[Federal Register Volume 84, Number 240 (Friday, December 13, 2019)]
[Notices]
[Pages 68301-68312]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-26901]


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DEPARTMENT OF VETERANS AFFAIRS


Pilot Program for Dental Health Care Access

AGENCY: Department of Veterans Affairs.

ACTION: Notice of Intent and request for comments.

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SUMMARY: Upon Congressional approval, VA intends to develop and 
implement a pilot program designed to increase veteran access to health 
care and support services at no additional cost to VA or veterans. The 
initial demonstration project VA proposes under this pilot program is 
to improve dental health care access for veterans by connecting them 
with community-based, pro bono or discounted, dental service providers. 
The objective of this pilot demonstration is to improve overall health 
by increasing access to dental services for enrolled veterans currently 
ineligible for dental services through VA. Improving the state of 
veteran health will be evaluated through assessment of emergency 
medical care visits. Thus, the anticipated impact of this pilot program 
is to improve quality of health while decreasing health care related 
costs associated with the provision of emergency care.

ADDRESSES: Written comments may be submitted through http://www.regulations.gov; by mail or hand delivery to the Director, Office 
of Regulation Policy and Management (00REG), Department of Veterans 
Affairs, 810 Vermont Avenue NW, Room 1064, Washington, DC 20420; or by 
fax to 202-273-9026. Comments should indicate that they are submitted 
in response to ``Notice of Intent and request for comments''. During 
the comment period, comments may also be viewed online through the 
Federal Docket Management System at www.regulations.gov.

DATES: Comments must be received on or before January 13, 2020.

FOR FURTHER INFORMATION CONTACT: Michael Akinyele, MBA, SES, VA Chief 
Innovation Officer, VA Innovation Center (VIC) (008E), Office of 
Enterprise Integration, 810 Vermont Ave. NW, Washington, DC 20420. 
Email: [email protected]; Phone: (202) 461-0462. (This is not a toll-
free number.)

SUPPLEMENTARY INFORMATION: 

1. Introduction

    On June 6, 2018, section 152 of Public Law 115-182, the John S. 
McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining 
Internal Systems and Strengthening Integrated Outside Networks Act of 
2018, or the VA MISSION Act of 2018 (hereinafter the MISSION Act), 
amended title 38 of the United States Code (U.S.C.) by adding a new 
section 1703E, Center for Innovation for Care and Payment (the Center). 
Section 1703E(f) allows VA to waive requirements in subchapters I, II, 
and III of chapter 17, title 38, U.S.C., as VA determines necessary for 
the purposes of carrying out pilot programs under this section. Before 
waiving any such authority, VA will submit to Congress a report on a 
request for a waiver that describes the specific authorities to be 
waived, the standard or standards to be used in lieu of the waived 
authorities, the reasons for such waiver or waivers, and other matters 
including metrics, cost estimates (both budgets and savings), and 
schedules.
    VA published a proposed rule (RIN 2900-AQ56) on the Center on July 
29, 2019 (84 FR 36507). VA published a final rule implementing its 
authority on October 25, 2019 (84 FR 57327); this

[[Page 68302]]

rule became effective on November 25, 2019.
    On December 6, 2019, VA submitted to Congressional leadership its 
first waiver request. This Notice is published to share this waiver 
request with the public, to solicit public feedback, and to comply with 
section 17.450(e)(2) of title 38, Code of Federal Regulations (CFR).
    VA seeks to develop and implement a pilot program designed to 
increase veteran access to health care and support services at no 
additional cost to VA or veterans. The initial demonstration project VA 
proposes under this pilot program is to improve dental health care 
access for veterans by connecting them with community-based, pro bono 
or discounted, dental service providers. The objective of this pilot 
demonstration is to improve overall health by increasing access to 
dental services for enrolled veterans currently ineligible for dental 
services through VA under 38 U.S.C. 1712. Improving the state of 
veteran health will be evaluated through assessment of emergency 
medical care visits. Thus, the anticipated impact of this pilot program 
is to improve quality of health while decreasing health care related 
costs associated with the provision of emergency care.
    Under 38 U.S.C. 1712, VA has limited authority to furnish 
outpatient dental care. Generally, veterans must either have a dental 
issue that is service-connected or qualify based on narrow criteria 
(e.g., the veteran is a former prisoner of war, the veteran has a 
service-connected disability rated as total, or treatment is medically 
necessary in preparation for hospital admission or for a veteran 
otherwise receiving VA care or services or reasonably necessary to 
complete dental care that began while the veteran was receiving 
hospital care). Under this authority, VA provides dental services on an 
annual basis to approximately only eight percent of veterans who are 
enrolled in the VA health care system. Poor oral health can have a 
significant negative effect on overall health. Neglecting oral health 
can lead to health problems, including oral cancer. Clinical 
researchers have found possible connections between gum problems and 
heart disease, bacterial pneumonia, and stroke (Mayo Clinic. (2019). 
Oral health: A window to your overall health. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475). Upon approval of this pilot, VA will work with groups such 
as the American Dental Association (ADA) and with Federally Qualified 
Health Centers (FQHC) across the U.S. to offer pro bono and discounted 
dental services to veterans.
    38 U.S.C. 523 authorizes VA to coordinate the provision of VA 
benefits and services (and information about such benefits and 
services) with appropriate programs (and information about such 
programs) conducted by private entities at the State and local level. 
Under section 523, VA may furnish local veterans with information about 
the free dental screening and care being offered by local providers and 
encourage them to make appointments for a screening but may not provide 
administrative support to local providers who agree to furnish the 
care.
    This waiver seeks to expand VA's authority under section 1712 and 
would allow VA to more effectively serve veterans. Specifically, VA 
administrative staff would be authorized to coordinate community-
provided care for enrolled veterans who are not eligible for VA 
provided dental care under 38 U.S.C. 1712 while educating them on the 
dental care options available in their local community. VA 
administrative staff would be authorized to work with other entities 
that would facilitate the connection between veterans and dental 
providers. The expected impact is that the minimal increase of the 
full-time employee equivalents (FTEE) to support pilot program 
implementation, reporting, and analysis will be less than the 
appreciated cost savings.

