[Federal Register Volume 84, Number 36 (Friday, February 22, 2019)]
[Proposed Rules]
[Pages 5629-5650]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-03030]


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

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AQ46


Veterans Community Care Program

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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

SUMMARY: The Department of Veterans Affairs (VA) proposes to amend its 
medical regulations to implement its authority for covered veterans to 
receive necessary hospital care, medical services, and extended care 
services from non-VA entities or providers in the community. Section 
101 of the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson 
VA Maintaining Internal Systems and Strengthening Integrated Outside 
Network Act of 2018 directs VA to implement a program to furnish such 
care and services to covered veterans through eligible entities and 
providers. This proposed rule would establish the criteria for 
determining when covered veterans may elect to receive such care and 
services through community health care entities or providers, as well 
as other parameters of this program.

DATES: Comments must be received on or before March 25, 2019.

ADDRESSES: Written comments may be submitted by email through http://www.regulations.gov; by mail or hand-delivery to Director, Office of 
Regulation Policy and Management (00REG), Department of Veterans 
Affairs, 810 Vermont Avenue NW, Room 1063B, Washington, DC 20420; or by 
fax to (202) 273-9026. (This is not a toll-free number.) Comments 
should indicate that they are submitted in response to ``RIN 2900-AQ46, 
Veterans Community Care Program.'' Copies of comments received will be 
available for public inspection in the Office of Regulation Policy and 
Management, Room 1063B, between the hours of 8:00 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 http://www.regulations.gov.

FOR FURTHER INFORMATION CONTACT: Joseph Duran, Office of Community Care 
(10D), Veterans Health Administration, Department of Veterans Affairs, 
Ptarmigan at Cherry Creek, Denver, CO 80209; [email protected], 
(303) 370-1637. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION:

Summary

    Purpose of This Regulatory Action: We propose to create new 
regulations to define and implement the Veterans Community Care Program 
authorized by section 1703 of title 38, United States Code (U.S.C.), as 
that statute will be amended by section 101 of the John S. McCain III, 
Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems 
and Strengthening Integrated Outside Networks (MISSION) Act of 2018, 
effective upon VA's issuance of implementing regulations. The Veterans 
Community Care Program will permit eligible veterans to elect to 
receive hospital care, medical services, and extended care services 
from eligible entities and providers. The Veterans Community Care 
Program would replace the Veterans Choice Program and would be used as 
the exclusive authority that determines eligibility under which VA 
would authorize covered veterans (as defined later in this rulemaking) 
to receive community care through eligible entities or providers.
    Summary of the Major Provisions of This Regulatory Action: This 
proposed rule--
     Would establish the exclusive authority under which VA 
would authorize covered veterans to receive care in the community from 
eligible entities or providers at VA expense when such veterans meet 
established eligibility criteria.
     Would define key terms used throughout the regulation. 
Many of these terms would be substantively similar to those defined in 
the Veterans Choice Program.
     Would define eligibility criteria, including conditions 
under which covered veterans could elect to have VA authorize non-VA 
care through eligible entities or providers, subject to the 
availability of appropriations. In general, covered veterans would have 
to be enrolled in the VA health care system (or be eligible for care 
and services without enrolling) and would have to require care or 
services from an eligible entity or provider, as proposed to be defined 
in sections 17.4005 and 17.4030 of title 38, Code of Federal 
Regulations (CFR), because VA determined at least one of the following 
six conditions was met:
    [cir] VA does not offer the required care or services;
    [cir] VA does not operate a full-service medical facility in the 
State in which the veteran resides;
    [cir] the veteran was eligible to receive care under the Veterans 
Choice Program and is eligible to receive care under certain 
grandfathering provisions;
    [cir] VA is not able to furnish care or services to a veteran in a 
manner that complies with VA's designated access standards;
    [cir] the veteran and the referring clinician determine it is in 
the best medical interest of the veteran to receive care or services 
from an eligible entity or provider based on consideration of certain 
criteria VA proposes to establish; or
    [cir] the veteran is seeking care or services from a VA medical 
service line that VA has determined is not providing care that complies 
with VA's standards for quality.
     Would describe the process VA would use to identify 
medical service lines that are underperforming and that could be the 
basis for eligibility to receive non-VA care.
     Would describe how non-VA care could be authorized through 
the election of a covered veteran who is eligible to receive non-VA 
care. Eligible veterans could also identify a specific entity or 
provider to furnish such care. VA would be able to authorize emergency 
care under certain conditions within 72 hours of such care being 
furnished.
     Would describe the effect of the Veterans Community Care 
Program on other benefits and services available to covered veterans. 
In general, no provision in this section would be

[[Page 5630]]

construed to alter or modify any other provision of law establishing 
specific eligibility criteria for certain hospital care, medical 
services, or extended care services. VA would continue to pay for and 
fill prescriptions written by non-VA health care providers to the 
extent such prescriptions were immediately required and were covered by 
the VA medical benefits package. VA would continue to calculate 
veterans' VA copayments under applicable regulations.
     Would establish those non-VA health care entities and 
providers that would be permitted to furnish care under the Veterans 
Community Care Program. The types of eligible entities or providers 
would be substantively identical to those presently permitted to 
participate under the Veterans Choice Program or in VA's other existing 
community care program.
     Would clarify payment rates and methodologies for care and 
services furnished by non-VA health care entities and providers through 
the Veterans Community Care Program, to include rates for Critical 
Access Hospitals as allowable under 42 U.S.C. 1395m, and other types of 
providers, including Federally Qualified Health Centers.
     Would designate access standards that would be a basis for 
eligibility for non-VA care.
    Costs and Benefits: As further detailed in the Regulatory Impact 
Analysis, which can be found as a supporting document at http://www.regulations.gov and is 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,'' this proposed rule would 
affect covered veterans and eligible health care entities and 
providers. Covered veterans who meet at least one of the eligibility 
criteria may elect to receive, at VA expense and upon VA's 
authorization, care and services from an eligible entity or provider of 
their choice. Participating eligible entities and providers would be 
paid for furnishing authorized hospital care, medical services, and 
extended care services to covered veterans under the Veterans Community 
Care Program in accordance with payment rates as described in this 
rulemaking.
    General Discussion: On June 6, 2018, the President signed into law 
the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA 
Maintaining Internal Systems and Strengthening Integrated Outside 
Networks (MISSION) Act of 2018 (hereafter referred to as the ``MISSION 
Act,'' Public Law 115-182, 132 Stat. 1395). This proposed rule would 
implement section 101 of the MISSION Act, which requires VA to 
implement a Veterans Community Care Program to furnish required care 
and services to covered veterans through eligible entities and 
providers. Section 101, which amends 38 U.S.C. 1703 upon the effective 
date of final regulations implementing this provision, further 
establishes the conditions under which VA would determine if covered 
veterans are eligible to elect to receive such care and services 
through eligible entities or providers, as well as other parameters of 
the Veterans Community Care Program. For the sake of convenience and 
understanding, we will refer to provisions of section 1703, as section 
101 of the MISSION Act will amend it, although we recognize that 
section 1703 as so amended is not legally effective until VA has 
published a final rule implementing the Veterans Community Care 
Program. (Where we are referring to a provision in current section 
1703, we will state ``current section 1703.'').
    We additionally clarify that throughout this rulemaking, the 
abbreviation ``U.S.C.'' or the term ``section'' will be used to 
indicate discussion of or reference to a statutory provision in the 
United States Code (e.g., ``section 1703'') or in another statute, 
while the abbreviation ``CFR'' or the section symbol ``Sec.  '' will be 
used to indicate discussion of or reference to an existing or proposed 
regulatory provision in the Code of Federal Regulations (e.g., 
``proposed Sec.  17.4005''). There may be instances where the term 
``section'' rather than the section symbol must be used at the 
beginning of a sentence to discuss or reference a regulatory provision, 
but it should be clear in the sentence that a regulatory provision is 
at issue. In general, any reference to a section that uses a period in 
it (e.g., Sec.  17.55) is a reference to the CFR, while any reference 
without such a period (e.g., section 1703) is a reference to the U.S.C.
    This proposed rule would implement in a regulatory framework the 
requirements in section 1703, consistent with the mandate that VA 
promulgate regulations to carry out the Veterans Community Care 
Program. Although VA is required to promulgate regulations, some of the 
provisions established in section 1703 are either self-executing and 
would not be more specifically interpreted by VA in regulation, or 
would be most appropriately established in the contracts, agreements, 
or other arrangements VA would use to purchase care under the Veterans 
Community Care Program. For instance, section 1703(h)(3)(A) establishes 
certain grounds for termination of a contract. There is no need to 
regulate this requirement, as section 1703 does not alter or amend VA's 
existing authority to enter into, modify, or terminate a contract. This 
rulemaking generally will not promulgate regulations that merely 
restate the substantive provisions in section 1703 that are clear and 
unambiguous, although such provisions would apply to the Veterans 
Community Care Program regardless. VA proposes to codify the new 
Veterans Community Care Program regulations at 38 CFR 17.4000 through 
17.4040.

Conforming Revisions to Regulations That Reference the Veterans Choice 
Program

    Subsection (p) of section 101 of the Veterans Access, Choice, and 
Accountability Act of 2014 (Pub. L. 113-146; 38 U.S.C. Sec.  1701 
note), as amended by section 143 of the MISSION Act, does not permit VA 
to furnish care and services through the Veterans Choice Program after 
June 6, 2019. However, this does not mean that all of the regulatory 
provisions under which the Veterans Choice Program is implemented 
(generally, 38 CFR 17.1500-17.1540) would be legally inoperative after 
June 6, 2019. There are some provisions in the Veterans Choice Program 
regulations (such as those provisions related to payment rates and 
limits on authorized care) that would need to continue to be in effect 
for resolution of claims arising from the Veterans Choice Program that 
would be in process after June 6, 2019 (for episodes of care performed 
under the Veterans Choice Program prior to June 6, 2019). We therefore 
do not propose to rescind the Veterans Choice Program regulations at 
this time, as VA will continue paying claims under such regulations for 
a period of time after the authority for the Veterans Choice Program 
expires, and we do not want to create any confusion as to how those 
claims should be processed or adjudicated. We anticipate further 
amendments to our regulations in the future to repeal the regulations 
governing the Veterans Choice Program and to remove references to the 
Veterans Choice Program in other regulations.
    We similarly do not propose to remove references to the Veterans 
Choice Program in other applicable VA regulations at this time, but 
would add references to the Veterans Community Care Program in such 
regulations. Specifically, we would amend Sec. Sec.  17.108(b)(4), 
17.108(c)(4), and 17.110(b)(4) to include references to the Veterans 
Community Care Program under Sec. Sec.  17.4000 through 17.4040 to 
ensure that copayments for inpatient

[[Page 5631]]

hospital care, outpatient medical care, and for medications reference 
the new Veterans Community Care Program in the same way these 
regulations currently reference the Veterans Choice Program. We also 
would amend Sec.  17.111(b)(3) to include a reference to extended care 
services furnished through the Veterans Community Care Program under 
Sec. Sec.  17.4000 through 17.4040 to ensure that copayments for 
extended care services (both institutional (i.e., continuous care 
occurring in a professional long-term care setting such as a nursing 
home) and non-institutional (i.e., non-continuous care occurring in 
non-professional settings such as a patient's home) under the new 
Veterans Community Care Program are treated the same way as copayments 
for non-institutional extended care services under the Veterans Choice 
Program.
    Finally, we would delete the list of authorities for Sec. Sec.  
17.108, 17.110, and 17.111 to comply with the guidelines of the Office 
of the Federal Register and would add the complete list of authorities 
for these regulations, including 38 U.S.C. 1703, among the authority 
citations listed for part 17.

Conforming Amendments for Revisions to 38 U.S.C. 1703

    We propose to make a number of conforming amendments to several 
existing regulations to reflect the consolidation of care and the 
initiation of the new Veterans Community Care Program. In general, for 
each of the regulations referenced below, we would also revise these 
regulations to remove specific authority citations in each section and 
instead to refer generally to these sections under the authority 
citation for part 17 to conform with publishing guidelines established 
by the Office of the Federal Register. We would generally impose sunset 
provisions on these regulations to ensure that they do not continue to 
apply to VA's decisions regarding community care after the new Veterans 
Community Care Program begins on June 6, 2019. We do not propose to 
rescind these regulations at this time to allow VA to close out any 
bills or claims for care or services furnished prior to June 6, 2019, 
and to continue to refer to the existing regulations while processing 
these claims. VA will rescind any elements of these regulations at a 
later point in time when we are confident that such rescissions will 
not affect operations or create confusion for veterans or providers.
    First, we propose to amend Sec.  17.46. Section 17.46 governs how 
VA furnishes hospital care under 38 U.S.C. 1710(a)(1), which generally 
requires VA to furnish hospital care and medical services the Secretary 
determines to be needed to any veteran for a service-connected 
disability and to any veteran who has a service-connected disability 
rated at 50 percent or more. Section 17.46 specifically requires VA to 
furnish care in a VA facility, or if that facility is incapable of 
furnishing care, arrange to admit the veteran to another VA facility, a 
DoD facility with which VA has a sharing agreement, or arrange for care 
on a contract basis if authorized by 38 U.S.C. 1703 and 38 CFR 17.52, 
if the veteran is in immediate need of hospitalization. If the veteran 
does not need immediate hospitalization, Sec.  17.46 further provides 
that VA will schedule the veteran for admission at a VA facility or 
refer the veteran to a DoD facility with which VA has a sharing 
agreement. We propose to amend Sec.  17.46 to clarify that paragraph 
(a) of this provision would no longer apply after June 6, 2019. We do 
not propose to make any changes to paragraph (b) of Sec.  17.46, which 
deals with eligibility for domiciliary care. While we do not generally 
believe that Sec.  17.46(a) is used or relied upon to authorize care in 
the community for eligible veterans, we believe it is important to 
avoid creating any confusion by establishing a sunset for this 
provision to ensure that any decisions regarding eligibility for a 
covered veteran to receive care in the community are made under the 
regulations proposed in this rulemaking.
    Second, we propose to amend Sec.  17.52 to add a new paragraph (c) 
that would similarly establish a sunset provision for this regulation. 
Section 17.52 generally establishes eligibility for community care 
under the existing 38 U.S.C. 1703. Upon the effective date of a final 
rule for this rulemaking, the current section 1703 will no longer 
exist. As a result, Sec.  17.52 would no longer apply to care furnished 
after June 6, 2019, as it would be implementing a statute that no 
longer exists.
    Third, we propose to amend Sec.  17.55 to clarify the scope of its 
applicability. Section 17.55 currently establishes payment rates and 
standards for hospital care furnished by non-VA entities or providers. 
Proposed Sec.  17.4035 as presented in this rulemaking would establish 
general parameters for payment, and thus would eliminate the need for 
this rule in part. However, it would not do so entirely. Current Sec.  
17.55 establishes payment rates for care that VA pays on a 
reimbursement basis, most notably emergency care under 38 U.S.C. 1728 
and 38 CFR 17.120 and 17.128, as well as payment for care for eligible 
family members of veterans stationed at Camp Lejeune under 38 U.S.C. 
1787 and 38 CFR 17.410. Because these programs will continue to operate 
independently from the new Veterans Community Care Program, VA is 
proposing to add language that would sunset the applicability of Sec.  
17.55 only for care and services furnished to covered veterans. 
Payments for care and services furnished under the Veterans Community 
Care Program would be subject to Sec.  17.4035 as proposed in this 
rule. We would also make a technical change to Sec.  17.55 to remove 
the reference to the Health Care Financing Administration and instead 
refer to the Centers for Medicare & Medicaid Services (CMS) given the 
change in this agency's name. We would make a similar revision to Sec.  
17.1004(b) where an HCFA form is referenced to instead refer to a CMS 
form.
    Finally, we propose to modify Sec.  17.56 to include a new 
paragraph (e). Similar to the changes above regarding Sec.  17.55, VA 
proposes to amend the current regulation to clarify that payments for 
care furnished under 38 U.S.C. 1725 and 38 CFR 17.1005, which govern 
VA's other authority to reimburse for emergency treatment, payments 
under 38 U.S.C. 1728 and 38 CFR 17.120 and 17.128, and payments under 
38 U.S.C. 1787 and 38 CFR 17.410 would continue under this regulation, 
while this section would no longer generally establish payment rates 
for care in the community after June 6, 2019.

