 38 United States Code (U.S.C.) within the 24-month
period preceding the furnishing of care under this section. Care under
chapter 17 of title 38, U.S.C., would include any of the following:
Care provided in a VA facility, care authorized by VA performed by a
community provider, care furnished by a State Veterans home, or urgent
care under this proposed section. Qualifying non-VA entities or
providers would include any non-VA entity or provider that has entered
into a contract, agreement, or other arrangement with VA to provide
services under this section.
VA proposes to refer to this benefit as urgent care, instead of
walk-in care. As explained in further detail below, this benefit will
include care provided at both urgent care facilities and walk-in retail
health clinics. We believe referring to this type of care as ``urgent
care'' would be consistent with industry practice.
This proposed rule would implement the mandates of section 1725A,
as added by the VA MISSION Act of 2018 as amended, by establishing a
new Sec. 17.4600.
Proposed paragraph (a) would establish the purpose for this
section. We would state that this section establishes procedures for
accessing urgent care, which would be available to eligible veterans
from qualifying non-VA entities or providers under the requirements
established by this rulemaking. This would be consistent with sections
1725A(a) and (g).
Proposed paragraph (b) would define the terms for this section. We
would define the term ``eligible veteran'' in proposed paragraph (b)(1)
as a veteran described in 38 U.S.C. 1725A(b). Section 1725A(b) defines
eligible veterans as those who are enrolled under section 1705(a) of
title 38, U.S.C. and who have received medical care under chapter 17 of
title 38, U.S.C., within the 24-month period preceding the furnishing
of urgent care under this new program. We would not restate the
definition in section 1725A in the event that this section is amended
in the future. As stated earlier, veterans have received care under
chapter 17 of title 38, U.S.C., when they have received care provided
in a VA facility, care authorized by VA and performed by a community
provider, care furnished by a State Veterans home, or urgent care under
this proposed section.
The term ``episodic care'' appears, but is not defined, in section
1725A(h). We propose to define the term ``episodic care'' in proposed
paragraph (b)(2) as care or services provided to an eligible veteran
for a particular health condition, or a limited set of particular
health conditions, without an ongoing relationship being established
between the eligible veteran and qualifying non-VA entities or
providers. Episodic care would be only for a particular health
condition (or a flu shot) or a limited set of particular health
conditions, to be addressed in a single visit. For example, an eligible
veteran could seek episodic care for a sore throat, an ankle sprain, or
both in a single visit. There would be no further relationship between
the qualifying non-VA entity or provider and the eligible veteran for
the treatment of those health conditions. VA believes that flu shots,
as well as therapeutic vaccines that are furnished in the course of
treatment of another condition, would be clinically appropriate because
the risk of an adverse reaction would be minimal for a flu shot, and
therapeutic vaccines would be necessary for the treatment of certain
conditions. For example, a veteran seeking treatment for a wound caused
by rusted metal requires treatment for the wound and may require a
tetanus vaccine as part of the course of treatment. VA acknowledges
that there may be other preventive treatments with minimal risk of
adverse action, however, VA considers these preventive care treatments
to be part of the veteran's longitudinal care, as such, these other
treatments should be provided by the veteran's primary care provider
and not as part of urgent care. As stated in section 1725A(h), urgent
care should not be used for the longitudinal management of health care.
These requirements are consistent with the general model of urgent care
where patients seek health care for the treatment of minor injuries and
illnesses through a single visit.
We propose to define the term ``longitudinal management of
conditions'' in proposed paragraph (b)(3) as outpatient care that
addresses important disease prevention and treatment goals and is
dependent upon bidirectional communications that are ongoing over an
extended period of time. Section 1725A(h) excludes from the definition
of walk-in care the longitudinal management of conditions; while we
would define the term ``longitudinal management of conditions,'' we
would also state that, for purposes of this section, the term
``longitudinal care'' is synonymous with longitudinal management of
conditions because we believe ``longitudinal care'' is better
understood and would be clearer in the context of the regulation. We
would only refer to outpatient care because urgent/walk-in care
providers do not provide inpatient care or extended care services. The
reference to bidirectional communications that are ongoing over an
extended period of time is intended to reflect that longitudinal care
occurs within the context of an ongoing relationship between the
provider and patient.