2. Effective Date, Duration, and Extension or Expansion of Pilot 
Program

    VA is authorized by 38 U.S.C. 1703E(a)(2) to carry out pilot 
programs the Secretary determines to be appropriate to develop 
innovative approaches to testing payment and service delivery models in 
order to reduce expenditures while preserving or enhancing the quality 
of care furnished by the Department. VA is also directed by law to test 
models in implementing pilot programs. See 38 U.S.C 1703E(f)(1), 
(h)(1). This pilot program is focused on VA collaborations with 
community entities or providers that connect veterans to pro bono and 
discounted services. The demonstration model that requires a waiver for 
implementation is focused on Care Coordination for Dental Benefits 
(CCDB). This would be the initial demonstration project for the 
Community Provider Collaborations for Veterans (CPCV) Pilot Program. 
CCDB would aim to improve access to needed dental care in a cost 
neutral way. The demonstration model's success would inform whether a 
different demonstration under CPCV connecting veterans to additional 
pro bono and discounted services would be beneficial. Upon 
Congressional approval of this pilot program and the waiver request 
necessary to implement the demonstration model, VA would begin taking 
necessary preliminary steps to commence the pilot program and 
demonstration model. These steps would include development of 
measurement tools and metrics, outreach to non-VA entities who can 
participate in the pilot program, and other administrative actions 
needed to support the pilot program. When VA is ready to commence the 
pilot program VA would notify the public of the date of the start of 
the pilot program. The pilot program's period of performance would 
commence upon the date identified in the notification to the public. 
The pilot program period of performance would be 5 years.
    VA may expand the scope or duration of a pilot program if, based on 
an analysis of the data developed pursuant to 38 CFR 17.450(g) for the 
pilot program, VA expects the pilot program to reduce spending without 
reducing the quality of care or expects to improve the quality of 
patient care without increasing spending. The pilot is designed to 
reduce utilization of emergency care by veterans to address dental care 
and subsequently reduce costs for these services. Expansion may only 
occur if VA determines that expansion would not deny or limit the 
coverage or provision of benefits for individuals under chapter 17. 
Consistent with 38 CFR 17.450(h), expansion of a pilot program may not 
occur until 60 days after VA has published a document in the Federal 
Register and submitted an interim report to Congress stating its intent 
to expand a pilot program. Examples of potential program expansions 
might include, but are not limited to, the geographic location of the 
pilot and the range of services provided. In general, pilot programs 
are limited to 5 years of operation. VA may extend the duration of a 
pilot program by up to an additional 5 years of operation. Any pilot 
program extended beyond its initial 5-year period must continue to 
comply with the provisions of this section regarding evaluation and 
reporting under 38 CFR 17.450(g).

3. Context for Prioritizing This Pilot Program

    While VA has a unique mission and framework, the Department is 
challenged by the same variability in access, escalating health care 
costs, and need for modernization faced by the

[[Page 68303]]

entire U.S. health care system. VA dental care is one facet of the 
overarching VA health care system that seeks to overcome these barriers 
via the CPCV Pilot Program.
     Problem Statement: Due to defined eligibility for dental care, VA 
only provides dental benefits to 8 percent of the veterans enrolled in 
the VA health care system every year. The remaining 92 percent of 
veterans use private dental insurance, pay out of pocket for dental 
services, rely on pro bono or discounted dental clinics and services, 
or forego critical dental services.
     Proposed Eligibility: Veterans currently enrolled in VA health 
care but who are ineligible for VA dental care under 38 U.S.C. 1712.
     Proposed Intervention: Provision of administrative support for 
accessing community-based dental care.
     Implementation Steps:
    (Step 1) Direct notice of eligibility to veterans.
    (Step 2) Veteran or Patient-Aligned Care Team (PACT) determines 
need for oral health care and contacts the CPCV Pilot Program Call 
Center and/or Portal.
    (Step 3) VA staff or CPCV Pilot Program Call Center and/or Patient 
Portal identify providers based on availability and location, and 
schedules necessary appointment for the veteran.
    (Step 4) Following the dental appointment, dental visit records are 
provided to the VA primary care provider.
     Proposed Sites: The CPCV Pilot Program will be delivered to 
eligible veterans at selected pilot sites which may include Veterans 
Integrated Service Networks (VISN) 2, 8, 10, 12, based on the following 
criteria: Current availability of pro bono and discounted dental 
service providers; Current demand for dental services; Number of 
veterans represented; Urban vs. rural population distribution.
[GRAPHIC] [TIFF OMITTED] TN13DE19.000

    VA offers comprehensive dental care benefits to certain qualifying 
veterans under 38 U.S.C. 1712; it also offers limited services to 
certain qualifying veterans under the same. In addition, veterans 
enrolled in VA health care may purchase dental insurance at a reduced 
cost through VADIP under 38 U.S.C. 1712C (U.S. Department of Veterans 
Affairs. (n.d.). VA Dental Insurance Program. Retrieved from https://www.va.gov/healthbenefits/VADIP. (Note: VADIP offers eligible 
individuals the opportunity to purchase discounted dental insurance 
coverage that includes diagnostic services, preventive services, 
endodontic and other restorative services, surgical services and 
emergency services)). According to an article in the Journal of Oral 
Microbiology, periodontal treatment may have a beneficial impact on 
health and wellbeing (Ryd[eacute]n, L., et al. (2016). Periodontitis 
Increases the Risk of a First Myocardial Infarction: A Report From the 
PAROKRANK Study. 2016 Feb 9; 133(6): 576-583. 13. doi: 10.1161/
CIRCULATIONAHA.115.020324). The Journal cites a 2016 Swedish study 
where 805 patients, less than 75 years of age with first-time acute 
myocardial infarction (AMI), were matched against 805 patients without 
AMI; clinical dental examinations and panoramic x-rays were conducted 
on all participating patients, and periodontitis (PD) was found to be 
more common among patients with AMI than the control group 
(Ryd[eacute]n, L., et al. (2016). Periodontitis Increases the Risk of a 
First Myocardial Infarction: A Report From the PAROKRANK Study. 2016 
Feb 9; 133(6): 576-583. 13. doi: 10.1161/CIRCULATIONAHA.115.020324.) 
The Mayo Clinic reiterates the range of diseases and conditions that 
have been linked to oral health including endocarditis, cardiovascular 
disease, pregnancy and birth complications, and pneumonia (Mayo Clinic. 
(2019). Oral health: A window to your overall health. Retrieved from 
https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475).