Sec.  17.4000, Purpose and Scope

    Proposed Sec.  17.4000(a) would establish that the purpose of 
proposed regulations Sec. Sec.  17.4000-17.4040 would be to implement 
the Veterans Community Care Program authorized by section 1703. As 
previously stated, we will refer to section 1703 as amended by section 
101 of the MISSION Act for clarity and convenience, even though those 
amendments technically will not come into effect until final 
regulations are effective to implement the Veterans Community Care 
Program.
    Section 17.4000(b) would state that the Veterans Community Care 
Program establishes when a covered veteran could elect to have VA 
authorize an episode of care for hospital care, medical services, or 
extended care services with eligible entities or providers. Section 
17.4000(b) would further state that Sec. Sec.  17.4000-.4040 do not 
affect eligibility for non-VA care under sections 1724, 1725, 1725A, or 
1728 of title 38, United States Code. Sections 1724, 1725, 1725A, and 
1728 establish other methods for accessing community care without 
requiring

[[Page 5632]]

express authorization from VA prior to the receipt of such care. 
Because sections 1724, 1725, 1725A, and 1728 establish distinct 
eligibility criteria that determine when VA can reimburse for care and 
services in the community as specified under those statutes, such 
criteria would not be affected by this proposed rule. This would 
relieve an individual that does meet the eligibility criteria under 
section 1725A, for instance, from also having to meet the eligibility 
criteria under section 1703 in order to receive care under section 
1725A. As another example, this clarification would not amend VA's 
authority to furnish care to veterans participating in VA's Foreign 
Medical Program under section 1724. Similarly, some veterans receive 
care from the Indian Health Service (IHS) and Tribal Health Programs 
(THP) under a sharing agreement with VA. VA has existing reimbursement 
agreements with IHS and THPs under which VA reimburses IHS and THPs for 
certain care provided to eligible American Indian/Alaskan Native 
veterans. Care provided under these agreements (generally referred to 
as ``other arrangements'' in statute) would not be affected by this 
proposed rule. This proposal also would not modify VA's existing 
statutory authorities to furnish care in the community at VA expense to 
anyone who is not a covered veteran (generally, non-veteran 
beneficiaries) who may be eligible for such care pursuant to other 
authorities, such as sections 1786 or 1787, because such individual 
would not meet the definition of covered veteran (as would be defined 
in proposed Sec.  17.4005). The requirements of those statutes and 
their implementing regulations would continue to apply, and VA would 
use those specific authorities when appropriate to furnish community 
care for non-veteran beneficiaries of care under chapter 17 of title 
38, U.S.C.

Sec.  17.4005, Definitions

    Proposed Sec.  17.4005 would define terms for purposes of 
Sec. Sec.  17.4000 through 17.4040. In general, these would be defined 
in the same way, or very similar ways, to terms used in VA's Veterans 
Choice Program regulation at Sec.  17.1505, where such definitions 
would support the same or similar concepts in the Veterans Community 
Care Program. Certain terms defined in Sec.  17.1505 would no longer be 
applicable in the Veterans Community Care Program and so would be 
excluded here. Other terms would be new to this section. The 
explanation that follows of the proposed definitions in Sec.  17.4005 
is presented by comparison to what is in current Sec.  17.1505, to 
provide a clearer understanding of whether or to what extent 
definitions or concepts are proposed to change from the Veterans Choice 
Program to the future Veterans Community Care Program. We do not 
propose to explain the omission of certain terms from Sec.  17.1505, 
but will instead explain the definitions we propose to adopt in Sec.  
17.4005 by reference to Sec.  17.1505.
    The term appointment is currently defined in Sec.  17.1505 to mean 
an authorized and scheduled encounter with a health care provider for 
the delivery of hospital care or medical services. Under Sec.  17.1505, 
a visit to an emergency room or an unscheduled visit to a clinic is not 
an appointment. The proposed definition of appointment in Sec.  17.4005 
would be slightly revised, to include the term extended care services, 
as all types of extended care services would be available for covered 
veterans who otherwise qualify for such care under the Veterans 
Community Care Program in accordance with sections 1703, 1710, and 
1710A. Also, the proposed definition of appointment would not include 
the sentence in current Sec.  17.1505 excluding emergency room visits 
and unscheduled visits, as certain forms of emergency care would be 
otherwise addressed in proposed Sec.  17.4020(c). We would further 
recognize that ad hoc telehealth encounters or same day care would be 
considered an appointment, even though these are not always scheduled 
in advance. The term appointment would be used primarily in proposed 
Sec.  17.4010, related to veteran eligibility to receive care or 
services through the Veterans Community Care Program.
    The term covered veteran would be newly defined in proposed Sec.  
17.4005 to mean a veteran enrolled under the system of patient 
enrollment in Sec.  17.36, or a veteran who otherwise meets the 
criteria to receive care and services notwithstanding his or her 
failure to enroll under 38 U.S.C. 1705(c)(2). This definition would be 
consistent with how the term covered veteran is defined in section 
1703(b) and would be relevant for determinations of veteran eligibility 
for community care under proposed Sec.  17.4010. We note that certain 
veterans are not required to enroll to receive care and services, 
although many would only qualify for a narrow range of services without 
enrolling. Section 1705(c)(2) directs VA to provide hospital care and 
medical services for the 12 month period following the veteran's 
discharge or release from service to any veteran referred to in 
sections 1710(a)(1) (which refers to furnishing hospital care and 
medical services determined to be needed for a service-connected 
disability and to any veteran with a service-connected disability rated 
at 50 percent or more) and (a)(2)(B) (which refers to furnishing 
hospital care, medical services, and nursing home care determined to be 
necessary to a veteran whose discharge or release from active military, 
naval, or air services was for a disability that was incurred or 
aggravated in the line of duty) for a disability specified in those 
provisions of law, notwithstanding the failure of the veteran to enroll 
in the VA health care system. Any veteran meeting these conditions 
would be considered a covered veteran under this definition. Moreover, 
there are a number of special treatment authorities, such as sections 
1702, 1710(a)(2)(F) and (e), 1720D, and 1720E, that direct VA to 
provide certain care and services to certain veterans. Although the 
conditions that can be treated under these special treatment 
authorities are not technically service-connected, as VA explained in a 
prior rulemaking titled ``Third Party Billing for Medical Care Provided 
under Special Treatment Authorities'' (RIN 2900-AP20), veterans 
eligible under these special treatment authorities are eligible for 
treatment of specific conditions, which although not adjudicated as 
service-connected, are treated as the practical equivalent for medical 
care purposes. 83 FR 31452, 31453 (July 6, 2018). As a result, we 
believe it would be consistent with our interpretation of these special 
treatment authorities under other laws and regulations to regard these 
as the practical equivalent of service-connected conditions as 
described in 1705(c)(2). Similarly, section 2 of Public Law 95-126, as 
amended (38 U.S.C. 5303 note), directs VA to provide the type of health 
care and related benefits authorized to be provided under chapter 17 
for any disability incurred or aggravated during active military, 
naval, or air service in the line of duty by a person other than one 
statutorily barred from receiving benefits under section 5303(a), but 
prohibits VA from providing such health care and related benefits 
pursuant to this section for any disability incurred or aggravated 
during a period of service from which such person was discharged by 
reason of a bad conduct discharge. We would, similar to the special 
treatment authorities, regard persons eligible under section 2 of 
Public Law 95-126 as satisfying the condition of not needing to enroll. 
Consequently, veterans who are not enrolled but who qualify for 
services under section 1705(c)(2),

[[Page 5633]]

section 2 of Public Law 95-126, or any of the special treatment 
authorities would be considered covered veterans for purposes of this 
definition and would be subject to the eligibility criteria in proposed 
Sec.  17.4010.
    The term eligible entity or provider would be newly defined in 
proposed Sec.  17.4005 to mean a health care entity or provider that 
meets the requirements of Sec.  17.4030. The section of this rule that 
discusses proposed Sec.  17.4030 will describe those requirements, but 
we note here that the potentially eligible entities and providers under 
the Veterans Community Care Program would be substantively identical to 
those expressly identified as eligible to participate in the Veterans 
Choice Program under current Sec.  17.1510. This proposed definition is 
not intended to make any substantive changes from the Veterans Choice 
Program in terms of the entities or providers that would participate in 
the Veterans Community Care Program, and any entities or providers 
furnishing care and services through VA's existing community care 
program would similarly be eligible if they enter into a contract, 
agreement, or other arrangement to furnish such care and services. This 
would include private providers that are typically thought of in 
relation to furnishing VA community care, as well as non-VA Federal or 
other health care providers such as the Department of Defense or the 
Indian Health Service. As described in further detail in proposed Sec.  
17.4030, the critical elements that must be met for an entity or 
provider to be an eligible entity or provider are (1) that the entity 
or provider must have entered into a contract, agreement, or other 
arrangement to furnish care and services under the Veterans Community 
Care Program; (2) the entity or provider not be a part of, or an 
employee of, VA; and (3) the entity or provider must be accessible to 
the covered veteran.
    The term episode of care is currently defined in Sec.  17.1505 to 
mean a necessary course of treatment, including follow-up appointments 
and ancillary and specialty services, which lasts no longer than 1 
calendar year from the date of the first appointment with a non-VA 
health care provider. The proposed definition of episode of care in 
Sec.  17.4005 would vary from the definition under current Sec.  
17.1505 by removing the reference to the date of the first appointment 
with a non-VA health care provider. The phrase seems unnecessary, as 
the episode of care would necessarily begin with the first such 
appointment. This change would not, however, create a broader standard 
than presently exists in the Veterans Choice Program in terms of the 
possible duration of an episode of care, because the definition of 
episode of care in proposed Sec.  17.4005 still means a necessary 
course of treatment, including follow-up appointments and ancillary and 
specialty services for identified health care needs. VA would therefore 
retain the responsibility for care coordination with eligible entity or 
providers in this proposed revised definition to determine whether 
ancillary and specialty care of any duration up to 1 year would be 
needed in the course of a veteran's care. For care or services that 
would need to extend beyond one year, additional care would need to be 
authorized by VA. In addition, it is possible that any one episode of 
care may not capture all care or treatment fully necessary to improve, 
restore, or promote a veteran's health, as a veteran may have multiple 
conditions that could require VA to authorize several episodes of care 
at the same time. While some episodes of care require only a single 
visit, and others may require multiple visits, in all cases VA would 
continue to authorize, as part of care coordination, only care that is 
clinically necessary over the course of treatment. If an eligible 
entity or provider believed that a veteran needed additional care 
beyond the authorized episode of care, the eligible entity or provider 
would be required to contact VA prior to administering or referring 
such care to ensure that this care was authorized and therefore would 
be paid for by VA. In short, under the revised definition of episode of 
care in proposed Sec.  17.4005, whether additional care constituted a 
new episode of care would continue to be a clinical determination based 
on generally acceptable clinical practices and protocols, whenever 
possible, as part of care coordination conducted by VA in close 
consultation with eligible entities or providers.
    The term extended care services would be newly defined in proposed 
Sec.  17.4005 to include the same services as described in 38 U.S.C. 
1710B(a). This definition would be required as section 1703(a)(1) makes 
extended care services available under the Veterans Community Care 
Program, whereas only certain non-institutional extended care services 
are available as medical services under the Veterans Choice Program. 
This proposed definition to include those services described is section 
1710B(a) would be sufficiently broad to capture all extended care 
services offered by VA.
    The term full-service VA medical facility would be newly defined in 
proposed Sec.  17.4505 to mean a VA medical facility that provides 
hospital care, emergency medical services, and surgical care and having 
a surgical complexity designation of at least standard. This proposed 
definition would also include a note that would state that VA maintains 
a website with a list of the facilities that have been designated with 
at least a surgical complexity of ``standard,'' which can be accessed 
on VA's website. This proposed definition would be relevant for 
determinations of certain veteran eligibility under proposed Sec.  
17.4010 and is consistent with how a VA facility is characterized for 
purposes of similar veteran eligibility under current Sec.  
17.1510(b)(3). The current location for information regarding the 
surgical complexity levels of VA facilities is on VA's website: 
www.va.gov/health/surgery. We do not propose to identify a specific URL 
in our regulations in the event that this information is ultimately 
moved to another page on VA's website.
    The terms hospital care and medical services would be newly defined 
in proposed Sec.  17.4005 by cross referencing to the applicable 
statutory definitions for these terms at 38 U.S.C. 1701(5) and (6), 
respectively, to sufficiently capture those types of care furnished by 
VA. These terms would be used throughout these proposed regulations, as 
section 1703(a)(1) requires the furnishing of hospital care, medical 
services, and extended care services through the Veterans Community 
Care Program. We have interpreted these terms through VA's medical 
benefits package in Sec.  17.38, and this benefits package would be 
available to covered veterans under the Veterans Community Care Program 
when clinically necessary, as required by section 1703(n)(1) and Sec.  
17.38(b). Section 1703(n)(1) prohibits VA from limiting the types of 
care or services covered veterans may receive under this section if it 
is in the best medical interest of the veteran to receive such care or 
services as determined by the veteran and the veteran's health care 
provider. We interpret section 1703(n)(1) to reinforce the requirement 
currently in regulation at Sec.  17.38(b) that care referred to in the 
medical benefits package will be provided to individuals only if it is 
determined by appropriate healthcare professionals that the care is 
needed to promote, preserve, or restore the health of the individual 
and is in accord with generally accepted standards of medical practice.
    The term health-care plan is currently defined in Sec.  17.1505 to 
mean an insurance policy or contract, medical or hospital service 
agreement, membership or subscription contract, or similar arrangement 
not administered by the Secretary of Veterans Affairs, under

[[Page 5634]]

