701 Part 17—Medical

Department of Veterans Affairs Pt. 17

§ 16.124 Conditions. 17.47 Considerations applicable in determining eligibility for hospital care, med- With respect to any research project ical services, nursing home care, or or any class of research projects the de- domiciliary care. partment or agency head of either the 17.48 Compensated Work Therapy/Transi- conducting or the supporting Federal tional Residences program. department or agency may impose ad- 17.49 Priorities for outpatient medical serv- ditional conditions prior to or at the ices and inpatient hospital care. time of approval when in the judgment of the department or agency head addi- USE OF DEPARTMENT OF DEFENSE, PUBLIC tional conditions are necessary for the HEALTH SERVICE OR OTHER FEDERAL HOS- protection of human subjects. PITALS 17.50 Use of Department of Defense, Public PART 17—MEDICAL Health Service or other Federal hospitals with beds allocated to the Department of Veterans Affairs. DEFINITIONS AND ACTIVE DUTY 17.51 Emergency use of Department of De- Sec. fense, Public Health Service or other 17.1 Incorporation by reference. Federal hospitals. 17.30 Definitions. 17.31 Duty periods defined. USE OF PUBLIC OR PRIVATE HOSPITALS

PROTECTION OF PATIENT RIGHTS 17.52 Hospital care and medical services in non-VA facilities. 17.32 Informed consent and advance direc- 17.53 Limitations on use of public or private tives. hospitals. 17.33 Patients’ rights. 17.54 [Reserved] TENTATIVE ELIGIBILITY DETERMINATIONS 17.55 Payment for authorized public or private hospital care. 17.34 Tentative eligibility determinations. 17.56 VA payment for inpatient and out- HOSPITAL OR NURSING HOME CARE AND patient health care professional services MEDICAL SERVICES IN FOREIGN COUNTRIES at non-departmental facilities and other medical charges associated with non-VA 17.35 Hospital care and outpatient services outpatient care. in foreign countries. USE OF COMMUNITY NURSING HOME CARE ENROLLMENT PROVISIONS AND MEDICAL FACILITIES BENEFITS PACKAGE 17.57 Use of community nursing homes. 17.36 Enrollment—provision of hospital and outpatient care to veterans. 17.58 Evacuation of community nursing 17.37 Enrollment not required—provision of homes. hospital and outpatient care to veterans. 17.60 Extensions of community nursing 17.38 Medical benefits package. home care beyond six months. 17.39 Certain Filipino veterans. COMMUNITY RESIDENTIAL CARE 17.40 Additional services for indigents. 17.61 Eligibility. EXAMINATIONS AND OBSERVATION AND 17.62 Definitions. EXAMINATION 17.63 Approval of community residential 17.41 Persons eligible for hospital observa- care facilities. tion and physical examination. 17.64 [Reserved] 17.42 Examinations on an outpatient basis. 17.65 Approvals and provisional approvals of community residential care facilities. HOSPITAL, DOMICILIARY AND NURSING HOME 17.66 Notice of noncompliance with VA CARE standards. 17.43 Persons entitled to hospital or domi- 17.67 Request for a hearing. ciliary care. 17.68 Notice and conduct of hearing. 17.44 Hospital care for certain retirees with 17.69 Waiver of opportunity for hearing. chronic disability (Executive Orders 17.70 Written decision following a hearing. 10122, 10400 and 11733). 17.45 Hospital care for research purposes. 17.71 Revocation of VA approval. 17.46 Eligibility for hospital, domiciliary or 17.72 Availability of information. nursing home care of persons discharged 17.73 Medical foster homes—general. or released from active military, naval, 17.74 Standards applicable to medical foster or air service. homes.

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USE OF SERVICES OF OTHER FEDERAL COPAYMENTS AGENCIES 17.108 Copayments for inpatient hospital 17.80 Alcohol and drug dependence or abuse care and outpatient medical care. treatment and rehabilitation in residen- 17.109 Presumptive eligibility for psychosis tial and nonresidential facilities by con- and mental illness other than psychosis. tract. 17.110 Copayments for medication. 17.81 Contracts for residential treatment 17.111 Copayments for extended care serv- services for veterans with alcohol or drug ices. dependence or abuse disabilities. 17.82 Contracts for outpatient services for CEREMONIES veterans with alcohol or drug dependence 17.112 Services or ceremonies on Depart- or abuse disabilities. ment of Veterans Affairs hospital or cen- 17.83 Limitations on payment for alcohol ter reservations. and drug dependence or abuse treatment and rehabilitation. REIMBURSEMENT FOR LOSS BY NATURAL DIS- ASTER OF PERSONAL EFFECTS OF HOSPITAL- RESEARCH-RELATED INJURIES IZED OR NURSING HOME PATIENTS 17.85 Treatment of research-related injuries 17.113 Conditions of custody. to human subjects. 17.114 Submittal of claim for reimburse- CARE DURING CERTAIN DISASTERS AND ment. EMERGENCIES 17.115 Claims in cases of incompetent patients. 17.86 Provision of hospital care and medical services during certain disasters and REIMBURSEMENT TO EMPLOYEES FOR THE COST emergencies under 38 U.S.C. 1785. OF REPAIRING OR REPLACING CERTAIN PER- SONAL PROPERTY DAMAGED OR DESTROYED OCATIONAL RAINING AND EALTH ARE LI V T H -C E - BY PATIENTS OR MEMBERS GIBILITY PROTECTION FOR PENSION RECIPI- ENTS 17.116 Adjudication of claims.

17.90 Medical care for veterans receiving vo- PAYMENT AND REIMBURSEMENT OF THE EX- cational training under 38 U.S.C. chapter PENSES OF MEDICAL SERVICES NOT PRE- 15. VIOUSLY AUTHORIZED 17.91 Protection of health-care eligibility. 17.120 Payment or reimbursement for emer- OUTPATIENT TREATMENT gency treatment furnished by non-VA providers to certain veterans with serv- 17.92 Outpatient care for research purposes. ice-connected disabilities. 17.93 Eligibility for outpatient services. 17.94 Outpatient medical services for mili- 17.121 Limitations on payment or reim- tary retirees and other beneficiaries. bursement of the costs of emergency 17.95 Outpatient medical services for De- treatment not previously authorized. partment of Veterans Affairs employees 17.122 Payment or reimbursement of the ex- and others in emergencies. penses of repairs to prosthetic appliances 17.96 Medication prescribed by non-VA phy- and similar devices furnished without sicians. prior authorization. 17.97 [Reserved] 17.123 Claimants. 17.98 Mental health services. 17.124 Preparation of claims. 17.125 Where to file claims. CHARGES, WAIVERS, AND COLLECTIONS 17.126 Timely filing. 17.127 Date of filing claims. 17.101 Collection or recovery by VA for med- 17.128 Allowable rates and fees. ical care or services provided or fur- 17.129 Retroactive payments prohibited. nished to a veteran for a nonservice-connected disability. 17.130 Payment for treatment dependent 17.102 Charges for care or services. upon preference prohibited. 17.103 Referrals of compromise settlement 17.131 Payment of abandoned claims prohib- offers. ited. 17.104 Terminations and suspensions. 17.132 Appeals. 17.105 Waivers. RECONSIDERATION OF DENIED CLAIMS 17.106 VA collection rules; third-party payers. 17.133 Procedures.

DISCIPLINARY CONTROL OF BENEFICIARIES RE- DELEGATION OF AUTHORITY CEIVING HOSPITAL, DOMICILIARY OR NURSING 17.142 Authority to approve sharing agree- HOME CARE ments, contracts for scarce medical spe- 17.107 VA response to disruptive behavior of cialist services and contracts for other patients. medical services.

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PROSTHETIC, SENSORY, AND REHABILITATIVE 17.252 Ex officio member of subcommittee. AIDS 17.253 Applicants for grants. 17.148 Service dogs. 17.254 Applications. 17.149 Sensori-neural aids. 17.255 Applications for grants for programs 17.150 Prosthetic and similar appliances. which include construction projects. 17.151 Invalid lifts for recipients of aid and 17.256 Amended or supplemental applica- attendance allowance or special monthly tions. compensation. 17.257 Awards procedures. 17.152 Devices to assist in overcoming the 17.258 Terms and conditions to which handicap of deafness. awards are subject. 17.153 Training in the use of appliances. 17.259 Direct costs. 17.154 Equipment for blind veterans. 17.260 Patient care costs to be excluded from direct costs. AUTOMOTIVE EQUIPMENT AND DRIVER 17.261 Indirect costs. TRAINING 17.262 Authority to approve applications 17.155 Minimum standards of safety and discretionary. quality for automotive adaptive equip- 17.263 Suspension and termination proce- ment. dures. 17.156 Eligibility for automobile adaptive 17.264 Recoupments and releases. equipment. 17.265 Payments. 17.157 Definition-adaptive equipment. 17.266 Copyrights and patents. 17.158 Limitations on assistance. 17.159 Obtaining vehicles for special driver CIVILIAN HEALTH AND MEDICAL PROGRAM OF training courses. THE DEPARTMENT OF VETERANS AFFAIRS (CHAMPVA)—MEDICAL CARE FOR SUR- DENTAL SERVICES VIVORS AND DEPENDENTS OF CERTAIN VET- 17.160 Authorization of dental examina- ERANS tions. 17.161 Authorization of outpatient dental 17.270 General provisions. treatment. 17.271 Eligibility. 17.162 Eligibility for Class II dental treat- 17.272 Benefit limitations/exclusions. ment without rating action. 17.273 Preauthorization. 17.163 Posthospital outpatient dental treat- 17.274 Cost sharing. ment. 17.275 Claim filing deadline. 17.164 Patient responsibility in making and 17.276 Appeal/review process. keeping dental appointments. 17.277 Third party liability/medical care 17.165 Emergency outpatient dental treat- cost recovery. ment. 17.278 Confidentiality of records. 17.166 Dental services for hospital or nursing home patients and domiciled mem- IN VITRO FERTILIZATION AND REIMBURSEMENT bers. OF ADOPTION EXPENSES 17.169 VA Dental Insurance Program for veterans and survivors and dependents of 17.380 In vitro fertilization treatment. veterans (VADIP). 17.390 Reimbursement for qualifying adoption expenses incurred by certain vet- AUTOPSIES erans.

17.170 Autopsies. HOSPITAL CARE AND MEDICAL SERVICES FOR CAMP LEJEUNE VETERANS AND FAMILIES VETERANS CANTEEN SERVICE 17.180 Delegation of authority. 17.400 Hospital care and medical services for Camp Lejeune veterans. SHARING OF MEDICAL FACILITIES, EQUIPMENT, AND INFORMATION HOSPITAL CARE AND MEDICAL SERVICES FOR SPOUSES AND FAMILIES 17.230 Contingency backup to the Depart- ment of Defense. 17.410 Hospital care and medical services for 17.240 Sharing health-care resources. Camp Lejeune family members. 17.241 Sharing medical information serv- 17.412 Fertility counseling and treatment ices. for certain spouses. 17.242 Coordination of programs with De- partment of Health and Human Services. AUTHORITY OF HEALTH CARE PROVIDERS TO PRACTICE IN VA GRANTS FOR EXCHANGE OF INFORMATION 17.415 Full practice authority for advanced 17.250 Scope of the grant program. practice registered nurses. 17.251 The Subcommittee on Academic Af- 17.417 Health care providers practicing via fairs. telehealth.

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CENTER FOR INNOVATION FOR CARE AND 17.632 Obligated service. PAYMENT 17.633 Deferment of obligated service. 17.634 Failure to comply with terms and 17.450 Center for Innovation for Care and conditions of participation. Payment. 17.635 Bankruptcy. CONFIDENTIALITY OF HEALTHCARE QUALITY 17.636 Cancellation, waiver, or suspension of ASSURANCE REVIEW RECORDS obligation. 17.500 General. PROGRAM FOR REPAYMENT OF EDUCATIONAL 17.501 Confidential and privileged docu- LOANS FOR CERTAIN VA PSYCHIATRISTS ments. 17.640 Purpose. 17.502 Applicability of other statutes. 17.641 Definitions. 17.503 Improper disclosure. 17.642 Eligibility. 17.504 Disclosure methods. 17.643 Application for the program for the 17.505 Disclosure authorities. repayment of educational loans. 17.506 Appeal of decision by Veterans 17.643 Application for the program for the Health Administration to deny disclo- repayment of educational loans. sure. 17.644 Selection of participants. 17.507 Employee responsibilities. 17.645 Award procedures. 17.508 Access to quality assurance records 17.646 Obligated service. and documents within the agency. 17.647 Failure to comply with terms and 17.509 Authorized disclosure: Non-Depart- conditions of participation. ment of Veterans Affairs requests. 17.510 Redisclosure. CHAPLAIN SERVICES 17.511 Penalties for violations. 17.655 Ecclesiastical endorsing organiza- VA HEALTH PROFESSIONAL SCHOLARSHIP tions. PROGRAM GRANTS FOR TRANSPORTATION OF VETERANS IN 17.600 Purpose. HIGHLY RURAL AREAS 17.601 Definitions. 17.602 Eligibility. 17.700 Purpose and scope. 17.603 Availability of HPSP scholarships. 17.701 Definitions. 17.604 Application for the HPSP. 17.702 Grants—general. 17.605 Selection of participants. 17.703 Eligibility and application. 17.606 Award procedures. 17.705 Scoring criteria and selection. 17.607 Obligated service. 17.710 Notice of Fund Availability. 17.608 Deferment of obligated service. 17.715 Grant agreements. 17.609 Pay during period of obligated serv- 17.720 Payments under the grant. ice. 17.725 Grantee reporting requirements. 17.610 Failure to comply with terms and 17.730 Recovery of funds by VA. conditions of participation. TRANSITIONAL HOUSING LOAN PROGRAM 17.611 Bankruptcy. 17.612 Cancellation, waiver, or suspension of 17.800 Purpose. obligation. 17.801 Definitions. 17.802 Application provisions. VETERANS HEALING VETERANS MEDICAL 17.803 Order of consideration. ACCESS AND SCHOLARSHIP PROGRAM 17.804 Loan approval criteria. 17.613 Purpose. 17.805 Additional terms of loans. 17.614 Definitions. HEALTH CARE BENEFITS FOR CERTAIN CHIL- 17.615 Eligibility. DREN OF VIETNAM VETERANS AND VETERANS 17.616 Award procedures. WITH COVERED SERVICE IN KOREA—SPINA 17.617 Agreement and obligated service. BIFIDA AND COVERED BIRTH DEFECTS 17.618 Failure to comply with terms and conditions of agreement. 17.900 Definitions. 17.901 Provision of health care. VISUAL IMPAIRMENT AND ORIENTATION AND 17.902 Preauthorization. MOBILITY PROFESSIONAL SCHOLARSHIP PRO- 17.903 Payment. GRAM 17.904 Review and appeal process. 17.625 Purpose. 17.905 Medical records. 17.626 Definitions. PAYMENT OR REIMBURSEMENT FOR EMERGENCY 17.627 Eligibility for the VIOMPSP. SERVICES FOR NONSERVICE-CONNECTED CON- 17.628 Availability of VIOMPSP scholar- DITIONS IN NON-VA FACILITIES ships. 17.629 Application for the VIOMPSP. 17.1000 Payment or reimbursement for 17.630 Selection of VIOMPSP participants. emergency services for nonservice-con- 17.631 Award procedures. nected conditions in non-VA facilities.

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17.1001 Definitions. AUTHORITY: 38 U.S.C. 501, and as noted in 17.1002 Substantive conditions for payment specific sections. or reimbursement. Section 17.32 also issued under 38 U.S.C. 17.1003 Emergency transportation. 7331–7334. 17.1004 Filing claims. Section 17.35 is also issued under 38 U.S.C. 17.1005 Payment limitations. 1724. 17.1006 Decisionmakers. Section 17.38 is also issued under 38 U.S.C. 17.1007 Independent right of recovery. 1703. 17.1008 Balance billing prohibited. Section 17.46 is also issued under 38 U.S.C. 1710. EXPANDED ACCESS TO NON-VA CARE THROUGH Section 17.52 is also issued under 38 U.S.C. THE VETERANS CHOICE PROGRAM 1701, 1703, 1710, 1712, and 3104. 17.1500 Purpose and scope. Section 17.55 is also issued under 38 U.S.C. 17.1505 Definitions. 513, 1703, and 1728. 17.1510 Eligible veterans. Section 17.56 is also issued under 38 U.S.C. 17.1515 Authorizing non-VA care. 1703 and 1728. 17.1520 Effect on other provisions. Sections 17.61 through 17.74 are also issued 17.1525 [Reserved] under 38 U.S.C. 1730. 17.1530 Eligible entities and providers. Section 17.105 is also issued under 38 U.S.C. 17.1535 Payment rates and methodologies. 501, 1721, 1722A, 1724, and 1725A. 17.1540 Claims processing system. Section 17.108 is also issued under 38 U.S.C. 501, 1703, 1710, 1725A, and 1730A. VET CENTERS Section 17.110 is also issued under 38 U.S.C. 17.2000 Vet Center services. 501, 1703, 1710, 1720D, 1722A, and 1730A. Section 17.111 is also issued under 38 U.S.C. HOME IMPROVEMENTS AND STRUCTURAL 101(28), 501, 1701(7), 1703, 1710, 1710B, 1720B, ALTERATIONS (HISA) PROGRAM 1720D, and 1722A. 17.3100 Purpose and scope. Section 17.125 is also issued under 38 U.S.C. 17.3101 Definitions. 7304. 17.3102 Eligibility. Section 17.169 is also issued under 38 U.S.C. 17.3103–17.3104 [Reserved] 1712C. 17.3105 HISA benefit lifetime limits. Sections 17.380, 17.390 and 17.412 are also 17.3106–17.3119 [Reserved] issued under sec. 260, Pub. L. 114–223, 130 17.3120 Application for HISA benefits. Stat. 857, and sec. 236, Public Law 115–141, 132 17.3121–17.3124 [Reserved] Stat. 348, and sec. 236, div. J, Pub. L 115–141, 17.3125 Approving HISA benefits applica- 132 Stat. 348. tions. Section 17.410 is also issued under 38 U.S.C. 17.3126 Disapproving HISA benefits applica- 1787. tions. Section 17.415 is also issued under 38 U.S.C. 17.3127–17.3129 [Reserved] 7301, 7304, 7402, and 7403. 17.3130 HISA benefits payment procedures. Section 17.417 also issued under 38 U.S.C. 1701 (note), 1709A, 1712A (note), 1722B, 7301, VETERANS COMMUNITY CARE PROGRAM 7330A, 7401–7403, 7406 (note). Section 17.450 is also issued under 38 U.S.C. 17.4000 Purpose and scope. 1703E. 17.4005 Definitions. Sections 17.613 through 17.618 are also 17.4010 Veteran eligibility. issued under Pub. L. 115–182, sec. 304. 17.4015 Designated VA medical service lines. Sections 17.640 and 17.647 are also issued 17.4020 Authorized non-VA care. under sec. 4, Pub. L. 114–2, 129 Stat. 30. 17.4025 Effect on other provisions. Sections 17.641 through 17.646 are also 17.4030 Eligible entities and providers. issued under 38 U.S.C. 501(a) and sec. 4, Pub. 17.4035 Payment rates. L. 114–2, 129 Stat. 30. 17.4040 Designated access standards. Section 17.655 also issued under 38 U.S.C. VETERANS CARE AGREEMENTS 501(a), 7304, 7405. Sections 17.4000 through 17.4040 also issued 17.4100 Definitions. under 38 U.S.C. 1703, 1703B, and 1703C. 17.4105 Purpose and scope. Section 17.4100 et seq. is also issued under 38 17.4110 Entity or provider certification. U.S.C. 1703A. 17.4115 VA use of Veterans Care Agree- Section 17.4600 is also issued under 38 ments. U.S.C. 1725A. 17.4120 Payment rates. 17.4125 Review of Veterans Care Agree- DEFINITIONS AND ACTIVE DUTY ments. 17.4130 Discontinuation of Veterans Care § 17.1 Incorporation by reference. Agreements. 17.4135 Disputes. (a) Certain materials are incor- 17.4600 Urgent care. porated by reference into this part

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with the approval of the Director of the (9) NFPA 101A, Guide on Alternative Federal Register under 5 U.S.C. 552(a) Approaches to Life Safety (2010 edi- and 1 CFR part 51. To enforce an edition), IBR approved for § 17.63. tion of a publication other than that (10) NFPA 720, Standard for the In- specified in this section, VA will pro- stallation of Carbon Monoxide (CO) De- vide notice of the change in a rule in tection and Warning Equipment (2012 the FEDERAL REGISTER and the mate- edition), IBR approved for § 17.74. rial will be made available to the pub- (Authority: 5 U.S.C. 552(a), 38 U.S.C. 501, lic. All approved materials are avail- 1721.) able for inspection at the Department [80 FR 44861, July 28, 2015] of Veterans Affairs, Office of Regula- tion Policy and Management (02REG), § 17.30 Definitions. 810 Vermont Avenue NW., Room 1068, When used in Department of Vet- Washington, DC 20420, call 202–461–4902, erans Affairs medical regulations, each or at the National Archives and of the following terms shall have the Records Administration (NARA). For meaning ascribed to it in this section: information on the availability of ap- (a) Medical services. The term medical proved materials at NARA, call (202) services includes, in addition to medical 741–6030, or go to: http:// examination, treatment, and rehabili- www.archives.gov/federallregister/ tative services: codeloflfederallregulations/ (1) Surgical services, dental services ibrllocations.html. and appliances as authorized in §§ 17.160 (b) National Fire Protection Associa- through 17.166, optometric and tion, 1 Batterymarch Park, Quincy, podiatric services, (in the case of a per- MA 02269. (For ordering information, son otherwise receiving care or services call toll-free 1–800–344–3555). under this chapter) the preventive (1) NFPA 10, Standard for Portable health care services set forth in 38 Fire Extinguishers (2010 edition), Incor- U.S.C. 1701(9), noninstitutional ex- poration by Reference (IBR) approved tended care, wheelchairs, artificial limbs, trusses and similar appliances, for §§ 17.63, 17.74, and 17.81. special clothing made necessary by the (2) NFPA 13, Standard for the Instal- wearing of prosthetic appliances, and lation of Sprinkler Systems (2010 edi- such other supplies or services as are tion), IBR approved for § 17.74. medically determined to be reasonable (3) NFPA 13D, Standard for the In- and necessary. stallation of Sprinkler Systems in One- and Two-Family Dwellings and Manu- (Authority: 38 U.S.C. 1701(6)(A)(i)) factured Homes (2010 edition), IBR ap- (2) Consultation, professional coun- proved for § 17.74. seling, marriage and family counseling, (4) NFPA 13R, Standard for the In- training, and mental health services stallation of Sprinkler Systems in Res- for the members of the immediate fam- idential Occupancies Up To and Includ- ily or legal guardian of the veteran or ing Four Stories in Height (2010 edi- the individual in whose household the tion), IBR approved for § 17.74. veteran certifies an intention to live, (5) NFPA 25, Standard for the Inspec- as necessary in connection with the tion, Testing, and Maintenance of veteran’s treatment. Water-Based Fire Protection Systems (3) Transportation and incidental ex- (2011 edition), IBR approved for § 17.74. penses for any person entitled to such (6) NFPA 30, Flammable and Combus- benefits under the provisions of § 70.10 tible Liquids Code (2012 edition), IBR of this chapter. approved for § 17.74. (7) NFPA 72, National Fire Alarm and (Authority: 38 U.S.C. 1701(6)) Signaling Code (2010 edition), IBR ap- (b) Domiciliary care. The term domi- proved for § 17.74. ciliary care— (8) NFPA 101, Life Safety Code (2012 (1) Means the furnishing of: edition), IBR approved for §§ 17.63, 17.74 (i) A temporary home to a veteran, (chapters 1 through 11, 24, and section embracing the furnishing of shelter, 33.7), 17.81, and 17.82. food, clothing and other comforts of

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home, including necessary medical Geodetic Survey or the Environmental services; or Science Services Administration, dur- (ii) A day hospital program con- ing the following dates: sisting of intensive supervised rehabili- (i) On or after July 29, 1945; tation and treatment provided in a (ii) Before July 29, 1945, under the fol- therapeutic residential setting for resi- lowing circumstances: dents with mental health or substance (A) While on transfer to one of the use disorders, and co-occurring medical Armed Forces; or psychosocial needs such as home- (B) While, in time of war or national lessness and unemployment. emergency declared by the President, (2) Includes travel and incidental ex- assigned to duty on a project for one of penses pursuant to § 70.10. the Armed Forces in an area deter- (Authority: 38 U.S.C. 1701(4)) mined by the Secretary of Defense to be of immediate military hazard; or [23 FR 6498, Aug. 22, 1958] (C) In the Philippine Islands on De- EDITORIAL NOTE: For FEDERAL REGISTER ci- cember 7, 1941, and continuously in tations affecting § 17.30, see the List of CFR such islands thereafter; or Sections Affected, which appears in the (4) Service as a cadet at the U.S. Finding Aids section of the printed volume Military, Air Force, or Coast Guard and at www.govinfo.gov. Academy, or as a midshipman at the § 17.31 Duty periods defined. U.S. Naval Academy. (5) Service in Women’s Army Auxil- Definitions of duty periods applicable iary Corps (WAAC). Recognized effec- to eligibility for medical benefits are tive March 18, 1980. as follows: (a) Active military, naval, or air service (6) Service of any person in a group includes: the members of which rendered service (1) Active duty. to the Armed Forces of the United (2) Any period of active duty for States in a capacity considered civilian training during which the individual employment or contractual service at was disabled from a disease or injury the time such service was rendered, if incurred or aggravated in line of duty. the Secretary of Defense: (3) Any period of inactive duty train- (i) Determines that the service of ing during which the individual was such group constituted active military disabled from an injury incurred or ag- service; and gravated in line of duty. (ii) Issues to each member of such (4) Any period of inactive duty train- group a discharge from such service ing during which the individual was under honorable conditions where the disabled from an acute myocardial in- nature and duration of the service of farction, a cardiac arrest, or a cerebro- such member so warrants. vascular accident which occurred dur- (7) Service in American Merchant ing such period of inactive duty train- Marine in Oceangoing Service any time ing. during the period December 7, 1941, to (b) Active duty means: August 15, 1945. Recognized effective (1) Full-time duty in the Armed January 19, 1988. Forces, other than active duty for (8) Service by the approximately 50 training. Chamorro and Carolinian former native (2) Full-time duty, other than for policemen who received military train- training purposes, as a commissioned ing in the Donnal area of central officer of the Regular or Reserve Corps Saipan and were placed under the com- of the Public Health Service during the mand of Lt. Casino of the 6th Provi- following dates: sional Military Police Battalion to ac- (i) On or after July 29, 1945; company U.S. Marines on active, com- (ii) Before July 29, 1945, under cir- bat-patrol activity any time during the cumstances affording entitlement to period August 19, 1945, to September 2, full military benefits; or 1945. Recognized effective September (3) Full-time duty as a commissioned 30, 1999. officer of the National Oceanic and At- (9) Service by Civilian Crewmen of mospheric Administration or its prede- the U.S. Coast and Geodetic Survey cessor organizations, the Coast and (USCGS) vessels, who performed their

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service in areas of immediate military with the American Expeditionary hazard while conducting cooperative Forces in World War II. Recognized ef- operations with and for the U.S. Armed fective January 22, 1981. Forces any time during the period De- (20) Service by Quartermaster Corps cember 7, 1941, to August 15, 1945. Keswick Crew on Corregidor (World Qualifying USCGS vessels specified by War II). Recognized effective February the Secretary of the Air Force are the 7, 1984. Derickson, Explorer, Gilbert, Hilgard, (21) Service by Reconstruction Aides E. Lester Jones, Lydonia, Patton, Sur- and Dietitians in World War I. Recog- veyor, Wainwright, Westdahl, Oceanog- nized effective July 6, 1981. rapher, Hydrographer, or Pathfinder. (22) Service by Signal Corps Female Recognized effective April 8, 1991. Telephone Operators Unit of World War (10) Service by Civilian Employees of I. Recognized effective May 15, 1979. Pacific Naval Air Bases who actively (23) Service by three scouts/guides, participated in Defense of Wake Island Miguel Tenorio, Penedicto Taisacan, during World War II. Recognized effec- and Cristino Dela Cruz, who assisted tive January 22, 1981. the U.S. Marines in the offensive oper- (11) Service by Civilian Navy Identi- ations against the Japanese on the fication Friend or Foe (IFF) Techni- Northern Mariana Islands from June cians who served in the Combat Areas 19, 1944, through September 2, 1945. of the Pacific any time during the pe- Recognized effective September 30, riod December 7, 1941, to August 15, 1999. 1945. Recognized effective August 2, (24) Service by U.S. civilian employ- 1988. ees of American Airlines who served (12) Service by Civilian personnel as- overseas as a result of American Air- signed to the Secret Intelligence Ele- lines’ Contract with the Air Transport ment of the Office of Strategic Services Command any time during the period (OSS). Recognized effective December December 14, 1941, to August 14, 1945. 27, 1982. Recognized effective October 5, 1990. (13) Service by Engineer Field Clerks (25) Service by U.S. civilian female (World War I). Recognized effective Au- employees of the U.S. Army Nurse gust 31, 1979. Corps while serving in the Defense of (14) Service by Guam Combat Patrol. Bataan and Corregidor any time during Recognized effective May 10, 1983. the period January 2, 1942, to February (15) Service by Honorably discharged 3, 1945. Recognized effective December members of the American Volunteer 13, 1993. Group (Flying Tigers) who served any (26) Service by U.S. Civilian Flight time during the period December 7, Crew and Aviation Ground Support 1941, to July 18, 1942. Recognized effec- Employees of Braniff Airways, who tive May 3, 1991. served overseas in the North Atlantic (16) Service by Honorably discharged or under the jurisdiction of the North members of the American Volunteer Atlantic Wing, Air Transport Com- Guard, Eritrea Service Command who mand (ATC), as a result of a Contract served any time during the period June with the ATC any time during the pe- 21, 1942, to March 31, 1943. Recognized riod February 26, 1942, to August 14, effective June 29, 1992. 1945. Recognized effective June 2, 1997. (17) Service by Male Civilian Ferry (27) Service by U.S. Civilian Flight Pilots. Recognized effective July 17, Crew and Aviation Ground Support 1981. Employees of Consolidated Vultree (18) Service with the Operational Aircraft Corporation (Consairway Divi- Analysis Group of the Office of Sci- sion), who served overseas as a result entific Research and Development, Of- of a Contract with the Air Transport fice of Emergency Management, which Command any time during the period served overseas with the U.S. Army Air December 14, 1941, to August 14, 1945. Corps any time during the period De- Recognized effective June 29, 1992. cember 7, 1941, to August 15, 1945. Rec- (28) Service by U.S. Flight Crew and ognized effective August 27, 1999. Aviation Ground Support Employees of (19) Service by Quartermaster Corps Northeast Airlines Atlantic Division, Female Clerical Employees serving who served overseas as a result of

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Northeast Airlines’ Contract with the (36) Service by U.S. Merchant Sea- Air Transport Command any time dur- men who served on blockships in sup- ing the period December 7, 1941, to Au- port of Operation Mulberry. Recognized gust 14, 1945. Recognized effective June effective October 18, 1985. 2, 1997. (37) Service by Wake Island Defend- (29) Service by U.S. Civilian Flight ers from Guam. Recognized effective Crew and Aviation Ground Support April 7, 1982. Employees of Northwest Airlines, who (38) Service by Women’s Air Forces served overseas as a result of North- Service Pilots (WASP). Recognized ef- west Airlines’ Contract with the Air fective November 23, 1977. Transport Command any time during (39) Service by persons who were in- the period December 14, 1941, to August jured while providing aerial transpor- 14, 1945. Recognized effective December tation of mail and serving under condi- 13, 1993. tions set forth in Public Law 73–140. (30) Service by U.S. Civilian Flight (40) Service in the Alaska Territorial Crew and Aviation Ground Support Guard during World War II, for any Employees of Pan American World Air- person who the Secretary of Defense ways and its Subsidiaries and Affili- determines was honorably discharged. ates, who served overseas as a result of (41) Service by Army field clerks. Pan American’s Contract with the Air (42) Service by Army Nurse Corps, Transport Command and Naval Air Navy Nurse Corps, and female dietetic Transport Service any time during the and physical therapy personnel as fol- period December 14, 1941, to August 14, lows: 1945. Recognized effective July 16, 1992. (i) Female Army and Navy nurses on (31) Service by U.S. Civilian Flight active service under order of the serv- Crew and Aviation Ground Support ice department; or Employees of Transcontinental and (ii) Female dietetic and physical Western Air (TWA), Inc., who served therapy personnel, excluding students overseas as a result of TWA’s Contract and apprentices, appointed with rel- with the Air Transport Command any ative rank after December 21, 1942, or time during the period December 14, commissioned after June 21, 1944. 1941, to August 14, 1945. The ‘‘Flight (43) Service by students who were en- Crew’’ includes pursers. Recognized ef- listed men in Aviation camps during fective May 13, 1992. World War I. (32) Service by U.S. Civilian Flight (44) Active service in the Coast Guard Crew and Aviation Ground Support after January 28, 1915, while under the Employees of United Air Lines (UAL), jurisdiction of the Treasury Depart- who served overseas as a result of ment, the Navy Department, the De- UAL’s Contract with the Air Transport partment of Transportation, or the De- Command any time during the period partment of Homeland Security. This December 14, 1941, to August 14, 1945. does not include temporary members of Recognized effective May 13, 1992. the Coast Guard Reserves. (33) Service by U.S. civilian volun- (45) Service by contract surgeons if teers who actively participated in the the disability was the result of injury Defense of Bataan. Recognized effec- or disease contracted in the line of tive February 7, 1984. duty during a period of war while actu- (34) Service by U.S. civilians of the ally performing the duties of assistant American Field Service (AFS) who surgeon or acting assistant surgeon served overseas operationally in World with any military force in the field, or War I any time during the period Au- in transit, or in a hospital. gust 31, 1917, to January 1, 1918. Recog- (46) Service by field clerks of the nized effective August 30, 1990. Quartermaster Corps. (35) Service by U.S. civilians of the (47) Service by lighthouse service American Field Service (AFS) who personnel who were transferred to the served overseas under U.S. Armies and service and jurisdiction of the War or U.S. Army Groups in World War II any Navy Departments by Executive Order time during the period December 7, under the Act of August 29, 1916. Effec- 1941, to May 8, 1945. Recognized effective July 1, 1939, service was consoli- tive August 30, 1990. dated with the Coast Guard.

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(48) Service by male nurses who were (57) Attendance at the preparatory enlisted in a Medical Corps. schools of the United States Air Force (49) Service by persons having a pen- Academy, the United States Military sionable or compensable status before Academy, or the United States Naval January 1, 1959. Academy for enlisted active duty mem- (50) Service by a Commonwealth bers who are reassigned to a pre- Army veteran or new Philippine Scout, paratory school without a release from as defined in 38 U.S.C. 1735, who resides active duty, and for other individuals in the United States and is a citizen of who have a commitment to active duty the United States or an alien lawfully in the Armed Forces that would be admitted to the United States for per- binding upon disenrollment from the manent residence; service by Regular preparatory school. Philippine Scouts and service in the In- (58) For purposes of providing med- sular Force of the Navy, Samoan Na- ical care under chapter 17 for a service- tive Guard, or Samoan Native Band of connected disability, service by any the Navy. person who has suffered an injury or (51) Service with the Revenue Cutter contracted a disease in line of duty Service while serving under direction while en route to or from, or at, a place of the Secretary of the Navy in co- for final acceptance or entry upon ac- operation with the Navy. Effective tive duty and: (i) Who has applied for enlistment or January 28, 1915, the Revenue Cutter enrollment in the active military, Service was merged into the Coast naval, or air service and has been pro- Guard. visionally accepted and directed or or- (52) Service during World War I in the dered to report to a place for final ac- Russian Railway Service Corps as cer- ceptance into such service; tified by the Secretary of the Army. (ii) Who has been selected or drafted (53) Service by members of training for service in the Armed Forces and camps authorized by section 54 of the has reported pursuant to the call of the National Defense Act (Pub. L. 64–85, 39 person’s local draft board and before Stat. 166), except for members of Stu- rejection; or dent Army Training Corps Camps at (iii) Who has been called into the the Presidio of San Francisco; Federal service as a member of the Na- Plattsburg, New York; Fort Sheridan, tional Guard, but has not been enrolled Illinois; Howard University, Wash- for the Federal service. ington, DC; Camp Perry, Ohio; and Note to paragraph (b)(58): The injury Camp Hancock, Georgia, from July 18, or disease must be due to some factor 1918, to September 16, 1918. relating to compliance with proper or- (54) Service in the Women’s Army ders. Draftees and selectees are in- Corps (WAC) after June 30, 1943. cluded when reporting for preinduction (55) Service in the Women’s Reserve examination or for final induction on of the Navy, Marine Corps, and Coast active duty. Such persons are not in- Guard. cluded for injury or disease suffered (56) Effective July 28, 1959, service by during the period of inactive duty, or a veteran who was discharged for period of waiting, after a final physical alienage during a period of hostilities examination and prior to beginning the unless evidence affirmatively shows trip to report for induction. Members the veteran was discharged at his or of the National Guard are included her own request. A veteran who was when reporting to a designated ren- discharged for alienage after a period dezvous. of hostilities and whose service was (59) Authorized travel to or from such honest and faithful is not barred from duty or service, as described in this benefits if he or she is otherwise enti- section. tled. A discharge changed prior to Jan- (60) The period of time immediately uary 7, 1957, to honorable by a board es- following the date an individual is dis- tablished under 10 U.S.C. 1552 and 1553 charged or released from a period of ac- will be considered as evidence that the tive duty, as determined by the Sec- discharge was not at the alien’s re- retary concerned to have been required quest. for that individual to proceed to that

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individual’s home by the most direct (iv) The itinerary; route, and in any event until midnight (v) The manner in which the travel of the date of such discharge or release. was performed; and (c) Active duty for training means: (vi) The immediate cause of dis- (1) Full-time duty in the Armed ability. Forces performed by Reserves for (NOTE TO PARAGRAPH (C)(6): Active training purposes. duty for training does not include duty (2) Full-time duty for training pur- performed as a temporary member of poses performed as a commissioned of- the Coast Guard Reserve.) ficer of the Reserve Corps of the Public (d) Inactive duty training means: Health service during the period cov- (1) Duty (other than full-time duty) ered in paragraph (b)(2) of this section. prescribed for Reserves (including com- (3) In the case of members of the missioned officers of the Reserve Corps Army National Guard or Air National of the Public Health Service) by the Guard of any State, full-time duty Secretary concerned under section 206, under sections 316, 502, 503, 504, or 505 of title 37 U.S.C., or any other provision title 32 U.S.C., or the prior cor- of law; responding provisions of law. (2) Special additional duties author- (4) Duty performed by a member of a ized for Reserves (including commis- Senior Reserve Officers’ Training Corps sioned officers of the Reserve Corps of program when ordered to such duty for the Public Health Service) by an au- the purpose of training or a practice thority designated by the Secretary cruise under chapter 103 of title 10 concerned and performed by them on a U.S.C. for a period of not less than four voluntary basis in connection with the weeks and which must be completed by prescribed training or maintenance ac- the member before the member is com- tivities of the units to which they are missioned. assigned. (5) Attendance at the preparatory (3) Duty (other than full-time duty) schools of the United States Air Force for members of the National Guard or Academy, the United States Military Air National Guard of any State under Academy, or the United States Naval the provisions of law stated in para- Academy by an individual who enters graph (c)(3) of this section. the preparatory school directly from (4) Training (other than active duty the Reserves, National Guard or civil- for training) by a member of, or appli- ian life, unless the individual has a cant for membership (as defined in 5 commitment to service on active duty U.S.C. 8140(g)) in, the Senior Reserve which would be binding upon Officers’ Training Corps prescribed disenrollment from the preparatory under chapter 103 of title 10 U.S.C. school. (5) Inactive duty for training does (6) Authorized travel to or from such not include work or study performed in duty as described in paragraph (c) of connection with correspondence this section if an individual, when au- courses, or attendance at an edu- thorized or required by competent au- cational institution in an inactive sta- thority, assumes an obligation to per- tus, or duty performed as a temporary form active duty for training and is member of the Coast Guard Reserve. disabled from an injury, acute myocar- (6) Travel to or from such duty as de- dial infarction, a cardiac arrest, or a scribed in this paragraph (d) if an indi- cerebrovascular accident incurred vidual, when authorized or required by while proceeding directly to or return- competent authority, assumes an obli- ing directly from such active duty for gation to perform inactive duty train- training. Authorized travel should take ing and is disabled from an injury, into account: acute myocardial infarction, a cardiac (i) The hour on which such individual arrest, or a cerebrovascular accident began so to proceed or to return; incurred while proceeding directly to (ii) The hour on which such indi- or returning directly from such inac- vidual was scheduled to arrive for, or tive duty training. Authorized travel on which such individual ceased to per- should take into account: form, such duty; (i) The hour on which such individual (iii) The method of travel employed; began so to proceed or to return;

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(ii) The hour on which such indi- rective document that is legally recog- vidual was scheduled to arrive for, or nized by a state. The validity of state- on which such individual ceased to per- authorized advance directives is deter- form, such duty; mined pursuant to applicable state law. (iii) The method of travel employed; For the purposes of this section, ‘‘ap- (iv) The itinerary; plicable state law’’ means the law of (v) The manner in which the travel the state where the advance directive was performed; and was signed, the state where the patient (vi) The immediate cause of dis- resided when the advance directive was ability. signed, the state where the patient now resides, or the state where the patient (Authority: 38 U.S.C. 101, 106, 501, 1734 and 1735.) is receiving treatment. VA will resolve any conflict between those state laws [34 FR 9339, June 13, 1969, as amended at 45 regarding the validity of the advance FR 6934, Jan. 31, 1980; 45 FR 43169, June 26, directive by following the law of the 1980; 48 FR 56580, Dec. 22, 1983; 61 FR 21965, May 13, 1996; 75 FR 54497, Sept. 8, 2010; 78 FR state that gives effect to the wishes ex- 78260, Dec. 26, 2013] pressed by the patient in the advance directive. PROTECTION OF PATIENT RIGHTS (v) Department of Defense (DoD) advance medical directive. A DoD advance § 17.32 Informed consent and advance medical directive is executed for mem- directives. bers of the armed services or military (a) Definitions. The following defini- dependents pursuant to 10 U.S.C. 1044C. tions are applicable for purposes of this It may include a durable power of at- section: torney for health care or a living will. Advance directive. A written state- Federal law exempts such advance di- ment by a person who has decision- rectives from any requirement of form, making capacity regarding preferences substance, formality, or recording that about future health care decisions if is provided for under the laws of an in- that person becomes unable to make dividual state. Federal law requires those decisions, in any of the following: that this type of advance directive be (i) Durable power of attorney for health given the same legal effect as an ad- care. A durable power of attorney for vance directive prepared and executed health care (DPAHC) is a type of ad- in accordance with the laws of the vance directive in which an individual state concerned. designates another person as an agent (vi) VA Advance Directive. A VA Ad- to make health care decisions on the vance Directive is completed on a form individual’s behalf. specified by VA. In VA, this form can (ii) Living will. A living will is a type be used by patients to designate a of advance directive in which an indi- health care agent and to document vidual documents personal preferences treatment preferences, including med- regarding future treatment options. A ical care, surgical care, and mental living will typically includes pref- health care. erences about life-sustaining treat- Close friend. Any person eighteen ment, but it may also include pref- years or older who has shown care and erences about other types of health concern for the welfare of the patient, care. who is familiar with the patient’s ac- (iii) Mental health (or psychiatric) ad- tivities, health, religious beliefs and vance directive. A mental health or psy- values, and who has presented a signed chiatric advance directive is executed written statement for the record that by patients whose future decision-mak- describes that person’s relationship to ing capacity is at risk due to mental and familiarity with the patient. illness. In this type of directive, the in- Decision-making capacity. The ability dividual indicates future mental health to understand and appreciate the na- treatment preferences. ture and consequences of health care (iv) State-authorized advance directive. treatment decisions, and the ability to A state-authorized advance directive is formulate a judgment and commu- a non-VA DPAHC, living will, mental nicate a clear decision concerning health directive, or other advance di- health care treatments

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Health care agent. An individual procedure may be performed without named by the patient in a durable the prior, voluntary informed consent power of attorney for health care of the patient. (DPAHC) to make health care decisions (1) In order to give informed consent, on the patient’s behalf, including deci- the patient must have decision-making sions regarding the use of life-sus- capacity. taining treatments, when the patient (2) In the event that the patient can no longer do so. lacks decision-making capacity, the re- Legal guardian. A person appointed quirements of this section are applica- by a court of appropriate jurisdiction ble to consent for treatments or proce- to make decisions, including medical dures obtained from a surrogate acting decisions, for an individual who has on behalf of the patient. been judicially determined to be in- (c) General requirements for informed competent. consent. Informed consent is the proc- Practitioner. A practitioner is any ess by which the practitioner discloses physician, dentist, or health care pro- to and discusses appropriate informa- fessional granted specific clinical privi- tion with a patient so that the patient leges to perform the treatment or pro- may make a voluntary choice about cedure. The term practitioner also in- whether to accept the proposed diag- cludes: nostic or therapeutic procedure or (i) Medical and dental residents, recourse of treatment. Appropriate infor- gardless of whether they have been mation is information that a reason- granted specific clinical privileges; and able person in the patient’s situation (ii) Other health care professionals would expect to receive in order to whose scope of practice agreement or make an informed choice about wheth- other formal delineation of job respon- er or not to undergo the treatment or sibility specifically permits them to procedure. (Appropriate information obtain informed consent, and who are includes tests that yield information appropriately trained and authorized that is extremely sensitive or that may to perform the procedure or to provide have a high risk of significant con- the treatment for which consent is sequence (e.g., physical, social, psycho- being obtained. logical, legal, or economic) that a rea- Signature consent. The documentation sonable person would want to know of informed consent with the signature and consider as part of his or her con- of the patient or surrogate and practi- sent decision.) The specific information tioner on a form prescribed by VA for and level of detail required will vary that purpose. depending on the nature of the treat- State-authorized portable orders. Spe- ment or procedure. cialized forms or identifiers (e.g., Do (1) The informed consent discussion Not Attempt Resuscitation (DNAR) should be conducted in person with the bracelets or necklaces) authorized by patient whenever practical. If it is im- state law or a state medical board or practical to conduct the discussion in association, that translate a patient’s person, or the patient expresses a pref- preferences with respect to life-sus- erence for communication through an- taining treatment decisions into stand- other modality, the discussion may be ing portable medical orders. conducted by telephone, through video Surrogate. An individual authorized conference, or by other VA-approved under this section to make health care electronic communication methods. decisions on behalf of a patient who (2) The practitioner must explain in lacks decision-making capacity. The language understandable to the patient term includes a health care agent, each of the following, as appropriate to legal guardian, next-of-kin, or close the treatment or procedure in ques- friend. tion: The nature of the proposed proce- (b) Informed consent. Patients receiv- dure or treatment; expected benefits; ing health care from VA have the right reasonably foreseeable associated to accept or refuse any medical treat- risks, complications or side effects; ment or procedure recommended to reasonable and available alternatives; them. Except as otherwise provided in and anticipated results if nothing is this section, no medical treatment or done.

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(3) The patient must be given the op- procedures that meet any of the fol- portunity to ask questions, to indicate lowing criteria: comprehension of the information pro- (i) Require the use of sedation; vided, and to grant or withhold consent (ii) Require anesthesia or narcotic freely without coercion. analgesia; (4) The practitioner must advise the (iii) Are considered to produce sig- patient if the proposed treatment is nificant discomfort to the patient; novel or unorthodox. (iv) Have a significant risk of com- (5) The patient may withhold or re- plication or morbidity; or voke consent at any time. (v) Require injections of any sub- (6) The practitioner may delegate to stance into a joint space or body cav- other trained personnel responsibility ity. for providing the patient with clinical (3) Consent for treatments and proce- information needed for the patient to dures that require signature consent make a fully informed consent decision must be documented in the health but must personally verify with the pa- record on a form prescribed by VA for tient that the patient has been appro- that purpose, or as otherwise specified priately informed and voluntarily con- in this paragraph (d). sents to the treatment or procedure. (i) If the patient or surrogate is un- (7) Practitioners may provide nec- able to execute a signature on the form essary medical care in emergency situ- due to a physical impairment, the pa- ations without the express consent of tient or surrogate may, in lieu of a sig- the patient when all of the following nature, sign the consent form with an apply: ‘‘X’’, thumbprint, or stamp. Two adult (i) Immediate medical care is nec- witnesses must witness the act of sign- essary to preserve life or prevent seri- ing and sign the consent form. By sign- ous impairment of the health of the pa- ing, the witnesses are attesting only to tient. the fact that they saw the patient or (ii) The patient is unable to consent. surrogate sign the form. As an alter- (iii) The practitioner determines that native to such a patient or surrogate the patient has no surrogate or that using a duly witnessed ‘‘X’’, thumb- waiting to obtain consent from the sur- print, or stamp to sign the form, a des- rogate would increase the hazard to the ignated third party may sign the form life or health of the patient. if acting at the direction of the patient (d) Documentation of informed consent. or surrogate and in the presence of the (1) The informed consent process must patient or surrogate. The signed form be appropriately documented in the must be filed in the patient’s health health record. For treatments and pro- record. cedures that are low risk and within (ii) A properly executed VA-author- broadly accepted standards of medical ized consent form is valid for a period practice, a progress note describing the of 60 calendar days. If, however, the clinical encounter and the treatment treatment plan involves multiple plan are sufficient to document that treatments or procedures, it will not be informed consent was obtained for such necessary to repeat the informed con- treatments or procedures. For tests sent discussion and documentation so that provide information that is ex- long as the course of treatment pro- tremely sensitive or that may have a ceeds as planned, even if treatment ex- high risk of significant consequences tends beyond the 60-day period. If there (e.g., physical, social, psychological, is a change in the patient’s condition legal, or economic) that a patient that might alter the diagnostic or might reasonably want to consider as therapeutic decision about upcoming part of the consent decision, the health or continuing treatment, the practi- record must specifically document that tioner must initiate a new informed the patient or surrogate consented to consent process and, if needed, com- the specific test. plete a new signature consent form (2) The patient’s and practitioner’s with the patient. signature on a form prescribed by VA (iii) When signature consent is re- for that purpose is required for all di- quired, but it is not practicable to ob- agnostic and therapeutic treatments or tain the signature in person following

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the informed consent discussion, a must be based on the patient’s best in- signed VA consent form transmitted by terest. mail, facsimile, in by secure electronic (2) Consent for a patient without a sur- mail, or other VA-approved modalities rogate. (i) If none of the surrogates list- and scanned into the record, is ade- ed in paragraph (e)(1) of this section is quate to proceed with treatment or available, a practitioner may either re- procedure. quest the assistance of District Chief (iv) When signature consent is re- Counsel to obtain a legal guardian for quired, but it is not practicable to ob- health care or follow the procedures tain the signed consent form, the in- outlined in paragraph (e)(2)(ii) of this formed consent conversation conducted section. by telephone or video conference must (ii) Facilities may use the following be audiotaped, videotaped, or witnessed process to make treatment decisions by a second VA employee in lieu of the for patients who lack decision-making signed consent form. The practitioner capacity and have no surrogate. must document the details of the con- (A) For treatments and procedures versation in the medical record. If that involve minimal risk, the practi- someone other than the patient is giv- tioner must verify that no authorized ing consent, the name of the person surrogate can be located, or that the giving consent and the authority of surrogate is not available. The practi- that person to act as surrogate must be tioner must attempt to explain the na- adequately identified in the medical ture and purpose of the proposed treat- record. ment to the patient and enter this in- (e) Patients who lack decision-making formation in the health record. capacity—(1) Identifying a surrogate deci- (B) For procedures that require sig- sion maker. If the practitioner who has nature consent, the practitioner must primary responsibility for the patient certify that the patient has no surrogate to the best of their knowledge. determines that the patient lacks deci- The attending physician and the Chief sion-making capacity and is unlikely of Service (or designee) must indicate to regain it within a reasonable period their approval of the treatment deci- of time, informed consent must be ob- sion in writing. Any decision to with- tained from the surrogate. Patients hold or withdraw life-sustaining treat- who are incapable of giving consent as ment for such patients must be re- a matter of law will be deemed to lack viewed by a multi-disciplinary com- decision-making capacity for the pur- mittee appointed by the facility Direc- poses of this section. tor, unless the patient has valid stand- (i) The following persons are author- ing orders regarding life-sustaining ized to act as a surrogate to consent on treatment, such as state-authorized behalf of a patient who lacks decision- portable orders. The committee func- making capacity in the following order tions as the patient’s advocate and of priority: may not include members of the treat- (A) Health care agent; ment team. The committee must sub- (B) Legal guardian; mit its findings and recommendations (C) Next-of-kin: a close relative of in a written report to the Chief of Staff the patient eighteen years of age or who must note his or her approval of older in the following priority: Spouse, the report in writing. The facility Di- child, parent, sibling, grandparent, or rector must be informed about the case grandchild; or and results of the review and may con- (D) Close friend. cur with the decision to withhold or (ii) A surrogate generally assumes withdraw life-sustaining treatment, the same rights and responsibilities as delegate final decision-making author- the patient in the informed consent ity to the facility Chief of Staff, or re- process. The surrogate’s decision must quest further review by District Chief be based on his or her knowledge of Counsel. what the patient would have wanted; (f) Special consent situations. (1) In the that is, substituted judgment, or, if the case of involuntarily committed pa- patient’s specific values and wishes are tients where the forced administration unknown, the surrogate’s decision of psychotropic medication is against

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the will of a patient (or the surrogate law, VA policy, or generally accepted does not consent), the following proce- standards of medical practice. dural protections must be provided: (2) Signing and witness requirements. (i) The patient or surrogate must be (i) A VA Advance Directive must be allowed to consult with independent signed by the patient. If the patient is specialists, legal counsel or other in- unable to sign a VA Advance Directive terested parties concerning the treat- due to a physical impairment, the pa- ment with psychotropic medication. tient may sign the advance directive Any recommendation to administer or form with an ‘‘X’’, thumbprint, or continue medication must be reviewed stamp. In the alternative, the patient by a multi-disciplinary committee ap- may designate a third party to sign the pointed by the facility Director for this directive at the direction of the patient purpose. and in the presence of the patient. (ii) The multi-disciplinary committee (ii) In all cases, a VA Advance Direc- must include a psychiatrist or a physi- tive must be signed by the patient in cian who has psychopharmacology the presence of both witnesses. Wit- privileges. The facility Director must nesses to the patient’s signing of an ad- concur with the committee’s rec- vance directive are attesting by their ommendation to administer psycho- signatures only to the fact that they tropic medications contrary to the pa- saw the patient or designated third tient’s or surrogate’s wishes. party sign the VA Advance Directive form. Neither witness may, to the wit- (iii) Continued administration of psy- ness’ knowledge, be named as a bene- chotropic medication must be reviewed ficiary in the patient’s estate, ap- every 30 days. The patient (or a rep- pointed as health care agent in the ad- resentative on the patient’s behalf) vance directive, or financially respon- may appeal the treatment decision to a sible for the patient’s care. Nor may a court of appropriate jurisdiction. witness be the designated third party (2) The patient must be informed if a who has signed the VA Advance Direc- proposed course of treatment or proce- tive form at the direction of the pa- dure involves approved medical re- tient and in the patient’s presence. search in whole or in part. If so, the pa- (3) Instructions in critical situations. In tient’s separate informed consent must certain situations, a patient with deci- be obtained for the components that sion-making capacity may present for constitute research pursuant to the in- care when critically ill and loss of deci- formed consent requirements for sion-making capacity is imminent. In human-subjects research set forth in such situations, VA will document the part 16 of this title. patient’s unambiguous verbal or non- (g) Advance directives—(1) General. To verbal instructions regarding pref- the extent consistent with applicable erences for future health care deci- Federal law, VA policy, and generally sions. These instructions will be hon- accepted standards of medical practice, ored and given effect should the pa- VA will follow the wishes of a patient tient lose decision-making capacity be- expressed in a valid advance directive fore being able to complete a new ad- when the practitioner determines and vance directive. The patient’s instruc- documents in the patient’s health tions must have been expressed to at record that the patient lacks decision- least two members of the health care making capacity and is unlikely to re- team. To confirm that the verbal or gain it within a reasonable period of non-verbal instructions of the patient time. An advance directive that is are, in fact, unambiguous, the sub- valid in one or more states under appli- stance of the patient’s instructions and cable law, including a mental health the names of at least two members of (or psychiatric) advance directive, a the health care team to whom they valid Department of Defense advance were expressed must be entered in the medical directive, or a valid VA Ad- patient’s electronic health record. vance Directive will be recognized (4) Revocation. A patient who has de- throughout the VA health care system, cision-making capacity may revoke an except for components therein that are advance directive or instructions in a inconsistent with applicable Federal critical situation at any time by using

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any means expressing the intent to re- (vi) The right to hold a professional, voke. occupational, or vehicle operator’s li- (5) VA policy and disputes. Neither the cense. treatment team nor surrogate may (b) Residents and inpatients. Subject override a patient’s clear instructions to paragraphs (c) and (d) of this sec- in an advance directive or in instruction, patients admitted on a residential tions given in a critical situation, ex- or inpatient care basis to the Depart- cept that those portions of an advance ment of Veterans Affairs medical care directive or instructions given in a system have the following rights: critical situation that are not con- (1) Visitations and communications. sistent with applicable Federal law, VA Each patient has the right to commu- policy, or generally accepted standards nicate freely and privately with per- of medical practice will not be given ef- sons outside the facility, including gov- fect. ernment officials, attorneys, and cler- gymen. To facilitate these communica- (The information collection requirements in tions each patient shall be provided the this section have been approved by the Office opportunity to meet with visitors dur- of Management and Budget under control ing regularly scheduled visiting hours, number 2900–0556) convenient and reasonable access to [62 FR 53961, Oct. 17, 1997, as amended at 70 public telephones for making and re- FR 71774, Nov. 30, 2005; 71 FR 68740, Nov. 28, ceiving phone calls, and the oppor- 2006; 72 FR 10366, Mar. 8, 2007; 74 FR 34503, tunity to send and receive unopened July 16, 2009; 85 FR 31701, May 27, 2020] mail. (i) Communications with attorneys, § 17.33 Patients’ rights. law enforcement agencies, or govern- (a) General. (1) Patients have a right ment officials and representatives of to be treated with dignity in a humane recognized service organizations when environment that affords them both the latter are acting as agents for the reasonable protection from harm and patient in a matter concerning Depart- appropriate privacy with regard to ment of Veterans Affairs benefits, shall their personal needs. not be reviewed. (2) Patients have a right to receive, (ii) A patient may refuse visitors. to the extent of eligibility therefor (iii) If a patient’s right to receive un- under the law, prompt and appropriate opened mail is restricted pursuant to treatment for any physical or emo- paragraph (c) of this section, the pa- tional disability. tient shall be required to open the (3) Patients have the right to the sealed mail while in the presence of an least restrictive conditions necessary appropriate person for the sole purpose to achieve treatment purposes. of ascertaining whether the mail con- (4) No patient in the Department of tains contraband material, i.e., imple- Veterans Affairs medical care system, ments which pose significant risk of except as otherwise provided by the ap- bodily harm to the patient or others or plicable State law, shall be denied legal any drugs or medication. Any such material will be held for the patient or rights solely by virtue of being volun- disposed of in accordance with instruc- tarily admitted or involuntarily com- tions concerning patients’ mail pub- mitted. Such legal rights include, but lished by the Veterans Health Adminis- are not limited to, the following: tration, Department of Veterans Af- (i) The right to hold and to dispose of fairs, and/or the local health care facil- property except as may be limited in ity. accordance with paragraph (c)(2) of this (iv) Each patient shall be afforded section; the opportunity to purchase, at the pa- (ii) The right to execute legal instru- tient’s expense, letter writing material ments (e.g., will); including stamps. In the event a pa- (iii) The right to enter into contrac- tient needs assistance in purchasing tual relationships; writing material, or in writing, reading (iv) The right to register and vote; or sending mail, the medical facility (v) The right to marry and to obtain will attempt, at the patient’s request, a separation, divorce, or annulment; to provide such assistance by means of

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volunteers, sufficient to mail at least reasonably believes that the full exer- one (1) letter each week. cise of the specific right would— (v) All information gained by staff (i) Adversely affect the patient’s personnel of a medical facility during physical or mental health, the course of assisting a patient in (ii) Under prevailing community writing, reading, or sending mail is to standards, likely stigmatize the pa- be kept strictly confidential except for tient’s reputation to a degree that any disclosure required by law. would adversely affect the patient’s re- (2) Clothing. Each patient has the turn to independent living, right to wear his or her own clothing. (iii) Significantly infringe upon the (3) Personal Possessions. Each patient rights of or jeopardize the health or has the right to keep and use his or her safety of others, or own personal possessions consistent (iv) Have a significant adverse im- with available space, governing fire pact on the operation of the medical fa- safety regulations, restrictions on cility, to such an extent that the pa- noise, and restrictions on possession of tient’s exercise of the specific right contraband material, drugs and medi- should be restricted. In determining cations. whether a patient’s specific right (4) Money. Each patient has the right should be restricted, the health care to keep and spend his or her own professional concerned must determine money and to have access to funds in that the likelihood and seriousness of his or her account in accordance with the consequences that are expected to instructions concerning personal funds result from the full exercise of the of patients published by the Veterans right are so compelling as to warrant Health Administration. the restriction. The Chief of Service or (5) Social Interaction. Each patient Chief of Staff, as designated by local has the right to social interaction with policy, should concur with the decision others. to impose such restriction. In this con- (6) Exercise. Each patient has the nection, it should be noted that there right to regular physical exercise and is no intention to imply that each of to be outdoors at regular and frequent the reasons specified in paragraphs intervals. Facilities and equipment for (c)(2)(i) through (iv) of this section are such exercise shall be provided. logically relevant to each of the rights (7) Worship. The opportunity for reli- set forth in paragraph (b)(1) of this sec- gious worship shall be made available tion. to each patient who desires such oppor- (3) If it has been determined under tunity. No patient will be coerced into paragraph (c)(2) of this section that a engaging in any religious activities valid and sufficient reason exists for against his or her desires. restricting any of the patient’s rights (c) Restrictions. (1) A right set forth in set forth in paragraph (b) of this sec- paragraph (b) of this section may be re- tion, the least restrictive method for stricted within the patient’s treatment protecting the interest or interests plan by written order signed by the ap- specified in paragraphs (c)(2)(i) through propriate health care professional if— (iv) of this section that are involved (i) It is determined pursuant to para- shall be employed. graph (c)(2) of this section that a valid (4) The patient must be promptly no- and sufficient reason exists for a re- tified of any restriction imposed under striction, and paragraph (c) of this section and the (ii) The order imposing the restric- reasons therefor. tion and a progress note detailing the (5) All restricting orders under para- indications therefor are both entered graph (c) of this section must be re- into the patient’s permanent medical viewed at least once every 30 days by record. the practitioner and must be concurred (2) For the purpose of paragraph (c) in by the Chief of Service or Chief of of this section, a valid and sufficient Staff. reason exists when, after consideration (d) Restraint and seclusion of patients. of pertinent facts, including the pa- (1) Each patient has the right to be free tient’s history, current condition and from physical restraint or seclusion ex- prognosis, a health care professional cept in situations in which there is a

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substantial risk of imminent harm by bathe at least every twenty-four (24) the patient to himself, herself, or oth- hours. ers and less restrictive means of pre- (5) Each patient in restraint or seclu- venting such harm have been deter- sion shall be provided nutrition and mined to be inappropriate or insuffi- fluid appropriately. cient. Patients will be physically re- (e) Medication. Patients have a right strained or placed in seclusion only on to be free from unnecessary or exces- the written order of an appropriate li- sive medication. Except in an emer- censed health care professional. The gency, medication will be administered reason for any restraint order will be only on a written order of an appro- clearly documented in the progress priate health care professional in that notes of the patient’s medical record. patient’s medical record. The written The written order may be entered on order may be entered on the basis of the basis of telephonic authority, but telephonic authority received from an in such an event, an appropriate li- appropriate health care professional, censed health care professional must but in such event, the written order examine the patient and sign a written must be countersigned by an appro- order within an appropriate timeframe priate health care professional within that is in compliance with current 24 hours of the ordering of the medica- community and/or accreditation stand- tion. An appropriate health care pro- ards. In emergency situations, where fessional will be responsible for all inability to contact an appropriate li- medication given or administered to a censed health care professional prior to patient. A review by an appropriate restraint is likely to result in imme- health care professional of the drug diate harm to the patient or others, regimen of each inpatient shall take the patient may be temporarily replace at least every thirty (30) days. It strained by a member of the staff until is recognized that administration of appropriate authorization can be re- certain medications will be reviewed ceived from an appropriate licensed more frequently. Medication shall not health care professional . Use of re- be used as punishment, for the conven- straints or seclusion may continue for ience of the staff, or in quantities a period of time that does not exceed which interfere with the patient’s current community and/or accredita- treatment program. tion standards, within which time an (f) Confidentiality. Information gained appropriate licensed health care profes- by staff from the patient or the pa- sional shall again be consulted to de- tient’s medical record will be kept con- termine if continuance of such re- fidential and will not be disclosed ex- straint or seclusion is required. Re- cept in accordance with applicable law. straint or seclusion may not be used as (g) Patient grievances. Each patient a punishment, for the convenience of has the right to present grievances staff, or as a substitute for treatment with respect to perceived infringement programs. of the rights described in this section (2) While in restraint or seclusion, or concerning any other matter on be- the patient must be seen within appro- half of himself, herself or others, to priate timeframes in compliance with staff members at the facility in which current community and/or accredita- the patient is receiving care, other De- tion standards: partment of Veterans Affairs officials, (i) By an appropriate health care pro- government officials, members of Con- fessional who will monitor and chart gress or any other person without fear the patient’s physical and mental con- or reprisal. dition; and (h) Notice of patient’s rights. Upon the (ii) By other ward personnel as fre- admission of any patient, the patient quently as is reasonable under existing or his/her representative shall be in- circumstances. formed of the rights described in this (3) Each patient in restraint or seclu- section, shall be given a copy of a sion shall have bathroom privileges ac- statement of those rights and shall be cording to his or her needs. informed of the fact that the statement (4) Each patient in restraint or seclu- of rights is posted at each nursing sta- sion shall have the opportunity to tion. All staff members assigned to

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work with patients will be given a copy and outpatient services to any veteran of the statement of rights and these outside of the United States, without rights will be discussed with them by regard to the veteran’s citizenship: their immediate supervisor. (1) If necessary for treatment of a (i) Other rights. The rights described service-connected disability, or any in this section are in addition to and disability associated with and held to not in derogation of any statutory, be aggravating a service-connected dis- constitutional or other legal rights. ability; (Authority: 38 U.S.C. 501, 1721) (2) If the care and services are furnished to a veteran participating in a [47 FR 55486, Dec. 10, 1982. Redesignated at 61 rehabilitation program under 38 U.S.C. FR 21965, May 13, 1996, as amended at 70 FR 67094, Nov. 4, 2005] chapter 31 who requires care and services for the reasons enumerated in TENTATIVE ELIGIBILITY § 17.47(i)(2). DETERMINATIONS (b) Under the Foreign Medical Pro- gram, the care and services authorized § 17.34 Tentative eligibility determina- under paragraph (a) of this section are tions. available in the Republic of the Phil- Subject to the provisions of §§ 17.36 ippines to a veteran who meets the re- through 17.38, when an application for quirements of paragraph (a) of this sec- hospital care or other medical services, tion. VA may also provide outpatient except outpatient dental care, has been services to a veteran referenced in filed which requires an adjudication as paragraph (a)(1) in the VA outpatient to service connection or a determina- clinic in Manila for the treatment of tion as to any other eligibility pre- such veteran’s service-connected condi- requisite which cannot immediately be tions within the limits of the clinic. established, the service (including Non-service connected conditions of a transportation) may be authorized veteran who has a service-connected without further delay if it is deter- disability may be treated within the mined that eligibility for care probably limits of the VA outpatient clinic in will be established. Tentative eligi- Manila. bility determinations under this sec- (c) Claims for payment or reimburse- tion, however, will only be made if: ment for services not previously au- (a) In emergencies. The applicant thorized by VA under this section are needs hospital care or other medical governed by §§ 17.123–17.127 and 17.129– services in emergency circumstances, 17.132. or (b) Based on discharge. The applica- [83 FR 29448, June 25, 2018] tion is filed within 6 months after date ENROLLMENT PROVISIONS AND MEDICAL of discharge under conditions other BENEFITS PACKAGE than dishonorable, and for a veteran who seeks eligibility based on a period § 17.36 Enrollment—provision of hos- of service that began after September pital and outpatient care to vet- 7, 1980, the veteran must meet the ap- erans. plicable minimum service require- (a) Enrollment requirement for veterans. ments under 38 U.S.C. 5303A. (1) Except as otherwise provided in (Authority: 38 U.S.C. 501, 5303A) § 17.37, a veteran must be enrolled in [35 FR 6586, Apr. 24, 1970. Redesignated at 61 the VA healthcare system as a condi- FR 21965, May 13, 1996, as amended at 64 FR tion for receiving the ’medical benefits 54212, Oct. 6, 1999; 78 FR 28142, May 14, 2013] package’ set forth in § 17.38.