4. Statement of Need

    In 2018, VA spent approximately $1.1 billion on veteran dental 
care, averaging approximately $2,185 per veteran (U.S. Department of 
Veterans Affairs. (n.d.). VA Dental Insurance Program. Retrieved from 
https://www.va.gov/healthbenefits/VADIP/. (Note: VADIP offers eligible 
individuals the opportunity to purchase discounted dental insurance 
coverage that includes diagnostic services, preventive services, 
endodontic and other restorative services, surgical services and 
emergency services). Currently, VA is operating at near maximum 
capacity providing dental care for eligible veterans and would require 
a significant budget increase to provide dental access to all veterans.
    While dental care is imperative to overall health and well-being, 
92 percent of veterans enrolled in VA health care are not eligible for 
VA dental care (U.S. Department of Veterans

[[Page 68304]]

Affairs. (2019). VA Dental Care. Retrieved from https://www.va.gov/health-care/about-va-health-benefits/dental-care/). Dental treatments 
occurring outside of VA may be fragmented and the data related to these 
visits is outside of VA's purview, potentially creating uncoordinated 
care and duplication of services. There were 115,000 veterans enrolled 
in VADIP as of January 31, 2017. However, it is unclear exactly how 
many veterans are without access to dental care or services, which 
could be correlated with poor oral health.
    Poor oral health is correlated with potentially avoidable and 
costly emergency department (ED) visits, causing more than two million 
visits to the ED each year (Lee, H.H., Lewis C.W., Saltzman B., Starks 
H. (2012). Visiting the emergency department for dental problems: 
Trends in utilization, 2001 to 2008. Am. J. Public Health. 2012; 
102:e77-e83. doi:10.2105/AJPH.2012.300965). This could be attributed to 
low oral health awareness, whereby individuals lack understanding 
around the importance of preventable dental services and the associated 
health care outcomes (V. Bowyer, et. al. (2011). Oral health awareness 
in adult patients with diabetes: A questionnaire study. British Dental 
Journal. [PDF file]. doi: 10.1038/sj.bdj.2011.769). In a study 
analyzing ED usage in New Jersey, individuals classified as ``high 
users,'' who had four or more visits during the study period, 
represented only 4.2 percent of all users but accounted for 21 percent 
of the visits. The study found that almost all the high users (94.3 
percent) had a diagnosis of ``dental disorder not otherwise 
specified.'' (DeLia, D., Lloyd, K., Feldman, C.A., & Cantor, J.C. 
(2016). Patterns of emergency department use for dental and oral health 
care: Implications for dental and medical care coordination. Journal of 
public health dentistry, 76(1), 1-8. doi: 10.1111/jphd.12103) We 
believe there is an opportunity for cost savings to be realized through 
reduction in ED utilization caused by increasing access to dental care.
    Amid public calls for modernization, VA is transitioning to a more 
automated health care system (U.S. Department of Veterans Affairs. 
(2019). Accelerating VA IT Modernization through DevOps. Retrieved from 
https://www.oit.va.gov/reports/year-in-review/2018/stabilizing-and-streamlining/devops). An online platform connecting veterans to pro 
bono or discounted dental care services could provide veterans 
increased access to quality care while possibly reducing costs 
associated with ED visits linked to oral health. To stay at the 
forefront of modernization, under this pilot program, VA would explore 
opportunities to enable and expand veteran access to a network of pro 
bono and discounted care dental providers. The CPCV Pilot Program aims 
to improve access to dental services, overall coordination of care, and 
beneficiary outcomes through an automated system or a call center that 
would facilitate pro bono or discounted services for veterans or VA 
employees providing direct administrative support to veterans.

5. Current Approach to Service Delivery and/or Payments

5.1 Dental Care

    VA is required to furnish dental care in accordance with 38 U.S.C. 
1712, as noted in Sections 1 and 3 above.

5.2. Community Entities and Providers

    Historically, community entities and providers have demonstrated a 
desire and willingness to support veterans through pro bono or 
discounted services. In the community, veterans have access to legal 
services, employment and training services, health and social services, 
supportive housing programs, income support services, and dental care. 
While various veteran-centered services exist, veterans are not always 
aware of and/or connected to these programs and services. Given the 
public's support of veterans and the available pro bono or discounted 
services for veterans, VA has identified a unique opportunity to engage 
with community entities and providers to help connect veterans to pro 
bono or discounted dental care programs and services.
    VA tracks dental care provided to veterans directly by VA or by 
authorized community care providers. However, VA has no mechanism to 
track dental care provided on a pro bono or discounted basis or dental 
care received by veterans not eligible for VA dental services. There 
are currently several non-profit organizations and companies who 
provide pro bono dental care for veterans. Veterans can receive pro 
bono or discounted dental care from providers if they meet the 
requirements of the program.
    In September 2019, the U.S. Department of Health and Human Services 
(HHS) Health Resources and Services Administration (HRSA) awarded over 
$85 million to 298 health centers to expand their oral health service 
capacity (U.S. Department of Health and Human Services. (2019). HHS 
Awards over $85 Million to Help Health Centers Expand Access to Oral 
Health Care. Retrieved from https://www.hhs.gov/about/news/2019/09/18/hhs-awards-over-85-million-help-health-centers-expand-access-oral-healthcare.html). These investments could enable HRSA-funded health 
centers to provide new, or enhance existing, oral health services to 
communities that include veterans.

6. Proposed Pilot Program

    This section describes the details and defines the terms of this 
pilot program and conditions that would justify pilot program expansion 
or termination. This demonstration model would be the initial 
demonstration being developed and tested for the CPCV Pilot Program. 
This demonstration model seeks to expand coordination and access to 
dental care for veterans not currently eligible for VA dental care.
    The demonstration model aims to enable VA to more effectively serve 
enrolled veterans not eligible for VA dental care under 38 U.S.C. 1712. 
In this demonstration model, VA would collaborate with community 
entities and providers to develop and implement interventions that are 
cost neutral to VA. The designed interventions would facilitate the 
referral and scheduling of pro bono and discounted services for 
veterans who need dental care and services but are not eligible to 
receive such dental care and services from VA. VA will work closely 
with OMB to refine the design and scope of the pilot demonstration and 
provide an update to Congress at a later date.