which health services for individuals are provided or the expenses of 
such services are paid; and does not include any such policy, contract, 
agreement, or similar arrangement pursuant to title XVIII or XIX of the 
Social Security Act (42 U.S.C. 1395 et seq.) or chapter 55 of title 10, 
United States Code. We would propose minor changes in proposed Sec.  
17.4005 to rename this term as other health-care plan contract because 
other health-care plan contract is the term that appears in section 
1703(j). This term would be relevant for purposes of proposed Sec.  
17.4010(c) related to when covered veterans participating in the 
Veterans Community Care Program would have to report on their third-
party health care insurance, similar to how the term health-care plan 
is used in current Sec.  17.1510(d).
    The term residence is currently defined in Sec.  17.1505 to mean a 
legal residence or personal domicile, even if such residence is 
seasonal. Section 17.1505 further provides that a person may maintain 
more than one residence but may only have one residence at a time. It 
also states that if a veteran lives in more than one location during a 
year, the veteran's residence is the residence or domicile where the 
person is staying at the time the veteran wants to receive hospital 
care or medical services through the Program. Finally, it states that a 
post office box or other non-residential point of delivery does not 
constitute a residence. We would propose minor edits to this definition 
in proposed Sec.  17.4005 to refer consistently to covered veterans 
instead of person or veteran, as this is the term used in these 
regulations. We also would include extended care services for the 
reasons described above. This term would be used in proposed Sec.  
17.4010, and the section of this rulemaking that explains proposed 
Sec.  17.4010 would explain VA's proposed revisions to certain 
geographic conditions that can establish eligibility for community 
care.
    The term schedule is currently defined in Sec.  17.1505 to mean 
identifying and confirming a date, time, location, and entity or health 
care provider for an appointment. We would clarify in proposed Sec.  
17.4005 that schedule requires identifying and confirming a date, time, 
and location for an appointment in advance of such appointment. We 
would further add a note explaining that a VA telehealth encounter 
would be considered to be scheduled even if such encounter is conducted 
on an ad hoc basis. In the years since the Veterans Choice Program was 
established, VA's telehealth program has grown, and its authority to 
furnish care has been buttressed through regulation (see Sec.  17.417) 
and statute (see section 1730C, as added by section 151 of the MISSION 
Act). Some telehealth encounters are scheduled well in advance of the 
appointment, while others are made available to eligible and interested 
veterans on an ad hoc basis (for example, if a veteran cancelled an 
appointment or did not show up to an appointment, VA schedulers may 
follow up with the veteran and ask the veteran if he or she would like 
to participate in a telehealth encounter at that moment). This note 
would clarify that in either scenario, a telehealth encounter would be 
considered scheduled and would thus qualify as an appointment under the 
definition of appointment described above. As described in further 
detail later in this regulation, if VA is able to furnish a covered 
veteran with care or services through telehealth, whether through a 
telehealth encounter that was scheduled well-in advance or one 
conducted on an ad hoc basis, and the veteran accepts the use of this 
modality for care, VA would determine that it was able to furnish such 
care or services in a manner that complies with designated access 
standards. We would similarly consider same-day services provided to a 
veteran who did not schedule an appointment in advance as scheduled. 
This is also a new service that VA has only begun routinely offering in 
the past several years and is distinct from the unscheduled visits we 
referred to in the Veterans Choice Program regulations at Sec.  
17.1505, as those were primarily concerned with open clinics (such as 
general group counseling or services, like access to a gymnasium, that 
do not have or require an appointment). Just as with telehealth, if VA 
were able to offer the care or services a veteran required on a same-
day basis, we would determine that VA was able to furnish the care or 
services in a manner that complies with designated access standards. 
The term schedule would be used throughout the proposed regulations, 
primarily in proposed Sec.  17.4010 related to veteran eligibility for 
care under the Veterans Community Care Program.
    The term VA facility would be newly defined in proposed Sec.  
17.4005 to mean a VA facility that offers hospital care, medical 
services, or extended care services, although the similar term VA 
medical facility was defined in Sec.  17.1505. This definition would be 
required in relation to certain veteran eligibility under the Veterans 
Community Care Program in proposed Sec.  17.4010. We note that we 
propose different definitions for full-service VA medical facility and 
VA facility, as these terms would be applied to discrete proposed 
eligibility criteria to furnish care under the Veterans Community Care 
Program. We propose to refer in this definition of VA facility to the 
types of care and services that a facility provides, rather than the 
designations of the facilities (e.g., VA medical center, community-
based outpatient clinic (CBOC), etc.) to ensure that any future 
descriptions of VA facilities would not result in a gap in our 
regulations for this Program. VA has multiple types of facilities from 
which VA care and services are furnished, including but not limited to 
medical centers, CBOCs, outreach clinics, and mobile clinics, among 
others. By defining VA facility broadly in terms of the types of care 
or services that could be provided, we would avoid the need to revise a 
specific list of facility types in the event that VA develops new types 
of facilities or renames existing types of facilities. We note that the 
term VA facility intends to capture a single site of care, and not for 
instance a grouping of multiple facilities that are under the direction 
of one administrative VA parent facility. We further note that Vet 
Centers, which were expressly excluded from the definition of a VA 
medical facility under Sec.  17.1505, would still be excluded, as Vet 
Centers do not furnish hospital care, medical services, or extended 
care services.
    The term VA medical service line would be newly defined in proposed 
Sec.  17.4005 to mean a specific medical service or set of services 
delivered in a VA facility. We believe this is consistent with but also 
more appropriately descriptive than the definition of the term in 
section 1703(o)(2). We propose to refer to VA facilities, rather than 
only VA medical centers, because this definition is relevant for 
purposes of establishing eligibility under section 1703(e), and 
paragraph (1)(B) of that subsection specifically refers to comparisons 
of timeliness and quality at a facility of the Department, rather than 
just a medical center. Moreover, reports from the Veterans' Affairs 
Committees of the Senate and the House of Representatives both 
consistently refer to this provision affecting VA facilities, rather 
than only VA medical centers. See S. Rpt. 115-212, p. 10; see also H. 
Rpt. 115-671, Part 1, pp. 5, 51. In this context, we believe using the 
term facility is appropriate. This definition would apply for purposes 
of proposed Sec. Sec.  17.4010(a)(6) and 17.4015.

Sec.  17.4010, Veteran Eligibility

    Section 1703(d) establishes the conditions under which, at the 
election of the veteran and subject to the

[[Page 5635]]

availability of appropriations, VA must furnish care in the community 
through eligible entities and providers. Section 1703(d)(3) requires VA 
to make determinations regarding whether these conditions are met for 
sections 1703(d)(1)(A)-(D). Section 1703(e) authorizes VA to furnish 
care in the community through eligible entities and providers. VA 
proposes to establish a single section of regulations, Sec.  17.4010, 
that would cover these three provisions of law under the general mantle 
of eligibility for ease of understanding and review and to align with 
dozens of other VA health care regulations. We emphasize that while we 
describe this as eligibility, covered veterans do not need to do 
anything other than contact VA to request care and provide the 
information required in paragraphs (b) and (c), as they typically 
would. It is VA's responsibility to determine whether the veteran has 
met any of the conditions described here and would be eligible to make 
an election to have VA authorize the care in the community.
    Similar to the definitions section above, portions of the following 
explanation of veteran eligibility in proposed Sec.  17.4010 will be 
presented by comparison to current veteran eligibility under the 
Veterans Choice Program at Sec.  17.1510, to provide a clearer 
understanding of whether eligibility is proposed to change under the 
future Veterans Community Care Program. We will also note where the 
proposed eligibility criteria align with informal criteria used in VA's 
existing community care program. We additionally reiterate that, for 
the sake of convenience and understanding, we will refer to provisions 
of section 1703, as section 101 of the MISSION Act will amend it, 
although we recognize that section 1703 as so amended is not legally 
effective until VA has published a final rule implementing the Veterans 
Community Care Program. When we do refer to the current section 1703 to 
describe current eligibility criteria, we will refer to it as such.
    Consistent with the structure of veteran eligibility determinations 
under the Veterans Choice Program at 38 CFR 17.1510, as well as the 
structure of veteran eligibility under 38 U.S.C. 1703(b), (d), and (e), 
proposed Sec.  17.4010 would establish that determinations of veteran 
access to care or services through the Veterans Community Care Program 
would be based on a two-part assessment. First, the introductory text 
of proposed Sec.  17.4010 would establish that a veteran must meet the 
definition of covered veteran, which as previously explained in the 
definitions section would mean that the veteran is enrolled under the 
system of patient enrollment in Sec.  17.36, or the veteran must 
otherwise meet the criteria to receive care and services 
notwithstanding his or her failure to enroll under 38 U.S.C. 
1705(c)(2). This requirement to establish a threshold eligibility 
related to a veteran's enrollment status would be consistent with 
definition of a covered veteran in section 1703(b), and would be 
consistent generally with the Veterans Choice Program (which was only 
available to enrolled veterans). The proposed definition of covered 
veteran would clarify that the Veterans Community Care Program would 
include veterans under section 1705(c)(2) not subject to the 
requirement to enroll. Veterans meeting either of these requirements 
would be considered a covered veteran. The second part of the 
assessment is for VA to determine whether any of the six conditions 
described in proposed Sec.  17.4010(a) are met. Moreover, such eligible 
veterans would have to provide VA with the information that would be 
required by proposed Sec.  17.4010(b) and (c) as a condition for 
receiving care and services through this Program.
    Proposed Sec.  17.4010(a) would state that the covered veteran 
would have to require hospital care, medical services, or extended care 
services. This is a core requirement for VA to furnish any care under 
the medical benefits package at 38 CFR 17.38(b), as such care must be 
necessary to promote, preserve, or restore the health of the veteran. 
In addition, one of the six conditions identified in sub-paragraphs (1) 
through (6) would have to be met. These conditions in proposed Sec.  
17.4010(a)(1)-(a)(6) would reflect the specific six conditions under 
sections 1703(d) and (e) for covered veterans to receive care through 
the Veterans Community Care Program, which generally are:
     VA does not offer the care or services the veteran 
requires;
     VA does not operate a full-service medical facility in the 
State in which the veteran resides;
     The veteran was eligible to receive care under the 
Veterans Choice Program and is eligible to receive care under certain 
grandfathering provisions;
     VA is not able to furnish care or services to a veteran in 
a manner that complies with VA's designated access standards;
     The veteran and the veteran's referring clinician 
determine it is in the best medical interest of the veteran to receive 
care or services from an eligible entity or provider based on 
consideration of certain criteria that VA would establish; or
     The veteran is seeking care or services from a VA medical 
service line that VA has determined is not providing care that complies 
with VA's standards for quality.
    The explanation that follows will provide more specific 
interpretations of these general conditions from sections 1703(d) and 
(e), and we note that each condition would be an independent means by 
which a covered veteran could access care or services through the 
Veterans Community Care Program. For instance, if a covered veteran did 
not qualify for community care under proposed Sec.  17.4010(a)(1), such 
veteran might still qualify under proposed Sec.  17.4010(a)(2)-(a)(6). 
The conditions in proposed Sec.  17.4010(a)(1)-(a)(6) would also not be 
mutually exclusive in an absolute sense. While VA proposes to 
distinguish each condition meaningfully, it may be the case that 
veterans could be considered eligible under more than one proposed 
criterion. For example, a veteran who resides in a State without a 
full-service VA medical facility might also require care or services 
that VA does not offer. Some of the conditions, such as residing in a 
State without a full-service VA medical facility, or qualifying under 
the grandfathering provision related to 40-mile eligibility and 
residence in one of the five States with the lowest population density 
in the 2010 census, would qualify a veteran to receive any clinically 
necessary hospital care, medical services, or extended care services 
that is in accord with generally accepted standards of medical practice 
and that is needed to promote, preserve, or restore the veteran's 
health. Other conditions, such as VA not offering the care or service a 
covered veteran requires, would only qualify the veteran to receive a 
particular episode of care in the community for that care or service. 
We will describe these general parameters of eligibility as we explain 
each specific criterion.
    Proposed Sec.  17.4010(a)(1) would establish eligibility for a 
covered veteran to access care and services through the Veterans 
Community Care Program if VA determined that no VA facility offered the 
hospital care, medical services, or extended care services the veteran 
requires. Proposed Sec.  17.4010(a)(1) would implement the eligibility 
criterion under section 1703(d)(1)(A) related to when the Department 
does not offer the care or services. VA proposes to interpret this 
criterion to capture certain care and services that VA does not offer 
at any of its facilities, (such as full obstetrics care, the limited 
provision of certain in vitro fertility services, and certain non-

[[Page 5636]]

institutional extended care services such as homemaker/home health aide 
services) and that VA exclusively relies on non-VA health care entities 
or providers to furnish. Covered veterans requiring such care and 
services would be considered eligible for the Veterans Community Care 
Program under proposed Sec.  17.4010(a)(1) for the specific care or 
service they require. Although this criterion would be an assessment of 
VA facilities at large, VA would capture whether a VA facility does not 
offer the specific care and service that a covered veteran requires in 
relation to the residence of the covered veteran, for instance, during 
the consultation with the VA clinician or member of the VA care 
coordination team at the time when access to care in the community is 
determined. We intend that proposed Sec.  17.4010(a)(1) would be a 
simple qualifier for covered veterans that need certain types of care 
that VA simply does not provide in any of its facilities. Any covered 
veteran requiring such care or services would not have to be assessed 
any further under other proposed eligibility criteria for community 
care. This would provide clarity for veterans and would be 
administratively simpler for VA. We note that proposed Sec.  
17.4010(a)(1) would not be used to limit access to community care 
generally in instances where a single VA facility offers the care or 
services required; covered veterans would simply be assessed under one 
of the other five eligibility criteria in proposed Sec.  17.4010(a)(2)-
(a)(6). We reiterate that each of the eligibility criteria in proposed 
Sec.  17.4010(a)(1)-(a)(6) would be an independent means by which a 
covered veteran could be considered eligible to receive required care 
or services through the Veterans Community Care Program. Because 
proposed Sec.  17.4010(a)(4) would separately assess eligibility for 
community care in a manner that considered whether individual VA 
facilities offered the required care or services in relation to 
individual covered veterans, the interpretation in proposed Sec.  
17.4010(a)(1) to consider the availability of care or services anywhere 
in the VA system would allow VA to give meaning to every community care 
eligibility criterion under section 1703(d), and would prevent any one 
criterion from subsuming others. Proposed Sec.  17.4010(a)(1) does not 
have an analogous or substantively similar eligibility criterion under 
current Sec.  17.1510, but would reflect current practice through both 
the Veterans Choice Program and VA's traditional community care 
program. Under the Veterans Choice Program, eligible veterans requiring 
services that VA does not provide in any location would qualify under 
the wait-time criteria, as the wait-time to receive that care in a VA 
facility would be infinite. Under the current section 1703(a), VA may 
contract with non-VA facilities to furnish care and services when VA 
facilities are not capable of furnishing the care or services required. 
Covered veterans would only be eligible under proposed Sec.  
17.4010(a)(1) for the specific care or service they require that VA 
does not furnish.
    Proposed Sec.  17.4010(a)(2) would establish eligibility for a 
covered veteran to receive care and services through the Veterans 
Community Care Program if VA has determined that it does not operate a 
full-service VA medical facility in the State in which such covered 
veteran resides. Proposed Sec.  17.4010(a)(2) would implement the 
eligibility criterion in section 1703(d)(1)(B). Proposed Sec.  
17.4010(a)(2) would be analogous to current Sec.  17.1510(b)(3)(i), 
although proposed Sec.  17.4010(a)(2) would not retain the 20-mile 
qualifying criterion in current 38 CFR 17.1510(b)(3)(ii), to be 
consistent with section 1703(d)(1)(B). VA has determined that this 
change would only affect a small portion of veterans residing in New 
Hampshire along the border with Vermont, and the effect would be to 
establish their eligibility to elect to receive community care under 
this new Program. We reiterate from the definitions section that VA 
would interpret a full-service VA medical facility to mean a VA medical 
facility that provides hospital care, emergency medical services, and 
surgical care and having a surgical complexity designation of at least 
``standard,'' which is how a VA facility is characterized in current 
Sec.  17.1510(b)(3)(i) for purposes of assessing the capabilities of a 
VA facility within a State to provide care and services. Currently, 
Alaska, Hawaii, New Hampshire, and most of the U.S. territories 
(American Samoa, the Northern Mariana Islands, Guam, and the U.S. 
Virgin Islands) qualify as States without a full-service VA medical 
facility. Eligibility under this criterion would qualify a covered 
veteran to elect to receive in the community any hospital care, medical 
services, or extended care services that is needed to promote, 
preserve, or restore the health of the veteran and that is in accord 
with generally accepted standards of medical practice.
    Proposed Sec.  17.4010(a)(3) would establish eligibility for a 
covered veteran to receive care and services through the Veterans 
Community Care Program if VA has determined that the covered veteran 
was eligible to receive care and services from an eligible entity or 
provider under section 101(b)(2)(B) of the Veterans Access, Choice, and 
Accountability Act of 2014 (Public Law 113-146; 38 U.S.C.1701 note) as 
of June 5, 2018, and continues to reside in a location that would have 
qualified the veteran under section 101(b)(2)(B), and one of two 
additional conditions is met: The veteran (i) resides in one of the 
five States with the lowest population density as determined by data 
from the 2010 decennial census (Alaska, Montana, North Dakota, South 
Dakota, or Wyoming); or (ii) does not reside in one of these States, 
but received care or services under title 38 U.S.C. in the year 
preceding June 6, 2018, and is seeking care before June 6, 2020. For 
purposes of this latter category, we note that receipt of care or 
services under title 38, U.S.C., would include literally any hospital 
care, medical service, or extended care service VA furnished to the 
veteran, whether in a VA facility or not. Proposed Sec.  17.4010(a)(3) 
would implement the eligibility criterion in section 1703(d)(1)(C), to 
effectively grandfather eligibility for those veterans who qualify for 
care under the Veterans Choice Program under current Sec.  
17.1510(b)(2) based on the 40-mile distance criterion. We note that, 
consistent with section 1703(d)(1)(C), the grandfathering of 
eligibility in proposed Sec.  17.4010(a)(3) would be carried forward 
indefinitely for only those covered veterans that reside in Alaska, 
Montana, North Dakota, South Dakota, or Wyoming. Any covered veterans 
that did not reside in one of these States would only be considered to 
have this grandfathered eligibility related to the 40-mile criterion in 
current Sec.  17.1510(b)(2) for the first two years after the date of 
enactment of the MISSION Act, until June 6, 2020. Eligibility under 
this proposed criterion would qualify a covered veteran to elect to 
receive in the community any hospital care, medical service, or 
extended care service that is needed to promote, preserve, or restore 
the health of the veteran and that is in accord with generally accepted 
standards of medical practice.
    Proposed Sec.  17.4010(a)(4) would establish conditions for a 
covered veteran to access care and services through the Veterans 
Community Care Program if the covered veteran has contacted an 
authorized VA official to request the care or services the veteran 
requires, but VA has determined it is not able to furnish such care or 
services