Proposed paragraph (b)(4) would define the term ``qualifying non-VA
entities or providers'' consistent with the definition in section
1725A(c), but we have specifically included Federally-qualified health
centers based on section 1725A(d). We would define ``qualifying non-VA
entity or provider'' as a non-VA entity or provider, including
Federally-qualified health centers as defined in 42 U.S.C.
1396d(l)(2)(B), that has entered into a contract, agreement, or other
arrangement with the Secretary to furnish urgent care under the
section. VA currently furnishes care in the community through networks
of providers that are maintained by third-party administrators. The
third-party administrator meets the definition of the qualifying non-VA
entity or provider--they are non-VA entities or providers that have
entered into a contract or agreement with the Secretary to furnish care
and services under this section--and it is through these administrators
that the urgent care benefit primarily will be provided.
We propose to define the term ``urgent care'' in proposed paragraph
(b)(5). This definition would include several key
[[Page 629]]
conditions as follows. This definition would only apply to this
section; other uses of the term ``urgent care'' or ``urgent services''
in other VA regulations, specifically Sec. Sec. 17.101, 17.106, and
70.71, would not refer to this benefit. Section 1725A(h) defines the
term ``walk-in care'' as non-emergent care provided by a qualifying
non-Department entity or provider that furnishes episodic care and not
longitudinal management of conditions and is otherwise defined through
regulations the Secretary shall promulgate. However, VA proposes to use
the term ``urgent care'' instead of ``walk-in care.'' Urgent care is an
industry standard description of the services described below available
at specific provider locations, including Federally Qualified Health
Centers (FQHCs) as required under section 1725A(h). VA prefers to use
an industry standard name for the benefit.
First, VA proposes to provide in proposed paragraph (b)(5) that
urgent care is those services being provided by walk-in retail health
clinics or urgent care facilities, as designated by the Centers for
Medicare and Medicaid Services, furnished by a qualifying non-VA entity
or provider, and as further defined in the paragraph. We believe that
defining urgent care to include those services that are furnished by
walk-in retail health clinics or urgent care facilities, as designated
by the Centers for Medicare and Medicaid Services, would be in
alignment with public expectations of the types of urgent care services
that are otherwise available under other health care plans. The Centers
for Medicare and Medicaid Services currently describes the services
that walk-in retail health clinics and urgent care facilities furnish
at the following website: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html. VA's proposed definition
would also allow the benefit available under this section to evolve
based upon advances in the industry regarding the types of services
offered by these clinics and facilities. A qualifying non-VA entity or
provider would have to enter into a contract, agreement, or other
arrangement with VA to furnish services under this section. This is a
requirement of section 1725A(c), and is also a critical part of the
definition of a ``qualifying non-VA entity or provider'' under
paragraph (b)(4). We note that, while we propose to define the scope of
services available as urgent care in paragraph (b)(5), because of our
reliance on contracts, agreements, or other arrangements, the actual
services available at a particular qualifying non-VA entity or provider
may vary. We further note that any care that is provided to an eligible
veteran that does not meet this definition, whether it be that the care
was provided by a non-qualifying entity or provider or that the care
provided was beyond the scope of urgent care as defined in this
section, will not be covered by VA. In these situations, the eligible
veteran would be liable for the cost of such care.
In proposed paragraph (b)(5)(i)(A), however, VA would not, except
as provided for in paragraph (b)(5)(i)(B) or (b)(5)(iii), include
preventive health services, as defined in 38 U.S.C. 1701(9). We would
exclude generally preventive services because, consistent with the
statutory requirement in section 1725A(e), the best way to ensure
continuity of care is to have preventive health services coordinated
and managed by a primary care provider furnishing longitudinal care.