6.1. Terms and Details of the Pilot Program

    This proposal outlines a pathway for veterans who are enrolled in 
VA health care but do not qualify for coverage through VA to schedule 
pro bono or discounted dental care using either a call center model or 
an automated self-service portal that would connect veterans to pro 
bono or discounted dental services, thus expanding access. The call 
center or portal would be administered by non-VA entities, but would 
likely not be administered by the community providers or entities 
furnishing pro bono or discounted dental services under this program. 
Additionally, the pilot would connect veterans to HRSA working with 
Federally Qualified Health Centers (FQHC), Community Health Centers 
(CHC), free dental clinics, or other parties to provide dental services 
on a pro bono or discounted basis.
    VA staff at selected sites would provide care coordination services 
between VA, community entities, and providers to support veterans

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participating in this demonstration model. Care coordination is the 
deliberate organization of patient care activities between two or more 
participants involved in a patient's care to facilitate the appropriate 
delivery of health care services (McDonald, K.M., et al. (2007). 
Closing the Quality Gap: A Critical Analysis of Quality Improvement 
Strategies. AHRQ Technical Reviews and Summaries, Vol 9.7. Retrieved 
from: https://www.ncbi.nlm.nih.gov/books/NBK44015/). VA would work with 
other entities in the community to provide a number to a call center or 
a web address for a self-service portal to schedule dental services. We 
anticipate there would be minimal impact on the current duties of VA 
staff. Any community entities or providers engaged in the development 
and implementation of this demonstration model should have proven 
experience with and commitment to serving veterans.
    A tiered approach to care could be implemented, where veterans have 
access to one-time, acute dental care options as well as longer term 
care options focused on preventative care and long-term dental 
management; decisions regarding what services will be provided would be 
subject to the decisions of private entities and providers offering pro 
bono or discounted dental services to eligible veterans. VA would 
collaborate with community entities to engage dental providers and non-
profit organizations to build a coalition of pro bono or discounted 
dental care providers willing to share their availability and service 
offerings with VA and provide their availability in the self-service 
portal. The portal would allow dental providers to indicate which tier 
of care they are willing to provide. The call center or online self-
service portal would improve access by connecting veterans with 
conveniently located community entities and providers offering dental 
services. It is expected that when the call center or self-service 
portal becomes available, information regarding the self-service portal 
would be relayed to veterans via a multisource campaign.
    The targeted benefits of the demonstration model are: Veterans 
ineligible for VA dental care experience improved access to dental care 
services; veterans benefit from enhanced care coordination with 
community dental providers and improved access to oral health care and 
benefits; Possibility of improved health outcomes by addressing oral 
health needs that impact and interact with other physical health and 
social determinants of health.
6.1.1. Deficits in Care and Affected Populations
    The demonstration model would focus on the expansion and 
coordination of access to dental care benefits for veterans who are not 
eligible for VA dental care. We estimate that approximately 92 percent 
of veterans who are enrolled in VA health care do not have access to 
comprehensive dental care through VA and are thus at an elevated risk 
for oral health issues and complications.
    The Healthy People 2020 Report highlighted limited access to and 
availability of dental services, and lack of awareness of the need for 
care, as critical barriers that impact a person's use of preventive 
dental health interventions. Social determinants that impact oral 
health include having lower levels of education and income, 
disabilities, other health conditions such as diabetes, and people from 
specific racial/ethnic groups (Office of Disease Prevention and Health 
Promotion. (2019). Oral Health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health).
    The ADA reports that 28 percent of adults between the ages of 35-44 
and 18 percent of adults 65 and older have untreated tooth decay 
(American Dental Association. (2013). Action for Dental Health: 
Bringing Disease Prevention into Communities. [PDF file]. Retrieved 
from https://www.ada.org/~/media/ADA/Public%20Programs/Files/bringing-
disease-prevention-to-communities_adh.ashx). Additionally, the Centers 
for Disease Control and Prevention (CDC) report that nearly 70 percent 
of American adults 65 years and older have periodontal disease (Centers 
for Disease Control and Prevention. (2016). Oral Health Conditions: 
Periodontal Disease. Retrieved from https://www.cdc.gov/oralhealth/periodontal-disease.html).The prevalence of dental health issues 
reinforces the importance of addressing dental health in a timely 
fashion. The CDC reports that over 80 percent of adults have had at 
least one cavity by age 34. There are significant cost impacts arising 
from poor dental care for patients and VA, both in medical claims 
(e.g., emergency department visits) and work productivity loss.
6.1.2. Pilot Program Interventions
    The core tenets of the demonstration model include developing and 
enhancing trusted collaborations with community dental providers, 
prioritizing care and interventions, and individualizing the approach 
to improving veterans' oral health care needs. This demonstration model 
enables a standardized and streamlined approach to facilitating 
veterans' access to pro bono dental care and services. VA intends to 
pursue a phased approach to developing and implementing interventions 
for this demonstration model. It is anticipated that the phased 
development and implementation approach would follow the sequence 
listed below.
    (1) Expanding on VA's experience establishing relationships with 
community entities to furnish services to VA and veterans at only 
nominal cost to VA, we intend to collaborate with community entities to 
establish a call center to schedule and coordinate appointments for 
veterans with high quality dental service providers participating in 
this demonstration model.
    (2) In addition to utilizing a call center to connect veterans to 
community providers participating in the CPCV pilot program, VA will 
also collaborate with community entities to develop and implement a 
patient portal that allows veterans to directly schedule visits and own 
their individual data on the platform. An additional feature of the 
self-service portal would be the control the veteran would have over 
granting access to dental providers, caregivers, and community support 
team members of their choice. While the patient portal would not be 
owned and operated by VA, VA would have access to the veteran data 
contained on the platform. The platform will ensure that all Privacy 
Act, Health Insurance Portability and Accountability Act of 1996 
(HIPPA), and VA information security standards are satisfied.
    We believe a self-service patient portal and/or call center would 
present an opportunity for VA to enable veteran care coordination with 
pro bono dental services in a manner that is cost neutral to VA with 
minimal impact on current VA operations even if this service offering 
is scaled nationwide through subsequent expansion after determining 
that the pilot program has been successful. This strategic approach 
would expand on previously demonstrated interest in collaborations with 
private entities as demonstrated by the success of VA's recent efforts 
with organizations such as Walmart, T-Mobile, and Microsoft. A non-VA 
owned self-service patient portal or call center also would allow VA to 
enable the development and implementation of a national directory of 
dentists who are already providing pro bono care in their communities. 
Additionally, the national directory would create opportunities to