[[Page 5637]]

in a manner that complies with designated VA access standards that 
would be established in proposed Sec.  17.4040. Proposed Sec.  
17.4010(a)(4) would implement the eligibility criterion in section 
1703(d)(1)(D). The proposed access standards themselves are explained 
in the section of this rule that discusses proposed Sec.  17.4040, 
which would implement both section 1703(d)(1)(D) and portions of 
section 1703B. Access to care in the community based upon this 
criterion generally would only qualify a covered veteran to receive a 
specific care or service within an episode of care, but in practice 
could amount to general eligibility for any care or service within 
multiple episodes of care. While described in greater detail in our 
discussion of proposed Sec.  17.4040, VA's designated access standards 
consider both wait-times to receive care or services, as well as the 
average driving time from the covered veteran's residence to such care 
and services. Because both the wait-time and the average driving time 
standards are specific to the type of care required, these would 
generally only qualify a veteran for a specific type of care or 
service. However, if a covered veteran resided in a location that was 
beyond the average driving time standard for any service, that covered 
veteran would effectively qualify for any clinically necessary hospital 
care, medical service, or extended care service (except for nursing 
home care, as described below). This criterion is essentially a 
permutation of the existing distance and wait-time criteria in the 
Veterans Choice Program under current Sec.  17.1510(b)(1) and (b)(2), 
as well as the general standards under current section 1703(a).
    Proposed Sec.  17.4010(a)(5) would establish eligibility for a 
covered veteran to receive care and services through the Veterans 
Community Care Program if the veteran and the veteran's referring 
clinician (either a VA or non-VA clinician) determine it is in the best 
medical interest of the veteran--for the purpose of achieving improved 
clinical outcomes--to receive the care or services the veteran requires 
from an eligible entity or provider, based on factors that could be 
considered under proposed Sec.  17.4010(a)(5)(i)-(vii). We note that we 
propose to qualify a determination of best medical interest in proposed 
Sec.  17.4010(a)(5) by expressly stating that such a determination 
would be for the purpose of the veteran achieving improved clinical 
outcomes by receiving the care or services in the community, versus 
from a VA health care provider. VA intends this distinction to clarify 
that the factors proposed in Sec.  17.4010(a)(5)(i)-(vii) would be 
considered in the context of clinical decision making. This is well-
supported by the reference in section 1703(d)(1)(E) to the 
determination being based on the best medical interest of the covered 
veteran based on criteria developed by the Secretary. The inclusion of 
language referencing improved clinical outcomes would clarify that 
other factors (such as mere convenience), when unconnected to any 
clinical outcome, would not be a basis for determining that receipt of 
care in the community is in the covered veteran's best medical 
interest.
    Sections 1703(d)(1)(E) and (d)(2) require VA to develop criteria to 
be used in determining the best medical interest of the veteran. 
Proposed Sec.  17.4010(a)(5) would implement the eligibility criterion 
in section 1703(d)(1)(E), and proposed Sec.  17.4010(a)(5)(i)-(vii) 
would describe the criteria that VA proposes to guide determinations of 
whether it is in the best medical interest that a veteran be furnished 
care or services by an eligible entity or provider. Section 1703(d)(2) 
identifies specific criteria that VA must consider in developing these 
factors; this list is not exhaustive, as demonstrated by the statute's 
direction to ensure that the criteria developed under paragraph (1)(E) 
include consideration of the criteria that follow. This language makes 
the most sense when subsection (d)(2) is understood as a minimum 
description of the criteria that must be considered by VA. Thus, the 
additional factors VA is proposing to adopt in proposed Sec.  
17.4010(a)(5)(v)-(vii), discussed further below, would be an exercise 
of discretion authorized by Congress.
    The specific factors that a veteran and a veteran's referring 
clinician could consider in proposed Sec.  17.4010(a)(5)(i)-(iv) would 
mirror those expressly listed in section 1703(d)(2)(A)-(D), and we note 
that two of these proposed factors (related to the nature of the care 
and services, and frequency that the care and services would be needed) 
are presently assessed in the Veterans Choice Program under Sec.  
17.1510(b)(4)(ii)(A)-(B). We would make a minor clarification to the 
statutory criteria in proposed paragraph (a)(5)(i) to refer to a 
facility or facilities where care could be provided, in case there is 
more than one location that could furnish the care. The language 
concerning a facility or facilities is intended to include both VA and 
non-VA facilities.
    Proposed Sec.  17.4010(a)(5)(v) would not mirror a statutory 
criteria, but is proposed in the Secretary's discretion to permit the 
additional consideration of whether there would be the potential for 
improved continuity of care if a non-VA health care provider furnished 
the care, such as instances where the veteran might have an existing 
relationship with a non-VA health care provider that would make 
adherence to a clinical regimen more likely than if a VA health care 
provider were to start newly furnishing care or services. Proposed 
Sec.  17.4010(a)(5)(vi) would similarly not mirror a statutory factor 
in section 1703(d)(2), but would permit the additional consideration of 
whether the quality of care provided by an eligible entity or provider 
might be considered more clinically appropriate for a veteran, such as 
when an eligible entity or provider might have more expertise in 
furnishing a specialized procedure than a VA health care provider.
    Proposed Sec.  17.4010(a)(5)(vii) would implement the factor in 
section 1703(d)(2)(E) to consider it in the best medical interest of 
the covered veteran to receive care or services from an eligible entity 
or provider if the veteran faces an unusual or excessive burden in 
accessing a VA facility. Proposed Sec.  17.4010(a)(5)(vii)(A)-(D) would 
implement the express considerations in section 1703(d)(2)(E)(i)-(iv), 
many of which mimic the unusual or excessive travel burden criteria in 
current Sec.  17.1510(b)(4)(ii). The unusual and excessive travel 
burden would apply to travel to a VA facility for any type or category 
of care and services under VA's medical benefits package. Proposed 
Sec.  17.4010(a)(5)(vii)(E) would implement the substantively similar 
consideration in current Sec.  17.1510(b)(4)(ii)(C), that a covered 
veteran's need for an attendant to travel to a VA medical facility to 
receive care and services could be assessed as a factor in the best 
medical interest determination.
    Proposed Sec.  17.4010(a)(6) would establish eligibility for a 
covered veteran to receive care and services through the Veterans 
Community Care Program if, in accordance with proposed Sec.  17.4015, 
explained later in this rule, VA has determined that a VA medical 
service line that would furnish the care or services the veteran 
requires is not providing such care or services in a manner that 
complies with VA's standards for quality. Proposed Sec.  17.4010(a)(6) 
would implement the eligibility criterion for community care in section 
1703(e), which permits but does not compel VA to furnish hospital care, 
medical services, or extended care services through the Veterans 
Community Care Program. We note this difference between the 
discretionary eligibility in section 1703(e) and the eligibility in 
section 1703(d), which is

[[Page 5638]]

required subject to the availability of appropriations, at the outset 
here, and will explain more fully in the discussion below that 
addresses proposed Sec.  17.4015 how VA would designate medical service 
lines based on data related to VA's standards for quality, and how this 
would be applied to eligibility decisions under this section.
    Proposed Sec.  17.4010(b) and (c) would incorporate without 
substantive change two requirements from the Veterans Choice Program at 
current Sec.  17.1510(c) and (d), respectively, related to veterans 
alerting VA of a change of residence, and veterans providing VA with 
information about any other health-care plan contract under which the 
veteran is covered. This information would continue to be needed in the 
Veterans Community Care Program so that VA could make accurate 
eligibility determinations under proposed Sec.  17.4010(a)(2)-(6) that 
would rely on a veteran's place of residence, and so that VA could 
continue to recover or collect reasonable charges for care and services 
furnished in the community for a non-service connected disability from 
a health plan contract, consistent with section 1703(j). The only 
changes from current Sec.  17.1510(c) and (d) would be referring to 
covered veterans instead of only veterans in both provisions and, 
proposed Sec.  17.4010(c), referring to care and services the veteran 
requires instead of care under the Veterans Choice Program, as well as 
referring to other health-care plan contracts instead of health-care 
plans, as previously explained in the definitions section of this 
rulemaking.
    Proposed Sec.  17.4010(d) would implement the requirements in 
section 1703(f) that any decisions concerning eligibility for community 
care under sections 1703(d) and (e) be subject to VA's clinical appeals 
process, and not be appealable to the Board of Veterans' Appeals. 
Proposed Sec.  17.4010(d) would refer to all eligibility determinations 
under proposed Sec.  17.4010(a) as being subject to VA's clinical 
appeals process. We note that VA's current clinical appeals process is 
established in VHA Directive 1041, titled ``Appeal of VHA Clinical 
Decisions,'' and any successor VHA policy would equally apply. The 
current Directive and any future policies are and will be made 
available on VA's website https://www.va.gov/vhapublications/publications.cfm?pub=1.

Sec.  17.4015, Designated VA Medical Service Lines

    Proposed Sec.  17.4015 would establish the process by which VA 
would identify its medical service lines that were not able to furnish 
care or service in a manner that complied with VA's standards for 
quality, so that veterans who would receive care or services through 
such VA medical service lines could be considered eligible for the 
Veterans Community Care Program under proposed Sec.  17.4010(a)(6).
    Consistent with section 1703(e)(1)(A)-(B), proposed Sec.  
17.4015(a) would establish that VA's permissive authority to consider 
covered veterans as eligible for community care under proposed Sec.  
17.4010(a)(6) would be based on whether VA medical service lines were 
identified by VA as underperforming in accordance with timeliness 
standards when compared with the same VA medical service lines at other 
VA facilities and based on two or more distinct and appropriate quality 
measures of VA's standards for quality when compared with non-VA 
medical service lines. Proposed Sec.  17.4015(b) would further clarify 
that VA's identification of its underperforming medical service lines 
would be based on the data that VA would analyze under proposed Sec.  
17.4015(a), VA's standards for quality themselves, as well as factors 
in proposed Sec.  17.4015(e) that would guide how VA would assess the 
information it gathered related to VA and non-VA medical service lines.
    Consistent with section 1703(e)(4), proposed Sec.  17.4015(c) would 
establish that VA would announce any VA medical service lines 
identified under proposed Sec.  17.4015(a) in a document in the Federal 
Register and would identify and describe the standards for quality VA 
used to inform its determination under proposed Sec.  17.4015(a), as 
well as how the data described in proposed Sec.  17.4015(a) and the 
factors identified in proposed Sec.  17.4015(e) were used to make the 
determinations. The announcement of this information through a document 
in the Federal Register would provide clear information to the public 
regarding how VA arrived at its choice of standards, while additionally 
allowing VA to remain nimble (subject to existing legal authorities, 
such as the Paperwork Reduction Act, as applicable) with its gathering 
and analysis of data related to its standards for quality, and possible 
identification of its medical service lines that are underperforming. 
Consistent with section 1703(e)(2), proposed Sec.  17.4015(c) would 
also establish that this document in the Federal Register would 
identify limitations, if any, concerning when and where covered 
veterans can receive qualifying care and services at their election in 
the community, which could include defined timeframes in which such 
care and services could be available, defined geographic areas in which 
such care and services may be provided, and a defined scope of services 
that veterans may elect to receive. Finally, in accordance with section 
1703(e)(4), VA would be required to take all reasonable steps to 
provide direct notice to covered veterans affected under this section. 
Such direct notice would generally include written correspondence and 
could include electronic messages or direct contact (in person or by 
phone).
    Proposed Sec.  17.4015(d) would restate the requirement from 
section 1703(e)(1)(C)(ii) that VA could not identify more than 3 of its 
medical service lines in any single VA facility, and not more than 36 
such service lines throughout VA nationally, when determining those 
underperforming service lines that might create eligibility for 
community care. We believe these provisions to be clear in the statute, 
but in the interest of being comprehensive, we have included these 
requirements in regulation to avoid confusion. To provide some scope of 
the relative impact of designating up to 36 service lines, we note that 
36 services lines would be a very small number of those that exist 
nationally. For instance, it is possible that a single VA medical 
center could have as many as 20 service lines itself, and VA operates 
more than 1,200 sites of care.
    Proposed Sec.  17.4015(e) would establish the factors that VA would 
consider when determining whether one of its medical service lines 
should be identified as underperforming; we clarify that the threshold 
requirements, in accordance with section 1703(e)(1)(B) are performance 
on timeliness standards when compared with medical services lines at 
other VA facilities and on quality standards when compared with non-VA 
medical service lines when external benchmarks are available. The data 
on performance for these timeliness and other quality standards will 
identify potential service lines that could be designated, and VA would 
apply the factors described in this paragraph to determine which 
service lines to designate. These same factors would also be used in 
the event that one of the limitations in proposed Sec.  17.4015(d) 
restricted VA's ability to designate all VA medical service lines that 
might be considered underperforming under proposed Sec.  17.4015(a). 
Proposed Sec.  17.4015(e)(1) would establish that VA would consider 
whether the differences between performance of individual VA medical 
service lines (concerning timeliness) and performance of VA

[[Page 5639]]

medical service lines and non-VA medical service lines (concerning 
quality) are clinically significant. This factor would allow VA to 
appropriately discern small differences in performance metrics as not 
evidencing underperformance per se.
    Proposed Sec.  17.4015(e)(2) would establish that VA would consider 
the likelihood or ease of remediation of a medical service line within 
a short timeframe in identifying whether it is underperforming, to 
permit VA to be selective as remediation would require further 
considerations of VA resource management or allocation. Section 1706A 
requires VA to develop plans and to remediate VA medical service lines 
that are identified as underperforming under section 1703(e). We 
therefore propose to consider the likelihood and ease of remediation in 
designating such service lines in the first place, as it would be 
illogical to designate a VA medical service line as underperforming and 
in need of the kind of intensive remediation envisioned by section 
1706A when a simple action (such as the purchase of new equipment) 
would be sufficient and is likely to occur. This view is further 
reinforced by the limited number of VA medical service lines VA could 
designate under this authority; VA should not use a limited authority 
when other options are already available.
    Proposed Sec.  17.4015(e)(3) would establish that VA would consider 
any recent trends (as they were known) that might concern a VA or non-
VA medical service line, as such trends could be more contemporary than 
the data or information upon which VA would be basing a determination 
of underperformance. Given the requirements to gather, analyze, and 
verify quality data, there may be a considerable period of time 
(sometimes up to 18-24 months) between when the data are first 
collected and when decisions can be made on that data. If VA had reason 
to believe, based on more contemporaneous information, that some of the 
factors that contributed to poor performance on quality metrics had 
already been corrected, VA would factor such evidence into its decision 
making.
    Proposed Sec.  17.4015(e)(4) would establish that VA would consider 
the number of veterans served by the medical service line or that could 
be affected by the designation. This could be considered in several 
ways. For example, this is likely to be a relevant consideration to 
allow VA to properly assess data about its own medical service lines, 
and for comparing a particular medical service line to other VA or to 
non-VA medical service lines. For example, a VA medical service line 
that only treated a few patients may be more likely to be adversely 
affected by a single negative outcome than would be other VA or non-VA 
service lines with larger numbers of patients. It could also be 
relevant when deciding whether to designate a VA medical service line 
at all, or in a situation where VA had to choose which service line to 
designate because one of the limitations in paragraph (d) applied. For 
example, if VA could only choose one of two VA medical service lines to 
designate, and one of those service lines only treated one patient 
within the past year, while another treated 1,000 patients, it would 
likely make more sense to designate the VA medical service line with a 
greater patient volume to ensure the maximum number of covered veterans 
receive access to community care.
    Proposed Sec.  17.4015(e)(5) would establish that VA would consider 
the potential impact on patient outcomes when considering whether a VA 
medical service line was underperforming. Some medical service lines, 
by the nature of their clinical area of responsibility, deal with more 
significant health concerns than others.
    Finally, proposed Sec.  17.4015(e)(6) would allow VA to take into 
account the effect that designating one VA medical service line would 
have on other VA medical service lines. For example, if VA identified a 
surgical line as underperforming, that could have collateral effects on 
a range of other service lines, such as cardiology, orthopedics, or 
gastroenterology. For instance, a cardiology service line would be less 
likely to undertake complex interventional procedures if there is not 
appropriate surgical support in the event of a procedural complication. 
VA could consider these secondary effects and weigh the relative costs 
and benefits associated with designating one VA medical service line as 
it would affect other service lines within the VA facility.
    We reiterate that proposed Sec.  17.4015 would establish a process 
by which VA would determine, announce, and explain the VA medical 
service lines it determines are underperforming based on an assessment 
of the timeliness of its care compared with other VA facilities and the 
quality of that service line's care when compared with two or more 
distinct and appropriate quality measures of VA's standards for 
quality. Proposed Sec.  17.4015 would not itself list VA's standards 
for quality as these standards and measures are dynamic and will evolve 
based on new discoveries and innovations as well as wider adoption of 
standardized quality measures across the U.S. health care industry; VA 
is submitting a report to Congress detailing its standards for quality 
no later than March 4, 2019. It also would not announce any VA medical 
service lines that VA might identify as underperforming in accordance 
with such standards, as this would be done through a document in the 
Federal Register under proposed Sec.  17.4015(c) and direct notice to 
affected veterans. The process in proposed Sec.  17.4015 would be the 
means of identifying those VA medical service lines that would be the 
basis for the eligibility determination under proposed Sec.  
17.4010(a)(6).