HOSPITAL OR NURSING HOME CARE AND NOTE TO PARAGRAPH (a)(1): A veteran may apply to be enrolled at any time. (See MEDICAL SERVICES IN FOREIGN COUN- § 17.36(d)(1).) TRIES (2) Except as provided in paragraph § 17.35 Hospital care and outpatient (a)(3) of this section, a veteran enrolled services in foreign countries. under this section and who, if required (a) Under the VA Foreign Medical by law to do so, has agreed to make Program, VA may furnish hospital care any applicable copayment is eligible

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for VA hospital and outpatient care as clearly interfere with normal employ- provided in the ‘‘medical benefits pack- ability. age’’ set forth in § 17.38. (4) Veterans who receive increased pension based on their need for regular NOTE TO PARAGRAPH (a)(2): A veteran’s enrollment status will be recognized through- aid and attendance or by reason of out the United States. being permanently housebound and other veterans who are determined to (3) A veteran enrolled based on hav- be catastrophically disabled by the ing a disorder associated with exposure Chief of Staff (or equivalent clinical of- to a toxic substance or radiation, for a ficial) at the VA facility where they disorder associated with service in the were examined. Southwest Asia theater of operations (5) Veterans not covered by para- during the Gulf War (the period be- graphs (b)(1) through (b)(4) of this sec- tween August 2, 1990, and November 11, tion who are determined to be unable 1998), or any illness associated with to defray the expenses of necessary service in combat in a war after the care under 38 U.S.C. 1722(a). Gulf War or during a period of hostility (6) Veterans of the Mexican border after November 11, 1998, as provided in period or of World War I; veterans sole- 38 U.S.C. 1710(e), is eligible for VA care ly seeking care for a disorder associ- provided in the ‘‘medical benefits pack- ated with exposure to a toxic substance age’’ set forth in § 17.38 for the disorder. or radiation, for a disorder associated (b) Categories of veterans eligible to be with service in the Southwest Asia the- enrolled. The Secretary will determine ater of operations during the Gulf War which categories of veterans are eligi- (the period between August 2, 1990, and ble to be enrolled based on the fol- November 11, 1998), or for any illness lowing order of priority: associated with service in combat in a (1) Veterans with a singular or com- war after the Gulf War or during a pe- bined rating of 50 percent or greater riod of hostility after November 11, based on one or more service-connected 1998, as provided and limited in 38 disabilities or unemployability; and U.S.C. 1710(e); Camp Lejeune veterans veterans awarded the Medal of Honor. pursuant to § 17.400; and veterans with 0 (2) Veterans with a singular or com- percent service-connected disabilities bined rating of 30 percent or 40 percent who are nevertheless compensated, in- based on one or more service-connected cluding veterans receiving compensa- disabilities. tion for inactive tuberculosis. (3) Veterans who are former prisoners (7) Veterans who agree to pay to the of war; veterans awarded the Purple United States the applicable copay- Heart; veterans with a singular or comment determined under 38 U.S.C. 1710(f) bined rating of 10 percent or 20 percent and 1710(g) if their income for the pre- based on one or more service-connected vious year constitutes ‘‘low income’’ disabilities; veterans who were dis- under the geographical income limits charged or released from active mili- established by the U.S. Department of tary service for a disability incurred or Housing and Urban Development for aggravated in the line of duty; veterans the fiscal year that ended on Sep- who receive disability compensation tember 30 of the previous calendar under 38 U.S.C. 1151; veterans whose en- year. For purposes of this paragraph, titlement to disability compensation is VA will determine the income of vet- suspended pursuant to 38 U.S.C. 1151, erans (to include the income of their but only to the extent that such vet- spouses and dependents) using the rules erans’ continuing eligibility for that in §§ 3.271, 3.272, 3.273, and 3.276. After care is provided for in the judgment or determining the veterans’ income and settlement described in 38 U.S.C. 1151; the number of persons in the veterans’ veterans whose entitlement to dis- family (including only the spouse and ability compensation is suspended be- dependent children), VA will compare cause of the receipt of military retired their income with the current applica- pay; and veterans receiving compensable ‘‘low-income’’ income limit for the tion at the 10 percent rating level public housing and section 8 programs based on multiple noncompensable in their area that the U.S. Department service-connected disabilities that of Housing and Urban Development

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publishes pursuant to 42 U.S.C. priority category 5 or priority category 1437a(b)(2). If the veteran’s income is 7, whichever is higher; below the applicable ‘‘low-income’’ in- (iii) Nonservice-connected veterans come limits for the area in which the who were in an enrolled status on Jan- veteran resides, the veteran will be uary 17, 2003, or who are moved from a considered to have ‘‘low income’’ for higher priority category or sub- purposes of this paragraph. To avoid a category due to no longer being eligi- hardship to a veteran, VA may use the ble for inclusion in such priority cat- projected income for the current year egory or subcategory and who subse- of the veteran, spouse, and dependent quently do not request disenrollment; children if the projected income is (iv) Nonservice-connected veterans below the ‘‘low income’’ income limit not included in paragraph (b)(8)(iii) of referenced above. This category is fur- this section and whose income is not ther prioritized into the following sub- greater than ten percent more than the categories: (i) Noncompensable zero percent income that would permit their enroll- service-connected veterans who are in ment in priority category 5 or priority an enrolled status on a specified date category 7, whichever is higher; announced in a FEDERAL REGISTER doc- (v) Noncompensable zero percent ument promulgated under paragraph service-connected veterans not in- (c) of this section and who subse- cluded in paragraph (b)(8)(i) or para- quently do not request disenrollment; graph (b)(8)(ii) of this section; and (ii) Nonservice-connected veterans (vi) Nonservice-connected veterans who are in an enrolled status on a spec- not included in paragraph (b)(8)(iii) or ified date announced in a FEDERAL paragraph (b)(8)(iv) of this section. REGISTER document promulgated under (c) FEDERAL REGISTER notification of paragraph (c) of this section and who eligible enrollees. (1) It is anticipated subsequently do not request that each year the Secretary will con- disenrollment; sider whether to change the categories (iii) Noncompensable zero percent and subcategories of veterans eligible service-connected veterans not in- to be enrolled. The Secretary at any cluded in paragraph (b)(7)(i) of this sec- time may revise the categories or sub- tion; and categories of veterans eligible to be en- (iv) Nonservice-connected veterans rolled by amending paragraph (c)(2) of not included in paragraph (b)(7)(ii) of this section. The preamble to a FED- this section. ERAL REGISTER document announcing (8) Veterans not included in priority which priority categories and subcat- category 4 or 7, who are eligible for egories are eligible to be enrolled must care only if they agree to pay to the specify the projected number of fiscal United States the applicable copay- year applicants for enrollment in each ment determined under 38 U.S.C. 1710(f) and 1710(g). This category is further priority category, projected healthcare prioritized into the following subcat- utilization and expenditures for vet- egories: erans in each priority category, appro- (i) Noncompensable zero percent priated funds and other revenue pro- service-connected veterans who were in jected to be available for fiscal year en- an enrolled status on January 17, 2003, rollees, and projected total expendi- or who are moved from a higher pri- tures for enrollees by priority cat- ority category or subcategory due to egory. The determination should in- no longer being eligible for inclusion in clude consideration of relevant inter- such priority category or subcategory nal and external factors, e.g., economic and who subsequently do not request changes, changes in medical practices, disenrollment; and waiting times to obtain an ap- (ii) Noncompensable zero percent pointment for care. Consistent with service-connected veterans not in- these criteria, the Secretary will deter- cluded in paragraph (b)(8)(i) of this sec- mine which categories of veterans are tion and whose income is not greater eligible to be enrolled based on the than ten percent more than the income order of priority specified in paragraph that would permit their enrollment in (b) of this section.

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(2) Unless changed by a rulemaking (ii) A veteran will be placed in the document in accordance with para- highest priority category or categories graph (c)(1) of this section, VA will en- for which the veteran qualifies. roll the priority categories of veterans (iii) A veteran may be placed in only set forth in § 17.36(b) beginning June 15, one priority category, except that a 2009, except that those veterans in sub- veteran placed in priority category 6 categories (v) and (vi) of priority cat- based on a specified disorder or illness egory 8 are not eligible to be enrolled. will also be placed in priority category (d) Enrollment and disenrollment proc- 7 or priority category 8, as applicable, ess—(1) Application for enrollment. A vet- if the veteran has previously agreed to eran who wishes to be enrolled must pay the applicable copayment, for all apply by submitting a VA Form 10– matters not covered by priority cat- 10EZ: egory 6. (i) To a VA medical facility or by (iv) A veteran who had been enrolled mail it to the U.S. Postal address on based on inclusion in priority category the form; or 5 and became no longer eligible for in- (ii) Online at the designated World clusion in priority category 5 due to Wide Web internet address; or failure to submit to VA a current VA (iii) By calling a designated tele- Form 10–10EZ will be changed auto- phone number and submitting applica- matically to enrollment based on in- tion information verbally. To complete clusion in priority category 6 or 8 (or a telephone application, the veteran more than one of these categories if seeking enrollment must attest to the the previous principle applies), as ap- accuracy and authenticity of their plicable, and be considered continu- verbal application for enrollment and ously enrolled. To meet the criteria for consent to VA’s copayment require- priority category 5, a veteran must be ments and third-party billing proce- eligible for priority category 5 based on dures. the information submitted to VA in a (2) Action on application. Upon receipt current VA Form 10–10EZ. To be cur- of a completed VA Form 10–10EZ, a VA rent, after VA has sent a form 10–10EZ network or facility director, or the to the veteran at the veteran’s last Deputy Under Secretary for Health for known address, the veteran must re- Operations and Management or Chief, turn the completed form (including sig- Health Administration Service or nature) to the address on the return en- equivalent official at a VA medical fa- velope within 60 days from the date VA cility, or Director, Health Eligibility sent the form to the veteran. Center, will accept a veteran as an en- (v) Veterans will be disenrolled, and rollee upon determining that the vet- reenrolled, in the order of the priority eran is in a priority category eligible categories listed with veterans in pri- to be enrolled as set forth in ority category 1 being the last to be § 17.36(c)(2). Upon determining that a disenrolled and the first to be re- veteran is not in a priority category el- enrolled. Similarly, within priority igible to be enrolled, the VA network categories 7 and 8, veterans will be or facility director, or the Deputy disenrolled, and reenrolled, in the order Under Secretary for Health for Oper- of the priority subcategories listed ations and Management or Chief, with veterans in subcategory (i) being Health Administration Service or the last to be disenrolled and first to be equivalent official at a VA medical fa- reenrolled. cility, or Director, Health Eligibility (4) [Reserved] Center, will inform the applicant that (5) Disenrollment. A veteran enrolled the applicant is ineligible to be en- in the VA health care system under rolled. paragraph (d)(2) of this section will be (3) Placement in enrollment categories. disenrolled only if: (i) Veterans will be placed in priority (i) The veteran submits to a VA Med- categories whether or not veterans in ical Center or to the VA Health Eligi- that category are eligible to be en- bility Center, 2957 Clairmont Road, rolled. NE., Suite 200, Atlanta, Georgia 30329–

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1647, a signed and dated document stat- tions specified in paragraph (e)(2) of ing that the veteran no longer wishes this section by a current medical ex- to be enrolled; or amination that documents that the pa- (ii) A VA network or facility direc- tient meets the permanent criteria and tor, or the Deputy Under Secretary for will continue to meet such criteria Health for Operations and Management (permanently) or would continue to or Chief, Health Administration Serv- meet such criteria (permanently) with- ice or equivalent official at a VA med- out the continuation of on-going treat- ical facility, or Director, Health Eligi- ment. bility Center, determines that the vet- (1) Quadriplegia and quadriparesis; eran is no longer in a priority category paraplegia; legal blindness defined as eligible to be enrolled, as set forth in visual impairment of 20/200 or less vis- § 17.36(c)(2). ual acuity in the better seeing eye with (6) Notification of enrollment status. corrective lenses, or a visual field re- Notice of a decision by a VA network striction of 20 degrees or less in the or facility director, or the Deputy better seeing eye with corrective Under Secretary for Health for Oper- lenses; persistent vegetative state; or a ations and Management or Chief, condition resulting from two of the fol- Health Administration Service or lowing procedures, provided the two equivalent official at a VA medical fa- procedures were not on the same limb: cility, or Director, Health Eligibility (i) Amputation, detachment, or re- Center, regarding enrollment status amputation of or through the hand; will be provided to the affected veteran (ii) Disarticulation, detachment, or by letter and will contain the reasons reamputation of or through the wrist; for the decision. The letter will include (iii) Amputation, detachment, or re- an effective date for any changes and a amputation of the forearm at or statement regarding appeal rights. The through the radius and ulna; decision will be based on all informa- (iv) Amputation, detachment, or tion available to the decisionmaker, disarticulation of the forearm at or including the information contained in through the elbow; VA Form 10–10EZ. (v) Amputation, detachment, or re- (e) Catastrophically disabled. For pur- amputation of the arm at or through poses of this section, catastrophically the humerus; disabled means to have a permanent se- (vi) Disarticulation or detachment of verely disabling injury, disorder, or the arm at or through the shoulder; disease that compromises the ability to (vii) Interthoracoscapular (fore- carry out the activities of daily living quarter) amputation or detachment; to such a degree that the individual requires personal or mechanical assist- (viii) Amputation, detachment, or re- ance to leave home or bed or requires amputation of the leg at or through constant supervision to avoid physical the tibia and fibula; harm to self or others. This definition (ix) Amputation or detachment of or is met if an individual has been found through the great toe; by the Chief of Staff (or equivalent (x) Amputation or detachment of or clinical official) at the VA facility through the foot; where the individual was examined to (xi) Disarticulation or detachment of have a permanent condition specified the foot at or through the ankle; in paragraph (e)(1) of this section; to (xii) Amputation or detachment of meet permanently one of the condi- the foot at or through malleoli of the tions specified in paragraph (e)(2) of tibia and fibula; this section by a clinical evaluation of (xiii) Amputation or detachment of the patient’s medical records that doc- the lower leg at or through the knee; uments that the patient previously (xiv) Amputation, detachment, or re- met the permanent criteria and con- amputation of the leg at or through tinues to meet such criteria (perma- the femur; nently) or would continue to meet such (xv) Disarticulation or detachment of criteria (permanently) without the the leg at or through the hip; and continuation of on-going treatment; or (xvi) Interpelviaabdominal (hind- to meet permanently one of the condi- quarter) amputation or detachment.

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(2)(i) Dependent in 3 or more Activi- (e) Subject to the provisions of ties of Daily Living (eating, dressing, § 21.240, a veteran participating in VA’s bathing, toileting, transferring, incon- vocational rehabilitation program de- tinence of bowel and/or bladder), with scribed in §§ 21.1 through 21.430 will re- at least 3 of the dependencies being ceive VA care provided for in the permanent with a rating of 1, using the ‘‘medical benefits package’’ set forth in Katz scale. § 17.38. (ii) A score of 2 or lower on at least (f) A veteran may receive care pro- 4 of the 13 motor items using the Func- vided for in the ’medical benefits pack- tional Independence Measure. age’ based on factors other than vet- (iii) A score of 30 or lower using the eran status (e.g., a veteran who is a Global Assessment of Functioning. private-hospital patient and is referred (f) VA Form 10–10EZ. Copies of VA to VA for a diagnostic test by that hos- Form 10–10EZ are available at any VA pital under a sharing contract; a vet- medical center and at https:// www.1010ez.med.va.gov/sec/vha/1010ez/. eran who is a VA employee and is examined to determine physical or men- (The Office of Management and Budget has tal fitness to perform official duties; a approved the information collection require- Department of Defense retiree under a ments in this section under control number 2900–0091) sharing agreement). (g) For care not provided within a (Authority: 38 U.S.C 101, 501, 1521, 1701, 1705, State, a veteran may receive VA care 1710, 1721, 1722) provided for in the ‘‘medical benefits [64 FR 54212, Oct. 6, 1999, as amended at 67 FR package’’ set forth in § 17.38 if author- 35039, May 17, 2002; 67 FR 62887, Oct. 9, 2002; ized under the provisions of 38 U.S.C. 68 FR 2672, Jan. 17, 2003; 74 FR 22834, May 15, 2009; 74 FR 48012, Sept. 21, 2009; 75 FR 52628, 1724 and 38 CFR 17.35. Aug. 27, 2010; 76 FR 52274, Aug. 22, 2011; 79 FR (h) Commonwealth Army veterans 72578, Dec. 3, 2013; 79 FR 57414, Sept. 24, 2014; and new Philippine Scouts may receive 81 FR 13997, Mar. 16, 2016; 84 FR 7815, Mar. 5, care provided for in the ‘‘medical bene- 2019] fits package’’ set forth in § 17.38 if authorized under the provisions of 38 § 17.37 Enrollment not required—provision of hospital and outpatient U.S.C. 1724 and 38 CFR 17.35. care to veterans. (i) A veteran may receive certain types of VA care not included in the Even if not enrolled in the VA healthcare system: ‘‘medical benefits package’’ set forth in (a) A veteran rated for service-con- § 17.38 if authorized by statute or other nected disabilities at 50 percent or sections of 38 CFR (e.g., humanitarian greater will receive VA care provided emergency care for which the indi- for in the ‘‘medical benefits package’’ vidual will be billed, compensation and set forth in § 17.38. pension examinations, dental care, (b) A veteran who has a service-con- domiciliary care, nursing home care, nected disability will receive VA care readjustment counseling, care as part provided for in the ‘‘medical benefits of a VA-approved research project, see- package’’ set forth in § 17.38 for that ing-eye or guide dogs, sexual trauma service-connected disability. counseling and treatment, special reg- (c) A veteran who was discharged or istry examinations). released from active military service (j) A veteran may receive an exam- for a disability incurred or aggravated ination to determine whether the vet- in the line of duty will receive VA care eran is catastrophically disabled and provided for in the ‘‘medical benefits therefore eligible for inclusion in pri- package’’ set forth in § 17.38 for that ority category 4. disability for the 12-month period fol- (k) A veteran may receive care for lowing discharge or release. psychosis or mental illness other than (d) When there is a compelling med- psychosis pursuant to 38 CFR 17.109. ical need to complete a course of VA treatment started when the veteran (Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, was enrolled in the VA healthcare sys- 1721, 1722) tem, a veteran will receive that treat- [64 FR 54217, Oct. 6, 1999, as amended at 67 FR ment. 35039, May 17, 2002; 78 FR 28142, May 14, 2013]

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§ 17.38 Medical benefits package. (xiv) Newborn care, post delivery, for (a) Subject to paragraphs (b) and (c) a newborn child for the date of birth of this section, the following hospital, plus seven calendar days after the birth outpatient, and extended care services of the child when the birth mother is a constitute the ‘‘medical benefits pack- woman veteran enrolled in VA health age’’ (basic care and preventive care): care and receiving maternity care fur- (1) Basic care. nished by VA or under authorization (i) Outpatient medical, surgical, and from VA and the child is delivered ei- mental healthcare, including care for ther in a VA facility, or in another fa- substance abuse. cility pursuant to a VA authorization (ii) Inpatient hospital, medical, sur- for maternity care at VA expense. gical, and mental healthcare, including (xv) Completion of forms (e.g., Fam- care for substance abuse. ily Medical Leave forms, life insurance (iii) Prescription drugs, including applications, Department of Education over-the-counter drugs and medical forms for loan repayment exemptions and surgical supplies available under based on disability, non-VA disability the VA national formulary system. program forms) by healthcare profes- (iv) Emergency care in VA facilities; sionals based on an examination or and emergency care in non-VA facili- knowledge of the veteran’s condition, ties in accordance with sharing con- but not including the completion of tracts or if authorized by§ 17.52(a)(3), forms for examinations if a third party § 17.53, § 17.54, §§ 17.120 through 17.132, or customarily will pay health care prac- §§ 17.4000 through 17.4040. titioners for the examination but will (v) Bereavement counseling as au- not pay VA. thorized in § 17.98. (2) Preventive care, as defined in 38 (vi) Comprehensive rehabilitative U.S.C. 1701(9), which includes: services other than vocational services (i) Periodic medical exams. provided under 38 U.S.C. chapter 31. (ii) Health education, including nu- (vii) Consultation, professional coun- trition education. seling, marriage and family counseling, (iii) Maintenance of drug-use profiles, training, and mental health services drug monitoring, and drug use edu- for the members of the immediate fam- cation. ily or legal guardian of the veteran or (iv) Mental health and substance the individual in whose household the abuse preventive services. veteran certifies an intention to live, (v) Immunizations against infectious as necessary and appropriate, in con- disease. nection with the veteran’s treatment (vi) Prevention of musculoskeletal as authorized under 38 CFR 71.50. (viii) Durable medical equipment and deformity or other gradually devel- prosthetic and orthotic devices, includ- oping disabilities of a metabolic or de- ing eyeglasses and hearing aids as au- generative nature. thorized under § 17.149. (vii) Genetic counseling concerning (ix) Home health services authorized inheritance of genetically determined under 38 U.S.C. 1717 and 1720C. diseases. (x) Reconstructive (plastic) surgery (viii) Routine vision testing and eye- required as a result of disease or trau- care services. ma, but not including cosmetic surgery (ix) Periodic reexamination of mem- that is not medically necessary. bers of high-risk groups for selected (xi)(A) Hospice care, palliative care, diseases and for functional decline of and institutional respite care; and sensory organs, and the services to (B) Noninstitutional extended care treat these diseases and functional de- services, including but not limited to clines. noninstitutional geriatric evaluation, (b) Provision of the ‘‘medical benefits noninstitutional adult day health care, package’’. Care referred to in the and noninstitutional respite care. ‘‘medical benefits package’’ will be pro- (xii) Payment of beneficiary travel as vided to individuals only if it is deter- authorized under 38 CFR part 70. mined by appropriate healthcare pro- (xiii) Pregnancy and delivery serv- fessionals that the care is needed to ices, to the extent authorized by law. promote, preserve, or restore the

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health of the individual and is in ac- (6) Membership in spas and health cord with generally accepted standards clubs. of medical practice. [64 FR 54217, Oct. 6, 1999, as amended at 67 FR (1) Promote health. Care is deemed to 35039, May 17, 2002; 73 FR 36798, June 30, 2008; promote health if the care will enhance 75 FR 54030, Sept. 3, 2010; 76 FR 11339, Mar. 2, the quality of life or daily functional 1011; 76 FR 26172, May 5, 2011; 76 FR 78571, level of the veteran, identify a pre- Dec. 19, 2011; 82 FR 6275, Jan. 19, 2017; 84 FR 26306, June 5, 2019] disposition for development of a condition or early onset of disease which can § 17.39 Certain Filipino veterans. be partly or totally ameliorated by (a) Any Filipino Commonwealth monitoring or early diagnosis and Army veteran, including one who was treatment, and prevent future disease. recognized by authority of the U.S. (2) Preserve health. Care is deemed to Army as belonging to organized Fili- preserve health if the care will main- pino guerilla forces, or any new Phil- tain the current quality of life or daily ippine Scout is eligible for hospital functional level of the veteran, prevent care, nursing home care, and out- the progression of disease, cure disease, patient medical services within the or extend life span. United States in the same manner and (3) Restoring health. Care is deemed to subject to the same terms and condi- restore health if the care will restore tions as apply to U.S. veterans, if such the quality of life or daily functional veteran or scout resides in the United level that has been lost due to illness States and is a citizen or lawfully ad- or injury. mitted to the United States for permanent residence. For purposes of these (c) In addition to the care specifi- VA health care benefits, the standards cally excluded from the ‘‘medical bene- described in 38 CFR 3.42(c) will be ac- fits package’’ under paragraphs (a) and cepted as proof of U.S. citizenship or (b) of this section, the ‘‘medical bene- lawful permanent residence. fits package’’ does not include the fol- (b) Commonwealth Army Veterans, lowing: including those who were recognized by (1) Abortions and abortion coun- authority of the U.S. Army as belong- seling. ing to organized Filipino guerilla (2) In vitro fertilization. Note: See forces, and new Philippine Scouts are § 17.380. not eligible for VA health care benefits (3) Drugs, biologicals, and medical if they do not meet the residency and devices not approved by the Food and citizenship requirements described in Drug Administration unless the treat- § 3.42(c). ing medical facility is conducting formal clinical trials under an Investiga- (The Office of Management and Budget has approved the information collection require- tional Device Exemption (IDE) or an ments in this section under control number Investigational New Drug (IND) appli- 2900–0091) cation, or the drugs, biologicals, or medical devices are prescribed under a (Authority: 38 U.S.C. 501, 1734) compassionate use exemption. [71 FR 6680, Feb. 9, 2006] (4) Gender alterations. § 17.40 Additional services for (5) Hospital and outpatient care for a indigents. veteran who is either a patient or in- In addition to the usual medical serv- mate in an institution of another gov- ices agreed upon between the govern- ernment agency if that agency has a ments of the United States and the Re- duty to give the care or services. This public of the Philippines to be made exclusion does not apply to veterans available to patients for whom the De- who are released from incarceration in partment of Veterans Affairs has au- a prison or jail into a temporary hous- thorized care at the Veterans Memorial ing program (such as a community res- Medical Center, any such patient deter- idential re-entry center or halfway mined by the U.S. Department of Vet- house). erans Affairs to be indigent or without funds may be furnished toilet articles

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and barber services, including § 17.42 Examinations on an outpatient haircutting and shaving necessary for basis. hygienic reasons. Physical examinations on an out- [33 FR 5299, Apr. 3, 1968, as amended at 47 FR patient basis may be furnished to ap- 58247, Dec. 30, 1982. Redesignated at 61 FR plicants who have been tentatively de- 21965, May 13, 1996] termined to be eligible for Department of Veterans Affairs hospital or domi- EXAMINATIONS AND OBSERVATION AND ciliary care to determine their need for EXAMINATION such care and to the same categories of persons for whom hospitalization for § 17.41 Persons eligible for hospital observation and physical examina- observation and examination may be tion. authorized under § 17.41. Hospitalization for observation and [35 FR 6586, Apr. 24, 1970. Redesignated and physical (including mental) examina- amended at 61 FR 21965, 21966, May 13, 1996] tion may be effected when requested by an authorized official, or when found HOSPITAL, DOMICILIARY AND NURSING necessary in examination of the fol- HOME CARE lowing persons: § 17.43 Persons entitled to hospital or (a) Claimants or beneficiaries of VA domiciliary care. for purposes of disability compensation, pension, participation in a reha- Hospital or domiciliary care may be bilitation program under 38 U.S.C. provided: chapter 31, and Government insurance. (a) Not subject to the eligibility pro- (38 U.S.C. 1711(a)) visions of 38 U.S.C. 1710, 1722, and 1729, (b) Claimants or beneficiaries re- and 38 CFR 17.44 and 17.45, for: ferred to a diagnostic center for study (1) Persons in the Armed Forces when to determine the clinical identity of an duly referred with authorization there- obscure disorder. for, may be furnished hospital care. (c) Employees of the Department of Emergency treatment may be ren- Veterans Affairs when necessary to de- dered, without obtaining formal au- termine their mental or physical fit- thorization, to such persons upon their ness to perform official duties. own application, when absent from (d) Claimants or beneficiaries of their commands. Identification of ac- other Federal agencies: tive duty members of the uniformed (1) Department of Justice—plaintiffs services will be made by military iden- in Government insurance suits. tification card. (2) United States Civil Service Com- (2) Hospital care may be provided, mission—annuitants or applicants for upon authorization, for beneficiaries of retirement annuity, and such examina- the Public Health Service, Office of tions of prospective appointees as may Workers’ Compensation Programs, and be requested. other Federal agencies. (3) Office of Workers’ Compensation (3) Pensioners of nations allied with Programs—to determine identity, se- the United States in World War I and verity, or persistence of disability. World War II may be supplied hospital (4) Railroad Retirement Board—ap- care when duly authorized. plicants for annuity under Public No. (b) Emergency hospital care may be 162, 75th Congress. provided for: (5) Other Federal agencies. (1) Persons having no eligibility, as a (e) Pensioners of nations allied with humanitarian service. the United States in World War I and (2) Persons admitted because of pre- World War II, upon authorization from sumed discharge or retirement from accredited officials of the respective the Armed Forces, but subsequently governments. found to be ineligible as such. (3) Employees (not potentially eligi- [13 FR 7156, Nov. 27, 1948, as amended at 16 ble as ex-members of the Armed FR 12091, Nov. 30, 1951; 19 FR 6716, Oct. 19, 1954; 32 FR 13813, Oct. 4, 1967; 39 FR 32606, Forces) and members of their families, Sept. 10, 1974; 49 FR 5616, Feb. 14, 1984. Redes- when residing on reservations of field ignated and amended at 61 FR 21965, 21966, facilities of the Department of Vet- May 13, 1996] erans Affairs, and when they cannot

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feasibly obtain emergency treatment (b) Under this section, the term from private facilities. chronic diseases shall include chronic (c) Hospital care when incidental to, arthritis, malignancy, psychiatric dis- and to the extent necessary for, the use orders, poliomyelitis with residuals, of a specialized Department of Vet- neurological disabilities, diseases of erans Affairs medical resource pursu- the nervous system, severe injuries to ant to a sharing agreement entered the nervous system, including quadri- into under § 17.240, may be authorized plegia, hemiplegia and paraplegia, tu- for any person designated by the other berculosis, blindness and deafness re- party to the agreement as a patient to quiring definitive rehabilitation, dis- be benefited under the agreement. (d) The authorization of services ability from major amputation, and under any provision of this section, ex- other diseases as may be agreed upon cept services for eligible veterans, is from time to time by the Under Sec- subject to charges as required by retary for Health and designated offi- § 17.102. cials of the Department of Defense and Department of Health and Human [23 FR 6498, Aug. 22, 1958, as amended at 24 FR 8327, Oct. 14, 1959; 32 FR 6841, May 4, 1967; Services. For the purpose of this sec- 34 FR 9340, June 13, 1969; 35 FR 6586, Apr. 24, tion, blindness is defined as corrected 1970; 39 FR 32606, Sept. 10, 1974. Redesignated visual acuity of 20/200 or less in the bet- and amended at 61 FR 21965, 21966, May 13, ter eye, or corrected central visual acu- 1996; 64 FR 54218, Oct. 6, 1999; 79 FR 54615, ity of more than 20/200 if there is a field Sept. 12, 2014] defect in which the peripheral field has § 17.44 Hospital care for certain retir- contracted to such an extent that its ees with chronic disability (Execu- widest diameter subtends the widest di- tive Orders 10122, 10400 and 11733). ameter of the field of the better eye at Hospital care may be furnished when an angle no greater than 20°. beds are available to members or (c) In the case of persons who are former members of the uniformed serv- former members of the Coast and Geo- ices (Army, Navy, Air Force, Marine detic Survey, care may be furnished Corps, Coast Guard, Coast and Geodetic under this section even though their Survey, now National Oceanic and At- retirement for disability was from the mospheric Administration hereinafter Environmental Science Services Ad- referred to as NOAA, and Public Health ministration or NOAA. Service) temporarily or permanently retired for physical disability or re- [34 FR 9340, June 13, 1969, as amended at 39 ceiving disability retirement pay who FR 1841, Jan. 15, 1974; 47 FR 58247, Dec. 30, require hospital care for chronic dis- 1982. Redesignated at 61 FR 21965, May 13, eases and who have no eligibility for 1996, as amended at 62 FR 17072, Apr. 9, 1997] hospital care under laws governing the § 17.45 Hospital care for research pur- Department of Veterans Affairs, or who poses. having eligibility do not elect hospitalization as Department of Veterans Subject to § 17.102(g), any person who Affairs beneficiaries. Care under this is a bona fide volunteer may be admit- section is subject to the following con- ted to a Department of Veterans Af- ditions: fairs hospital when the treatment to be (a) Persons defined in this section rendered is part of an approved Depart- who are members or former members of ment of Veterans Affairs research the active military, naval, or air serv- project and there are insufficient vet- ice must agree to pay the subsistence eran-patients suitable for the project. rate set by the Secretary of Veterans Affairs, except that no subsistence [35 FR 11470, July 17, 1970. Redesignated at 61 charge will be made for those persons FR 21965, May 13, 1996; 79 FR 54615, Sept. 12, who are members or former members of 2014] the Public Health Service, Coast Guard, Coast and Geodetic Survey now NOAA, and enlisted personnel of the Army, Navy, Marine Corps, and Air Force.

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§ 17.46 Eligibility for hospital, domi- (vii) Share in some measure, however ciliary or nursing home care of per- slight, in the maintenance and oper- sons discharged or released from ation of the facility. active military, naval, or air serv- (viii) Make rational and competent ice. decisions as to his or her desire to re- (a) In furnishing hospital care on or main or leave the facility. before June 6, 2019, under 38 U.S.C. [24 FR 8328, Oct. 4, 1959, as amended at 30 FR 1710(a)(1), VA officials shall: 1787, Feb. 9, 1965; 32 FR 13813, Oct. 4, 1967; 34 (1) If the veteran is in immediate FR 9340, June 13, 1969; 39 FR 1841, Jan. 15, need of hospitalization, furnish care at 1974; 45 FR 6935, Jan. 31, 1980; 51 FR 25064, VA facility where the veteran applies July 10, 1986; 52 FR 11259, Apr. 8, 1987; 53 FR or, if that facility is incapable of fur- 9627, Mar. 24, 1988; 53 FR 32391, Aug. 25, 1988; nishing care, arrange to admit the vet- 56 FR 5757, Feb. 13, 1991. Redesignated and amended at 61 FR 21965, 21966, May 13, 1996; 84 eran to the nearest VA medical center, FR 26306, June 5, 2019] or Department of Defense hospital with which VA has a sharing agreement § 17.47 Considerations applicable in under 38 U.S.C. 8111, which is capable of determining eligibility for hospital providing the needed care, or if VA or care, medical services, nursing DOD facilities are not available, ar- home care, or domiciliary care. range for care on a contract basis if au- (a)(1) For applicants discharged or re- thorized by 38 U.S.C. 1703 and 38 CFR leased for disability incurred or aggra- 17.52; or vated in line of duty and who are not in (2) If the veteran needs non-imme- receipt of compensation for service- diate hospitalization, schedule the vet- connected or service-aggravated dis- eran for admission at VA facility where ability, the official records of the the veteran applies, if the schedule per- Armed Forces relative to findings of mits, or refer the veteran for admission line of duty for its purposes will be ac- or scheduling for admission at the cepted in determining eligibility for nearest VA medical center, or Depart- hospital care or medical services. ment of Defense facility with which VA Where the official records of the Armed has a sharing agreement under 38 Forces show a finding of disability not U.S.C. 8111. incurred or aggravated in line of duty (b) Domiciliary care may be fur- and evidence is submitted to the De- nished when needed to: partment of Veterans Affairs which (1) Any veteran whose annual income permits of a different finding, the deci- does not exceed the maximum annual sion of the Armed Forces will not be rate of pension payable to a veteran in binding upon the Department of Vet- need of regular aid and attendance, or erans Affairs, which will be free to (2) Any veteran who the Secretary make its own determination of line of determines had no adequate means of duty incurrence or aggravation upon support. An additional requirement for evidence so submitted. It will be in- eligibility for domiciliary care is the cumbent upon the applicant to present ability of the veteran to perform the controverting evidence and, until such following: evidence is presented and a determina- (i) Perform without assistance daily tion favorable to the applicant is made ablutions, such as brushing teeth; by the Department of Veterans Affairs, bathing; combing hair; body elimi- the finding of the Armed Forces will nations. control and hospital care or medical (ii) Dress self, with a minimum of as- services will not be authorized. Such sistance. controverting evidence, when received (iii) Proceed to and return from the from an applicant, will be referred to dining hall without aid. the adjudicating agency which would (iv) Feed Self. have jurisdiction if the applicant was (v) Secure medical attention on an filing claim for pension or disability ambulatory basis or by use of person- compensation, and the determination ally propelled wheelchair. of such agency as to line of duty, which (vi) Have voluntary control over body is promptly to be communicated to the eliminations or control by use of an ap- head of the field facility receiving the propriate prosthesis. application for hospital care or medical

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services , will govern the facility Di- provided for the disability for which rector’s disapproval or approval of such the compensation is being paid or for care or services,other eligibility re- any other disability. Treatment under quirements having been met. Where the authority of 38 U.S.C. 1710(a)(1) the official records of the Armed may not be authorized during any pe- Forces show that the disability for riod when disability compensation which a veteran was discharged or re- under § 3.362 of this title is not being leased from the Armed Forces under paid because of the provision of other than dishonorable conditions was § 3.362(b), except to the extent con- incurred or aggravated in the line of tinuing eligibility for such treatment duty, such showing will be accepted for is provided for in the judgment for set- the purpose of determining his or her tlement described in § 3.362(b) of this eligibility for hospital care or medical title. services, notwithstanding the fact that the Department of Veterans Affairs has (Authority: 38 U.S.C. 1710(a); sec. 701, Pub. L. made a determination in connection 98–160, Pub. L. 99–272) with a claim for monetary benefits that the disability was incurred or ag- (2) For purposes of eligibility for gravated not in line of duty. domiciliary care, the phrase no ade- (2) In those exceptional cases where quate means of support refers to an ap- the official records of the Armed plicant for domiciliary care whose an- Forces show discharge or release under nual income exceeds the annual rate of other than dishonorable conditions be- pension for a veteran in receipt of reg- cause of expiration of period of enlist- ular aid and attendance, as defined in ment or any other reason except dis- 38 U.S.C. 1503, but who is able to dem- ability, but also show a disability in- onstrate to competent VA medical au- curred or aggravated in line of duty thority, on the basis of objective evi- during the said enlistment; and the dis- dence, that deficits in health and/or ability so recorded is considered in functional status render the applicant medical judgment to be or to have been incapable of pursuing substantially of such character, duration, and degree gainful employment, as determined by as to have justified a discharge or re- the Chief of Staff, and who is otherwise lease for disability had the period of without the means to provide ade- enlistment not expired or other reason quately for self, or be provided for in for discharge or release been given, the the community. Under Secretary for Health, upon consideration of a clear, full statement of (Authority: 38 U.S.C. 1710(a); sec. 701, Pub. L. circumstances, is authorized to ap- 98–160, Pub. L. 99–272) prove hospital care or medical services, provided other eligibility requirements (c) A disability, disease, or defect will are met. A typical case of this kind comprehend any acute, subacute, or will be one where the applicant was chronic disease (or a general medical, under treatment for the said disability tuberculous, or neuropsychiatric type) recorded during his or her service at of any acute, subacute, or chronic sur- the time discharge or release was given gical condition susceptible of cure or for the reason other than disability. decided improvement by hospital care (b)(1) Under 38 U.S.C. 1710(a)(1), vet- or medical services; or any condition erans who are receiving disability com- which does not require hospital care or pensation awarded under § 3.362 of this medical services for an acute or chron- chapter, where a disease, injury or the ic condition but requires domiciliary aggravation of an existing disease or care. Domiciliary care, as the term im- injury occurs as a result of VA exam- plies, is the provision of a temporary ination, medical or surgical treatment, home, with such ambulant medical or of hospitalization in a VA health care as is needed. To be provided with care facility or of participation in a re- domiciliary care, the applicant must habilitation program under 38 U.S.C. consistently have a disability, disease, ch. 31, under any law administered by or defect which is essentially chronic VA and not the result of his/her own in type and is producing disablement of willful misconduct. Treatment may be such degree and probable persistency

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as will incapacitate from earning a liv- the same sources of income and exclu- ing for a prospective period. sions from income, as determinations with respect to income are made for de- (Authority: 38 U.S.C. 1701, 1710) termining eligibility for pension under (d)(1) For purposes of determining §§ 3.271 and 3.272 of this title. The term eligibility for hospital care, medical attributable income means income of a services, or nursing home care under veteran for the calendar year preceding § 17.47(a), a veteran will be determined application for care, determined in the unable to defray the expenses of nec- same manner as the manner in which a essary care if the veteran agrees to determination is made of the total provide verifiable evidence, as deter- amount of income by which the rate of mined by the Secretary, that: pension for such veteran under 38 (i) The veteran is eligible to receive U.S.C. 1521 would be reduced if such medical assistance under a State plan veteran were eligible for pension under approved under title XIX of the Social that section. Security Act; (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. (Authority: 42 U.S.C. 1396 et seq.) 99–272) (ii) The veteran is in receipt of pen- (5) In order to avoid hardship VA sion under 38 U.S.C. 1521; or may determine that a veteran is eligi- (iii) The veteran’s attributable in- ble for care notwithstanding that the come does not exceed $15,000 if the vet- veteran does not meet the income re- eran has no dependents, $18,000 if the quirements established in paragraph veteran has one dependent, plus $1,000 (d)(1)(iii) or (d)(2) of this section, if pro- for each additional dependent. jections of the veteran’s income for the year following application for care are (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. substantially below the income re- 99–272) quirements established in paragraph (2) For purposes of determining eligi- (d)(1)(iii) or (d)(2) of this section. bility for hospital care, medical services, or nursing home care under (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. § 17.47(c), a veteran will be determined 99–272) eligible for necessary care if the vet- (e)(1) If VA determines that an indi- eran agrees to provide verifiable evi- vidual was incorrectly charged a co- dence, as determined by the Secretary, payment, VA will refund the amount of that: The veteran’s attributable in- any copayment actually paid by that come does not exceed $20,000 if the vet- individual. eran has no dependents, $25,000 if the veteran has one dependent, plus $1,000 (Authority: 38 U.S.C. 501; sec. 19011, Pub. L. for each additional dependent. 99–272) (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. (2) In the event a veteran provided in- 99–272) accurate information on an application (3) Effective on January 1 of each and is incorrectly deemed eligible for year after calendar year 1986, the care under 38 U.S.C. 1710(a)(1) or (a)(2) amounts set forth in paragraph (d)(1) rather than 38 U.S.C. 1710(a)(3), VA and (2) of this section shall be in- shall retroactively bill the veteran for creased by the percentage by which the the applicable copayment. maximum rates of pension were increased under 38 U.S.C. 5312(a), during (Authority: 38 U.S.C. 501 and 1710; sec. 19011, the preceding year. Pub. L. 99–272) (f) If a veteran who receives hospital, (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. nursing home, or outpatient care under 99–272) 38 U.S.C. 1710(a)(3) by virtue of the vet- (4) Determinations with respect to eran’s eligibility for hospital care and attributable income made under para- medical services under 38 U.S.C. graph (d)(1) and (2) of this section, shall 1710(a), fails to pay to the United be made in the same manner, including States the amounts agreed to under

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those sections shall be grounds for de- pursuant to § 17.47, or persons receiving termining, in accordance with guide- outpatient medical services pursuant lines promulgated by the Under Sec- to § 17.93 and who it is believed may be retary for Health, that the veteran is entitled to hospital care and/or medical not eligible to receive further care services or to reimbursement for all or under those sections until such part of the cost thereof from any one amounts have been paid in full. or more of the following parties: (i) Workers’ Compensation or employ- (Authority: 38 U.S.C. 1710, 1721; sec. 19011, er’s liability statutes, State or Federal; Pub. L. 99–272) (ii) By reason of statutory or other (g)(1) Persons hospitalized and/or re- relationships with third parties, in- ceiving medical services who have no cluding those liable for damages be- service-connected disabilities pursuant cause of negligence or other legal to § 17.47, and/or persons receiving out- wrong; patient medical services pursuant to (iii) By reason of a statute in a State, § 17.93 who have no service-connected or political subdivision of a State; disabilities who it is believed may be (A) Which requires automobile acci- eligible for hospital care and/or med- dent reparations or; ical services, or reimbursement for the (B) Which provides compensation or expenses of care or services for all or payment for medical care to victims part of the cost thereof by reason of suffering personal injuries as the result the following: of a crime of personal violence; (i) Membership in a union, fraternal (iv) Right to maintenance and cure in or other organization, or admiralty; (ii) Coverage under an insurance pol- will not be furnished hospital care or icy, or contract, medical, or hospital medical services without charge there- service agreement, membership, or fore to the extent of the amount for subscription contract or similar ar- which such parties are, will become, or rangement under which health services may be liable. Persons believed enti- for individuals are provided or the ex- tled to care under circumstances de- penses of such services are paid, will scribed in paragraph (g)(2)(ii) of this not be furnished hospital care or med- section will be required to complete ical services without charge therefore such forms as the Secretary may re- to the extent of the amount for which quire, such as a power of attorney and such parties referred to in paragraphs assignment. Notice of this assignment (g)(1)(i) or (g)(1)(ii) of this section, are, will be mailed promptly to the party or will become, or may be liable. Persons parties believed to be liable. When the believed entitled to care under any of amount of charges is ascertained, a bill the plans discussed above will be re- therefore will be mailed to such party quired to provide such information as or parties. Persons believed entitled to the Secretary may require. Provisions care under circumstances described in of this paragraph are effective April 7, paragraph (g)(2)(i) or (g)(2)(iii) of this 1986, except in the case of a health care section will be required to complete policy or contract that was entered such forms as the Secretary may re- into before that date, the effective date quire. shall be the day after the plan was modified or renewed or on which there (Authority: 38 U.S.C. 1729, sec. 19013, Pub. L. was any change in premium or cov- 99–272) erage and will apply only to care and (h) Within the limits of Department services provided by VA after the date of Veterans Affairs facilities, any vet- the plan was modified, renewed, or on eran who is receiving nursing home which there was any change in pre- care in a hospital under the direct ju- mium or coverage. risdiction of the Department of Vet- erans Affairs, may be furnished med- (Authority: 38 U.S.C. 1729; sec. 19013, Pub. L. ical services to correct or treat any 99–272) nonservice-connected disability of such (2) Persons hospitalized and/or receiv- veteran, in addition to treatment inci- ing medical services for the treatment dent to the disability for which the of nonservice-connected disabilities veteran is hospitalized, if the veteran

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is willing, and such services are reason- takes into account the patient’s im- ably necessary to protect the health of mune status and/or the infectivity of such veteran. the HIV or other pathogens (such as tu- (i) Participating in a rehabilitation pro- berculosis, cytomegalovirus, gram under 38 U.S.C. chapter 31 refers to cryptosporidiosis, etc.). Hospital Direc- any veteran tors are responsible for assuring that (1) Who is eligible for and entitled to admission criteria of all programs in participate in a rehabilitation program the medical center do not discriminate under chapter 31. solely on the basis of alcohol, drug (i) Who is in an extended evaluation abuse or infection with human im- period for the purpose of determining munodeficiency virus. Quality Assur- feasibility, or ance Programs should include indica- (ii) For whom a rehabilitation objec- tors and monitors for nondiscrimina- tive has been selected, or tion. (iii) Who is pursuing a rehabilitation program, or (Authority: 38 U.S.C. 7333) (iv) Who is pursuing a program of independent living, or (k) In seeking medical care from VA (v) Who is being provided employ- under 38 U.S.C. 1710 or 1712, a veteran ment assistance under 38 U.S.C. chap- shall furnish such information and evi- ter 31, and dence as the Secretary may require to (2) Who is medically determined to be establish eligibility. in need of hospital care or medical (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. services (including dental) for any of 99–272) the following reasons: [32 FR 13813, Oct. 4, 1967] (i) Make possible his or her entrance into a rehabilitation program; or EDITORIAL NOTE: For FEDERAL REGISTER ci- (ii) Achieve the goals of the veteran’s tations affecting § 17.47, see the List of CFR vocational rehabilitation program; or Sections Affected, which appears in the (iii) Prevent interruption of a reha- Finding Aids section of the printed volume and at www.govinfo.gov. bilitation program; or (iv) Hasten the return to a rehabilita- § 17.48 Compensated Work Therapy/ tion program of a veteran in inter- Transitional Residences program. rupted or leave status; or (v) Hasten the return to a rehabilita- (a) This section sets forth require- tion program of a veteran placed in dis- ments for persons residing in housing continued status because of illness, in- under the Compensated Work Therapy/ jury or a dental condition; or Transitional Residences program. (vi) Secure and adjust to employment (b) House managers shall be respon- during the period of employment as- sible for coordinating and supervising sistance; or the day-to-day operations of the facili- (vii) To enable the veteran to achieve ties. The local VA program coordinator maximum independence in daily living. shall select each house manager and may give preference to an individual (Authority: 38 U.S.C. 3104(a)(9); Pub. L. 96– who is a current or past resident of the 466, sec. 101(a)) facility or the program. A house manager must have the following qualifica- (j) Veterans eligible for treatment tions: under chapter 17 of 38 U.S.C. who are alcohol or drug abusers or who are in- (1) A stable, responsible and caring fected with the human immuno- demeanor; deficiency virus (HIV) shall not be dis- (2) Leadership qualities including the criminated against in admission or ability to motivate; treatment by any Department of Vet- (3) Effective communication skills erans Affairs health care facility solely including the ability to interact; because of their alcohol or drug abuse (4) A willingness to accept feedback; or dependency or because of their viral (5) A willingness to follow a chain of infection. This does not preclude the command. rule of clinical judgment in deter- (c) Each resident admitted to the mining appropriate treatment which Transitional Residence, except for a

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house manager, must also be in the Treatment team. However, the length Compensated Work Therapy program. of stay should not exceed 12 months. (d) Each resident, except for a house (Authority: 38 U.S.C. 2032) manager, must bi-weekly, in advance, pay a fee to VA for living in the hous- [70 FR 29627, May 24, 2005, as amended at 79 FR 54615, Sept. 12, 2014] ing. The local VA program coordinator will establish the fee for each resident § 17.49 Priorities for outpatient med- in accordance with the provisions of ical services and inpatient hospital paragraph (d)(1) of this section. care. (1) The total amount of actual oper- In scheduling appointments for out- ating expenses of the residence (utili- patient medical services and admis- ties, maintenance, furnishings, appli- sions for inpatient hospital care, the ances, service equipment, all other op- Under Secretary for Health shall give erating costs) for the previous fiscal priority to: year plus 15 percent of that amount (a) Veterans with service-connected equals the total operating budget for disabilities rated 50 percent or greater the current fiscal year. The total oper- based on one or more disabilities or ating budget is to be divided by the av- unemployability; and erage number of beds occupied during (b) Veterans needing care for a serv- the previous fiscal year and the result- ice-connected disability. ing amount is the average yearly (Authority: 38 U.S.C. 101, 501, 1705, 1710) amount per bed. The bi-weekly fee shall equal 1/26th of the average yearly [67 FR 58529, Sept. 17, 2002] amount per bed, except that a resident USE OF DEPARTMENT OF DEFENSE, PUB- shall not, on average, pay more than 30 LIC HEALTH SERVICE OR OTHER FED- percent of their gross CWT (Com- ERAL HOSPITALS pensated Work Therapy) bi-weekly earnings. The VA program manager § 17.50 Use of Department of Defense, shall, bi-annually, conduct a review of Public Health Service or other Fed- the factors in this paragraph for deter- eral hospitals with beds allocated to mining resident payments. If he or she the Department of Veterans Affairs. determines that the payments are too Hospital facilities operated by the high or too low by more than 5 percent Department of Defense or the Public of the total operating budget, he or she Health Service (or any other agency of shall recalculate resident payments the United States Government) may be under the criteria set forth in this used for the care of VA patients pursu- paragraph, except that the calculations ant to agreements between VA and the shall be based on the current fiscal department or agency operating the fa- year (actual amounts for the elapsed cility. When such an agreement has portion and projected amounts for the been entered into and a bed allocation remainder). for VA patients has been provided for in a specific hospital covered by the (2) If the revenues of a residence do agreement, care may be authorized not meet the expenses of the residence within the bed allocation for any vet- resulting in an inability to pay actual eran eligible under 38 U.S.C. 1710 or operating expenses, the medical center § 17.44. Care in a Federal facility not of jurisdiction shall provide the funds operated by VA, however, shall not be necessary to return the residence to authorized for any military retiree fiscal solvency in accordance with the whose sole basis for eligibility is under provisions of this section. § 17.44, or, except in Alaska and Hawaii, (e) The length of stay in housing for any retiree of the uniformed serv- under the Compensated Work Therapy/ ices suffering from a chronic disability Transitional Residences program is whose entitlement is under § 17.44 or based on the individual needs of each § 17.46(a)(2) regardless of whether he or resident, as determined by consensus of she may have dual eligibility under the resident and his/her VA Clinical other provisions of § 17.46. [79 FR 54615, Sept. 12, 2014]

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§ 17.51 Emergency use of Department (i) A veteran who has a service-con- of Defense, Public Health Service or nected disability rated at 50 percent or other Federal hospitals. more, Hospital care in facilities operated (ii) A veteran who has been furnished by the Department of Defense or the hospital care, nursing home care, domi- Public Health Service (or any other ciliary care, or medical services, and agency of the U.S. Government) which requires medical services to complete do not have beds allocated for the care treatment incident to such care or of Department of Veterans Affairs pa- services (each authorization for non- tients may be authorized subject to the VA treatment needed to complete limitations enumerated in § 17.50 only treatment may continue for up to 12 in emergency circumstances for any months, and new authorizations may veteran otherwise eligible for hospital be issued by VA as needed), and care under 38 U.S.C. 1710 or 38 CFR (iii) A veteran of the Mexican border 17.46. period or World War I or who is in receipt of increased pension or additional [33 FR 19010, Dec. 20, 1968. Redesignated and compensation based on the need for aid amended at 61 FR 21965, 21966, May 13, 1996] and attendance or housebound benefits USE OF PUBLIC OR PRIVATE HOSPITALS when it has been determined based on an examination by a physician em- § 17.52 Hospital care and medical serv- ployed by VA (or, in areas where no ices in non-VA facilities. such physician is available, by a physi- (a) When VA facilities or other gov- cian carrying out such function under ernment facilities are not capable of a contract or fee arrangement), that furnishing economical hospital care or the medical condition of such veteran medical services because of geographic precludes appropriate treatment in VA inaccessibility or are not capable of facilities; furnishing care or services required, (3) Hospital care or medical services VA may contract with non-VA facili- for the treatment of medical emer- ties for care in accordance with the gencies which pose a serious threat to provisions of this section. When de- the life or health of a veteran receiving mand is only for infrequent use, indi- hospital care or medical services in a vidual authorizations may be used. facility over which the Secretary has Care in public or private facilities, direct jurisdiction or government facil- however, subject to the provisions of ity with which the Secretary con- §§ 17.53, 17.54, 17.55 and 17.56, will only tracts, and for which the facility is not be authorized, whether under a con- staffed or equipped to perform, and tract or an individual authorization, transfer to a public or private hospital for— which has the necessary staff or equip- (1) Hospital care or medical services ment is the only feasible means of pro- to a veteran for the treatment of— viding the necessary treatment, until (i) A service-connected disability; or such time following the furnishing of (ii) A disability for which a veteran care in the non-VA facility as the vet- was discharged or released from the ac- eran can be safely transferred to a VA tive military, naval, or air service or facility; (iii) A disability of a veteran who has (4) Hospital care for women veterans; a total disability permanent in nature (5) Through September 30, 1988, hos- from a service-connected disability, or pital care or medical services that will (iv) For a disability associated with obviate the need for hospital admission and held to be aggravating a service- for veterans in the Commonwealth of connected disability, or Puerto Rico, except that the dollar ex- (v) For any disability of a veteran penditure in Fiscal year 1986 cannot ex- participating in a rehabilitation proceed 85% of the Fiscal year 1985 obliga- gram under 38 U.S.C. ch. 31 and when tions, in Fiscal year 1987 the dollar ex- there is a need for hospital care or penditure cannot exceed 50% of the Fis- medical services for any of the reasons cal year 1985 obligations and in Fiscal enumerated in § 17.48(i). year 1988 the dollar expenditure cannot (2) Medical services for the treatment exceed 25% of the Fiscal year 1985 obli- of any disability of— gations.