[[Page 68306]]

promote further research on the impact of oral health on other health 
and well-being outcomes.
    Finally, a self-service patient portal or call center could 
encourage increased participation from existing pro bono providers, 
such as those affiliated with Dentists for Veterans, and the 
participation of additional dentists who do not currently offer pro 
bono services to veterans (Dentists for Veterans. (n.d.). About Us. 
Retrieved from http://www.dentistsforveterans.org/about-us/. (Note: 
Dentists for Veterans is an existing non-profit organization that 
provides low- to no-cost dental services to veterans and targets low 
income, physically disabled, and mentally ill veterans in Southern 
California.). Other groups, for example, include Everyone for Veterans, 
a private, non-profit organization based in the State of Washington, 
that connects veterans and their spouses to local community services 
and dental care (Everyone for Veterans (n.d.). About Us. Retrieved from 
https://www.everyoneforveterans.org/about-us.html), and Dental 
Lifeline, which has a network of 15,000 volunteer dentists and 3,700 
volunteer laboratories that provides care to those who cannot afford 
dental care and have either a permanent disability, a medically fragile 
condition, or are over 65 (Dental Lifeline Network. (2019). About Us. 
Retrieved from https://dentallifeline.org/about-us/). Non-profit 
organizations that provide pro bono or discounted dental care to the 
general population could also be utilized in the demonstration model.
    VA staff could also provide direct administrative support, either 
using the call center or portal or through other means, to help 
veterans access these pro bono or discounted dental services.
    Where VA refers a veteran to specific providers, which would occur 
if the call center or portal is not operational, then the Department 
will provide the veteran with a list of providers which includes a 
prominent disclaimer that, ``The list is provided for informational 
purposes. The Department of Veterans Affairs does not endorse any 
listed provider.''
6.1.3. Pilot Program Costs
    VA would collaborate with community entities or providers and 
dental providers to create multiple avenues for veterans to access pro 
bono dental care and discounted dental services provided by community 
providers. Information in this section is considered acquisition 
sensitive and therefore excluded, however, VA anticipates expending 
between $5 million and $10 million annually on the execution of the 
CPCV pilot program. VA would bear the impact evaluation and strategic 
execution and performance management/oversight of the pilot program.
6.1.4. Pilot Program Implementation
    VA anticipates executing this pilot program in metropolitan areas 
with greater access to pro bono and discounted dental services in the 
community and in areas with access to FQHCs. Any enrolled veteran 
ineligible for VA dental benefits in participating areas would be 
eligible to participate, and any veteran affected by this program would 
receive direct notice about the program. It is anticipated that 
veterans would be able to self-identify their need for this program. VA 
staff working on a veterans' care team would receive information about 
this demonstration model and could recommend that veterans use the 
available resources.
    VA would provide direct notice to veterans in selected areas 
regarding the CPCV Pilot Program through hard copy materials and 
informational advertisements in predetermined VA facilities and on VA's 
website. VA would also explore opportunities with media organizations 
to promote the demonstration model and the available resources. 
Finally, VA would include information on several national VA websites 
about this pilot program, how to access the portal, and eligibility 
criteria for qualifying veterans (U.S. Department of Veterans Affairs. 
(2019). VA Dentistry--Improving Veterans' Oral Health. Retrieved from 
https://www.va.gov/dental/) and VA Innovation Center (VIC) (U.S. 
Department of Veterans Affairs. (n.d.). VA Innovation Center. Retrieved 
from https://www.innovation.va.gov/).
    VA, supporting providers, and participating veterans would have 
full access to self-reported beneficiary data. Veterans would be 
enabled and authorized to expand or limit the access to this data. The 
beneficiary data collected will be subject to the Privacy Act, HIPAA, 
and VA's information security requirements.
    This pilot program would start upon the date identified in VA's 
notification to the public announcing the commencement of the program. 
The time between Congressional approval and VA's notification to the 
public announcing the start of the program would allow VA to engage the 
community, develop intervention requirements (such as available 
capacity of certified providers willing to provide services), and 
execute any necessary agreements with other entities; it would also 
give VA time to address other administrative requirements for the 
program. VA would engage dental care entities and providers willing to 
offer pro bono services or discounted dental care services to veterans 
and discuss how the pilot would operate while addressing any provider 
concerns. Initial outreach would focus on dental associations and 
dental provider organizations that have a history of working with 
veterans.
6.1.5. Pilot Program Beneficiaries
    Enrolled veterans who are not eligible to receive dental care from 
VA under 38 U.S.C. 1712 would be eligible for the CCDB demonstration 
model. Initial veteran outreach and education would focus on enrolled 
veterans in metropolitan areas with access to discounted services and 
pro bono providers, but if this pilot program proves successful, VA 
could look for rural areas with available pro bono providers or those 
offering discounted services as well.
6.1.6. Pilot Program Evaluation
    To evaluate the CCDB demonstration model, the performance of the 
intervention group would be compared to at least one control group.
    Intervention group: Veterans that are not currently eligible to 
receive VA dental services.
    Control group: Risk-stratified, randomized, and prospectively 
matched veteran enrolled in VA health care who are eligible to receive 
dental benefits in VA; or are ineligible to receive dental benefits in 
VA and not enrolled in the CCDB demonstration.
    Sample performance data includes: Cost savings from reducing ED 
visits linked to oral health issues; Impact on access and veteran 
experience; Impact on patient satisfaction and customer experience 
measures mapped to Office of Management and Budget (OMB) Circular A-11 
domains and applicable Consumer Assessment of Healthcare Providers and 
Systems (CAHPS) Dental Plan survey results (OMB approval would be 
needed to distribute the CAHPS Dental Plan survey to demonstration 
participants.) Examples of data sources include: VA claims, encounters, 
and commercial claims.
    Sample evaluation questions: Will experience outcomes for the 
intervention group exceed the control group? Which of the interventions 
utilized in this demonstration model will be most effective for 
veterans to access pro bono dental care? Will VA achieve cost savings 
as a result of a reduction in the number of ED visits linked to oral 
health issues?