Sec.  17.4020, Authorized Non-VA Care

    Proposed Sec.  17.4020 would describe the process and requirements 
for authorizing non-VA care under this Program, similar to current 
Sec.  17.1515.
    Proposed Sec.  17.4020(a) and (b) would implement, without 
substantive change, two provisions from the Veterans Choice Program at 
Sec.  17.1515 (a) and (b), respectively, related to a covered veteran's 
election to receive care in the community, and related to a covered 
veteran's selection of an eligible entity or provider. These provisions 
would be carried over to the Veterans Community Care Program to confirm 
a veteran's ability to elect to receive community care under 
appropriate circumstances, consistent with section 1703(d)(3), and to 
ensure continuity of veteran experience from the Veterans Choice 
Program in being able to choose an eligible entity or provider, while 
also being consistent with section 1703(g)(2). Section 1703(g)(2) 
provides that VA may not prioritize providers in a manner that limits 
the choice of a covered veteran in selecting an eligible entity or 
provider. The only non-substantive changes from current Sec.  
17.1515(a) would be referring to covered veterans in proposed Sec.  
17.4020(a) and removing language related to a veteran's election to be 
placed on an electronic waiting list for VA care because such a waiting 
list is not an express option in section 1703 related to a veteran's 
election to receive VA care versus VA community care. Proposed Sec.  
17.4020(a) would retain the premise in the Veterans Choice Program that 
the covered veteran who has been determined to be eligible for 
community care could elect to still receive such care through VA, or 
could elect to receive such care through an eligible entity or 
provider. We would clarify that any authorized care must be determined 
to be clinically necessary. This is a requirement both of existing 
Sec.  17.38(b), as well as section 1703(n)(1), but adding

[[Page 5640]]

this language would be particularly critical for determinations by a 
non-VA referring clinician that receiving care or services would be in 
the best medical interest of the covered veteran. VA must ultimately 
determine that such care is clinically necessary. Section 17.4020(b) 
would also refer now to covered veterans for the reasons previously 
explained.
    In paragraph (c) of Sec.  17.4020, we would clarify the timelines 
associated with the authorization of care and services. In general, 
care furnished under the Veterans Community Care Program must be 
furnished following an authorization by VA that such care and services 
are to be provided to a covered veteran. However, we recognize that 
emergency care will be needed in applicable situations. VA currently 
permits emergency care, in certain situations, to be considered as 
authorized for purpose of current section 1703 through regulation at 
Sec.  17.54. We propose to rescind and reserve the existing Sec.  17.54 
and instead establish a comparable rule in paragraph (c) of Sec.  
17.4020. We believe this is authorized under the new section 1703 
amendments. Section 1703(a)(3) states that covered veterans may only 
receive care or services under this section upon the authorization of 
such care or services by VA, but it does not state that such 
authorization must occur in advance. We presume Congress was aware of 
the existing provisions allowing for authorizations within 72 hours, 
and did not consider it necessary to require prior authorization to 
allow VA to continue this practice. This presumption is based on the 
principle of statutory interpretation that Congress does not make 
sweeping changes to existing practice without explicitly stating so. We 
would state clearly, though, that this paragraph would not affect 
eligibility for, or create any new rules or conditions affecting, 
reimbursement for emergency treatment under sections 1725 or 1728. 
These authorities permit VA to reimburse eligible veterans for the 
receipt of emergency treatment under certain conditions, and no aspect 
of the VA MISSION Act of 2018 affected eligibility for care under these 
authorities. Care that cannot be authorized under this paragraph would 
be considered for reimbursement under 1725 or 1728, as applicable.
    Paragraph (c)(1) would state that VA could authorize emergency 
treatment after it has been furnished to a covered veteran. This is 
consistent with the description of the scope of this provision above. 
We would define the term emergency treatment to be consistent with the 
definition of section 1725(f)(1). We would not reproduce the definition 
in this regulation in the event that any future changes are made to the 
statute; by cross-referencing, this would ensure that our regulations 
and statutes remain consistent on this point. In general, emergency 
treatment under section 1725(f)(1) means medical care or services 
furnished that, in the judgment of VA, meet three conditions. First, 
that VA or other Federal facilities are not feasibly available and an 
attempt to use them beforehand would not be reasonable. Second, that 
the care or services are rendered in a medical emergency of such nature 
that a prudent layperson reasonably expects that delay in seeking 
immediate medical attention would be hazardous to life or health. 
Third, emergency treatment continues until such time that the veteran 
can be transferred safely to a VA facility or other Federal facility 
and such facility is capable of accepting such transfer, or such time 
as the VA facility or other Federal facility accepts such transfer if 
at the time the veteran could have been transferred safely to a VA or 
other Federal facility, no VA or other Federal facility agreed to 
accept such transfer and the non-VA facility in which such medical care 
or services were furnished made and documented reasonable attempts to 
transfer the veteran to a VA or other Federal facility.
    Proposed paragraph (c)(2) would state that VA could only authorize 
emergency treatment under this paragraph if the covered veteran, 
someone acting on the covered veteran's behalf, or the eligible entity 
or provider notifies VA within 72 hours of such care or services being 
furnished and VA approves the furnishing under paragraph (c)(3). This 
would be consistent with existing Sec.  17.54(a), with the specific 
inclusion of an eligible entity or provider being a possible entity 
that could notify VA; Sec.  17.54(a) only refers to notification by the 
veteran or by others in his or her behalf, so our proposed language in 
paragraph (c)(2) would still provide flexibility while recognizing that 
an eligible entity or provider might be the most appropriate party to 
notify VA given their contractual relationship to furnish care on VA's 
behalf. This 72-hour requirement is consistent with the window for 
approval under existing Sec.  17.54(a). We believe the 72-hour 
requirement continues to be a reasonable period of time as it would 
allow notification upon stabilization of the patient or upon the next 
business day in the overwhelming majority of cases. We would not retain 
the language from Sec.  17.54(a)(2) concerning non-contiguous States 
because, as noted in proposed paragraph (c)(3)(i), this rule would only 
apply to emergency care furnished by eligible entities or providers who 
have a contract or agreement to furnish care on VA's behalf; this 
relationship would provide the means for notifying VA in a timely 
manner, while the prior rule in Sec.  17.54 did not require such a 
relationship.
    Notification, however, would not guarantee that care would be 
approved by VA as authorized; paragraph (c)(2) would note that 
paragraph (c)(3) would further describe the conditions under which VA 
would approve such care. Paragraph (c)(3) would explain that VA would 
approve care as authorized only if three conditions are met. First, the 
veteran must be receiving emergency treatment from an eligible entity 
or provider. This is a requirement for the care to be furnished under 
section 1703 and these proposed regulations. It would also ensure that 
all care furnished is subject to the payment rates established in a 
contract or agreement. VA would further require the notification be 
submitted appropriately, as further described in paragraph (c)(4), and 
provided within 72 hours of the beginning of such treatment. This would 
ensure that VA is able to make an appropriate determination as soon as 
possible as to whether or not the emergency treatment is qualifying 
care under these authorities. Finally, VA would limit emergency 
treatment to services covered by VA's medical benefits package. This 
would ensure VA does not authorize any care or services it lacks the 
authority to furnish at all.
    Paragraph (c)(4) would stipulate requirements that the notice must 
satisfy to be accepted as notice for purposes of this paragraph. The 
notice would need to contain three elements. First, it would have to be 
made to an appropriate VA official at the nearest VA medical facility. 
While we would not define how this official would be defined through 
the regulation, we believe that either through the contract or 
agreement the eligible entity or provider has with VA or through 
another means (like each VA medical facility's website), the eligible 
entity or provider would know the right official to contact. Veterans 
or other parties could simply contact their VA medical center to 
provide this information. This would ensure that the appropriate 
officials are notified and can make determinations under this 
authority. Second, the notice would have to identify the covered 
veteran. This would ensure VA could review and determine the veteran 
actually meets the definition of a covered veteran for

[[Page 5641]]

purposes of these regulations. Finally, the notice would have to 
identify the eligible entity or provider furnishing the emergency 
treatment. This would ensure that the entity or provider is in fact 
eligible to furnish care and services for VA pursuant to a contract or 
agreement authorizing such entity or provider to furnish care and 
services on our behalf.
    We note that we have not included language in this proposed rule to 
address the provisions in section 1703(l) regarding organ and bone 
marrow transplants. VA will address this through a subsequent 
rulemaking. Section 1703(l) provides that the Secretary shall determine 
whether to authorize an organ or bone marrow transplant for a covered 
veteran at a non-VA facility. If the rulemaking focused on organ and 
bone marrow transplants is not effective by the time this rule for the 
Veterans Community Care Program is effective, the Secretary will 
effectively have exercised his discretion to determine that the 
election of a covered veteran eligible under Sec.  17.4010(a) on where 
to receive organ or bone marrow transplant care controls.
    We further note that section 153 of the MISSION Act added a new 
section 1788 to title 38, U.S.C., specifically authorizing VA to 
provide for an operation on a live donor to carry out a transplant 
procedure for an eligible veteran, notwithstanding that the live donor 
may not be eligible for VA health care. VA will issue separate 
regulations concerning this new authority. Any comments on care for 
living donors will be considered outside the scope of this rulemaking.

Sec.  17.4025, Effect on Other Provisions

    Proposed Sec.  17.4025 would address the effect of the Veterans 
Community Care Program on other provisions and programs administered by 
VA, similar to current Sec.  17.1520.
    Proposed Sec.  17.4025(a) would provide that, consistent with 
section 1703(n)(2), no provision in these sections may be construed to 
alter or modify any other provision of law establishing specific 
eligibility criteria for hospital care, medical services, or extended 
care services. If particular services, such as dental benefits under 
Sec. Sec.  17.160-17.169, have unique eligibility standards, only 
veterans who are eligible under proposed Sec.  17.4010 and meet the 
eligibility standards for those services can elect to receive them 
through the Veterans Community Care Program. Nothing in section 1703 or 
these regulations would waive the eligibility requirements established 
in other applicable statutes or regulations. This is substantively 
similar to the first sentence of current Sec.  17.1520(a).
    Similar to the second sentence of current Sec.  17.1520(a), 
proposed Sec.  17.4025(b) would address VA's paying for and filling of 
prescriptions obtained by covered veterans from eligible entities and 
providers, but would clarify VA's current practice that distinguishes 
circumstances under which VA pays for (versus fills) such 
prescriptions. Proposed Sec.  17.4025(b)(1) would retain the practice 
in the Veterans Choice Program that VA will pay for prescriptions, 
including prescription drugs, over the counter drugs, and medical and 
surgical supplies written by non-VA health care providers furnishing 
services through VA community care, but would clarify that such payment 
would be for a course of treatment that lasts no longer than 14 days. 
This current practice to limit payment for non-VA prescriptions is 
reasonable, as it would allow VA to ensure that any amount of 
medication in excess of 14 days would be filled through VA's 
Consolidated Mail Order Pharmacy system to ensure cost and quality 
controls. VA believes that the economies of scale related to bulk 
purchase of medications allow for the best maximization of Federal 
resources. Proposed Sec.  17.4025(b)(2) would establish the correlate 
rule from the Veterans Choice Program, that VA would fill longer-term 
prescriptions for courses of treatment that exceed 14 days if they are 
filled through VA's Consolidated Mail Order Pharmacy system.
    Proposed Sec.  17.4025(b)(3) and (b)(4) would further clarify 
current practice under the Veterans Choice Program regarding VA paying 
for or filling prescriptions written by non-VA health care providers 
for durable medical equipment (DME) and devices. Although not expressly 
stated in current Sec.  17.1520, the Veterans Choice Program currently 
permits VA to pay for such prescriptions to be furnished by a community 
provider only when there is an urgent or emergent need for the durable 
medical equipment or medical device, meaning the veteran has a medical 
condition of acute onset or exacerbation manifesting itself by severity 
of symptoms including pain, soft tissues symptomatology, bone injuries, 
etc. Urgent or emergent DME or medical devices may include, but are not 
limited to: Splints, crutches, canes, slings, soft collars, walkers, 
and manual wheelchairs. This current practice to limit payment for non-
VA prescriptions of DME or medical devices to only what is immediately 
needed is reasonable, as VA must ensure administrative oversight as 
well as clinical appropriateness of all other DME and medical devices 
prescribed by non-VA health care providers. DME and medical devices are 
specific to a particular clinical need and in most cases are further 
specifically tailored to fit or serve an individual, and as such 
require direct provision by VA (except when urgently needed) to ensure 
clinical appropriateness and the best use of Federal resources. 
Proposed Sec.  17.4025(b)(3) would establish that VA would pay for 
prescriptions written by eligible entities or providers for covered 
veterans that have an immediate need for durable medical equipment and 
medical devices to address urgent or emergent conditions, and would 
parenthetically reference a non-exhaustive list of such devices to 
include splints, crutches, and manual wheelchairs. Proposed 38 CFR 
17.4025(b)(4) would then establish a correlate rule that VA would fill 
prescriptions written by eligible entities or providers for covered 
veterans for DME and medical devices without any limitation related to 
the equipment being required for an urgent or emergent need.
    Proposed Sec.  17.4025(c) would restate with slight revision the 
last sentence of current Sec.  17.1520(b), as veterans would continue 
to be liable as applicable under Sec. Sec.  17.108(b)(4) and (c)(4), 
17.110(b)(4), and 17.111(b)(3) for copayments for community care that 
is furnished through the Veterans Community Care Program. The Veterans 
Community Care Program would not alter the current treatment of veteran 
copayments for community care as exists in the Veterans Choice Program. 
We are not including the language in the first sentence of 17.1520(b), 
concerning VA's liability for deductibles, cost-shares, or copayments 
required by an eligible veterans' health-care plan, because that 
language was originally included in the Veterans Choice Program 
regulations when VA was a secondary payer to an eligible veteran's 
other health insurance. That language was needed to ensure veterans 
faced no additional liability for using the Veterans Choice Program, as 
opposed to VA's traditional community care programs where VA was and is 
the primary payer. Under the Veterans Community Care Program, VA will 
be the primary payer, so this language is unnecessary.

Sec.  17.4030, Eligible Entities and Providers

    Similar to current Sec.  17.1530 under the Veterans Choice Program, 
proposed Sec.  17.4030 would establish requirements for non-VA entities 
and providers to be

[[Page 5642]]

eligible to furnish hospital care, medical services, and extended care 
services to covered veterans under the Veterans Community Care Program. 
We would not identify specific lists of health care entities or 
providers (e.g., Department of Defense, Medicare providers, etc.), as 
section 1703(c) already provides VA broad authority to include 
additional health care providers who enter into contracts or agreements 
to furnish care and services under this Program. Proposed Sec.  
17.4030(b) would establish conditions that non-VA entities and 
providers must meet to be considered eligible to furnish care or 
services under the Veterans Community Care Program. We note that the 
requirements in this paragraph are not exhaustive, as there are other 
provisions established in law (namely, in 1703(h)(3)(A)(IV) and section 
108 of the MISSION Act) that must be met to be a participating eligible 
entity or provider.
    Proposed Sec.  17.4030(a) would require the non-VA entity or 
provider to enter into a contract, agreement, or other arrangement to 
furnish care and services under the Veterans Community Care Program 
established by these regulations. The terms of the contract, agreement, 
or other arrangement will impose additional requirements that must be 
met, particularly concerning additional qualifications, but it is not 
necessary to regulate these conditions because entities or providers 
will agree to be bound by them through the contract, agreement, or 
other arrangement.
    Proposed Sec.  17.4030(b) would be consistent with existing Sec.  
17.1530(a), which prohibits an entity or provider that is part of VA, 
or providers who are employed by VA from furnishing care or services 
while acting within the scope of their VA employment, from being an 
eligible entity or provider. As we explained in the Veterans Choice 
Program regulations, the purpose of VA's use of community providers to 
furnish care is to ensure that veterans are able to access non-VA 
entities or providers, so it would be contrary to the purpose of the 
statute to include VA entities or providers within the definition of 
eligible entities or providers for community care. This same rationale 
applies to the Veterans Community Care program for covered veterans.
    Proposed Sec.  17.4030(c) would require that the non-VA entity or 
provider be accessible to an eligible veteran. VA would make 
determinations regarding accessibility by considering the length of 
time the veteran would have to wait to receive care or services from 
the entity or provider; the qualifications of the entity or provider; 
and the distance between the eligible veteran's residence and the 
entity or provider. This language would be substantively identical to 
Sec.  17.1530(c), which requires that non-VA entities or providers in 
the Veterans Choice Program be accessible to veterans eligible under 
that Program. As the Veterans Community Care Program is intended, like 
the Veterans Choice Program, to expand access to care, we believe that 
imposing the same assurance of accessibility is appropriate. We would 
make minor edits to include references to extended care services for 
the reasons explained above.