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(6) Hospital care or medical services (b) The Under Secretary for Health that will obviate the need for hospital shall only furnish care and treatment admission for veterans in Alaska, Ha- under paragraph (a) of this section to waii, Virgin Islands and other terri- veterans described in § 17.47(d). tories of the United States except that (1) To the extent that resources are the annually determined hospital pa- available and are not otherwise re- tient load and incidence of the fur- quired to assure that VA can furnish nishing of medical services to veterans needed care and treatment to veterans hospitalized or treated at the expense described in § 17.47 (a) and (c), and of VA in government and non-VA fa- (2) If the veteran agrees to pay the cilities in each such State or territory United States an amount as deter- shall be consistent with the patient mined under 38 U.S.C. 1710. load or incidence of the provision of (c) The provisions of this section medical services for veterans hospital- shall not apply to care furnished by VA ized or treated by VA within the 48 after June 6, 2019. contiguous States. (7) Outpatient dental services and [51 FR 25066, July 10, 1986, as amended at 53 treatment, and related dental appli- FR 32391, Aug. 25, 1988; 54 FR 53057, Dec. 27, 1989; 58 FR 32446, June 10, 1993. Redesignated ances, for a veteran who is a former and amended at 61 FR 21965, 21966, May 13, prisoner of war and was detained or in- 1996; 62 FR 17072, Apr. 9, 1997; 75 FR 78915, terned for a period of not less that 181 Dec. 17, 2010; 77 FR 70895, Nov. 28, 2012; 78 FR days. 76063, Dec. 16, 2013; 79 FR 54615, Sept. 12, 2014; (8) Hospital care or medical services 84 FR 26306, June 5, 2019] for the treatment of medical emergencies which pose a serious threat to § 17.53 Limitations on use of public or the life or health of a veteran which de- private hospitals. veloped during authorized travel to the The admission of any patient to a hospital, or during authorized travel private or public hospital at Depart- after hospital discharge preventing ment of Veterans Affairs expense will completion of travel to the originally only be authorized if a Department of designated point of return (and this Veterans Affairs medical center or will encompass any other medical serv- other Federal facility to which the pa- ices necessitated by the emergency, in- tient would otherwise be eligible for cluding extra ambulance or other admission is not feasibly available. A transportation which may also be fur- Department of Veterans Affairs facility nished at VA expense. may be considered as not feasibly (9) Diagnostic services necessary for available when the urgency of the ap- determination of eligibility for, or of plicant’s medical condition, the rel- the appropriate course of treatment in ative distance of the travel involved, or connection with, furnishing medical the nature of the treatment required services at independent VA outpatient makes it necessary or economically ad- clinics to obviate the need for hospital visable to use public or private facili- admission. ties. In those instances where care in (10) For any disability of a veteran public or private hospitals at Depart- receiving VA contract nursing home ment of Veterans Affairs expense is au- care. The veteran is receiving contract thorized because a Department of Vet- nursing home care and requires emer- erans Affairs or other Federal facility gency treatment in non-VA facilities. was not feasibly available, as defined (11) For completion of evaluation for in this section, the authorization will observation and examination (O&E) be continued after admission only for purposes, clinic directors or their des- the period of time required to stabilize ignees will authorize necessary diag- or improve the patient’s condition to nostic services at non-VA facilities (on the extent that further care is no an inpatient or outpatient basis) in longer required to satisfy the purpose order to complete requests from VA for which it was initiated. Regional Offices for O&E of a person to [39 FR 17223, May 14, 1974, as amended at 47 determine eligibility for VA benefits or FR 58248, Dec. 30, 1982. Redesignated at 61 FR services. 21965, May 13, 1996]

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§ 17.54 [Reserved] PRICER program, in accordance with subpart F of 42 CFR part 412. § 17.55 Payment for authorized public (e) In addition to the amount payable or private hospital care. under paragraph (a) of this section, VA Except as otherwise provided in this shall pay, for each discharge, an section, payment for public or private amount to cover the non-Federal hos- hospital care furnished on or before pital’s capital-related costs, kidney, June 6, 2019, under 38 U.S.C. 1703 and heart and liver acquisition costs in- § 17.52, or at any time under 38 U.S.C. curred by hospitals with approved 1728 and §§ 17.120 and 17.128 or under 38 transplantation centers, direct costs of U.S.C. 1787 and § 17.410, shall be based medical education, and the costs of on a prospective payment system simi- qualified nonphysician anesthetists in lar to that used in the Medicare pro- small rural hospitals. These amounts gram for paying for similar inpatient will be determined by the Under Sec- hospital services in the community. retary for Health on an annual basis Payment shall be made using the Cen- and published in the ‘‘Notices’’ section ters for Medicare & Medicaid Services of the FEDERAL REGISTER. (CMS) PRICER for each diagnosis-re- (f) Payment shall be made only for lated group (DRG) applicable to the those services authorized by VA. episode of care. (g) Payments made in accordance (a) Payment shall be made of the full with this section shall constitute pay- prospective payment amount per dis- ment in full and the provider or agent charge, as determined according to the for the provider may not impose any methodology in subparts D and G of 42 additional charge on a veteran or his or CFR part 412, as appropriate. her health care insurer for any inpa- (b)(1) In the case of a veteran who tient services for which payment is was transferred to another facility be- made by the VA. fore completion of care, VA shall pay (h) Hospitals of distinct part hospital the transferring hospital an amount units excluded from the prospective calculated by the HCFA PRICER for payment system by Medicare and hos- each patient day of care, not to exceed pitals that do not participate in Medi- the full DRG rate as provided in para- care will be paid at the national cost- graph (a) of this section. The hospital to-charge ratio times the billed that ultimately discharges the patient will receive the full DRG payment. charges that are reasonable, usual, cus- tomary, and not in excess of rates or (2) In the case of a veteran who has transferred from a hospital and/or dis- fees the hospital charges the general tinct part unit excluded by Medicare public for similar services in the com- from the DRG-based prospective pay- munity. ment system or from a hospital that (i) A hospital participating in an al- does not participate in Medicare, the ternative payment system that has transferring hospital will receive a been granted a Federal waiver from the payment for each patient day of care prospective payment system under the not to exceed the amount provided in provisions of 42 U.S.C. section paragraph (i) of this section. 1395f(b)(3) or 42 U.S.C. section 1395ww(c) (c) VA shall pay the providing facil- for the purposes of Medicare payment ity the full DRG-based rate or reason- shall not be subject to the payment able cost, without regard to any copay- methodology set forth in this section ments or deductible required by any so long as such Federal waiver remains Federal law that is not applicable to in effect. VA. (j) Payments for episodes of hospital (d) If the cost or length of a veteran’s care furnished in Alaska that begin care exceeds an applicable threshold during the period starting on the effec- amount, as determined by the HCFA tive date of this section through the PRICER program, VA shall pay, in ad- 364th day thereafter will be in the dition to the amount payable under amount determined by the HCFA paragraph (a) of this section, an outlier PRICER plus 50 percent of the dif- payment calculated by the HCFA ference between the amount billed by

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the hospital and the amount deter- lings (if the facility has had at least mined by the PRICER. Claims for serv- eight billings) from non-VA facilities ices provided during that period will be under the corresponding procedure accepted for payment by VA under this code during the previous fiscal year, paragraph (k) until December 31 of the with billings ranked from the highest year following the year in which this to the lowest. The VA Fee Schedule section became effective. amount is the charge falling at the (k) Notwithstanding other provisions 75th percentile. If the authorizing facil- of this section, VA, for public or pri- ity has not had at least eight such bil- vate hospital care covered by this sec- lings, then this paragraph does not tion, will pay the lesser of the amount apply. determined under paragraphs (a) (ii) The amount negotiated by a re- through (j) of this section or the pricing agent if the provider is partici- amount negotiated with the hospital or pating within the repricing agent’s net- its agent. work and VA has a contract with that [55 FR 42852, Oct. 24, 1990. Redesignated and repricing agent. For the purposes of amended at 61 FR 21965, 21966, May 13, 1996; 62 this section, repricing agent means a FR 17072, Apr. 9, 1997; 63 FR 39515, July 23, contractor that seeks to connect VA 1998; 65 FR 66637, Nov. 7, 2000; 84 FR 26306, with discounted rates from non-VA June 5, 2019] providers as a result of existing contracts that the non-VA provider may § 17.56 VA payment for inpatient and have within the commercial health outpatient health care professional services at non-departmental facili- care industry. ties and other medical charges asso- (iii) The amount that the provider ciated with non-VA outpatient care. bills the general public for the same (a) Except for health care profes- service. sional services provided in the state of (b) For physician and non-physician Alaska (see paragraph (b) of this sec- professional services rendered in Alas- tion), VA will determine the amounts ka, VA will pay for services in accord- paid under § 17.52 or § 17.120 for health ance with a fee schedule that uses the care professional services, and all other Health Insurance Portability and Ac- medical services associated with non- countability Act mandated national VA outpatient care, using the applica- standard coding sets. VA will pay a ble method in this section: specific amount for each service for (1) If a specific amount has been ne- which there is a corresponding code. gotiated with a specific provider, VA Under the VA Alaska Fee Schedule, the will pay that amount. amount paid in Alaska for each code (2) If an amount has not been nego- will be 90 percent of the average tiated under paragraph (a)(1) of this amount VA actually paid in Alaska for section, VA will pay the lowest of the the same services in Fiscal Year (FY) following amounts: 2003. For services that VA provided less (i) The applicable Medicare fee sched- than eight times in Alaska in FY 2003, ule or prospective payment system for services represented by codes estab- amount (‘‘Medicare rate’’) for the pe- lished after FY 2003, and for unit-based riod in which the service was provided codes prior to FY 2004, VA will take the (without any changes based on the sub- Centers for Medicare and Medicaid sequent development of information Services’ rate for each code and mul- under Medicare authorities), subject to tiply it times the average percentage the following: paid by VA in Alaska for Centers for (A) In the event of a Medicare waiver, Medicare and Medicaid Services-like the payment amount will be calculated codes. VA will increase the amounts on in accordance with such waiver. the VA Alaska Fee Schedule annually (B) In the absence of a Medicare rate in accordance with the published na- or Medicare waiver, payment will be tional Medicare Economic Index (MEI). the VA Fee Schedule amount for the For those years where the annual aver- period in which the service was pro- age is a negative percentage, the fee vided. The VA Fee Schedule amount is schedule will remain the same as the determined by the authorizing VA previous year. Payment for non-VA medical facility, which ranks all bil- health care professional services in

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Alaska shall be the lesser of the the United States an amount as deter- amount billed or the amount cal- mined in 38 U.S.C. 1710(f). culated under this subpart. (c) Payments made by VA to a non- (Authority: 38 U.S.C. 1710, 1720; sec. 19011, VA facility or provider under this sec- Pub. L. 99–272) tion shall be considered payment in (Authority: 38 U.S.C. 1720(b) full. Accordingly, the facility or provider or agent for the facility or pro- [51 FR 25067, July 10, 1986. Redesignated and vider may not impose any additional amended at 61 FR 21965, 21966, May 13, 1996 charge for any services for which pay- and further redesignated at 63 FR 39515, July ment is made by VA. 23, 1998; 79 FR 54615, Sept. 12, 2014] (d) In a case where a veteran has paid § 17.58 Evacuation of community nurs- for emergency treatment for which VA ing homes. may reimburse the veteran under § 17.120, VA will reimburse the amount When veterans are evacuated from a that the veteran actually paid. Any community nursing home as the result amounts due to the provider but un- of an emergency, they may be relo- paid by the veteran will be reimbursed cated to another facility that meets to the provider under paragraphs (a) certain minimum standards, as set and (b) of this section. forth in 38 CFR 51.59(c)(1). (e) Except for payments for care furnished under 38 U.S.C. 1725 and § 17.1005, (Authority: 38 U.S.C. 501, 1720) under 38 U.S.C. 1728 and §§ 17.120 and [76 FR 55571, Sept. 8, 2011] 17.128, or under 38 U.S.C. 1787 and § 17.410, the provisions of this section § 17.60 Extensions of community nurs- shall not apply to care furnished by VA ing home care beyond six months. after June 6, 2019, or care furnished Directors of health care facilities pursuant to an agreement authorized may authorize, for any veteran whose by 38 U.S.C. 1703A. hospitalization was not primarily for a [75 FR 78915, Dec. 17, 2010, as amended at 78 service-connected disability, an exten- FR 26251, May 6, 2013; 78 FR 68364, Nov. 14, sion of nursing care in a public or pri- 2013; 79 FR 16200, Mar. 25, 2014; 84 FR 26306, vate nursing home care facility at VA June 5, 2019] expense beyond six months when the USE OF COMMUNITY NURSING HOME CARE need for nursing home care continues FACILITIES to exist and (a) Arrangements for payment of § 17.57 Use of community nursing such care through a public assistance homes. program (such as Medicaid) for which (a) Nursing home care in a contract the veteran has applied, have been de- public or private nursing home facility layed due to unforeseen eligibility may be authorized for the following: problems which can reasonably be ex- Any veteran who has been discharged pected to be resolved within the exten- from a hospital under the direct juris- sion period, or diction of VA and is currently receiv- (b) The veteran has made specific ar- ing VA hospital based home health rangements for private payment for services. such care, and (1) Such arrangements cannot be ef- (Authority: 38 U.S.C. 1720; sec. 108, Pub. L. 99–166) fectuated as planned because of unforseen, unavoidable difficulties, (b) To the extent that resources are such as a temporary obstacle to liq- available and are not otherwise re- uidation of property, and quired to assure that VA can furnish (2) Such difficulties can reasonably needed care and treatment to veterans be expected to be resolved within the described in 38 U.S.C. 1710(a)(1) and (a)(2), the Under Secretary for Health extension period; or may furnish care under this paragraph (c) The veteran is terminally ill and to any veteran described in 38 U.S.C. life expectancy has been medically de- 1710(a)(3) if the veteran agrees to pay termined to be less than six months.

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(d) In no case may an extension has jurisdiction to approve a commu- under paragraph (a) or (b) of this sec- nity residential care facility. tion exceed 45 days. Community residential care means the (Authority: 38 U.S.C. 501, 1720(a)) monitoring, supervision, and assistance, in accordance with a statement [53 FR 13121, Apr. 21, 1988. Redesignated at 61 of needed care, of the activities of daily FR 21965, May 13, 1996] living activities and instrumental ac- COMMUNITY RESIDENTIAL CARE tivities of daily living, of referred veterans in an approved home in the com- SOURCE: 54 FR 20842, May 15, 1989, unless munity by the facility’s provider. otherwise noted. Hearing official means the Director or, if designated by the Director, the § 17.61 Eligibility. Associate Director or Chief of Staff of VA health care personnel may assist a Department of Veterans Affairs Med- a veteran by referring such veteran for ical Center or Outpatient Clinic which placement in a privately or publicly- has jurisdiction to approve a commu- owned community residential care fa- nity residential care facility. cility if: Instrumental activities of daily living (a) At the time of initiating the as- are tasks that are not necessary for sistance: fundamental functioning, but allow an (1) The veteran is receiving VA med- individual to live independently in a ical services on an outpatient basis or community. Instrumental activities of VA medical center, domiciliary, or daily living include: housekeeping and nursing home care; or cleaning room; meal preparation; tak- (2) Such care or services were fur- ing medications; laundry; assistance nished the veteran within the pre- with transportation; shopping—for gro- ceding 12 months; ceries, clothing or other items; ability (b) The veteran does not need hos- to use the telephone; ability to manage pital or nursing home care but is un- finances; writing letters; and obtaining able to live independently because of appointments. medical (including psychiatric) condi- Oral hearing means the in person tes- tions and has no suitable family re- timony of representatives of a commu- sources to provide needed monitoring, nity residential care facility and of VA supervision, and any necessary assist- before the hearing official and the re- ance in the veteran’s activities of daily view of the written evidence of record living and instrumental activities of by that official. daily living ; and Paper hearing means a review of the (c) The facility has been approved in written evidence of record by the hear- accordance with § 17.63 of this part. ing official. [54 FR 20842, May 15, 1989. Redesignated and [84 FR 33697, July 15, 2019] amended at 61 FR 21965, 21966, May 13, 1996; 84 FR 33696, July 15, 2019] § 17.63 Approval of community resi- § 17.62 Definitions. dential care facilities. For the purpose of §§ 17.61 through The approving official may approve a 17.72: community residential care facility, Activities of daily living means basic based on the report of a VA inspection daily tasks an individual performs as and on any findings of necessary in- part of self-care which may be used as terim monitoring of the facility, if that a measurement of the functional status facility meets the following standards: of a person including: walking; bath- (a) Health and safety standards. The ing, shaving, brushing teeth, combing facility must: hair; dressing; eating; getting in or get- (1) Meet all State and local regulating out of bed; and toileting. tions including construction, mainte- Approving official means the Director nance, and sanitation regulations; or, if designated by the Director, the (2) Meet the requirements in the ap- Associate Director or Chief of Staff of plicable provisions of NFPA 101 and a Department of Veterans Affairs Med- NFPA 101A (incorporated by reference, ical Center or Outpatient Clinic which see § 17.1) and the other publications

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referenced in those provisions. The in- (3) Maintain at least one functional stitution shall provide sufficient staff toilet and lavatory, and bathing or to assist patients in the event of fire or shower facility for every six people liv- other emergency. Any equivalencies or ing in the facility, including provider variances to VA requirements must be and staff. approved by the appropriate Veterans (d) Laundry service. The facility must Health Administration Veterans Inte- provide or arrange for laundry service. grated Service Network (VISN) Direc- (e) Residents’ bedrooms. Residents’ tor; bedrooms must: (3) Have safe and functioning systems (1) Contain no more than four beds; for heating and/or cooling, as needed (a (i) Facilities approved before August heating or cooling system is deemed to 24, 2017 may not establish any new resi- be needed if VA determines that, in the dent bedrooms with more than two county, parish, or similar jurisdiction beds per room; where the facility is located, a major- (ii) Facilities approved after August ity of community residential care fa- 24, 2017 may not provide resident bed- cilities or other extended care facilities rooms containing more than two beds have one), hot and cold water, elec- per room. tricity, plumbing, sewage, cooking, (2) Measure, exclusive of closet space, laundry, artificial and natural light, at least 100 square feet for a single-resi- and ventilation. dent room, or 80 square feet for each (4) Meet the following additional re- resident in a multiresident room; and quirements, if the provisions for One (3) Contain a suitable bed for each and Two-Family Dwellings, as defined resident and appropriate furniture and in NFPA 101, are applicable to the fa- furnishings. cility: (f) Nutrition. The facility must: (i) Portable fire extinguishers must (1) Provide a safe and sanitary food be installed, inspected, and maintained service that meets individual nutri- in accordance with NFPA 10 (incor- tional requirements and residents’ porated by reference, see § 17.1); and preferences; (ii) The facility must meet the re- (2) Plan menus to meet currently rec- quirements in section 33.7 of NFPA 101. ommended dietary allowances; (b) Level of care. The community resi- (g) Activities. The facility must plan dential care facility must provide the and facilitate appropriate recreational resident, at a minimum, a base level of and leisure activities to meet indi- care to include room and board; nutri- vidual needs. tion consisting of three meals per day (h) Residents’ rights. The facility must and two snacks, or as required to meet have written policies and procedures special dietary needs; laundry services; that ensure the following rights for transportation (either provided or ar- each resident: ranged) to VA and healthcare appoint- (1) Each resident has the right to: ments; and accompanying the resident (i) Be informed of the rights de- to appointments if needed; 24-hour su- scribed in this section; pervision, if indicated; and care, super- (ii) The confidentiality and non- vision, and assistance with activities of disclosure of information obtained by daily living and instrumental activi- community residential care facility ties of daily living. In those cases staff on the residents and the residents’ where the resident requires more than records subject to the requirements of a base level of care, the medically ap- applicable law; propriate level of care must be pro- (iii) Be able to inspect the residents’ vided. own records kept by the community (c) Interior plan. The facility must: residential care facility; (1) Have comfortable dining areas, (iv) Exercise rights as a citizen; and adequate in size for the number of resi- (v) Voice grievances and make rec- dents; ommendations concerning the policies (2) Have confortable living room and procedures of the facility. areas, adequate in size to accommodate (2) Financial affairs. Residents must a reasonable proportion of residents; be allowed to manage their own per- and sonal financial affairs, except when the

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resident has been restricted in this (j) Staff requirements. (1) Sufficient, right by law. If a resident requests as- qualified staff must be on duty and sistance from the facility in managing available to care for the resident and personal financial affairs the request ensure the health and safety of each must be documented. resident. (3) Privacy. Residents must: (2) The community residential care (i) Be treated with respect, consider- provider and staff must have the fol- ation, and dignity; lowing qualifications: Adequate edu- (ii) Have access, in reasonable pri- cation, training, or experience to main- vacy, to a telephone within the facil- tain the facility. ity; (3) The community residential care (iii) Be able to send and receive mail provider must develop and implement unopened and uncensored; and written policies and procedures that (iv) Have privacy of self and posses- prohibit mistreatment, neglect, and sions. abuse of residents and misappropria- (4) Work. No resident will perform tion of resident property. household duties, other than personal (4) Except as provided in paragraph housekeeping tasks, unless the resident (j)(5)(ii) of this section, the community receives compensation for these duties residential care provider must not em- or is told in advance they are vol- ploy individuals who— untary and the patient agrees to do (i) Have been convicted within 7 them. years by a court of law of any of the (5) Freedom of association. Residents following offenses or their equivalent have the right to: in a state or territory: (i) Receive visitors and associate (A) Murder, attempted murder, or freely with persons and groups of their manslaughter; own choosing both within and outside (B) Arson; the facility; (C) Assault, battery, assault and bat- (ii) Make contacts in the community tery, assault with a dangerous weapon, and achieve the highest level of inde- mayhem or threats to do bodily harm; pendence, autonomy, and interaction (D) Burglary; in the community of which the resi- (E) Robbery; dent is capable; (F) Kidnapping; (iii) Leave and return freely to the (G) Theft, fraud, forgery, extortion or facility, and blackmail; (iv) Practice the religion of their own (H) Illegal use or possession of a fire- choosing or choose to abstain from re- arm; ligious practice. (I) Rape, sexual assault, sexual bat- (6) Transfer. Residents have the right tery, or sexual abuse; to transfer to another facility or to an (J) Child or elder abuse, or cruelty to independent living situation. children or elders; or (i) Records. (1) The facility must (K) Unlawful distribution or posses- maintain records on each resident in a sion with intent to distribute a con- secure place. Resident records must in- trolled substance; or clude a copy of all signed agreements (ii) Have had a finding entered within with the resident. Resident records 6 months into an applicable State reg- may be disclosed only with the permis- istry or with the applicable licensing sion of the resident; an authorized authority concerning abuse, neglect, agent, fiduciary, or personal represent- mistreatment of individuals or mis- ative if the resident is not competent; appropriation of property. or when required by law. (5)(i) If the conviction by a court of (2) The facility must maintain and law of a crime enumerated in para- make available, upon request of the ap- graph (j)(4)(i) of this section occurred proving VA official, records estab- greater than 7 years in the past, or a lishing compliance with paragraphs finding was entered into an applicable (j)(1) and (2) of this section; written State registry as specified in paragraph policies and procedures required under (j)(4)(ii) of this section more than 6 paragraph (j)(3) of this section; and, months in the past, the community emergency notification procedures. residential care provider must perform

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an individual assessment of the appli- (D) The name of any public or private cant or employee to determine suit- officials or VHA program offices that ability for employment. The individual have been notified of the alleged viola- assessment must include consideration tions, if any; of the following factors: (E) Whether additional investigation (A) The nature of the job held or is necessary to provide VHA with more sought; information about the alleged viola- (B) The nature and gravity of the of- tion; fense or offenses; (F) The name of the alleged victim; (C) The time that has passed since (G) Contact information for the resi- the conviction and/or completion of the dent’s next of kin or other designated sentence; family member, agent, personal rep- (D) The facts or circumstances surrounding the offense or conduct; resentative, or fiduciary; and (E) The number of offenses for which (H) Contact information for a person the individual was convicted; who can provide additional details at (F) The employee or applicant’s age the community residential care pro- at the time of conviction, or release vider, including a name, position, loca- from prison; tion, and phone number. (G) The nexus between the criminal (ii) The community residential care conduct of the person and the job du- provider must notify the resident’s ties of the position; next of kin, caregiver, other designated (H) Evidence that the individual per- family member, agent, personal rep- formed the same type of work, post- resentative, or fiduciary of the alleged conviction, with the same or a dif- incident concurrently with submission ferent employer, with no known inci- of the incident report to the approving dents of criminal conduct; official. (I) The length and consistency of em- (iii) The community residential care ployment history before and after the provider must have evidence that all offense or conduct; rehabilitation ef- alleged violations involving mistreat- forts, including education or training; ment, neglect, or abuse, including inju- and, ries of unknown source, and misappro- (J) Employment or character ref- priation of resident property are docu- erences and any other information re- mented and thoroughly investigated, garding fitness for the particular posi- and must prevent further abuse while tion. the investigation is in progress. The re- (ii) An individual assessment must be sults of all investigations must be re- performed to determine suitability for ported to the approving official within employment for any conviction defined 5 working days of the incident and to in paragraph (j)(8)(iv), regardless of the other officials in accordance with all age of the conviction. other applicable law, and appropriate (6)(i) The community residential care corrective action must be taken if the provider must ensure that all alleged alleged violation is verified. Any cor- violations involving mistreatment, neglect, or abuse, including injuries of rective action taken by the community unknown source, and misappropriation residential care provider as a result of of resident property are reported to the such investigation must be reported to approving official immediately, which the approving official, and to other of- means no more than 24 hours after the ficials as required under all other ap- provider becomes aware of the alleged plicable law. violation; and to other officials in ac- (iv) The community residential care cordance with State law. The report, at provider must remove all duties requir- a minimum, must include— ing direct resident contact with vet- (A) The facility name, address, tele- eran residents from any employee al- phone number, and owner; leged to have violated this paragraph (B) The date and time of the alleged (j) during the investigation of such em- violation; ployee. (C) A summary of the alleged viola- (7) For purposes of this paragraph (j), tion; the term ‘‘employee’’ includes a:

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(i) Non-VA health care provider at residential care facility must be re- the community residential care facil- viewed annually by the facility and ity; VA, or as required due to changes in (ii) Staff member of the community care needs. residential care facility who is not a (4) The charges for community resi- health care provider, including a con- dential care must be reasonable and tractor; and comparable to the current average rate (iii) Person with direct resident ac- for residential care in the State or Re- cess. The term ‘‘person with direct gion for the same level of care provided resident access’’ means an individual to the resident. Notwithstanding, any living in the facility who is not receiv- year to year increase in the charge for ing services from the facility, who may care in a community residential care have access to a resident or a resident’s facility for the same level of care may property, or may have one-on-one con- not exceed the annual percentage in- tact with a resident. crease in the National Consumer Price (8) For purposes of this paragraph (j), Index (CPI) for that year. In estab- an employee is considered ‘‘convicted’’ lishing an individual residential rate, of a criminal offense— consideration should be given to the (i) When a judgment of conviction level of care required and the indi- has been entered against the individual vidual needs of the resident. The ap- by a Federal, State, or local court, re- proving official may approve a rate: gardless of whether there is an appeal (i) Lower than the current average pending; rate for residential care in the State or (ii) When there has been a finding of Region for the same level of care if the guilt against the individual by a Fed- community residential care facility eral, State, or local court; and the resident or authorized personal (iii) When a plea of guilty or nolo representative agreed to such rate, pro- contendere by the individual has been vided such lower rate does not result in accepted by a Federal, State, or local a lower level of care than the resident court; or requires; (iv) When the individual has entered (ii) Higher than the current average into participation in a first offender, rate for residential care in the State or deferred adjudication, or other ar- Region for the same level of care if the rangement or program where judgment community residential care facility of conviction has been withheld. and the resident or authorized personal (9) For purposes of this paragraph (j), representative agreed to such rate, and the terms ‘‘abuse’’ and ‘‘neglect’’ have the higher rate is related to the indi- the same meaning set forth in 38 CFR vidual needs of the resident which ex- 51.90(b). ceed the base level of care as defined in (k) Cost of community residential care. paragraph (b) of this section. Examples (1) Payment for the charges of commu- of services which exceed the base level nity residential care is not the respon- of care include, but are not limited to, sibility of the United States Govern- handling disbursement of funds solely ment or VA. at the request of the resident; fulfilling (2) The cost of community residential special dietary requests by the resident care should reflect the cost of pro- or family member; accompanying the viding the base level of care as defined resident to an activity center; assisting in paragraph (b) of this section. in or providing scheduled socialization (3) The resident or an authorized per- activities; supervision of an unsafe sonal representative and a representa- smoker; bowel and bladder care; inter- tive of the community residential care vention related to behavioral issues; facility must agree upon the charge and transportation other than for VA and payment procedures for commu- and healthcare appointments. nity residential care. Any agreement (5) The approving official may ap- between the resident or an authorized prove a deviation from the require- personal representative and the comments of paragraph (k)(4) of this sec- munity residential care facility must tion if the resident chooses to pay be approved by the approving official. more for care at a facility which ex- The charge for care in a community ceeds the base level of care as defined

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in paragraph (b) of this section not- cannot be corrected as provided in withstanding the resident’s needs. paragraph (b) of this section for provisional approval of the community resi- (The information collection requirements in this section have been approved by the Office dential care facility; and granting the of Management and Budget under control waiver is in the best interests of the number 2900–0844.) veteran in the facility and VA’s community residential care program. In [54 FR 20842, May 15, 1989, as amended at 54 FR 22754, May 26, 1989. Redesignated at 61 FR order to reach the above determina- 21965, May 13, 1996, as amended at 61 FR tions, the VA safety expert may re- 63720, Dec. 2, 1996; 69 FR 18803, Apr. 9, 2004; 74 quest supporting documentation from FR 63308, Dec. 3, 2009; 76 FR 10248, Feb. 24, the community residential care facil- 2011; 82 FR 34415, July 25, 2017; 82 FR 35451, ity. July 31, 2017; 84 FR 33697, July 15, 2019] (2) In those instances where a waiver is granted, the subject standard is § 17.64 [Reserved] deemed to have been met for purposes § 17.65 Approvals and provisional ap- of approval of the community residen- provals of community residential tial care facility under paragraphs (a) care facilities. or (b) of this section. The waiver and (a) An approval of a facility meeting date of issuance will be noted on each all of the standards in 38 CFR 17.63 annual survey of the facility as long as based on the report of a VA inspection the waiver remains valid and in place. and any findings of necessary interim (3) A waiver issued under this section monitoring of the facility shall be for a remains valid so long as the commu- 12-month period. nity residential care facility operates (b) The approving official, based on continuously under this program with- the report of a VA inspection and on out a break. VA may, on the rec- any findings of necessary interim mon- ommendation of an approving official, itoring of the facility, may provide a rescind a waiver issued under this sec- community residential care facility tion if a VA inspector determines that with a provisional approval if that fa- there has been a change in cir- cility does not meet one or more of the cumstances and that the deficiency can standards in 38 CFR 17.63, provided that now be corrected, or a VA safety expert the deficiencies do not jeopardize the finds that the deficiency jeopardizes health or safety of the residents, and the health and safety of residents. that the facility management and VA [74 FR 63308, Dec. 3, 2009, as amended at 78 agree to a plan of correcting the defi- FR 32126, May 29, 2013] ciencies in a specified amount of time. A provisional approval shall not be for § 17.66 Notice of noncompliance with more than 12 months and shall not be VA standards. for more time than VA determines is If the hearing official determines reasonable for correcting the specific that an approved community residen- deficiencies. tial care facility does not comply with (c) An approval may be changed to a the standards set forth in § 17.63 of this provisional approval or terminated part, the hearing official shall notify under the provisions of §§ 17.66 through the community residential care facil- 17.71 because of a subsequent failure to ity in writing of: meet the standards of § 17.63 and a pro- (a) The standards which have not visional approval may be terminated been met; under the provisions of §§ 17.66 through (b) The date by which the standards 17.71 based on failure to meet the plan must be met in order to avoid revoca- of correction or failure otherwise to tion of VA approval; meet the standards of § 17.63. (c) The community residential care (d)(1) VA may waive one or more of facility’s opportunity to request an the standards in 38 CFR 17.63 for the oral or paper hearing under § 17.67 of approval of a particular community this part before VA approval is re- residential care facility, provided that voked; and a VA safety expert certifies that the (d) The date by which the hearing of- deficiency does not endanger the life or ficial must receive the community res- safety of the residents; the deficiency idential care facility’s request for a

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hearing, which shall not be less than 10 (b) Upon the receipt of a community calendar days and not more than 20 residential care facility’s request for a calendar days after the date of VA no- paper hearing, the hearing official tice of noncompliance, unless the hear- shall notify the community residential ing official determines that noncompli- care facility operator that written ance with the standards threatens the statements and other evidence must be lives of community residential care submitted to the hearing official by a residents in which case the hearing of- specified date in order to be considered ficial must receive the community res- as part of the record. idential care facility’s request for an (c) In all hearings, the community oral or paper hearing within 36 hours of residential care facility operator and receipt of VA notice. VA may be represented by counsel. [54 FR 20842, May 15, 1989. Redesignated and [54 FR 20842, May 15, 1989. Redesignated at 61 amended at 61 FR 21965, 21967, May 13, 1996; 78 FR 21965, May 13, 1996] FR 32126, May 29, 2013] § 17.69 Waiver of opportunity for hear- § 17.67 Request for a hearing. ing. The community residential care fa- If representatives of a community cility operator must specify in writing residential care facility which receive whether an oral or paper hearing is re- a notice of noncompliance under § 17.66 quested. The request for the hearing of this part fail to appear at an oral must be sent to the hearing official. hearing of which they have been noti- Timely receipt of a request for a hear- fied or fail to submit written state- ing will stay the revocation of VA ap- ments for a paper hearing in accord- proval until the hearing official issues ance with § 17.68 of this part, unless the a written decision on the community hearing official determines that their residential care facility’s compliance failure was due to circumstances be- with VA standards. The hearing official yond their control, the hearing official may accept a request for a hearing re- shall: ceived after the time limit, if the com- (a) Consider the representatives of munity residential care facility shows the community residential care facil- that the failure of the request to be re- ity to have waived their opportunity ceived by the hearing official’s office for a hearing; and, by the required date was due to cir- (b) Revoke VA approval of the com- cumstances beyond its control. munity residential care facility and notify the community residential care [54 FR 20842, May 15, 1989. Redesignated at 61 facility of this revocation. FR 21965, May 13, 1996] [54 FR 20842, May 15, 1989. Redesignated and § 17.68 Notice and conduct of hearing. amended at 61 FR 21965, 21967, May 13, 1996] (a) Upon receipt of a request for an § 17.70 Written decision following a oral hearing, the hearing official shall: hearing. (1) Notify the community residential (a) The hearing official shall issue a care facility operator of the date, time, written decision within 20 days of the and location for the hearing; and completion of the hearing. An oral (2) Notify the community residential hearing shall be considered completed care facility operator that written when the hearing ceases to receive in statements and other evidence for the person testimony. A paper hearing record may be submitted to the hear- shall be considered complete on the ing official before the date of the hear- date by which written statements must ing. An oral hearing shall be informal. be submitted to the hearing official in The rules of evidence shall not be fol- order to be considered as part of the lowed. Witnesses shall testify under record. oath or affirmation. A recording or (b) The hearing official’s determina- transcript of every oral hearing shall tion of a community residential care be made. The hearing official may ex- facility’s noncompliance with VA clude irrelevant, immaterial, or unduly standards shall be based on the prepon- repetitious testimony. derance of the evidence.

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(c) The written decision shall in- ards set forth in § 17.63 of this part and clude: determines that the community resi- (1) A statement of the facts; dential care facility shall have an addi- (2) A determination whether the com- tional time period to remedy the non- munity residential care facility com- compliance, the hearing official shall plies with the standards set forth in review at the end of the time period § 17.63 of this part; and the evidence of the community residen- (3) A determination of the time pe- tial care facility’s compliance with the riod, if any, the community residential standards which were to have been met care facility shall have to remedy any by the end of that time period and de- noncompliance with VA standards be- termine if the community residential fore revocation of VA approval occurs. care facility complies with the stand- (d) The hearing official’s determina- ards. If the community residential care tion of any time period under para- facility fails to comply with these or graph (c)(3) of this section shall con- any other standards, the procedures set sider the safety and health of the resi- forth in §§ 17.66–17.71 of this part shall dents of the community residential be followed. care facility and the length of time since the community residential care [54 FR 20842, May 15, 1989. Redesignated and facility received notice of the non- amended at 61 FR 21965, 21967, May 13, 1996] compliance. § 17.72 Availability of information. [54 FR 20842, May 15, 1989. Redesignated and VA standards will be made available amended at 61 FR 21965, 21967, May 13, 1996] to other Federal, State and local agen- § 17.71 Revocation of VA approval. cies charged with the responsibility of licensing, or otherwise regulating or (a) If a hearing official determines inspecting community residential care under § 17.70 of this part that a commu- facilities. nity residential care facility does not comply with the standards set forth in [54 FR 20842, May 15, 1989. Redesignated at 61 § 17.63 of this part and determines that FR 21965, May 13, 1996] the community residential care facility shall not have further time to rem- § 17.73 Medical foster homes—general. edy the noncompliance, the hearing of- (a) Purpose. Through the medical fos- ficial shall revoke approval of the com- ter home program, VA recognizes and munity residential care facility and approves certain medical foster homes notify the community residential care for the placement of veterans. The facility of this revocation. choice to become a resident of a med- (b) Upon revocation of VA approval, ical foster home is a voluntary one on VA health care personnel shall: the part of each veteran. VA’s role is (1) Cease referring veterans to the limited to referring veterans to ap- community residential care facility; proved medical foster homes. When a and, veteran is placed in an approved home, (2) Notify any veteran residing in the VA will provide inspections to ensure community residential care facility of that the home continues to meet the the facility’s disapproval and request requirements of this part, as well as permission to assist in the veteran’s re- oversight and medical foster home moval from the facility. If a veteran caregiver training. If a medical foster has a person or entity authorized by home does not meet VA’s criteria for law to give permission on behalf of the approval, VA will not refer any veteran veteran, VA health care personnel shall to the home or provide any of these notify that person or entity of the services. VA may also provide certain community residential care facility’s medical benefits to veterans placed in disapproval and request permission to medical foster homes, consistent with assist in removing the veteran from the VA program in which the veteran the community residential care facil- is enrolled. ity. (b) Definitions. For the purposes of (c) If the hearing official determines this section and § 17.74: that a community residential care fa- Labeled means that the equipment or cility fails to comply with the stand- materials have attached to them a

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label, symbol, or other identifying dential care facilities under §§ 17.65 mark of an organization recognized as through 17.72 except as follows: having jurisdiction over the evaluation (1) Where §§ 17.65 through 17.72 ref- and periodic inspection of such equip- erence § 17.63. ment or materials, and by whose label- (2) Because VA does not physically ing the manufacturer indicates compli- place veterans in medical foster homes, ance with appropriate standards or per- VA also does not assist veterans in formance. moving out of medical foster homes as Medical foster home means a private we do for veterans in other community home in which a medical foster home residential care facilities under caregiver provides care to a veteran § 17.72(d)(2); however, VA will assist resident and: such veterans in locating an approved (i) The medical foster home caregiver medical foster home when relocation is lives in the medical foster home; necessary. (ii) The medical foster home care- (e) Duties of Medical foster home caregiver owns or rents the medical foster givers. The medical foster home care- home; and giver, with assistance from relief care- (iii) There are not more than three givers, provides a safe environment, residents receiving care (including vet- room and board, supervision, and per- eran and non-veteran residents). sonal assistance, as appropriate for Medical foster home caregiver means each veteran. the primary person who provides care to a veteran resident in a medical fos- [77 FR 5188, Feb. 2, 2012] ter home. § 17.74 Standards applicable to med- Placement refers to the voluntary de- ical foster homes. cision by a veteran to become a resident in an approved medical foster (a) General. A medical foster home home. must: Veteran resident means a veteran re- (1) Meet all applicable state and local siding in an approved medical foster regulations, including construction, home who meets the eligibility criteria maintenance, and sanitation regula- in paragraph (c) of this section. tions. (c) Eligibility. VA health care per- (2) Have safe and functioning systems sonnel may assist a veteran by refer- for heating, hot and cold water, elec- ring such veteran for placement in a tricity, plumbing, sewage, cooking, medical foster home if: laundry, artificial and natural light, (1) The veteran is unable to live inde- and ventilation. Ventilation for cook pendently safely or is in need of nurs- stoves is not required. ing home level care; (3) Except as otherwise provided in (2) The veteran must be enrolled in, this section, meet the applicable provi- or agree to be enrolled in, either a VA sions of chapters 1 through 11 and 24, Home Based Primary Care or VA Spi- and section 33.7 of NFPA 101 (incor- nal Cord Injury Homecare program, or porated by reference, see § 17.1), and the a similar VA interdisciplinary program other codes and chapters identified in designed to assist medically complex this section, as applicable. Existing veterans living in the home; and buildings or installations that do not (3) The medical foster home has been comply with the installation provisions approved in accordance with paragraph of the codes or standards referenced in (d) of this section. paragraph (b)(1) through (5), (b)(8), and (d) Approval of medical foster homes. (b)(10) of § 17.1 shall be permitted to be Medical foster homes will be approved continued in service, provided that the by a VA Medical Foster Homes Coordi- lack of conformity with these codes nator based on the report of a VA in- and standards does not present a seri- spection and on any findings of nec- ous hazard to the occupants. essary interim monitoring of the med- (b) Community residential care facility ical foster home, if that home meets standards applicable to medical foster the standards established in § 17.74. The homes. Medical foster homes must com- approval process is governed by the ply with § 17.63(c), (d), (f), (h), (j) and process for approving community resi- (k).

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(c) Activities. The facility must plan causes an alarm in all smoke alarms and facilitate appropriate recreational within the medical foster home. Smoke and leisure activities. detectors or smoke alarms must not be (d) Residents’ bedrooms. Each veteran installed in the kitchen or any other resident must have a bedroom: location subject to causing false (1) With a door that closes and alarms. latches; (2) CO detectors or CO alarms must (2) That contains a suitable bed and be installed in any medical foster home appropriate furniture; and with a fuel-burning appliance, fire- (3) That is single occupancy, unless place, or an attached garage, in accord- the veteran agrees to a multi-occupant ance with NFPA 720 (incorporated by bedroom. reference, see § 17.1). (e) Windows. VA may grant provi- (3) Combination CO/smoke detectors sional approval for windows used as a and combination CO/smoke alarms are secondary means of escape that do not permitted. meet the minimum size and dimensions (4) Smoke detectors and smoke required by chapter 24 of NFPA 101 (in- alarms must initiate a signal to a re- corporated by reference, see § 17.1) if mote supervising station to notify the windows are a minimum of 5.0 emergency forces in the event of an square feet (and at least 20 inches wide alarm. and at least 22 inches high). The sec- (5) Smoke and/or CO alarms and ondary means of escape must be smoke and/or CO detectors, and all brought into compliance with chapter other elements of a fire alarm system, 24 no later than 60 days after a veteran must be inspected, tested, and main- resident is placed in the home. tained in accordance with NFPA 72 (in- (f) Special locking devices. Special corporated by reference, see § 17.1) and locking devices that do not comply NFPA 720 (incorporated by reference, with section 7.2.1.5 of NFPA 101 (incor- see § 17.1). porated by reference, see § 17.1) are per- (h) Sprinkler systems. (1) If a sprinkler mitted where the clinical needs of the system is installed, it must be in- veteran resident require specialized se- spected, tested, and maintained in ac- curity measures and with the written cordance with NFPA 25 (incorporated approval of: by reference, see § 17.1), unless the (1) The responsible VA clinician; and sprinkler system is installed in accord- (2) The VA fire/safety specialist or ance with NFPA 13D (incorporated by the Director of the VA Medical Center reference, see § 17.1). If a sprinkler sys- of jurisdiction. tem is installed in accordance with (g) Smoke and carbon monoxide (CO) NFPA 13D, it must be inspected annu- detectors and smoke and CO alarms. Med- ally by a competent person. ical foster homes must comply with (2) If sprinkler flow or pressure this paragraph (g) no later than 60 days switches are installed, they must acti- after the first veteran is placed in the vate notification appliances in the home. Prior to compliance, VA inspec- medical foster home, and must initiate tors will provisionally approve a med- a signal to the remote supervising sta- ical foster home for the duration of tion. this 60-day period if the medical foster (i) Fire extinguishers. At least one 2– home mitigates risk through the use of A:10–B:C rated fire extinguisher must battery-operated single station alarms, be visible and readily accessible on provided that the alarms are installed each floor, including basements, and before any veteran is placed in the must be maintained in accordance with home. the manufacturer’s instructions. Port- (1) Smoke detectors or smoke alarms able fire extinguishers must be in- must be provided in accordance with spected, tested, and maintained in ac- sections 24.3.4.1.1 or 24.3.4.1.2 of NFPA cordance with NFPA 10 (incorporated 101 (incorporated by reference, see by reference, see § 17.1). § 17.1); section 24.3.4.1.3 of NFPA 101 (j) Emergency lighting. Each occupied will not be used. In addition, smoke floor must have at least one plug-in re- alarms must be interconnected so that chargeable flashlight, operable and the operation of any smoke alarm readily accessible, or other approved

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emergency lighting. Such emergency spond to a fire alarm and evacuate the lighting must be tested monthly and medical foster home, unless the vet- replaced if not functioning. eran resident is unable to participate. (k) Fireplaces. A non-combustible (2) The medical foster home caregiver hearth, in addition to protective glass must demonstrate the ability to evac- doors or metal mesh screens, is re- uate all occupants within three min- quired for fireplaces. Hearths and pro- utes to a point of safety outside of the tective devices must meet all applica- medical foster home that has access to ble state and local fire codes. a public way, as defined in NFPA 101 (l) Portable heaters. Portable heaters (incorporated by reference, see § 17.1). may be used if they are maintained in (3) If all occupants are not evacuated good working condition and: within three minutes or if a veteran (1) The heating elements of such resident is either permanently or tem- heaters do not exceed 212 degrees Fahr- porarily unable to participate in drills, enheit (100 degrees Celsius); then the medical foster home will be (2) The heaters are labeled; and given a 60-day provisional approval, (3) The heaters have tip-over protec- after which time the home must have tion. established one of the following reme- (m) Oxygen safety. Any area where dial options or VA will terminate the oxygen is used or stored must not be approval in accordance with § 17.65. near an open flame and must have a (i) The home is protected throughout posted ‘‘No Smoking’’ sign. Oxygen with an automatic sprinkler system in cylinders must be adequately secured accordance with section 9.7 of NFPA or protected to prevent damage to cyl- 101 (incorporated by reference, see inders. Whenever possible, transfilling § 17.1) and whichever of the following of liquid oxygen must take place out- apply: NFPA 13 (incorporated by ref- side of the living areas of the home. erence, see § 17.1); NFPA 13R (incor- (n) Smoking. Smoking must be pro- porated by reference, see § 17.1); or hibited in all sleeping rooms, including NFPA 13D (incorporated by reference, sleeping rooms of non-veteran residents. Ashtrays must be made of non- see § 17.1). combustible materials. (ii) Each veteran resident who is per- (o) Special/other hazards. (1) Extension manently or temporarily unable to par- cords must be three-pronged, grounded, ticipate in a drill or who fails to evac- sized properly, and not present a haz- uate within three minutes must have a ard due to inappropriate routing, bedroom located at the ground level pinching, damage to the cord, or risk of with direct access to the exterior of the overloading an electrical panel circuit. home that does not require travel (2) Flammable or combustible liquids through any other portion of the resi- and other hazardous material must be dence, and access to the ground level safely and properly stored in either the must meet the requirements of the original, labeled container or a safety Americans with Disabilities Act. The can as defined by NFPA 30 (incor- medical foster home caregiver’s bed- porated by reference, see § 17.1). room must also be on ground level. (p) Emergency egress and relocation (4) The 60-day provisional approval drills. Operating features of the medical under paragraph (p)(3) of this section foster home must comply with section may be contingent upon increased fire 33.7 of NFPA 101 (incorporated by ref- prevention measures, including but not erence, see § 17.1), except that section limited to prohibiting smoking or use 33.7.3.6 of NFPA 101 does not apply. In- of a fireplace. However, each veteran stead, VA will enforce the following re- resident who is temporarily unable to quirements: participate in a drill will be permitted (1) Before placement in a medical fos- to be excused from up to two drills ter home, the veteran will be clinically within one 12-month period, provided evaluated by VA to determine whether that the two excused drills are not con- the veteran is able to participate in secutive, and this will not be a cause emergency egress and relocation drills. for VA to not approve the home. Within 24 hours after arrival, each vet- (5) For purposes of paragraph (p), the eran resident must be shown how to re- term all occupants means every person

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in the home at the time of the emer- of this section cannot be complied with gency egress and relocation drill, in- absent undue expense, there is no other cluding non-residents. nearby home which can serve as an (q) Records of compliance with this sec- adequate alternative, and the equiva- tion. The medical foster home must lency is in the best interest of the vet- comply with § 17.63(i) regarding facility eran. records, and must document all inspec- (t) Cost of medical foster homes. (1) tion, testing, drills and maintenance Payment for the charges to veterans activities required by this section. for the cost of medical foster home Such documentation must be main- care is not the responsibility of the tained for 3 years or for the period United States Government. specified by the applicable NFPA (2) The resident or an authorized per- standard, whichever is longer. Docu- sonal representative and a representa- mentation of emergency egress and re- tive of the medical foster home facility location drills must include the date, must agree upon the charge and pay- time of day, length of time to evacuate ment procedures for medical foster the home, the name of each medical home care. foster home caregiver who partici- (3) The charges for medical foster pated, the name of each resident, home care must be comparable to whether the resident participated, and prices charged by other assisted living whether the resident required assist- and nursing home facilities in the area ance. based on the veteran’s changing care (r) Local permits and emergency re- needs and local availability of medical sponse. Where applicable, a permit or foster homes. (The Office of Manage- license must be obtained for occupancy ment and Budget has approved the in- or business by the medical foster home formation collection requirements in caregiver from the local building or this section under control number 2900– business authority. When there is a 0777.) home occupant who is incapable of self- [77 FR 5189, Feb. 2, 2012, as amended at 80 FR preservation, the local fire department 44862, July 28, 2015] or response agency must be notified by the medical foster home within 7 days USE OF SERVICES OF OTHER FEDERAL of the beginning of the occupant’s resi- AGENCIES dency. (s) Equivalencies. Any equivalencies § 17.80 Alcohol and drug dependence to VA requirements must be in accord- or abuse treatment and rehabilita- ance with section 1.4.3 of NFPA 101 (in- tion in residential and nonresiden- corporated by reference, see § 17.1), and tial facilities by contract. must be approved in writing by the ap- (a) Alcohol and drug dependence or propriate Veterans Health Administra- abuse treatment and rehabilitation tion, Veterans Integrated Service Net- may be authorized by contract in non- work (VISN) Director. A veteran living residential facilities and in residential in a medical foster home when the facilities provided by halfway houses, equivalency is granted or who is placed therapeutic communities, psychiatric there after it is granted must be noti- residential treatment centers and fied in writing of the equivalencies and other community-based treatment fa- that he or she must be willing to ac- cilities, when considered to be medi- cept such equivalencies. The notice cally advantageous and cost effective must describe the exact nature of the for the following: equivalency, the requirements of this (1) Veterans who have been or are section with which the medical foster being furnished care by professional home is unable to comply, and explain staff over which the Secretary has ju- why the VISN Director deemed the risdiction and such transitional care is equivalency necessary. Only equiva- reasonably necessary to continue lencies that the VISN Director deter- treatment; mines do not pose a risk to the health (2) Persons in the Armed Forces who, or safety of the veteran may be grant- upon discharge therefrom will become ed. Also, equivalencies may only be eligible veterans, when duly referred granted when technical requirements with authorization for Department of

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Veterans Affairs medical center hos- § 17.81 Contracts for residential treat- pital care in preparation for treatment ment services for veterans with al- and rehabilitation in this program cohol or drug dependence or abuse under the following limitations: disabilities. (i) Such persons may be accepted by (a) Contracts for treatment services transfer only during the last 30 days of authorized under § 17.80(a) may be such person’s enlistment or tour of awarded in accordance with applicable duty, Department of Veterans Affairs and (ii) The person requests transfer in Federal procurement procedures. Such writing for treatment for a specified contracts will be awarded only after period of time during the last 30 days the quality and effectiveness, including of such person’s enlistment period or adequate protection for the safety of tour of duty, the residents of the contractor’s pro- (iii) Treatment does not extend be- gram, has been determined and then yond the period of time specified in the only to contractors, determined by the request unless such person requests in Under Secretary for Health or designee writing an extension for a further spec- to meet the following requirements. ified period of time and such request is (1) Meet fire safety requirements as approved by the Department of Vet- follows: erans Affairs Medical Center Director (i) The building must meet the re- authorizing treatment and rehabilita- quirements in the applicable provisions tion, of NFPA 101 (incorporated by ref- (iv) Such care and treatment will be erence, see § 17.1) and the other publica- provided as if the person were a vet- tions referenced in those provisions. eran, subject to reimbursement by the Any equivalencies or variances to VA respective military service for the requirements must be approved by the costs of hospital care and control appropriate Veterans Health Adminis- treatment provided while the person is tration Veterans Integrated Service an active duty member. Network (VISN) Director. (b) The maximum period for one (ii) Where applicable, the home must treatment episode is limited to 60 days. have a current occupancy permit The Department of Veterans Affairs issued by the local and state govern- Medical Center Director may authorize ments in the jurisdiction where the one 30-day extension. home is located. (c) Any person who has been dis- (iii) All Department of Veterans Af- charged or released from active mili- fairs sponsored residents will be mentary, naval or air service, and who, tally and physically capable of leaving upon application for treatment and re- the building, unaided, in the event of habilitative services under the author- an emergency. Halfway house, thera- ity of this section is determined to be peutic community and other residen- legally ineligible for such treatment or tial program management must agree rehabilitation services shall be: that all the other residents in any (1) Provided referral services to assist building housing veterans will also the person, to the maximum extent have such capability. possible, in obtaining treatment and (iv) There must be at least one staff rehabilitation services from sources member on duty 24 hours a day. outside the Department of Veterans Af- (v) The facility must meet the fol- fairs, not at Department of Veterans lowing additional requirements, if the Affairs expense and, provisions for One and Two-Family (2) If pertinent, advised of the right Dwellings, as defined in NFPA 101, are to apply to the appropriate military, applicable to the facility: naval or air service and the Depart- (A) Portable fire extinguishers shall ment of Veterans Affairs for review of be installed, inspected, and maintained such person’s discharge or release from in accordance with NFPA 10 (incor- such service. porated by reference, see § 17.1). (Authority: 38 U.S.C. 1720A) (B) The facility shall meet the re- [47 FR 57706, Dec. 28, 1982. Redesignated at 61 quirements in section 33.7 of NFPA 101. FR 21965, May 13, 1996, as amended at 61 FR (vi) An annual fire and safety inspec- 56897, Nov. 5, 1996] tion shall be conducted at the halfway

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house or residential facility by quali- ness/recovery process, and for upgrad- fied Department of Veterans Affairs ing skills and improving personal rela- personnel. If a review of past Depart- tionships. ment of Veterans Affairs inspections or (7) Data normally maintained and in- inspections made by the local authori- cluded in a medical record as a func- ties indicates that a fire and safety in- tion of compliance with State or com- spection would not be necessary, then munity licensing standards will be ac- the visit to the facility may be waived. cessible. (2) Be in compliance with existing (b) Representatives of the Depart- standards of State safety codes and ment of Veterans Affairs will inspect local, and/or State health and sanita- the facility prior to award of a con- tion codes. tract to assure that prescribed require- (3) Be licensed under State or local ments can be met. Inspections may authority. also be carried out at such other times (4) Where applicable, be accredited by as deemed necessary by the Depart- the State. ment of Veterans Affairs. (5) Comply with the requirements of (c) All requirements in this rule, and the ‘‘Confidentiality of Alcohol and Department of Veterans Affairs reports Drug Abuse Patient Records’’ (42 CFR of inspection of residential facilities part II) and the ‘‘Confidentiality of furnishing treatment and rehabilita- Certain Medical Records’’ (38 U.S.C. tion services to eligible veterans shall 7332), which shall be part of the con- to the extent possible, be made avail- tract. able to all government agencies (6) Demonstrate an existing capa- charged with the responsibility of li- bility to furnish the following: censing or otherwise regulating or in- (i) A supervised alcohol and drug free specting such institutions. environment, including active affili- (d) An individual case record will be ation with Alcoholics Anonymous (AA) created for each client which shall be programs. maintained in security and confidence (ii) Staff sufficient in numbers and as required by the ‘‘Confidentiality of position qualifications to carry out the Alcohol and Drug Abuse Patient policies, responsibilities, and programs Records’’ (42 CFR part 2) and the of the facility. ‘‘Confidentiality of Certain Medical (iii) Board and room. Records’’ (38 U.S.C. 7332), and will be (iv) Laundry facilities for residents made available on a need to know basis to do their own laundry. to appropriate Department of Veterans (v) Structured activities. Affairs staff members involved with (vi) Appropriate group activities, in- the treatment program of the veterans cluding physical activities. concerned. (vii) Health and personal hygiene (e) Contractors under this section maintenance. shall provide reports of budget and case (viii) Monitoring administration of load experience upon request from a medications. Department of Veterans Affairs offi- (ix) Supportive social service. cial. (x) Individual counseling as appro- (Authority: 38 U.S.C. 1720A) priate. (xi) Opportunities for learning/devel- [47 FR 57707, Dec. 28, 1982. Redesignated and amended at 61 FR 21965, 21967, May 13, 1996; 61 opment of skills and habits which will FR 63720, Dec. 2, 1996; 69 FR 18803, Apr. 9, enable Department of Veterans Affairs 2004; 76 FR 10249, Feb. 24, 2011] sponsored residents to adjust to and maintain freedom from dependence on § 17.82 Contracts for outpatient serv- or involvement with alcohol or drug ices for veterans with alcohol or abuse or dependence during or subse- drug dependence or abuse disabil- quent to leaving the facility. ities. (xii) Support for the individual desire (a) Contracts for treatment services for sobriety (alcohol/drug abuse-free authorized under § 17.80 may be award- life style). ed in accordance with applicable De- (xiii) Opportunities for learning, test- partment of Veterans Affairs and Fed- ing, and internalizing knowledge of ill- eral procurement procedures. Such

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contracts will be awarded only after Drug Abuse Patient Records’’ (42 CFR the quality and effectiveness, including part 2) and the ‘‘Confidentiality of Cer- adequate protection for the safety of tain Medical Records’’ (38 U.S.C. 7332), the participants of the contractor’s which shall be part of the contract. program, has been determined and then (6) Demonstrate an existing capa- only to contractors determined by the bility to furnish the following: Under Secretary for Health or designee (i) A supervised, alcohol and drug to be fully capable of meeting the fol- free environment, including active af- lowing standards: filiation with Alcoholics Anonymous (1) The following minimum fire safe- (AA) programs. ty requirements must be met: (ii) Staff sufficient in numbers and (i) The building must meet the re- position qualifications to carry out the quirements in the applicable provisions policies, responsibilities, and programs of the NFPA 101 (incorporated by ref- of the facility. erence, see § 17.1) and the other publica- (iii) Structured activities. tions referenced in those provisions. (iv) Appropriate group activities. Any equivalencies or variances to VA (v) Monitoring medications. requirements must be approved by the (vi) Supportive social service. appropriate Veterans Health Adminis- (vii) Individual counseling as appro- tration Veterans Integrated Service priate. Network (VISN) Director. (viii) Opportunities for learning/de- (ii) Where applicable, the facility velopment of skills and habits which must have a current occupancy permit will enable Department of Veterans Af- issued by the local and state govern- fairs sponsored residents to adjust to ments in the jurisdiction where the and maintain freedom from dependence home is located. on or involvement with alcohol or drug (iii) All Department of Veterans Af- abuse or dependence during or subse- fairs sponsored patients will be men- quent to leaving the facility. tally and physically capable of leaving (ix) Support for the individual desire the building, unaided, in the event of for sobriety (alcohol/drug abuse-free an emergency. life style). (iv) As a minimum, fire exit drills (x) Opportunities for learning, test- must be held at least quarterly, and a ing, and internalizing knowledge of ill- written plan for evacuation in the ness/recovery process, and to upgrade event of fire shall be developed and re- skills and improve personal relation- viewed annually. The plan shall outline ships. the duties, responsibilities and actions (7) Data normally maintained and in- to be taken by the staff in the event of cluded in a medical record as a func- a fire emergency. This plan shall be tion of compliance with State or com- implemented during fire exit drills. munity licensing standards will be ac- (v) An annual fire and safety inspec- cessible. tion shall be conducted at the facility (b) Representatives of the Depart- by qualified Department of Veterans ment of Veterans Affairs will inspect Affairs personnel. If a review of past the facility prior to award of a con- Department of Veterans Affairs inspec- tract to assure that prescribed require- tions or inspections made by the local ments can be met. Inspections may authorities indicates that a fire and also be carried out at such other times safety inspection would not be nec- as deemed necessary by the Depart- essary, then the visit to the facility ment of Veterans Affairs. may be waived. (c) All requirements in this rule and (2) Conform to existing standards of Department of Veterans Affairs reports State safety codes and local and/or of inspection of residential facilities State health and sanitation codes. furnishing treatment and rehabilita- (3) Be licensed under State or local tion services to eligible veterans shall, authority. to the extent possible, be made avail- (4) Where applicable, be accredited by able to all government agencies the State. charged with the responsibility of li- (5) Comply with the requirements of censing or otherwise regulating or in- the ‘‘Confidentiality of Alcohol and specting such institutions.