[[Page 68307]]

6.1.7. Potential for Impact on Center for Innovation for Care and 
Payment Priorities
    Section 1703E(a)(3) identifies specific objectives for pilot 
programs. This demonstration model would focus on improving access to, 
and quality, timeliness, and patient satisfaction of care and services, 
and creating cost savings for VA by expanding the availability of 
dental services through administrative support to veterans currently 
ineligible for VA dental care. The care would be provided by high-
quality providers with oversight provided by HRSA and FQHCs in a timely 
fashion, and we expect patient satisfaction would improve as a result. 
Better care should also reduce costs to VA for ED visits linked to oral 
health issues. The following table contains key measures and desired 
outcomes that were identified by VA leadership to determine the success 
of care delivery.
[GRAPHIC] [TIFF OMITTED] TN13DE19.001

6.1.8. Impact on Desired Outcomes
    Connecting veterans to pro bono and discounted dental care would 
enable enrolled veterans that are ineligible for VA dental care to 
access the services they need at no cost or reduced cost, filling a 
significant deficit in care. Providing needed dental care to veterans 
through local community providers would simplify access to care for 
patients. The self-service automated platform would centralize 
information related to the availability and specialty of dental care 
providers in the community willing to provide pro bono or discounted 
services to veterans. This pilot program would be expected to occur 
over a period of 5 years to allow adequate time to design and test 
interventions and aggregate relevant metrics for evaluation.

6.2 Responsibilities of Key Stakeholders

    The key stakeholders and associated responsibilities of related 
parties involved in the operation of the CCDB demonstration model 
include:

[[Page 68308]]

[GRAPHIC] [TIFF OMITTED] TN13DE19.002

6.3. Pilot Program Expansion or Termination

6.3.1.1. Terms
    This is a demonstration model of the CPCV Pilot Program. Consistent 
with 38 CFR 17.450(h), VA may expand the scope or duration of a pilot 
program if, based on an analysis of the data and analysis developed for 
the CCDB demonstration model, VA expects this pilot program to (1) 
reduce spending without reducing the quality of care, (2) improve the 
quality of patient care without increasing spending, or (3) improve the 
quality of care while reducing spending. Expansion of the pilot program 
may occur if the combined results of the impact analysis and evaluation 
of the demonstration models tested under a pilot program indicate that 
the desired outcomes of the pilot program were achieved. VA may not 
expand a pilot program if VA determines that such expansion would deny 
or limit the coverage or provision of benefits for individuals 
receiving benefits under chapter 17 of title 38, U.S.C. Expansion of a 
pilot program may not occur until 60 days after VA has published a 
document in the Federal Register and submitted an interim report to 
Congress stating its intent to expand a pilot program. Examples of 
potential program expansions might include, but are not limited to, the 
geographic location of the pilot and the range of services provided. VA 
may also extend the duration of a pilot program by up to an additional 
5 years of operation, and any pilot program extended beyond its initial 
5-

[[Page 68309]]

year period must continue to comply with the provisions in section 
17.450 regarding evaluation and reporting.
6.3.1.2. Conditions
    VA would continuously monitor the performance of this demonstration 
model. This demonstration model is designed to reduce spending without 
reducing the quality of care and improve the quality of patient care 
without increasing spending. The metrics to be measured and compared to 
the study population include but are not limited to improved veteran 
satisfaction and reduced ED utilization.
6.3.1.3. Implementation Approaches
    The demonstration model would evaluate veteran populations, access 
requirements, deficits in care assessments, and available provider 
networks in determining geographic expansion selection.
6.3.2. Pilot Program Termination or Cessation
6.3.2.1. Terms
    Pilot termination is defined as ending the pilot program earlier 
than its authorized period (in this case, 5 years from commencement) 
upon a determination by the Secretary that the pilot program is not 
producing quality enhancement or quality preservation, or is not 
resulting in the reduction of expenditures, and that it is not possible 
or advisable to modify the pilot program either through submission of a 
new waiver request or through modification under section 17.450(i). 
Section 17.450(j) establishes these conditions. If VA determined that 
the CCDB demonstration model was not producing quality enhancement or 
quality preservation, or was not resulting in the reduction of 
expenditures, and that it was not possible or advisable to modify the 
demonstration model, VA would terminate the demonstration model within 
30 days of submitting an interim report to Congress that stated such 
determination. VA would also publish a document in the Federal Register 
regarding the pilot program's termination.
    Cessation of a pilot program is defined as the on-schedule ending 
of a pilot program, and it may occur if the combined results of the 
independent impact analysis of the demonstration model tested under a 
pilot program indicate that the desired outcomes of the pilot program 
were not achieved or are inconclusive. VA would also publish a document 
in the Federal Register regarding the pilot program's cessation.
6.3.2.2. Implementation Approaches
    For the demonstration model, VA would initiate termination with 
written notification to all beneficiaries, stakeholders, and vendors 
contractually engaged to support the implementation of this 
demonstration model. This termination would occur within 30 days of VA 
submitting an interim report to Congress stating that VA has determined 
a pilot program is not producing quality enhancement or quality 
preservation, or is not resulting in the reduction of expenditures, and 
that it is not possible or advisable to modify the pilot program either 
through submission of a new waiver request or through modification 
under section 17.450(i). Notification would be provided to allow for 
appropriate announcements and initiation of demonstration model 
termination activities. VA would provide notification 90 days in 
advance of the cessation of a pilot program.

7. Request for Waivers

    To implement the CPCV Pilot Program, we require Congressional 
approval of a waiver from current restrictions in VA statutes.