Sec.  17.4035, Payment Rates

    Similar to current Sec.  17.1535 for the Veterans Choice Program, 
proposed Sec.  17.4035 would establish the rate structure for payment 
for hospital care, medical services, and extended care services 
furnished pursuant to a contract or an agreement authorized by section 
1703A would be the rates set forth in the terms of such contract or 
agreement. Such payment rates would comply with parameters defined in 
proposed Sec.  17.4035(a)-(e), as described below, and would be 
analogous to the parameters established in section 1703(i).
    Proposed Sec.  17.4035(a) would establish that, except as otherwise 
provided in proposed Sec.  17.4035, payment rates would not exceed the 
applicable Medicare fee schedule (including but not limited to 
allowable rates under 42 U.S.C. 1395m) or prospective payment system 
amount (hereafter referred to as ``Medicare rate''), if any, for the 
period in which the service was provided (without any changes based on 
the subsequent development of information under Medicare authorities). 
This would be analogous to the general provision in section 1703(i)(1), 
that, with exceptions, the rates paid for care and services may not 
exceed the applicable Medicare rate. This would also be similar to 
current Sec.  17.1535(a)(1). The parenthetical language in proposed 
Sec.  17.4035(a), to indicate that VA's rates would be based on 
Medicare rates without any changes based on the subsequent development 
of information under Medicare authorities is intended to limit VA's 
rate adjustments to an annual basis in line with Medicare's annual 
payment update, versus other adjustments that Medicare may make to its 
rates throughout any given year that is typically provider-specific and 
is based on provider and other reporting.
    Proposed Sec.  17.4035(b) would establish that, with respect to 
services furnished in a State with an All-Payer Model Agreement under 
section 1814(b)(3) of the Social Security Act (42 U.S.C. 1395f(b)(3)) 
that became effective on or after January 1, 2014, the Medicare rate 
under paragraph (a) would be calculated based on the payment rates 
under such agreement. This is consistent with section 1703(i)(4) and 
Sec.  17.1535(a)(4).
    Proposed Sec.  17.4035(c) would establish, consistent with section 
1703(i)(2)(A), that payment rates for services furnished in a highly 
rural area may exceed the limitations set forth in proposed Sec.  
17.4035(a)-(b). Proposed Sec.  17.4035(c) would further establish that 
the term highly rural area means an area located in a county that has 
fewer than seven individuals residing in that county per square mile, 
consistent with the definition of highly rural area in section 
1703(i)(2)(B).
    Proposed Sec.  17.4035(c) would further interpret that the 
assessment of a highly rural area would be made in relation to the 
areas where the services are furnished, and not the areas where the 
individuals receiving the care or services may reside as provided under 
section 1703(i)(2)(A). We believe this interpretation is reasonable 
because the typical laws of supply and demand dictate that in highly 
rural areas, the scarcity of health care providers and other health 
care resources tends to create increased prices for delivery of health 
care services. Additionally, it may not be accurate that, in all cases, 
individuals who reside in highly rural areas are receiving care and 
services in those same areas, and VA would not want to adopt an 
interpretation that would permit payment of higher rates to health care 
providers in other than highly rural areas. Attempting to tie payment 
rates to particular patients, rather than setting general rates for 
particular health care providers, would be administratively cumbersome 
and could lead to selective acceptance of patients that would adversely 
affect other patients.
    Proposed Sec.  17.4035(d) would establish that VA may deviate from 
the parameters set forth in proposed Sec.  17.4035(a)-(c) when VA 
determines that, based on patient needs, market analyses, health care 
provider qualifications, or other factors, it is not practicable to 
limit payments as would be dictated by application of proposed Sec.  
17.4035(a)-(d). This general exception would be consistent with the 
provision in section 1703(i)(1) that authorizes VA to pay at rates not 
to exceed the Medicare rate to the extent practicable. Proposed Sec.  
17.4035(d) would afford VA the flexibility to ensure it can reach 
agreement with non-VA entities or providers to furnish necessary 
services when factors that drive costs may shift

[[Page 5643]]

faster than established Medicare rates. This flexibility would not be a 
guarantee of payments above applicable Medicare rates because the 
introductory language in proposed Sec.  17.4035 would establish that 
payment rates are ultimately set forth in the terms of the contract or 
agreement under which the care and services are furnished. Such 
contracts or agreements will provide for the relevant procedures and 
review process for any payments that might utilize the exception in 
proposed Sec.  17.4035(d), to ensure a consistent level of VA 
oversight.
    Finally, proposed Sec.  17.4035(e) would establish, consistent with 
section 1703(i)(3), that payment rates for services furnished in Alaska 
would not be subject to paragraphs (a) through (d) and would be set 
forth in the terms of the procurement contract or agreement authorized 
by section 1703A, pursuant to which such services are furnished. 
Proposed Sec.  17.4035(e) would further state that, if no payment rate 
is set forth in the terms of such a contract or agreement to which 
services are furnished, payment rates for services furnished in Alaska 
would follow the Alaska Fee Schedule of the Department of Veterans 
Affairs. Under the VA Alaska Fee Schedule, as described in Sec.  
17.56(b), the amount paid in Alaska for each code will be 90 percent of 
the average amount VA actually paid in Alaska for the same services in 
Fiscal Year (FY) 2003. For services that VA provided less than eight 
times in Alaska in FY 2003, for services represented by codes 
established after FY 2003, and for unit-based codes prior to FY 2004, 
VA will take the Centers for Medicare and Medicaid Services' (CMS) rate 
for each code and multiply it times the average percentage paid by VA 
in Alaska for CMS-like codes. VA will increase the amounts on the VA 
Alaska Fee Schedule annually in accordance with the published national 
Medicare Economic Index (MEI). For those years where the annual average 
is a negative percentage, the Fee Schedule will remain the same as the 
previous year.

Sec.  17.4040, Designated Access Standards

    Proposed Sec.  17.4040 would establish the designated access 
standards by which VA would assess the availability of VA care and 
services in relation to individual covered veterans for purposes of 
eligibility determinations under proposed Sec.  17.4010(a)(4). As we 
explained in the context of Sec.  17.4015, this section would not 
establish all of VA's access standards, just as Sec.  17.4015 would not 
establish VA's standards for quality. Proposed Sec.  17.4040 would 
implement both section 1703(d)(1)(D) related to VA's eligibility 
determinations for community care, and portions of section 1703B 
related to VA's establishment of access standards. Section 
1703(d)(1)(D) refers specifically to eligibility based on an inability 
to furnish care or services in a manner that complies with VA's 
designated access standards. This section would establish these 
designated access standards, which cover all care or services under 
VA's medical benefits package (with the exception of institutional 
extended care services, or nursing home care), to allow VA to determine 
whether the condition under proposed Sec.  17.4010(a)(4) has been met. 
In publishing these standards through a final rule implementing this 
section, we would also satisfy part of the requirement in section 
1703B(g); VA will also publish the final designated access standards on 
its website when they are effective.
    In developing these proposed designated access standards, VA 
researched access standards established by Federal- and State-level 
agencies, consulted with the Department of Defense (DoD), the 
Department of Health and Human Services (HHS), as well as several 
commercial entities to identify best practices and acceptable standards 
for consideration, as required by section 1703B(c). On June 29, 2018, 
VA published a Notice in the Federal Register requesting public 
comments, and on July 13, 2018, VA held a public meeting to provide an 
additional opportunity for public comment. Results of these 
consultations will be discussed in a report to Congress detailing the 
access standards, which is required by 38 U.S.C. 1703B(d)(1).
    A prime consideration were the existing standards in the Veterans 
Choice Program; these standards measure timeliness of and distance to 
receive care. Other access standards that VA researched measured the 
distance from the patient's home to the service needed, whereas VA 
currently measures, under the Veterans Choice Program, the distance 
from the patient's home to the nearest VA medical facility with a full-
time primary care physician. This difference means that veterans, 
particularly in rural areas, currently must often travel farther to 
receive specialty care than they would under the proposed rule, if 
finalized, because they do not qualify for community care under the 
Veterans Choice Program distance criterion Changing VA's distance-
related measurement for community care to be the distance from the 
patient's home to the care or service needed would assist VA in 
determining when covered veterans can be served directly by VA and when 
covered veterans can choose community care, thereby helping to ensure 
adequate health care access for covered veterans.
    Further changing the standard to refer to an average driving time 
would recognize that distance is often a poor indicator of actual 
conditions; veterans in large metropolitan areas may be physically 
closer to VA facilities than their counterparts in rural areas, but may 
actually face more significant challenges in accessing care based on 
traffic. Adopting access standards based on average driving time would 
result in more equitable access for all covered veterans. VA's proposal 
to use the average driving time is premised on the use of a personal 
vehicle, but we believe this applies to many of the veterans we serve, 
and that it would be too difficult to fairly and consistently implement 
and operationalize a system that considered the variety of 
transportation options potentially available to an individual veteran. 
We note that the proposed approach is similar to that taken by DoD.
    Using the results of its access standards analysis, VA developed 
and modeled several options using VA's Enrollee Health Care Projection 
Model. After considering this information, VA determined that its 
access standards should reflect a driving time-based criterion that 
considers the care or services needed in relation to the veteran's 
residence and should reflect a wait-time criterion that would be 
considered in tandem with the driving time criterion. VA used the same 
rationale as TRICARE Prime in proposing its standards related to travel 
standards, opting to use time versus distance. To reiterate, distance-
based criteria do not recognize the inherent variation of driving 
speeds in rural versus urban areas. Traffic levels and speed limits 
allow rural residents to travel farther and faster than urban 
residents. The switch to average drive-time criteria versus distance 
provides a more consistent standard of access for urban and rural 
veterans. More specific analyses showed trends of 30-minute drive times 
for primary care and 60-minute drive times for specialty care in 
TRICARE, State Medicaid plans, State insurance departments, and 
commercial health plans. VA determined that it would be reasonable to 
fall in line with these other network expectations throughout the 
industry. The proposed wait-time standards would similarly fall within 
the range of appointment wait-time standards found in other government 
organizations, State programs, and commercial entities (e.g., 7-28 days 
for primary care and 15-30 days for specialty care). Further, the

[[Page 5644]]

proposed wait-time standards are achievable in most VA facilities and 
are consistent with capabilities identified in the private sector. On 
average, VA national wait times (as of December 2018) for new 
appointments (e.g., the first appointment in a new episode of care 
versus a subsequent appointment in the continuation of an existing 
episode of care) are approximately 21.6 days for primary care, 11.2 
days for mental health care, and 23.2 days for specialty care. We note 
that data presented in VA's report to Congress, and that VA has 
provided previously to Congress, includes different averages, but this 
variance is due simply to when the data were collected; the information 
in the report to Congress and what has previously been provided was 
from the fall of 2018. The proposed wait-time standard of 20 days for 
primary care and mental health, for example, is both in line with other 
similar industry standards and is a manageable goal for access to VA 
care.
    The following access standards would therefore be designated in 
proposed Sec.  17.4040(a) to apply for purposes of eligibility 
determinations under Sec.  17.4010(a)(4). For primary care, mental 
health care, and non-institutional extended care services, proposed 
Sec.  17.4040(a)(1) would establish that the access standard would not 
be met if VA cannot schedule an appointment for a covered veteran with 
a VA health care provider that can furnish the required care or 
services within 30 minutes average driving time of the veteran's 
residence, and within 20 days of the date of request, unless a later 
date has been agreed to by the veteran in consultation with the VA 
provider. For specialty care, proposed Sec.  17.4040(a)(2) would 
establish that the designated access standard would not be met if VA 
cannot schedule an appointment for the covered veteran with a VA health 
care provider that can furnish the required care or services within 60 
minutes average driving time of the veteran's residence, and within 28 
days of the date of request, unless a later date has been agreed to by 
the veteran in consultation with the VA provider.
    The later date that a veteran could agree to be scheduled for an 
appointment would be determined through the veteran's consultation with 
a VA health care provider. This consultation would ensure that the 
veteran's preferred date to be seen, as well as clinical considerations 
regarding the appropriate time for an appointment, were taken into 
account. For instance, veterans might agree to a later date because 
they prefer to be seen after the 20 or 28 days (as applicable) from the 
date they contact VA to request an appointment, such as if the veteran 
expects to be traveling. In such a case, the veteran might discuss this 
later date with a provider to ensure that it was clinically appropriate 
to delay the appointment.
    A veteran might also agree to a later date because the provider has 
consulted with the veteran, and the provider has determined that an 
appointment would not be clinically useful until after the 20 or 28 
days (as applicable) from the date the veteran might contact VA to 
request an appointment. This scenario most often arises in the context 
of follow-up appointments, where a veteran might contact VA to schedule 
an appointment that is, for instance, no sooner than 30 days away to 
accommodate the completion of necessary diagnostic tests that were 
ordered by the provider as part of the veteran's prior appointment. 
This scenario can also arise outside of the context of typical follow-
up care, such as for regularly scheduled, routine care or treatment 
that typically occurs perhaps only once or twice a year. For instance, 
a veteran could agree to a later date for a routine dental cleaning 
that the veteran typically schedules to receive every six months.
    The option in proposed Sec.  17.4040(a)(1)(ii) and (a)(2)(ii) for a 
veteran to agree to a later date is similar to the definition of the 
term wait-time goals of the Veterans Health Administration in current 
Sec.  17.1505, because the veteran's preference as well as clinical 
appropriateness would continue to be considered in determining the 
later date. We believe that proposed Sec.  17.4040(a)(1)(ii) and 
(a)(2)(ii) are more simply stated than current Sec.  17.1505, and are 
framed in a more veteran-centric manner because these provisions 
propose to shift the decision for the later date entirely to the 
veteran. In practice, we do not believe that this proposed shift would 
create significant changes in veteran eligibility for VA community care 
based on the wait-time standard, because the veteran's agreement to a 
later date would still be informed by consultation with the VA health 
care provider. However, as proposed Sec.  17.4040(a)(1)(ii) and 
(a)(2)(ii) would be a significant technical change from the way the 
wait-time goals of the Veterans Health Administration are written in 
current Sec.  17.1505, we invite comment on this issue as with other 
changes as described in this rulemaking.
    A full explanation of the estimated impact of these proposed access 
standards, when compared to the distance-based and wait-time based 
standards in current Sec.  17.1510(b)(1) and (b)(2), can be found in 
the Regulatory Impact Analysis that accompanies this proposed rule, 
which can be found as a supporting document at http://www.regulations.gov and is 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.'' For purposes of this 
rulemaking, VA believes these proposed access standards are reasonable 
applications of VA's discretion to establish access standards in 38 
U.S.C. 1703B. Section 1703B confers broad authority on the Secretary to 
establish access standards, and sections 1703B and 1703(d)(1)(D) 
further authorize the Secretary to designate certain access standards 
as the basis for eligibility for community care.
    Proposed Sec.  17.4040(b) would establish, similar to current Sec.  
17.1510(e), that for purposes of calculating the distance from the 
veteran's residence to a VA facility for eligibility determinations, VA 
would use geographic information system software. As with current Sec.  
17.1510(e), proposed Sec.  17.4040(b) cannot be more specific in naming 
the system software or describing its methodology because it is 
proprietary. The most substantive change from current Sec.  17.1510(e) 
is that proposed Sec.  17.4040(b) would use the phrase average driving 
time instead of driving distance, because the access standards under 
proposed Sec.  17.4040(a) would be based on average driving time. The 
average driving time in proposed Sec.  17.4040(a) and (b) would be 
calculated by using the geographic information system software to 
calculate the average drive time from the veteran's residence to the 
applicable VA facility, based on predictive traffic patterns from 
historical data, as opposed to real-time traffic conditions.
    We note that we do not propose to regulate the process described in 
section 1703B(h), which must be followed to review requests from 
veterans to determine whether or not VA can furnish care or services 
within the designated access standards. Because this is a procedural 
requirement relating to VA's operations and will not affect veteran 
eligibility, we are not proposing to include this process in this 
rulemaking, but will establish such a process through internal policy. 
However, we anticipate that veterans would contact VA to request such 
reviews in the same manner they would contact VA to seek care generally 
that then might be referred to the community under an access standard.
    We further note that we have considered whether VA would want to 
ensure the continued utilization of VA