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(d) An individual case record will be under this section shall be provided in created for each client which shall be VA medical facilities. maintained in security and confidence (1) If VA medical facilities are not as required by the ‘‘Confidentiality of capable of furnishing economical care Alcohol and Drug Abuse Patient or are not capable of furnishing the Records’’ (42 CFR part 2) and the care or services required, VA medical ‘‘Confidentiality of Certain Medical facility directors shall contract for the Records’’ (38 U.S.C. 7332), and will be needed care. made available on a need to know basis (2) If inpatient care must be provided to appropriate Department of Veterans to a non-veteran under this section, VA Affairs staff members involved with medical facility directors may contract the treatment program of the veterans for such care. concerned. (3) If a research subject needs treatment in a medical emergency for a con- (Authority: 38 U.S.C. 1720A) dition covered by this section, VA med- [47 FR 57708, Dec. 28, 1982. Redesignated and ical facility directors shall provide rea- amended at 61 FR 21965, 21967, May 13, 1996; 61 sonable reimbursement for the emer- FR 63720, Dec. 2, 1996; 62 FR 17072, Apr. 9, gency treatment in a non-VA facility. 1997; 69 FR 18803, Apr. 9, 2004; 76 FR 10249, (c) For purposes of this section, ‘‘VA Feb. 24, 2011] employee’’ means any person appointed by VA as an officer or employee and § 17.83 Limitations on payment for alcohol and drug dependence or acting within the scope of his or her abuse treatment and rehabilitation. appointment (VA appoints officers and employees under title 5 and title 38 of The authority to enter into contracts the United States Code). shall be effective for any fiscal year only to such extent or in such amounts (Authority: 38 U.S.C. 501, 7303) as are provided in appropriation acts, [63 FR 11124, Mar. 6, 1998] and payments shall not exceed these amounts. CARE DURING CERTAIN DISASTERS AND EMERGENCIES (Authority: Pub. L. 96–22, 38 U.S.C. 1720A) [47 FR 57708, Dec. 28, 1982. Redesignated at 61 § 17.86 Provision of hospital care and FR 21965, May 13, 1996] medical services during certain disasters and emergencies under 38 RESEARCH-RELATED INJURIES U.S.C. 1785. (a) This section sets forth regulations § 17.85 Treatment of research-related regarding the provision of hospital care injuries to human subjects. and medical services under 38 U.S.C. (a) VA medical facilities shall pro- 1785. vide necessary medical treatment to a (b) During and immediately following research subject injured as a result of a disaster or emergency referred to in participation in a research project ap- paragraph (c) of this section, VA under proved by a VA Research and Develop- 38 U.S.C. 1785 may furnish hospital care ment Committee and conducted under and medical services to individuals (in- the supervision of one or more VA em- cluding those who otherwise do not ployees. This section does not apply to: have VA eligibility for such care and (1) Treatment for injuries due to non- services) responding to, involved in, or compliance by a subject with study otherwise affected by that disaster or procedures, or emergency. (2) Research conducted for VA under (c) For purposes of this section, a dis- a contract with an individual or a non- aster or emergency means: VA institution. (1) A major disaster or emergency declared by the President under the Rob- NOTE TO § 17.85(a)(1) AND (a)(2): Veterans ert T. Stafford Disaster Relief and who are injured as a result of participation Emergency Assistance Act (42 U.S.C. in such research may be eligible for care 5121 et seq.) (Stafford Act); or from VA under other provisions of this part. (2) A disaster or emergency in which (b) Except in the following situa- the National Disaster Medical System tions, care for VA research subjects established pursuant to section 2811(b)

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of the Public Health Service Act (42 (a) For purposes of determining eligi- U.S.C. 300hh–11(b)) is activated either bility for this medical benefit, the by the Secretary of Health and Human term participating in a vocational train- Services under paragraph (3)(A) of that ing program under 38 U.S.C. chapter 15 section or as otherwise authorized by means the same as the term partici- law. pating in a rehabilitation program under (d) For purposes of paragraph (b) of 38 U.S.C. chapter 31 as defined in this section, the terms hospital care and § 17.47(i). Eligibility for such medical medical services have the meanings care will continue only while the vet- given such terms by 38 U.S.C. 1701(5) eran is participating in the vocational and 1701(6). training program. (e) Unless the cost of care is charged (b) The term hospital care and medical at rates agreed upon in a sharing services means class V dental care, pri- agreement as described in § 17.102(e), ority III medical services, nursing the cost of hospital care and medical home care and non-VA hospital care services provided under this section to and/or fee medical/dental care if VA is an officer or employee of a department unable to provide the required medical or agency of the United States (other care economically at VA or other gov- than VA) or to a member of the Armed ernment facilities because of geo- Forces shall be calculated in accord- graphic inaccessibility or because of ance with the provisions of § 17.102(c) the unavailability of the required serv- and (h). Other individuals who receive ices at VA facilities. hospital care or medical services under (Authority: 38 U.S.C. 1524, 1525, 1516) this section are responsible for the cost [51 FR 19330, May 29, 1986, as amended at 56 of the hospital care or medical services FR 3422, Jan. 30, 1991. Redesignated and when charges are mandated by Federal amended at 61 FR 21965, 21967, May 13, 1996; 79 law (including applicable appropriation FR 54615, Sept. 12, 2014] acts) or when the cost of care or services is not reimbursed by other-than- § 17.91 Protection of health-care eligi- VA Federal departments or agencies. bility. When individuals are responsible under Any veteran whose entitlement to this section for the cost of hospital VA pension is terminated by reason of care or medical services, VA will bill in income from work or training shall, the amounts calculated in accordance subject to paragraphs (a) and (b) of this with the provisions of § 17.102(h), with- section, retain for 3 years after the ter- out applying the exception provided in mination, the eligibility for hospital the first paragraph of § 17.102. care, nursing home care and medical (f) VA may furnish care and services services (not including dental) which under this section to a veteran without the veteran otherwise would have had regard to whether that individual is en- if the pension had not been terminated rolled in the VA healthcare system as a result of the veteran’s receipt of under 38 U.S.C. 1705 and § 17.36 of this earnings from activity performed for part. remuneration or gain by the veteran but only if the veteran’s annual income (Authority: 38 U.S.C. 501, 1785) from sources other than such earnings [73 FR 26946, May 12, 2008] would, taken alone, not result in the termination of the veteran’s pension. VOCATIONAL TRAINING AND HEALTH- (a) A veteran who participates in a CARE ELIGIBILITY PROTECTION FOR vocational training program under 38 PENSION RECIPIENTS U.S.C. chapter 15 is eligible for the one- time 3 year retention of hospital care, § 17.90 Medical care for veterans re- nursing home care and medical serv- ceiving vocational training under ices benefits at any time that the vet- 38 U.S.C. chapter 15. eran’s pension is terminated by reason Hospital care, nursing home care and of income from the veteran’s employ- medical services may be provided to ment. any veteran who is participating in a (b) A veteran who does not partici- vocational training program under 38 pate in a vocational training program U.S.C. chapter 15. under 38 U.S.C. chapter 15 is eligible for

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the one-time 3 year retention of hos- VA facility where the veteran applies. pital care and medical services benefits If the needed medical services are not only if the veteran’s pension is termi- available there, VA shall arrange for nated by reason of income from the care at the nearest VA medical facility veteran’s employment during the pe- or Department of Defense facility (with riod February 1, 1985 through January which VA has a sharing agreement) 31, 1989. that can provide the needed care. If VA (Authority: 38 U.S.C. 1524, 1525, 1516) and Department of Defense facilities are not available, VA shall arrange for [51 FR 19330, May 29, 1986. Redesignated at 61 FR 21965, May 13, 1996] care on a fee basis, but only if the veteran is eligible to receive medical serv- OUTPATIENT TREATMENT ices in non-VA facilities under § 17.52. If the veteran is not in immediate need § 17.92 Outpatient care for research purposes. of outpatient medical services, VA shall schedule the veteran for care Subject to the provisions of § 17.101, where the veteran applied, if the sched- any person who is a bona fide volunteer ule there permits, or refer the veteran may be furnished outpatient treatment for scheduling to the nearest VA med- when the treatment to be rendered is ical center or Department of Defense part of an approved Department of Vet- facility (with which VA has a sharing erans Affairs research project and agreement). there are insufficient veteran-patients suitable for the project. (c) VA may furnish on an ambulatory or outpatient basis medical services as [35 FR 11470, July 17, 1970. Redesignated and needed to the following applicants, ex- amended at 61 FR 21965, 21967, May 13, 1996] cept that applications for dental treat- § 17.93 Eligibility for outpatient serv- ment must also meet the provisions of ices. § 17.123. (a) VA shall furnish on an ambula- (1) For veterans participating in a reha- tory or outpatient basis medical serv- bilitation program under 38 U.S.C. chap- ices as are needed, to the following ap- ter 31. Medical services on an ambula- plicants under the conditions stated, tory or outpatient basis may be pro- except that applications for dental vided as determined medically nec- treatment must also meet the provi- essary for a veteran participating in a sions of § 17.161. rehabilitation program under 38 U.S.C. chapter 31 as defined in § 17.47(i). (Authority: 38 U.S.C. 1710, 1712) (2) [Reserved] (1) For compensation and pension ex- (Authority: 38 U.S.C. 1710, 1712) aminations. A compensation and pen- [55 FR 20150, May 15, 1990, as amended at 58 sion examination shall be performed FR 25565, Apr. 27, 1993. Redesignated and for any veteran who is directed to have amended at 61 FR 21965, 21967, May 13, 1996; 64 such an examination by VA. FR 54218, Oct. 6, 1999; 79 FR 54615, Sept. 12, 2014] (Authority: 38 U.S.C. 111 and 501) (2) For adjunct treatment. Subject to § 17.94 Outpatient medical services for the provisions of §§ 17.36 through 17.38, military retirees and other beneficiaries. medical services on an ambulatory or outpatient basis shall be provided to Outpatient medical services for mili- veteans for an adjunct nonservice-con- tary retirees and other beneficiaries for nected condition associated with and which charges shall be made as re- held to be aggravating a disability quired by § 17.101, may be authorized from a disease or injury adjudicated as for persons properly referred by au- being service-connected. thorized officials of other Federal (b) The term ‘‘shall furnish’’ in this agencies for which the Secretary of section and 38 U.S.C. 1710(a)(1) and Veterans Affairs may agree to render (a)(2) means that, if the veteran is in such service under the conditions stip- immediate need of outpatient medical ulated by the Secretary and pensioners services, VA shall furnish care at the of nations allied with the United

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States in World War I and World War II only so long as such veteran’s annual when duly authorized. income does not exceed the maximum [32 FR 13815, Oct. 4, 1967, as amended at 45 FR annual income limitation by more than 6937, Jan. 31, 1980; 47 FR 58249, Dec. 30, 1982. $ 1,000, and Redesignated and amended at 61 FR 21965, (b) The drugs and medicines are pre- 21967, May 13, 1996] scribed as specific therapy in the treatment of any of the veteran’s illnesses § 17.95 Outpatient medical services for Department of Veterans Affairs em- or injuries. ployees and others in emergencies. (Authority: 38 U.S.C. 1706, 1710, 1712(d)) Outpatient medical services for [68 FR 43929, July 25, 2003, as amended at 74 which charges shall be made as re- FR 44291, Aug. 28, 2009; 78 FR 42456, July 16, quired by § 17.102 may be authorized for 2013; 79 FR 54615, Sept. 12, 2014; 81 FR 46602, employees of the Department of Vet- July 18, 2016] erans Affairs, their families, and the general public in emergencies, subject § 17.97 [Reserved] to conditions stipulated by the Sec- retary of Veterans Affairs. § 17.98 Mental health services. (Authority: 38 U.S.C. 1784) (a) Following the death of a veteran, [47 FR 58249, Dec. 30, 1982. Redesignated and bereavement counseling involving serv- amended at 61 FR 21965, 21967, May 13, 1996; 79 ices defined in 38 U.S.C. 1783, may be FR 54615, Sept. 12, 2014] furnished to persons who were receiving mental health services in connec- § 17.96 Medication prescribed by non- tion with treatment of the veteran VA physicians. under 38 U.S.C. 1710, 1712A, 1717, or 1781, Any prescription, which is not part of prior to the veteran’s death, but may authorized Department of Veterans Af- only be furnished in instances where fairs hospital or outpatient care, for the veteran’s death had been unex- drugs and medicines ordered by a pri- pected or occurred while the veteran vate or non-Department of Veterans Affairs doctor of medicine or doctor of was participating in a VA hospice or osteopathy duly licensed to practice in similar program. Bereavement coun- the jurisdiction where the prescription seling may be provided only to assist is written, shall be filled by a Depart- individuals with the emotional and ment of Veterans Affairs pharmacy or psychological stress accompanying the a non-VA pharmacy under contract veteran’s death, and only for a limited with VA, including non-VA pharmacy period of time, as determined by the in a state home under contract with Medical Center Director, but not to ex- VA for filling prescriptions for patients ceed 60 days. The Medical Center Direc- in state homes, provided: tor may approve a longer period of (a) The prescription is for: time when medically indicated. (1) A veteran who by reason of being (b) For purposes of paragraph (a) of permanently housebound or in need of this section, an unexpected death is regular aid and attendance is in receipt one which occurs when in the course of of increased compensation under 38 an illness the provider of care did not U.S.C. chapter 11, or increased pension or could not have anticipated the tim- under § 3.1(u) (Section 306 Pension) or ing of the death. Ordinarily, the pro- § 3.1(w) (Improved Pension), of this vider of care can anticipate the pa- chapter, as a veteran of a period of war as defined by 38 U.S.C. 101(11) (or, al- tient’s death and can inform the pa- though eligible for such pension, is in tient and family of the immediacy and receipt of compensation as the greater certainty of death. If that has not benefit), or taken place, a death can be described (2) A veteran in need of regular aid as unexpected. and attendance who was formerly in re- (Authority: 38 U.S.C. 1783) ceipt of increased pension as described in paragraph (a)(1) of this section [53 FR 7186, Mar. 7, 1988. Redesignated and whose pension has been discontinued amended at 61 FR 21965, 21967, May 13, 1996; 79 solely by reason of excess income, but FR 54616, Sept. 12, 2014]

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CHARGES, WAIVERS, AND COLLECTIONS will bill using its most recent published or posted charge. For care for § 17.101 Collection or recovery by VA which VA has not established a charge, for medical care or services pro- VA will bill according to the method- vided or furnished to a veteran for ology set forth in paragraph (a)(8) of a nonservice-connected disability. this section. (a)(1) General. This section covers col- (3) Data sources. In this section, data lection or recovery by VA, under 38 sources are identified by name. The U.S.C. 1729, for medical care or services specific editions of these data sources provided or furnished to a veteran: used to calculate actual charge (i) For a nonservice-connected dis- amounts, and information on where ability for which the veteran is enti- these data sources may be obtained, tled to care (or the payment of ex- will be presented along with the data penses of care) under a health plan con- for calculating actual charge amounts, tract; either in notices in the FEDERAL REG- (ii) For a nonservice-connected dis- ISTER or on the Internet site of the ability incurred incident to the vet- Veterans Health Administration Chief eran’s employment and covered under a Business Office, currently at http:// worker’s compensation law or plan www.va.gov/cbo, under ‘‘Charge Data.’’ that provides reimbursement or indem- (4) Amount of recovery or collection— nification for such care and services; or third party liability. A third-party payer (iii) For a nonservice-connected dis- liable under a health plan contract has ability incurred as a result of a motor the option of paying either the billed vehicle accident in a State that re- charges described in this section or the quires automobile accident reparations amount the health plan demonstrates insurance. is the amount it would pay for care or (2) Based on the meth- Methodologies. services furnished by providers other odologies set forth in this section, the than entities of the United States for charges billed will include the fol- the same care or services in the same lowing types of charges, as appropriate: geographic area. If the amount sub- Acute inpatient facility charges; mitted by the health plan for payment skilled nursing facility/sub-acute inpa- is less than the amount billed, VA will tient facility charges; partial hos- accept the submission as payment, sub- pitalization facility charges; out- ject to verification at VA’s discretion patient facility charges; physician and in accordance with this section. A VA other professional charges, including employee having responsibility for col- professional charges for anesthesia services and dental services; pathology lection of such charges may request and laboratory charges; observation that the third party health plan submit care facility charges; ambulance and evidence or information to substan- other emergency transportation tiate the appropriateness of the pay- charges; and charges for durable med- ment amount (e.g., health plan or in- ical equipment, drugs, injectables, and surance policies, provider agreements, other medical services, items, and sup- medical evidence, proof of payment to plies identified by HCPCS Level II other providers in the same geographic codes. In addition, the charges billed area for the same care and services VA for prescription drugs not administered provided). during treatment will be the amount (5) Definitions. For purposes of this determined under paragraph (m) of this section: section. Data for calculating actual APC means Medicare Ambulatory charge amounts based on the meth- Payment Classification. odologies set forth in this section will CMS means the Centers for Medicare either be published in a notice in the and Medicaid Services. FEDERAL REGISTER or will be posted on CPI-U means Consumer Price Index— the Internet site of the Veterans All Urban Consumers. Health Administration Chief Business CPT code and CPT procedure code Office, currently at http://www.va.gov/ mean Current Procedural Terminology cbo, under ‘‘Charge Data.’’ For care for code, a five-digit identifier defined by which VA has established a charge, VA the American Medical Association for

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a specified physician service or proce- ices provided at non-provider-based en- dure. tities will be billed as professional DME means Durable Medical Equip- charges only. Professional charges for ment. both provider-based entities and non- DRG means Diagnosis Related Group. provider-based entities are produced by Geographic area means a three-digit the methodologies set forth in this sec- ZIP Code area, where three-digit ZIP tion, with professional charges for pro- Codes are the first three digits of vider-based entities based on facility standard U.S. Postal Service ZIP practice expense RVUs, and profes- Codes. sional charges for non-provider-based HCPCS code means a Healthcare entities based on non-facility practice Common Procedure Coding System expense RVUs. Level II identifier, consisting of a let- (7) Charges for medical care or services ter followed by four digits, defined by provided by non-VA providers at VA ex- CMS for a specified physician service, pense. When medical care or services procedure, test, supply, or other med- are furnished at the expense of the VA ical service. by non-VA providers, the charges billed ICU means Intensive Care Unit, infor such care or services will be the cluding coronary care units. higher of the charges determined ac- MDR means Medical Data Research, cording to this section, or the amount a medical charge database published by VA paid to the non-VA provider. Ingenix, Inc. (8) Charges when a new DRG or CPT/ MedPAR means the Medicare Pro- HCPCS code identifier does not have an vider Analysis and Review file. established charge. When VA does not Non-provider-based means a VA have an established charge for a new health care entity (such as a small VA DRG or CPT/HCPCS code to be used in community-based outpatient clinic) determining a billing charge under the that functions as the equivalent of a applicable methodology in this section, doctor’s office or for other reasons does then VA will establish an interim bill- not meet CMS provider-based criteria, ing charge or establish an interim and, therefore, is not entitled to bill charge to be used for determining a outpatient facility charges. billing charge under the applicable Provider-based means the outpatient methodology in paragraphs (a)(8)(i) department of a VA hospital or any through (a)(8)(viii) of this section. other VA health care entity that meets CMS provider-based criteria. Provider- (i) If a new DRG or CPT/HCPCS code based entities are entitled to bill out- identifier replaces a DRG or CPT/ patient facility charges. HCPCS code identifier, the most re- RBRVS means Resource-Based Rel- cently established charge for the iden- ative Value Scale. tifier being replaced will continue to be RVU means Relative Value Unit. used for determining a billing charge Unlisted procedures mean procedures, under paragraphs (b), (e), (f), (g), (h), services, items, and supplies that have (i), (k), or (l) of this section until such not been defined or specified by the time as VA establishes a charge for the American Medical Association or CMS, new identifier. and the CPT and HCPCS codes used to (ii) If medical care or service is pro- report such procedures, services, items, vided or furnished at VA expense by a and supplies. non-VA provider and a charge cannot (6) Provider-based and non-provider- be established under paragraph (a)(8)(i) based entities and charges. Each VA of this section, then VA’s billing health care entity (medical center, charge for such care or service will be hospital, community-based outpatient the amount VA paid to the non-VA pro- clinic, independent outpatient clinic, vider without additional calculations etc.) is designated as either provider- under this section. based or non-provider-based. Provider- (iii) If a new CPT/HCPCS code has based entities are entitled to bill out- been established for a prosthetic device patient facility charges; non-provider- or durable medical equipment subject based entities are not. The charges for to paragraph (l) of this section and a physician and other professional serv- charge cannot be established under

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paragraphs (a)(8)(i) or (ii) of this sec- characteristics to the new CPT/HCPCS tion, VA’s billing charge for such pros- code. thetic device or durable medical equip- (viii) If a charge cannot be estab- ment will be 1 and 1⁄2 times VA’s aver- lished under paragraphs (a)(8)(i) age actual cost without additional cal- through (a)(8)(vii) of this section, then culations under this section. VA will not charge under this section (iv) If a new medical identifier DRG for the care or service. code has been assigned to a particular (9) Care provided under special treat- type of medical care or service and a ment authorities. (i) Notwithstanding charge cannot be established under any other provisions in this section, paragraphs (a)(8)(i) through (iii) of this VA will not seek recovery or collection section, then until such time as VA es- of reasonable charges from a third tablishes a charge for the new medical party payer for: identifier DRG code, the interim (A) Hospital care, medical services, charge for use in paragraph (b) of this and nursing home care provided by VA section will be the average charge of or at VA expense under 38 U.S.C. all medical DRG codes that are within 1710(a)(2)(F) and (e). plus or minus 10 of the numerical rel- (B) Counseling and appropriate care ative weight assigned to the new med- and services furnished to veterans for ical identifier DRG code. psychological trauma authorized under (v) If a new surgical identifier DRG 38 U.S.C. 1720D. (C) Medical examination, and hos- code has been assigned to a particular pital care, medical services, and nurs- type of medical care or service and a ing home care furnished to veteran for charge cannot be established under cancer of the head or neck as author- paragraphs (a)(8)(i) through (iv) of this ized under 38 U.S.C. 1720E. section, then until such time as VA es- (ii) VA may continue to exercise its tablishes a charge for the new surgical right to recover or collect reasonable identifier DRG code, the interim charges from third parties, pursuant to charge for use in paragraph (b) of this this section, for the cost of care that section will be the average charge of VA provides to these same veterans for all surgical DRG codes that are within conditions and disabilities that VA de- plus or minus 10 of the numerical rel- termines are not covered by any of the ative weight assigned to the new sur- special treatment authorities. gical identifier DRG code. (b) Acute inpatient facility charges. (vi) If a new identifier CPT/HCPCS When VA provides or furnishes acute code is assigned to a particular type or inpatient services within the scope of item of medical care or service and a care referred to in paragraph (a)(1) of charge cannot be established under this section, acute inpatient facility paragraphs (a)(8)(i) through (v) of this charges billed for such services will be section, then until such time as VA es- determined in accordance with the pro- tablishes a charge for the new identi- visions of this paragraph. Acute inpa- fier for use in paragraphs (e), (f), (g), tient facility charges consist of per (h), (i), (k), or (l) of this section, VA’s diem charges for room and board and billing charge will be the Medicare al- for ancillary services that vary by geo- lowable charge multiplied by 1 and 1⁄2, graphic area and by DRG. These without additional calculations under charges are calculated as follows: this section. (1) Formula. For each acute inpatient (vii) If a new identifier CPT/HCPCS stay, or portion thereof, for which a code is assigned to a particular type or particular DRG assignment applies, the item of medical care or service and a total acute inpatient facility charge is charge cannot be established under the sum of the applicable charges de- paragraphs (a)(8)(i) through (vi) of this termined pursuant to paragraphs section, then until such time as VA es- (b)(1)(i), (ii), and (iii) of this section. tablishes a charge for the new identi- For purposes of this section, standard fier, the interim charge for use in para- room and board days and ICU room and graphs (e), (f), (g), (h), (i), (k), or (l) of board days are mutually exclusive: VA this section will be the charge for the will bill either a standard room and CPT/HCPCS code that is closest in board per diem charge or an ICU room

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and board per diem charge, as applica- one from the MedStat claims database, ble, for each day of a given acute inpa- a database of nationwide commercial tient stay. insurance claims. Average per diem (i) Standard room and board charges. charges are calculated based on all Multiply the nationwide standard room available charges, except for care re- and board per diem charge determined ported for emergency room, ambu- pursuant to paragraph (b)(2) of this sec- lance, professional, and observation tion by the appropriate geographic care. These two data sources may re- area adjustment factor determined pur- port charges for two differing periods suant to paragraph (b)(3) of this sec- of time; when this occurs, the data tion. The result constitutes the area- source charges with the earlier center specific standard room and board per date are trended forward to the center diem charge. Multiply this amount by date of the other data source, based on the number of days for which standard changes to the inpatient hospital serv- room and board charges apply to ob- ices component of the CPI-U. Results tain the total acute inpatient facility obtained from these two data sources standard room and board charge. are then combined into a single weight- (ii) ICU room and board charges. Mul- ed average per diem charge for each tiply the nationwide ICU room and DRG. The resulting charge for each board per diem charge determined pur- DRG is then separated into its two suant to paragraph (b)(2) of this section components, a room and board compo- by the appropriate geographic area ad- nent and an ancillary component, with justment factor determined pursuant the per diem charge for each compo- to paragraph (b)(3) of this section. The nent calculated by multiplying the result constitutes the area-specific ICU weighted average per diem charge by room and board per diem charge. Mul- the corresponding percentage deter- tiply this amount by the number of mined pursuant to paragraph (b)(2)(i) of days for which ICU room and board per this section. The room and board per diem charges apply to obtain the total diem charge is further differentiated acute inpatient facility ICU room and into a standard room and board per board charge. diem charge and an ICU room and (iii) Ancillary charges. Multiply the board per diem charge by multiplying nationwide ancillary per diem charge the average room and board charge by determined pursuant to paragraph the corresponding DRG-specific ratios (b)(2) of this section by the appropriate determined pursuant to paragraph geographic area adjustment factor de- (b)(2)(ii) of this section. The resulting termined pursuant to paragraph (b)(3) per diem charges for standard room of this section. The result constitutes and board, ICU room and board, and the area-specific ancillary per diem ancillary services for each DRG are charge. Multiply this amount by the then each multiplied by the final ratio number of days of acute inpatient care determined pursuant to paragraph to obtain the total acute inpatient fa- (b)(2)(iii) of this section to reflect the cility ancillary charge. nationwide 80th percentile charges. Fi- NOTE TO PARAGRAPH (b)(1): If there is a nally, the resulting amounts are each change in a patient’s condition and/or treat- trended forward from the center date of ment during a single acute inpatient stay the trended data sources to the effec- such that the DRG assignment changes (for tive time period for the charges, as set example, a psychiatric patient who develops a medical or surgical problem), then calcula- forth in paragraph (b)(2)(iv) of this sections of acute inpatient facility charges will tion. The results constitute the nation- be made separately for each DRG, according wide 80th percentile standard room and to the number of days of care applicable for board, ICU room and board, and ancil- each DRG, and the total acute inpatient fa- lary per diem charges. cility charge will be the sum of the total (i) Room and board charge and ancil- acute inpatient facility charges for the dif- lary charge component percentages. ferent DRGs. Using only those cases from the (2) Per diem charges. To establish a MedPAR file for which a distinction be- baseline, two nationwide average per tween room and board charges and an- diem amounts for each DRG are cal- cillary charges can be determined, the culated, one from the MedPAR file and percentage of the total charges for

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room and board compared to the com- change so obtained is then applied to bined total charges for room and board the 80th percentile charges. and ancillary services, and the percent- (3) Geographic area adjustment factors. age of the total charges for ancillary For each geographic area, the average services compared to the combined per diem room and board charges and total charges for room and board and ancillary charges from the MedPAR ancillary services, are calculated by file are calculated for each DRG. The DRG. DRGs are separated into two groups, (ii) Standard room and board per diem surgical and non-surgical. For each of charge and ICU room and board per diem these groups of DRGs, for each geo- charge ratios. Using only those cases graphic area, average room and board from the MedPAR file for which a dis- per diem charges and ancillary per tinction between room and board and ancillary charges can be determined, diem charges are calculated, weighted overall average per diem room and by nationwide VA discharges and by board charges are calculated by DRG. average lengths of stay from the com- Then, using the same cases, an average bined MedPAR file and MedStat claims standard room and board per diem database. This results in four average charge is calculated by dividing total per diem charges for each geographic non-ICU room and board charges by area: room and board for surgical total non-ICU room and board days. DRGs, ancillary for surgical DRGs, Similarly, an average ICU room and room and board for non-surgical DRGs, board per diem charge is calculated by and ancillary for non-surgical DRGs. dividing total ICU room and board Four corresponding national average charges by total ICU room and board per diem charges are obtained from the days. Finally, ratios of standard room MedPAR file, weighted by nationwide and board per diem charges to average VA discharges and by average lengths overall room and board per diem of stay from the combined MedPAR file charges are calculated by DRG, as are and MedStat claims database. Four ge- ratios of ICU room and board per diem ographic area adjustment factors are charges to average overall room and then calculated for each geographic board per diem charges. area by dividing each geographic area (iii) 80th percentile. Using cases from average per diem charge by the cor- the MedPAR file with separately iden- responding national average per diem tifiable semi-private room rates, the charge. ratio of the day-weighted 80th percentile semi-private room and board (c) Skilled nursing facility/sub-acute in- per diem charge to the average semi- patient facility charges. When VA pro- private room and board per diem vides or furnishes skilled nursing/sub- charge is obtained for each geographic acute inpatient services within the area. The geographic area-based ratios scope of care referred to in paragraph are averaged to obtain a final 80th per- (a)(1) of this section, skilled nursing fa- centile ratio. cility/sub-acute inpatient facility (iv) Trending forward. 80th percentile charges billed for such services will be charges for each DRG, obtained as de- determined in accordance with the pro- scribed in paragraph (b)(2) of this sec- visions of this paragraph. The skilled tion, are trended forward based on nursing facility/sub-acute inpatient fa- changes to the inpatient hospital serv- cility charges are per diem charges ices component of the CPI-U. Actual that vary by geographic area. The fa- CPI-U changes are used from the center cility charges cover care, including date of the trended data sources room and board, nursing care, pharma- through the latest available month as ceuticals, supplies, and skilled reha- of the time the calculations are per- bilitation services (e.g., physical ther- formed. The three-month average an- apy, inhalation therapy, occupational nual trend rate as of the latest avail- therapy, and speech-language pathol- able month is then held constant to the ogy), that is provided in a nursing midpoint of the calendar year in which home or hospital inpatient setting, is the charges are primarily expected to provided under a physician’s orders, be used. The projected total CPI-U

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and is performed by or under the gen- (i) 80th percentile adjustment factor. eral supervision of professional per- Using the MedPAR skilled nursing fa- sonnel such as registered nurses, li- cility file, the ratio of the day-weight- censed practical nurses, physical thera- ed 80th percentile room and board per pists, occupational therapists, speech- diem charge to the day-weighted aver- language pathologists, and audiol- age room and board per diem charge is ogists. These charges are calculated as obtained for each geographic area. The follows: geographic area-based ratios are aver- (1) Formula. For each stay, multiply aged to obtain the 80th percentile ad- the nationwide per diem charge deter- justment factor. mined pursuant to paragraph (c)(2) of (ii) Trending forward. The 80th per- this section by the appropriate geo- centile charge is trended forward based graphic area adjustment factor deter- on changes to the inpatient hospital mined pursuant to paragraph (c)(3) of services component of the CPI-U. Ac- this section. The result constitutes the tual CPI-U changes are used from the area-specific per diem charge. Finally, time period of the source data through multiply the area-specific per diem the latest available month as of the charge by the number of days of care to time the calculations are performed. The three-month average annual trend obtain the total skilled nursing facil- rate as of the latest available month is ity/sub-acute inpatient facility charge. then held constant to the midpoint of (2) Per diem charge. To establish a the calendar year in which the charges baseline, a nationwide average per are primarily expected to be used. The diem billed charge is calculated based projected total CPI-U change so ob- on charges reported in the MedPAR tained is then applied to the 80th per- skilled nursing facility file. For this centile charge. purpose, the following MedPAR charge (3) Geographic area adjustment factors. categories are included: room and The average billed per diem charge for board (private, semi-private, and ward), each geographic area is calculated physical therapy, occupational ther- from the MedPAR skilled nursing facil- apy, inhalation therapy, speech-lan- ity file. This amount is divided by the guage pathology, pharmacy, medical/ nationwide average billed charge cal- surgical supplies, and ‘‘other’’ services. culated in paragraph (c)(2) of this sec- The following MedPAR charge cat- tion. The geographic area adjustment egories are excluded from the calcula- factor for charges for each VA facility tion of the per diem charge and will be is the ratio for the geographic area in billed separately, using the charges de- which the facility is located. termined as set forth in other applica- (d) Partial hospitalization facility ble paragraphs of this section, when charges. When VA provides or furnishes these services are provided to skilled partial hospitalization services that nursing patients or sub-acute inpa- are within the scope of care referred to tients: ICU and CCU room and board, in paragraph (a)(1) of this section, the laboratory, radiology, cardiology, di- facility charges billed for such services alysis, operating room, blood and blood will be determined in accordance with administration, ambulance, MRI, anes- the provisions of this paragraph. Par- thesia, durable medical equipment, tial hospitalization facility charges are emergency room, clinic, outpatient, per diem charges that vary by geo- professional, lithotripsy, and organ ac- graphic area. These charges are cal- quisition services. The resulting aver- culated as follows: age per diem billed charge is then mul- (1) Formula. For each partial hos- tiplied by the 80th percentile adjust- pitalization stay, multiply the nation- ment factor determined pursuant to wide per diem charge determined pur- paragraph (c)(2)(i) of this section to ob- suant to paragraph (d)(2) of this section tain a nationwide 80th percentile by the appropriate geographic area ad- charge level. Finally, the resulting justment factor determined pursuant amount is trended forward to the effec- to paragraph (d)(3) of this section. The tive time period for the charges, as set result constitutes the area-specific per forth in paragraph (c)(2)(ii) of this sec- diem charge. Finally, multiply the tion. area-specific per diem charge by the

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number of days of care to obtain the and by CPT/HCPCS code. These charges total partial hospitalization facility apply in the situations set forth in charge. paragraph (e)(1) of this section and are (2) Per diem charge. To establish a calculated as set forth in paragraph baseline, a nationwide median per diem (e)(2) of this section. billed charge is calculated based on (1) Settings and circumstances in which charges associated with partial hos- outpatient facility charges apply. Out- pitalization from the outpatient facil- patient facility charges consist of facility component of the Medicare Stand- ity charges for procedures, diagnostic ard Analytical File 5 percent Sample. tests, evaluation and management That median per diem billed charge is services, and other medical services, then multiplied by the 80th percentile items, and supplies provided in the fol- adjustment factor determined pursuant lowing settings and circumstances: to paragraph (d)(2)(i) of this section to (i) Outpatient departments and clin- obtain a nationwide 80th percentile ics at VA medical centers; charge level. Finally, the resulting (ii) Other VA provider-based entities; amount is trended forward to the effec- and tive time period for the charges, as set (iii) VA non-provider-based entities, forth in paragraph (d)(2)(ii) of this sec- for procedures and tests for which no tion. corresponding professional charge is (i) 80th percentile adjustment factor. established under the provisions of The 80th percentile adjustment factor paragraph (f) of this section. for partial hospitalization facility (2) Formula. For each outpatient fa- charges is the same as that computed cility charge CPT/HCPCS code, mul- for skilled nursing facility/sub-acute tiply the nationwide 80th percentile inpatient facility charges under para- charge determined pursuant to paragraph (c)(2)(i) of this section. graph (e)(3) of this section by the ap- (ii) Trending forward. The 80th per- propriate geographic area adjustment centile charge is trended forward based factor determined pursuant to para- on changes to the outpatient hospital graph (e)(4) of this section. The result services component of the CPI-U. Ac- constitutes the area-specific out- tual CPI-U changes are used from the patient facility charge. When multiple time period of the source data through surgical procedures are performed dur- the latest available month as of the ing the same outpatient encounter by a time the calculations are performed. provider or provider team, the out- The three-month average annual trend patient facility charges for such proce- rate as of the latest available month is dures will be reduced as set forth in then held constant to the midpoint of paragraph (e)(5) of this section. the calendar year in which the charges (3) Nationwide 80th percentile charges are primarily expected to be used. The by CPT/HCPCS code. For each CPT/ projected total CPI-U change so ob- HCPCS code for which outpatient facil- tained is then applied to the 80th per- ity charges apply, the nationwide 80th centile charges, as described in para- percentile charge is calculated as set graph (d)(2) of this section. forth in either paragraph (e)(3)(i) or (3) Geographic area adjustment factors. (e)(3)(ii) of this section. The resulting The geographic area adjustment fac- amount is trended forward to the effec- tors for partial hospitalization facility tive time period for the charges, as set charges are the same as those com- forth in paragraph (e)(3)(iii) of this sec- puted for outpatient facility charges tion. The results constitute the nation- under paragraph (e)(4) of this section. wide 80th percentile outpatient facility (e) Outpatient facility charges. When charges by CPT/HCPCS code. VA provides or furnishes outpatient fa- (i) Nationwide 80th percentile charges cility services that are within the for CPT/HCPCS codes which have APC scope of care referred to in paragraph assignments. Using the outpatient facil- (a)(1) of this section, the charges billed ity charges reported in the outpatient for such services will be determined in facility component of the Medicare accordance with the provisions of this Standard Analytical File 5 percent paragraph. Charges for outpatient fa- Sample, claim records are selected for cility services vary by geographic area which all charges can be assigned to an

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APC. Using this subset of the 5 percent culated for each of the APC categories Sample data, nationwide median set forth in paragraph (e)(3)(i)(D) of charge to Medicare APC payment this section, again using the reported 5 amount ratios, by APC, and nationwide percent Sample frequencies as weights. 80th percentile to median charge ratios, For APCs where the 5 percent Sample by APC, are computed according to the frequencies provide a statistically methodology set forth in paragraphs credible result, the APC-specific (e)(3)(i)(A) and (e)(3)(i)(B) of this sec- weighted average nationwide 80th per- tion, respectively. The product of these centile to median charge ratio so ob- two ratios by APC is then computed, tained is accepted without further ad- resulting in a composite nationwide justment. However, if the 5 percent 80th percentile charge to Medicare APC Sample data do not produce statis- payment amount ratio. This ratio is tically credible results for any specific then compared to the alternate nation- APC, then the APC category-specific wide 80th percentile charge to Medicare ratio is applied for that APC. APC payment amount ratio computed (C) Alternate nationwide 80th percentile in paragraph (e)(3)(i)(C) of this section, charge to Medicare APC payment amount and the lesser amount is selected and ratios. A minimum 80th percentile multiplied by the current Medicare charge to Medicare APC payment APC payment amount. The resulting amount ratio is set at 2.0 for APCs with product is the APC-specific nationwide Medicare APC payment amounts of $25 80th percentile charge amount for each or less. A maximum 80th percentile applicable CPT/HCPCS code. charge to Medicare APC payment (A) Nationwide median charge to Medi- amount ratio is set at 6.5 for APCs with care APC payment amount ratios. For Medicare APC payment amounts of each CPT/HCPCS code, the ratio of me- $10,000 or more. Using linear interpola- dian billed charge to Medicare APC tion with these endpoints, the alter- payment amount is determined. The nate APC-specific nationwide 80th per- weighted average of these ratios for centile charge to Medicare APC pay- each APC is then obtained, using the ment amount ratio is then computed, reported 5 percent Sample frequencies based on the Medicare APC payment as weights. In addition, corresponding amount. ratios are calculated for each of the (D) APC categories for the purpose of APC categories set forth in paragraph establishing 80th percentile to median fac- (e)(3)(i)(D) of this section, again using tors. For the purpose of the statistical the reported 5 percent Sample fre- methodology set forth in paragraph quencies as weights. For APCs where (e)(3)(i) of this section, APCs are as- the 5 percent Sample frequencies pro- signed to the following APC categories: vide a statistically credible result, the (1) Radiology. APC-specific weighted average nation- (2) Drugs. wide median charge to Medicare APC (3) Office, Home, and Urgent Care payment amount ratio so obtained is Visits. accepted without further adjustment. (4) Cardiovascular. However, if the 5 percent Sample data (5) Emergency Room Visits. do not produce statistically credible (6) Outpatient Psychiatry, Alcohol results for any specific APC, then the and Drug Abuse. APC category-specific ratio is applied (7) Pathology. for that APC. (8) Surgery. (B) Nationwide 80th percentile to me- (9) Allergy Immunotherapy, Allergy dian charge ratios. For each CPT/HCPCS Testing, Immunizations, and Thera- code, a geographically normalized na- peutic Injections. tionwide 80th percentile billed charge (10) All APCs not assigned to any of amount is divided by a similarly nor- the above groups. malized nationwide median billed (ii) Nationwide 80th percentile charges charge amount. The weighted average for CPT/HCPCS codes which do not have of these ratios for each APC is then ob- APC assignments. Nationwide 80th per- tained, using the reported 5 percent centile billed charge levels by CPT/ Sample frequencies as weights. In addi- HCPCS code are computed from the tion, corresponding ratios are cal- outpatient facility component of the

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MDR database, from the MedStat as the ratio of the CPT/HCPCS code claims database, and from the out- weighted average charge level for each patient facility component of the Medi- geographic area to the nationwide CPT/ care Standard Analytical File 5 percent HCPCS code weighted average charge Sample. If the MDR database contains level. sufficient data to provide a statis- (5) Multiple surgical procedures. When tically credible 80th percentile charge, multiple surgical procedures are per- then that result is retained for this formed during the same outpatient en- purpose. If the MDR database does not counter by a provider or provider team provide a statistically credible 80th as indicated by multiple surgical CPT/ percentile charge, then the result from HCPCS procedure codes, then each the MedStat database is retained for CPT/HCPCS procedure code will be this purpose, provided it is statistically billed at 100 percent of the charges es- credible. If neither the MDR nor the tablished under this section. MedStat databases provide statis- (f) Physician and other professional tically credible results, then the na- charges except for anesthesia services and tionwide 80th percentile billed charge certain dental services. When VA pro- computed from the 5 percent Sample vides or furnishes physician and other data is retained for this purpose. The professional services, other than pro- nationwide 80th percentile charges re- fessional anesthesia services and cer- tained from each of these data sources tain professional dental services, with- are trended forward to the effective in the scope of care referred to in para- time period for the charges, as set graph (a)(1) of this section, physician forth in paragraph (e)(3)(iii) of this sec- and other professional charges billed tion. for such services will be determined in (iii) Trending forward. The charges for accordance with the provisions of this each CPT/HCPCS code, obtained as de- paragraph. Charges for professional scribed in paragraph (e)(3) of this sec- dental services identified by CPT code tion, are trended forward based on are determined in accordance with the changes to the outpatient hospital provisions of this paragraph; charges services component of the CPI-U. Ac- for professional dental services identi- tual CPI-U changes are used from the fied by HCPCS Level II code are deter- time period of the source data through mined in accordance with the provi- the latest available month as of the sions of paragraph (h) of this section. time the calculations are performed. Physician and other professional The three-month average annual trend charges consist of charges for profes- rate as of the latest available month is sional services that vary by geographic then held constant to the midpoint of area, by CPT/HCPCS code, by site of the calendar year in which the charges service, and by modifier, where appli- are primarily expected to be used. The cable. These charges are calculated as projected total CPI-U change so ob- follows: tained is then applied to the 80th per- (1) Formula. For each CPT/HCPCS centile charges, as described in para- code or, where applicable, each CPT/ graph (e)(3) of this section. HCPCS code and modifier combination, (4) Geographic area adjustment factors. multiply the total geographically-ad- For each geographic area, a single adjusted RVUs determined pursuant to justment factor is calculated as the paragraph (f)(2) of this section by the arithmetic average of the outpatient applicable geographically-adjusted con- geographic area adjustment factor pub- version factor (a monetary amount) de- lished in the Milliman USA, Inc., termined pursuant to paragraph (f)(3) Health Cost Guidelines (this factor of this section to obtain the physician constitutes the ratio of the level of charge for each CPT/HCPCS code in a charges for each geographic area to the particular geographic area. Then, mul- nationwide level of charges), and a geo- tiply this charge by the appropriate graphic area adjustment factor devel- factors for any charge-significant oped from the MDR database (see para- modifiers, determined pursuant to graph (a)(3) of this section for Data paragraph (f)(4) of this section. Sources). The MDR-based geographic (2)(i) Total geographically-adjusted area adjustment factors are calculated RVUs for physician services that have

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Medicare RVUs. The work expense and charges are obtained, where statis- practice expense RVUs for CPT/HCPCS tically credible, from the Prevailing codes, other than the codes described Healthcare Charges System nationwide in paragraphs (f)(2)(ii) and (f)(2)(iii) of commercial insurance database. For this section, are compiled using Medi- each of these CPT/HCPCS codes, na- care Physician Fee Schedule RVUs. tionwide total RVUs are obtained by The sum of the geographically-adjusted taking the nationwide 80th percentile work expense RVUs determined pursu- billed charges obtained using the pre- ant to paragraph (f)(2)(i)(A) of this sec- ceding three databases and dividing by tion and the geographically-adjusted the untrended nationwide conversion practice expense RVUs determined pur- factor for the corresponding CPT/ suant to paragraph (f)(2)(i)(B) of this HCPCS code group determined pursu- section equals the total geographi- ant to paragraphs (f)(3) and (f)(3)(i) of cally-adjusted RVUs. this section. For any remaining CPT/ (A) Geographically-adjusted work ex- HCPCS codes that have not been as- pense RVUs. For each CPT/HCPCS code signed RVUs using the preceding data for each geographic area, the Medicare sources, the nationwide total RVUs are Physician Fee Schedule work expense calculated by summing the work ex- RVUs are multiplied by the work expense and non-facility practice expense pense Medicare Geographic Practice RVUs found in Ingenix/St. Anthony’s Cost Index. The result constitutes the RBRVS. The resulting nationwide total geographically-adjusted work expense RVUs obtained using these four data RVUs. sources are multiplied by the geo- (B) Geographically-adjusted practice ex- graphic area adjustment factors deter- pense RVUs. For each CPT/HCPCS code mined pursuant to paragraph (f)(2)(iv) for each geographic area, the Medicare of this section to obtain the area-spe- Physician Fee Schedule practice ex- cific total RVUs. pense RVUs are multiplied by the prac- (iii) RVUs for CPT/HCPCS codes des- tice expense Medicare Geographic ignated as unlisted procedures. For CPT/ Practice Cost Index. The result con- HCPCS codes designated as unlisted stitutes the geographically-adjusted procedures, total RVUs are developed practice expense RVUs. In these cal- based on the weighted median of the culations, facility practice expense total RVUs of CPT/HCPCS codes within RVUs are used to obtain geographi- the series in which the unlisted proce- cally-adjusted practice expense RVUs dure code occurs. A nationwide VA dis- for use by provider-based entities, and tribution of procedures and services is non-facility practice expense RVUs are used for the purpose of computing the used to obtain geographically-adjusted weighted median. The resulting nation- practice expense RVUs for use by non- wide total RVUs are multiplied by the provider-based entities. geographic area adjustment factors de- (ii) RVUs for CPT/HCPCS codes that do termined pursuant to paragraph not have Medicare RVUs and are not des- (f)(2)(iv) of this section to obtain the ignated as unlisted procedures. For CPT/ area-specific total RVUs. HCPCS codes that are not assigned (iv) RVU geographic area adjustment RVUs in paragraphs (f)(2)(i) or (f)(2)(iii) factors for CPT/HCPCS codes that do not of this section, total RVUs are devel- have Medicare RVUs, including codes oped based on various charge data that are designated as unlisted proce- sources. For these CPT/HCPCS codes, dures. The adjustment factor for each the nationwide 80th percentile billed geographic area consists of the weight- charges are obtained, where statis- ed average of the work expense and tically credible, from the MDR data- practice expense Medicare Geographic base. For any remaining CPT/HCPCS Practice Cost Indices for each geo- codes, the nationwide 80th percentile graphic area using charge data for rep- billed charges are obtained, where sta- resentative CPT/HCPCS codes statis- tistically credible, from the Part B tically selected and weighted for work component of the Medicare Standard expense and practice expense. Analytical File 5 percent Sample. For (3) Geographically-adjusted 80th per- any remaining CPT/HCPCS codes, the centile conversion factors. CPT/HCPCS nationwide 80th percentile billed codes are separated into the following

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23 CPT/HCPCS code groups: allergy section, are trended forward based on immunotherapy, allergy testing, car- changes to the physicians’ services diovascular, chiropractor, consults, component of the CPI-U. Actual CPI-U emergency room visits and observation changes are used from the time period care, hearing/speech exams, immuniza- of the source data through the latest tions, inpatient visits, maternity/cesar- available month as of the time the cal- ean deliveries, maternity/non-deliv- culations are performed. The three- eries, maternity/normal deliveries, month average annual trend rate as of miscellaneous medical, office/home/ur- the latest available month is then held gent care visits, outpatient psychiatry/ constant to the midpoint of the cal- alcohol and drug abuse, pathology, endar year in which the charges are physical exams, physical medicine, ra- primarily expected to be used. The pro- diology, surgery, therapeutic injec- jected total CPI-U change so obtained tions, vision exams, and well baby is then applied to the 23 conversion fac- exams. For each of the 23 CPT/HCPCS tors. code groups, representative CPT/ (iii) Geographic area adjustment fac- HCPCS codes are statistically selected tors. Using the 80th percentile charges and weighted so as to give a weighted for the selected CPT/HCPCS codes from average RVU comparable to the paragraph (f)(3) of this section for each weighted average RVU of the entire geographic area, a geographic area-spe- CPT/HCPCS code group (the selected cific conversion factor is calculated for CPT/HCPCS codes are set forth in the each of the 23 CPT/HCPCS code groups Milliman USA, Inc., Health Cost Guide- by dividing the weighted average lines fee survey); see paragraph (a)(3) of charge by the weighted average geo- this section for Data Sources. The 80th graphically-adjusted RVU. The result- percentile charge for each selected ing conversion factor for each geo- CPT/HCPCS code is obtained from the graphic area for each of the 23 CPT/ MDR database. A nationwide conver- HCPCS code groups is divided by the sion factor (a monetary amount) is cal- corresponding nationwide conversion culated for each CPT/HCPCS code factor determined pursuant to para- group as set forth in paragraph (f)(3)(i) graph (f)(3)(i) of this section. The re- of this section. The nationwide conversion factors for each of the 23 CPT/ sulting ratios are the geographic area HCPCS code groups are trended for- adjustment factors for the conversion ward to the effective time period for factors for each of the 23 CPT/HCPCS the charges, as set forth in paragraph code groups for each geographic area. (f)(3)(ii) of this section. The resulting (4) Charge adjustment factors for speci- amounts for each of the 23 groups are fied CPT/HCPCS code modifiers. Sur- multiplied by geographic area adjust- charges are calculated in the following ment factors determined pursuant to manner: From the Part B component of paragraph (f)(3)(iii) of this section, re- the Medicare Standard Analytical File sulting in geographically-adjusted 80th 5 percent Sample, the ratio of weighted percentile conversion factors for each average billed charges for CPT/HCPCS geographic area for the 23 CPT/HCPCS codes with the specified modifier to the code groups for the effective charge pe- weighted average billed charge for riod. CPT/HCPCS codes with no charge (i) Nationwide conversion factors. modifier is calculated, using the fre- Using the nationwide 80th percentile quency of procedure codes with the charges for the selected CPT/HCPCS modifier as weights in both weighted codes from paragraph (f)(3) of this sec- average calculations. The resulting ration, a nationwide conversion factor is tios constitute the surcharge factors calculated for each of the 23 CPT/ for specified charge-significant CPT/ HCPCS code groups by dividing the HCPCS code modifiers. weighted average charge by the weight- (5) Certain charges for providers other ed average RVU. than physicians. When services for (ii) Trending forward. The nationwide which charges are established accord- conversion factors for each of the 23 ing to the preceding provisions of this CPT/HCPCS code groups, obtained as paragraph (f) are performed by pro- described in paragraph (f)(3)(i) of this viders other than physicians, the

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charges for those services will be as de- These charges are calculated as fol- termined by the preceding provisions of lows: this paragraph, except as follows: (1) Formula. For each anesthesia CPT/ (i) Outpatient facility charges. When HCPCS code, multiply the total anes- the services of providers other than thesia RVUs determined pursuant to physicians are furnished in outpatient paragraph (g)(2) of this section by the facility settings or in other facilities applicable geographically-adjusted con- designated as provider-based, and out- version factor (a monetary amount) de- patient facility charges for those serv- termined pursuant to paragraph (g)(3) ices have been established under para- of this section to obtain the profes- graph (e) of this section, then the out- sional anesthesia charge for each CPT/ patient facility charges established HCPCS code in a particular geographic under paragraph (e) will apply instead area. of the charges established under this (2) Total RVUs for professional anes- paragraph (f). thesia services. The total anesthesia (ii) Charges for professional services. RVUs for each anesthesia CPT/HCPCS Charges for the professional services of code are the sum of the base units (as the following providers will be 100 per- compiled by CMS) for that CPT/HCPCS cent of the amount that would be code and the number of time units re- charged if the care had been provided ported for the anesthesia service, by a physician: where one time unit equals 15 minutes. (A) Nurse practitioner. For anesthesia CPT/HCPCS codes des- (B) Clinical nurse specialist. ignated as unlisted procedures, base units are developed based on the (C) Physician Assistant. weighted median base units for anes- (D) Clinical psychologist. thesia CPT/HCPCS codes within the se- (E) Clinical social worker. ries in which the unlisted procedure (F) Dietitian. code occurs. A nationwide VA distribu- (G) Clinical pharmacist. tion of procedures and services is used (H) Marriage and family therapist. for the purpose of computing the (I) Licensed professional mental weighted median base units. health counselor. (3) Geographically-adjusted 80th per- (g) Professional charges for anesthesia centile conversion factors. A nationwide services. When VA provides or furnishes 80th percentile conversion factor is cal- professional anesthesia services within culated according to the methodology the scope of care referred to in para- set forth in paragraph (g)(3)(i) of this graph (a)(1) of this section, professional section. The nationwide conversion fac- anesthesia charges billed for such serv- tor is then trended forward to the ef- ices will be determined in accordance fective time period for the charges, as with the provisions of this paragraph. set forth in paragraph (g)(3)(ii) of this Charges for professional anesthesia section. The resulting amount is multi- services personally performed by anes- plied by geographic area adjustment thesiologists will be 100 percent of the factors determined pursuant to para- charges determined as set forth in this graph (g)(3)(iii) of this section, result- paragraph. Charges for professional an- ing in geographically-adjusted 80th per- esthesia services provided by non-medi- centile conversion factors for each geo- cally directed certified registered nurse graphic area for the effective charge anesthetists will also be 100 percent of period. the charges determined as set forth in (i) Nationwide conversion factor. Pre- this paragraph. Charges for profes- liminary 80th percentile conversion sional anesthesia services provided by factors for each area are compiled from medically directed certified registered the MDR database. Then, a preliminary nurse anesthetists will be 100 percent nationwide weighted-average 80th per- of the charges determined as set forth centile conversion factor is calculated, in this paragraph. Professional anes- using as weights the population (cen- thesia charges consist of charges for sus) frequencies for each geographic professional services that vary by geo- area as presented in the Milliman USA, graphic area, by CPT/HCPCS code base Inc., Health Cost Guidelines (see para- units, and by number of time units. graph (a)(3) of this section for Data

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Sources). A nationwide 80th percentile and by HCPCS code. These charges are fee by CPT/HCPCS code is then com- calculated as follows: puted by multiplying this conversion (1) Formula. For each HCPCS dental factor by the MDR base units for each code, multiply the nationwide 80th per- CPT/HCPCS code. An adjusted 80th percentile charge determined pursuant to centile conversion factor by CPT/ paragraph (h)(2) of this section by the HCPCS code is then calculated by di- appropriate geographic area adjust- viding the nationwide 80th percentile ment factor determined pursuant to fee for each procedure code by the an- paragraph (h)(3) of this section. The re- esthesia base units (as compiled by sult constitutes the area-specific den- CMS) for that CPT/HCPCS code. Fi- tal charge. nally, a nationwide weighted average (2) Nationwide 80th percentile charges 80th percentile conversion factor is cal- by HCPCS code. For each HCPCS dental culated using combined frequencies for code, 80th percentile charges are ex- billed base units and time units from tracted from three independent data the part B component of the Medicare sources: Prevailing Healthcare Charges Standard Analytical File 5 percent System database; National Dental Ad- Sample as weights. visory Service nationwide pricing (ii) Trending forward. The nationwide index; and the Dental UCR Module of conversion factor, obtained as de- the Comprehensive Healthcare Pay- scribed in paragraph (g)(3)(i) of this ment System, a release from Ingenix section, is trended forward based on from a nationwide database of dental charges (see paragraph (a)(3) of this sec- changes to the physicians’ services tion for Data Sources). Charges for component of the CPI-U. Actual CPI-U each database are then trended forward changes are used from the time period to a common date, based on actual of the source data through the latest changes to the dental services compo- available month as of the time the cal- nent of the CPI-U. Charges for each culations are performed. The three- HCPCS dental code from each data month average annual trend rate as of source are combined into an average the latest available month is then held 80th percentile charge by means of the constant to the midpoint of the cal- methodology set forth in paragraph endar year in which the charges are (h)(2)(i) of this section. HCPCS dental primarily expected to be used. The pro- codes designated as unlisted are as- jected total CPI-U change so obtained signed 80th percentile charges by is then applied to the conversion fac- means of the methodology set forth in tor. paragraph (h)(2)(ii) of this section. Fi- (iii) Geographic area adjustment fac- nally, the resulting amounts are each tors. The preliminary 80th percentile trended forward to the effective time conversion factors for each geographic period for the charges, as set forth in area described in paragraph (g)(3)(i) of paragraph (h)(2)(iii) of this section. The this section are divided by the cor- results constitute the nationwide 80th responding preliminary nationwide percentile charge for each HCPCS den- 80th percentile conversion factor also tal code. described in paragraph (g)(3)(i). The re- (i) Averaging methodology. The aver- sulting ratios are the adjustment fac- age charge for any particular HCPCS tors for each geographic area. dental code is calculated by first com- (h) Professional charges for dental serv- puting a preliminary mean average of ices identified by HCPCS Level II codes. the three charges for each code. Statis- When VA provides or furnishes out- tical outliers are identified and re- patient dental professional services moved by testing whether any charge within the scope of care referred to in differs from the preliminary mean paragraph (a)(1) of this section, and charge by more than 50 percent of the such services are identified by HCPCS preliminary mean charge. In such code rather than CPT code, the charges cases, the charge most distant from the billed for such services will be deter- preliminary mean is removed as an mined in accordance with the provi- outlier, and the average charge is cal- sions of this paragraph. The charges for culated as a mean of the two remaining dental services vary by geographic area charges. In cases where none of the

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charges differ from the preliminary Health Cost Guidelines as weights (see mean charge by more than 50 percent paragraph (a)(3) of this section for Data of the preliminary mean charge, the Sources). Similarly, using nationwide average charge is calculated as a mean average charge levels, a nationwide av- of all three reported charges. erage charge by dental class of proce- (ii) Nationwide 80th percentile charges dure codes is calculated. The normal- for HCPCS dental codes designated as un- ized geographic adjustment factor for listed procedures. For HCPCS dental each dental class of procedure codes codes designated as unlisted proce- and for each geographic area is the dures, 80th percentile charges are de- ratio of the local average charge di- veloped based on the weighted median vided by the corresponding nationwide 80th percentile charge of HCPCS dental average charge. Finally, the geo- codes within the series in which the graphic area adjustment factor is the unlisted procedure code occurs. The arithmetic average of the cor- distribution of procedures and services responding factors from the data from the Prevailing Healthcare sources mentioned in the first sentence Charges System nationwide commer- of this paragraph (h)(3). cial insurance database is used for the (i) Pathology and laboratory charges. purpose of computing the weighted me- When VA provides or furnishes pathol- dian. ogy and laboratory services within the (iii) Trending forward. 80th percentile scope of care referred to in paragraph charges for each dental procedure code, (a)(1) of this section, charges billed for obtained as described in paragraph such services will be determined in ac- (h)(2) of this section, are trended for- cordance with the provisions of this ward based on the dental services com- paragraph. Pathology and laboratory ponent of the CPI-U. Actual CPI-U charges consist of charges for services changes are used from the time period that vary by geographic area and by of the source data through the latest CPT/HCPCS code. These charges are available month as of the time the cal- calculated as follows: culations are performed. The three- (1) Formula. For each CPT/HCPCS month average annual trend rate as of code, multiply the total geographi- the latest available month is then held cally-adjusted RVUs determined pursu- constant to the midpoint of the cal- ant to paragraph (i)(2) of this section endar year in which the charges are by the applicable geographically-ad- primarily expected to be used. The pro- justed conversion factor (a monetary jected total CPI-U change so obtained amount) determined pursuant to para- is then applied to the 80th percentile graph (i)(3) of this section to obtain the charges. pathology/laboratory charge for each (3) Geographic area adjustment factors. CPT/HCPCS code in a particular geo- A geographic adjustment factor (con- graphic area. sisting of the ratio of the level of (2)(i) Total geographically-adjusted charges in a given geographic area to RVUs for pathology and laboratory serv- the nationwide level of charges) for ices that have Medicare-based RVUs. each geographic area and dental class Total RVUs are developed based on the of service is obtained from Milliman Medicare Clinical Diagnostic Labora- USA, Inc., Dental Health Cost Guide- tory Fee Schedule (CLAB). The CLAB lines, a database of nationwide com- payment amounts are upwardly ad- mercial insurance charges and relative justed such that the adjusted payment costs; and a normalized geographic ad- amounts are, on average, equivalent to justment factor computed from the Medicare Physician Fee Schedule pay- Dental UCR Module of the Comprehen- ment levels, using statistical compari- sive Healthcare Payment System com- sons to the 80th percentile derived from piled by Ingenix, as follows: Using local the MDR database. These adjusted pay- and nationwide average charges re- ment amounts are then divided by the ported in the Ingenix data, a local corresponding Medicare conversion fac- weighted average charge for each den- tor to derive RVUs for each CPT/ tal class of procedure codes is cal- HCPCS code. The resulting nationwide culated using utilization frequencies total RVUs are multiplied by the geo- from the Milliman USA, Inc., Dental graphic adjustment factors determined

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pursuant to paragraph (i)(2)(iv) of this wide total RVUs are multiplied by the section to obtain the area-specific geographic area adjustment factors de- total RVUs. termined pursuant to paragraph (ii) RVUs for CPT/HCPCS codes that do (i)(2)(iv) of this section to obtain the not have Medicare-based RVUs and are area-specific total RVUs. not designated as unlisted procedures. (iv) RVU geographic area adjustment For CPT/HCPCS codes that are not as- factors for CPT/HCPCS codes that do not signed RVUs in paragraphs (i)(2)(i) or have Medicare RVUs, including codes (i)(2)(iii) of this section, total RVUs are that are designated as unlisted proce- developed based on various charge data dures. The adjustment factor for each sources. For these CPT/HCPCS codes, geographic area consists of the weight- the nationwide 80th percentile billed ed average of the work expense and charges are obtained, where statis- practice expense Medicare Geographic tically credible, from the MDR data- Practice Cost Indices for each geo- base. For any remaining CPT/HCPCS graphic area using charge data for rep- codes, the nationwide 80th percentile resentative CPT/HCPCS codes statis- billed charges are obtained, where sta- tically selected and weighted for work tistically credible, from the Part B expense and practice expense. component of the Medicare Standard (3) Geographically-adjusted 80th per- Analytical File 5 percent Sample. For centile conversion factors. Representa- any remaining CPT/HCPCS codes, the tive CPT/HCPCS codes are statistically nationwide 80th percentile billed selected and weighted so as to give a charges are obtained, where statis- weighted average RVU comparable to tically credible, from the Prevailing the weighted average RVU of the entire Healthcare Charges System nationwide pathology/laboratory CPT/HCPCS code commercial insurance database. For group (the selected CPT/HCPCS codes each of these CPT/HCPCS codes, na- are set forth in the Milliman USA, Inc., tionwide total RVUs are obtained by Health Cost Guidelines fee survey). The taking the nationwide 80th percentile 80th percentile charge for each selected billed charges obtained using the pre- CPT/HCPCS code is obtained from the ceding three databases and dividing by MDR database. A nationwide conver- the untrended nationwide conversion sion factor (a monetary amount) is cal- factor determined pursuant to para- culated as set forth in paragraph graphs (i)(3) and (i)(3)(i) of this section. (i)(3)(i) of this section. The nationwide For any remaining CPT/HCPCS codes conversion factor is trended forward to that have not been assigned RVUs the effective time period for the using the preceding data sources, the charges, as set forth in paragraph nationwide total RVUs are calculated (i)(3)(ii) of this section. The resulting by summing the work expense and non- amount is multiplied by a geographic facility practice expense RVUs found in area adjustment factor determined pur- Ingenix/St. Anthony’s RBRVS. The re- suant to paragraph (i)(3)(iv) of this sec- sulting nationwide total RVUs ob- tion, resulting in the geographically- tained using these four data sources adjusted 80th percentile conversion fac- are multiplied by the geographic area tor for the effective charge period. adjustment factors determined pursu- (i) Nationwide conversion factors. ant to paragraph (i)(2)(iv) of this sec- Using the nationwide 80th percentile tion to obtain the area-specific total charges for the selected CPT/HCPCS RVUs. codes from paragraph (i)(3) of this sec- (iii) RVUs for CPT/HCPCS codes des- tion, a nationwide conversion factor is ignated as unlisted procedures. For CPT/ calculated by dividing the weighted av- HCPCS codes designated as unlisted erage charge by the weighted average procedures, total RVUs are developed RVU. based on the weighted median of the (ii) Trending forward. The nationwide total RVUs of CPT/HCPCS codes within conversion factor, obtained as de- the series in which the unlisted proce- scribed in paragraph (i)(3) of this sec- dure code occurs. A nationwide VA dis- tion, is trended forward based on tribution of procedures and services is changes to the physicians’ services used for the purpose of computing the component of the CPI-U. Actual CPI-U weighted median. The resulting nation- changes are used from the time period

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of the source data through the latest Medicare Standard Analytical File 5 available month as of the time the cal- percent Sample. Then, using the 80th culations are performed. The three- percentile observation line item month average annual trend rate as of charges for each unique hourly length the latest available month is then held of stay, a standard linear regression constant to the midpoint of the cal- technique is used to calculate the na- endar year in which the charges are tionwide 80th percentile base charge primarily expected to be used. The pro- and 80th percentile hourly charge. Fi- jected total CPI-U change so obtained nally, the resulting amounts are each is then applied to the pathology/labora- trended forward to the effective time tory conversion factor. period for the charges, as set forth in (iii) Geographic area adjustment factor. paragraph (j)(2)(ii) of this section. The Using the 80th percentile charges for results constitute the nationwide 80th the selected CPT/HCPCS codes from percentile base and hourly facility paragraph (i)(3) of this section for each charges for observation care. geographic area, a geographic area-spe- (ii) Trending forward. The nationwide cific conversion factor is calculated by 80th percentile base and hourly facility dividing the weighted average charge charges for observation care, obtained by the weighted average geographi- as described in paragraph (j)(2)(i) of cally-adjusted RVU. The resulting geo- this section, are trended forward based graphic area conversion factor is di- on changes to the outpatient hospital vided by the corresponding nationwide services component of the CPI-U. Ac- conversion factor determined pursuant tual CPI-U changes are used from the to paragraph (i)(3)(i) of this section. time period of the source data through The resulting ratios are the geographic the latest available month as of the area adjustment factors for pathology time the calculations are performed. and laboratory services for each geo- The three-month average annual trend graphic area. rate as of the latest available month is (j) Observation care facility charges. then held constant to the midpoint of When VA provides observation care the calendar year in which the charges within the scope of care referred to in are primarily expected to be used. The paragraph (a)(1) of this section, the fa- projected total CPI-U change so ob- cility charges billed for such care will tained is then applied to the 80th per- be determined in accordance with the centile charges. provisions of this paragraph. The (3) Geographic area adjustment factors. charges for this care vary by geo- The geographic area adjustment fac- graphic area and number of hours of tors for observation care facility care. These charges are calculated as charges are the same as those com- follows: puted for outpatient facility charges (1) Formula. For each occurrence of under paragraph (e)(4) of this section. observation care, add the nationwide (k) Ambulance and other emergency base charge determined pursuant to transportation charges. When VA pro- paragraph (j)(2) of this section to the vides ambulance and other emergency product of the number of hours in ob- transportation services that are within servation care and the hourly charge the scope of care referred to in para- also determined pursuant to paragraph graph (a)(1) of this section, the charges (j)(2) of this section. Then multiply billed for such services will be deter- this amount by the appropriate geo- mined in accordance with the provi- graphic area adjustment factor deter- sions of this paragraph. The charges for mined pursuant to paragraph (j)(3) of these services vary by HCPCS code, this section. The result constitutes the length of trip, and geographic area. area-specific observation care facility These charges are calculated as fol- charge. lows: (2)(i) Nationwide 80th percentile obser- (1) Formula. For each occasion of am- vation care facility charges. To calculate bulance or other emergency transpor- nationwide base and hourly facility tation service, add the nationwide base charges, all claims with observation charge for the appropriate HCPCS code care line items are selected from the determined pursuant to paragraph outpatient facility component of the (k)(2)(i) of this section to the product

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of the number of miles traveled and the tion, is trended forward based on appropriate HCPCS code mileage changes to the outpatient hospital charge determined pursuant to para- services component of the CPI-U. Ac- graph (k)(2)(ii) of this section. Then tual CPI-U changes are used from the multiply this amount by the appro- time period of the source data through priate geographic area adjustment fac- the latest available month as of the tor determined pursuant to paragraph time the calculations are performed. (k)(3) of this section. The result con- The three-month average annual trend stitutes the area-specific ambulance or rate as of the latest available month is other emergency transportation serv- then held constant to the midpoint of ice charge. the calendar year in which the charges (2)(i) Nationwide 80th percentile all-in- are primarily expected to be used. The clusive base charge. To calculate a na- projected total CPI-U change so ob- tionwide all-inclusive base charge, all tained is then applied to the 80th per- ambulance and other emergency trans- centile charges. portation claims are selected from the (3) Geographic area adjustment factors. outpatient facility component of the The geographic area adjustment fac- Medicare Standard Analytical File 5 tors for ambulance and other emer- percent Sample. Excluding professional gency transportation charges are the and mileage charges, as well as all-in- same as those computed for outpatient clusive charges which are reported on facility charges under paragraph (e)(4) such claims, the total charge per of this section. claim, including incidental supplies, is (l) Charges for durable medical equip- computed. Then, the 80th percentile ment, drugs, injectables, and other med- amount for each HCPCS code is com- ical services, items, and supplies identified puted. Finally, the resulting amounts by HCPCS Level II codes. When VA pro- are each trended forward to the effec- vides DME, drugs, injectables, or other tive time period for the charges, as set medical services, items, or supplies forth in paragraph (k)(2)(iii) of this sec- that are identified by HCPCS Level II tion. The results constitute the nation- codes and that are within the scope of wide 80th percentile all-inclusive base care referred to in paragraph (a)(1) of charge for each HCPCS base charge this section, the charges billed for such code. services, items, and supplies will be de- (ii) Nationwide 80th percentile mileage termined in accordance with the provi- charge. To calculate a nationwide mile- sions of this paragraph. The charges for age charge, all ambulance and other these services, items, and supplies vary emergency transportation claims are by geographic area, by HCPCS code, selected from the outpatient facility and by modifier, when applicable. component of the Medicare Standard These charges are calculated as fol- Analytical File 5 percent Sample. Ex- lows: cluding professional, incidental, and (1) Formula. For each HCPCS code, base charges, as well as claims with multiply the nationwide charge deter- all-inclusive charges, the total mileage mined pursuant to paragraphs (l)(2), charge per claim is computed. This (l)(3), and (l)(4) of this section by the amount is divided by the number of appropriate geographic area adjust- miles reported on the claim. Then, the ment factor determined pursuant to 80th percentile amount for each HCPCS paragraph (l)(5) of this section. The re- code, using miles as weights, is com- sult constitutes the area-specific puted. Finally, the resulting amounts charge. are each trended forward to the effec- (2) Nationwide 80th percentile charges tive time period for the charges, as set for HCPCS codes with RVUs. For each forth in paragraph (k)(2)(iii) of this sec- applicable HCPCS code, RVUs are com- tion. The results constitute the nation- piled from the data sources set forth in wide 80th percentile mileage charge for paragraph (l)(2)(i) of this section. The each HCPCS mileage code. RVUs are multiplied by the charge (iii) Trending forward. The nationwide amount for each incremental RVU de- 80th percentile charge for each HCPCS termined pursuant to paragraph code, obtained as described in para- (l)(2)(ii) of this section, and this graphs (k)(2)(i) and (k)(2)(ii) of this sec- amount is added to the fixed charge