Section 1725A(e) requires that the Secretary ensure continuity of care
for eligible veterans receiving this benefit. Preventive health
services are a critical component to VA's health care management
system. VA believes that urgent care is fundamentally distinct from
providing longitudinal health care within VA or the community. The best
way to address a veteran's health care needs would be to manage a
veteran's preventive health services as part of their overall health
care rather than attempting to furnish such services on an episodic and
uncoordinated basis. As such, we believe that to ensure continuity of
care, as required by section 1725A(e), VA should exclude generally
preventive health services from the definition of urgent care.
We would further define urgent care in proposed paragraph
(b)(5)(i)(B) to include immunizations against influenza (flu shots), as
well as therapeutic vaccines that are necessary in the course of
treatment of an otherwise included service. Vaccinations are included
within the definition of preventive health services in 38 U.S.C.
1701(9)(G) (which refers to immunizations) and as such would have been
excluded under paragraph (b)(5)(i)(A).
We would also add in paragraph (b)(5)(ii) another requirement of
urgent care: It must be furnished as ``episodic care for eligible
veterans needing immediate non-emergent medical attention, but does not
include longitudinal care.'' This is based on the definition of walk-in
care in section 1725A(h).
Finally, we propose to state in paragraph (b)(5)(iii) that VA may
provide additional services it determines to be appropriate if it is in
the interest of eligible veterans', based on identified health needs.
VA would inform the public via Federal Register document, published as
soon as practicable, and other communication as VA determines
appropriate. VA's determination that additional services are in the
interest of eligible veterans could be made to expand services
regionally or nationally and for specified periods of time. This
authority would only allow for the provision of services that
qualifying non-VA entities or providers would otherwise furnish, but
that would be excluded by our definition of the benefit of urgent care.
Principally, these services would include preventive health services,
including immunizations that are not for influenza or therapeutic
vaccines. For example, if there is a localized outbreak of an
infectious disease, VA could provide eligible veterans immunizations to
prevent this disease as part of urgent care until the outbreak is
contained.
Proposed paragraph (c) would establish procedures for urgent care.
Procedures are required pursuant to section 1725A(a). We would state in
proposed paragraph (c)(1) that eligible veterans may ``receive urgent
care from a qualifying non-VA entity or provider without prior approval
from VA.'' We believe this would be consistent with the general
understanding of urgent and walk-in care, as well as the structure of
the statute, which authorizes this benefit outside of the general
Veterans Community Care Program under the amendments to section 1703,
as made by section 101 of the VA MISSION Act of 2018. The general
Veterans Community Care Program requires authorization for services,
see amendments to section 1703(a)(3), while there is no similar
requirement in section 1725A. This arrangement, combined with the
Senate Committee's report on this language, suggest that the purpose of
this provision is to ensure that eligible veterans have access to
convenient care. See S. Rpt. 115-212, p. 18.
We would provide in proposed paragraph (c)(2) that VA will publish
a website containing information on urgent care, including the names,
locations, and contact information for qualifying non-VA entities or
providers within an eligible veteran's community. The website would
also include a list of services and other general information on the
urgent care program established under this section.
Proposed paragraph (c)(3) would provide, in general, eligibility
under the
[[Page 630]]
section does not affect eligibility for hospital care or medical
services under the medical benefits package, as defined in Sec. 17.38,
or other benefits addressed in title 38. Nothing in the section waives
the eligibility requirements established in other statutes or
regulations. This proposed paragraph would address the effect of urgent
care on other provisions and programs administered by VA. Proposed
paragraph (c)(3) would provide that, generally, eligibility for urgent
care does not affect eligibility for hospital care or medical services
under the medical benefits package or other benefits addressed in title
38. If particular services have unique eligibility standards, only
veterans who are eligible under this section and who meet the
eligibility standards for those services can elect to receive urgent
care for them. Additionally, nothing in this section waives the
eligibility requirements established in other statutes or regulations.
