[Federal Register Volume 88, Number 77 (Friday, April 21, 2023)]
[Rules and Regulations]
[Pages 24481-24483]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-08298]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AQ70


Medical Benefits Package; Chiropractic Services

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: The Department of Veterans Affairs (VA) is amending its 
medical regulations to add chiropractic services to the definitions of 
medical services and preventive care. VA will further revise the 
definition of medical services to include rehabilitative services 
consistent with its statutory definition and to reflect changes made in 
other VA medical regulations and in prior legislation not previously 
codified. The amendments will make the amended regulations consistent 
with current practices, prior changes in law and other VA medical 
regulations, and changes in law made by the Consolidated Appropriations 
Act, 2018. These amendments will not substantively change the current 
administration of medical benefits to veterans.

DATES: This rule is effective May 22, 2023.

FOR FURTHER INFORMATION CONTACT: Anthony Lisi, D.C., Director, Veterans 
Health Administration Chiropractic Service, Rehabilitation and 
Prosthetic Services (12RPS3), 810 Vermont Ave. NW, Washington, DC 
20420, (203) 932-5711, ext. 5341. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: On October 21, 2021, VA published a proposed 
rule in the Federal Register (86 FR 58237) that would revise its 
medical regulations to explicitly include chiropractic and 
rehabilitative care. VA provided a 60-day comment period, which ended 
on December 20, 2021. VA received six comments on the proposed rule.
    Section 1710 of title 38 of the United States Code (U.S.C.) 
requires VA to furnish hospital care and medical services which the 
Secretary determines to be needed for eligible veterans. The term 
medical services is defined in 38 U.S.C. 1701(6) to include medical 
examination, treatment, and rehabilitation, and further lists 
particular types of medical services in section 1701(6)(A)-(H). Section 
245 of Public Law 115-141, the Consolidated Appropriations Act, 2018 
(March 23, 2018), amended 38 U.S.C. 1701(6) to add chiropractic 
services to the definition of medical services, amended section 1701(8) 
to include chiropractic services to the definition of rehabilitative 
services, and amended section 1701(9) to add chiropractic examinations 
and services to the definition of preventive services. VA regulates 
definitions for certain terms, to include medical services, in title 38 
Code of Federal Regulations (CFR) 17.30, and regulates the provision of 
hospital care and medical services in 38 CFR 17.38. This final rule 
amends 38 CFR 17.30 and 17.38, consistent with the proposed rule, to 
conform to these statutory changes and expressly recognize chiropractic 
services as medical services.
    All six comments--including one submitted by the American 
Chiropractic Association, the largest professional organization 
representing chiropractors in the U.S.--expressed support for the rule, 
and we thank the commenters for their support. While all comments were 
supportive, four warrant clarification.
    One commenter is a chiropractor working with veterans who expressed 
a personal desire, as well as a desire held by the commenter's 
patients, to see chiropractic care covered as part of veteran medical 
benefits. We believe this commenter supported the addition of 
chiropractic services as part of the medical benefits package in 
proposed Sec.  17.38(a)(2)(x) but may not have understood that 
chiropractic services have been provided by VA to veterans since 2000. 
We clarify for the commenter, and reiterate from the proposed rule, 
that the proposed changes are intended to expressly recognize 
chiropractic services as medical services available to veterans, making 
VA regulations consistent with changes in law made by the Consolidated 
Appropriations Act of 2018 as well as with current VA practice. The 
proposed changes will not affect the administration of medical 
benefits, which currently include chiropractic services. We do not make 
any changes based on this comment.
    While voicing support for the proposed rule, one commenter stated 
the change does not go far enough, because it does not include other 
``whole-person'' medical treatments and

[[Page 24482]]