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amount also determined pursuant to is applied to the RVUs specified for paragraph (l)(2)(ii) of this section. each of the groups set forth in para- Then, for each HCPCS code, this charge graph (l)(2)(i) of this section, yielding is multiplied by the appropriate 80th two charge amounts for each HCPCS percentile to median charge ratio de- code group: a charge amount per incre- termined pursuant to paragraph mental RVU, and a fixed charge (l)(2)(iii) of this section. Finally, the amount. resulting amount is trended forward to (iii) 80th Percentile to median charge the effective time period for the ratios. Two ratios are obtained for each charges, as set forth in paragraph HCPCS code group set forth in para- (l)(2)(iv) of this section to obtain the graph (l)(2)(i) of this section by divid- nationwide 80th percentile charge. ing the weighted average 80th per- (i) RVUs for DME, drugs, injectables, centile charge by the weighted average and other medical services, items, and median charge derived from two data supplies. For the purpose of the statis- sources: Medicare data, as represented tical methodology set forth in para- by the combined Part B and DME com- graph (l)(2)(ii) of this section, HCPCS ponents of the Medicare Standard Ana- codes are assigned to the following lytical File 5% Sample; and the MDR HCPCS code groups. For the HCPCS database. Charge frequencies from the codes in each group, the RVUs or Medicare data are used as weights amounts indicated constitute the when calculating all weighted aver- RVUs: ages. For each HCPCS code group, the (A) Chemotherapy Drugs: Ingenix/St. smaller of the two ratios is selected as Anthony’s RBRVS Practice Expense the adjustment from median to 80th RVUs. percentile charges. (B) Other Drugs: Ingenix/St. Antho- (iv) Trending forward. The charges for ny’s RBRVS Practice Expense RVUs. each HCPCS code, obtained as de- (C) DME—Hospital Beds: Medicare scribed in paragraph (l)(2)(iii) of this DME Fee Schedule amounts. section, are trended forward based on (D) DME—Medical/Surgical Supplies: changes to the medical care commod- Medicare DME Fee Schedule amounts. ities component of the CPI-U. Actual (E) DME—Orthotic Devices: Medicare CPI-U changes are used from the time DME Fee Schedule amounts. period of the source data through the (F) DME—Oxygen and Supplies: latest available month as of the time Medicare DME Fee Schedule amounts. the calculations are performed. The (G) DME—Wheelchairs: Medicare three-month average annual trend rate DME Fee Schedule amounts. as of the latest available month is then (H) Other DME: Medicare DME Fee held constant to the midpoint of the Schedule amounts. calendar year in which the charges are (I) Enteral/Parenteral Supplies: primarily expected to be used. The pro- Medicare Parenteral and Enteral Nu- jected total CPI-U change so obtained trition Fee Schedule amounts. is then applied to the 80th percentile (J) Surgical Dressings and Supplies: charges, as described in paragraph Medicare DME Fee Schedule amounts. (l)(2)(iii) of this section. (K) Vision Items—Other Than (3) Nationwide 80th percentile charges Lenses: Medicare DME Fee Schedule for HCPCS codes without RVUs. For each amounts. applicable HCPCS code, 80th percentile (L) Vision Items—Lenses: Medicare charges are extracted from three inde- DME Fee Schedule amounts. pendent data sources: the MDR data- (M) Hearing Items: Ingenix/St. An- base; Medicare, as represented by the thony’s RBRVS Practice Expense combined Part B and DME components RVUs. of the Medicare Standard Analytical (ii) Charge amounts. Using combined File 5 percent Sample; and Milliman Part B and DME components of the USA, Inc., Optimized HMO (Health Medicare Standard Analytical File 5% Maintenance Organization) Data Sets Sample, the median billed charge is (see paragraph (a)(3) of this section for calculated for each HCPCS code. A Data Sources). Charges from each data- mathematical approximation method- base are then trended forward to the ef- ology based on least squares techniques fective time period for the charges, as

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set forth in paragraph (l)(3)(i) of this centile charges of HCPCS codes within section. Charges for each HCPCS code the series in which the unlisted or un- from each data source are combined specified code occurs. A nationwide VA into an average 80th percentile charge distribution of procedures, services, by means of the methodology set forth items, and supplies is used for the pur- in paragraph (l)(3)(ii) of this section. pose of computing the weighted me- The results constitute the nationwide dian. 80th percentile charge for each applica- (5) Geographic area adjustment factors. ble HCPCS code. For the purpose of geographic adjust- (i) Trending forward. The charges ment, HCPCS codes are combined into from each database for each HCPCS two groups: drugs and DME/supplies, as code, obtained as described in para- set forth in paragraph (l)(5)(i) of this graph (l)(3) of this section, are trended section. The geographic area adjust- forward based on changes to the med- ment factor for each of these groups is ical care commodities component of calculated as the ratio of the area-spe- the CPI-U. Actual CPI-U changes are cific weighted average charge deter- used from the time period of each mined pursuant to paragraph (l)(5)(ii) source database through the latest of this section divided by the nation- available month as of the time the cal- wide weighted average charge deter- culations are performed. The three- mined pursuant to paragraph (l)(5)(iii) month average annual trend rate as of of this section. the latest available month is then held (i) Combined HCPCS code groups for ge- constant to the midpoint of the cal- ographic area adjustment factors for endar year in which the charges are DME, drugs, injectables, and other med- primarily expected to be used. The pro- ical services, items, and supplies. For the jected total CPI-U change so obtained purpose of the statistical methodology is then applied to the 80th percentile set forth in paragraph (l)(5) of this sec- charges, as described in paragraph (l)(3) tion, each of the HCPCS code groups of this section. set forth in paragraph (l)(2)(i) of this (ii) Averaging methodology. The aver- section is assigned to one of two com- age 80th percentile trended charge for bined HCPCS code groups, as follows: any particular HCPCS code is cal- (A) Chemotherapy Drugs: Drugs. culated by first computing a prelimi- (B) Other Drugs: Drugs. nary mean average of the three charges (C) DME—Hospital Beds: DME/sup- for each HCPCS code. Statistical plies. outliers are identified and removed by (D) DME—Medical/Surgical Supplies: testing whether any charge differs DME/supplies. from the preliminary mean charge by (E) DME—Orthotic Devices: DME/ more than 5 times the preliminary supplies. mean charge, or by less than 0.2 times (F) DME—Oxygen and Supplies: the preliminary mean charge. In such DME/supplies. cases, the charge most distant from the preliminary mean is removed as an (G) DME—Wheelchairs: DME/sup- outlier, and the average charge is cal- plies. culated as a mean of the two remaining (H) Other DME: DME/supplies. charges. In cases where none of the (I) Enteral/Parenteral Supplies: DME/ charges differ from the preliminary supplies. mean charge by more than 5 times the (J) Surgical Dressings and Supplies: preliminary mean charge, or less than DME/supplies. 0.2 times the preliminary mean charge, (K) Vision Items—Other Than the average charge is calculated as a Lenses: DME/supplies. mean of all three reported charges. (L) Vision Items—Lenses: DME/sup- (4) Nationwide 80th percentile charges plies. for HCPCS codes designated as unlisted or (M) Hearing Items: DME/supplies. unspecified. For HCPCS codes des- (ii) Area-specific weighted average ignated as unlisted or unspecified pro- charges. Using the median charges by cedures, services, items, or supplies, HCPCS code from the MDR database 80th percentile charges are developed for each geographic area and utiliza- based on the weighted median 80th per- tion frequencies by HCPCS code from

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the combined Part B and DME compo- the same charges prescribed by the Office of nents of the Medicare Standard Ana- Management and Budget for use under the lytical File 5 percent Sample, an area- Federal Medical Care Recovery Act, 42 U.S.C. specific weighted average charge is cal- 2651–2653. culated for each combined HCPCS code (Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, group. 1720D, 1720E, 1721, 1722, 1729) (iii) Nationwide weighted average (The Office of Management and Budget has charges. Using the area-specific weight- approved the information collection require- ed average charges determined pursu- ments in this section under control number ant to paragraph (l)(5)(ii) of this sec- 2900–0606) tion, a nationwide weighted average [68 FR 70715, Dec. 19, 2003, as amended at 69 charge is calculated for each combined FR 1061, Jan. 7, 2004; 72 FR 68072, Dec. 4, 2007; HCPCS code group, using as weights 75 FR 61623, Oct. 6, 2010; 83 FR 31454, July 6, the population (census) frequencies for 2018] each geographic area as presented in the Milliman USA, Inc., Health Cost § 17.102 Charges for care or services. Guidelines (see paragraph (a)(3) of this Except as provided in § 17.101, charges section for Data Sources). at the indicated rates shall be made for (m) Charges for prescription drugs not Department of Veterans Affairs hos- administered during treatment. Notwith- pital care or medical services (includ- standing other provisions of this sec- ing, but not limited to, dental services, tion regarding VA charges, when VA supplies, medicines, orthopedic and provides or furnishes prescription prosthetic appliances, and domiciliary drugs not administered during treat- or nursing home care) as follows: ment, within the scope of care referred (a) Furnished in error or on tentative to in paragraph (a)(1) of this section, eligibility. Charges at rates prescribed charges billed separately for such pre- by the Under Secretary for Health scription drugs will consist of the shall be made for inpatient or out- amount that equals the total of the ac- patient care or services (including tual cost to VA for the drugs and the domiciliary care) authorized for any national average of VA administrative person on the basis of eligibility as a costs associated with dispensing the veteran or a tentative eligibility deter- drugs for each prescription. The actual mination under § 17.34 but he or she was VA cost of a drug will be the actual subsequently found to have been ineli- amount expended by the VA facility for gible for such care or services as a vet- the purchase of the specific drug. The eran because the military service or administrative cost will be determined any other eligibility requirement was annually using VA’s managerial cost not met, or accounting system. Under this ac- (b) Furnished in a medical emergency. counting system, the average adminis- Charges at rates prescribed by the trative cost is determined by adding Under Secretary for Health shall be the total VA national drug general made for any inpatient or outpatient overhead costs (such as costs of build- care or services rendered any person in ings and maintenance, utilities, bill- a medical emergency who was not eli- ing, and collections) to the total VA gible for such care or services as a vet- national drug dispensing costs (such as eran, if: costs of the labor of the pharmacy de- (1) The care or services were rendered partment, packaging, and mailing) as a humanitarian service, under with the sum divided by the actual § 17.43(b)(1) or § 17.95 to a person neither number of VA prescriptions filled na- claiming eligibility as a veteran nor tionally. Based on this accounting sys- for whom the establishment of eligi- tem, VA will determine the amount of bility as a veteran was expected, or the average administrative cost annu- (2) The person for whom care or serv- ally for the prior fiscal year (October ices were rendered was a Department of through September) and then apply the Veterans Affairs employee or a mem- charge at the start of the next calendar ber of a Department of Veterans Af- year. fairs employee’s family; or NOTE TO § 17.101: The charges generated by (c) Furnished beneficiaries of the De- the methodology set forth in this section are partment of Defense or other Federal

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agencies. Except as provided for in paragraph (c) of this section is based on paragraph (f) of this section and the the Monthly Program Cost Report second sentence of this paragraph, (MPCR), which sets forth the actual charges at rates prescribed by the Of- basic costs and per diem rates by type fice of Management and Budget shall of inpatient care, and actual basic be made for any inpatient or out- costs and rates for outpatient care vis- patient care or services authorized for its or prescriptions filled. Factors for a member of the Armed Forces on ac- depreciation of buildings and equip- tive duty or for any beneficiary or des- ment and Central Office overhead are ignee of any other Federal agency. added, based on accounting manual in- Charges for services provided a member structions. Additional factors are or former member of a uniformed serv- added for interest on capital invest- ice who is entitled to retired or re- ment and for standard fringe benefit tainer pay, or equivalent pay, will be costs covering government employee at rates prescribed by the Secretary retirement and disability costs. The (E.O. 11609, dated July 22, 1971, 36 FR current year billing rates are projected 13747), or on prior year actual rates by applying (d) Furnished pensioners of allied na- the budgeted percentage increase. In tions. Charges at rates prescribed by addition, based on the detail available the Under Secretary for Health shall be in the MPCR, VA intends to, on each made for any inpatient or outpatient bill break down the all-inclusive rate care or services rendered a pensioner of into its three principal components; a nation allied with the United States namely, physician cost, ancillary serv- in World War I and World War II; or ices cost, and nursing, room and board (e) Furnished under sharing agree- cost. The rates generated by the fore- ments. Charges at rates agreed upon in going methodology will be published by an agreement for sharing specialized either VA or OMB in the ‘Notices’ sec- medical resources shall be made for all tion of the FEDERAL REGISTER. medical care or services, either on an inpatient or outpatient basis, rendered (Authority: 38 U.S.C. 1729; sec. 19013, Pub. L. to a person designated by the other 99–272) party to the agreement as a patient to [32 FR 11382, Aug. 5, 1967, as amended at 34 be benefited under the agreement; or FR 7807, May 16, 1969; 35 FR 11470, July 17, (f) Furnished military retirees with 1970; 36 FR 18794, Sept. 22, 1971; 47 FR 50861, chronic disability. Charges for subsist- Nov. 10, 1982; 47 FR 58249, Dec.30, 1982; 52 FR ence at rates prescribed by the Under 3010, Jan. 30, 1987. Redesignated and amended Secretary for Health shall be made for at 61 FR 21965, 21967, May 13, 1996; 62 FR the period during which hospital care 17072, Apr. 9, 1997. Redesignated and amended is rendered when such care is rendered at 64 FR 22678, 22683, Apr. 27, 1999; 69 FR 1061, to a member or former member of the Jan. 7, 2004; 73 FR 26946, May 12, 2008] Armed Forces required to pay the sub- § 17.103 Referrals of compromise set- sistence rate under § 17.47 (b)(2) and tlement offers. (c)(2). (g) Furnished for research purposes. Any offer to compromise or settle Charges will not be made for medical any charges or claim for $20,000 or less services, including transportation, fur- asserted by the Department of Vet- nished as part of an approved Depart- erans Affairs in connection with the ment of Veterans Affairs research medical program shall be referred as project, except that if the services are follows: furnished to a person who is not eligi- (a) To Chief Financial Officers of the ble for the services as a veteran, the Consolidated Patient Account Centers. If medical care appropriation shall be re- the debt represents charges made under imbursed from the research appropria- §§ 17.108, 17.110, or 17.111, the com- tion at the same rates used for billings promise offer shall be referred to the under paragraph (b) of this section. Chief Financial Officer of the Consoli- (h) Computation of charges. The meth- dated Patient Account Center (CPAC) od for computing the charges under for application of the collection stand- § 17.86 and under paragraphs (a), (b), (d), ards in § 1.900 et seq. of this chapter, (f), and (g) and the last sentence of provided:

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(1) The debt does not exceed $1,000, (a) Of charges for medical services. If and the debt represents charges made under (2) There has been a previous denial §§ 17.108, 17.110, or 17.111 questions con- of waiver of the debt by the CPAC cerning suspension or termination of Committee on Waivers and Com- collection action shall be referred to promises. the Chief Financial Officer of the Con- (b) To Regional Counsel. If the debt in solidated Patient Account Center for any amount represents charges for application of the collection standards medical services for which there is or in § 1.900 et seq. of this chapter, or may be a claim against a third party (b) Of other debts. If the debt is of a tort-feasor or under workers’ com- type other than those contemplated in pensation laws or Pub. L. 87–693; 76 paragraph (a) of this section, questions Stat. 593 (see § 1.903 of this chapter) or concerning suspension or termination involves a claim contemplated by of collection action shall be referred in § 1.902 of this chapter over which the accordance with the same referral pro- Department of Veterans Affairs lacks cedures for compromise offers (except jurisdiction, the compromise offer (or the Fiscal activity shall make final de- request for waiver or proposal to termi- terminations in terminations or sus- nate or suspend collection action) shall pensions involving claims of $150 or be promptly referred to the field sta- less pursuant to the provisions of § 1.900 tion Regional Counsel having jurisdic- et seq. of this chapter.) tion in the area in which the claim [34 FR 7807, May 16, 1969, as amended at 39 arose, or FR 26403, July 19, 1974. Redesignated and (c) To Committee on Waivers and Com- amended at 61 FR 21966, 21967, May 13, 1996; 80 promises. If one of the following situa- FR 23241, Apr. 27, 2015] tions contemplated in paragraph (c)(1) through (3) of this section applies § 17.105 Waivers. (1) If the debt represents charges Applications or requests for waiver of made under § 17.101(a), but is not of a debts or claims asserted by the Depart- type contemplated in paragraph (a) of ment of Veterans Affairs in connection this section, or with the medical program generally (2) If the debt represents charges for will be denied by the facility Fiscal ac- medical services made under § 17.101(b), tivity on the basis there is no legal au- or thority to waive debts, unless the ques- (3) A claim arising in connection tion of waiver should be referred as fol- with any transaction of the Veterans lows: Health Administration for which the (a) Of charges for medical services. If instructions in paragraph (a) or (b) of the debt represents charges made under this section or in § 17.105(c) are not ap- § 17.102, the application or request for plicable, then, the compromise offer waiver should be referred for disposi- should be referred for disposition under tion under § 1.900 et seq. of this chapter § 1.900 et seq. of this chapter to the field to the field facility Committee on station Committee on Waivers and Waivers and Compromises which shall Compromises which shall take final ac- take final action, or tion. (b) Of claims against third persons and other claims. If the debt is of a type con- [39 FR 26403, July 19, 1974, as amended at 47 FR 58250, Dec. 30, 1982. Redesignated and templated in § 17.103(b), the waiver amended at 61 FR 21966, 21967, May 13, 1996; 62 question should be referred in accord- FR 17072, Apr. 9, 1997; 80 FR 23241, Apr. 27, ance with the same referral procedures 2015] for compromise offers in such categories of claims, or § 17.104 Terminations and suspen- (c) Of charges for copayments. If the sions. debt represents charges for outpatient Any proposal to suspend or terminate medical care, inpatient hospital care, collection action on any charges or medication or extended care services claim for $20,000 or less asserted by the copayments made under §§ 17.108, 17.110, Department of Veterans Affairs in con- 17.111, or 17.4600, the claimant must re- nection with the medical program shall quest a waiver by submitting VA Form be referred as follows: 5655 (Financial Status Report) to the

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Consolidated Patient Account Center through any VA facility to a veteran (CPAC) Chief Financial Officer. The who is also a beneficiary under the claimant must submit this form within third-party payer’s plan. VA’s right to the time period provided in § 1.963(b) of recover or collect is limited to the ex- this chapter and may request a hearing tent that the beneficiary or a non- under § 1.966(a) of this chapter. The government provider of care or services CPAC Chief Financial Officer may ex- would be eligible to receive reimburse- tend the time period for submitting a ment or indemnification from the claim if the Chairperson of the Com- third-party payer if the beneficiary mittee on Waivers and Compromises were to incur the costs on the bene- could do so under § 1.963(b) of this chap- ficiary’s own behalf. ter. The CPAC Chief Financial Officer (2) Definitions. For the purposes of will apply the standard ‘‘equity and this section: good conscience’’ in accordance with Automobile liability insurance means §§ 1.965 and 1.966(a) of this chapter, and insurance against legal liability for may waive all or part of the claimant’s health and medical expenses resulting debts. A decision by the CPAC Chief Fi- from personal injuries arising from op- nancial Officer under this provision is eration of a motor vehicle. Automobile final (except that the decision may be liability insurance includes: reversed or modified based on new and (A) Circumstances in which liability material evidence, fraud, a change in benefits are paid to an injured party law or interpretation of law, or clear only when the insured party’s tortious and unmistakable error shown by the acts are the cause of the injuries; and evidence in the file at the time of the (B) Uninsured and underinsured cov- prior decision as provided in § 1.969 of erage, in which there is a third-party this chapter) and may be appealed in tortfeasor who caused the injuries (i.e., accordance with 38 CFR parts 19 and 20. benefits are not paid on a no-fault (d) Other debts. If the debt represents basis), but the insured party is not the any claim or charges other than those tortfeasor. contemplated in paragraphs (a) and (b) Health-plan contract means any plan, of this section, and is a debt for which policy, program, contract, or liability waiver has been specifically provided arrangement that provides compensa- for by law or under the terms of a con- tion, coverage, or indemnification for tract, initial action shall be taken at expenses incurred by a beneficiary for the station level for referral of the re- medical care or services, items, prod- quest for waiver through channels for ucts, and supplies. It includes but is action by the appropriate designated not limited to: official. If, however, the question of (A) Any plan offered by an insurer, waiver may also involve a concurrent reinsurer, employer, corporation, orga- opportunity to negotiate a compromise nization, trust, organized health care settlement, the application shall be re- group or other entity. ferred to the Committee on Waivers (B) Any plan for which the bene- and Compromises. ficiary pays a premium to an issuing (The Office of Management and Budget has agent as well as any plan to which the approved the information collection require- beneficiary is entitled as a result of ments in this section under control number employment or membership in or asso- 2900–0165) ciation with an organization or group. [39 FR 26403, July 19, 1974. Redesignated and (C) Any Employee Retirement In- amended at 61 FR 21966, 21967, May 13, 1996; 69 come and Security Act (ERISA) plan. FR 62204, Oct. 25, 2004; 80 FR 23241, Apr. 27, (D) Any Multiple Employer Trust 2015; 84 FR 26017, June 5, 2019] (MET). (E) Any Multiple Employer Welfare § 17.106 VA collection rules; third- Arrangement (MEWA). party payers. (F) Any Health Maintenance Organi- (a)(1) General rule. VA has the right zation (HMO) plan, including any such to recover or collect reasonable plan with a point-of-service provision charges from a third-party payer for or option. medical care and services provided for (G) Any individual practice associa- a nonservice-connected disability in or tion (IPA) plan.

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(H) Any exclusive provider organiza- any organization that is recognized as tion (EPO) plan. a health maintenance organization. (I) Any physician hospital organiza- Third-party payer means an entity, tion (PHO) plan. other than the person who received the (J) Any integrated delivery system medical care or services at issue (first (IDS) plan. party) and VA who provided the care or (K) Any management service organi- services (second party), responsible for zation (MSO) plan. the payment of medical expenses on be- (L) Any group or individual medical half of a person through insurance, services account. agreement or contract. This term includes, but is not limited to the fol- (M) Any participating provider orga- lowing: nization (PPO) plan or any PPO provi- (A) State and local governments that sion or option of any third-party payer provide such plans other than Med- plan. icaid. (N) Any Medicare supplemental in- (B) Insurance underwriters or car- surance plan. riers. (O) Any automobile liability insur- (C) Private employers or employer ance plan. groups offering self-insured or partially (P) Any no fault insurance plan, in- self-insured medical service or health cluding any personal injury protection plans. plan or medical payments benefit plan (D) Automobile liability insurance for personal injuries arising from the underwriter or carrier. operation of a motor vehicle. (E) No fault insurance underwriter or Medicare supplemental insurance plan carrier. means an insurance, medical service or (F) Workers’ compensation program health-plan contract primarily for the or plan sponsor, underwriter, carrier, purpose of supplementing an eligible or self-insurer. person’s benefit under Medicare. The (G) Any other plan or program that is term has the same meaning as ‘‘Medi- designed to provide compensation or care supplemental policy’’ in section coverage for expenses incurred by a 1882(g)(1) of the Social Security Act (42 beneficiary for healthcare services or U.S.C. 1395, et seq.) and 42 CFR part 403, products. subpart B. (H) A third-party administrator. No-fault insurance means an insur- (b) Calculating reasonable charges. (1) ance contract providing compensation The ‘‘reasonable charges’’ subject to for medical expenses relating to per- recovery or collection by VA under this sonal injury arising from the operation section are calculated using the appli- of a motor vehicle in which the com- cable method for such charges estab- pensation is not premised on who may lished by VA in 38 CFR 17.101. have been responsible for causing such (2) If the third-party payer’s plan in- injury. No-fault insurance includes per- cludes a requirement for a deductible sonal injury protection and medical or copayment by the beneficiary of the payments benefits in cases involving plan, VA will recover or collect reason- personal injuries resulting from operable charges less that deductible or co- ation of a motor vehicle. payment amount. Participating provider organization (c) VA’s right to recover or collect is ex- means any arrangement in a third- clusive. The only way for a third-party party payer plan under which coverage payer to satisfy its obligation under is limited to services provided by a se- this section is to pay the VA facility or lect group of providers who are mem- other authorized representative of the bers of the PPO or incentives (for ex- United States. Payment by a third- ample, reduced copayments) are pro- party payer to the beneficiary does not vided for beneficiaries under the plan satisfy the third-party’s obligation to receive health care services from the under this section. members of the PPO rather than from (1) Pursuant to 38 U.S.C. 1729(b)(2), other providers who, although author- the United States may file a claim or ized to be paid, are not included in the institute and prosecute legal pro- PPO. However, a PPO does not include ceedings against a third-party payer to

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enforce a right of the United States third-party payer that would have the under 38 U.S.C. 1729 and this section. effect of excluding from coverage or Such filing or proceedings must be in- limiting payment for any medical care stituted within six years after the last or services for which payment by the day of the provision of the medical care third-party payer under 38 U.S.C. 1729 or services for which recovery or col- or this part is required, is preempted lection is sought. by 38 U.S.C. 1729(f) and shall have no (2) An authorized representative of force or effect in connection with the the United States may compromise, third-party payer’s obligations under settle or waive a claim of the United 38 U.S.C. 1729 or this part. States under this section. (f) Impermissible exclusions by third- (3) The remedies authorized for col- party payers. (1) Statutory requirement. lection of indebtedness due the United Under 38 U.S.C. 1729(f), no provision of States under 31 U.S.C. 3701, et seq., 28 any third-party payer’s plan having the CFR part 11, 31 CFR parts 900 through effect of excluding from coverage or 904 and 38 CFR part 1, are available to limiting payment for certain care if effect collections under this section. that care is provided in or through any (4) A third-party payer may not, VA facility shall operate to prevent without the consent of a U.S. Govern- collection by the United States. ment official authorized to take action (2) General rules. The following are under 38 U.S.C. 1729 and this part, off- general rules for the administration of set or reduce any payment due under 38 38 U.S.C. 1729 and this part, with exam- U.S.C. 1729 or this part on the grounds ples provided for clarification. The ex- that the payer considers itself due a re- amples provided are not exclusive. A fund from a VA facility. A written re- third-party payer may not reduce, off- quest for a refund must be submitted set, or request a refund for payments and adjudicated separately from any made to VA under the following condi- other claims submitted to the third- tions: party payer under 38 U.S.C. 1729 or this (i) Express exclusions or limitations part. in third-party payer plans that are in- (d) Assignment of benefits or other sub- consistent with 38 U.S.C. 1729 are inop- mission by beneficiary not necessary. The erative. For example, a provision in a obligation of the third-party payer to third-party payer’s plan that purports pay is not dependent upon the bene- to disallow or limit payment for serv- ficiary executing an assignment of ben- ices provided by a government entity efits to the United States. Nor is the or paid for by a government program obligation to pay dependent upon any (or similar exclusion) is not a permis- other submission by the beneficiary to sible ground for refusing or reducing the third-party payer, including any third-party payment. claim or appeal. In any case in which (ii) No objection, precondition or lim- VA makes a claim, appeal, representa- itation may be asserted that defeats tion, or other filing under the author- the statutory purpose of collecting ity of this part, any procedural require- from third-party payers. For example, ment in any third-party payer plan for a provision in a third-party payer’s the beneficiary of such plan to make plan that purports to disallow or limit the claim, appeal, representation, or payment for services for which the pa- other filing must be deemed to be satis- tient has no obligation to pay (or simi- fied. A copy of the completed VA Form lar exclusion) is not a permissible 10–10EZ or VA Form 10–10EZR that in- ground for refusing or reducing third- cludes a veteran’s insurance declara- party payment. tion will be provided to payers upon re- (iii) Third-party payers may not quest, in lieu of a claimant’s statement treat claims arising from services pro- or coordination of benefits form. vided in or through VA facilities less (e) Preemption of conflicting State laws favorably than they treat claims aris- and contracts. Any provision of a law or ing from services provided in other hos- regulation of a State or political sub- pitals. For example, no provision of an division thereof and any provision of employer sponsored program or plan any contract or agreement that pur- that purports to make ineligible for ports to establish any requirement on a coverage individuals who are eligible

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to receive VA medical care and serv- made available only for the purposes of ices shall be permissible. verifying the care and services which (iv) The lack of a participation agree- are the subject of the claim(s) for payment or the absence of privity of con- ment under 38 U.S.C. 1729, and for tract between a third-party payer and verifying that the care and services VA is not a permissible ground for re- met the permissible criteria of the fusing or reducing third-party pay- terms and conditions of the third-party ment. payer’s plan. Patient care records will (v) A provision in a third-party payer not be made available under any other plan, other than a Medicare supple- circumstances to any other entity. VA mental plan, that seeks to make Medi- will not make available to a third- care the primary payer and the plan party payer any other patient or VA the secondary payer or that would op- records. erate to carve out of the plan’s cov- (Authority: 31 U.S.C. 3711, 38 U.S.C. 501, 1729, erage an amount equivalent to the 42 U.S.C. 2651) Medicare payment that would be made if the services were provided by a pro- [76 FR 37204, June 24, 2011, as amended at 79 vider to whom payment would be made FR 54616, Sept. 12, 2014] under Part A or Part B of Medicare is DISCIPLINARY CONTROL OF BENE- not a permissible ground for refusing FICIARIES RECEIVING HOSPITAL, DOMI- or reducing payment as the primary CILIARY OR NURSING HOME CARE payer to VA by the third-party payer unless the provision expressly dis- § 17.107 VA response to disruptive be- allows payment as the primary payer havior of patients. to all providers to whom payment would not be made under Medicare (in- (a) Definition. For the purposes of cluding payment under Part A, Part B, this section: a Medicare HMO, or a Medicare Advan- VA medical facility means VA medical tage plan). centers, outpatient clinics, and domi- (vi) A third-party payer may not ciliaries. refuse or reduce third-party payment (b) Response to disruptive patients. The to VA because VA’s claim form did not time, place, and/or manner of the pro- report hospital acquired conditions vision of a patient’s medical care may (HAC) or present on admission condi- be restricted by written order of the tions (POA). VA is exempt from the Chief of Staff of the VA Medical Center Medicare Inpatient prospective pay- of jurisdiction or his or her designee if: ment system and the Medicare rules (1) The Chief of Staff or designee de- for reporting POA or HAC information termines pursuant to paragraph (c) of to third-party payers. this section that the patient’s behavior (vii) Health Maintenance Organiza- at a VA medical facility has jeopard- tions (HMOs) may not exclude claims ized or could jeopardize the health or or refuse to certify emergent and ur- safety of other patients, VA staff, or gent services provided within the guests at the facility, or otherwise HMO’s service area or otherwise cov- interfere with the delivery of safe med- ered non-emergency services provided ical care to another patient at the fa- out of the HMO’s service area. In addi- cility; tion, opt-out or point-of-service op- (2) The order is narrowly tailored to tions available under an HMO plan may address the patient’s disruptive behav- not exclude services otherwise payable ior and avoid undue interference with under 38 U.S.C. 1729 or this part. the patient’s care; (g) Records. Pursuant to 38 U.S.C. (3) The order is signed by the Chief of 1729(h), VA shall make available for in- Staff or designee, and a copy is entered spection and review to representatives into the patient’s permanent medical of third-party payers, from which the record; United States seeks payment, recov- (4) The patient receives a copy of the ery, or collection under 38 U.S.C. 1729, order and written notice of the proce- appropriate health care records (or cop- dure for appealing the order to the Net- ies of such records) of patients. How- work Director of jurisdiction as soon as ever, the appropriate records will be possible after issuance; and

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(5) The order contains an effective of Staff shall forward the order and the date and any appropriate limits on the patient’s request to the Network Direc- duration of or conditions for con- tor for a final decision. The Network tinuing the restrictions. The Chief of Director shall issue a final decision on Staff or designee may order restric- this matter within 30 days. VA will en- tions for a definite period or until the force the order while it is under review conditions for removing conditions by the Network Director. The Chief of specified in the order are satisfied. Un- Staff will provide the patient who less otherwise stated, the restrictions made the request written notice of the imposed by an order will take effect Network Director’s final decision. upon issuance by the Chief of Staff or designee. Any order issued by the Chief NOTE TO § 17.107: Although VA may restrict of Staff or designee shall include a the time, place, and/or manner of care under summary of the pertinent facts and the this section, VA will continue to offer the bases for the Chief of Staff’s or des- full range of needed medical care to which a ignee’s determination regarding the patient is eligible under title 38 of the United States Code or Code of Federal Regulations. need for restrictions. Patients have the right to accept or refuse (c) Evaluation of disruptive behavior. treatments or procedures, and such refusal In making determinations under para- by a patient is not a basis for restricting the graph (b) of this section, the Chief of provision of care under this section. Staff or designee must consider all pertinent facts, including any prior coun- (Authority: 38 U.S.C. 501, 901, 1721) seling of the patient regarding his or [75 FR 69883, Nov. 16, 2010. Redesignated at 76 her disruptive behavior or any pattern FR 37204, June 24, 2011; 79 FR 54616, Sept. 12, of such behavior, and whether the dis- 2014] ruptive behavior is a result of the patient’s individual fears, preferences, or COPAYMENTS perceived needs. A patient’s disruptive behavior must be assessed in connec- § 17.108 Copayments for inpatient hos- tion with VA’s duty to provide good pital care and outpatient medical care. quality care, including care designed to reduce or otherwise clinically address (a) General. This section sets forth re- the patient’s behavior. quirements regarding copayments for (d) Restrictions. The restrictions on inpatient hospital care and outpatient care imposed under this section may medical care provided to veterans by include but are not limited to: VA. (1) Specifying the hours in which (b) Copayments for inpatient hospital nonemergent outpatient care will be care. (1) Except as provided in para- provided; graphs (d) or (e) of this section, a vet- (2) Arranging for medical and any eran, as a condition of receiving inpa- other services to be provided in a par- tient hospital care provided by VA ticular patient care area (e.g., private (provided either directly by VA or ob- exam room near an exit); tained by VA by contract, provider (3) Arranging for medical and any agreement, or sharing agreement), other services to be provided at a spe- must agree to pay VA (and is obligated cific site of care; to pay VA) the applicable copayment, (4) Specifying the health care pro- as set forth in paragraph (b)(2), (b)(3), vider, and related personnel, who will or (b)(4) of this section. be involved with the patient’s care; (2) The copayment for inpatient hos- (5) Requiring police escort; or (6) Authorizing VA providers to ter- pital care shall be, during any 365-day minate an encounter immediately if period, a copayment equaling the sum certain behaviors occur. of: (e) Review of restrictions. The patient (i) $10 for every day the veteran re- may request the Network Director’s receives inpatient hospital care, and view of any order issued under this sec- (ii) The lesser of: tion within 30 days of the effective date (A) The sum of the inpatient Medi- of the order by submitting a written care deductible for the first 90 days of request to the Chief of Staff. The Chief care and one-half of the inpatient

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Medicare deductible for each subse- grated, accessible healthcare services quent 90 days of care (or fraction thereby clinicians who are accountable for of) after the first 90 days of such care addressing a large majority of personal during such 365-day period, or healthcare needs, developing a sus- (B) VA’s cost of providing the care. tained partnership with patients, and (3) The copayment for inpatient hos- practicing in the context of family and pital care for veterans enrolled in pri- community. Primary care includes, but ority category 7 shall be 20 percent of is not limited to, diagnosis and man- the amount computed under paragraph agement of acute and chronic bio- (b)(2) of this section. psychosocial conditions, health pro- (4) For inpatient hospital care fur- motion, disease prevention, overall nished through the Veterans Choice care management, and patient and Program under §§ 17.1500 through caregiver education. Each patient’s 17.1540, or the Veterans Community identified primary care clinician deliv- Care Program under §§ 17.4000 through ers services in the context of a larger 17.4040, the copayment amount at the interdisciplinary primary care team. time of furnishing such care or services Patients have access to the primary by a non-VA entity or provider is $0. care clinician and much of the primary VA will determine and assess the vet- care team without need of a referral. In eran’s copayment amount at the end of contrast, specialty care is generally the billing process, but at no time will provided through referral. A specialty a veteran’s copayment be more than care outpatient visit is an episode of the amount identified in paragraph care furnished in a clinic that does not (b)(2) or (3) of this section. provide primary care, and is only pro- NOTE TO § 17.108(b): The requirement that a vided through a referral. Some exam- veteran agree to pay the copayment would ples of specialty care provided at a spe- be met by submitting to VA a signed VA cialty care clinic are radiology services Form 10–10EZ. This is the application form requiring the immediate presence of a for enrollment in the VA healthcare system physician, audiology, optometry, mag- and also is the document used for providing means-test information annually. netic resonance imagery (MRI), com- puterized axial tomography (CAT) (c) Copayments for outpatient medical scan, nuclear medicine studies, sur- care. (1) Except as provided in para- gical consultative services, and ambu- graphs (d), (e), or (f) of this section, a latory surgery. veteran, as a condition for receiving (4) For outpatient medical care fur- outpatient medical care provided by nished through the Veterans Choice VA (provided either directly by VA or Program under §§ 17.1500 through obtained by VA by contract, provider 17.1540, or the Veterans Community agreement, or sharing agreement), Care Program under §§ 17.4000 through must agree to pay VA (and is obligated 17.4040, the copayment amount at the to pay VA) a copayment as set forth in time of furnishing such care or services paragraph (c)(2) or (c)(4) of this section. by a non-VA entity or provider is $0. (2) The copayment for outpatient VA will determine and assess the vet- medical care is $15 for a primary care eran’s copayment amount at the end of outpatient visit and $50 for a specialty the billing process, but at no time will care outpatient visit. If a veteran has more than one primary care encounter a veteran’s copayment be more than on the same day and no specialty care the amount identified in paragraph encounter on that day, the copayment (c)(2) of this section. amount is the copayment for one pri- NOTE TO § 17.108(c): The requirement that a mary care outpatient visit. If a veteran veteran agree to pay the copayment would has one or more primary care encoun- be met by submitting to VA a signed VA ters and one or more specialty care en- Form 10–10EZ. This is the application form counters on the same day, the copay- for enrollment in the VA healthcare system ment amount is the copayment for one and also is the document used for providing means-test information annually. specialty care outpatient visit. (3) For purposes of this section, a pri- (d) Veterans not subject to copayment mary care visit is an episode of care requirements for inpatient hospital care or furnished in a clinic that provides inte- outpatient medical care. The following

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veterans are not subject to the copay- (3) Special registry examinations (in- ment requirements of this section: cluding any follow-up examinations or (1) A veteran with a compensable testing ordered as part of the special service-connected disability. registry examination) offered by VA to (2) A veteran who is a former pris- evaluate possible health risks associ- oner of war. ated with military service; (3) A veteran awarded a Purple Heart. (4) Counseling and care for sexual (4) A veteran who was discharged or trauma as authorized under 38 U.S.C released from active military service 1720D; for a disability incurred or aggravated (5) Compensation and pension exami- in the line of duty; nations requested by the Veterans Ben- (5) A veteran who receives disability efits Administration; compensation under 38 U.S.C. 1151. (6) Care provided as part of a VA-ap- (6) A veteran whose entitlement to proved research project authorized by disability compensation is suspended 38 U.S.C. 7303; pursuant to 38 U.S.C. 1151, but only to (7) Outpatient dental care provided the extent that the veteran’s con- under 38 U.S.C. 1712; tinuing eligibility for care is provided (8) Readjustment counseling and re- for in the judgment or settlement de- lated mental health services author- scribed in 38 U.S.C. 1151. ized under 38 U.S.C 1712A; (7) A veteran whose entitlement to (9) Emergency treatment paid for disability compensation is suspended under 38 U.S.C. 1725 or 1728; because of the receipt of military re- (10) Care or services authorized under tirement pay. 38 U.S.C. 1720E for certain veterans re- (8) A veteran of the Mexican border garding cancer of the head or neck; period or of World War I. (11) Publicly announced VA public (9) A military retiree provided care health initiatives (e.g., health fairs) or under an interagency agreement as de- an outpatient visit solely consisting of fined in section 113 of Public Law 106– preventive screening and immuniza- 117, 113 Stat. 1545. tions (e.g., influenza immunization, (10) A veteran who VA determines to pneumonococcal immunization, hyper- be unable to defray the expenses of nec- tension screening, hepatitis C screen- essary care under 38 U.S.C. 1722(a). ing, tobacco screening, alcohol screen- (11) A veteran who VA determines to ing, hyperlipidemia screening, breast be catastrophically disabled, as defined cancer screening, cervical cancer in 38 CFR 17.36(e). screening, screening for colorectal can- (12) A veteran receiving care for psy- cer by fecal occult blood testing, and chosis or a mental illness other than education about the risks and benefits psychosis pursuant to § 17.109. of prostate cancer screening); (13) A veteran who was awarded the (12) Weight management counseling Medal of Honor. (individual and group); (e) Services not subject to copayment re- (13) Smoking cessation counseling quirements for inpatient hospital care, (individual and group); outpatient medical care, or urgent care. (14) Laboratory services, flat film ra- The following are not subject to the co- diology services, and electrocardio- payment requirements under this sec- grams; tion or, except for § 17.108(e)(1), (2), (4), (15) Hospice care; (10), and (14), the copayment require- (16) In-home video telehealth care; ments under § 17.4600. and (1) Care provided to a veteran for a (17) Mental health peer support serv- noncompensable zero percent service- ices. connected disability; (f) Additional care not subject to out- (2) Care authorized under 38 U.S.C. patient copayment. Outpatient care is 1710(e) for Vietnam-era herbicide-ex- not subject to the outpatient copay- posed veterans, radiation-exposed vet- ment requirements under this section erans, Gulf War veterans, post-Gulf when provided to a veteran during a War combat-exposed veterans, or Camp day for which the veteran is required Lejeune veterans pursuant to § 17.400; to make a copayment for extended care

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services that were provided either di- § 17.110 Copayments for medication. rectly by VA or obtained for VA by (a) General. This section sets forth re- contract. quirements regarding copayments for [66 FR 63448, Dec. 6, 2001, as amended at 68 medications provided to veterans by FR 60854, Oct. 24, 2003; 70 FR 22596, May 2, VA. For purposes of this section, the 2005; 73 FR 20532, Apr. 16, 2008; 75 FR 54030, term ‘‘medication’’ means prescription Sept. 3, 2010; 76 FR 52274, Aug. 22, 2011; 77 FR and over-the-counter medications, as 13198, Mar. 6, 2012; 78 FR 28143, May 14, 2013; 79 FR 57414, Sept. 24, 2014; 79 FR 65584, Nov. determined by the Food and Drug Ad- 5, 2014; 79 FR 70939, Nov. 28, 2014; 84 FR 7815, ministration (FDA), but does not mean Mar. 5, 2019; 84 FR 26017, 26306, June 5, 2019] medical supplies, oral nutritional supplements, or medical devices. Oral nu- § 17.109 Presumptive eligibility for tritional supplements are commer- psychosis and mental illness other cially prepared nutritionally enhanced than psychosis. products used to supplement the intake (a) Psychosis. Eligibility for benefits of individuals who cannot meet nutri- under this part is established by this ent needs by diet alone. section for treatment of an active psy- (b) Copayments. (1) Copayment amount. chosis, and such condition is exempted Unless exempted under paragraph (c) of from copayments under §§ 17.108, 17.110, this section, a veteran is obligated to and 17.111 for any veteran of World War pay VA a copayment for each 30-day or II, the Korean conflict, the Vietnam less supply of medication provided by era, or the Persian Gulf War who devel- VA on an outpatient basis (other than oped such psychosis: medication administered during treat- (1) Within 2 years after discharge or ment). release from the active military, naval, (i) For each 30-day or less supply of or air service; and Tier 1 medications, the copayment (2) Before the following date associ- amount is $5. ated with the war or conflict in which (ii) For each 30-day or less supply of he or she served: Tier 2 medications, the copayment (i) World War II: July 26, 1949. amount is $8. (ii) Korean conflict: February 1, 1957. (iii) For each 30-day or less supply of (iii) Vietnam era: May 8, 1977. Tier 3 medications, the copayment (iv) Persian Gulf War: The end of the amount is $11. 2-year period beginning on the last day (iv) For purposes of this section: of the Persian Gulf War. (A) Multi-source medication is any one (b) Mental illness (other than psy- of the following: chosis). Eligibility under this part is es- (1) A medication that has been and tablished by this section for treatment remains approved by the FDA— of an active mental illness (other than psychosis), and such condition is ex- (i) Under sections 505(b)(2) or 505(j) of empted from copayments under the Food, Drug, and Cosmetic Act §§ 17.108, 17.110, and 17.111 for any vet- (FDCA, 21 U.S.C. 355), and that has eran of the Persian Gulf War who de- been granted an A-rating in the cur- veloped such mental illness other than rent version of the FDA’s Approved psychosis: Drug Products with Therapeutic (1) Within 2 years after discharge or Equivalence Evaluations (the Orange release from the active military, naval, Book); or or air service; and (ii) Under section 351(k) of the Public (2) Before the end of the 2-year period Health Service Act (PHSA, 42 U.S.C. beginning on the last day of the Per- 262), and that has been granted an I or sian Gulf War. B rating in the current version of the (c) No minimum service required. Eligi- FDA’s Lists of Licensed Biological bility for care and waiver of copay- Products with Reference Product Ex- ments will be established under this clusivity and Biosimilarity or Inter- section without regard to the veteran’s changeability Evaluations (the Purple length of active-duty service. Book). FDA determines both therapeutic equivalence for drugs and inter- (Authority: 38 U.S.C. 501, 1702, 5303A) changeability for biological products. [78 FR 28143, May 14, 2013] (2) A medication that—

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(i) Has been and remains approved by meet all of the criteria in paragraphs the FDA pursuant to FDCA section (b)(2)(i), (ii), and (iii) will be eligible to 505(b)(1) or PHSA section 351(a); be considered Tier 1 medications, and (ii) Which is referenced by at least only those medications that meet all of one FDA-approved product that meets the criteria in paragraph (b)(2)(i) of the criteria of paragraph (b)(1)(iv)(A)(1) this section will be assessed using the of this section; and criteria in paragraphs (b)(2)(ii) and (iii) Which is covered by a con- (iii). tracting strategy in place with pricing (i) A medication must meet all of the such that it is lower in cost than other following criteria: generic sources. (A) The VA acquisition cost for the (3) A medication that— medication is less than or equal to $10 (i) Has been and remains approved by for a 30-day supply of medication; the FDA pursuant to FDCA section (B) The medication is not a topical 505(b)(1) or PHSA section 351(a); and cream, a product used to treat mus- (ii) Has the same active ingredient or culoskeletal conditions, an antihis- active ingredients, works in the same tamine, or a steroid-containing medi- way and in a comparable amount of cation; time, and is determined by VA to be (C) The medication is available on substitutable for another medication the VA National Formulary; that has been and remains approved by the FDA pursuant to FDCA section (D) The medication is not an anti- 505(b)(1) or PHSA section 351(a). This biotic that is primarily used for short may include but is not limited to insu- periods of time to treat infections; and lin and levothyroxine. (E) The medication primarily is used (4) A listed drug, as defined in 21 CFR to either treat or manage a chronic 314.3, that has been approved under condition, or to reduce the risk of ad- FDCA section 505(c) and is marketed, verse health outcomes secondary to the sold, or distributed directly or indi- chronic condition, for example, medi- rectly to retail class of trade with ei- cations used to treat high blood pres- ther labeling, packaging (other than sure to reduce the risks of heart at- repackaging as the listed drug in blis- tack, stroke, and kidney failure. For ter packs, unit doses, or similar pack- purposes of this section, conditions aging for use in institutions), product that typically are known to persist for code, labeler code, trade name, or 3 months or more will be considered trademark that differs from that of the chronic. listed drug. (ii) The medication must be among (B) Tier 1 medication means a multi- the top 75 most commonly prescribed source medication that has been identi- multi-source medications that meet fied using the process described in the criteria in paragraph (b)(2)(i) of paragraph (b)(2) of this section. this section, based on the number of (C) Tier 2 medication means a multi- prescriptions issued for a 30-day or less source medication that is not identi- supply on an outpatient basis during a fied using the process described in fixed period of time. paragraph (b)(2) of this section. (iii) VA must determine that the (D) Tier 3 medication means a medica- medication identified provides max- tion approved by the FDA under a New imum clinical value consistent with Drug Application (NDA) or a biological budgetary resources. product approved by the FDA pursuant (3) Information on Tier 1 medications. to a biologics license agreement (BLA) Not less than once per year, VA will that retains its patent protection and publish a list of Tier 1 medications in exclusivity and is not a multi-source the FEDERAL REGISTER and on VA’s medication identified in paragraph Web site at www.va.gov/health. (b)(1)(iv)(A)(3) or (4) of this section. (4) Veterans Choice Program. For medi- (2) Determining Tier 1 medications. Not cations furnished through the Veterans less than once per year, VA will iden- Choice Program under §§ 17.1500 tify a subset of multi-source medica- through 17.1540, or the Veterans Com- tions as Tier 1 medications using the munity Care Program under §§ 17.4000 criteria below. Only medications that through 17.4040, the copayment amount

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at the time the veteran fills the pre- (11) Medication for a veteran who was scription is $0. VA will determine and awarded the Medal of Honor. assess the veteran’s copayment amount [66 FR 63451, Dec. 6, 2001, as amended at 74 at the end of the billing process, but at FR 69285, Dec. 31, 2009; 75 FR 32672, June 9, no time will a veteran’s copayment be 2010; 75 FR 54030, Sept. 3, 2010; 76 FR 52274, more than the amount identified in Aug. 22, 2011; 76 FR 78826, Dec. 20, 2011; 77 FR paragraphs (b)(1)(i) through (iii) of this 76867, Dec. 31, 2012; 78 FR 28143, May 14, 2013; 78 FR 79317, Dec. 30, 2013; 79 FR 57414, Sept. section. 24, 2014; 79 FR 63821, Oct. 27, 2014; 79 FR 65585, (5) Copayment cap. The total amount Nov. 5, 2014; 80 FR 55545, Sept. 16, 2015; 81 FR of copayments for medications in a cal- 88120, Dec. 7, 2016; 81 FR 89390, Dec. 12, 2016; endar year for an enrolled veteran will 84 FR 7815, Mar. 5, 2019; 84 FR 26306, June 5, not exceed $700. 2019] (c) Medication not subject to the copay- § 17.111 Copayments for extended care ment requirements. The following are ex- services. empt from the copayment require- (a) General. This section sets forth re- ments of this section: quirements regarding copayments for (1) Medication for a veteran who has extended care services provided to vet- a service-connected disability rated erans by VA (either directly by VA or 50% or more based on a service-con- paid for by VA). nected disability or unemployability. (b) Copayments. (1) Unless exempted (2) Medication for a veteran’s service- under paragraph (f) of this section, as a connected disability. condition of receiving extended care (3) Medication for a veteran whose services from VA, a veteran must agree annual income (as determined under 38 to pay VA and is obligated to pay VA U.S.C. 1503) does not exceed the max- a copayment as specified by this sec- imum annual rate of VA pension which tion. A veteran has no obligation to would be payable to such veteran if pay a copayment for the first 21 days of such veteran were eligible for pension extended care services that VA pro- under 38 U.S.C. 1521. vided the veteran in any 12-month pe- (4) Medication authorized under 38 riod (the 12-month period begins on the U.S.C. 1710(e) for Vietnam-era herbi- date that VA first provided extended care services to the veteran). However, cide-exposed veterans, radiation-ex- for each day that extended care serv- posed veterans, Persian Gulf War vet- ices are provided beyond the first 21 erans, post-Persian Gulf War combat- days, a veteran is obligated to pay VA exposed veterans, or Camp Lejeune vet- the copayment amount set forth below erans pursuant to § 17.400. to the extent the veteran has available (5) Medication for treatment of sex- resources. Available resources are ual trauma as authorized under 38 based on monthly calculations, as de- U.S.C. 1720D. termined under paragraph (d) of this (6) Medication for treatment of can- section. The following sets forth the cer of the head or neck authorized extended care services provided by VA under 38 U.S.C. 1720E. and the corresponding copayment (7) Medications provided as part of a amount per day: VA approved research project author- (i) Adult day health care—$15. ized by 38 U.S.C. 7303. (ii) Domiciliary care—$5. (8) Medication for a veteran who is a (iii) Institutional respite care—$97. former prisoner of war. (iv) Institutional geriatric evaluation—$97. (9) A veteran who VA determines to (v) Non-institutional geriatric eval- be catastrophically disabled, as defined uation—$15. in 38 CFR 17.36(e). (vi) Non-institutional respite care— (10) A veteran receiving care for psy- $15. chosis or a mental illness other than (vii) Nursing home care—$97. psychosis pursuant to § 17.109. (2) For purposes of counting the number of days for which a veteran is obligated to make a copayment under this section, VA will count each day that

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adult day health care, non-institu- services, if such nursing care and med- tional geriatric evaluation, and non-in- ical services are prescribed by, or are stitutional respite care are provided performed under the general direction and will count each full day and partial of, persons duly licensed to provide day for each inpatient stay except for such care (nursing services must be the day of discharge. provided 24 hours a day). Such term in- (3) For hospital care and medical cludes services furnished in skilled services considered non-institutional nursing care facilities. Such term ex- care furnished through the Veterans cludes hospice care. Choice Program under §§ 17.1500 (8) Respite care means care which is of through 17.1540, as well as extended limited duration, is furnished on an care services furnished through the intermittent basis to a veteran who is Veterans Community Care Program suffering from a chronic illness and under §§ 17.4000 through 17.4040, the co- who resides primarily at home, and is payment amount at the time of fur- furnished for the purpose of helping the nishing such care or services by a non- veteran to continue residing primarily VA entity or provider is $0. VA will de- at home. (Respite providers tempo- termine and assess the veteran’s copay- rarily replace the caregivers to provide ment amount at the end of the billing services ranging from supervision to process, but at no time will a veteran’s skilled care needs.) copayment be more than the amount (d) Effect of the veteran’s financial re- identified in paragraph (b)(1) or (2) of sources on obligation to pay copayment. this section. (1) A veteran is obligated to pay the co- (c) Definitions. For purposes of this payment to the extent the veteran and section: the veteran’s spouse have available re- (1) Adult day health care is a thera- sources. For veterans who have been peutic outpatient care program that receiving extended care services for 180 provides medical services, rehabilita- days or less, their available resources tion, therapeutic activities, socializa- are the sum of the income of the vet- tion, nutrition and transportation eran and the veteran’s spouse, minus services to disabled veterans in a con- the sum of the veterans allowance, the gregate setting. spousal allowance, and expenses. For (2) Domiciliary care is defined in veterans who have been receiving ex- § 17.30(b). tended care services for 181 days or (3) Extended care services means adult more, their available resources are the day health care, domiciliary care, in- sum of the value of the liquid assets, stitutional geriatric evaluation, non- the fixed assets, and the income of the institutional geriatric evaluation, veteran and the veteran’s spouse, nursing home care, institutional res- minus the sum of the veterans allow- pite care, and noninstitutional respite ance, the spousal allowance, the spous- care. al resource protection amount, and (4) Geriatric evaluation is a special- (but only if the veteran—has a spouse ized, diagnostic/consultative service or dependents residing in the commu- provided by an interdisciplinary team nity who is not institutionalized) ex- that is for the purpose of providing a penses. When a veteran is legally sepa- comprehensive assessment, care plan, rated from a spouse, available re- and extended care service recommenda- sources do not include spousal income, tions. expenses, and assets or a spousal allow- (5) Institutional means a setting in a ance. hospital, domiciliary, or nursing home (2) For purposes of determining avail- of overnight stays of one or more days. able resources under this section: (6) Noninstitutional means a service (i) Income means current income (in- that does not include an overnight cluding, but not limited to, wages and stay. income from a business (minus busi- (7) Nursing home care means the ac- ness expenses), bonuses, tips, severance commodation of convalescents or other pay, accrued benefits, cash gifts, inher- persons who are not acutely ill and not itance amounts, interest income, in need of hospital care, but who re- standard dividend income from non tax quire nursing care and related medical deferred annuities, retirement income,

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pension income, unemployment pay- counts (e.g., IRA, 401Ks, annuities), art, ments, worker’s compensation pay- rare coins, stamp collections, and col- ments, black lung payments, tort set- lectibles of the veteran, spouse, and de- tlement payments, social security pay- pendents. This includes household and ments, court mandated payments, pay- personal items (e.g., furniture, cloth- ments from VA or any other Federal ing, and jewelry) except when the vet- programs, and any other income). The eran’s spouse or dependents are living amount of current income will be stat- in the community. ed in frequency of receipt, e.g., per (v) Spousal allowance is an allowance week, per month. of $20 per day that is included only if (ii) Expenses means basic subsistence the spouse resides in the community expenses, including current expenses (not institutionalized). for the following: rent/mortgage for (vi) Spousal resource protection amount primary residence; vehicle payment for means the value of liquid assets equal one vehicle; food for veteran, veteran’s to the Maximum Community Spouse spouse, and veteran’s dependents; edu- Resource Standard published by the cation for veteran, veteran’s spouse, Centers for Medicare and Medicaid and veteran’s dependents; court-or- Services (CMS) as of January 1 of the dered payments of veteran or veteran’s current calendar year if the spouse is spouse (e.g., alimony, child-support); residing in the community (not institu- and including the average monthly ex- tionalized). penses during the past year for the fol- (vii) Veterans allowance is an allow- lowing: utilities and insurance for the ance of $20 per day. primary residence; out-of-pocket medical care costs not otherwise covered (3) The maximum amount of a copay- by health insurance; health insurance ment for any month equals the copay- premiums for the veteran, veteran’s ment amount specified in paragraph spouse, and veteran’s dependents; and (b)(1) of this section multiplied by the taxes paid on income and personal number of days in the month. The co- property. payment for any month may be less than the amount specified in paragraph (iii) Fixed Assets means: (A) Real property and other non-liq- (b)(1) of this section if the veteran pro- uid assets; except that this does not in- vides information in accordance with clude— this section to establish that the copayment should be reduced or elimi- (1) Burial plots; nated. (2) A residence if the residence is: (i) The primary residence of the vet- (e) Requirement to submit information. eran and the veteran is receiving only (1) Unless exempted under paragraph (f) noninstitutional extended care service; of this section, a veteran must submit or to a VA medical facility a completed (ii) The primary residence of the vet- VA Form 10–10EC and documentation eran’s spouse or the veteran’s depend- requested by the Form at the following ents (if the veteran does not have a times: spouse) if the veteran is receiving in- (i) At the time of initial request for stitutional extended care service. an episode of extended care services; (3) A vehicle if the vehicle is: (ii) At the time of request for ex- (i) The vehicle of the veteran and the tended care services after a break in veteran is receiving only noninstitu- provision of extended care services for tional extended care service; or more than 30 days; and (ii) The vehicle of the veteran’s (iii) Each year at the time of submis- spouse or the veteran’s dependents (if sion to VA of VA Form 10–10EZ. the veteran does not have a spouse) if (2) When there are changes that the veteran is receiving institutional might change the copayment obliga- extended care service. tion (i.e., changes regarding marital (B) [Reserved] status, fixed assets, liquid assets, ex- (iv) Liquid assets means cash, stocks, penses, income (when received), or dividends received from IRA, 401K’s whether the veteran has a spouse or de- and other tax deferred annuities, pendents residing in the community), bonds, mutual funds, retirement ac- the veteran must report those changes

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to a VA medical facility within 10 days with the care and treatment of pa- of the change. tients. Organizations must provide as- (f) Veterans and care that are not sub- surance that their members will obey ject to the copayment requirements. The all rules in effect at the hospital or following veterans and care are not center involved, and act in a dignified subject to the copayment requirements and proper manner; of this section: (2) Partisan activities are inappro- (1) A veteran with a compensable priate and all activities must be nonservice-connected disability. partisan in nature. An activity will be (2) A veteran whose annual income considered partisan and therefore inap- (determined under 38 U.S.C. 1503) is less propriate if it includes commentary in than the amount in effect under 38 support of, or in opposition to, or at- U.S.C. 1521(b). tempts to influence, any current policy (3) Care for a veteran’s noncompen- of the Government of the United States sable zero percent service-connected or any State of the United States. If disability. the activity is closely related to par- (4) An episode of extended care serv- tisan activities being conducted out- ices that began on or before November side the hospital or center reserva- 30, 1999. tions, it will be considered partisan and (5) Care authorized under 38 U.S.C. 1710(e) for Vietnam-era herbicide-ex- therefore inappropriate. posed veterans, radiation-exposed vet- (b) Requests for permission to hold erans, Persian Gulf War veterans,post- services or ceremonies will be ad- Persian Gulf War combat-exposed vet- dressed to the Secretary, or the Direc- erans, or Camp Lejeune veterans pursu- tor of the Department of Veterans Af- ant to § 17.400. fairs hospital or center involved. Such (6) Care for treatment of sexual trau- applications will describe the proposed ma as authorized under 38 U.S.C. 1720D. activity in sufficient detail to enable a (7) Care or services authorized under determination as to whether it meets 38 U.S.C. 1720E for certain veterans re- the standards set forth in paragraph (a) garding cancer of the head or neck. of this section. If permission is grant- (8) A veteran who VA determines to ed, the Director of the hospital or cen- be catastrophically disabled, as defined ter involved will assign an appropriate in 38 CFR 17.36(e), is exempt from co- time, and render assistance where ap- payments for adult day health care, propriate. No organization will be non-institutional respite care, and non- given exclusive permission to use the institutional geriatric care. hospital or center reservation on any (9) A veteran receiving care for psy- particular occasion. Where several re- chosis or a mental illness other than quests are received for separate activi- psychosis pursuant to § 17.109. ties, the Director will schedule each so (10) A veteran who was awarded the as to avoid overlapping or interference, Medal of Honor. or require appropriate modifications in the scope or timing of the activity. [67 FR 35040, May 17, 2002, as amended at 69 FR 39846, July 1, 2004; 76 FR 52274, Aug. 22, [35 FR 2389, Feb. 3, 1970. Redesignated at 61 2011; 78 FR 28143, May 14, 2013; 78 FR 70864, FR 21966, May 13, 1996, and further redesig- Nov. 27, 2013; 79 FR 57414, Sept. 24, 2014; 79 FR nated at 67 FR 35040, May 17, 2002] 65585, Nov. 5, 2014; 84 FR 7815, Mar. 5, 2019; 84 FR 26307, June 5, 2019] REIMBURSEMENT FOR LOSS BY NATURAL DISASTER OF PERSONAL EFFECTS OF CEREMONIES HOSPITALIZED OR NURSING HOME PA- § 17.112 Services or ceremonies on De- TIENTS partment of Veterans Affairs hospital or center reservations. § 17.113 Conditions of custody. (a) Services or ceremonies on Depart- When the personal effects of a pa- ment of Veterans Affairs hospital or tient who has been or is hospitalized or center reservations are subject to the receiving nursing home care in a De- following limitations: partment of Veterans Affairs hospital (1) All activities must be conducted or center were or are duly delivered to with proper decorum, and not interfere a designated location for custody and