However, eligibility for urgent care could affect eligibility for other
benefits indirectly. For example, section 1725(b)(2)(B) provides that
to be eligible for reimbursement for emergency treatment, a veteran
must have received care under chapter 17 of title 38, U.S.C., within
the 24-month period preceding the furnishing of such emergency
treatment. If a veteran's only care within the 24-month period
preceding the furnishing of such emergency treatment was for urgent
care pursuant to these regulations, the veteran would satisfy this
eligibility requirement and could be eligible for reimbursement for
emergency treatment under section 1725.
Proposed paragraph (d) would establish the copayment obligations
for eligible veterans. Section 1725A(f)(1)(A) authorizes the Secretary
to require an eligible veteran to pay the United States a copayment for
each episode of hospital care or medical services provided under the
section if the eligible veteran would be required to pay a copayment
under this title. Section 1725A(f)(1)(B) states that an eligible
veteran not required to pay a copayment under the title may access
walk-in care without a copayment for the first two visits in a calendar
year. For any additional visits, a copayment at an amount determined by
the Secretary may be required. Section 1725A(f)(1)(C) further states
that an eligible veteran required to pay a copayment under the title
may be required to pay a regular copayment for the first two walk-in
care visits in a calendar year. For any additional visits, a higher
copayment at an amount determined by the Secretary may be required.
Similarly, section 1725A(f)(2) states that after the first two episodes
of care furnished to an eligible veteran under the section, the
Secretary may adjust the copayment required of the veteran under the
subsection based upon the priority group of enrollment of the eligible
veteran, the number of episodes of care furnished to the eligible
veteran during a year, and other factors the Secretary considers
appropriate under the section.
In this rulemaking, we propose to establish a regular copayment for
urgent care of $30. An eligible veteran's liability for the $30 regular
copayment would depend on the veteran's enrollment category and the
number of visits in a calendar year, as further explained below. We
note that section 1725A(f)(3), which allows the Secretary to prescribe
by rule the amount or amounts of copayments required under this
section, allows the Secretary to establish unique regular copayments
applicable to urgent care when provided under this section. We further
note that section 1725A(f)(4) states that sections 8153(c) and 1703A(j)
do not apply to section 1725A(f). Sections 8153(c) and 1703A(j)
stipulate that care furnished pursuant to an agreement authorized by
one of these sections is subject to the same terms as though provided
in a facility of the Department, and that provisions of chapter 17
applicable to veterans receiving such care and services in a VA medical
facility shall apply to veterans treated under this section. We
interpret these exemptions, along with section 1725A(f)(3), to permit
the Secretary to establish unique copayment amounts applicable to
urgent care.
Copayments are a common feature of health care, including VA health
care. They are an important mechanism for guiding behavior to ensure
that patients receive care at an appropriate location. As previously
stated in this rulemaking, urgent care does not include longitudinal
care. Urgent care is considered to be a convenient option for care, but
is not intended to be used as a substitute for traditional primary
care. Also, collecting copayments allows VA to utilize its health care
resources more efficiently.
VA believes that $30 amount is consistent with the copayments
charged by other Federal programs for similar benefits under the
TRICARE and Medicare programs. Also, the $30 amount is a reasonable
charge because it is considerably less than what is commercially
available, which on average is approximately $67, based on an analysis
VA conducted of private sector benefits under commercial health plans.
This amount is consistent with legislative history suggesting that the
copayment amount not exceed $50 per visit. S. Rpt. 115-212, p. 19. We
believe that the convenience associated with accessing urgent care
merits a copayment amount that could be higher than the amount that
would apply if VA furnished that care in a VA facility or through
authorized community care. Eligible veterans would not owe copayments
at the time of service, consistent with current practice for VA and VA-
authorized community care.