7.1. Statutory Requirements

7.1.1. Specific Authorities To Be Waived
    Specifically, Congress must waive the limitations in 38 U.S.C. 1712 
concerning the population of veterans eligible for VA dental care and 
services to permit VA to offer administrative support to enrolled 
veterans otherwise ineligible for this care.
7.1.2. Standard(s) To Be Used in Lieu of Waived Authorities
    Congressional approval of this waiver would allow VA to operate the 
pilot program as though 38 U.S.C. 1712 were revised as described below:
    (a) By redesignating subsections (d) and (e) as subsections (e) and 
(f), respectively;
    (b) by inserting after subsection (c) the following new subsection 
(d):
    ``(d)(1) Through collaboration with community entities and 
providers approved by the Secretary, the Secretary may provide 
administrative support for the provision of dental care to enrolled 
veterans for care that they are not eligible to receive from the 
Department.
    ``(2) Notwithstanding any other provision of law, the Secretary 
shall incur no liability (including under section 1151 of this title) 
for any disability, injury, or death resulting from care furnished by a 
non-Department entity or provider pursuant to this subsection.''
7.1.3. Reason(s) for Waivers
    As previously explained, VA has limited statutory authority to 
furnish dental care. This waiver would authorize VA to provide 
administrative support for the provision of needed outpatient dental 
care in the community to enrolled veterans who are not eligible to 
receive that dental care from VA under 38 U.S.C. 1712. This waiver 
would authorize VA staff, in the scope of their normal duties, to work 
with community entities or providers approved by the Secretary to refer 
veterans to dental care resources that are provided pro bono or at a 
discount. This waiver would also expressly exempt VA from any liability 
that may arise from tortious conduct by a community provider. A 
veteran's sole remedy in such a situation would be recovery against the 
provider of services.
    This waiver would expand VA's authority under section 1712 and 
would allow VA to more effectively serve veterans ineligible for VA 
dental benefits. Specifically, VA administrative staff would be 
authorized to educate veterans who are not eligible for VA dental care 
on the dental care options available to them from the community. VHA 
administrative staff would be authorized to connect veterans to 
resources that can schedule veterans for dental care.
7.1.4. Metrics To Be Used To Determine the Impact of Waivers
    Metrics used to assess the pilot would include utilization of care 
and services related to oral care, ED utilization, ED outcomes, and 
patient satisfaction. These would be used to assess the effect of the 
waiver upon the quality, timeliness, or patient satisfaction of care 
and services furnished through the pilot program.

[[Page 68310]]

[GRAPHIC] [TIFF OMITTED] TN13DE19.003

Assumptions
    Funds spent on care and services related to oral health and ED 
utilization would include both data on community care utilization and 
VA internal data.
    Quality would be measured through monitoring of ED utilization for 
oral health. Veteran experience would be measured by sources such as 
customer experience measures mapped to OMB Circular No. A-11 domains 
and applicable CAHPS survey results. Consistent with 38 CFR 17.450(g), 
evaluation of this pilot will include a survey of participants or 
beneficiaries to determine their satisfaction with the pilot program. 
VA will make the evaluation results available to the public on the VA 
Innovation Center website. All collections of information will be 
conducted in accordance with the requirements of the Paperwork 
Reduction Act of 1995 (44 U.S.C. 3501 et seq.).
7.1.5. Anticipated Cost Savings
    Anticipated benefits for the CCDB demonstration model are improved 
patient care and satisfaction, as well as reduced expenditures 
associated with ED visits linked to oral health issues. Improving ED 
utilization is a quality metric because by eliminating time spent on 
dental services that could have been treated in a clinic, ED Physicians 
can devote their time to higher priority patients.
    VA anticipates that reduced expenditures associated with ED visits 
linked to oral health issues would reduce costs for other related 
Federal programs, but we anticipate that VA would be unable to measure 
the impacts to other related Federal programs.
    This waiver would have minimal to no net cost impact to VA, as VA 
would not be paying for the pro bono or discounted dental services and 
would not be liable for any tortious conduct by community providers. 
This provision would have no impact on VA clinicians (medical doctors 
and nurse practitioners), as they routinely provide general oral 
assessment for enrolled veterans eligible for dental benefits as part 
of their examination. VA also anticipates this would have no impact on 
clinic medical support assistants that might recommend the scheduling 
portal or otherwise provide administrative support.
    Improved access to care should lead to better dental health 
outcomes and reduced unnecessary utilization of care and services 
associated with poor oral health that could lead to cost savings. 
Improved access to dental health services could lead to a reduction in 
ED utilization for dental health care needs. Drivers of these cost 
savings would include improved access to care, increased use of 
preventative oral care, and improved care coordination.
    VA does not have a reliable actuarial basis to identify the 
estimated cost savings. Further analysis would be required to determine 
potential savings over current expenditures for participating veterans. 
Development of a comprehensive financial impact model could be pursued 
once the details of this demonstration model are finalized. Factors 
that would influence the financial predictions include: Overall acuity 
and health risk factors of the demonstration population; Participation 
strategies and speed of uptake (pilot elements); Specific services 
offered by pro bono care providers, location of service, etc.; 
Comorbidities associated with oral health care; Operational plans for 
VHA pilot program sites and Office of Information and Technology.
    The detailed budgetary impact and anticipated cost savings analysis 
associated with these cost factors will be provided at a later date.
    Based on information from ADA from private providers, there are 
significantly lower costs for common preventive services compared to 
common restorative services, as represented below (American Dental 
Association. (2013). Action for Dental Health: Bringing Disease 
Prevention to Communities. Retrieved from https://www.ada.org/~/media/
ADA/Public%20Programs/Files/bringing-disease-prevention-to-
communities_adh.ashx).
[GRAPHIC] [TIFF OMITTED] TN13DE19.004


[[Page 68311]]


7.1.6. Schedule of Interim Reports
    VA would submit interim reports to the Committees on Veterans' 
Affairs of the House of Representatives and the Senate no later than 
once every 6 months from the date of the commencement of the pilot 
program. These interim reports would describe the results of the pilot 
program so far and the feasibility and advisability of continuing the 
pilot program.
7.1.7. Schedule for Cessation of Pilot Program and Submission of Final 
Report
    Absent any extension of the pilot program pursuant to 38 CFR 
17.450(h), VA would end the pilot program 5 years after the date on 
which it commences. VA would submit a final report on the pilot program 
describing the results of the pilot program and the feasibility and 
advisability of making the pilot program permanent no later than 6 
months after the end date of the pilot program.
7.1.8. Estimated Budget of Demonstration Model
    VA would not be paying for the pro bono dental services so there 
would be no costs related to care. However, the direct costs to VA of 
operating the CCDB demonstration model would depend on participation, 
duration, and other factors.
Assumptions
    VA would incur only nominal costs associated with monitoring the 
results of the program. Section 1703E(g)(2)(A) states the Secretary may 
not expend more than $50 million in any fiscal year from amounts 
provided in advance in appropriations acts for the Veterans Health 
Administration and for information technology systems. In section 
17.450(d), VA clarified this authority to state that it will obligate 
no more than $50 million in any fiscal year for the conduct of the 
pilot programs (including all administrative and overhead costs, such 
as measurement, evaluation, and expenses to implement the pilot 
programs themselves) operated under this authority; VA also will not 
actively operate more than 10 pilot programs at the same time.