[[Page 5645]]

care and services that VA has particular expertise in directly 
providing, such as VA's specialized care models for veterans with 
disabilities such as traumatic brain injury, posttraumatic stress 
disorder, and military sexual trauma. VA Centers of Excellence, such as 
the Polytrauma Rehabilitation Centers, deliver certain types of 
specialized care that may improve quality of care or reduce costs when 
compared with similar care that might be furnished in the community. 
However, there are far fewer Centers of Excellence than VA medical 
centers, and as there would be fewer locations in relation to the total 
number of veterans nationwide, travel distances for veterans to these 
Centers of Excellence could in many cases exceed the designated access 
standards in this rule. At this time, VA does not propose to designate 
(or not designate) particular access standards for these or other types 
of more specialized care; the general specialty care access standards 
would apply. Moreover, veterans would be made aware if such care was 
available from VA outside of the designated access standards to be 
fully informed of their options prior to electing to receive care in 
the community or in VA. Similarly, VA does not propose at this time to 
designate particular access standards for care that it might consider 
to be its foundational services. VA will continue to sharpen its focus 
on directly providing those services that are most important to the 
coordination and management of a veteran's overall medical and health 
needs, while purchasing services that can be as effectively or more 
conveniently delivered by non-VA providers. VA will continue to examine 
whether its proposed designated access standards should be revised with 
future rulemakings to account for such specialized areas of expertise 
as the care provided by Centers of Excellence or other similar 
organizations within VA (such as the War Related Illness and Injury 
Study Center), as well as VA's foundational services, and we welcome 
public comment on whether any of these services, or others, should be 
further considered in terms of designated access standards for purposes 
of eligibility for community care.
    We note that institutional extended care services (nursing home 
care) are not the subject of a designated access standard; the 
designated access standards in paragraphs (a) and (b) only cover 
primary care, mental health, non-institutional extended care, and 
specialty care, but nursing home care does not fit within any of these 
categories. Nursing home care is distinct from specialty care--it is a 
form of extended care services, and is subject to copayments related to 
extended care services under Sec.  17.111 (as opposed to specialty 
care, which is subject to copayments under Sec.  17.108). We have not 
included a designated access standard for nursing home care because of 
the unique nature of this care, as it is VA's anecdotal experience in 
referring nursing home care to the community that the relative scarcity 
of such resources in the community, the variability in quality in 
community nursing homes, and the expense associated with such care are 
all variables that make the assignment of a standardized wait time, for 
instance, impracticable. Any covered veteran requiring nursing home 
care may still qualify to receive such care in the community, but the 
veteran would have to qualify for non-VA care under this section under 
a different eligibility criterion in Sec.  17.1410(a).
    Section 17.4040 would establish access standards that would be 
applicable until further rulemaking amended them. VA has preliminarily 
determined that its goal is to revise over time the access standards 
that would be designated in proposed Sec.  17.4040, after designated 
access standards are made effective through final rulemaking, in order 
to reduce the maximum wait-times for primary and mental health care 
services from 20 days to 14 days no sooner than June 2020. This 
reduction from 20 days to 14 days is not proposed in this rulemaking, 
and VA would need to publish a future rulemaking should it proceed with 
this goal. Presently, implementing a 14-day wait-time standard would be 
difficult for VA due to the current availability of primary care 
providers and variability in primary care appointment wait-times across 
VA facilities. However, we share this goal with the public at this 
time, as it may influence the comments submitted by the public on the 
current proposed designated access standard of 20 days.

Improving VA

    While this proposed rulemaking has focused on the new Veterans 
Community Care Program required by the MISSION Act, we believe it is 
important to note that the MISSION Act also improves care furnished 
directly in VA facilities in a number of ways. For example, section 
1703C of title 38, U.S.C. as added by section 104 of the MISSION Act, 
requires VA to establish standards for quality. VA is proposing 
standards for quality in a report that will be submitted to Congress no 
later than March 4, 2019. If VA designated a medical service line under 
proposed Sec.  17.4015, we would also be required to begin remediation 
efforts for that service line under section 1706A. However, VA's 
remediation efforts will not be limited to just those service lines 
designated under Sec.  17.4015. In addition to establishing standards 
for quality, section 1703C requires VA to publish the quality rating of 
VA medical facilities in the Hospital Compare website for the purpose 
of providing Veterans with information that allows them to compare 
performance measure information among VA and non-VA health care 
providers. We take this charge seriously, and will be monitoring 
performance to ensure we direct resources appropriately. We will 
develop a consolidated and integrated network of community providers to 
ensure that all Veteran care furnished by VA, whether delivered in our 
facilities or purchased in the community, represents the best possible 
care, every time and everywhere.
    As noted earlier, each year, VA will incorporate the collected 
data, assessments, and remediation plans under sections 1703C and 1706A 
to inform its resourcing requirements and prioritization of those 
resources. VA will also consider performance of its facilities against 
its access standards for appointment wait times when making resource 
allocation decisions.
    There are numerous provisions within the MISSION Act that require 
the assessment, collection, and monitoring of data about VA performance 
and improvement, including information on remediation, on a regular 
annual basis. See, e.g., sections 401(d) and 505(b) of the MISSION Act; 
see also sections 1703(m)(1), (3); 1703B(d)(3); 1703B(e); and 
1706A(d)(1). VA is also required, on a quadrennial basis, to conduct 
market assessments and develop a strategic plan that specifies a four-
year forecast of demand for care and capacity to furnish care in VA and 
in the community. Through these requirements, VA will provide analyses 
and assessments on VA's performance in terms of timeliness, quality, 
and other elements of its health care system collected at the level of 
the medical service line, and no less than annually, VA will develop 
and publish a consolidated report detailing a description of care 
provided both internally and externally. This information will be used 
to detail resource allocations and the related budget requirements to 
address quality and access issues, as well as for efforts to improve 
the VA workforce and

[[Page 5646]]

address the problem of underserved facilities.

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

    The Paperwork Reduction Act of 1995 (44 U.S.C. 3507) requires that 
VA consider the impact of paperwork and other information collection 
burdens imposed on the public. Under 44 U.S.C. 3507(a), an agency may 
not collect or sponsor the collection of information, nor may it impose 
an information collection requirement unless it displays a currently 
valid Office of Management and Budget (OMB) control number. See also 5 
CFR 1320.8(b)(2)(vi).
    This proposed rule would amend information collection requirements 
currently approved under control number 2900-0823 and would impose new 
collections of information requirements and burden. VA will separately 
notice and take comment on the information collection requirements 
associated with this proposed rulemaking in the Federal Register. As 
required by 44 U.S.C. 3507(d), VA will submit these information 
collection amendments to OMB for its review. Notice of OMB approval for 
this information collection will be published in a future Federal 
Register document.

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. Although some eligible entities or providers that would 
furnish care and services to veterans under this rule might be 
considered small entities, there would be no significant adverse 
economic impact. To the extent there is any impact on small entities, 
it would be a potential increase in business due to proposed expanded 
eligibility for non-VA care. While this rulemaking defines payment 
rates and eligible entities and providers, it does so in a way that is 
consistent with VA's current authorities. We note that a separate and 
subsequent rulemaking, RIN 2900-AQ45, will authorize VA to enter into 
agreements with eligible providers, many of whom will likely be small 
businesses. We will further consider the effects on such entities 
through that rulemaking. 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, 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 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.''
    VA has examined the economic, interagency, budgetary, legal, and 
policy implications of this regulatory action and determined that the 
action would be 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 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 proposed rule is expected to 
be an E.O. 13771 regulatory action. Details on the estimated costs of 
this proposed rule can be found in the rule's economic analysis. 
Preliminary estimates of the administrative costs that would be tallied 
for E.O. 13771 purposes appear in the rightmost column of the 
Regulatory Impact Analysis (RIA) Table 8.
    Executive Order 12866 also directs agencies to ``in most cases . . 
. include a comment period of not less than 60 days.'' This regulation 
would replace the existing Veterans Choice Program and VA's traditional 
community care program to be the means for covered veterans to receive 
VA care in the community from eligible entities or providers. Providing 
a 30-day comment period would allow the Secretary to ensure a smooth 
transition from the current Veterans Choice Program that will expire on 
June 6, 2019, and prevent lapses in regulatory oversight for VA's 
national community care program. On June 6, 2019, if this rulemaking is 
not finalized, no one other VA authority would permit expressly the 
application of the time and geographic standards in determining 
eligibility for VA community care, which the public and veterans have 
come to expect. Delays in implementation of the Veterans Community Care 
Program arising because the regulatory standards and guidelines were 
not in place by June 6, 2019, would result in inconsistent decision 
making in VA facilities, which would increase the likelihood that 
veterans' care would be delayed. Having clear, consistent criteria is 
essential to ensuring that Veterans receive the right care in the right 
place at the right time. Moreover, we believe VA community care is now 
a familiar benefit to the public, and that 30 days would be a 
sufficient period of time for the public to comment on this rulemaking, 
which incorporates many of the provisions of the prior Veterans Choice 
Program. In sum, providing a 60-day public comment period instead of a 
30-day public comment period would be against public interest and 
contrary to 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 5647]]

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 will 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: 64.007, Blind 
Rehabilitation Centers; 64.008, Veterans Domiciliary Care; 64.009, 
Veterans Medical Care Benefits; 64.010, Veterans Nursing Home Care; 
64.011, Veterans Dental Care; 64.012, Veterans Prescription Service; 
64.013, Veterans Prosthetic Appliances; 64.014, Veterans State 
Domiciliary Care; 64.015, Veterans State Nursing Home Care; 64.016, 
Veterans State Hospital Care; 64.018, Sharing Specialized Medical 
Resources; 64.019, Veterans Rehabilitation Alcohol and Drug Dependence; 
64.022, Veterans Home Based Primary Care; and 64.024, VA Homeless 
Providers Grant and Per Diem Program.

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, Medical 
devices, Mental health programs, Nursing homes, Reporting and 
recordkeeping requirements, Veterans.

    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. Robert L. 
Wilkie, Secretary, Department of Veterans Affairs, approved this 
document on January 2, 2019, for publication.

    Dated: January 15, 2019.
Michael P. Shores,
Director, 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 general authority citation and specific authority citations for 
part 17 continue to read as follows:

    Authority:  38 U.S.C. 501, and as noted in specific sections.
* * * * *
    Section 17.46 is also issued under 38 U.S.C. 1710.
* * * * *
    Section 17.52 is also issued under 38 U.S.C. 1701, 1703, 1710, 
1712, and 3104.
* * * * *
    Section 17.55 is also issued under 38 U.S.C. 513, 1703, and 
1728.
    Section 17.56 is also issued under 38 U.S.C. 1703 and 1728.
* * * * *
    Section 17.108 is also issued under 38 U.S.C. 501, 1703, 1710, 
1725A, and 1730A.
* * * * *
    Section 17.110 is also issued under 38 U.S.C. 501, 1703, 1710, 
1720D, 1722A, and 1730A.
    Section 17.111 is also issued under 38 U.S.C. 101(28), 501, 
1701(7), 1703, 1710, 1710B, 1720B, 1720D, and 1722A.
* * * * *
    Section 17.4000 et seq. is also issued under 38 U.S.C. 1703, 
1703B, and 1703C.
* * * * *


Sec.  17.46  [Amended]

0
2. Amend Sec.  17.46 in paragraph (a) introductory text by adding the 
phrase ``prior to June 6, 2019,'' after the phrase ``In furnishing 
hospital care''.
0
b. Removing the authority citation at the end of paragraph (a) and 
paragraph (b).
0
3. Amend Sec.  17.52 by removing the authority citations following 
paragraphs (a)(1) through (10) and by adding paragraph (c).
    The addition reads as follows:


Sec.  17.52  Hospital care and medical services in non-VA facilities.

* * * * *
    (c) The provisions of this section shall not apply to care 
furnished by VA after June 6, 2019.


Sec.  17.54   [Removed and Reserved]

0
4. Remove and reserve Sec.  17.54.
0
5. Amend Sec.  17.55 by revising the introductory text and removing the 
authority citation at the end of the section.
    The revision reads as follows:


Sec.  17.55  Payment for authorized public or private hospital care.

    Except as otherwise provided in this section, payment for public or 
private hospital care furnished prior to June 6, 2019, under 38 U.S.C. 
1703 and 38 CFR 17.52, or at any time under 38 U.S.C. 1728 and 38 CFR 
17.120 and 17.128 of this part or under 38 U.S.C. 1787 and 38 CFR 
17.410 of this part, shall be based on a prospective payment system 
similar to that used in the Medicare program for paying for similar 
inpatient hospital services in the community. Payment shall be made 
using the Centers for Medicare & Medicaid Services (CMS) PRICER for 
each diagnosis-related group (DRG) applicable to the episode of care.
* * * * *
0
6. Amend Sec.  17.56 by adding paragraph (e) and removing the authority 
citation at the end of the section.
    The addition reads as follows:


Sec.  17.56  VA payment for inpatient and outpatient health care 
professional services at non-departmental facilities and other medical 
charges associated with non-VA outpatient care.

* * * * *
    (e) Except for payments for care furnished under 38 U.S.C. 1725 and 
section 17.1005 of this part, under 38 U.S.C. 1728 and 38 CFR 17.120 
and 17.128 of this part, or under 38 U.S.C. 1787 and 38 CFR 17.410 of 
this part, the provisions of this section shall not apply to care 
furnished by VA after June 6, 2019, or care furnished pursuant to an 
agreement authorized by 38 U.S.C. 1703A.
* * * * *
0
7. Amend Sec.  17.108:
0
a. In paragraph (b)(4), by adding the phrase ``, or the Veterans 
Community Care Program under Sec.  17.4000 through 17.4040'' after the 
phrase ``Veterans Choice Program under Sec.  17.1500 through 17.1540'';
0
b. In paragraph (c)(4), by adding the phrase ``, or the Veterans 
Community Care Program under Sec.  17.4000 through 17.4040'' after the 
phrase ``Veterans Choice Program under Sec.  17.1500 through 17.1540''; 
and
0
c. Removing the authority citation at the end of the section.


Sec.  17.110  [Amended]

0
8. Amend Sec.  17.110 in paragraph (b)(4) by adding the phrase ``, or 
the Veterans Community Care Program under Sec.  17.4000 through 
17.4040'' after the phrase ``Veterans Choice Program under Sec.  
17.1500 through 17.1540'' and by removing the authority citation at the 
end of the section.


Sec.  17.111  [Amended]

0
9. Amend Sec.  17.111 by in paragraph (b)(3) by adding the phrase ``, 
as well as extended care services furnished through the Veterans 
Community Care Program under Sec.  17.4000 through 17.4040,'' after the 
phrase ``hospital care and medical services considered non-

[[Page 5648]]

institutional care furnished through the Veterans Choice Program under 
Sec.  17.1500 through 17.1540'' and by removing the authority citation 
at the end of the section.


Sec.  17.1004  [Amended]

0
10. Amend Sec.  17.1004 in paragraph (b) introductory text by removing 
the phrase ``HCFA 1500'' and adding in its place ``CMS 1500'' and by 
removing the authority citation at the end of the section.
0
11. Add an undesignated center heading and Sec. Sec.  17.4000 through 
17.4040 to read as follows:

Veterans Community Care Program

Sec.
17.4000 Purpose and scope.
17.4005 Definitions.
17.4010 Veteran eligibility.
17.4015 Designated VA medical service lines.
17.4020 Authorized non-VA care.
17.4025 Effect on other provisions.
17.4030 Eligible entities and providers.
17.4035 Payment rates.
17.4040 Designated access standards.