Consistent with section 1725A(f)(1)(B), we propose to require all
eligible veterans who are enrolled in priority groups 1-6, except those
veterans described in Sec. 17.36(d)(3)(iii), to only pay the $30
copayment after three urgent care visits. For further information on
priority groups see Sec. 17.36. Although these veterans are not
required to pay copayments for other health care services furnished or
paid for by VA, section 1725A(f)(1)(B) authorizes VA to start requiring
a copayment after two visits, we believe that is appropriate to require
a copayment after three visits instead of two. For those veterans who
are enrolled in priority groups 7-8, including those veterans described
in Sec. 17.36(d)(3)(iii), we propose to charge the $30 for all visits
and will not exercise the authority under section 1725A(f)(1)(C) and
(f)(2) to increase their copayment rate after two visits.
Therefore, we would state in proposed paragraph (d)(1) that, except
as provided in paragraph (d)(2) or (d)(3), an eligible veteran, as a
condition for receiving urgent care provided by VA under this section,
must agree to pay VA (and is obligated to pay VA) a copayment of $30 if
the veteran is enrolled in priority groups 1-6, except those veterans
described in Sec. 17.36(d)(3)(iii) and has more than three urgent care
visits under this section in a year, or if the veteran is enrolled in
priority groups 7-8, including those veterans described in Sec.
17.36(d)(3)(iii). These conditions would be stated in proposed
paragraph (d)(1)(i), dealing with veterans enrolled in priority groups
1-6 generally, and in proposed paragraph (d)(1)(ii), dealing with
veterans enrolled in priority groups 7-8.
Proposed paragraph (d)(2) would provide that an eligible veteran
who receives urgent care under Sec. 17.4600(b)(5)(iii) or urgent care
consisting solely of an immunization against influenza (flu shot) is
not subject to a copayment under paragraph (d)(1). VA would not charge
a copayment for
[[Page 631]]
flu shots to be consistent with private care best practice standards
and be in alignment with other Federal programs. The Affordable Care
Act requires health insurers to cover the flu shot without charging a
copayment or coinsurance. While the insurer can require an individual
to go to a specific facility to receive a flu shot, most insurers allow
individuals to go to walk-in clinics for this benefit. Additionally,
neither Medicare nor TRICARE charges a copayment for the flu shot. If
VA were to charge a copayment for flu shots, we would not be aligned
with the private sector or other government agencies. Furthermore, VA
does not currently require a copayment for a flu shot if veterans
receive one at a VA clinic on a walk-in basis, and we believe it is in
the veterans' best interest to continue this practice.
Proposed paragraph (d)(3) would provide that if an eligible veteran
receives more than one type of care on the same day that would subject
the veteran to a copayment under Sec. 17.108, which establishes
copayments for inpatient and outpatient care, or Sec. 17.111, which
establishes copayments for extended care services, VA would only charge
the higher copayment for that day. We would only charge one copayment
to reduce the burden on the part of the eligible veteran. This is
consistent with how VA charges copayments for multiple VA visits in the
same day. See Sec. 17.108(c)(2) and (f). VA would also only charge a
single copayment if an eligible veteran receives more than one episode
of care under Sec. 17.4600 on the same day.
VA also proposes to amend Sec. 17.105 to reflect the copayments as
established in this rulemaking. First, VA would propose to include
proposed Sec. 17.4600 among the list of regulatory authorities under
which copayments would be subject to a waiver under Sec. 17.105(c).
This would ensure that urgent care copayments would be treated the same
as other copayments for eligible veterans seeking a waiver of their
liability. Second, VA would delete the list of authorities for Sec.
17.105 to comply with the guidelines of the Office of the Federal
Register, but would add the complete list of authorities for this
regulation, including 38 U.S.C. 1725A, among the authority citations
listed for part 17.
VA similarly proposes to amend Sec. 17.108(e) to make clear that
the copayment exemptions for outpatient medical care specified in that
section also apply to urgent care under this section. This would ensure
consistent application of copayment rules for eligible veterans. We
would make similar conforming changes regarding the list of authorities
for Sec. 17.108.
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 proposed rulemaking if
possible or, if not possible, such guidance would be superseded by this
rulemaking.
Paperwork Reduction Act
This rulemaking does not contain any provisions constituting
collections of information under the Paperwork Reduction Act of 1995
(44 U.S.C. 3501-3521).