methodologies such as osteopathic manipulation, physical therapy, and 
massage therapy. The commenter recommended listing these three 
modalities alongside chiropractic care as covered preventive care 
services under 38 CFR 17.38(a)(2)(x). VA embraces whole health by 
offering various complimentary and integrative health approaches and 
promoting veteran self-care and well-being. However, the primary 
purpose of this rulemaking is to conform Sec.  17.38 with the statutory 
changes made to 38 U.S.C. 1701 in the Consolidated Appropriations Act, 
2018, and not to conform VA regulations to reflect an exhaustive list 
of all treatment modalities that may be available as either basic or 
preventive care in the medical benefits package in Sec.  17.38(a). We 
clarify for the commenter, however, that the additional modalities 
mentioned by the commenter are currently authorized forms of outpatient 
care for veterans under Sec.  17.38(a)(1)(i), dependent upon factors 
like provider availability and medical necessity. We do not make any 
changes from the proposed rule based on this comment.
    A supportive comment submitted by a group of graduate students 
stated a belief that VA currently provides only limited chiropractic 
services and that the proposed rule would authorize additional 
chiropractic resources for veterans through the hiring of additional 
chiropractors. To clarify, the proposed rule did not pose regulatory 
revisions to increase chiropractic resources or services, but only to 
conform current regulatory language to the authorizing statutory 
language and current VA practice. Chiropractic resources are already 
available at VA medical centers and through the Community Care Program.
    In the group comment referenced above, one individual commenter 
also stated that while they supported the rule and did not find any 
issue with VA providing chiropractic care prior to the regulations 
being published and effective, the commenter suggested that, in the 
future, VA should not authorize new types of treatment or care without 
first, or simultaneously, publishing a regulation. We thank the 
commenter for that suggestion. However, in some situations VA is able 
to administer medically necessary benefits to veterans as soon as they 
are authorized without having to wait for regulations to be published.
    The commenter detailed their own experience serving on active duty 
and as a veteran receiving health care through VA, and we thank the 
commenter for their service. We do not make any changes from the 
proposed rule based on this comment.
    One commenter expressed support for making chiropractic services 
available in nursing homes, a term which could apply to various VA-run 
and VA-affiliated programs, such as: Community Living Centers, which 
are VA-run nursing homes; Community Nursing Homes, which are nursing 
homes owned and operated by commercial providers where VA contracts for 
beneficiary care; and State Veterans Homes, which are recognized by VA, 
but owned and operated by the state where they are located. While 
chiropractic care is available to veterans eligible for the medical 
benefits package, we note that these services may not be available on-
site at each type of nursing home to which the commenter may have been 
referring.
    Based on the rationale set forth in the Supplementary Information 
to the proposed rule and in this final rule, VA is adopting the 
proposed rule as a final rule without changes.

Paperwork Reduction Act

    This action does not contain any provisions constituting 
collections of information under the Paperwork Reduction Act of 1995 
(44 U.S.C. 3501-3521).

Regulatory Flexibility Act

    The Secretary hereby certifies that this final 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. There would be no material changes to the medical benefits 
available to veterans. Therefore, pursuant to 5 U.S.C. 605(b), the 
initial and final regulatory flexibility analysis requirements of 5 
U.S.C. 603 and 604 do not apply.

Executive Order 12866 and 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
The Office of Information and Regulatory Affairs has determined that 
this rule is not a significant regulatory action under Executive Order 
12866. The Regulatory Impact Analysis associated with this rulemaking 
can be found as a supporting document at www.regulations.gov.

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 final rule will have no such effect on 
State, local, and tribal governments, or on the private sector.

Assistance Listings

    The Assistance Listings numbers and titles for the programs 
affected by this document are 64.014, Veterans State Domiciliary Care; 
64.015, Veterans State Nursing Home Care; 64.029, Purchase Care 
Program; 64.049, VHA Community Living Center.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Claims, Day care, Dental 
health, Health care, Health facilities, Health professions, Health 
records, Homeless, Medical and Dental schools, Medical devices, Medical 
research, Mental health programs, Nursing homes, Reporting and 
recordkeeping requirements, Veterans.

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved this 
document on April 14, 2023, 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.

Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
General Counsel, Department of Veterans Affairs.

    For the reasons set forth in the preamble, we amend 38 CFR part 17 
as follows:

PART 17--MEDICAL

0
1. The authority citation for part 17 is amended by adding an entry for 
Sec.  17.30 and revising the entry for Sec.  17.38 to read in part as 
follows:

    Authority: 38 U.S.C. 501, and as noted in specific sections.

    Section 17.30 is also issued under 38 U.S.C. 1701.
* * * * *

[[Page 24483]]

    Section 17.38 is also issued under 38 U.S.C. 1701 and 1703.
* * * * *


0
2. Amend Sec.  17.30 by:
0
a. Revising paragraphs (a) introductory text and (a)(1);
0
b. Redesignating paragraphs (a)(2) and (3) as paragraphs (a)(3) and 
(4), respectively; and
0
c. Adding new (a)(2) to read as follows:


Sec.  17.30  Definitions.

* * * * *
    (a) Medical services. The term medical services includes the 
following:
    (1) Medical examination, treatment, and rehabilitative services (as 
defined in 38 U.S.C. 1701(8)).
    (2) Surgical services, dental services and appliances as authorized 
in Sec. Sec.  17.160 through 17.166, optometric and podiatric services, 
chiropractic services, preventive health care services set forth in 38 
U.S.C. 1701(9), noninstitutional extended care, and items and services 
as authorized in Sec. Sec.  17.3200 through 17.3250.
* * * * *

0
3. Amend Sec.  17.38 by adding paragraph (a)(2)(x) to read as follows:


Sec.  17.38  Medical benefits package.

    (a) * * *
    (2) * * *
    (x) Chiropractic services.
* * * * *
[FR Doc. 2023-08298 Filed 4-20-23; 8:45 am]
BILLING CODE 8320-01-P