Veterans Community Care Program


Sec.  17.4000   Purpose and scope.

    (a) Purpose. Sections 17.4000 through 17.4040 implement the 
Veterans Community Care Program, authorized by 38 U.S.C. 1703.
    (b) Scope. The Veterans Community Care Program establishes when a 
covered veteran may elect to have VA authorize an episode of care for 
hospital care, medical services, or extended care services from an 
eligible entity or provider. Sections 17.4000 through 17.4040 do not 
affect eligibility for non-VA care under sections 1724, 1725, 1725A, or 
1728 of title 38, United States Code.


Sec.  17.4005   Definitions.

    For purposes of the Veterans Community Care Program under 
Sec. Sec.  17.4000 through 17.4040:
    Appointment means an authorized and scheduled encounter with a 
health care provider for the delivery of hospital care, medical 
services, or extended care services.
    Covered veteran means a veteran enrolled under the system of 
patient enrollment in Sec.  17.36, or a veteran who otherwise meets the 
criteria to receive care and services notwithstanding his or her 
failure to enroll under 38 U.S.C. 1705(c)(2).
    Eligible entity or provider means a health care entity or provider 
that meets the requirements of Sec.  17.4030.
    Episode of care means a necessary course of treatment, including 
follow-up appointments and ancillary and specialty services, which 
lasts no longer than 1 calendar year.
    Extended care services include the same services as described in 38 
U.S.C. 1710B(a).
    Full-service VA medical facility means a VA medical facility that 
provides hospital care, emergency medical services, and surgical care 
and having a surgical complexity designation of at least ``standard.''

    Note:  VA maintains a website with a list of the facilities that 
have been designated with at least a surgical complexity of 
``standard,'' which can be accessed on VA's website.

    Hospital care has the same meaning as defined in 38 U.S.C. 1701(5).
    Medical services have the same meaning as defined in 38 U.S.C. 
1701(6).
    Other health-care plan contract means an insurance policy or 
contract, medical or hospital service agreement, membership or 
subscription contract, or similar arrangement not administered by the 
Secretary of Veterans Affairs, under which health services for 
individuals are provided or the expenses of such services are paid; and 
does not include any such policy, contract, agreement, or similar 
arrangement pursuant to title XVIII or XIX of the Social Security Act 
(42 U.S.C. 1395 et seq.) or chapter 55 of title 10, United States Code.
    Residence means a legal residence or personal domicile, even if 
such residence is seasonal. A covered veteran may maintain more than 
one residence but may only have one residence at a time. If a covered 
veteran lives in more than one location during a year, the covered 
veteran's residence is the residence or domicile where they are staying 
at the time they want to receive hospital care, medical services, or 
extended care services through the Veterans Community Care Program. A 
post office box or other non-residential point of delivery does not 
constitute a residence.
    Schedule means identifying and confirming a date, time, location, 
and entity or health care provider for an appointment in advance of 
such appointment.

    Note:  A VA telehealth encounter and a same-day care encounter 
are considered to be scheduled even if such an encounter is 
conducted on an ad hoc basis.

    VA facility means a VA facility that offers hospital care, medical 
services, or extended care services.
    VA medical service line means a specific medical service or set of 
services delivered in a VA facility.


Sec.  17.4010   Veteran eligibility.

    Section 1703(d) of title 38, U.S.C., establishes the conditions 
under which, at the election of the veteran and subject to the 
availability of appropriations, VA must furnish care in the community 
through eligible entities and providers. VA has regulated these 
conditions under paragraphs (a)(1) through (5) of this section. If VA 
determines that a covered veteran meets at least one or more of the 
conditions in paragraph (a) of this section and has provided 
information required by paragraphs (b) and (c) of this section, the 
covered veteran may elect to receive authorized non-VA care under Sec.  
17.4020.
    (a) The covered veteran requires hospital care, medical services, 
or extended care services and:
    (1) No VA facility offers the hospital care, medical services, or 
extended care services the veteran requires.
    (2) VA does not operate a full-service VA medical facility in the 
State in which the veteran resides.
    (3) The veteran was eligible to receive care and services from an 
eligible entity or provider under section 101(b)(2)(B) of the Veterans 
Access, Choice, and Accountability Act of 2014 (Pub. L. 113-146, sec. 
101, as amended; 38 U.S.C. 1701 note) as of June 5, 2018, and continues 
to reside in a location that would qualify the veteran under that 
provision, and:
    (i) Resides in Alaska, Montana, North Dakota, South Dakota, or 
Wyoming; or
    (ii) Does not reside in one of the States described in paragraph 
(a)(3)(i) of this section, but received care or services under title 38 
U.S.C. between June 6, 2017, and June 6, 2018, and is seeking care 
before June 6, 2020.
    (4) Has contacted an authorized VA official to request the care or 
services the veteran requires, but VA has determined it is not able to 
furnish such care or services in a manner that complies with designated 
access standards established in Sec.  17.4040.
    (5) The veteran and the veteran's referring clinician determine it 
is in the best medical interest of the veteran, to access the care or 
services the veteran requires from an eligible entity or provider, 
based on one or more of the following factors, as applicable:
    (i) The distance between the veteran and the facility or facilities 
that could provide the required care or services;
    (ii) The nature of the care or services required by the veteran;
    (iii) The frequency the veteran requires the care or services;
    (iv) The timeliness of available appointments for the required care 
or services;

[[Page 5649]]

    (v) The potential for improved continuity of care;
    (vi) The quality of the care provided;
    (vii) Whether the veteran faces an unusual or excessive burden in 
accessing a VA facility based on consideration of the following:
    (A) Excessive driving distance; geographical challenges, such as 
the presence of a body of water (including moving water and still 
water) or a geologic formation that cannot be crossed by road; or 
environmental factors, such as roads that are not accessible to the 
general public, traffic, or hazardous weather.
    (B) Whether care and services are available from a VA facility that 
is reasonably accessible.
    (C) Whether a medical condition of the veteran affects the ability 
to travel.
    (D) Whether there is a compelling reason the veteran needs to 
receive care and services from a non-VA facility.
    (E) 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.
    (6) In accordance with Sec.  17.4015, VA has determined that a VA 
medical service line that would furnish the care or services the 
veteran requires is not providing such care or services in a manner 
that complies with VA's standards for quality.
    (b) If the covered veteran changes his or her residence, the 
covered veteran must update VA about the change within 60 days.
    (c) A covered veteran must provide to VA information on any other 
health-care plan contract under which the veteran is covered prior to 
obtaining authorization for care and services the veteran requires. If 
the veteran changes such other health-care plan contract, the veteran 
must update VA about the change within 60 days.
    (d) Review of veteran eligibility determinations. The review of any 
decisions under paragraph (a) of this section are subject to VA's 
clinical appeals process, and such decisions may not be appealed to the 
Board of Veterans' Appeals.
    (The information collection is pending Office of Management and 
Budget approval.)


Sec.  17.4015  Designated VA medical service lines.

    (a) VA may identify VA medical service lines that are 
underperforming based on the timeliness of care when compared with the 
same medical service line at other VA facilities and based on data 
related to two or more distinct and appropriate quality measures of 
VA's standards for quality when compared with non-VA medical service 
lines.
    (b) VA will make determinations regarding VA medical service lines 
under this section using data described in paragraph (a) of this 
section, VA standards for quality, and based on factors identified in 
paragraph (e) of this section.
    (c) VA will announce annually any VA medical service lines 
identified under paragraph (a) of this section by publishing a document 
in the Federal Register. Such document will identify and describe the 
standards for quality VA used to inform the determination under 
paragraph (a), as well as how the data described in paragraph (a) and 
factors identified in paragraph (e) of this section were used to make 
the determinations. Such document will also identify limitations, if 
any, concerning when and where covered veterans can receive qualifying 
care and services at their election in the community based on this 
section. Such limitations may include a defined timeframe, a defined 
geographic area, and a defined scope of services. VA will also take 
reasonable steps to provide direct notice to covered veterans affected 
under this section.
    (d) VA will identify no more than 3 VA medical services lines in a 
single VA facility under this section, and no more than 36 VA medical 
service lines nationally under this section.
    (e) In determining whether a VA medical service line should be 
identified under paragraph (a) of this section, and to comply with 
paragraph (c) of this section, VA will consider:
    (1) Whether the differences between performance of individual VA 
medical service lines, and between performance of VA medical service 
lines and non-VA medical service lines, is clinically significant.
    (2) Likelihood and ease of remediation of the VA medical service 
line within a short timeframe.
    (3) Recent trends concerning the VA medical service line or non-VA 
medical service line.
    (4) The number of covered veterans served by the medical service 
line or that could be affected by the designation.
    (5) The potential impact on patient outcomes.
    (6) The effect that designating one VA medical service line would 
have on other VA medical service lines.


Sec.  17.4020   Authorized non-VA care.

    (a) Electing non-VA care. A covered veteran eligible for the 
Veterans Community Care Program under Sec.  17.4010 may choose to 
schedule an appointment with a VA health care provider, or have VA 
authorize the veteran to receive an episode of care for hospital care, 
medical services, or extended care services from an eligible entity or 
provider when VA determines such care or services are clinically 
necessary.
    (b) Selecting an eligible entity or provider. A covered veteran may 
specify a particular eligible entity or provider. If a covered veteran 
does not specify a particular eligible entity or provider, VA will 
refer the veteran to a specific eligible entity or provider.
    (c) Authorizing emergency treatment. This paragraph applies only to 
emergency treatment furnished to a covered veteran by an eligible 
entity or provider when such treatment was not the subject of an 
election by a veteran under paragraph (a) of this section. This 
paragraph does not affect eligibility for, or create any new rules or 
conditions affecting, reimbursement for emergency treatment under 
section 1725 or 1728 of title 38, United States Code.
    (1) Under the conditions set forth in this paragraph, VA may 
authorize emergency treatment after it has been furnished to a covered 
veteran. For purposes of this paragraph, ``emergency treatment'' has 
the meaning defined in section 1725(f)(1) of title 38, United States 
Code.
    (2) VA may only authorize emergency treatment under this paragraph 
if the covered veteran, someone acting on the covered veteran's behalf, 
or the eligible entity or provider notifies VA within 72-hours of such 
care or services being furnished and VA approves the furnishing of such 
care or services under paragraph (c)(3) of this section.
    (3) VA may approve emergency treatment of a covered veteran under 
this paragraph only if:
    (i) The veteran is receiving emergency treatment from an eligible 
entity or provider.
    (ii) The notice to VA complies with the provisions of paragraph 
(c)(4) of this section and is submitted within 72 hours of the 
beginning of such treatment.
    (iii) The emergency treatment only includes services covered by 
VA's medical benefits package in Sec.  17.38 of this part.
    (4) Notice to VA must:
    (i) Be made to the appropriate VA official at the nearest VA 
facility;
    (ii) Identify the covered veteran; and
    (iii) Identify the eligible entity or provider.

[[Page 5650]]

Sec.  17.4025   Effect on other provisions.

    (a) General. No provision in this section may be construed to alter 
or modify any other provision of law establishing specific eligibility 
criteria for certain hospital care, medical services, or extended care 
services.
    (b) Prescriptions. Notwithstanding any other provision of this 
part, VA will:
    (1) Pay for prescriptions written by eligible entities or providers 
for covered veterans, including over-the-counter drugs and medical and 
surgical supplies, available under the VA national formulary system to 
cover a course of treatment no longer than 14 days.
    (2) Fill prescriptions written by eligible entities or providers 
for covered veterans, including over-the-counter drugs and medical and 
surgical supplies, available under the VA national formulary system.
    (3) Pay for prescriptions written by eligible entities or providers 
for covered veterans that have an immediate need for durable medical 
equipment and medical devices that are required for urgent or emergent 
conditions (e.g., splints, crutches, manual wheelchairs).
    (4) Fill prescriptions written by eligible entities or providers 
for covered veterans for durable medical equipment and medical devices 
that are not required for urgent or emergent conditions.
    (c) Copayments. Covered veterans are liable for a VA copayment for 
care or services furnished under the Veterans Community Care Program, 
if required by Sec.  17.108(b)(4), Sec.  17.108(c)(4), Sec.  
17.110(b)(4), or Sec.  17.111(b)(3).


Sec.  17.4030  Eligible entities and providers.

    To be eligible to furnish care and services under the Veterans 
Community Care Program, entities or providers:
    (a) Must enter into a contract, agreement, or other arrangement to 
furnish care and services under the Veterans Community Care Program 
under Sec. Sec.  17.4000 through 17.4040.
    (b) Must either:
    (1) Not be a part of, or an employee of, VA; or
    (2) If the provider is an employee of VA, not be acting within the 
scope of such employment while providing hospital care, medical 
services, or extended care services through the Veterans Community Care 
Program under Sec. Sec.  17.4000 through 17.4040.
    (c) Must be accessible to the eligible veteran. VA will determine 
accessibility by considering the following factors:
    (1) The length of time the eligible veteran would have to wait to 
receive hospital care, medical services, or extended care services from 
the entity or provider;
    (2) The qualifications of the entity or provider to furnish the 
hospital care, medical services, or extended care services from the 
entity or provider; and
    (3) The distance between the eligible veteran's residence and the 
entity or provider.


Sec.  17.4035  Payment rates.

    The rates paid by VA for hospital care, medical services, and 
extended care services (hereafter in this section referred to as 
``services'') furnished pursuant to a procurement contract or an 
agreement authorized by section 1703A of this title will be the rates 
set forth in the terms of such contract or agreement. Such payment 
rates will comply with the following parameters:
    (a) Except as otherwise provided in this section, payment rates 
will not exceed the applicable Medicare fee schedule (including but not 
limited to allowable rates under 42 U.S.C. 1395m) or prospective 
payment system amount (hereafter ``Medicare rate''), if any, for the 
period in which the service was provided (without any changes based on 
the subsequent development of information under Medicare authorities).
    (b) With respect to services furnished in a State with an All-Payer 
Model Agreement under section 1814(b)(3) of the Social Security Act (42 
U.S.C. 1395f(b)(3)) that became effective on or after January 1, 2014, 
the Medicare payment rates under paragraph (a) of this section will be 
calculated based on the payment rates under such agreement.
    (c) Payment rates for services furnished in a highly rural area may 
exceed the limitations set forth in paragraphs (a) and (b) of this 
section. The term ``highly rural area'' means an area located in a 
county that has fewer than seven individuals residing in that county 
per square mile.
    (d) Payment rates may deviate from the parameters set forth in 
paragraphs (a) through (c) of this section when VA determines, based on 
patient needs, market analyses, health care provider qualifications, or 
other factors, that it is not practicable to limit payment for services 
to the rates available under paragraphs (a) through (c).
    (e) Payment rates for services furnished in Alaska are not subject 
to paragraphs (a) through (d) of this section and will be set forth in 
the terms of the procurement contract or agreement authorized by 
section 1703A of this title, pursuant to which such services are 
furnished. If no payment rate is set forth in the terms of such a 
contract or agreement pursuant to which such services are furnished, 
payment rates for services furnished in Alaska will follow the Alaska 
Fee Schedule of the Department of Veterans Affairs.


Sec.  17.4040  Designated access standards.

    (a) The following access standards have been designated to apply 
for purposes of eligibility determinations to access care in the 
community through the Veterans Community Care Program under Sec.  
17.4010(a)(4).
    (1) Primary care, mental health care, and non-institutional 
extended care services: VA cannot schedule an appointment for the 
covered veteran with a VA health care provider for the required care or 
service:
    (i) Within 30 minutes average driving time of the veteran's 
residence, and
    (ii) Within 20 days of the date of request unless a later date has 
been agreed to by the veteran in consultation with the VA health care 
provider.
    (2) Specialty care: VA cannot schedule an appointment for the 
covered veteran with a VA health care provider for the required care or 
service:
    (i) Within 60 minutes average driving time of the veteran's 
residence, and
    (ii) Within 28 days of the date of request unless a later date has 
been agreed to by the veteran in consultation with the VA health care 
provider.
    (b) For purposes of calculating average driving time from the 
veteran's residence in paragraph (a) of this section, VA will use 
geographic information system software.

[FR Doc. 2019-03030 Filed 2-21-19; 8:45 am]
 BILLING CODE 8320-01-P