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loss of such personal effects has oc- earthquake, or other natural disaster curred or occurs by fire, earthquake, or as required under the provisions of other natural disaster, either during § 17.113. The responsible official will such storage or during laundering, re- make claim for the patient, adding the imbursement will be made as provided certification in all details as provided in §§ 17.113 and 17.114. for in § 17.113. After countersignature of [39 FR 1843, Jan. 15, 1974. Redesignated and this certification by the Director, pay- amended at 61 FR 21966, 21967, May 13, 1996, ment will be made as provided in and further redesignated at 67 FR 35039, May § 17.113, and the amount thereby dis- 17, 2002] bursed will be turned over to the Direc- § 17.114 Submittal of claim for reim- tor for custody. bursement. [39 FR 1843, Jan. 15, 1974, as amended at 49 The claim for reimbursement for per- FR 5616, Feb. 14, 1984. Redesignated and sonal effects damaged or destroyed will amended at 61 FR 21966, 21967, May 13, 1996, be submitted by the patient to the Di- and further redesignated at 67 FR 35039, May rector. The patient will separately list 17, 2002] and evaluate each article with a nota- tion as to its condition at the time of REIMBURSEMENT TO EMPLOYEES FOR THE the fire, earthquake, or other natural COST OF REPAIRING OR REPLACING disaster i.e., whether new, worn, etc. CERTAIN PERSONAL PROPERTY DAM- The date of the fire, earthquake, or AGED OR DESTROYED BY PATIENTS OR other natural disaster will be stated. It MEMBERS will be certified by a responsible official that each article listed was stored § 17.116 Adjudication of claims. in a designated location at the time of Claims comprehended. Claims for reim- loss by fire, earthquake, or other nat- bursing Department of Veterans Af- ural disaster or was in process of laun- fairs employees for cost of repairing or dering. The patient will further state replacing their personal property dam- whether the loss of each article was aged or destroyed by patients or mem- complete or partial, permitting of bers while such employees are engaged some further use of the article. The re- in the performance of their official du- sponsible official will certify that the ties will be adjudicated by the Director amount of reimbursement claimed on of the medical center concerned. Such each article of personal effects is not in claims will be considered under the fol- excess of the fair value thereof at time lowing conditions, both of which must of loss. The certification will be prepared in triplicate, signed by the re- have existed and, if either one is lack- sponsible officer who made it, and ing, reimbursement or payment for the countersigned by the Director of the cost or repair of the damaged article medical center. After the above papers will not be authorized: have been secured, voucher will be pre- (a) The claim must be for an item of pared, signed, and certified, and for- personal property normally used by the warded to the Fiscal Officer for ap- employee in his or her day to day em- proval, payment to be made in accord- ployment, e.g., eyeglasses, hearing ance with fiscal procedure. The origi- aids, clothing, etc., and, nal list of property and certificate are (b) Such personal property was dam- to be attached to voucher. aged or destroyed by a patient or domi- [39 FR 1843, Jan. 15, 1974, as amended at 49 ciliary member while the employee was FR 5616, Feb. 14, 1984. Redesignated at 61 FR engaged in the performance of official 21966, May 13, 1996, and further redesignated duties. at 67 FR 35039, May 17, 2002] Reimbursement or payment as pro- § 17.115 Claims in cases of incom- vided in this paragraph will be made in petent patients. a fair and reasonable amount, taking Where the patient is insane and in- into consideration the condition and competent, the patient will not be required to make claim for reimbursement for personal effects lost by fire,

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reasonable value of the article at the (b) In a medical emergency. Emergency time it was damaged or destroyed. treatment not previously authorized including medical services, profes- [28 FR 5083, May 22, 1963, as amended at 39 FR 1843, Jan. 15, 1974; 49 FR 5616, Feb. 14, sional services, ambulance services, an- 1984. Redesignated and amended at 61 FR cillary care and medication (including 21965, May 13, 1996, and further redesignated a short course of medication related to at 67 FR 35039, May 17, 2002] and necessary for the treatment of the emergency condition that is provided PAYMENT AND REIMBURSEMENT OF THE directly to or prescribed for the patient EXPENSES OF MEDICAL SERVICES NOT for use after the emergency condition PREVIOUSLY AUTHORIZED is stabilized and the patient is discharged) was rendered in a medical § 17.120 Payment or reimbursement emergency of such nature that a pru- for emergency treatment furnished dent layperson would have reasonably by non-VA providers to certain veterans with service-connected dis- expected that delay in seeking imme- abilities. diate medical attention would have been hazardous to life or health. This To the extent allowable, payment or standard is met by an emergency med- reimbursement of the expenses of ical condition manifesting itself by emergency treatment, not previously acute symptoms of sufficient severity authorized, in a private or public (or (including severe pain) that a prudent Federal) hospital not operated by the layperson who possesses an average Department of Veterans Affairs, or of knowledge of health and medicine any emergency treatment not pre- could reasonably expect the absence of viously authorized including transpor- immediate medical attention to result tation (except prosthetic appliances, in placing the health of the individual similar devices, and repairs) will be in serious jeopardy, serious impair- paid on the basis of a claim timely ment to bodily functions, or serious filed, under the following cir- dysfunction of any bodily organ or cumstances: part. And, (a) For veterans with service connected (c) When Federal facilities are unavail- disabilities. Emergency treatment not able. VA or other Federal facilities that previously authorized was rendered to VA has an agreement with to furnish a veteran in need of such emergency health care services for veterans were treatment: not feasibly available, and an attempt (1) For an adjudicated service-con- to use them beforehand or obtain prior nected disability; VA authorization for the services re- (2) For nonservice-connected disabil- quired would not have been reasonable, ities associated with and held to be ag- sound, wise, or practicable, or treat- gravating an adjudicated service-con- ment had been or would have been re- nected disability; fused. (3) For any disability of a veteran who (Authority: 38 U.S.C. 1724, 1728, 7304) has a total disability permanent in nature resulting from a service-connected [39 FR 1844, Jan. 15, 1974, as amended at 49 disability (does not apply outside of FR 5616, Feb. 14, 1984; 51 FR 8672, Mar. 13, the States, Territories, and possessions 1986; 56 FR 3422, Jan. 30, 1991. Redesignated at 61 FR 21966, May 13, 1996; 76 FR 79070, Dec. 21, of the United States, the District of 2011; 80 FR 79484, Dec. 22, 2015] Columbia, and the Commonwealth of Puerto Rico); or § 17.121 Limitations on payment or re- (4) For any illness, injury or dental imbursement of the costs of emer- condition in the case of a veteran who gency treatment not previously au- is participating in a rehabilitation pro- thorized. gram under 38 U.S.C. ch. 31 and who is (a) Emergency Treatment. Except as medically determined to be in need of provided in paragraph (b) of this sec- hospital care or medical services for tion, VA will not approve claims for any of the reasons enumerated in payment or reimbursement of the costs § 17.47(i)(2); and of emergency treatment not previously authorized for any period beyond the (Authority: 38 U.S.C. 1724, 1728) date on which the medical emergency

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ended. For this purpose, VA considers the point of refusal of transfer by the that an emergency ends when the des- veteran. ignated VA clinician at the VA facility (Authority: 38 U.S.C. 1724, 1728, 7304) has determined that, based on sound medical judgment, the veteran who re- [76 FR 79071, Dec. 21, 2011] ceived emergency treatment: (1) Could have been transferred from § 17.122 Payment or reimbursement of the expenses of repairs to pros- the non-VA facility to a VA medical thetic appliances and similar de- center (or other Federal facility that vices furnished without prior au- VA has an agreement with to furnish thorization. health care services for veterans) for The expenses of repairs to prosthetic continuation of treatment, or appliances, or similar appliances, (2) Could have reported to a VA med- therapeutic or rehabilitative aids or ical center (or other Federal facility devices, furnished without prior au- that VA has an agreement with to fur- thorization, but incurred in the care of nish health care services for veterans) an adjudicated service-connected dis- for continuation of treatment. ability (or, in the case of a veteran who (b) Continued non-emergency treat- is participating in a rehabilitation pro- ment. Claims for payment or reimburse- gram under 38 U.S.C. ch. 31 and who is ment of the costs of emergency treat- determined to be in need of the repairs ment not previously authorized may for any of the reasons enumerated in only be approved for continued, non- § 17.47(g)) may be paid or reimbursed on emergency treatment, if: the basis of a timely filed claim, if (1) The non-VA facility notified VA at the time the veteran could be safely (Authority: 38 U.S.C. 1728) transferred to a VA facility (or other (a) Obtaining the repairs locally was Federal facility that VA has an agree- necessary, expedient, and not a matter ment with to furnish health care serv- of preference to using authorized ices for veterans), and the transfer of sources, and the veteran was not accepted; and (b) The costs were reasonable, except (2) The non-VA facility made and that where it is determined the costs documented reasonable attempts to re- were excessive or unreasonable, the quest transfer of the veteran to a VA claim may be allowed to the extent the facility (or to another Federal facility costs were deemed reasonable and dis- that VA has an agreement with to fur- allowed as to the remainder. In no cir- nish health care services for veterans), cumstances will any claim for repairs which means the non-VA facility con- be allowed to the extent the costs ex- tacted either the VA Transfer Coordi- ceed $125. nator, Administrative Officer of the Day, or designated staff responsible for (Authority: 38 U.S.C. 1728, 7304) accepting transfer of patients, at a [33 FR 19011, Dec. 20, 1968, as amended at 49 local VA (or other Federal facility) and FR 5616, Feb. 14, 1984; 51 FR 8672, Mar. 13, documented such contact in the vet- 1986. Redesignated and amended at 61 FR eran’s progress/physicians’ notes, dis- 21966, 21967, May 13, 1996] charge summary, or other applicable medical record. § 17.123 Claimants. (c) Refusal of transfer. If a stabilized A claim for payment or reimburse- veteran who requires continued non- ment of services not previously author- emergency treatment refuses to be ized may be filed by the veteran who transferred to an available VA facility received the services (or his/her guard- (or other Federal facility that VA has ian) or by the hospital, clinic, or com- an agreement with to furnish health munity resource which provided the care services for veterans), VA will services, or by a person other than the make payment or reimbursement only veteran who paid for the services. for the expenses related to the initial [39 FR 1844, Jan. 15, 1974, as amended at 45 evaluation and the emergency treat- FR 53807, Aug. 13, 1980. Redesignated at 61 FR ment furnished to the veteran up to 21966, May 13, 1996]

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§ 17.124 Preparation of claims. must be filed within the following time limits: Claims for costs of services not previously authorized shall be on such (a) A claim must be filed within 2 forms as shall be prescribed and shall years after the date the care or serv- include the following: ices were rendered (and in the case of (a) The claimant shall specify the continuous care, payment will not be amount claimed and furnish bills, made for any part of the care rendered vouchers, invoices, or receipts or other more than 2 years prior to filing documentary evidence establishing claim), or that such amount was paid or is owed, (b) In the case of case or services ren- and dered prior to a VA adjudication allow- (b) The claimant shall provide an ex- ing service-connection: planation of the circumstances necessi- (1) The claim must be filed within 2 tating the use of community medical years of the date the veteran was noti- care, services, or supplies instead of fied by VA of the allowance of the Department of Veterans Affairs care, award of service-connection. services, or supplies, and (2) VA payment may be made for care (c) The claimant shall furnish such related to the service-connected dis- other evidence or statements as are ability received only within a 2-year deemed necessary and requested for ad- period prior to the date the veteran judication of the claim. filed the original or reopened claim [33 FR 19011, Dec. 20, 1968, as amended at 39 which resulted in the award of service- FR 1844, Jan. 15, 1974. Redesignated at 61 FR connection but never prior to the effec- 21966, May 13, 1996] tive date of the award of service-connection within that 2-year period. § 17.125 Where to file claims. (3) VA payment will never be made Generally, VA must preauthorize VA for any care received beyond this 2- payment for health care services pro- year period whether service connected vided in the community when such or not. care is provided in a State as that term is defined in 38 U.S.C. 101(20). (Authority: 38 U.S.C. 7304) (a) Where VA payment for such serv- [33 FR 19012, Dec. 20, 1968, as amended at 39 ices has not been authorized in ad- FR 1844, Jan. 15, 1974; 45 FR 53807, Aug. 13, vance, claims for payment for such 1980; 51 FR 8673, Mar. 13, 1986. Redesignated health care services provided in a State at 61 FR 21966, May 13, 1996] should be submitted to the VA medical facility nearest to where those services § 17.127 Date of filing claims. were provided. The date of filing any claim for pay- (b) Claims for payment for hospital ment or reimbursement of the expenses care and outpatient services authorized of medical care and services not pre- under § 17.35(a) and provided in Canada viously authorized shall be the post- must be submitted to Veterans Affairs mark date of a formal claim, or the Canada, Foreign Countries Operations date of any preceding telephone call, Unit, 2323 Riverside Dr., 2nd Floor, Ot- telegram, or other communication con- tawa, Ontario, Canada K1A OP5. stituting an informal claim. (c) All other claims for payment for hospital care and outpatient services [39 FR 1844, Jan. 15, 1974. Redesignated at 61 authorized under § 17.35(a) and provided FR 21966, May 13, 1996] outside a State must be submitted to the Foreign Medical Program, P.O. Box § 17.128 Allowable rates and fees. 469061, Denver, CO 80246–9061. When it has been determined that a [83 FR 29448, June 25, 2018] veteran has received public or private hospital care or outpatient medical § 17.126 Timely filing. services, the expenses of which may be Claims for payment or reimburse- paid under § 17.120 of this part, the payment of the expenses of medical care or ment of such expenses shall be paid in services not previously authorized

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accordance with §§ 17.55 and 17.56 of this § 17.132 Appeals. part. When any claim for payment or reim- (Authority: Section 233, Pub. L. 99–576) bursement of expenses of medical care or services rendered in non-Department [63 FR 39515, July 23, 1998] of Veterans Affairs facilities or from § 17.129 Retroactive payments prohib- non-Department of Veterans Affairs re- ited. sources has been disallowed, the claimant shall be notified of the reasons for When a claim for payment or reim- the disallowance and of the right to bursement of expenses of services not initiate an appeal to the Board of Vet- previously authorized has not been erans Appeals by filing a Notice of Dis- timely filed in accordance with the agreement, and shall be furnished such provisions of § 17.126, the expenses of other notices or statements as are re- any such care or services rendered quired by part 19 of this chapter, gov- prior to the date of filing the claim erning appeals. shall not be paid or reimbursed. In no event will a bill or claim be paid or al- [33 FR 19012, Dec. 20, 1968. Redesignated at 61 lowed for any care or services rendered FR 21966, May 13, 1996] prior to the effective date of any law, RECONSIDERATION OF DENIED CLAIMS or amendment to the law, under which eligibility for the medical services at § 17.133 Procedures. Department of Veterans Affairs ex- (a) Scope. This section sets forth re- pense has been established. consideration procedures regarding [39 FR 1844, Jan. 15, 1974. Redesignated and claims for benefits administered by the amended at 61 FR 21966, 21968, May 13, 1996] Veterans Health Administration (VHA). These procedures apply to § 17.130 Payment for treatment de- claims for VHA benefits regarding deci- pendent upon preference prohib- sions that are appealable to the Board ited. of Veterans’ Appeals (e.g., reimburse- No reimbursement or payment of ment for non-VA care not authorized in services not previously authorized will advance, reimbursement for bene- be made when such treatment was pro- ficiary travel expenses, reimbursement cured through private sources in pref- for home improvements or structural erence to available Government facili- alterations, etc.). These procedures do ties. not apply when other regulations providing reconsideration procedures do [39 FR 1844, Jan. 15, 1974. Redesignated at 61 FR 21966, May 13, 1996] apply (this includes CHAMPVA (38 CFR 17.270 through 17.278) and spina bifida § 17.131 Payment of abandoned claims (38 CFR 17.904) and any other regula- prohibited. tions that contain reconsideration procedures). Also, these procedures do not Any informal claim for the payment apply to decisions made outside of or reimbursement of medical expenses VHA, such as decisions made by the which is not followed by a formal Veterans Benefits Administration and claim, or any formal claim which is not adopted by VHA for decisionmaking. followed by necessary supporting evi- These procedures are not mandatory, dence, within 1 year from the date of and a claimant may choose to appeal the request for a formal claim or sup- the denied claim to the Board of Vet- porting evidence shall be deemed aban- erans’ Appeals pursuant to 38 U.S.C. doned, and payment or reimbursement 7105 without utilizing the provisions of shall not be authorized on the basis of this section. Submitting a request for such abandoned claim or any future reconsideration shall constitute a no- claim for the same expenses. For the tice of disagreement for purposes of fil- purpose of this section, time limita- ing a timely notice of disagreement tions shall be computed from the date under 38 U.S.C. 7105(b). following the date of request for a for- (b) Process. An individual who dis- mal claim or supporting evidence. agrees with the initial decision denying [33 FR 19012, Dec. 20, 1968. Redesignated at 61 the claim in whole or in part may ob- FR 21966, May 13, 1996] tain reconsideration under this section

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by submitting a reconsideration re- ing, clinics, and any other group or in- quest in writing to the Director of the dividual capable of furnishing such healthcare facility of jurisdiction with- services to provide scarce medical spe- in one year of the date of the initial de- cialist services at Department of Vet- cision. The reconsideration decision erans Affairs health care facilities (in- will be made by the immediate super- cluding, but not limited to, services of visor of the initial VA decision-maker. physicians, dentists, podiatrists, op- The request must state why it is con- tometrists, nurses, physicians’ assist- cluded that the decision is in error and ants, expanded function dental auxil- must include any new and relevant in- iaries, technicians, and other medical formation not previously considered. support personnel); and Any request for reconsideration that (c) When a sharing agreement or con- does not identify the reason for the dis- tract for scarce medical specialist serv- pute will be returned to the sender ices is not warranted, contracts au- without further consideration. The re- thorized under the provisions of 38 quest for reconsideration may include U.S.C. 8153 for medical and ancillary a request for a meeting with the imme- services. The authority under this sec- diate supervisor of the initial VA deci- tion generally will be exercised by ap- sion-maker, the claimant, and the proval of proposed contracts or agree- claimant’s representative (if the claim- ments negotiated at the health care fa- ant wishes to have a representative cility level. Such approval, however, present). Such a meeting shall only be will not be necessary in the case of any for the purpose of discussing the issues purchase order or individual authoriza- and shall not include formal procedures tion for which authority has been dele- (e.g., presentation, cross-examination gated in 48 CFR 801.670–3. All such con- of witnesses, etc.). The meeting will be tracts and agreements will be nego- taped and transcribed by VA if re- tiated pursuant to 48 CFR chapters 1 quested by the claimant and a copy of and 8. the transcription shall be provided to the claimant. After reviewing the mat- (Authority: 38 U.S.C. 512, 7409, 8153) ter, the immediate supervisor of the [45 FR 6938, Jan. 31, 1980. Redesignated at 61 initial VA decision-maker shall issue a FR 21966, May 13, 1996, as amended at 62 FR written decision that affirms, reverses, 17072, Apr. 9, 1997; 79 FR 54616, Sept. 12, 2014] or modifies the initial decision. PROSTHETIC, SENSORY, AND NOTE TO § 17.133: The final decision of the REHABILITATIVE AIDS immediate supervisor of the initial VA decision-maker will inform the claimant of fur- § 17.148 Service dogs. ther appellate rights for an appeal to the Board of Veterans’ Appeals. (a) Definitions. For the purposes of this section: (The Office of Management and Budget has approved the information collection require- Service dogs are guide or service dogs ments in this section under control number prescribed for a disabled veteran under 2900–0600) this section. (Authority: 38 U.S.C. 511, 38 U.S.C. 7105) (b) Clinical requirements. VA will provide benefits under this section to a [64 FR 44660, Aug. 17, 1999] veteran with a service dog only if: DELEGATION OF AUTHORITY (1) The veteran is diagnosed as having a visual, hearing, or substantial § 17.142 Authority to approve sharing mobility impairment; and agreements, contracts for scarce (2) The VA clinical team that is medical specialist services and con- treating the veteran for such impair- tracts for other medical services. ment determines based upon medical The Under Secretary for Health is judgment that it is optimal for the vet- delegated authority to enter into eran to manage the impairment and (a) Sharing agreements authorized live independently through the assist- under 38 U.S.C. 8153 and § 17.240; ance of a trained service dog. Note: If (b) Contracts with schools and col- other means (such as technological de- leges of medicine, osteopathy, den- vices or rehabilitative therapy) will tistry, podiatry, optometry, and nurs- provide the same level of independence,

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then VA will not authorize benefits or deductibles associated with the pol- under this section. icy; however, the veteran will be re- (3) For the purposes of this section, sponsible for any cost of care that ex- substantial mobility impairment ceeds the maximum amount authorized means a spinal cord injury or dysfunc- by the policy for a particular proce- tion or other chronic impairment that dure, course of treatment, or policy substantially limits mobility. A chron- year. If a dog requires care that may ic impairment that substantially lim- exceed the policy’s limit, the insurer its mobility includes but is not limited will, whenever reasonably possible to a traumatic brain injury that com- under the circumstances, provide ad- promises a veteran’s ability to make vance notice to the veteran. appropriate decisions based on environ- (ii) The policy will guarantee cov- mental cues (i.e., traffic lights or dan- erage for all treatment (and associated gerous obstacles) or a seizure disorder prescription medications), subject to that causes a veteran to become immo- premiums, copayments, deductibles or bile during and after a seizure event. annual caps, determined to be medi- (c) Recognized service dogs. VA will cally necessary, including euthanasia, recognize, for the purpose of paying by any veterinarian who meets the re- benefits under this section, the fol- quirements of the insurer. The veteran lowing service dogs: will not be billed for these covered (1) The dog and veteran must have costs, and the insurer will directly re- successfully completed a training pro- imburse the provider. gram offered by an organization ac- (iii) The policy will not exclude dogs credited by Assistance Dogs Inter- with preexisting conditions that do not national or the International Guide prevent the dog from being a service Dog Federation, or both (for dogs that dog. perform both service- and guide-dog as- (2) Hardware, or repairs or replace- sistance). The veteran must provide to ments for hardware, that are clinically VA a certificate showing successful determined to be required by the dog to completion issued by the accredited organization that provided such program. perform the tasks necessary to assist (2) Dogs obtained before September 5, the veteran with his or her impair- 2012 will be recognized if a guide or ment. To obtain such devices, the vet- service dog training organization in ex- eran must contact the Prosthetic and istence before September 5, 2012 cer- Sensory Aids Service at his or her local tifies that the veteran and dog, as a VA medical facility and request the team, successfully completed, no later items needed. than September 5, 2013, a training pro- (3) Payments for travel expenses as- gram offered by that training organiza- sociated with obtaining a dog under tion. The veteran must provide to VA a paragraph (c)(1) of this section. Travel certificate showing successful comple- costs will be provided only to a veteran tion issued by the organization that who has been prescribed a service dog provided such program. Alternatively, by a VA clinical team under paragraph the veteran and dog will be recognized (b) of this section. Payments will be if they comply with paragraph (c)(1) of made as if the veteran is an eligible this section. beneficiary under 38 U.S.C. 111 and 38 (d) Authorized benefits. Except as CFR part 70, without regard to whether noted in paragraph (d)(3) of this sec- the veteran meets the eligibility cri- tion, VA will provide to a veteran en- teria as set forth in 38 CFR part 70. rolled under 38 U.S.C. 1705 only the fol- Note: VA will provide payment for lowing benefits for one service dog at travel expenses related to obtaining a any given time in accordance with this replacement service dog, even if the section: veteran is receiving other benefits (1) A commercially available insur- under this section for the service dog ance policy, to the extent commer- that the veteran needs to replace. cially practicable, that meets the fol- (4) The veteran is responsible for pro- lowing minimum requirements: curing and paying for any items or ex- (i) VA, and not the veteran, will be penses not authorized by this section. billed for any premiums, copayments, This means that VA will not pay for

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items such as license tags, nonprescrip- care, or which resulted from treatment tion food, grooming, insurance for per- of that medical condition; sonal injury, non-sedated dental (7) Those with a significant func- cleanings, nail trimming, boarding, tional or cognitive impairment evi- pet-sitting or dog-walking services, denced by deficiencies in activities of over-the-counter medications, or other daily living, but not including nor- goods and services not covered by the mally occurring visual or hearing im- policy. The dog is not the property of pairments; and VA; VA will never assume responsi- (8) Those visually or hearing im- bility for, or take possession of, any paired so severely that the provision of service dog. sensori-neural aids is necessary to per- (e) Dog must maintain ability to func- mit active participation in their own tion as a service dog. To continue to re- medical treatment. ceive benefits under this section, the (c) VA will furnish needed hearing service dog must maintain its ability aids to those veterans who have serv- to function as a service dog. If at any ice-connected hearing disabilities rated time VA learns from any source that 0 percent if there is organic conductive, the dog is medically unable to main- mixed, or sensory hearing impairment, tain that role, or VA makes a clinical and loss of pure tone hearing sensi- determination that the veteran no tivity in the low, mid, or high-fre- longer requires the dog, VA will pro- quency range or a combination of fre- vide at least 30 days notice to the vet- quency ranges which contribute to a eran before benefits will no longer be loss of communication ability; how- authorized. ever, hearing aids are to be provided (Authority: 38 U.S.C. 501, 1714) only as needed for the service-con- (The Office of Management and Budget has nected hearing disability. approved the information collection require- (Authority: 38 U.S.C. 501,1707(b) ments in this section under control number 2900–0785.) [62 FR 30242, June 3, 1997, as amended at 69 FR 33575, June 16, 2004] [77 FR 54381, Sept. 5, 2012]

§ 17.149 Sensori-neural aids. § 17.150 Prosthetic and similar appliances. (a) Notwithstanding any other provision of this part, VA will furnish need- Artificial limbs, braces, orthopedic ed sensori-neural aids (i.e., eyeglasses, shoes, hearing aids, wheelchairs, med- contact lenses, hearing aids) only to ical accessories, similar appliances in- veterans otherwise receiving VA care cluding invalid lifts and therapeutic or services and only as provided in this and rehabilitative devices, and special section. clothing made necessary by the wear- (b) VA will furnish needed sensori- ing of such appliances, may be pur- neural aids (i.e., eyeglasses, contact chased, made or repaired for any vet- lenses, hearing aids) to the following eran upon a determination of feasi- veterans: bility and medical need, provided: (1) Those with a compensable service- (a) As part of outpatient care. The ap- connected disability; pliances or repairs are a necessary part (2) Those who are former prisoners of of outpatient care for which the vet- war; eran is eligible under 38 U.S.C. 1710 and (3) Those awarded a Purple Heart; 38 CFR 17.93 (or a necessary part of out- (4) Those in receipt of benefits under patient care authorized under § 17.94) or 38 U.S.C. 1151; (b) As part of hospital care. The appli- (5) Those in receipt of increased pen- ances or repairs are a necessary part of sion based on the need for regular aid inpatient care for any service-con- and attendance or by reason of being nected disability or any nonservice- permanently housebound; connected disability, if: (6) Those who have a visual or hear- (1) The nonservice-connected dis- ing impairment that resulted from the ability is associated with an aggra- existence of another medical condition vating a service-connected disability, for which the veteran is receiving VA or

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(2) The nonservice-connected dis- cally prohibited from doing so because ability is one for which hospital admis- of a serious disease or disability); and sion was authorized, or (c) The veteran has been medically (3) The nonservice-connected dis- determined incapable of moving him- ability is associated with and aggra- self or herself from his or her bed to a vating a nonservice-connected dis- wheelchair, or from his or her wheel- ability for which hospital admission chair to his or her bed, without the aid was authorized, or of an attendant, because of the dis- (4) The nonservice-connected disability involving the use of his or her ability is one for which treatment may extremities; and be authorized under the provisions of (d) An invalid lift would be a feasible § 17.48(h), or means by which the veteran could ac- (c) As part of domiciliary care. The ap- complish the necessary maneuvers be- pliances or repairs are necessary for tween bed and wheelchair, and is medi- continued domiciliary care, or are nec- cally determined necessary. essary to treat a member’s service-connected disability, or nonservice-con- [33 FR 12315, Aug. 31, 1968, as amended at 36 nected disability associated with and FR 3117, Feb. 13, 1971; 54 FR 34983, Aug. 23, aggravating a service-connected dis- 1989. Redesignated at 61 FR 21966, May 13, ability, or 1996] (d) As part of nursing home care. The § 17.152 Devices to assist in over- appliances or repairs are a necessary coming the handicap of deafness. part of nursing home care furnished in facilities under the direct and exclu- Devices for assisting in overcoming sive jurisdiction of the Department of the handicap of deafness (including Veterans Affairs. telecaptioning television decoders) may be furnished to any veteran who is [32 FR 13816, Oct. 4, 1967, as amended at 33 FR profoundly deaf (rated 80% or more dis- 12315, Aug. 31, 1968; 34 FR 9341, June 13, 1969; abled for hearing impairment by the 35 FR 17948, Nov. 21, 1970; 54 FR 34983, Aug. 23, 1989. Redesignated and amended at 61 FR Department of Veterans Affairs) and is 21966, 21968, May 13, 1996; 79 FR 54616, Sept. entitled to compensation on account of 12, 2014] such hearing impairment.

§ 17.151 Invalid lifts for recipients of (Authority: 38 U.S.C. 1717(c)) aid and attendance allowance or [53 FR 46607, Nov. 18, 1988. Redesignated at 61 special monthly compensation. FR 21966, May 13, 1996; 79 FR 54616, Sept. 12, An invalid lift may be furnished if: 2014] (a) The applicant is a veteran who is § 17.153 Training in the use of appli- receiving (1) special monthly com- ances. pensation (including special monthly compensation based on the need for aid Beneficiaries supplied prosthetic and and attendance) under the provisions of similar appliances will be additionally 38 U.S.C. 1114(r), or (2) comparable com- entitled to fitting and training in the pensation benefits at the rates pre- use of the appliances. Such training scribed under 38 U.S.C. 1134, or (3) in- will usually be given in Department of creased pension based on the need for Veterans Affairs facilities and by De- aid and attendance or a greater com- partment of Veterans Affairs employ- pensation benefit rather than aid and ees, but may be obtained under con- attendance pension to which he or she tract if determined necessary. has been adjudicated to be presently eligible; and [26 FR 5871, June 30, 1961. Redesignated at 61 FR 21966, May 13, 1996] (b) The veteran has loss, or loss of use, of both lower extremities and at least one upper extremity (loss of use may result from paralysis or other impairment to muscle power and includes all cases in which the veteran cannot use his or her extremities or is medi-

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§ 17.154 Equipment for blind veterans. items, authorization of suitable adaptive equipment will not be delayed. Ap- VA may furnish mechanical and/or proval of such adaptive equipment, electronic equipment considered nec- however, shall be subject to the judg- essary as aids to overcoming the handi- ment of designated certifying officials cap of blindness to blind veterans enti- that it meets implicit standards of tled to disability compensation for a safety and quality adopted by the in- service-connected disability. dustry or as later developed by the De- (Authority: 38 U.S.C. 1714) partment of Veterans Affairs. [77 FR 54382, Sept. 5, 2012] [40 FR 8819, Mar. 3, 1975. Redesignated at 61 FR 21966, May 13, 1996, as amended at 62 FR AUTOMOTIVE EQUIPMENT AND DRIVER 17072, Apr. 9, 1997] TRAINING § 17.156 Eligibility for automobile § 17.155 Minimum standards of safety adaptive equipment. and quality for automotive adaptive equipment. Automobile adaptive equipment may be authorized if the Under Secretary (a) The Under Secretary for Health or for Health or designee determines that designee is authorized to develop and such equipment is deemed necessary to establish minimum standards of safety insure that the eligible person will be and quality for adaptive equipment able to operate the automobile or other provided under 38 U.S.C. chapter 39. conveyance in a manner consistent (b) In the performance of this func- with such person’s safety and so as to tion, the following considerations will satisfy the applicable standards of li- apply: censure established by the State of (1) Minimum standards of safety and such person’s residency or other proper quality will be developed and promul- licensing authority. gated for basic adaptive equipment spe- (a) Persons eligible for adaptive cifically designed to facilitate oper- equipment are: ation and use of standard passenger (1) Veterans who are entitled to re- motor vehicles by persons who have ceive compensation for the loss or per- specified types of disablement and for manent loss of use of one or both feet; the installation of such equipment. or the loss or permanent loss of use of (2) In those instances where custom- one or both hands; or ankylosis of one built adaptive equipment is designed or both knees, or one of both hips if the and installed to meet the peculiar disability is the result of injury in- needs of uniquely disabled persons and curred or disease contracted in or ag- where the incidence of probable usage gravated by active military, naval or is not such as to justify development of air service. formal standards, such equipment will (2) Members of the Armed Forces be inspected and, if in order, approved serving on active duty who are suf- for use by a qualified designee of the fering from any disability described in Under Secretary for Health. paragraph (a)(1) of this section in- (3) Adaptive equipment, available to curred or contracted during or aggra- the general public, which is manufac- vated by active military service are el- tured under standards of safety im- igible to receive automobile adaptive posed by a Federal agency having au- equipment. thority to establish the same, shall be (b) Payment or reimbursement of deemed to meet required standards for reasonable costs for the repair, replace- use as adaptive equipment. These in- ment, or reinstallation of adaptive clude such items as automatic trans- equipment deemed necessary for the missions, power brakes, power steering operation of the automobile may be au- and other automotive options. thorized by the Under Secretary for (c) For those items where specific De- Health or designee. partment of Veterans Affairs standards of safety and quality have not as yet (Authority: 38 U.S.C. 3902) been developed, or where such stand- [53 FR 46607, Nov. 18, 1988. Redesignated at 61 ards are otherwise provided as with FR 21966, May 13, 1996, as amended at 62 FR custom-designed or factory option 17072, Apr. 9, 1997]

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§ 17.157 Definition-adaptive equip- (2) For purposes of paragraph (a)(1) of ment. this section, an eligible person shall be The term, adaptive equipment, deemed to have access to and use of an means equipment which must be part automobile or other conveyance for of or added to a conveyance manufac- which the Department of Veterans Af- tured for sale to the general public to fairs has provided adaptive equipment make it safe for use by the claimant, if that person has sold, given or trans- and enable that person to meet the ap- ferred the vehicle to a spouse, family plicable standards of licensure. Adapt- member or other person residing in the ive equipment includes any term speci- same household as the eligible person, fied by the Under Secretary for Health or to a business owned by such person. or designee as ordinarily necessary for any of the classes of losses or combina- (Authority: 38 U.S.C. 3903) tion of such losses specified in § 17.156 of this part, or as deemed necessary in (b) Eligible persons may be reim- an individual case. Adaptive equipment bursed for the actual cost of adaptive includes, but is not limited to, a basic equipment subject to a dollar amount automatic transmission, power steer- for specific items established from ing, power brakes, power window lifts, time to time by the Under Secretary power seats, air-conditioning equip- for Health. ment when necessary for the health and safety of the veteran, and special (Authority: 38 U.S.C. 3902) equipment necessary to assist the eligi- (c) Reimbursement for a repair to an ble person into or out of the auto- item of adaptive equipment is limited mobile or other conveyance, regardless to the current vehicles of record and of whether the automobile or other only to the basic components author- conveyance is to be operated by the eli- ized as automobile adaptive equipment. gible person or is to be operated for such person by another person; and any Reimbursable amounts for repairs are modification of the interior space of limited to the cost of parts and labor the automobile or other conveyance if based on the amounts published in gen- needed because of the physical condi- erally acceptable commercial esti- tion of such person in order for such mating guides for domestic auto- person to enter or operate the vehicle. mobiles. (Authority: 38 U.S.C. 3901, 3902) (Authority: 38 U.S.C. 3902) [53 FR 46608, Nov. 18, 1988. Redesignated and [53 FR 46608, Nov. 18, 1988. Redesignated and amended at 61 FR 21966, 21968, May 13, 1996] amended at 61 FR 21966, 21968, May 13, 1996]

§ 17.158 Limitations on assistance. § 17.159 Obtaining vehicles for special (a) An eligible person shall not be en- driver training courses. titled to adaptive equipment for more The Secretary may obtain by pur- than two automobiles or other convey- chase, lease, gift or otherwise, any ances at any one time or during any automobile, motor vehicle, or other four-year period except when due to conveyance deemed necessary to con- circumstances beyond control of such duct special driver training courses at person, one of the automobiles or con- Department of Veterans Affairs health veyances for which adaptive equipment care facilities. The Secretary may sell, was provided during the applicable assign, transfer or convey any such four-year period is no longer available for the use of such person. automobile, vehicle or conveyance to (1) Circumstances beyond the control which the Department of Veterans Af- of the eligible person are those where fairs holds title for such price or under the vehicle was lost due to fire, theft, such terms deemed appropriate by the accident, court action, or when repairs Secretary. Any proceeds received from are so costly as to be prohibitive or a such disposition shall be credited to different vehicle is required due to a change in the eligible person’s physical condition.

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the applicable Department of Veterans (h) Persons defined in § 17.93. Affairs appropriation. [13 FR 7162, Nov. 27, 1948, as amended at 21 (Authority: 38 U.S.C. 3903(e)(3)) FR 10388, Dec. 28, 1956; 23 FR 6503, Aug. 22, 1958; 27 FR 11424, Nov. 20, 1962; 29 FR 1463, [45 FR 6939, Jan. 31, 1980. Redesignated at 54 Jan. 29, 1964; 30 FR 1789, Feb. 9, 1965; 32 FR FR 46607, Nov. 18, 1988, and further redesig- 13817, Oct. 4, 1967; 33 FR 5300, Apr. 3, 1968; 35 nated at 61 FR 21966, May 13, 1996] FR 6586, Apr. 24, 1970; 49 FR 5617, Feb. 14, 1984. Redesignated and amended at 61 FR DENTAL SERVICES 21966, 21968, May 13, 1996; 79 FR 54616, Sept. 12, 2014] § 17.160 Authorization of dental examinations. § 17.161 Authorization of outpatient dental treatment. When a detailed report of dental ex- Outpatient dental treatment may be amination is essential for a determina- authorized by the Chief, Dental Serv- tion of eligibility for benefits, dental ice, for beneficiaries defined in 38 examinations may be authorized for U.S.C. 1712(b) and 38 CFR 17.93 to the the following classes of claimants or extent prescribed and in accordance beneficiaries: with the applicable classification and (a) Those having a dental disability provisions set forth in this section. adjudicated as incurred or aggravated (a) Class I. Those having a service- in active military, naval, or air service connected compensable dental dis- or those requiring examination to de- ability or condition, may be authorized termine whether the dental disability any dental treatment indicated as rea- is service connected. sonably necessary to maintain oral (b) Those having disability from dis- health and masticatory function. There ease or injury other than dental, adju- is no time limitation for making appli- dicated as incurred or aggravated in cation for treatment and no restriction as to the number of repeat episodes of active military, naval, or air service treatment. but with an associated dental condition (b) Class II. (1)(i) Those having a serv- that is considered to be aggravating ice-connected noncompensable dental the basic service-connected disorder. condition or disability shown to have (c) Those for whom a dental examina- been in existence at time of discharge tion is ordered as a part of a general or release from active service, which physical examination. took place after September 30, 1981, (d) Those requiring dental examina- may be authorized any treatment indi- tion during hospital, nursing home, or cated as reasonably necessary for the domiciliary care. one-time correction of the service-con- (e) Those held to have suffered dental nected noncompensable condition, but injury or aggravation of an existing only if: dental injury, as the result of examina- (A) They served on active duty dur- tion, hospitalization, or medical or sur- ing the Persian Gulf War and were dis- gical (including dental) treatment that charged or released, under conditions other than dishonorable, from a period had been awarded. of active military, naval, or air service (f) Veterans who are participating in of not less than 90 days, or they were a rehabilitation program under 38 discharged or released under conditions U.S.C. chapter 31 are entitled to such other than dishonorable, from any dental services as are professionally other period of active military, naval, determined necessary for any of the or air service of not less than 180 days; reasons enumerated in § 17.47(g). (B) Application for treatment is made within 180 days after such dis- (Authority: 38 U.S.C. 1712(b); ch. 31) charge or release. (g) Those for whom a special dental (C) The certificate of discharge or reexamination is authorized by the lease does not bear a certification that Under Secretary for Health or the As- the veteran was provided, within the 90-day period immediately before such sistant Chief Medical Director for Den- discharge or release, a complete dental tistry. examination (including dental X-rays)

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and all appropriate dental treatment authority, application may be made indicated by the examination to be within one year after the date of cor- needed, and rection. (D) Department of Veterans Affairs dental examination is completed with- (Authority: 38 U.S.C. 1712) in six months after discharge or re- (c) Class II (a). Those having a serv- lease, unless delayed through no fault ice-connected noncompensable dental of the veteran. condition or disability adjudicated as (ii) Those veterans discharged from resulting from combat wounds or serv- their final period of service after Au- ice trauma may be authorized any gust 12, 1981, who had reentered active treatment indicated as reasonably nec- military service within 90 days after essary for the correction of such serv- the date of a discharge or release from ice-connected noncompensable condi- a prior period of active military serv- tion or disability. ice, may apply for treatment of service-connected noncompensable dental (Authority: 38 U.S.C. 501; 1712(a)(1)(C)) conditions relating to any such periods of service within 180 days from the date (d) Class II(b). Certain homeless and of their final discharge or release. other enrolled veterans eligible for a (iii) If a disqualifying discharge or re- one-time course of dental care under 38 lease has been corrected by competent U.S.C. 2062. authority, application may be made (Authority: 38 U.S.C. 2062; 38 U.S.C. within 180 days after the date of correc- 1712(a)(1)(H)) tion. (2)(i) Those having a service-con- (e) Class II(c). Those who were pris- nected noncompensable dental condi- oners of war, as determined by the con- tion or disability shown to have been cerned military service department, in existence at time of discharge or re- may be authorized any needed out- lease from active service, which took patient dental treatment. place before October 1, 1981, may be au- (Authority: Pub. L. 100–322; Pub. L. 108–170; thorized any treatment indicated as 38 U.S.C. 1712(a)(1)(F)) reasonably necessary for the one-time correction of the service-connected (f) Class IIR (Retroactive). Any veteran noncompensable condition, but only if: who had made prior application for and (A) They were discharged or released, received dental treatment from the De- under conditions other than dishonor- partment of Veterans Affairs for non- able, from a period of active military, compensable dental conditions, but was naval or air service of not less than 180 denied replacement of missing teeth days. which were lost during any period of (B) Application for treatment is service prior to his/her last period of made within one year after such dis- service may be authorized such pre- charge or release. viously denied benefits under the fol- (C) Department of Veterans Affairs lowing conditions: dental examination is completed with- (1) Application for such retroactive in 14 months after discharge or release, benefits is made within one year of unless delayed through no fault of the April 5, 1983. (2) Existing Department of Veterans veteran. Affairs records reflect the prior denial (ii) Those veterans discharged from of the claim. their final period of service before Au- gust 13, 1981, who had reentered active All Class IIR (Retroactive) treatment military service within one year from authorized will be completed on a fee the date of a prior discharge or release, basis status. may apply for treatment of service- connected noncompensable dental con- (Authority: 38 U.S.C. 1712) ditions relating to any such prior peri- (g) Class III. Those having a dental ods of service within one year of their condition professionally determined to final discharge or release. be aggravating disability from an asso- (iii) If a disqualifying discharge or re- ciated service-connected condition or lease has been corrected by competent disability may be authorized dental

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treatment for only those dental condi- time of discharge or release from actions which, in sound professional judg- tive service, and ment, are having a direct and material detrimental effect upon the associated (Authority: 38 U.S.C. 1712) basic condition or disability. (b) The treatment will not involve re- (h) Class IV. Those whose service-con- placement of a missing tooth noted at nected disabilities are rated at 100% by the time of Department of Veterans Af- schedular evaluation or who are enti- fairs examination except: tled to the 100% rate by reason of indi- (1) In conjunction with authorized ex- vidual unemployability may be author- traction replacement, or ized any needed dental treatment. (2) When a determination can be made on the basis of sound professional (Authority: 38 U.S.C. 1712) judgment that a tooth was extracted or lost on active duty. (i) Class V. A veteran who is partici- (c) Individuals whose entire tour of pating in a rehabilitation program duty consisted of active or inactive under 38 U.S.C. chapter 31 may be au- duty for training shall not be eligible thorized such dental services as are for treatment under this section. professionally determined necessary [37 FR 6847, Apr. 5, 1972, as amended at 48 FR for any of the reasons enumerated in 16682, Apr. 19, 1983. Redesignated and amend- § 17.47(g). ed at 61 FR 21966, 21968, May 13, 1996]

(Authority: 38 U.S.C. 1712(b); chapter 31) § 17.163 Posthospital outpatient dental treatment. (j) Class VI. Any veterans scheduled for admission or otherwise receiving The Chief, Dental Service may authorize outpatient dental care which is care and services under chapter 17 of 38 reasonably necessary to complete U.S.C. may receive outpatient dental treatment of a nonservice-connected care which is medically necessary, i.e., dental condition which was begun is for dental condition clinically deter- while the veteran was receiving De- mined to be complicating a medical partment of Veterans Affairs author- condition currently under treatment. ized hospital care. (Authority: 38 U.S.C. 1712) (Authority: 38 U.S.C. 1712(a)(1)(E)) [20 FR 9505, Dec. 20, 1955] [45 FR 6939, Jan. 31, 1980. Redesignated at 61 FR 21966, May 13, 1996; 79 FR 54616, Sept. 12, EDITORIAL NOTE: For FEDERAL REGISTER ci- 2014] tations affecting § 17.161, see the List of CFR Sections Affected, which appears in the § 17.164 Patient responsibility in mak- Finding Aids section of the printed volume ing and keeping dental appoint- and at www.govinfo.gov. ments. § 17.162 Eligibility for Class II dental Any veteran eligible for dental treat- treatment without rating action. ment on a one-time completion basis only and who has not received such When an application has been made treatment within 3 years after filing for class II dental treatment under the application shall be presumed to § 17.161(b), the applicant may be deemed have abandoned the claim for dental eligible and dental treatment author- treatment. ized on a one-time basis without rating [45 FR 6939, Jan. 31, 1980. Redesignated at 61 action if: FR 21966, May 13, 1996] (a) The examination to determine the need for dental care has been accom- § 17.165 Emergency outpatient dental plished within the specified time limit treatment. after date of discharge or release unless When outpatient emergency dental delayed through no fault of the vet- care is provided, as a humanitarian eran, and sound dental judgment war- service, to individuals who have no es- rants a conclusion the condition origi- tablished eligibility for outpatient den- nated in or was aggravated during serv- tal care, the treatment will be re- ice and the condition existed at the stricted to the alleviation of pain or

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extreme discomfort, or the remediation must offer coverage to the following of a dental condition which is deter- persons: mined to be endangering life or health. (1) Any veteran who is enrolled under The provision of emergency treatment 38 U.S.C. 1705 in accordance with 38 to persons found ineligible for dental CFR 17.36. care will not entitle the applicant to (2) Any survivor or dependent of a further dental treatment. Individuals veteran who is eligible for medical care provided emergency dental care who under 38 U.S.C. 1781 and 38 CFR 17.271. are found to be ineligible for such care (c) Premiums, coverage, and selection of will be billed. participating insurer. (1) Premiums. Pre- miums and copayments will be paid by (Authority: 38 U.S.C. 501) the insured in accordance with the [50 FR 14704, Apr. 15, 1985; 50 FR 21604, May terms of the insurance plan. Premiums 28, 1985. Redesignated at 61 FR 21966, May 13, and copayments will be determined by 1996] VA through the contracting process, and will be adjusted on an annual § 17.166 Dental services for hospital or nursing home patients and domi- basis. The participating insurer will ciled members. notify all insureds in writing of the amount and effective date of such ad- Persons receiving hospital, nursing justment. home, or domiciliary care pursuant to (2) Benefits. Participating insurers the provisions of §§ 17.46 and 17.47, will must offer, at a minimum, coverage for be furnished such dental services as are the following dental care and services: professionally determined necessary to (i) Diagnostic services. the patients’ or members’ overall hos- (A) Clinical oral examinations. pital, nursing home, or domiciliary (B) Radiographs and diagnostic imag- care. ing. [30 FR 1790, Feb. 9, 1965. Redesignated at 61 (C) Tests and laboratory examina- FR 21966, May 13, 1996] tions. (ii) Preventive services. § 17.169 VA Dental Insurance Program (A) Dental prophylaxis. for veterans and survivors and de- (B) Topical fluoride treatment (office pendents of veterans (VADIP). procedure). (a) General. (1) The VA Dental Insur- (C) Sealants. ance Program (VADIP) provides pre- (D) Space maintenance. mium-based dental insurance coverage (iii) Restorative services. through which individuals eligible (A) Amalgam restorations. under paragraph (b) of this section may (B) Resin-based composite restora- choose to obtain dental insurance from tions. a participating insurer. Enrollment in (iv) Endodontic services. VADIP does not affect the insured’s (A) Pulp capping. eligibility for outpatient dental serv- (B) Pulpotomy and pulpectomy. ices and treatment, and related dental (C) Root canal therapy. appliances, under 38 U.S.C. 1712. (D) Apexification and recalcification (2) The following definitions apply to procedures. this section: (E) Apicoectomy and periradicular Insured means an individual, identi- services. fied in paragraph (b) of this section, (v) Periodontic services. who has enrolled in an insurance plan (A) Surgical services. through VADIP. (B) Periodontal services. Participating insurer means an insur- (vi) Oral surgery. ance company that has contracted with (A) Extractions. VA to offer a premium-based dental in- (B) Surgical extractions. surance plan to veterans, survivors, (C) Alveoloplasty. and dependents through VADIP. There (D) Biopsy. may be more than one participating in- (vii) Other services. surer. (A) Palliative (emergency) treatment (b) Covered veterans and survivors and of dental pain. dependents. A participating insurer (B) Therapeutic drug injection.

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(C) Other drugs and/or medications. that prevents the use of the benefits (D) Treatment of postsurgical com- under the plan. plications. (iii) If the insured is prevented by se- (E) Crowns. rious medical condition from being (F) Bridges. able to obtain benefits under the plan. (G) Dentures. (iv) If the insured would suffer severe financial hardship by continuing in (3) Selection of participating insurer. VADIP. VA will use the Federal competitive (v) For any reason during the month- contracting process to select a partici- to-month coverage period, after the pating insurer, and the insurer will be initial 12-month enrollment period. responsible for the administration of (3) All insured requests for voluntary VADIP. disenrollment must be submitted to (d) Enrollment. (1) VA, in connection the insurer for determination of wheth- with the participating insurer, will er the insured qualifies for market VADIP through existing VA disenrollment under the criteria in communication channels to notify all paragraphs (e)(2)(i) through (v) of this eligible persons of their right to volun- section. Requests for disenrollment due tarily enroll in VADIP. The partici- to a serious medical condition or finan- pating insurer will prescribe all further cial hardship must include submission enrollment procedures, and VA will be of written documentation that verifies responsible for confirming that a per- the existence of a serious medical con- son is eligible under paragraph (b) of dition or financial hardship. The writ- this section. ten documentation submitted to the (2) The initial period of enrollment insurer must show that circumstances will be for a period of 12 calendar leading to a serious medical condition months, followed by month-to-month or financial hardship originated after enrollment, subject to paragraph (e)(5) the effective date coverage began, and of this section, as long as the insured will prevent the insured from main- remains eligible for coverage under taining the insurance benefits. paragraph (b) of this section and choos- (4) If the participating insurer denies es to continue enrollment, so long as a request for voluntary disenrollment VA continues to authorize VADIP. because the insured does not meet any (3) The participating insurer will criterion under paragraphs (e)(2)(i) agree to continue to provide coverage through (v) of this section, the partici- to an insured who ceases to be eligible pating insurer must issue a written de- under paragraphs (b)(1) through (2) of cision and notify the insured of the this section for at least 30 calendar basis for the denial and how to appeal. days after eligibility ceased. The in- The participating insurer will establish sured must pay any premiums due dur- the form of such appeals whether oral- ing this 30-day period. This 30-day cov- ly, in writing, or both. The decision erage does not apply to an insured who and notification of appellate rights is disenrolled under paragraph (e) of must be issued to the insured no later this section. than 30 days after the request for vol- (e) Disenrollment. (1) Insureds may be untary disenrollment is received by the involuntarily disenrolled at any time participating insurer. The appeal will for failure to make premium payments. be decided and that decision issued in (2) Insureds must be permitted to vol- writing to the insured no later than 30 untarily disenroll, and will not be re- days after the appeal is received by the quired to continue to pay any copay- participating insurer. An insurer’s de- ments or premiums, under any of the cision of an appeal is final. following circumstances: (5) Month-to-month enrollment, as (i) For any reason, during the first 30 described in paragraph (d)(2) of this days that the beneficiary is covered by section, may be subject to conditions the plan, if no claims for dental serv- in insurance contracts, whereby upon ices or benefits were filed by the involuntarily disenrolling, an enrollee sured. may be prevented from re-enrolling for (ii) If the insured relocates to an area a certain period of time as specified in outside the jurisdiction of the plan the insurance contract.

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(f) Other appeals procedures. Partici- (iii) Consent is implied where a pating insurers will establish and be re- known surviving spouse or next of kin sponsible for determination and appeal does not inquire after the well-being of procedures for all issues other than the deceased veteran for a period of at voluntary disenrollment. least 6 months before the date of the (g) Limited preemption of State and veteran’s death; or local law. To achieve important Federal (iv) Consent is implied where there is interests, including but not limited to no known surviving spouse or next of the assurance of the uniform delivery kin of the deceased veteran. of benefits under VADIP and to ensure (b) Death resulting from crime. If it is the operation of VADIP plans at the suspected that death resulted from lowest possible cost to VADIP enroll- crime and if the United States has ju- ees, paragraphs (b), (c)(1), (c)(2), (d), risdiction over the area where the body and (e)(2) through (5) of this section is found, the Director of the Depart- preempt conflicting State and local ment of Veterans Affairs facility will laws, including laws relating to the inform the Office of Inspector General business of insurance. Any State or of the known facts concerning the local law, or regulation pursuant to death. Thereupon the Office of Inspec- such law, is without any force or effect tor General will transmit all such in- on, and State or local governments formation to the United States Attor- have no legal authority to enforce ney for such action as may be deemed them in relation to, the paragraphs ref- appropriate and will inquire whether erenced in this paragraph or decisions the United States Attorney objects to made by VA or a participating insurer an autopsy if otherwise it be appro- under these paragraphs. priate. If the United States Attorney (The Office of Management and Budget has has no objection, the procedure as to approved the information collection requirement in this section under control number autopsy will be the same as if the 2900–0789.) death had not been reported to him or her. [78 FR 32130, May 29, 2013, as amended at 78 (c) Jurisdiction. If the United States FR 62443, Oct. 22, 2013; 82 FR 16288, Apr. 4, 2017] does not have exclusive jurisdiction over the area where the body is found AUTOPSIES the local medical examiner/coroner will be informed. If the local medical § 17.170 Autopsies. examiner/coroner declines to assume (a) General. (1) Except as otherwise jurisdiction the procedure will be the provided in this section, the Director of same as is provided in paragraph (b) of a VA facility may order an autopsy on this section. If a Federal crime is indi- a decedent who died while undergoing cated by the evidence, the procedure of VA care authorized by § 17.38 or § 17.52, paragraph (b) of this section will also if the Director determines that an au- be followed. topsy is required for VA purposes for (d) Applicable law. (1) The laws of the the following reasons: state where the autopsy will be per- (i) Completion of official records; or formed are to be used to identify the (ii) Advancement of medical knowl- person who is authorized to grant VA edge. permission to perform the autopsy and, (2) VA may order an autopsy to be if more than one person is identified, performed only if consent is first ob- the order of precedence among such tained under one of the following cir- persons. cumstances: (2) When the next of kin, as defined (i) Consent is granted by the sur- by the laws of the state where the au- viving spouse or next of kin of the de- topsy will be performed, consists of a cedent; number of persons such as children, (ii) Consent is implied where a known parents, brothers and sisters, etc., per- surviving spouse or next of kin does mission to perform an autopsy may be not respond within a specified period of accepted when granted by the person in time to VA’s request for permission to the appropriate class who assumes the conduct an autopsy; right and duty of burial.