7.2. Regulatory Requirements

7.2.1. Geographic Location
    This pilot would serve enrolled veterans who are not eligible for 
dental care from VA in metropolitan areas with greater access to pro 
bono and discounted dental services in the community. Metropolitan 
areas generally have more dental providers, and more dental providers 
who are willing to provide pro bono or discounted services, than other 
areas. The veteran population in metropolitan areas is also more 
densely located, allowing more veterans to be served by these 
providers. It is believed that operating this pilot program in 
metropolitan areas would address deficits in care related to oral 
health by expanding access to quality dental care at no cost or at a 
discounted cost. In Section 3, we identified VISN 2, 8, 10, and 12 as 
possible areas in which the pilot program would be operated.
7.2.2. Any Applicable Provision of Existing Regulations Implementing 
Any Laws To Be Waived
    No existing regulations would need to be waived to execute this 
pilot program.
7.2.3. Notice of Eligibility
    An initial outreach communication plan would focus on introducing 
this demonstration model and building program awareness. VA would take 
reasonable actions to provide direct notice to veterans eligible to 
participate in this demonstration model and would provide general 
notice to other individuals who are also eligible to participate. 
Direct notice would include hard copy materials and informational 
advertisements in VA health care facilities selected for this model. VA 
would also explore opportunities with media organizations to promote 
the demonstration model and the available resources. Finally, VA would 
include information on several national VA websites about this pilot 
program, how to access the portal, and information about how eligible 
veterans could participate. VA would engage dental care entities and 
providers willing to offer pro bono or discounted services to veterans 
and discuss how the pilot would operate while addressing any provider 
concerns. Initial outreach would focus on dental associations and 
dental provider organizations that have a history of working with 
veterans. During the initial period, strategic monthly outreach 
campaigns would be identified and presented for approval. Each 
communication outreach plan would include outreach goals, target 
groups, release dates, and campaign distribution details.
7.2.4. Definitions
    VA's regulations at 38 CFR 17.450(b) provide general definitions of 
terms in the statute and VA's regulations, but also permit further 
definition through the pilot program proposal. VA offers no further 
definition of terms in its regulations, but it has previously 
identified the metrics it would use to determine whether the program is 
successful.
7.2.4.1. Patient Satisfaction of Care and Services
    Patient satisfaction of care and services refers to patients' 
rating of their experiences of care and services. Patient satisfaction 
of care and services would not be further defined for this pilot 
program.
7.2.4.2. Payment Models
    Payment models refer to the types of payment, reimbursement, or 
incentives that VA deems appropriate for advancing the health and well-
being of beneficiaries. Payment models would not be further defined for 
this pilot program.
7.2.4.3. Quality Enhancement
    Quality enhancement refers to improvement or improvements in such 
factors as quality, beneficiary-level outcomes, and functional status 
as documented through improvements in measurement data from a reliable 
and valid source. Quality enhancement would not be further defined for 
this pilot program.
7.2.4.4. Quality Preservation
    Quality preservation refers to the maintenance of such factors as 
oral health, beneficiary-level outcomes, and functional status as 
documented through maintenance of measurement data from an evidence-
based source. Quality preservation would not be further defined for 
this pilot program.
7.2.4.5. Reduction in Expenditure
    Reduction in expenditure refers to, but is not limited to, cost 
stabilization, cost avoidance, or decreases in long- or short-term 
spending. Reduction in expenditure would not be further defined for 
this pilot program.
7.2.5. Measures
    Measures to assess whether VA is achieving its goals would include 
the following: Reducing costs of ED utilization related to oral health; 
and improving veteran satisfaction.
7.2.6. Schedule of the Release of Evaluation Results in the Proposal
    In addition to interim and final status reports, an evaluation 
would be completed at the end of the demonstration model and the pilot 
program to determine if the tested models and interventions were more 
effective than the status quo. Interim reports would be submitted every 
6 months, and a final report would be submitted within 6 months of the 
completion of the pilot program.

[[Page 68312]]

8. Additional Considerations

8.1. Sustainable Value Creation and Capture

    Veterans participating in the CCDB demonstration model would gain 
coordinated access to high quality pro bono or discounted dental 
services, enabling them to receive preventative and restorative dental 
care. Value creation may occur after the successful implementation of 
the CCDB demonstration model by: Addressing deficits in care resulting 
from underutilization of preventative care, geographic barriers, and 
poor clinical outcomes for the veterans participating in the 
demonstration model; Addressing availability of pro bono or discounted 
community dental care services for veterans ineligible for dental care 
under 38 U.S.C. 1712; Enhancing access to dental care and improved 
satisfaction with the availability of dental services; Improving the 
coordination of care and benefits for veterans to increase their access 
to dental care benefits, thereby improving overall health outcomes.
8.1.1. Impacted Stakeholders
    VA anticipates that the CCDB demonstration model would create cost 
savings related to overall veterans health, increased access to care, 
and improved health outcomes through the delivery of pro bono or 
discounted dental services and care coordination. Due to the current 
statutory eligibility criteria for VA's dental program, the impact to 
VA dental care expenditures would be limited. However, we expect that 
this demonstration model would result in reduced overall VA health care 
expenditures due to the relationship between improved oral health and 
comorbid disease states. Pro bono dental providers and those offering 
discounts would benefit from a well-coordinated scheduling process that 
allowed them to list their availability on a platform where veterans 
could schedule appointments directly.
8.1.2. Maximizing Pilot Program Impact
    The impact of the pilot program could be enhanced by developing a 
culture of cooperation. Further, this pilot program would: (1) Increase 
the availability of dental health benefits to veterans, and (2) Improve 
the coordination, execution, and efficiency of dental health care 
delivery.
    Existing non-profit organizations and pro bono providers or those 
offering discounted services should be encouraged to recruit their 
peers to expand the care coordination platform. There is potential for 
this demonstration model to expand to include coordination of other 
needed services for veterans over time.

8.2. Pilot Program Modifications

    Consistent with section 17.450(i), the Secretary may modify 
elements of this pilot program in a manner that is consistent with the 
parameters of the Congressional approval of the waiver described above. 
Such modifications would not require a new submission to Congress for 
approval.

8.3. Record Keeping

    VA would maintain all pilot program records and relevant analysis 
in accordance with applicable record control schedules.
Signing Authority
    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Pamela 
Powers, Chief of Staff, Department of Veterans Affairs, approved this 
document on December 10, 2019, for publication.

Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
the Secretary, Department of Veterans Affairs.
[FR Doc. 2019-26901 Filed 12-12-19; 8:45 am]
 BILLING CODE 8320-01-P