Regulatory Flexibility Act
The Secretary hereby certifies that this proposed rule would not
have a significant economic impact on a substantial number of small
entities as they are defined in the Regulatory Flexibility Act, 5
U.S.C. 601-612. This proposed rule would not have a significant
economic impact on qualifying non-VA entities or providers. To the
extent there is any such impact, it would 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 would
only be submitted for care that would 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.
Executive Orders 12866 and 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,'' 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
the Executive Order.
VA has examined the economic, interagency, budgetary, legal, and
policy implications of this regulatory action and determined that the
action 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 FYTD.
Executive Order 12866 also directs agencies to ``in most cases . .
. include a comment period of not less than 60 days.'' This regulation
will increase access to care for eligible veterans in local communities
across the country. Providing a 30-day comment period will allow the
Secretary to expedite the commencement of this new benefit thereby
increasing access to health care for eligible veterans. Moreover, we
believe that urgent care is a common benefit among other health care
plans and thus should not be an unfamiliar benefit to the public. Given
general public familiarity with this benefit, we believe that 30 days
would be a sufficient period of time for the public to comment on this
rulemaking. In sum, providing a 60-day public comment period instead of
a 30-day public comment period would be against public interest and the
health and safety of eligible veterans. For the above reasons, the
Secretary issues this rule with a 30-day public comment period. VA will
consider and address comments that are received within 30 days of the
date this proposed rule is published in the Federal Register.
[[Page 632]]
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 one year. This proposed rule would have no such
effect on State, local, and tribal governments, or on the private
sector.
Catalog of Federal Domestic Assistance
The Catalog of Federal Domestic Assistance numbers and titles for
the programs affected by this document are as follows: 64.009, Veterans
Medical Care Benefits; 64.012, Veterans Prescription Service; 64.013,
Veterans Prosthetic Appliances; and 64.018, Sharing Specialized Medical
Resources.
List of Subjects in 38 CFR Part 17
Administrative practice and procedure, Claims, Day care, Dental
health, Government contracts, Health care, Health facilities, Health
professions, Health records, Mental health programs, Nursing homes,
Reporting and recordkeeping requirements, Travel and transportation
expenses, Veterans.
Signing Authority
The Secretary of Veterans Affairs 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. Robert L.
Wilkie, Secretary, Department of Veterans Affairs, approved this
document on November 9, 2018, for publication.
Dated: January 25, 2019.
Consuela Benjamin,
Regulations Development Coordinator, Office of Regulation Policy &
Management, Office of the Secretary, Department of Veterans Affairs.
For the reasons set forth in the preamble, we propose to amend 38
CFR part 17 as follows:
PART 17--MEDICAL
0
1. The authority citation for part 17 is amended by adding entries for
Sec. Sec. 17.105, 17.108, and 17.4600 to read in part as follows:
Authority: 38 U.S.C. 501, and as noted in specific sections.
* * * * *
Section 17.105 is also issued under 38 U.S.C. 501, 1721, 1722A,
1724, and 1725A.
Section 17.108 is also issued under 38 U.S.C. 501, 1710, 1725A,
1730A, Sec. 101, Pub. L. 113-146, 128 Stat. 1754.
* * * * *
Section 17.4600 is also issued under 38 U.S.C. 1725A.
Sec. 17.105 [Amended]
0
2. Amend Sec. 17.105 by:
0
a. In paragraph (c), removing ``or 17.111'' and adding in its place
``17.111, or 17.4600''.
0
b. Removing the authority citation at the end of the section.
0
3. Amend Sec. 17.108 by:
0
a. Revising paragraph (e) introductory text.
0
b. Removing the authority citation at the end of the section.
The revision reads as follows:
Sec. 17.108 Copayments for inpatient hospital care and outpatient
medical care.
* * * * *
(e) Services not subject to copayment requirements for inpatient
hospital care, outpatient medical care, or urgent care. The following
are not subject to the copayment requirements under this section or
Sec. 17.4600.