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(e) Death outside a VA facility. The Di- SHARING OF MEDICAL FACILITIES, rector of a VA facility may order an EQUIPMENT, AND INFORMATION autopsy on a veteran who was undergoing VA care authorized by § 17.38 or § 17.230 Contingency backup to the § 17.52, and whose death did not occur in Department of Defense. a VA facility. Such authority also in- (a) Priority care to active duty per- cludes transporting the body at VA’s sonnel. The Secretary, during and/or expense to the facility where the au- immediately following a period of war topsy will be performed, and the return or national emergency declared by the of the body. Consent for the autopsy Congress or the President that involves will be obtained as stated in paragraph the use of United States Armed Forces (d) of this section. The Director must in armed conflict, is authorized to fur- determine that such autopsy is reason- nish hospital care, nursing home care, ably required for VA purposes for the and medical services to members of the following reasons: Armed Forces on active duty. The Sec- (1) The completion of official records; retary may give higher priority in the or furnishing of such care and services in (2) Advancement of medical knowl- VA facilities to members of the Armed edge. Forces on active duty than to any (Authority: 38 U.S.C. 501, 1703, 1710) other group of persons eligible for such [16 FR 5701, June 15, 1951, as amended at 18 care and services with the exception of FR 2414, Apr. 24, 1953; 24 FR 8330, Oct. 14, 1959; veterans with service-connected dis- 35 FR 6586, Apr. 24, 1970; 36 FR 23386, Dec. 9, abilities. 1971; 45 FR 6939, Jan. 31, 1980. Redesignated and amended at 61 FR 21966, 21968, May 13, (Authority: 38 U.S.C. 8111A, Pub. L. 97–174) 1996; 61 FR 29294, June 10, 1996; 68 FR 17551, Apr. 10, 2003; 77 FR 38181, June 27, 2012] (b) Contract authority. During a period in which the Secretary is authorized to VETERANS CANTEEN SERVICE furnish care and services to members of the Armed Forces under paragraph (a) § 17.180 Delegation of authority. of this section, the Secretary, to the In connection with the Veterans Can- extent authorized by the President and teen Service, the Under Secretary for subject to the availability of appro- Health is hereby delegated authority as priations or reimbursements, may au- follows: thorize VA facilities to enter into con- (a) To exercise the powers and func- tracts with private facilities for the tions of the Secretary with respect to provision during such period of hos- the maintenance and operation of the pital care and medical services for cer- Veterans Canteen Service. tain veterans. These veterans include (b) To designate the Assistant Chief only those who are receiving hospital Medical Director for Administration to care under 38 U.S.C. 1710 or, in emer- administer the overall operation of the gencies, for those who are eligible for Veterans Canteen Service and to des- treatment under that section, or who ignate selected employees of the Vet- are receiving care under 38 U.S.C. erans Canteen Service to perform the 1710(g). This authorization pertains functions described in the enabling only to circumstances in which VA fa- statute, 38 U.S.C. ch. 78, so as to effec- cilities are not capable of furnishing or tively maintain and operate the Vet- continuing to furnish the care or serv- erans Canteen Service. ices required because of the furnishing [20 FR 337, Jan. 14, 1955, as amended at 36 FR of care and services to members of the 23386, Dec. 9, 1971; 45 FR 6939, Jan. 31, 1980. Armed Forces. Redesignated at 61 FR 21966, May 13, 1996, as amended at 62 FR 17072, Apr. 9, 1997; 79 FR (Authority: 38 U.S.C. 8111A) 54616, Sept. 12, 2014] (Authority: Sec. 501 and 1720(a) of Title 38, (Authority: 31 U.S.C. 7501–7507) U.S.C.) [52 FR 23825, June 25, 1987. Redesignated at 61 [49 FR 5617, Feb. 14, 1984. Redesignated at 61 FR 21966, May 13, 1996; 80 FR 43322, July 22, FR 21966, May 13, 1996; 79 FR 54616, Sept. 12, 2015] 2014]

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§ 17.240 Sharing health-care resources. (2) Procedures jointly prescribed by Subject to such terms and conditions the Secretary of Health and Human as the Under Secretary for Health shall Services and the Secretary of Veterans prescribe, agreements may be entered Affairs to assure reasonable quality of into for sharing medical resources be- care and service and efficient and eco- tween Department health-care facili- nomical utilization of resources. ties and any health-care provider, or (Authority: 38 U.S.C. 8153) other entity or individual with geographical limitations determined by [32 FR 6841, May 4, 1967, as amended at 35 FR the Under Secretary for Health, pro- 18198, Nov. 28, 1970; 39 FR 1846, Jan. 15, 1974; 45 FR 6940, Jan. 31, 1980; 47 FR 58250, Dec. 30, vided: 1982; 54 FR 34983, Aug. 23, 1989. Redesignated (a) The agreement will achieve one of at 61 FR 21966, May 13, 1996, as amended at 62 the following purposes: (1) It will se- FR 17072, Apr. 9, 1997; 79 FR 54616, Sept. 12, cure the use of a health-care resource 2014] which otherwise might not be feasibly available by providing for the mutual § 17.241 Sharing medical information use or exchange of use of health-care services. resources when such an agreement will (a) Agreements for exchange of informa- obviate the need for a similar resource tion. Subject to such terms and condi- to be installed or provided at a facility tions as the Under Secretary for Health operated by the Department of Vet- shall prescribe, Directors of Depart- erans Affairs, or ment of Veterans Affairs medical cen- (2) It will secure effective use of De- ters, may enter into agreements with partment of Veterans Affairs health- medical schools, Federal, State or care resources by providing for the mu- local, public or private hospitals, re- tual use, or exchange of use, of healthcare resources in a facility operated by search centers, and individual members the Department of Veterans Affairs, of the medical profession, under which which have been justified on the basis medical information and techniques of veterans’ care, but which are not will be freely exchanged and the med- utilized to their maximum effective ca- ical information services of all parties pacity; and to the agreement will be available for (b) The agreement is determined to use by any party to the agreement be in the best interest of the prevailing under conditions specified in the agree- standards of the Department of Vet- ment. erans Affairs Medical Program; and (b) Purpose of sharing agreements. (c) The agreement provides for recip- Agreements for the exchange of infor- rocal reimbursement based on a charge mation shall be used to the maximum which covers the full cost of the use of extent practicable to create at each health-care resources, incidental hos- Department of Veterans Affairs med- pital care or other needed services, sup- ical center which has entered into such plies used, and normal depreciation and an agreement, an environment of aca- amortization costs of equipment. demic medicine which will help the (d) Reimbursement for medical care hospital attract and retain highly rendered to an individual who is enti- trained and qualified members of the tled to hospital or medical services medical profession. (Medicare) under subchapter XVIII of (c) Use of electronic equipment. Recent chapter 7 of title 42 U.S.C., and who has developments in electronic equipment no entitlement to medical care from shall be utilized under information the Department of Veterans Affairs, sharing programs to provide a close will be made to such facility, or if the educational, scientific, and profes- contract or agreement so provides, to sional link between Department of Vet- the community health care facility erans Affairs medical centers and which is party to the agreement, in ac- major medical centers. cordance with: (d) Furnishing information services on a (1) Rates prescribed by the Secretary fee basis. The educational facilities and of Health and Human Services, after programs established at Department of consultation with the Secretary of Vet- Veterans Affairs Medical Centers and erans Affairs, and the electronic link to medical centers

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shall be made available for use by med- rying out agreements for the exchange ical entities in the surrounding med- of medical information, techniques, ical community which have not en- and information services. The grant tered into sharing agreements with the funds may be used for the employment Department of Veterans Affairs, in of personnel, the construction of facili- order to bring about utilization of all ties, the purchasing of equipment, re- medical information in the sur- search, training or demonstration ac- rounding medical community, particu- tivities when necessary to implement larly in remote areas, and to foster and exchange of information agreements. encourage the widest possible coopera- [33 FR 6011, Apr. 19, 1968. Redesignated and tion and consultation among all mem- amended at 61 FR 21966, 21968, May 13, 1996] bers of the medical profession in the surrounding medical community. § 17.251 The Subcommittee on Aca- (e) Establishing fees for information demic Affairs. services. Subject to such terms and con- There is established within the Spe- ditions as the Under Secretary for cial Medical Advisory Group author- Health shall prescribe, Directors of De- ized under the provisions of 38 U.S.C. partment of Veterans Affairs medical 7312 a Subcommittee on Academic Af- centers shall charge for information fairs, and the Subcommittee shall ad- and educational facilities and services vise the Secretary, through the Under made available under paragraph (d) of Secretary for Health, in matters perti- this section. The fee may be on an an- nent to achieving the objectives of pro- nual or other periodic basis, at rates grams for exchange of medical infor- determined, after appropriate study, to mation. The Subcommittee shall re- be fair and equitable. The financial sta- view each application for a grant and tus of any user of such services shall be prepare a written report setting forth taken into consideration in estab- recommendations as to the final action lishing the amount of the fee to be to be taken on the application. paid. [42 FR 54804, Oct. 11, 1977. Redesignated at 61 [32 FR 6841, May 4, 1967, as amended at 47 FR FR 21966, May 13, 1996, as amended at 62 FR 58250, Dec. 30, 1982. Redesignated at 61 FR 17072, Apr. 9, 1997] 21966, May 13, 1996, as amended at 62 FR 17072, Apr. 9, 1997] § 17.252 Ex officio member of sub- § 17.242 Coordination of programs committee. with Department of Health and The Assistant Chief Medical Director Human Services. for Academic Affairs shall be an ex Programs for sharing specialized officio member of the Subcommittee medical resources or medical informa- on Academic Affairs. tion services shall be coordinated to a [42 FR 54804, Oct. 11, 1977. Redesignated at 61 maximum extent practicable, with pro- FR 21966, May 13, 1996] grams carried out under part F, title XVI of the Public Health Service Act § 17.253 Applicants for grants. under the jurisdiction of the Depart- Applicants for grants generally will ment of Health and Human Services. be persons authorized to represent a [32 FR 6842, May 4, 1967, as amended at 45 FR medical school, hospital, or research 6940, Jan. 31, 1980; 47 FR 58250, Dec. 30, 1982. center which has in effect or has ten- Redesignated at 61 FR 21966, May 13, 1996] tatively approved an agreement with the Department of Veterans Affairs to GRANTS FOR EXCHANGE OF INFORMATION exchange medical information. § 17.250 Scope of the grant program. [33 FR 6011, Apr. 19, 1968. Redesignated at 61 The provisions of § 17.250 through FR 21966, May 13, 1996] § 17.266 are applicable to grants under 38 U.S.C. 8155 for programs for the ex- § 17.254 Applications. change of medical information. The Each application for a grant shall be purpose of these grants is to assist submitted to the Under Secretary for medical schools, hospitals, and re- Health on such forms as shall be pre- search centers in planning and car- scribed and shall include the following

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evidence, assurances, and supporting Comptroller General of the United documents: States, or any of their authorized rep- (a) To specify amount. Each applica- resentatives, access to its books, docu- tion shall show the amount of the ments, papers, and records which are grant requested, and if the grant is to pertinent to the grant for the purposes be for more than one objective, the of audit and examination, and amounts allocated to each objective (g) To include assurance progress re- (e.g., to training, demonstrations, or ports will be made. Each application construction) shall be specified, and shall include sufficient assurances the (b) To include copy of agreement. Each applicant will furnish the Under Sec- application shall be accompanied by a retary for Health periodic progress re- copy of the agreement for the exchange ports in sufficient detail showing the of information or information services which the grant funds applied for will status of the project, planning, pro- implement, and gram, or system funded by the grant (c) To include descriptions and plans. for which application is made, and the Each application shall include a de- extent to which the stated objectives scription of the use to which the grant will have been achieved, and funds will be applied in sufficient de- (h) To include civil rights assurances. tail to show need, purpose, and jus- Each application shall include suffi- tifications, and shall be illustrated by cient assurances that no part of the financial and budgetary data, and grant funds will be used either by the (d) To include cost participation infor- grantee or by any contractor or sub- mation. Each application shall show the contractor to be paid from grant funds amount of the grant requested to be for any purpose which is inconsistent used for direct expenses by category of with regulations promulgated by the direct expenses, the amount requested Secretary (part 18 of this chapter) im- for indirect expenses related to the di- plementing title VI of the Civil Rights rect expenses, any additional amounts Act of 1964, or inconsistent with Execu- which will be applied to the program or tive Order 11246 (30 FR 12319) and any planning from other Federal agencies, implementing regulations the Sec- and from other sources, and amounts retary of Labor may promulgate. or expenses which will be borne by the applicant, and [33 FR 6011, Apr. 19, 1968, as amended at 36 (e) To include assurance records will be FR 320, Jan. 9, 1971; 42 FR 54804, Oct. 11, 1977. kept. Each application shall include Redesignated and amended at 61 FR 21966, sufficient assurances that the appli- 21969, May 13, 1996] cant shall keep records which fully disclose the amount and disposition of the § 17.255 Applications for grants for proceeds of the grant, the total cost of programs which include construction projects. the project or undertaking in connection with which the grant is made or In addition to the documents and evi- used, the portion of the costs supplied dence required by § 17.254, any applica- by non-Federal sources, and such other tion for a grant for the construction of records as will facilitate an effective any facility, structure or system which audit. All such records shall be re- is part of an exchange of information tained by the applicant (grantee) for a program shall include the following: period of 3 years after the submission (a) Each application shall include of the final expenditure report, or if complete descriptions, maps, and sur- litigation, claim or audit is started be- veys of the construction site, and docu- fore the expiration of the 3-year period, mentary evidence and explanations the records shall be retained until all showing ownership, and litigation, claims or audit findings in- (b) Each application shall include volving the records have been resolved, complete plans and specifications for and (f) To include assurance records will be the construction project, and where ap- made available. Each application shall plicable, sufficient explanations of include sufficient assurances the appli- technical applications so that they cant will give the Secretary and the may be understood by the layman, and

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(c) Each application shall contain as- § 17.258 Terms and conditions to surance that the rates of pay for labor- which awards are subject. ers and mechanics engaged in construc- Each certificate of award of a grant tion activities will not be less than the for planning or implementing an agree- prevailing local wage rates for similar ment for the exchange of information work as determined in accordance with or information facilities shall specify the provisions of 40 U.S.C. 3141–3144, that the grant is subject to the fol- 3146, and 3147. lowing terms and conditions: [33 FR 6012, Apr. 19, 1968. Redesignated and (a) Grants subject to terms of agreement amended at 61 FR 21966, 21969, May 13, 1996; 79 for exchange of information. Each grant FR 54616, Sept. 12, 2014] shall be subject to, and the certificate shall incorporate by reference, all § 17.256 Amended or supplemental ap- terms, conditions, and obligations plications. specified in the agreement or planning An amended application, or an appli- protocols which the grant will imple- cation for a supplemental grant, may ment, and be considered either before or after (b) Grants subject to assurances in ap- final action has been taken on the plication. Each grant shall be subject to original application. Amended applica- all assurances made by the grantee in tions and applications for supplemental its application for the grant as re- grants shall be subject to the same quired by §§ 17.254 through 17.256, and terms, conditions and requirements (c) Grants subject to limitations on use necessary for original applications. of funds. Each grant shall be subject to the limitations on the use of grant [33 FR 6012, Apr. 19, 1968. Redesignated at 61 FR 21966, May 13, 1996] funds, either for direct or indirect costs, as prescribed in §§ 17.259 through § 17.257 Awards procedures. 17.261, and (d) Grants subject to special provisions. Applications for grants for planning Each grant shall be subject to any spe- or implementing agreements for the cial terms or conditions which may be exchange of medical information or in- warranted by circumstances applicable formation facilities shall be reviewed to individual applications, and speci- by the Under Secretary for Health or fied in the certificate of award. designee. If it is determined approval of the grant is warranted, rec- [33 FR 6012, Apr. 19, 1968. Redesignated and ommendations to that effect shall be amended at 61 FR 21966, 21969, May 13, 1996] made to the Secretary in writing and shall be accompanied by the following: § 17.259 Direct costs. (a) The recommendation for approval Direct costs to which grant funds shall be accompanied by the written may be applied may include in propor- recommendation of the Subcommittee tion to time and effort spent, but are on Academic Affairs, and not limited to, fees and costs directly (b) The recommendation for approval paid to personnel or for fringe benefits, shall be accompanied by the written rent, publications, educational pro- draft of the certificate of award stating grams, training, research, demonstra- all conditions which the grantee is re- tion activities, or construction carried quired to agree to under the provisions out in connection with pilot programs of § 17.258 and all other conditions to for planning or exchange of informa- which it has been determined the grant tion. will be subject, and [33 FR 6012, Apr. 19, 1968. Redesignated at 61 (c) The recommendation shall in- FR 21966, May 13, 1996] clude a certification that sufficient appropriated funds are available, and § 17.260 Patient care costs to be ex- that the application for the grant is cluded from direct costs. sufficient in all details as specified in Grant funds for planning or imple- §§ 17.254 through 17.256. menting agreements for the exchange [33 FR 6012, Apr. 19, 1968, as amended at 42 of medical information shall not be FR 54805, Oct. 11, 1977. Redesignated and available for the payment of any hos- amended at 61 FR 21966, 21969, May 13, 1996] pital, medical, or other costs involving

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the care of patients except to the ex- (a) Posttermination appeal. The fol- tent that such costs are determined to lowing procedures are applicable for re- be incident to research, training, or viewing postaward disputes which may demonstration activities carried out in arise in the administration of or car- connection with an exchange of infor- rying out of the Exchange of Medical mation program. Information Grant Program. (1) Reviewable decisions. The Depart- [33 FR 6012, Apr. 19, 1968. Redesignated at 61 ment of Veterans Affairs reserves the FR 21966, May 13, 1996] right to terminate any grant in whole § 17.261 Indirect costs. or in part at any time before the date of completion, whenever it determines The grantee shall allocate expendi- that the grantee has failed to comply tures as between direct and indirect with conditions of the agreement, or costs according to generally accepted otherwise failed to comply with any accounting procedures. The amount al- law, regulation, assurance, term, or located for indirect costs may be com- condition applicable to the grant. puted on a percentage basis or on the (2) Notice. The Department of Vet- basis of a negotiated lump-sum allow- erans Affairs shall promptly notify the ance. In the method of computation grantee in writing of the determina- used, only indirect costs shall be in- tion. The notice shall set forth the rea- cluded which bear a reasonable rela- son for the determination in sufficient tionship to the planning or program detail to enable the grantee to respond, funded by the grant and shall not ex- and shall inform the grantee of his or ceed a percentage greater than the per- her opportunity for review by the As- centage the total institutional indirect sistant Chief Medical Director as pro- cost is of the total direct salaries and vided in this section. wages paid by the institution. (3) Request for appeal. A grantee with [33 FR 6012, Apr. 19, 1968. Redesignated at 61 respect to whom a determination de- FR 21966, May 13, 1996] scribed in paragraph (a)(1) of this section has been made, and who desires re- § 17.262 Authority to approve applica- view, may file with the Assistant Chief tions discretionary. Medical Director for Academic Affairs Notwithstanding any recommenda- an application for review of such deter- tion by the Subcommittee on Aca- mination. The grantee’s application for demic Affairs of the Special Medical review must be post-marked no later Advisory Group, or any recommenda- than 30 days after the postmarked date tion by the Under Secretary for Health of notification provided pursuant to or designee, the final determination on paragraph (a)(2) of this section. any application for a grant rests solely (4) Contents of request. The applica- with the Secretary. tion for review must clearly identify the question or questions in dispute, [42 FR 54805, Oct. 11, 1977. Redesignated and contain a full statement of the grant- amended at 61 FR 21966, 21969, May 13, 1996] ee’s position in respect to such question or questions, and provide perti- § 17.263 Suspension and termination nent facts and reasons in support of his procedures. or her position. The Assistant Chief Termination of a grant means the Medical Director for Academic Affairs cancellation of Department of Veterans will promptly send a copy of the grant- Affairs sponsorship, in whole or in ee’s application to the Department of part, under an agreement at any time Veterans Affairs official responsible for prior to the date of completion. Sus- the determination which is to be re- pension of a grant is an action by the viewed. Department of Veterans Affairs which (5) Effect of submission. When an appli- temporarily suspends Department of cation for review has been filed no ac- Veterans Affairs sponsorship under the tion may be taken by the Department grant pending corrective action by the of Veterans Affairs pursuant to such grantee or pending a decision to termi- determination until such application nate the grant by the Department of has been disposed of, except that the Veterans Affairs. filing of the application shall not affect

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the authority which the constituent (10) Participation by a party. Either agency may have to suspend the sys- party may participate in person, or by tem under a grant during proceedings counsel pursuant to the procedure set under this section or otherwise to forth in this section. withhold or defer payments under the (b) Termination for convenience. The grant. Department of Veterans Affairs or the (6) Consideration of request. When an grantee may terminate a grant in application for review has been filed whole or in part when both parties with the Assistant Chief Medical Direc- agree that the continuation of the tor for Academic Affairs, and it has project would not produce beneficial been determined that the application results commensurate with the further meets the requirements stated in this expenditure of funds. The two parties paragraph, all background material of shall agree upon the termination con- the issues shall be reviewed. If the ap- ditions, including the effective date and, in the case of partial termi- plication does not meet the require- nations, the portion to be terminated. ments, the grantee shall be notified of The grantee shall not incur new obliga- the deficiencies. tions for the terminated portion after (7) Presentation of case. If the Assist- the effective date, and shall cancel as ant Chief Medical Director for Aca- many outstanding obligations as pos- demic Affairs believes there is no dis- sible. The Department of Veterans Af- pute as to material fact, the resolution fairs shall allow full credit to the of which would be materially assisted grantee for the Department of Vet- by oral testimony, both parties shall be erans Affairs share of the notified of the issues to be considered, noncancellable obligations, properly and take steps to afford both parties incurred by the grantee prior to termi- the opportunity for presenting their nation. cases, at the option of the Assistant (c) Suspension procedures. When a Chief Medical Director for Academic grantee has failed to comply with the Affairs, in whole or in part in writing, terms of the grant agreement and con- or in an informal conference. Where it ditions or standards, the Department is concluded that oral testimony is re- of Veterans Affairs may, on reasonable quired to resolve a dispute over a mate- notice to the grantee, suspend the rial fact, both parties shall be afforded grant and withhold further payments, an opportunity to present and cross-ex- prohibit the grantee from incurring ad- amine witnesses at a hearing. ditional obligations of funds, pending (8) Decision. After both parties have corrective action by the grantee, or presented their cases, the Assistant make a decision to terminate as de- Chief Medical Director for Academic scribed in paragraph (a) of this section. Affairs shall prepare an initial written The Department of Veterans Affairs decision which shall include findings of shall allow all necessary and proper fact and conclusions based thereon. costs that the grantee could not rea- Copies of the decision shall be mailed sonably avoid during the period of sus- promptly to each of the parties to- pension provided that they meet the gether with a notice informing them of provisions of the applicable Federal their right to appeal the decision of the cost principles. Secretary, or to the officer or em- [42 FR 54805, Oct. 11, 1977. Redesignated at 61 ployee to whom the Secretary has dele- FR 21966, May 13, 1996] gated such authority, by submitting written comments thereon within a § 17.264 Recoupments and releases. specified reasonable time. In any case where the Department of (9) Final decision. Upon filing com- Veterans Affairs or a grantee’s obliga- ments with the Secretary, or des- tions under an exchange of information ignated officer or employee, the review agreement implemented by grant funds of the initial decision shall be con- are terminated, or where grant-fi- ducted on the basis of the decision, the nanced equipment or facilities cease to hearing record, if any, and written be used for the purposes for which comments submitted by both parties. grant support was given, or when The decision shall be final. grant-financed property is transferred,

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the grantee shall return the propor- grantee meets all of the above require- tionate value of such equipment or fa- ments of this section except that ad- cility as was financed by the grant. vances will be less than $250,000, or for When it is determined the Department a period less than 12 months. Reim- of Veterans Affairs equitable interest bursement by Treasury check is a pay- is greater that proportionate value, ment made to a grantee upon request then a claim in such greater amount for reimbursement from the grantee shall be asserted. If it is determined an and shall be the preferred method when amount less than proportionate value the grantee does not meet the require- or less than the Department of Vet- ments of paragraphs (b) and (c) of this erans Affairs equitable interest should section. This method may be used on be recouped, or that the Department of any construction agreement, or if the Veterans Affairs should execute any re- major portion of the program is accom- leases, then a proposal concerning such plished through private market financ- a settlement or releases complete with ing or Federal loans, and the Federal explanations and justifications shall be assistance constitutes a minor portion submitted to the Assistant Chief Med- of the program. When the reimburse- ical Director for Academic Affairs for a final determination. ment method is used, the Department of Veterans Affairs shall make pay- [42 FR 54805, Oct. 11, 1977. Redesignated at 61 ment within 30 days after receipt of the FR 21966, May 13, 1996] billing, unless billing is improper. Un- § 17.265 Payments. less otherwise required by law, payments shall not be withheld for proper Payments of grant funds are made to charges at any time during the grant grantees through a letter-of-credit, an period unless a grantee has failed to advance by Treasury check, or a reim- comply with the program objectives, bursement by Treasury check, as ap- award conditions, or Federal reporting propriate. A letter-of-credit is an in- requirements; or the grantee is instrument certified by an authorized of- debted. ficial of the Department of Veterans Affairs which authorizes the grantee to [42 FR 54806, Oct. 11, 1977. Redesignated at 61 draw funds when needed from the FR 21966, May 13, 1996] Treasury, through a Federal Reserve bank and the grantee’s commercial § 17.266 Copyrights and patents. bank and shall be used by the Depart- If a grant-supported program results ment of Veterans Affairs where all the in copyrightable material or patent- following conditions exist: able inventions or discoveries, the (a) When there is or will be a con- United States Government shall have tinuing relationship between the grant- the right to use such publications or ee and the Department of Veterans Af- inventions on a royalty-free basis. fairs for at least a 12-month period and the total amount of advance payments [33 FR 6013, Apr. 19, 1968. Redesignated at 61 expected to be received within that pe- FR 21966, May 13, 1996] riod is $250,000, or more; (b) When the grantee has established CIVILIAN HEALTH AND MEDICAL PRO- or demonstrated the willingness and GRAM OF THE DEPARTMENT OF VET- ability to maintain procedures that ERANS AFFAIRS (CHAMPVA)—MED- will minimize the time elapsing be- ICAL CARE FOR SURVIVORS AND DE- tween the transfer of funds and their PENDENTS OF CERTAIN VETERANS disbursement by the grantee; and (c) When the grantee’s financial man- SOURCE: 63 FR 48102, Sept. 9, 1998, unless agement meets the standards for fund otherwise noted. control and accountability. An advance by Treasury check is a payment made § 17.270 General provisions. to a grantee upon its request before (a) CHAMPVA is the Civilian Health outlays are made by the grantee, or and Medical Program of the Depart- through use of predetermined payment ment of Veterans Affairs and is admin- schedules and shall be used by the De- istered by the Health Administration partment of Veterans Affairs when the Center, Denver, Colorado. Pursuant to

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38 U.S.C. 1781, VA is authorized to pro- misconduct and that results in the in- vide medical care in the same or simi- ability to continue or resume the cho- lar manner and subject to the same or sen program of education must remain similar limitations as medical care fur- eligible for medical care until: nished to certain dependents and sur- (i) The end of the six-month period vivors of active duty and retired mem- beginning on the date the disability is bers of the Armed Forces. The removed; or CHAMPVA program is designed to ac- (ii) The end of the two-year period complish this purpose. Under beginning on the date of the onset of CHAMPVA, VA shares the cost of the disability; or medically necessary services and supplies for eligible beneficiaries as set (iii) The twenty-third birthday of the forth in §§ 17.271 through 17.278. child, whichever occurs first. (b) For purposes of §§ 17.270 through 17.278, the definitions of ‘‘child,’’ (Authority: 38 U.S.C. 501, 1781) ‘‘service-connected condition/dis- (b) CHAMPVA and Medicare entitle- ability,’’ ‘‘spouse,’’ and ‘‘surviving ment. (1) Individuals under age 65 who spouse’’ must be those set forth further are entitled to Medicare Part A and en- in 38 U.S.C. 101. The term ‘‘fiscal year’’ rolled in Medicare Part B, retain refers to October 1, through September CHAMPVA eligibility as secondary 30. payer to Medicare Parts A and B, Medi- (Authority: 38 U.S.C. 501, 1781) care supplemental insurance plans, and Medicare HMO plans. [63 FR 48102, Sept. 9, 1998, as amended at 73 FR 65553, Nov. 4, 2008] (2) Individuals age 65 or older, and not entitled to Medicare Part A, retain § 17.271 Eligibility. CHAMPVA eligibility.

(a) General entitlement. The following NOTE TO PARAGRAPH (b)(2): If the person is persons are eligible for CHAMPVA ben- not eligible for Part A of Medicare, a Social efits provided that they are not eligible Security Administration ‘‘Notice of Dis- under Title 10 for the TRICARE Pro- allowance’’ certifying that fact must be sub- gram or Part A of Title XVIII of the mitted. Additionally, if the individual is en- Social Security Act (Medicare) except titled to only Part B of Medicare, but not as provided in paragraph (b) of this sec- Part A, or Part A through the Premium HI tion. provisions, a copy of the individual’s Medi- (1) The spouse or child of a veteran care card or other official documentation who has been adjudicated by VA as noting this must be provided. having a permanent and total service- (3) Individuals age 65 on or after June connected disability; 5, 2001, who are entitled to Medicare (2) The surviving spouse or child of a Part A and enrolled in Medicare Part veteran who died as a result of an adju- B, are eligible for CHAMPVA as sec- dicated service-connected condition(s); ondary payer to Medicare Parts A and or who at the time of death was adju- B, Medicare supplemental insurance dicated permanently and totally dis- plans, and Medicare HMO plans for abled from a service-connected condi- services received on or after October 1, tion(s); 2001. (3) The surviving spouse or child of a (4) Individuals age 65 or older prior to person who died on active military service and in the line of duty and not June 5, 2001, who are entitled to Medi- due to such person’s own misconduct; care Part A and who have not pur- and chased Medicare Part B, are eligible for (4) An eligible child who is pursuing a CHAMPVA as secondary payer to Medi- full-time course of instruction ap- care Part A and any other health insur- proved under 38 U.S.C. Chapter 36, and ance for services received on or after who incurs a disabling illness or injury October 1, 2001. while pursuing such course (between (5) Individuals age 65 or older prior to terms, semesters or quarters; or during June 5, 2001, who are entitled to Medi- a vacation or holiday period) that is care Part A and who have purchased not the result of his or her own willful Medicare Part B must continue to

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carry Part B to retain CHAMPVA eligi- (5) Radiology, laboratory, and patho- bility as secondary payer for services logical services and machine diagnostic received on or after October 1, 2001. testing not related to a specific illness or injury or a definitive set of symp- (Authority: 38 U.S.C. 501, 1781) toms. NOTE TO § 17.271: Eligibility criteria specific (6) Services and supplies above the to Dependency and Indemnity Compensation appropriate level required to provide (DIC) benefits are not applicable to necessary medical care. CHAMPVA eligibility determinations. (7) Services and supplies related to an [63 FR 48102, Sept. 9, 1998, as amended at 67 inpatient admission primarily to per- FR 4359, Jan. 30, 2002; 73 FR 65553, Nov. 4, form diagnostic tests, examinations, 2008] and procedures that could have been and are performed routinely on an out- § 17.272 Benefits limitations/exclu- patient basis. sions. (8) Postpartum inpatient stay of a (a) Benefits cover allowable expenses mother for purposes of staying with for medical services and supplies that the newborn infant (primarily for the are medically necessary and appro- purpose of breast feeding the infant) priate for the treatment of a condition when the infant (but not the mother) and that are not specifically excluded requires the extended stay; or contin- from program coverage. Covered bene- ued inpatient stay of a newborn infant fits may have limitations. The fact primarily for purposes of remaining that a physician may prescribe, order, with the mother when the mother (but recommend, or approve a service or not the newborn infant) requires ex- supply does not, of itself, make it tended postpartum inpatient stay. medically necessary or make the (9) Therapeutic absences from an in- charge an allowable expense, even patient facility or residential treat- though it is not listed specifically as ment center (RTC). an exclusion. The following are specifi- (10) Custodial care. cally excluded from program coverage: (11) Inpatient stays primarily for (1) Services, procedures or supplies domiciliary care purposes. for which the beneficiary has no legal obligation to pay, or for which no (12) Inpatient stays primarily for rest charge would be made in the absence of or rest cures. coverage under a health benefits plan. (13) Services and supplies provided as (2) Services and supplies required as a a part of, or under, a scientific or med- result of an occupational disease or in- ical study, grant, or research program. jury for which benefits are payable (14) Services and supplies not pro- under workers’ compensation or simi- vided in accordance with accepted pro- lar protection plan (whether or not fessional medical standards or related such benefits have been applied for or to experimental or investigational pro- paid) except when such benefits are ex- cedures or treatment regimens. hausted and are otherwise not excluded (15) Services or supplies prescribed or from CHAMPVA coverage. provided by a member of the bene- (3) Services and supplies that are ficiary’s immediate family, or a person paid directly or indirectly by a local, living in the beneficiary’s or sponsor’s State or Federal government agency household. (Medicaid excluded), including court- (16) Services and supplies that are (or ordered treatment. In the case of the are eligible to be) payable under an- following exceptions, CHAMPVA as- other medical insurance or program, sumes primary payer status: either private or governmental, such as (i) Medicaid. coverage through employment or Medi- (ii) State Victims of Crime Com- care. pensation Programs. (17) Services or supplies subject to (4) Services and supplies that are not preauthorization (see § 17.273) that were medically or psychologically necessary obtained without the required for the diagnosis or treatment of a cov- preauthorization; and services and sup- ered condition (including mental dis- plies that were not provided according order) or injury. to the terms of the preauthorization.

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(18) Inpatient stays primarily to con- mined to be medically necessary) in- trol or detain a runaway child, whether cluding prescription medications. or not admission is to an authorized in- (23) Services and supplies related to stitution. transsexualism or other similar condi- (19) Services and supplies (to include tions such as gender dysphoria (includ- prescription medications) in connec- ing, but not limited to, intersex sur- tion with cosmetic surgery which is gery and psychotherapy, except for am- performed to primarily improve phys- biguous genitalia which was docu- ical appearance or for psychological mented to be present at birth). purposes or to restore form without (24) Sex therapy, sexual advice, sex- correcting or materially improving a ual counseling, sex behavior modifica- bodily function. (20) Electrolysis. tion, psychotherapy for mental dis- (21) Dental care with the following orders involving sexual deviations (e.g., exceptions: transvestic fetish), or other similar (i) Dental care that is medically nec- services, and any supplies provided in essary in the treatment of an otherwise connection with therapy for sexual covered medical condition, is an inte- dysfunctions or inadequacies. gral part of the treatment of such med- (25) Removal of corns or calluses or ical condition, and is essential to the trimming of toenails and other routine control of the primary medical condi- foot care services, except those re- tion. quired as a result of a diagnosed sys- (ii) Dental care required in prepara- temic medical disease affecting the tion for, or as a result of, radiation lower limbs, such as severe diabetes. therapy for oral or facial cancer. (26) Services and supplies, to include (iii) Gingival Hyperplasia. psychological testing, provided in con- (iv) Loss of jaw substance due to di- nection with a specific developmental rect trauma to the jaw or due to treat- disorder. The following exception ap- ment of neoplasm. plies: Diagnostic and evaluative serv- (v) Intraoral abscess when it extends ices required to arrive at a differential beyond the dental alveolus. diagnosis for an otherwise eligible (vi) Extraoral abscess. child unless the state is required to (vii) Cellulitis and osteitis which is provide those services under Public clearly exacerbating and directly affecting a medical condition currently Law 94–142, Education for All Handi- under treatment. capped Children Act of 1975 as amended, (viii) Repair of fracture, dislocation, see 20 U.S.C. chapter 33. and other injuries of the jaw, to in- (27) Surgery to reverse voluntary sur- clude removal of teeth and tooth frag- gical sterilization procedures. ments only when such removal is inci- (28) Services and supplies related to dental to the repair of the jaw. artificial insemination (including (ix) Treatment for stabilization of semen donors and semen banks), in myofascial pain dysfunction syndrome, vitro fertilization, gamete also referred to as temporomandibular intrafallopian transfer and all other joint (TMJ) syndrome. Authorization is noncoital reproductive technologies. limited to initial radiographs, up to (29) Nonprescription contraceptives. four office visits, and the construction (30) Diagnostic tests to establish pa- of an occlusal splint. ternity of a child; or tests to determine (x) Total or complete ankyloglossia. sex of an unborn child. (xi) Adjunctive dental and ortho- (31) Preventive care (such as routine, dontic support for cleft palate. annual, or employment-requested phys- (xii) Prosthetic replacement of jaw due to trauma or cancer. ical examinations; routine screening (22) Nonsurgical treatment of obesity procedures; and immunizations). The or morbid obesity for dietary control following exceptions apply: or weight reduction (with the excep- (i) Well-child care from birth to age tion of gastric bypass, gastric stapling, six. Periodic health examinations de- or gastroplasty procedures in connec- signed for prevention, early detection, tion with morbid obesity when deter- and treatment of disease are covered to

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include screening procedures, immuni- economic purposes, stress manage- zations, and risk counseling. The fol- ment, life style modification, etc.). lowing services are payable when re- (34) Acupuncture, whether used as a quired as part of a well-child care pro- therapeutic agent or as an anesthetic. gram and when rendered by the attend- (35) Hair transplants, wigs, or ing pediatrician, family physician, or a hairpieces, except that benefits may be pediatric nurse practitioner. extended for one wig or hairpiece per (A) Newborn examination, heredity beneficiary (lifetime maximum) when and metabolic screening, and newborn the attending physician certifies that circumcision. alopecia has resulted from treatment (B) Periodic health supervision visits of malignant disease and the bene- intended to promote optimal health for ficiary certifies that a wig or hairpiece infants and children to include the fol- has not been obtained previously lowing services: through the U.S. Government (includ- (1) History and physical examination. ing the Department of Veterans Af- (2) Vision, hearing, and dental fairs). The wig or hairpiece benefit does screening. not include coverage for the following: (3) Developmental appraisal to in- (i) Maintenance, wig or hairpiece clude body measurement. supplies, or replacement of the wig or (4) Immunizations as recommended hairpiece. by the Centers for Disease Control (ii) Hair transplant or any other sur- (CDC) and Prevention Advisory Com- gical procedure involving the attach- mittee on Immunization Practices. ment of hair or a wig or hairpiece to (5) Pediatric blood lead level test. the scalp. (6) Tuberculosis screening. (iii) Any diagnostic or therapeutic (7) Blood pressure screening. method or supply intended to encour- (8) Measurement of hemoglobin and age hair growth. hematocrit for anemia. (36) Self-help, academic education or (9) Urinalysis. vocational training services and sup- (C) Additional services or visits re- plies. quired because of specific findings or (37) Exercise equipment, spas, whirl- because the particular circumstances pools, hot tubs, swimming pools, of the individual case are covered if health club membership or other such medically necessary and otherwise au- charges or items. thorized for benefits under CHAMPVA. (38) General exercise programs, even (ii) Rabies vaccine following an ani- if recommended by a physician. mal bite. (39) Services of an audiologist or (iii) Tetanus vaccine following an ac- speech therapist, except when pre- cidental injury. scribed by a physician and rendered as (iv) Rh immune globulin. a part of treatment addressed to the (v) Pap smears. physical defect itself and not to any (vi) Mammography tests. educational or occupational deficit. (vii) Genetic testing and counseling (40) Eye exercises or visual training determined to be medically necessary. (orthoptics). (viii) Chromosome analysis in cases (41) Eye and hearing examinations of habitual abortion or infertility. except when rendered in connection (ix) Gamma globulin. with medical or surgical treatment of a (x) School-required physical exami- covered illness or injury or in connec- nations for beneficiaries through age 17 tion with well-child care. that are provided on or after October 1, (42) Eyeglasses, spectacles, contact 2001. lenses, or other optical devices with (32) Chiropractic and naturopathic the following exceptions: services. (i) When necessary to perform the (33) Counseling services that are not function of the human lens, lost as a medically necessary in the treatment result of intraocular surgery, ocular in- of a diagnosed medical condition (such jury or congenital absence. as educational counseling; vocational (ii) Pinhole glasses prescribed for use counseling; and counseling for socio- after surgery for detached retina.

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(iii) Lenses prescribed as ‘‘treat- (46) Services or advice rendered by ment’’ instead of surgery for the fol- telephone are excluded except that a lowing conditions: diagnostic or monitoring procedure (A) Contact lenses used for treatment which incorporates electronic trans- of infantile glaucoma. mission of data or remote detection (B) Corneal or scleral lenses pre- and measurement of a condition, activ- scribed in connection with treatment ity, or function (biotelemetry) is cov- of keratoconus. ered when: (C) Scleral lenses prescribed to retain (i) The procedure, without electronic moisture when normal tearing is not data transmission, is a covered benefit; present or is inadequate. and (D) Corneal or scleral lenses pre- (ii) The addition of electronic data scribed to reduce a corneal irregularity transmission or biotelemetry improves other than astigmatism. the management of a clinical condition (iv) The specified benefits are limited in defined circumstances; and to one set of lenses related to one (iii) The electronic data or biotelem- qualifying eye condition as set forth in etry device has been classified by the paragraphs (a)(42)(iii)(A) through (D) of U.S. Food and Drug Administration, ei- this section. If there is a prescription ther separately or as part of a system, change requiring a new set of lenses, for use consistent with the medical but still related to the qualifying eye condition and clinical management of condition, benefits may be extended for such condition. a second set of lenses, subject to med- (47) Air conditioners, humidifiers, de- ical review. humidifiers, and purifiers. (43) Hearing aids or other auditory (48) Elevators. sensory enhancing devices. (49) Alterations to living spaces or (44) Prostheses with the following ex- permanent features attached thereto, ceptions: even when necessary to accommodate (i) Dental prostheses specifically reinstallation of covered durable medical quired in connection with otherwise equipment or to facilitate entrance or covered orthodontia directly related to exit. the surgical correction of a cleft palate (50) Items of clothing, even if re- anomaly. quired by virtue of an allergy (such as (ii) Any prostheses, other than dental cotton fabric versus synthetic fabric prostheses, determined to be medically and vegetable-dyed shoes). necessary because of significant condi- (51) Food, food substitutes, vitamins tions resulting from trauma, con- or other nutritional supplements, in- genital anomalies, or disease, includ- cluding those related to prenatal care ing, but not limited to: for a home patient whose condition (A) Artificial limbs. permits oral feeding. (B) Voice prostheses. (52) Enuretic (bed-wetting) condi- (C) Eyes. tioning programs. (D) Items surgically inserted in the (53) Autopsy and post-mortem exami- body as an integral part of a surgical nations. procedure. (54) All camping, even when orga- (E) Ears, noses, and fingers. nized for a specific therapeutic purpose (45) Orthopedic shoes, arch supports, (such as diabetic camp or a camp for shoe inserts, and other supportive de- emotionally disturbed children), or vices for the feet, including special or- when offered as a part of an otherwise dered, custom-made built-up shoes, or covered treatment plan. regular shoes later built up with the (55) Housekeeping, homemaker, or at- following exceptions: tendant services, including a sitter or (i) Shoes that are an integral part of companion. an orthopedic brace, and which cannot (56) Personal comfort or convenience be used separately from the brace. items, such as beauty and barber serv- (ii) Extra-depth shoes with inserts or ices, radio, television, and telephone. custom molded shoes with inserts for (57) Smoking cessation services and individuals with diabetes. supplies.

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(58) Megavitamin psychiatric ther- (72) Drug maintenance programs apy; orthomolecular psychiatric ther- where one addictive drug is substituted apy. for another, such as methadone sub- (59) All transportation except for spe- stituted for heroin. cialized transportation with life sus- (73) Immunotherapy for malignant taining equipment, when medically re- diseases except for treatment of Stage quired for the treatment of a covered O and Stage A carcinoma of the blad- condition. der. (60) Inpatient mental health services (74) Services and supplies provided by in excess of 30 days in any fiscal year other than a hospital, such as non- (or in an admission), in the case of a skilled nursing homes, intermediate patient nineteen years of age or older; care facilities, halfway houses, homes 45 days in any fiscal year (or in an ad- for the aged, or other institutions of mission), in the case of a patient under similar purpose. 19 years of age; or 150 days of residen- (75) Services performed when the pa- tial treatment care in any fiscal year tient is not physically present. (or in an admission) unless a waiver for (76) Medical photography. extended coverage is granted in ad- (77) Special tutoring. vance. (78) Surgery for psychological rea- (61) Outpatient mental health serv- sons. ices in excess of 23 visits in a fiscal (79) Treatment of premenstrual syn- year unless a waiver for extended cov- drome (PMS). erage is granted in advance. (80) Medications not requiring a pre- (62) Institutional services for partial scription, except for insulin and related hospitalization in excess of 60 treat- diabetic testing supplies and syringes. ment days in any fiscal year (or in an (81) Thermography. admission) unless a waiver for extended (82) Removal of tattoos. coverage is granted in advance. (83) Penile implant/testicular pros- (63) Detoxification in a hospital set- thesis procedures and related supplies ting or rehabilitation facility in excess for psychological impotence. of seven days. (84) Dermabrasion of the face except (64) Outpatient substance abuse serv- in those cases where coverage has been ices in excess of 60 visits during a ben- authorized for reconstructive or plastic efit period. A benefit period begins surgery required to restore body form with the first date of covered service following an accidental injury or to re- and ends 365 days later. vise disfiguring and extensive scars re- (65) Family therapy for substance sulting from neoplastic surgery. abuse in excess of 15 visits during a (85) Chemical peeling for facial wrin- benefit period. A benefit period begins kles. with the first date of covered service (86) Panniculectomy, body sculpting and ends 365 days later. procedures. (66) Services that are provided to a (b) CHAMPVA-determined allowable beneficiary who is referred to a pro- amount. vider of such services by a provider (1) The term allowable amount is the who has an economic interest in the fa- maximum CHAMPVA-determined level cility to which the patient is referred, of payment to a hospital or other au- unless a waiver is granted. thorized institutional provider, a phy- (67) Abortion except when a physi- sician or other authorized individual cian certifies that the life of the moth- professional provider, or other author- er would be endangered if the fetus ized provider for covered services. The were carried to term. CHAMPVA-allowable amount is deter- (68) Abortion counseling. mined prior to cost sharing and the ap- (69) Aversion therapy. plication of deductibles and/or other (70) Rental or purchase of bio- health insurance. feedback equipment. (2) A Medicare-participating hospital (71) Biofeedback therapy for treat- must accept the CHAMPVA-deter- ment of ordinary muscle tension states mined allowable amount for inpatient (including tension headaches) or for services as payment-in-full. (Reference psychosomatic conditions. 42 CFR parts 489 and 1003).

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(3) An authorized provider of covered for services provided through VA facili- medical services or supplies must ac- ties. cept the CHAMPVA-determined allow- (c) To provide financial protection able amount as payment-in-full. against the impact of a long-term ill- (4) A provider who has collected and ness or injury, a calendar year cost not made appropriate refund, or at- limit or ‘‘catastrophic cap’’ has been tempts to collect from the beneficiary, placed on the beneficiary cost-share any amount in excess of the amount for covered services and sup- CHAMPVA-determined allowable plies. Credits to the annual cata- amount may be subject to exclusion strophic cap are limited to the applied from Federal benefit programs. annual deductible(s) and the beneficiary cost-share amount. Costs above (Authority: 38 U.S.C. 501, 1781) the CHAMPVA-allowable amount, as [63 FR 48102, Sept. 9, 1998, as amended at 67 well as costs associated with non-cov- FR 4359, Jan. 30, 2002; 73 FR 65553, Nov. 4, ered services are not credited to the 2008] catastrophic cap computation. After a family has paid the maximum cost- § 17.273 Preauthorization. share and deductible amounts for a cal- Preauthorization or advance ap- endar year, CHAMPVA will pay allow- proval is required for any of the fol- able amounts for the remaining cov- lowing: ered services through the end of that (a) Non-emergent inpatient mental calendar year. health and substance abuse care in- (i) Through December 31, 2001, the an- cluding admission of emotionally dis- nual cap on cost sharing is $7,500 per turbed children and adolescents to resi- CHAMPVA-eligible family. dential treatment centers. (ii) Effective January 1, 2002, the cap (b) All admissions to a partial hos- on cost sharing is $3,000 per pitalization program (including alcohol CHAMPVA-eligible family. rehabilitation). (d) If the CHAMPVA benefit payment (c) Outpatient mental health visits in is under $1.00, payment will not be excess of 23 per calendar year and/or issued. Catastrophic cap and deductible more than two (2) sessions per week. will, however, be credited. (d) Dental care. (Authority: 38 U.S.C. 501, 1781) (e) Durable medical equipment with a [67 FR 4359, Jan. 30, 2002, as amended at 67 purchase or total rental price in excess FR 6875, Feb. 14, 2002] of $2,000. (f) Organ transplants. § 17.275 Claim filing deadline. (Authority: 38 U.S.C. 501, 1781) (a) Unless an exception is granted under paragraph (b) of this section, [63 FR 48102, Sept. 9, 1998, as amended at 74 claims for medical services and sup- FR 31374, July 1, 2009] plies must be filed with the Center no § 17.274 Cost sharing. later than: (1) One year after the date of service; (a) With the exception of services ob- or tained through VA facilities, (2) In the case of inpatient care, one CHAMPVA is a cost-sharing program year after the date of discharge; or in which the cost of covered services is (3) In the case of retroactive approval shared with the beneficiary. for medical services/supplies, 180 days CHAMPVA pays the CHAMPVA-deter- following beneficiary notification of mined allowable amount less the de- authorization; or ductible, if applicable, and less the ben- (4) In the case of retroactive approval eficiary cost share. of CHAMPVA eligibility, 180 days fol- (b) In addition to the beneficiary cost lowing notification to the beneficiary share, an annual (calendar year) out- of authorization for services occurring patient deductible requirement ($50 per on or after the date of first eligibility. beneficiary or $100 per family) must be (b) Requests for an exception to the satisfied prior to the payment of out- claim filing deadline must be sub- patient benefits. There is no deductible mitted, in writing, to the Center and requirement for inpatient services or include a complete explanation of the

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circumstances resulting in late filing request for review by the Director, along with all available supporting Health Administration Center, or his documentation. Each request for an ex- or her designee. The Director, Health ception to the claim filing deadline Administration Center, or his or her willbe reviewed individually and con- designee will review the claim, and any sidered on its own merit. The Director, relevant supporting documentation, Health Administration Center, or his and issue a decision in writing that af- or her designee may grant exceptions firms, reverses or modifies the previous to the requirements in paragraph (a) of decision. The decision of the Director, this section if he or she determines Health Administration Center, or his that there was good cause for missing or her designee with respect to benefit the filing deadline. For example, when coverage and computation of benefits dual coverage exists CHAMPVA pay- is final. ment, if any, cannot be determined (Authority: 38 U.S.C. 501, 1781) until after the primary insurance carrier has adjudicated the claim. In such NOTE TO § 17.276: Denial of CHAMPVA bene- circumstances an exception may be fits based on legal eligibility requirements may be appealed to the Board of Veterans’ granted provided that the delay on the Appeals in accordance with 38 CFR part 20. part of the primary insurance carrier is Medical determinations are not appealable not attributable to the beneficiary. to the Board. 38 CFR 20.101. Delays due to provider billing proce- [63 FR 48102, Sept. 9, 1998, as amended at 73 dures do not constitute a valid basis FR 65553, Nov. 4, 2008] for an exception. (Authority: 38 U.S.C. 501, 1781) § 17.277 Third-party liability/medical care cost recovery. [63 FR 48102, Sept. 9, 1998, as amended at 73 The Center will actively pursue FR 65553, Nov. 4, 2008] third-party liability/medical care cost § 17.276 Appeal/review process. recovery in accordance with applicable law. Notice of the initial determination regarding payment of CHAMPVA bene- (Authority: 42 U.S.C. 2651; 38 U.S.C. 501, 1781) fits will be provided to the beneficiary [63 FR 48102, Sept. 9, 1998, as amended at 79 on a CHAMPVA Explanation of Bene- FR 54616, Sept. 12, 2014] fits (EOB) form. The EOB form is generated by the CHAMPVA automated § 17.278 Confidentiality of records. payment processing system. If a bene- Confidentiality of records will be ficiary disagrees with the determina- maintained in accordance with 38 CFR tion concerning covered services or cal- 1.460 through 1.582. culation of benefits, he or she may re- (Authority: 5 U.S.C. 552, 552a; 38 U.S.C. 501, quest reconsideration. Such requests 1781, 5701, 7332) must be submitted to the Center in writing within one year of the date of IN VITRO FERTILIZATION AND the initial determination. The request REIMBURSEMENT OF ADOPTION EXPENSES must state why the beneficiary believes the decision is in error and must § 17.380 In vitro fertilization treat- include any new and relevant informa- ment. tion not previously considered. Any re- (a)(1) In vitro fertilization may be quest for reconsideration that does not provided when clinically appropriate identify the reason for dispute will be to— returned to the claimant without fur- (i) A veteran who has a service-con- ther consideration. After reviewing the nected disability that results in the in- claim and any relevant supporting doc- ability of the veteran to procreate umentation, a CHAMPVA benefits ad- without the use of fertility treatment; visor will issue a written determina- and, tion to the beneficiary that affirms, re- (ii) The spouse of such veteran, as verses or modifies the previous deci- provided in § 17.412. sion. If the beneficiary is still dissatis- (2) For the purposes of this section, fied, within 90 days of the date of the ‘‘a service-connected disability that re- decision he or she may make a written sults in the inability of the veteran to

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procreate without the use of fertility in section 473(c) of the Social Security treatment’’ means, for a male veteran, Act (42 U.S.C. 673(c))). a service-connected injury or illness (2) Reimbursement for qualifying that prevents the successful delivery of adoption expenses may be requested sperm to an egg; and, for a female vet- only for an adoption that became final eran with ovarian function and a pat- after September 29, 2016, and must be ent uterine cavity, a service-connected requested: injury or illness that prevents the egg (i) No later than 2 years after the from being successfully fertilized by adoption is final; or, sperm. (ii) In the case of adoption of a for- (3) In vitro fertilization treatment eign child, no later than 2 years from will be provided under this section the date the certificate of United when clinically appropriate and to the States citizenship is issued. same extent such treatment is provided (3) In the case of adoption of a for- to a member of the Armed Forces who eign child, reimbursement for quali- incurs a serious injury or illness on ac- fying adoption expenses may be re- tive duty pursuant to 10 U.S.C. quested only after United States citi- 1074(c)(4)(A), as described in the April 3, zenship has been granted to the adopt- 2012, memorandum issued by the As- ed child. sistant Secretary of Defense for Health (4) Reimbursement for qualifying Affairs on the subject of ‘‘Policy for adoption expenses may not be made Assisted Reproductive Services for the under this section for any expense paid Benefit of Seriously or Severely Ill/In- to or for a covered veteran under any jured (Category II or III) Active Duty other adoption benefits program ad- Service Members,’’ and the guidance ministered by the Federal Government issued by the Department of Defense to or under any such program adminis- implement such policy, including any tered by a State or local government. limitations on the amount of such ben- (b) Limitations. (1) Reimbursement efits available to such a member. per adopted child. No more than $2,000 may be reimbursed under this section (b) The time periods regarding em- to a covered veteran, or to two covered bryo cryopreservation and storage set veterans who are spouses of each other, forth in part III(G) and in part IV(H) of for expenses incurred in the adoption of the memorandum referenced in para- a child. In the case of two married cov- graph (a)(3) of this section do not ered veterans, only one spouse may apply. Embryo cryopreservation and claim reimbursement for any one adop- storage may be provided to an indi- tion. vidual described in paragraph (a)(1) of (2) Maximum reimbursement in any this section without limitation on the calendar year. No more than $5,000 may duration of such cryopreservation and be paid under this section to a covered storage. veteran in any calendar year. In the [82 FR 6275, Jan. 19, 2017, as amended at 82 case of two married covered veterans, FR 11153, Feb. 21, 2017; 84 FR 8257, Mar. 7, the couple is limited to a maximum of 2019] $5,000 per calendar year. (c) Definitions. For the purposes of § 17.390 Reimbursement for qualifying this section: adoption expenses incurred by cer- (1) ‘‘Covered veteran’’ means a vet- tain veterans. eran with a service-connected dis- (a) General. A covered veteran may ability that results in the inability of request reimbursement for qualifying the veteran to procreate without the adoption expenses incurred by the vet- use of fertility treatment. eran in the adoption of a child under 18 (2) ‘‘Qualifying adoption expenses’’ years of age. means reasonable and necessary ex- (1) An adoption for which expenses penses that are directly related to the may be reimbursed under this section legal adoption of a child under 18 years includes an adoption by a married or of age, but only if such adoption is ar- single person, an infant adoption, an ranged by a qualified adoption agency. intercountry adoption, and an adoption Such term does not include any ex- of a child with special needs (as defined pense incurred:

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(i) For items such as clothing, bed- judge unless either State law or local ding, toys and books; court rules authorize that the adoption (ii) For travel; or order may be signed by a commis- (iii) In connection with an adoption sioner, magistrate or court referee. The arranged in violation of Federal, State, covered veteran must submit a full or local law. English translation of any foreign lan- (3) ‘‘Reasonable and necessary ex- guage document, to include the trans- penses’’ include: lator’s certification that he or she is (i) Public and private agency fees, incompetent to translate the foreign lan- cluding adoption fees charged by an guage to English and that his or her agency in a foreign country; translation is complete and correct. (ii) Placement fees, including fees (2) For foreign adoptions, proof of charged to adoptive parents for coun- U.S. citizenship of the child, including seling; any of the following: (iii) Legal fees (including court costs) (i) A copy of Certificate of Citizen- or notary expenses; ship. (iv) Medical expenses, including hos- (ii) A copy of a U.S. court order that pital expenses of the biological mother recognizes the foreign adoption, or doc- and medical care of the child to be uments the re-adopting of the child in adopted; and the United States. (v) Temporary foster care charges (iii) A letter from the United States when payment of such charges is re- Citizenship and Immigration Services, quired before the adoptive child’s which states the status of the child’s placement. adoption. (4) ‘‘Qualified adoption agency’’ (iv) A copy of the child’s U.S. pass- means any of the following: port (page with personal information (i) A State or local government agen- only). cy which has responsibility under (3) For U.S. adoptions, documenta- State or local law for child placement tion to show that the adoption was through adoption. handled by a qualified adoption agency (ii) A nonprofit, voluntary adoption or other source authorized by a State agency which is authorized by State or or local law to provide adoption place- local law to place children for adop- ment. Acceptable forms of proof that tion. the adoption was handled by a qualified (iii) Any other source authorized by a adoption agency include: State to provide adoption placement if (i) A copy of placement agreement the adoption is supervised by a court from the adoption agency showing the under State or local law. agreement entered into between the (iv) A foreign government or an agen- member and the agency. cy authorized by a foreign government (ii) A letter from the adoption agency to place children for adoption, in any stating that the agency arranged the case in which: adoption and that the agency is a li- (A) The adopted child is entitled to censed child placing agency in the automatic citizenship under section 320 United States. of the Immigration and Nationality (iii) Receipts for payment to the Act (8 U.S.C. 1431); or adoption agency, as well as proof, (e.g., (B) A certificate of citizenship has a copy of the agency’s web page), of the been issued for such child under section agency’s status as a for-profit or non- 322 of that Act (8 U.S.C. 1433). profit licensed child placing agency. (d) Applying for reimbursement of quali- (4) For foreign adoptions, documenta- fying adoption expenses. An application tion to show that the adoption was for reimbursement must be submitted handled by a qualified adoption agency. on a form prescribed for such purpose In addition to the forms of acceptable by VA. Information and documentation proof that the adoption was handled by must include: a qualified adoption agency listed in (1) A copy of the final adoption de- paragraph (d)(3) of this section, the cree, certificate or court order grant- documentation must also include: ing the adoption. For U.S. adoptions, (i) A document that describes the the court order must be signed by a mission of the foreign agency and its

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authority from the foreign government Camp Lejeune veteran means any vet- to place children for adoption; and eran who served at Camp Lejeune on (ii) A placement agreement from the active duty, as defined in 38 U.S.C. adoption agency or letter from the 101(21), in the Armed Forces for at least adoption agency stating the specific 30 (consecutive or nonconsecutive) days services it provided for the adoption. during the period beginning on August (5) Documentation to substantiate 1, 1953, and ending on December 31, reasonable and necessary expenses paid 1987. A veteran served at Camp Lejeune by the covered veteran. Acceptable if he or she was stationed at Camp forms of documentation include re- Lejeune, or traveled to Camp Lejeune ceipts, cancelled checks, or a letter as part of his or her professional du- from the adoption agency showing the ties. amount paid by the member. Receipts Covered illness or condition means any from a foreign entity should include the U.S. currency equivalency. Recon- of the following illnesses and condi- struction of expense records is permis- tions: sible when the original records are un- (i) Esophageal cancer; available and the covered veteran sub- (ii) Lung cancer; mits a notarized affidavit stating the (iii) Breast cancer; costs. (iv) Bladder cancer; (6) Checking or savings account in- (v) Kidney cancer; formation to facilitate VA providing (vi) Leukemia; reimbursement to the covered veteran (vii) Multiple myeloma; under this section. (viii) Myelodysplastic syndromes; (e) Failure to establish eligibility. If (ix) Renal toxicity; documents submitted by a covered vet- (x) Hepatic steatosis; eran in support of an application for reimbursement do not establish eligi- (xi) Female infertility; bility for reimbursement or justify (xii) Miscarriage; claimed expenses, VA will retain the (xiii) Scleroderma; application and advise the covered vet- (xiv) Neurobehavioral effects; and eran of additional documentation need- (xv) Non-Hodgkin’s lymphoma. ed. All requested documentation must (c) Limitations. For a Camp Lejeune be submitted to VA within 90 calendar veteran, VA will assume that a covered days of VA request. illness or condition is attributable to (The Office of Management and Budget has the veteran’s active duty service at approved the information collection require- Camp Lejeune unless it is clinically de- ment in this section under control number termined, under VA clinical practice 2900–0860) guidelines, that such an illness or con- [83 FR 9212, Mar. 5, 2018, as amended at 84 FR dition resulted from a cause other than 68048, Dec. 13, 2019; 85 FR 31983, May 28, 2020] such service. (d) Copayments—(1) Exemption. (i) HOSPITAL CARE AND MEDICAL SERVICES Camp Lejeune veterans who served at FOR CAMP LEJEUNE VETERANS AND Camp Lejeune between January 1, 1957, FAMILIES and December 31, 1987, are not subject § 17.400 Hospital care and medical to copayment requirements for hos- services for Camp Lejeune veterans. pital care and medical services provided for a covered illness or condition (a) General. In accordance with this section, VA will provide hospital care on or after August 6, 2012. and medical services to Camp Lejeune (ii) Camp Lejeune veterans who veterans. Camp Lejeune veterans will served at Camp Lejeune between Au- be enrolled pursuant to § 17.36(b)(6). gust 1, 1953, and December 31, 1956, are (b) Definitions. For the purposes of not subject to copayment requirements this section: for hospital care and medical services Camp Lejeune means any area within provided for a covered illness or condi- the borders of the U.S. Marine Corps tion on or after December 16, 2014. Base Camp Lejeune or Marine Corps (2) Retroactive exemption. VA will re- Air Station New River, North Carolina. imburse Camp Lejeune veterans for

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any copayments paid to VA for hos- (A) Is related to a Camp Lejeune vet- pital care and medical services pro- eran by birth; vided for a covered illness or condition (B) Was married to a Camp Lejeune if either of the following is true: veteran; or (i) For Camp Lejeune veterans who (C) Was a legal dependent of a Camp served at Camp Lejeune between Janu- Lejeune veteran. ary 1, 1957, and December 31, 1987, VA Camp Lejeune veteran has the mean- provided the hospital care or medical ing set forth in § 17.400(b). services to the Camp Lejeune veteran Health-plan contract has the meaning on or after August 6, 2012, and the vet- set forth in § 17.1001(a). eran requested Camp Lejeune veteran Third party has the meaning set forth status no later than September 24, 2016; in § 17.1001(b). or (c) Application. An individual may (ii) For Camp Lejeune veterans who apply for benefits under this section by served at Camp Lejeune between Au- completing and submitting an applica- gust 1, 1953, and December 31, 1956, VA tion form. provided the hospital care or medical (d) Payment or reimbursement of certain services to the Camp Lejeune veteran medical care and hospital services. VA on or after December 16, 2014, and the will provide payment or reimburse- veteran requested Camp Lejeune vet- ment for hospital care and medical eran status no later than July 18, 2018. services provided to a Camp Lejeune family member by a non-VA provider if (The Office of Management and Budget has all of the following are true: approved the information collection requirement in this section under control number (1) The Camp Lejeune family member 2900–0091.) or provider of care or services has submitted a timely claim for payment or (Authority: 38 U.S.C. 1710) reimbursement, which means: [81 FR 46605, July 18, 2016] (i) In the case of a Camp Lejeune family member who resided at Camp HOSPITAL CARE AND MEDICAL SERVICES Lejeune between January 1, 1957, and FOR SPOUSES AND FAMILIES December 31, 1987, for hospital care and medical services received prior to the § 17.410 Hospital care and medical date an application for benefits is filed services for Camp Lejeune family per paragraph (c) of this section, the members. hospital care and medical services (a) General. In accordance with this must have been provided on or after section and subject to the availability March 26, 2013, but no more than 2 of funds appropriated for such purpose, years prior to the date that VA re- VA will provide payment or reimburse- ceives the application. The claim for ment for certain hospital care and payment or reimbursement must be re- medical services furnished to Camp ceived by VA no more than 60 days Lejeune family members by non-VA after VA approves the application; health care providers. (ii) In the case of a Camp Lejeune (b) Definitions. For the purposes of family member who resided at Camp this section: Lejeune between August 1, 1953, and Camp Lejeune has the meaning set December 31, 1956, for hospital care and forth in § 17.400(b). medical services received prior to the Camp Lejeune family member means an date an application for benefits is filed individual who: per paragraph (c) of this section, the (i) Resided at Camp Lejeune (or was hospital care and medical services in utero while his or her mother either must have been provided on or after resided at Camp Lejeune or served at December 16, 2014, but no more than 2 Camp Lejeune under § 17.400(b)) for at years prior to the date that VA re- least 30 (consecutive or nonconsecu- ceives the application. The claim for tive) days during the period beginning payment or reimbursement must be re- on August 1, 1953, and ending on De- ceived by VA no more than 60 days cember 31, 1987; and after VA approves the application; (ii) Meets one of the following cri- (iii) For hospital care and medical teria: services provided on or after the date

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an application for benefits is filed per § 17.412 Fertility counseling and treat- paragraph (c) of this section, the claim ment for certain spouses. for payment or reimbursement must be (a)(1) VA may provide fertility coun- received by VA no more than 2 years seling and treatment to a spouse of a after the later of either the date of dis- veteran described in § 17.380 to the ex- charge from a hospital or the date that tent such services are available to a medical services were rendered; veteran under § 17.38, and consistent (2) The Camp Lejeune family mem- with the benefits relating to reproduc- ber’s treating physician certifies that tive assistance provided to a member the claimed hospital care or medical of the Armed Forces who incurs a seri- services were provided for a covered illness or condition as defined in ous injury or illness on active duty § 17.400(b), and provides information pursuant to 10 U.S.C. 1074(c)(4)(A), as about any co-morbidities, risk factors, described in the April 3, 2012, memo- or other exposures that may have con- randum issued by the Assistant Sec- tributed to the illness or condition; retary of Defense for Health Affairs on (3) VA makes the clinical finding, the subject of ‘‘Policy for Assisted Re- under VA clinical practice guidelines, productive Services for the Benefit of that the illness or condition did not re- Seriously or Severely Ill/Injured (Cat- sult from a cause other than the resi- egory II or III) Active Duty Service dence of the family member at Camp Members,’’ and the guidance issued by Lejeune; the Department of Defense to imple- (4) VA would be authorized to provide ment such policy, including any limi- the claimed hospital care or medical tations on the amount of such benefits services to a veteran under VA’s med- available to such a member. ical benefits package in § 17.38; (2) VA may provide in vitro fertiliza- (5) The Camp Lejeune family member tion to a spouse of a veteran described or hospital care or medical service pro- in § 17.380 when clinically appropriate vider has exhausted without success all and consistent with the benefits relat- claims and remedies reasonably avail- ing to reproductive assistance provided able to the family member or provider to a member of the Armed Forces who against a third party, including health- incurs a serious injury or illness on ac- plan contracts; and tive duty pursuant to 10 U.S.C. (6) Funds were appropriated to imple- 1074(c)(4)(A), as described in the April 3, ment 38 U.S.C. 1787 in a sufficient 2012, memorandum issued by the As- amount to permit payment or reim- sistant Secretary of Defense for Health bursement. Affairs on the subject of ‘‘Policy for (e) Payment or reimbursement amounts. Assisted Reproductive Services for the Payments or reimbursements under Benefit of Seriously or Severely Ill/In- this section will be in amounts deter- jured (Category II or III) Active Duty mined in accordance with this para- Service Members,’’ and the guidance graph (e). issued by the Department of Defense to (1) If a third party is partially liable implement such policy, including any for the claimed hospital care or med- limitations on the amount of such ben- ical services, then VA will pay or reim- efits available to such a member. burse the lesser of the amount for (b) The time periods regarding em- which the Camp Lejeune family mem- bryo cryopreservation and storage set ber remains personally liable or the forth in part III(G) and in part IV(H) of amount for which VA would pay for the memorandum referenced in para- such care under §§ 17.55 and 17.56. graph (a) of this section do not apply. (2) If VA is the sole payer for hospital Embryo cryopreservation and storage care and medical services, then VA will may be provided to a spouse of a cov- pay or reimburse in accordance with ered veteran without limitation on the §§ 17.55 and 17.56, as applicable. duration of such cryopreservation and (The information collection require- storage. ments have been submitted to OMB and are pending OMB approval.) [82 FR 6276, Jan. 19, 2017, as amended at 81 FR 11153, Feb. 21, 2017; 84 FR 8257, Mar. 7, [82 FR 21122, May 5, 2017] 2019]

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AUTHORITY OF HEALTH CARE PROVIDERS (i) A CNP has full practice authority TO PRACTICE IN VA to: (A) Take comprehensive histories, § 17.415 Full practice authority for ad- provide physical examinations and vanced practice registered nurses. other health assessment and screening (a) Advanced practice registered nurse activities, diagnose, treat, and manage (APRN). For purposes of this section, patients with acute and chronic ill- an advanced practice registered nurse nesses and diseases; (APRN) is an individual who: (B) Order laboratory and imaging (1) Has completed a nationally-ac- studies and integrate the results into credited, graduate-level educational clinical decision making; program that prepares them for one of (C) Prescribe medication and durable the three APRN roles of Certified medical equipment; Nurse Practitioner (CNP), Clinical (D) Make appropriate referrals for Nurse Specialist (CNS), or Certified patients and families, and request con- Nurse-Midwife (CNM); sultations; (2) Has passed a national certifi- (E) Aid in health promotion, disease cation examination that measures prevention, health education, and knowledge in one of the APRN roles de- counseling as well as the diagnosis and scribed in paragraph (a)(1) of this sec- management of acute and chronic dis- tion; eases. (ii) A CNS has full practice authority (3) Has obtained a license from a to provide diagnosis and treatment of State licensing board in one of three health or illness states, disease man- recognized APRN roles described in agement, health promotion, and pre- paragraph (a)(1) of this section; and vention of illness and risk behaviors (4) Maintains certification and licen- among individuals, families, groups, sure as required by paragraphs (a)(2) and communities within their scope of and (3) of this section. practice. (b) Full practice authority. For pur- (iii) A CNM has full practice author- poses of this section, full practice au- ity to provide a range of primary thority means the authority of an health care services to women, includ- APRN to provide services described in ing gynecologic care, family planning paragraph (d) of this section without services, preconception care (care that the clinical oversight of a physician, women veterans receive before becom- regardless of State or local law restric- ing pregnant, including reducing the tions, when that APRN is working risk of birth defects and other prob- within the scope of their VA employ- lems such as the treatment of diabetes ment. and high blood pressure), prenatal and (c) Granting of full practice authority. postpartum care, childbirth, and care VA may grant full practice authority of a newborn, and treating the partner to an APRN subject to the following: of their female patients for sexually (1) Verification that the APRN meets transmitted disease and reproductive the requirements established in para- health, if the partner is also enrolled in graph (a) of this section; and the VA healthcare system or is not re- (2) Determination that the APRN has quired to enroll. demonstrated the knowledge and skills (2) The full practice authority of an necessary to provide the services de- APRN is subject to the limitations im- scribed in paragraph (d) of this section posed by the Controlled Substances without the clinical oversight of a phy- Act, 21 U.S.C. 801 et seq., and that sician, and is thus qualified to be privi- APRN’s State licensure on the author- leged for such scope of practice. ity to prescribe, or administer con- (d) Services provided by an APRN with trolled substances, as well as any other full practice authority. (1) Subject to the limitations on the provision of VA care limitations established in paragraph set forth in applicable Federal law and (d)(2) of this section, the full practice policy. authority for each of the three APRN (e) Preemption of State and local law. roles includes, but is not limited to, To achieve important Federal inter- providing the following services: ests, including but not limited to the