* * * * *
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4. Add Sec. 17.4600 to read as follows:
Sec. 17.4600 Urgent care.
(a) Purpose. The purpose of this section is to establish procedures
for accessing urgent care. Eligible veterans may obtain urgent care
from qualifying non-VA entities or providers under these requirements.
(b) Definitions. The following definitions apply to this section.
(1) Eligible veteran means a veteran described in 38 U.S.C.
1725A(b).
(2) Episodic care means care or services provided to an eligible
veteran for a particular health condition, or a limited set of
particular health conditions, without an ongoing relationship being
established between the eligible veteran and qualifying non-VA entities
or providers.
(3) Longitudinal management of conditions means outpatient care
that addresses important disease prevention and treatment goals and is
dependent upon bidirectional communications that are ongoing over an
extended period of time. For purposes of this section, the term
``longitudinal management of conditions'' and ``longitudinal care'' are
synonymous.
(4) Qualifying non-VA entity or provider means a non-VA entity or
provider, including Federally-qualified health centers as defined in 42
U.S.C. 1396d(l)(2)(B), that has entered into a contract, agreement, or
other arrangement with the Secretary to furnish urgent care under this
section.
(5) Urgent care means those services being provided by walk-in
retail health clinics or urgent care facilities, as designated by the
Centers for Medicare and Medicaid Services, furnished by a qualifying
non-VA entity or provider, and as further defined in paragraphs
(b)(5)(i) through (iii) of this section.
(i)(A) Except as provided in paragraph (b)(5)(i)(B) or (b)(5)(iii)
of this section, urgent care does not include preventive health
services, as defined in section 1701(9) of title 38, United States
Code.
(B) Urgent care includes immunization against influenza (flu
shots), as well as therapeutic vaccines that are necessary in the
course of treatment of an otherwise included service.
(ii) Urgent care may only be furnished as episodic care for
eligible veterans needing immediate non-emergent medical attention, but
does not include longitudinal care.
(iii) If VA determines that the provision of additional services is
in the interest of eligible veterans, based upon identified health
needs, VA may offer such additional services under this section as VA
determines appropriate. Such services may be limited in duration and
location. VA will inform the public through a Federal Register
document, published as soon as practicable, and other communications,
as appropriate.
(c) Procedures. (1) Eligible veterans may receive urgent care from
a qualifying non-VA entity or provider without prior approval from VA.
(2) VA will publish a website containing information on urgent
care, including the names, locations, and contact information for
qualifying non-VA entities or providers.
(3) In general, eligibility under this section does not affect
eligibility for hospital care or medical services under the medical
benefits package, as defined in Sec. 17.38, or other benefits
addressed in this title. Nothing in this section waives the eligibility
requirements established in other statutes or regulations.
(d) Copayment. (1) Except as provided in paragraphs (d)(2) and (3)
of this section, an eligible veteran, as a condition for receiving
urgent care provided by VA under this section, must agree to pay VA
(and is obligated to pay VA) a copayment of $30:
(i) After three visits in a calendar year if such eligible veteran
is enrolled under Sec. 17.36(b)(1) through (6), except those veterans
described in Sec. 17.36(d)(3)(iii) for all matters not covered by
priority category 6.
(ii) If such eligible veteran is enrolled under Sec. 17.36(b)(7)
or (8), including veterans described in Sec. 17.36(d)(3)(iii).
[[Page 633]]
(2) An eligible veteran who receives urgent care under paragraph
(b)(5)(iii) of this section or urgent care consisting solely of an
immunization against influenza (flu shot) is not subject to a copayment
under paragraph (d)(1) of this section.
(3) If an eligible veteran would be required to pay more than one
copayment under this section, or a copayment under this section and a
copayment under Sec. 17.108 or Sec. 17.111, on the same day, the
eligible veteran will only be charged the higher copayment.
[FR Doc. 2019-00277 Filed 1-30-19; 8:45 am]
BILLING CODE 8320-01-P