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ability to provide the same comprehen- or the beneficiary is physically lo- sive care to veterans in all States cated. Health care providers’ practice under 38 U.S.C. 7301, this section pre- is subject to the limitations imposed empts conflicting State and local laws by the Controlled Substances Act, 21 relating to the practice of APRNs when U.S.C. 801, et seq., on the authority to such APRNs are working within the prescribe or administer controlled sub- scope of their VA employment. Any stances, as well as any other limita- State or local law, or regulation pursu- tions on the provision of VA care set ant to such law, is without any force or forth in applicable Federal law and pol- effect on, and State or local govern- icy. This section only grants health ments have no legal authority to en- care providers the ability to practice force them in relation to, activities telehealth within the scope of their VA performed under this section or deci- employment and does not otherwise sions made by VA under this section. grant health care providers additional [81 FR 90206, Dec. 14, 2016] authorities that go beyond what is required or authorized by Federal law § 17.417 Health care providers prac- and regulations or as defined in the ticing via telehealth. laws and practice acts of the health (a) Definitions. The following defini- care providers’ State license, registra- tions apply to this section. tion, or certification. (1) Beneficiary. The term beneficiary (2) Situations where a health care means a veteran or any other indi- provider’s VA practice of telehealth vidual receiving health care under title may be inconsistent with a State law 38 of the United States Code. (2) Health care provider. The term or State license, registration, or cer- health care provider means an indi- tification requirements related to tele- vidual who: health include when: (i) Is licensed, registered, or certified (i) The beneficiary and the health in a State to practice a health care spe- care provider are physically located in cialty identified under 38 U.S.C. 7402(b); different States during the episode of (ii) Is appointed to an occupation in care; the Veterans Health Administration (ii) The beneficiary is receiving serv- that is listed in or authorized under 38 ices in a State other than the health U.S.C. 7401(1) or (3); care provider’s State of licensure, reg- (iii) Maintains credentials (e.g., a li- istration, or certification; cense, registration, or certification) in (iii) The health care provider is deliv- accordance with the requirements of ering services in a State other than the his or her health care specialty as iden- health care provider’s State of licen- tified under 38 U.S.C. 7402(b); and sure, registration, or certification; (iv) Is not a VA-contracted health (iv) The health care provider is deliv- care provider. ering services either on or outside VA (3) State. The term State means a property; State as defined in 38 U.S.C. 101(20), or (v) The beneficiary is receiving serv- a political subdivision of such a State. ices while she or he is located either on (4) Telehealth. The term telehealth or outside VA property; means the use of electronic information or telecommunications tech- (vi) The beneficiary has or has not nologies to support clinical health previously been assessed, in person, by care, patient and professional health- the health care provider; or related education, public health, and (vii) Other State requirements would health administration. prevent or impede the practice of (b) Health care provider’s practice via health care providers delivering tele- telehealth. (1) Health care providers health to VA beneficiaries. may provide telehealth services, within (c) Preemption of State law. To achieve their scope of practice, functional important Federal interests, including, statement, and/or in accordance with but not limited to, the ability to pro- privileges granted to them by VA, irre- vide the same complete health care and spective of the State or location within hospital service to beneficiaries in all a State where the health care provider States under 38 U.S.C. 7301, this section

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preempts conflicting State laws relat- factors as clinical quality, beneficiary- ing to the practice of health care pro- level outcomes, and functional status viders when such health care providers as documented through improvements are practicing telehealth within the in measurement data from a reliable scope of their VA employment. Any and valid source, and as further defined State law, rule, regulation or require- in a pilot program proposal. ment pursuant to such law, is without Quality preservation refers to the any force or effect on, and State gov- maintenance of such factors as clinical ernments have no legal authority to quality, beneficiary-level outcomes, enforce them in relation to, this sec- and functional status as documented tion or decisions made by VA under through maintenance of measurement this section. data from an evidence-based source, and as further defined in a pilot pro- [83 FR 21906, May 11, 2018] gram proposal. CENTER FOR INNOVATION FOR CARE AND Reduction in expenditure refers to, but PAYMENT is not limited to, cost stabilization, cost avoidance, or decreases in long- or § 17.450 Center for Innovation for Care short-term spending, and as further de- and Payment. fined in a pilot program proposal. (a) Purpose and organization. The pur- NOTE: VA will also consider the pro- pose of this section is to establish proposal’s potential impact on expendi- cedures for the Center for Innovation tures for other related Federal pro- for Care and Payment. grams; however, this potential impact (1) The Center for Innovation for will not count against the limitation in Care and Payment will be responsible paragraph (d)(2) of this section. for working across VA to carry out Service delivery models refer to all pilot programs to develop innovative methods or programs for furnishing approaches to testing payment and care or services. service delivery models to reduce ex- (c) Geographic locations. VA will make penditures while preserving or enhanc- decisions regarding the location of ing the quality of care furnished by each pilot program based upon the ap- VA. propriateness of testing a specific (2) The Center for Innovation for model in a specific area while taking Care and Payment will not operate efforts to ensure that pilot programs within any specific administration but are operated in geographically diverse will operate in VA’s corporate portfolio areas of the country. VA will include in to ensure the limited number of con- its proposal to Congress and publish a current pilot programs under this sec- document in the FEDERAL REGISTER tion are not redundant of or conflicted identifying the geographic locations by ongoing innovation efforts within proposed for each pilot program, the any specific administration. rationale for those selections, and how (b) Definitions. The following defini- VA believes the selected locations will tions apply to this section. address deficits in care for a defined Access refers to entry into or use of population. VA services. (d) Limitations. In carrying out pilot Patient satisfaction of care and services programs under this section, VA will refers to patients’ rating of their expe- not: riences of care and services and as fur- (1) Actively operate more than 10 ther defined in a pilot program pro- pilot programs at the same time; and posal. (2) Consistent with 38 U.S.C. 1703E(d), Payment models refer to the types of obligate more than $50 million in any payment, reimbursement, or incentives fiscal year in the conduct of the pilot that VA deems appropriate for advanc- programs (including all administrative ing the health and well-being of bene- and overhead costs, such as measure- ficiaries. ment, evaluation, and expenses to im- Pilot program refers to a pilot pro- plement the pilot programs them- gram conducted under this section. selves) operated under this section, un- Quality enhancement refers to im- less VA determines it to be necessary provement or improvements in such and submits a report to the appropriate

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Committees of Congress that sets forth (1) VA may expand the scope or dura- the amount of, and justification for, tion of a pilot program if, based on an the additional expenditure. analysis of the data developed pursuant (e) Waiver of authorities. In carrying to paragraph (g) of this section for the out pilot programs under this section, pilot program, VA expects the pilot VA may waive statutory provisions by program to reduce spending without re- adding to or removing from statutory ducing the quality of care or improve text in subchapters I, II, and III of the quality of patient care without in- chapter 17, title 38, U.S.C., upon Con- creasing spending. Expansion may only gressional approval, including waiving occur if VA determines that expansion any provisions of law in any provision would not deny or limit the coverage codified in or included as a note to any or provision of benefits for individuals section in subchapter I, II, or III of under 38 U.S.C. chapter 17. Expansion chapter 17, title 38. of a pilot program may not occur until (1) Upon Congressional approval of 60 days after VA has published a docu- the waiver of a provision of law under ment in the FEDERAL REGISTER and this section, VA will also deem waived submitted an interim report to Con- any applicable provision of regulation gress stating its intent to expand a implementing such law as identified in pilot program. VA’s pilot program proposal. (2) VA may expand the scope of a (2) VA will publish a document in the pilot program by modifying, among FEDERAL REGISTER providing informa- other elements of a pilot program, the tion about, and seeking comment on, range of services provided, the quali- each proposed pilot program upon its fying conditions covered, the geo- submission of a proposal to Congress graphic location of the pilot program, for approval. VA will publish a docu- or the population of eligible partici- ment in the FEDERAL REGISTER to in- pants in a manner that increases par- form the public of any pilot programs ticipation in or benefits under a pilot that have been approved by Congress. program. (f) Notice of eligibility. VA will take (3) In general, pilot programs are lim- reasonable actions to provide direct no- ited to 5 years of operation. VA may tice to veterans eligible to participate extend the duration of a pilot program in a pilot program operated under this by up to an additional 5 years of oper- section and will provide general notice ation. Any pilot program extended be- to other individuals eligible to partici- yond its initial 5-year period must con- pate in a pilot program. VA will an- tinue to comply with the provisions of nounce its methods of providing notice this section regarding evaluation and to veterans, the public, and other indi- reporting under paragraph (g) of this viduals eligible to participate through section. the document it publishes in the FED- (i) Modification of pilot programs. The ERAL REGISTER for each proposed and Secretary may modify elements of a approved pilot program. pilot program in a manner that is con- (g) Evaluation and reporting. VA will sistent with the parameters of the Con- evaluate each pilot program operated gressional approval of the waiver de- under this section and report its find- scribed in paragraph (e) of this section. ings. Evaluations may be based on Such modification does not require a quantitative data, qualitative data, or submission to Congress for approval both. Whenever appropriate, evalua- under paragraph (e) of this section. tions will include a survey of partici- (j) Termination of pilot programs. If VA pants or beneficiaries to determine determines that a pilot program is not their satisfaction with the pilot pro- producing quality enhancement or gram. VA will make the evaluation re- quality preservation, or is not result- sults available to the public on the VA ing in the reduction of expenditures, Innovation Center website on the and that it is not possible or advisable schedule identified in VA’s proposal for to modify the pilot program either the pilot program. through submission of a new waiver re- (h) Expansion of pilot programs. VA quest under paragraph (e) of this sec- may expand a pilot program consistent tion or through modification under with this paragraph (h). paragraph (i) of this section, VA will

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terminate the pilot program within 30 (e) The regulations in §§ 17.500 days of submitting an interim report to through 17.511 do not waive the sov- Congress that states such determina- ereign immunity of the United States, tion. VA will also publish a document and do not waive the confidentiality in the FEDERAL REGISTER regarding the provisions and disclosure restrictions pilot program’s termination. of 38 U.S.C. 5705. [84 FR 57329, Oct. 25, 2019] (Authority: 38 U.S.C. 5705)

CONFIDENTIALITY OF HEALTHCARE § 17.501 Confidential and privileged QUALITY ASSURANCE REVIEW RECORDS documents. (a) Documents and parts of docu- AUTHORITY: 38 U.S.C. 5705. ments are considered confidential and SOURCE: 59 FR 53355, Oct. 24, 1994, unless privileged if they were produced by or otherwise noted. for the VA in the process of conducting systematic healthcare reviews for the § 17.500 General. purpose of improving the quality of (a) Section 5705, title 38, United health care or improving the utiliza- States Code was enacted to protect the tion of healthcare resources in VA integrity of the VA’s medical quality healthcare facilities and meet the cri- assurance program by making con- teria in paragraphs (b) and (c) of this fidential and privileged certain records section. The four classes of healthcare and documents generated by this pro- quality assurance reviews with exam- gram and information contained there- ples are: in. Disclosure of quality assurance (1) Monitoring and evaluation re- records and documents made confiden- views conducted by a facility: tial and privileged by 38 U.S.C. 5705 and (i) Medical records reviews, the regulations in §§ 17.500 through (ii) Drug usage evaluations, 17.511 may only be made in accordance (iii) Blood usage reviews, with the provisions of 38 U.S.C. 5705 (iv) Surgical case/invasive procedure and those regulations. reviews, (b) The purpose of the regulations in (v) Service and program monitoring §§ 17.500 through 17.511 is to specify and including monitoring performed by in- provide for the limited disclosure of dividual services or programs, several those quality assurance documents services or programs working together, which are confidential under the provi- or individuals from several services or sions of 38 U.S.C. 5705. programs working together as a team, (c) For purposes of the regulations in (vi) Mortality and morbidity reviews, §§ 17.500 through 17.511, the VA’s med- (vii) Infection control review and sur- ical quality assurance program con- veillance, sists of systematic healthcare reviews (viii) Occurrence screening, carried out by or for VA for the pur- (ix) Tort claims peer reviews (except pose of improving the quality of med- reviews performed to satisfy the re- ical care or improving the utilization quirements of a governmental body or of healthcare resources in VA medical a professional health care organization facilities. These review activities may which is licensing practitioners or involve continuous or periodic data monitoring their professional perform- collection and may relate to either the ance), structure, process, or outcome of (x) Admission and continued stay re- health care provided in the VA. views, (d) Nothing in the regulations in (xi) Diagnostic studies utilization re- §§ 17.500 through 17.511 shall be con- views, strued as authority to withhold any (xii) Reports of special incidents (VA record or document from a committee Form 10-2633 or similar forms) and fol- or subcommittee of either House of low-up documents unless developed Congress or any joint committee or during or as a result of a Board of In- subcommittee of Congress, if such vestigation; record or document pertains to any (2) Focused reviews which address matter within the jurisdiction of such specific issues or incidents and which committee or joint committee. are designated by the reviewing office

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at the outset of the review as protected produced by healthcare evaluators in by 38 U.S.C. 5705 and the regulations in deliberating on the findings of §§ 17.500 through 17.511; focused reviews healthcare reviews, or prepared for pur- may be either: poses of discussion or consideration by (i) Facility focused reviews; healthcare evaluators during a quality (ii) VA Central Office or Regional fo- assurance review; or cused reviews; (4) Are memoranda, letters, or other (3) VA Central Office or Regional documents from the medical facility to general oversight reviews to assess fa- the Regional Director or VA Central cility compliance with VA program re- Office which contain information gen- quirements if the reviews are des- erated by a quality assurance activity ignated by the reviewing office at the meeting the criteria in § 17.501 (a) and outset of the review as protected by 38 (b); or U.S.C. 5705 and the regulations in (5) Are memoranda, letters, or other §§ 17.500 through 17.511; and documents produced by the Regional (4) Contracted external reviews of Director or VA Central Office which ei- care, specifically designated in the con- ther respond to or contain information tract or agreement as reviews pro- generated by a quality assurance activ- tected by 38 U.S.C. 5705 and the regula- ity meeting the criteria in § 17.501 (a) tions in §§ 17.500 through 17.511. and (b). (b) The Under Secretary for Health, (d) Documents which meet the cri- Regional Director or facility Director teria in this section are confidential will describe in advance in writing and privileged whether they are pro- those quality assurance activities in- duced at the medical facility, Regional cluded under the classes of healthcare or VA Central Office levels, or by ex- quality assurance reviews listed in ternal contractors performing paragraph (a) of this section. Only doc- healthcare quality assurance reviews. uments and parts of documents resulting from those activities which have (e) Documents which are confidential been so described are protected by 38 and privileged may be in written, com- U.S.C. 5705 and the regulations in puter, electronic, photographic or any §§ 17.500 through 17.511. If an activity is other form. not described in a VA Central Office or (f) Documents which contain con- Regional policy document, this re- fidential and privileged material in one quirement may be satisfied at the fa- part, but not in others, such as Clinical cility level by description in advance of Executive Board minutes, should be the activity and its designation as pro- filed and maintained as if the entire tected in the facility quality assurance document was protected by 38 U.S.C. plan or other policy document. 5705. This is not required if the con- (c) Documents and parts of docu- fidential and privileged material is de- ments generated by activities which leted. meet the criteria in paragraphs (a) and (g) The following records and docu- (b) of this section shall be confidential ments and parts of records and docu- and privileged only if they: ments are not confidential even if they (1) Identify, either implicitly or ex- meet the criteria in paragraphs (a) plicitly, individual practitioners, pa- through (c) of this section: tients, or reviewers except as provided (1) Statistical information regarding in paragraph (g)(6) of this section; or VA healthcare programs or activities (2) Contain discussions relating to that does not implicitly or explicitly the quality of VA medical care or utili- identify individual VA patients or VA zation of VA medical resources by employees or individuals involved in healthcare evaluators during the the quality assurance process; course of a review of quality assurance (2) Summary documents or records information or data, even if they do which only identify study topics, the not identify practitioners, patients, or period of time covered by the study, reviewers; or criteria, norms, and/or major overall (3) Are individual committee, service, findings, but which do not identify in- or study team minutes, notes, reports, dividual healthcare practitioners, even memoranda, or other documents either by implication;

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(3) The contents of Credentialing and (13) Documents and reports developed Privileging folders as described in during or as a result of safety moni- VACO policy documents (38 U.S.C. 5705- toring not directly related to the care protected records shall not be filed in of specified individual patients; Credentialing and Privileging folders); (14) Documents and reports developed (4) Records and documents developed during or as a result of resource man- during or as a result of Boards of Inves- agement activities not directly related tigations; to the care of specified individual pa- (5) Completed patient satisfaction tients; and survey questionnaires and findings (15) Information and records derived from patient satisfaction surveys; from patient medical records or facil- (6) Records and documents which ity administrative records, which are only indicate the number of patients not protected by 38 U.S.C. 5705 and the treated by a practitioner, either by di- regulations in §§ 17.500 through 17.511, agnosis or in aggregate, or number of may be sent or communicated to a procedures performed by a practi- third party payor who has asked for tioner, either by procedure or in aggre- this information in response to a VA gate; request for reimbursement based on (7) Records and documents developed Public Law 99–272 and Public Law 101– during or as a result of reviews per- 508. Reviews conducted at the request formed to satisfy the requirements of a of the third party payor do not gen- governmental body or a professional erate records protected by 38 U.S.C. healthcare organization which is li- 5705 and the regulations in §§ 17.500 censing practitioners or monitoring through 17.511 since the reviews are not their professional performance, e.g., undertaken as part of the VA’s quality National Practitioner Data Bank, Fed- assurance program. eration of State Medical Boards, and National Council of State Boards of (Authority: 38 U.S.C. 5705) Nursing; (8) Documents and reports developed § 17.502 Applicability of other statutes. during or as a result of site visits by (a) Disclosure of quality assurance the Office of the Medical Inspector ex- records and documents which are not cept to the extent that the documents confidential and privileged under 38 and reports contain information that U.S.C. 5705 and the confidentiality reg- meets the criteria described in this sec- ulations in §§ 17.500 through 17.511 will tion and are produced by or for VA by be governed by the provisions of the other than the Office of Medical In- Freedom of Information Act, and, if ap- spector; plicable, the Privacy Act and any other (9) External reviews conducted by VA VA or federal confidentiality statutes. Central Office or a Region other than (b) When included in a quality assur- those designated by the reviewing of- ance review, confidential records pro- fice under paragraph (a)(2) or (a)(3) of tected by other confidentiality stat- this section as protected by 38 U.S.C. utes such as 5 U.S.C. 552a (the Privacy 5705 and the regulations in §§ 17.500 Act), 38 U.S.C. 7332 (drug and alcohol through 17.511; abuse, sickle cell anemia, HIV infec- (10) Documents and reports of Profes- tion), and 38 U.S.C. 5701 (veterans’ sional Standards Boards, Credentialing names and addresses) retain whatever Committees, Executive Committees of confidentiality protection they have Medical Staff, and similar bodies, inso- under these laws and applicable regula- far as the documents relate to the tions and will be handled accordingly. credentialing and privileging of practi- To the extent that information pro- tioners; tected by 38 U.S.C. 5701 or 7332 or the (11) Documents and reports developed Privacy Act is incorporated into qual- during or as a result of data validation ity assurance records, the information activities; in the quality assurance records is still (12) Documents and reports developed protected by these statutes. during or as a result of occupational health monitoring; (Authority: 38 U.S.C. 5705)

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§ 17.503 Improper disclosure. ized to disclose any confidential and (a) Improper disclosure is the disclo- privileged quality assurance records or sure of confidential and privileged documents under their control to other healthcare quality assurance review agencies, organizations, or individuals records or documents (or information where 38 U.S.C. 5705 or the regulations contained therein), as defined in in §§ 17.500 through 17.511 expressly pro- § 17.501, to any person who is not au- vide for disclosure. thorized access to the records or docu- (Authority: 38 U.S.C. 5705) ments under the statute and the regulations in §§ 17.500 through 17.511. § 17.506 Appeal of decision by Vet- (b) ‘‘Disclosure’’ means the commu- erans Health Administration to nication, transmission, or conveyance deny disclosure. in any way of any confidential and When a request for records or docu- privileged quality assurance records or ments subject to the regulations in documents or information contained in §§ 17.500 through 17.511 is denied in them to any individual or organization whole or in part by the VA medical fa- in any form by any means. cility Director, Regional Director or (Authority: 38 U.S.C. 5705) Under Secretary for Health, the VA official denying the request in whole or § 17.504 Disclosure methods. in part will notify the requestor in writing of the right to appeal this deci- (a) Disclosure of confidential and sion to the General Counsel of the De- privileged quality assurance records and documents or the information con- partment of Veterans Affairs within 60 tained therein outside VA, where per- days of the date of the denial letter. mitted by the statute and the regula- The final Department decision will be tions in §§ 17.500 through 17.511, will al- made by the General Counsel or the ways be by copies, abstracts, sum- Deputy General Counsel. maries, or similar records or docu- (Authority: 38 U.S.C. 5705) ments prepared by the Department of Veterans Affairs and released to the re- § 17.507 Employee responsibilities. questor. The original confidential and (a) All VA employees and other indi- privileged quality assurance records viduals who have access to records des- and documents will not be removed ignated as confidential and privileged from the VA facility by any person, VA under 38 U.S.C. 5705 and the regulations employee or otherwise, except in ac- in §§ 17.500 through 17.511 will treat the cordance with § 17.508(c) or where oth- findings, views, and actions relating to erwise legally required. quality assurance in a confidential (b) Disclosure of confidential and manner. privileged quality assurance records (b) All individuals who have had ac- and documents to authorized individ- cess to records designated as confiden- uals under either § 17.508 or § 17.509 shall tial and privileged under 38 U.S.C. 5705 bear the following statement: ‘‘These and the regulations in §§ 17.500 through documents or records (or information 17.511 will not disclose such records or contained herein) are confidential and information therein to any person or privileged under the provisions of 38 organization after voluntary or invol- U.S.C. 5705, which provide for fines up untary termination of their relation- to $20,000 for unauthorized disclosures ship to the VA. thereof, and the implementing regulations. This material shall not be dis- (Authority: 38 U.S.C. 5705) closed to anyone without authorization § 17.508 Access to quality assurance as provided for by that law or the regu- records and documents within the lations in §§ 17.500 through 17.511.’’ agency. (Authority: 38 U.S.C. 5705) (a) Access to confidential and privileged quality assurance records and § 17.505 Disclosure authorities. documents within the Department pur- The VA medical facility Director, suant to this section is restricted to Regional Director, Under Secretary for VA employees (including consultants Health, or their designees are author- and contractors of VA) who have a

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need for such information to perform priate VHA official, e.g., Service Chief, their government duties or contractual Medical Center Director. responsibilities and who are authorized (g) In general, confidential and privi- access by the VA medical facility Di- leged quality assurance records and rector, Regional Director, the Under documents will be maintained for a Secretary for Health, or their designees minimum of 3 years and may be held or by the regulations in §§ 17.500 longer if needed for research studies or through 17.511. quality assurance or legal purposes. (b) To foster continuous quality im- (Authority: 38 U.S.C. 5705) provement, practitioners on VA rolls, whether paid or not, will have access to § 17.509 Authorized disclosure: Non- confidential and privileged quality as- Department of Veterans Affairs re- surance records and documents relat- quests. ing to evaluation of the care they pro- (a) Requests for confidential and vided. privileged quality assurance records (c) Any quality assurance record or and documents from organizations or document, whether confidential and individuals outside VA must be made privileged or not, may be provided to to the Department and must specify the General Counsel or any attorney the nature and content of the informa- within the Office of General Counsel, tion requested, to whom the informa- wherever located. These documents tion should be transmitted or dis- may also be provided to a Department closed, and the purpose listed in para- of Justice (DOJ) attorney who is inves- graphs (b) through (j) of this section tigating a claim or potential claim for which the information requested against the VA or who is preparing for will be used. In addition, the requestor litigation involving the VA. If nec- will specify to the extent possible the essary, such a record or document may beginning and final dates of the period be removed from the VA medical facil- for which disclosure or access is re- ity to the site where the General Coun- quested. The request must be in writ- sel or any attorney within the Office of ing and signed by the requestor. Except as specified in paragraphs (b) and (c) of General Counsel or the DOJ attorney is this section, these requests should be conducting an investigation or pre- forwarded to the Director of the facil- paring for litigation. ity in possession of the records or docu- (d) Any quality assurance record or ments for response. The procedures document or the information contained outlined in 38 U.S.C. 5701, 5 U.S.C. 552 therein, whether confidential and privi- and 552a, and 38 CFR 1.500 through 1.582 leged or not, will be provided to the De- will be followed where applicable. partment of Veterans Affairs Office of (b) Disclosure shall be made to Fed- Inspector General upon request. A eral agencies upon their written re- written request is not required. quest to permit VA’s participation in (e) To the extent practicable, docu- healthcare programs including ments accessed under paragraph (b) of healthcare delivery, research, plan- this section will not include the iden- ning, and related activities with the re- tity of peer reviewers. Reasonable ef- questing agencies. Any Federal agency forts will be made to edit documents so may apply to the Under Secretary for as to protect the identities of review- Health for approval. If the VA decides ers, but the inability to completely do to participate in the healthcare pro- so will not bar access under paragraph gram with the requestor, the request- (b). ing agency will enter into an agree- (f) No individual shall be permitted ment with VA to ensure that the agen- access to confidential and privileged cy and its staff will ensure the con- quality assurance records and docu- fidentiality of any quality assurance ments identified in § 17.501 unless such records or documents shared with the individual has been informed of the agency. penalties for unauthorized disclosure. (c) Qualified persons or organiza- Any misuse of confidential and privi- tions, including academic institutions, leged quality assurance records or doc- engaged in healthcare program activi- uments shall be reported to the appro- ties shall, upon request to and approval

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by the Under Secretary for Health, Re- (5) Participation by VA will enhance gional Director, medical facility Direc- related VA healthcare program activi- tor, or their designees, have access to ties; and confidential and privileged medical (6) Access to the record by the re- quality assurance records and docu- quester is required for VA to partici- ments to permit VA participation in a pate in a healthcare program with the healthcare activity with the requestor, requester. provided that no records or documents (g) Protected quality assurance are removed from the VA facility in records or documents, including possession of the records. records pertaining to a specific indi- (d) When a request under paragraphs vidual, will for purposes authorized (b) or (c) of this section concerns access under law be disclosed to a civil or for research purposes, the request, to- criminal law enforcement govern- gether with the research plan or pro- mental agency or instrumentality tocol, shall first be submitted to and charged under applicable law with the approved by an appropriate VA medical protection of public health or safety, facility Research and Development including state licensing and discipli- Committee and then approved by the nary agencies, if a written request for Director of the VA medical facility. such records or documents is received The VA medical facility staff together from an official of such an organiza- with the qualified person(s) conducting tion. The request must state the pur- the research shall be responsible for pose authorized by law for which the the preservation of the anonymity of records will be used. The Under Sec- the patients, clients, and providers and retary for Health, Regional Director, shall not disseminate any records or medical facility Director, or their des- documents which identify such individ- ignees will determine the extent to uals directly or indirectly without the which the information is disclosable. individual’s consent. This applies to (h) Federal agencies charged with the handling of data or information as protecting the public health and wel- well as reporting or publication of find- fare, federal and private agencies ings. These requirements are in addi- which engage in various monitoring tion to other applicable protections for and quality control activities, agencies the research. responsible for licensure of individual health care facilities or programs, and (e) Individually identified patient similar organizations will be provided medical record information which is confidential and privileged quality as- protected by another statute as pro- surance records and documents if a vided in § 17.502 may not be disclosed to written request for such records or doc- a non-VA person or organization, in- uments is received from an official of cluding disclosures for research pur- such an organization. The request must poses under paragraph (d), except as state the purpose for which the records provided in that statute. will be used. The Under Secretary for (f) Under paragraph (b), the Under Health, Regional Director, medical fa- Secretary for Health or designee or cility Director, or their designees will under paragraph (c), the Under Sec- determine the extent to which the in- retary for Health, Regional Director, formation is disclosable. medical facility Director, or their des- (i) JCAHO (Joint Commission on Ac- ignees may approve a written request if creditation of Healthcare Organiza- it meets the following criteria: tions) survey teams and similar na- (1) Participation by VA will benefit tional accreditation agencies or boards VA patient care; or and other organizations requested by (2) Participation by VA will enhance VA to assess the effectiveness of qual- VA medical research; or ity assurance program activities or to (3) Participation by VA will enhance consult regarding these programs are VA health services research; or entitled to disclosure of confidential (4) Participation by VA will enhance and privileged quality assurance docu- VA healthcare planning or program de- ments with the following qualifica- velopment activities; or tions:

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(1) Accreditation agencies which are been disclosed under § 17.508 or § 17.509 charged with assessing all aspects of shall make further disclosure of such medical facility patient care, e.g., record or document except as provided JCAHO, may have access to all con- for in 38 U.S.C. 5705 and the regulations fidential and privileged quality assur- in §§ 17.500 through 17.511. ance records and documents. (Authority: 38 U.S.C. 5705) (2) Accreditation agencies charged with more narrowly focused review § 17.511 Penalties for violations. (e.g., College of American Pathologists, American Association of Blood Banks, Any person who knows that a docu- Nuclear Regulatory Commission, etc.) ment or record is a confidential and may have access only to such confiden- privileged quality assurance document tial and privileged records and docu- or record described in §§ 17.500 through ments as are relevant to their respec- 17.511 and willfully discloses such con- tive focus. fidential and privileged quality assur- (j) Confidential and privileged qual- ance record or document or informa- ity assurance records and documents tion contained therein, except as au- shall be released to the General Ac- thorized by 38 U.S.C. 5705 or the regula- counting Office if such records or docu- tions in §§ 17.500 through 17.511, shall be ments pertain to any matter within its fined not more than $5,000 in the case jurisdiction. of a first offense and not more than (k) Confidential and privileged qual- $20,000 in the case of each subsequent ity assurance records and documents offense. shall be released to both VA and non- (Authority: 38 U.S.C. 5705) VA healthcare personnel upon request to the extent necessary to meet a med- VA HEALTH PROFESSIONAL SCHOLARSHIP ical emergency affecting the health or PROGRAM safety of any individual. (l) For any disclosure made under AUTHORITY: 38 U.S.C. 7601–7619, 7633, 7634, paragraphs (a) through (i) of this sec- and 7636. tion, the name of and other identifying information regarding any individual § 17.600 Purpose. VA patient, employee, or other indi- The purpose of §§ 17.600 through 17.612 vidual associated with VA shall be de- is to establish the requirements for the leted from any confidential and privi- award of scholarships under the VA leged quality assurance record or docu- Health Professional Scholarship Pro- ment before any disclosure under these gram (HPSP) to students pursuing a quality assurance regulations in course of study leading to a degree in §§ 17.500 through 17.511 is made, if dis- certain health care occupations, listed closure of such name and identifying in 38 U.S.C. 7401(1) and (3), to assist in information would constitute a clearly providing an adequate supply of such unwarranted invasion of personal pri- personnel for VA. The HPSP allows VA vacy. to provide scholarship awards to facili- (m) Disclosure of the confidential tate recruitment and retention of em- and privileged quality assurance ployees in several hard-to-fill health records and documents identified in care occupations. § 17.501 will not be made to any indi- (Authority: 38 U.S.C. 7601(b)) vidual or agency until that individual or agency has been informed of the [78 FR 51069, Aug. 20, 2013] penalties for unauthorized disclosure § 17.601 Definitions. or redisclosure. The following definitions apply to (Authority: 38 U.S.C. 5705) §§ 17.600 through 17.636: [59 FR 53355, Oct. 24, 1994, as amended at 79 Acceptable level of academic standing FR 54616, Sept. 12, 2014] means the level at which a participant may continue to attend school under § 17.510 Redisclosure. the standards and practices of the No person or entity to whom a qual- school at which a participant is en- ity assurance record or document has rolled in a course of study for which an

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HPSP or VIOMPSP scholarship was torate that meets the core curriculum awarded. and supervised practice requirements Acceptance agreement means a signed in visual impairment and blindness. legal document between VA and a par- Full-time student means an individual ticipant of the HPSP or VIOMPSP that who meets the requirements for full specifies the obligations of VA and the time attendance as defined by the participant upon acceptance to the school in which they are enrolled. HPSP or VIOMPSP. An acceptance HPSP means the VA Health Profes- agreement must incorporate by ref- sional Scholarship Program authorized erence, and cannot be inconsistent by 38 U.S.C. 7601 through 7619. with, §§ 17.600 through 17.612 (for HPSP Mobility agreement means a signed agreements) or §§ 17.626 through 17.636 legal document between VA and a par- (for VIOMPSP agreements), and must ticipant of the HPSP or VIOMPSP, in include: which the participant agrees to accept (1) A mobility agreement. assignment at a VA facility selected by (2) Agreement to accept payment of VA where he or she will fulfill the obli- the scholarship. gated service requirement. A mobility (3) Agreement to perform obligated agreement must be included in the par- service. ticipant’s acceptance agreement. Relo- (4) Agreement to maintain enroll- cation to another geographic location ment and attendance in the course of may be required. study for which the scholarship was Obligated service means the period of awarded, and to maintain an accept- time during which the HPSP or able level of academic standing. VIOMPSP participant must be em- Affiliation agreement means a legal ployed by VA in a full-time clinical oc- document that enables the clinical cupation for which the degree prepared education of trainees at a VA or non- the participant as a requirement of the VA medical facility. An affiliation acceptance agreement. agreement is required for all education Part-time student—(1) HPSP. For the or training that involves direct patient purposes of the HPSP, part-time stu- contact, or contact with patient infor- dent means an individual who is a VA mation, by trainees from a non-VA in- employee, and who has been accepted stitution. for enrollment or enrolled for study Citizen of the United States means any leading to a degree on a less than full- person born, or lawfully naturalized, in time basis but no less than half-time the United States, subject to its juris- basis. diction and protection, and owing alle- (2) VIOMPSP. For the purposes of the giance thereto. VIOMPSP, part-time student means an Credential means the licensure, reg- individual who has been accepted for istration, certification, required edu- enrollment or enrolled for study lead- cation, relevant training and experi- ing to a degree on a less than full-time ence, and current competence nec- basis but no less than half-time basis. essary to meet VA’s qualification Participant or scholarship program par- standards for employment in certain ticipant means an individual whose ap- health care occupations. plication to the HPSP or VIOMPSP has Degree represents the successful com- been approved, whose acceptance pletion of the course of study for which agreement has been consummated by a scholarship was awarded. VA, and who has yet to complete the (1) HPSP. For the purposes of the period of obligated service or otherwise HPSP, VA recognizes the following de- satisfy the obligation or financial li- grees: a doctor of medicine; doctor of abilities of such agreement. osteopathy; doctor of dentistry; doctor Required fees means those fees which of optometry; doctor of podiatry; or an are charged by the school to all stu- associate, baccalaureate, master’s, or dents pursuing a similar curriculum in doctorate degree in another health care the same school. discipline needed by VA. Scholarship Program means the VA (2) VIOMPSP. For the purposes of the Health Professional Scholarship Pro- VIOMPSP, VA recognizes a bachelor’s, gram (HPSP) authorized by 38 U.S.C. master’s, education specialist or doc- 7601 through 7619.

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School means an academic institution § 17.602 Eligibility. that is accredited by a body or bodies (a) To be eligible for a scholarship recognized for accreditation by the under this program an applicant U.S. Department of Education or by must— the Council for Higher Education Ac- (1) Be unconditionally accepted for creditation (CHEA), and that meets the enrollment or be enrolled as a full-time following requirements: student in an accredited school located (1) For the purposes of the HPSP, of- in a State; fers a course of study leading to a degree in a health care service discipline (2) Be pursuing a degree annually needed by VA. designated by the Secretary for participation in the Scholarship Program; (2) For the purposes of the VIOMPSP, offers a course of study leading to a de- (Authority: 38 U.S.C. 7602(a)(1), 7612(b)(1)) gree in visual impairment or orientation and mobility. (3) Be in a discipline or program an- School year means for purposes of the nually designated by the Secretary for HPSP and its stipend payment, and the participation in the Scholarship Pro- VIOMPSP, all or part of the 12-month gram; period that starts on the date the par- (4) Be a citizen of the United States; ticipant begins school as a full-time and student. (5) Submit an application to partici- Secretary means the Secretary of Vet- pate in the Scholarship Program to- erans Affairs or designee. gether with a signed contract. State means one of the several States, (6) Clinical tours. An applicant for a Territories and possessions of the scholarship under the HPSP must United States, the District of Columbia agree to perform clinical tours while and the Commonwealth of Puerto Rico. enrolled in the course of education or Under Secretary for Health means the training for which the scholarship is Under Secretary for Health of the De- provided. VA will determine the assign- partment of Veterans Affairs or des- ments and locations of the clinical ignee. tour. VA means the Department of Vet- erans Affairs. (Authority: 38 U.S.C. 7618(b)) VA employee means an individual per- (b) To be eligible for a scholarship as manently employed by VA. A VA em- a part-time student under this pro- ployee does not include an individual gram, an applicant must satisfy re- who is employed temporarily or on a quirements of paragraph (a) of this sec- contractual basis. tion and in addition must— VA health care facility means a VA (1) Be a full-time VA employee per- medical center, independent outpatient manently assigned to a VA health care clinic, domiciliary, nursing home (com- facility at the time of application and munity living center), residential on the date when the scholarship is treatment program, and any of a vari- awarded; ety of community based clinics (includ- (2) Remain a VA employee for the du- ing community based outpatient clin- ration of the scholarship award. ics, rural health resource centers, primary care telehealth clinics, and Vet (Authority: 38 U.S.C. 7612(c)(3)(B)) Centers), consolidated mail outpatient pharmacies, and research centers. (c) Any applicant who, at the time of VIOMPSP means the Visual Impair- application, owes a service obligation ment and Orientation and Mobility to any other entity to perform service Professional Scholarship Program au- after completion of the course of study thorized by 38 U.S.C. 7501 through 7505. is ineligible to receive a scholarship (Authority: 38 U.S.C. 301, 7501(a)(1), 7504, 7602(a), 7604(1)(B), 7633) [78 FR 51069, Aug. 20, 2013]

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under the Department of Veterans Af- tion, including a signed written accept- fairs Scholarship Program. ance agreement. (Authority: 38 U.S.C. 7602(b)) (Authority: 38 U.S.C. 7612(c)(1)(B)) (Approved by the Office of Management and (The Office of Management and Budget has Budget under control number 2900–0352) approved the information collection require- [47 FR 10810, Mar. 12, 1982, as amended at 48 ments in this section under control number FR 37399, Aug. 18, 1983; 54 FR 28674, July 7, 2900–0793.) 1989; 78 FR 51070, Aug. 20, 2013] [78 FR 51070, Aug. 20, 2013]

§ 17.603 Availability of HPSP scholar- § 17.605 Selection of participants. ships. (a) General. In deciding which HPSP (a) General. A HPSP scholarship will application to approve, VA will first be awarded only when necessary to as- consider applications submitted by ap- sist VA in alleviating shortages or an- plicants entering their final year of ticipated shortages of personnel in the education or training and applicants health professions stated in paragraph who previously received HPSP scholar- (b) of this section. VA will determine ships and who meet the conditions of the existence of shortage of personnel paragraph (f) of this section. Except for in accordance with specific criteria for paragraph (f) of this section, applicants each health care profession. VA has the authority to establish the number of will be evaluated and selected using scholarships to be awarded in a fiscal the criteria specified in paragraph (b) year, and the number that will be of this section. If there are a larger awarded to full-time and part-time stu- number of equally qualified applicants dents. than there are awards to be made, then (b) Qualifying fields of education—(1) VA will first select veterans, and then Physicians and dentists—(i) VA will use a random method as the basis for award not less than 50 HPSP scholar- further selection. In selecting partici- ships each year to individuals who are pants to receive awards as part-time accepted for enrollment or are enrolled students, VA may, at VA’s discretion— in a program of education or training leading to employment as a physician (Authority: 38 U.S.C. 7612(b)(5)) or dentist until such date as VA deter- (1) Award scholarships geographi- mines that the staffing shortage of cally to part-time students so that physicians and dentists in VA is less available scholarships may be distrib- than 500. uted on a relatively equal basis to stu- (ii) Once the staffing shortage of phy- dents working throughout the VA sicians and dentists is less than 500, VA health care system, and/or will award HPSP scholarships to indi- (2) Award scholarships on the basis of viduals in an amount equal to not less retention needs within the VA health than ten percent of the staffing short- care system. age of physicians and dentists in VA. (2) Other health care professions. VA (Authority: 38 U.S.C. 7603(d)) will grant HPSP scholarships in a (b) Selection. In evaluating and select- course of study in those disciplines or ing participants, the Secretary will programs other than physician or den- take into consideration those factors tist where recruitment is necessary for determined necessary to assure effec- the improvement of health care of vet- tive participation in the Scholarship erans as listed in 38 U.S.C. 7401(1) and Program. The factors may include, but (3). not be limited to— (Authority: 38 U.S.C. 7401(1), (3), 7612(b)(2), (1) Work/volunteer experience, in- 7612(b)(4), and 7603(b)(1)) cluding prior health care employment [78 FR 51070, Aug. 20, 2013, as amended at 85 and Department of Veterans Affairs FR 13053, Mar. 6, 2020] employment; (2) Faculty and employer rec- § 17.604 Application for the HPSP. ommendations; An applicant for the HPSP must sub- (3) Academic performance; and mit an accurate and complete applica-

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(4) Career goals. § 17.606 Award procedures. (a) Amount of scholarship. (1) A schol- (Authority: 38 U.S.C. 7633) arship award will consist of (i) tuition (c) Selection of part-time students. Fac- and required fees, (ii) other educational tors in addition to those specified in expenses, including books and labora- paragraph (b) of this section, which tory equipment, and (iii) except as pro- may be considered in awarding scholar- vided in paragraph (a)(2) of this sec- ships to part-time students may in- tion, a monthly stipend, for the dura- clude, but are not limited to: tion of the scholarship award. All such (1) Length of service of a VA em- payments to scholarship participants ployee in a health care facility; are exempt from Federal taxation. (2) Honors and awards received from (Authority: 38 U.S.C. 7636) VA, and other sources; (3) VA work performance evaluation; (2) No stipend may be paid to a par- (4) A recommendation for selection ticipant who is a full-time VA em- for a part-time scholarship from a VA ployee. Medical District. (3) The Secretary may determine the amount of the stipend paid to partici- (Authority: 38 U.S.C. 7452(d)(1)) pants, whether part-time students or full-time students, but that amount (d) Notification of approval. VA will may not exceed the maximum amount notify the individual in writing that provided for in 38 U.S.C. 7613(b). his or her application has been accept- (4) In the case of a part-time student ed and approved. An individual be- who is a part-time employee, the max- comes a participant in the program imum stipend, if more than a nominal upon receipt of such approval by VA. stipend is paid, will be reduced in accordance with the proportion that the (e) Duration of scholarship award. Sub- number of credit hours carried by such ject to the availability of funds for the participant bears to the number of Scholarship Program, the Secretary credit hours required to be carried by a will award a participant a full-time full-time student in the course of train- scholarship under these regulations for ing being pursued by the participant. a period of from 1 to 4 school years and (5) A full stipend may be paid only a participant of a part-time scholarship for the months the part-time student is for a period of 1 to 6 school years. attending classes.

(Authority: 38 U.S.C. 7612(c)(1)(A) and 7614(3)) (Authority: 38 U.S.C. 7614(2)) (f) Continuation awards. Subject to (6) The Secretary may make arrange- the availability of funds for the Schol- ments with the school in which the arship Program and selection, the Sec- participant is enrolled for the direct retary will award a continuation schol- payment of the amount of tuition and/ arship for completion of the degree for or reasonable educational expenses on which the scholarship was awarded if— the participant’s behalf. (1) The award will not extend the total period of Scholarship Program (Authority: 38 U.S.C. 7613(c)) support beyond 4 years for a full-time (7) A participant’s eligibility for a scholarship, and beyond 6 years for a stipend ends at the close of the month part-time scholarship; and in which degree requirements are met. (2) The participant remains eligible (b) Leave-of-absence, repeated course for continued participation in the work. The Secretary may suspend Scholarship Program. scholarship payments to or on behalf of a participant if the school (1) approves (Authority: 38 U.S.C. 7603(d)) a leave-of-absence for the participant (Approved by the Office of Management and for health, personal, or other reasons, Budget under control number 2900–0352) or (2) requires the participant to repeat [48 FR 37399, Aug. 18, 1983, as amended at 54 course work for which the Secretary FR 28674, July 7, 1989; 78 FR 51070, Aug. 20, previously has made payments under 2013] the Scholarship Program. Additional

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costs relating to the repeated course (iii) VA mentor. VA will ensure that work will not be paid under this pro- the participant is assigned a mentor gram. Any scholarship payments sus- who is employed at the same facility pended under this section will be re- where the participant performs his or sumed by the Secretary upon notifica- her obligated service at the commence- tion by the school that the participant ment of such service. has returned from the leave-of-absense (2) Obligated service shall begin on or has satisfactorily completed the re- the degree completion date for a par- peated course work and is proceeding ticipant who, on that date, is a full- as a full-time student in the course of time VA employee working in a capac- study for which the scholarship was ity for which the degree program pre- awarded. pared the participant. (Authority: 38 U.S.C. 7633) (Authority: 38 U.S.C. 7616(b), 7616(c), 7618(a)) [48 FR 37400, Aug. 18, 1983, as amended at 55 FR 40170, Oct. 2, 1990] (c) Duration of service—(1) Full-time student—(i) Physician or dentist. A par- § 17.607 Obligated service. ticipant who attended school as a full- (a) General. Except as provided in time student will agree to serve as a paragraph (d) of this section, each par- full-time physician or dentist in the ticipant is obligated to provide service Veterans Health Administration for 18 as a Department of Veterans Affairs months for each school year or part employee in full-time clinical practice thereof for which a scholarship was in the participant’s discipline in an as- awarded. signment or location determined by (ii) Other health care profession. A par- the Secretary. ticipant who attended school as a full- time student in a health care profes- (Authority: 38 U.S.C. 7616(a)) sion other than physician or dentist will agree to serve as a full-time clin- (b) Beginning of service. (1)(i) Date of ical employee in the Veterans Health employment. Except as provided in paragraph (b)(2) of this section, a partici- Administration for 1 calendar year for pant’s obligated service will begin on each school year or part thereof for the date VA appoints the participant which a scholarship was awarded, but as a full-time VA employee in a clin- for no less than 2 years. ical occupation for which the degree (2) Part-time student. Obligated serv- prepared the participant. VA will ap- ice to VA for a participant who at- point the participant to such position tended school as a part-time student as soon as possible, but no later than 90 must be satisfied by full-time clinical days after the date that the participant employment. The period of obligated receives his or her degree, or the date service will be reduced from that which the participant becomes licensed in a a full-time student must serve under State or becomes certified, whichever paragraph (c)(1) of this section in ac- is later. VA will actively assist and cordance with the proportion that the monitor participants to ensure State number of credit hours carried by the licenses or certificates are obtained in part-time student in any school year a minimal amount of time following bears to the number of credit hours re- graduation. If a participant fails to ob- quired to be carried by a full-time stu- tain his or her degree, or fails to be- dent who is pursuing the same degree; come licensed in a State or become cer- however, the period of obligated serv- tified no later than 180 days after re- ice will not be for less than 1 year. ceiving the degree, the participant is considered to be in breach of the ac- (Authority: 38 U.S.C. 7612(c)(1)(B), 7612(c)(3)(A), 7618(c)) ceptance agreement. (ii) Notification. VA will notify the (d) Location for service. VA reserves participant of the work assignment and the right to make final decisions on its location no later than 60 days be- the location for service obligation. A fore the date on which the participant participant who receives a scholarship must begin work. as a full-time student must be willing

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to relocate to another geographic loca- vanced clinical training may, at the tion to carry out his or her service ob- time of approval of such deferment and ligation according to the participant’s at the discretion of the Secretary and mobility agreement. A participant who upon the recommendation of the Under received a scholarship as a part-time Secretary for Health, incur an addi- student may be allowed to serve the pe- tional period of obligated service— riod of obligated service at the health (1) At the rate of one-half of a cal- care facility where the individual was endar year for each year of approved assigned when the scholarship was au- clinical training (or a proportionate thorized, if there is a vacant position ratio thereof) if the training is in a spe- which will satisfy the individual’s mobility agreement at that facility. cialty determined to be necessary to meet health care requirements of the (Authority: 38 U.S.C. 7616(a)) Veterans Health Administration; De- partment of Veterans Affairs; or (e) Creditability of advanced clinical (2) At the rate of three-quarters of a training. No period of advanced clinical training will be credited toward satis- calendar year for each year of approved fying the period of obligated service in- graduate training (or a proportionate curred under the Scholarship Program. ratio thereof) if the training is in a medical specialty determined not to be (Authority: 38 U.S.C. 7616(b)(3)(A)(ii) necessary to meet the health care re- [47 FR 10810, Mar. 12, 1982, as amended at 48 quirements of the Veterans Health Ad- FR 37400, Aug. 18, 1983; 54 FR 28675, July 7, ministration. Specialties necessary to 1989; 78 FR 51070, Aug. 20, 2013; 85 FR 13053, meet the health care requirements of Mar. 6, 2020] the Veterans Health Administration § 17.608 Deferment of obligated serv- will be prescribed periodically by the ice. Secretary when, and if, this provision (a) Request for deferment. A partici- for an additional period of obligated pant receiving a degree from a school service is to be used. of medicine, osteopathy, dentistry, optometry, or podiatry, may request (Authority: 38 U.S.C. 7616(b)(4)(B)) deferment of obligated service to com- (d) Altering deferment. Before altering plete an approved program of advanced the length or type of approved ad- clinical training. The Secretary may vanced clinical training for which the defer the beginning date of the obli- period of obligated service was deferred gated service to allow the participant to complete the advanced clinical under paragraphs (a) or (b) of this sec- training program. The period of this tion, the participant must request and deferment will be the time designated obtain the Secretary’s written ap- for the specialty training. proval of the alteration.

(Authority: 38 U.S.C. 7616(b)(3)(A)(i)) (Authority: 38 U.S.C. 7633) (b) Deferment requirements. Any par- (e) Beginning of service after deferment. ticipant whose period of obligated serv- Any participant whose period of obli- ice is deferred shall be required to take gated service has been deferred under all or part of the advanced clinical paragraph (a) or (b) of this section training in an accredited program in an must begin the obligated service effec- educational institution having an Af- tive on the date of appointment under filiation Agreement with a Department title 38 in full-time clinical practice in of Veterans Affairs health care facility, an assignment or location in a Depart- and such training will be undertaken in ment of Veterans Affairs health care a Department of Veterans Affairs facility as determined by the Sec- health-care facility. retary. The assignment will be made by the Secretary within 120 days prior to (Authority: 38 U.S.C. 7616(b)(4)) or no later than 30 days following the (c) Additional service obligation. A par- completion of the requested graduate ticipant who has requested and re- training for which the deferment was ceived deferment for approved ad-

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granted. Travel and relocation regula- (4) Who is enrolled in a program or tions will apply. education or training leading to employment as a physician, fails to suc- (Authority: 38 U.S.C. 7616(b)(2)) cessfully complete post-graduate train- [47 FR 10810, Mar. 12, 1982; 47 FR 13523, Mar. ing leading to eligibility for board cer- 31, 1982, as amended at 54 FR 28675, July 7, tification in a specialty. 1989; 61 FR 21969, May 13, 1996; 79 FR 54616, Sept. 12, 2014] (5) Fails to become licensed to practice in the discipline for which the de- § 17.609 Pay during period of obligated gree program prepared the participant, service. if applicable, in a State within 1 year The initial appointment of physi- from the date such person becomes eli- cians for obligated service will be made gible to apply for State licensure; or in a grade commensurate with qualifications as determined in 38 U.S.C. (Authority: 38 U.S.C. 7617(b)(4)) 7404(b) A physician serving a period of (6) Is a part-time student and fails to obligated service is not eligible for in- maintain employment in a permanent centive special pay during the first assignment in a VA health care facility three years of such obligated service. A while enrolled in the course of training physician may be paid primary special being pursued; the participant must in- pay at the discretion of the Secretary stead of performing any service obliga- upon the recommendation of the Under tion, pay to the United States an Secretary for Health. amount equal to all scholarship funds (Authority: 38 U.S.C. 7431–7433) awarded under the written contract executed in accordance with § 17.602. Pay- [47 FR 10810, Mar. 12, 1982, as amended at 54 ment of this amount must be made FR 28676, July 7, 1989; 61 FR 21969, May 13, within 1 year from the date academic 1996; 79 FR 54616, Sept. 12, 2014] training terminates unless a longer pe- § 17.610 Failure to comply with terms riod is necessary to avoid hardship. No and conditions of participation. interest will be charged on any part of this indebtedness. (a) If a participant, other than one described in paragraph (b) of this sec- (Authority: 38 U.S.C. 7617(b)) tion fails to accept payment or instructs the school not to accept pay- (c) Participants who breach their ment of the scholarship provided by contracts by failing to begin or com- the Secretary, the participant must, in plete their service obligation (for any addition to any service or other obliga- reason) other than as provided for tion incurred under the contract, pay under paragraph (b) of this section are to the United States the amount of liable to repay the amount of all schol- $1,500 liquidated damages. Payment of arship funds paid to them and to the this amount must be made within 90 school on their behalf, plus interest, days of the date on which the partici- multiplied by three, minus months of pant fails to accept payment of the service obligation satisfied, as deter- scholarship award or instructs the mined by the following formula: school not to accept payment.

(Authority: 38 U.S.C. 7617(a)) (b) If a participant: (1) Fails to maintain an acceptable in which: level of academic standing; ‘A’ is the amount the United States is enti- (2) Is dismissed from the school for tled to recover; disciplinary reasons; ‘j’ is the sum of the amounts paid to or on (3) Voluntarily terminates the course behalf of the applicant and the interest on of study or program for which the such amounts which would be payable if, scholarship was awarded including in at the time the amounts were paid, they were loans bearing interest at the max- the case of a full-time student, a reduc- imum legal prevailing rate, as determined tion of course load from full-time to by the Treasurer of the United States; part-time before completing the course ‘t’ is the total number of months in the ap- of study or program; plicant’s period of obligated service; and

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‘s’ is the number of months of the period of to repay any scholarship funds that obligated service served by the participant. have already been paid to or on behalf The amount which the United States is of the participant, or to fulfill any entitled to recover shall be paid within other acceptance agreement require- 1 year of the date on which the appli- ment. If a waiver is granted, then the cant failed to begin or complete the pe- waived amount of scholarship funds riod of obligated service, as determined may be considered taxable income. by the Secretary. (ii) Suspensions. VA may approve an initial request for a suspension for a (Authority: 38 U.S.C. 7617(c)(1)(2)) period of up to 1 year. A suspension (Approved by the Office of Management and may be extended for one additional Budget under control number 2900–0352) year, after which time the participant [47 FR 10810, Mar. 12, 1982; 47 FR 13523, Mar. will be in breach of his or her accept- 31, 1982, as amended at 48 FR 37400, Aug. 18, ance agreement. If a suspension is ap- 1983; 54 FR 28676, July 7, 1989; 54 FR 46611, proved: Nov. 6, 1989; 61 FR 24237, May 14, 1996; 85 FR (A) VA will temporarily discontinue 13053, Mar. 6, 2020] providing any scholarship funds to or on behalf of the participant while the § 17.611 Bankruptcy. participant’s scholarship is in a sus- Any payment obligation incurred pended status; or may not be discharged in bankruptcy (B) VA will temporarily delay the en- under title 11 U.S.C. until 5 years after forcement of acceptance agreement re- the date on which the payment obliga- quirements. tion is due. This section applies to par- (2) The Secretary may waive or sus- ticipants in the HPSP and the pend any service or payment obligation VIOMPSP. incurred by a participant whenever (Authority: 38 U.S.C. 7505(d), 7634(c)) compliance by the participant (i) is im- [78 FR 51071, Aug. 20, 2013] possible, due to circumstances beyond the control of the participant or (ii) § 17.612 Cancellation, waiver, or sus- whenever the Secretary concludes that pension of obligation. a waiver or suspension of compliance (a) General. (1) This section applies to would be in the best interest of the De- participants in the HPSP or the partment of Veterans Affairs. VIOMPSP. (2) Any obligation of a participant for (Authority: 38 U.S.C. 7634(b)) service or payment will be cancelled (c) Compliance by a participant with upon the death of the participant. a service or payment obligation will be considered impossible due to cir- (Authority: 38 U.S.C. 7634(a)) cumstances beyond the control of the (b) Waivers or suspensions. (1) A par- participant if the Secretary deter- ticipant may seek a waiver or suspen- mines, on the basis of such information sion of the obligated service or pay- and documentation as may be required, ment obligation incurred under this that the participant suffers from a program by submitting a written re- physical or mental disability resulting quest to VA setting forth the basis, cir- in permanent inability to perform the cumstances, and causes which support service or other activities which would the requested action. Requests for be necessary to comply with the obli- waivers or suspensions must be sub- gation. mitted to VA no later than 1 year after (d) Waivers or suspensions of service the date VA notifies the participant or payment obligations, when not re- that he or she is in breach of his or her lated to paragraph (c) of this section, acceptance agreement. A participant and when considered in the best inter- seeking a waiver or suspension must est of the Department of Veterans Af- comply with requests for additional in- fairs, will be determined by the Sec- formation from VA no later than 30 retary on an individual basis. days after the date of any such request. (e) Eligibility to reapply for award. Any (i) Waivers. A waiver is a permanent previous participant of any federally release by VA of the obligation either sponsored scholarship program who

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breached his or her acceptance agree- (2) Quillen College of Medicine at ment or similar agreement in such East Tennessee State University. scholarship program is not eligible to (3) Boonshoft School of Medicine at apply for a HPSP or VIOMPSP. This Wright State University. includes participants who previously (4) Joan C. Edwards School of Medi- applied for, and received, a waiver cine at Marshall University. under this section. (5) University of South Carolina (f) Finality of decisions. Decisions to School of Medicine. approve or disapprove waiver requests (6) Charles R. Drew University of are final and binding determinations. Medicine and Science. Such determinations are not subject to (7) Howard University College of reconsideration or appeal. Medicine. (8) Meharry Medical College. (Authority: 38 U.S.C. 7505(c), 7634(a), 7634(b)) (9) Morehouse School of Medicine. [47 FR 10810, Mar. 12, 1982, as amended at 78 VA means the Department of Vet- FR 51071, Aug. 20, 2013] erans Affairs. VHVMASP means the Veterans Heal- VETERANS HEALING VETERANS MEDICAL ing Veterans Medical Access and ACCESS AND SCHOLARSHIP PROGRAM Scholarship Program authorized by VETERANS HEALING VETERANS MEDICAL section 304 of the VA MISSION Act of ACCESS AND SCHOLARSHIP PROGRAM 2018, Public Law 115–182. § 17.615 Eligibility. SOURCE: Sections 17.613 through 17.618 appear at 84 FR 61551, Nov. 13, 2019, unless oth- A veteran is considered eligible to re- erwise noted. ceive funding for the VHVMASP if such veteran meets the following criteria. § 17.613 Purpose. (a) Has been discharged or released, The purpose of §§ 17.613 through 17.618 under conditions other than dishonor- is to establish the requirement for the able, from the Armed Forces for not Veterans Healing Veterans Medical Ac- more than 10 years before the date of cess and Scholarship Program application for admission to a covered (VHVMASP). The VHVMASP will pro- medical school; vide funding for the medical education (b) Is not concurrently receiving edu- of two eligible veterans from each cov- cational assistance under chapter 30, ered medical school. 31, 32, 33, 34, or 35 of title 38 United States Code or chapter 1606 or 1607 of § 17.614 Definitions. title 10 United States Code at the time The following definitions apply to the veteran would be receiving §§ 17.613 through 17.618. VHVMASP funding; Acceptable level of academic standing (c) Applies for admission to a covered means: medical school for the entering class of (1) Maintaining a cumulative grade 2020; point average at or above passing, as (d) Indicates on the application to determined by the medical school; the covered medical school that they (2) Completing all required courses would like to be considered for the with a passing grade; VHVMASP; (3) Successfully completing the re- (e) Meets the minimum admissions quired course of study for graduation criteria for the covered medical school within four academic years; to which the eligible veteran applies; (4) Successfully passing the required and United States Medical Licensing Ex- (f) Agrees to the terms stated in aminations steps 1 and 2, within the § 17.617. timeframe for graduation from medical school; and § 17.616 Award procedures. (5) Having no final determinations of (a) Distribution of funds. (1) Each cov- unprofessional conduct or behavior. ered medical school that opts to par- Covered medical school means any of ticipate in the VHVMASP will reserve the following: two seats in the entering class of 2020 (1) Texas A&M College of Medicine. for eligible veterans who receive funds

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for the VHVMASP. Funding will be completion of residency, or fellowship, awarded to two eligible veterans with if applicable, the participant is consid- the highest admissions ranking among ered to be in breach of the acceptance veteran applicants for such entering agreement; and class for each covered medical school. (4) Serve as a full-time clinical prac- (2) If two or more eligible veterans do tice employee in VA for a period of four not apply for admission at a covered years. medical school for the entering class of (b) Obligated service—(1) General. An 2020, VA will distribute the available eligible veteran’s obligated service will funding to eligible veterans who ap- begin on the date on which the eligible plied, and are accepted, for admission veteran begins full-time permanent at other covered medical schools. employment with VA as a clinical (b) Amount of funds. An eligible vet- practice employee. VA will appoint the eran will receive funding from the participant to such position as soon as VHVMASP equal to the actual cost of the following: possible, but no later than 90 days after (1) Tuition at the covered medical the date that the participant completes school for which the veteran enrolls for residency, or fellowship, if applicable, a period of not more than 4 years; or the date the participant becomes li- (2) Books, fees, and technical equip- censed in a State, whichever is later. ment; (2) Location and position of obligated (3) Fees associated with the National service. VA reserves the right to make Residency Match Program; final decisions on the location and po- (4) Two away rotations, performed sition of the obligated service. during the fourth year of school, at a (The Office of Management and Budg- VA medical facility; and et has approved the information collec- (5) A monthly stipend for the four- tion requirements in this section under year period during which the eligible control number 2900–0793.) veteran is enrolled in a covered medical school in an amount to be deter- § 17.618 Failure to comply with terms mined by VA. and conditions of agreement. (a) Participant fails to satisfy terms of § 17.617 Agreement and obligated service. agreement. If an eligible veteran who accepts funding for the VHVMASP (a) Agreement. Each eligible veteran breaches the terms of the agreement who accepts funds from the VHVMASP stated in § 17.617, the United States is will enter into an agreement with VA entitled to recover damages in an where the eligible veteran agrees to the amount equal to the total amount of following: VHVMASP funding received by the eli- (1) Maintain enrollment, attendance, gible veteran. and acceptable level of academic standing as defined by the covered medical (b) Repayment period. The eligible school; veteran will pay the amount of dam- (2) Complete post-graduate training ages that the United States is entitled leading to eligibility for board certifi- to recover under this section in full to cation in a physician specialty applica- the United States no later than 1 year ble to VA; after the date of the breach of the (3) After completion of medical agreement. school and post-graduate training, ob- (c) Waivers. The Under Secretary for tain and maintain a license to practice Health, or designee, may waive or sus- medicine in a State. Eligible veterans pend any service or financial liability must ensure that State licenses are ob- incurred by a participant whenever tained in a minimal amount of time compliance by the participant is im- following completion of residency, or possible, due to circumstances beyond fellowship, if the veteran is enrolled in the control of the participant, or when- a fellowship program approved by VA. ever the Under Secretary for Health, or If a participant fails to obtain his or designee, concludes that a waiver or her degree, or fails to become licensed suspension of compliance is in the VA’s in a State no later than 90 days after best interest.

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VISUAL IMPAIRMENT AND ORIENTATION (b) Obligated service to another entity. AND MOBILITY PROFESSIONAL SCHOL- Any applicant who, at the time of ap- ARSHIP PROGRAM plication, owes a service obligation to any other entity to perform service SOURCE: Sections 17.625 through 17.636 ap- after completion of the course of study pear at 78 FR 51071, Aug. 20, 2013, unless oth- is ineligible to receive a VIOMPSP erwise noted. scholarship. § 17.625 Purpose. (Authority: 38 U.S.C. 7501(a), 7502(a), 7504(3)) The purpose of §§ 17.625 through 17.636 § 17.628 Availability of VIOMPSP is to establish the requirements for the scholarships. award of scholarships under the Visual Impairment and Orientation and Mo- VA will make awards under the bility Professional Scholarship Pro- VIOMPSP only when VA determines it gram (VIOMPSP) to students pursuing is necessary to assist in alleviating a program of study leading to a degree shortages or anticipated shortages of in visual impairment or orientation personnel in visual impairment or ori- and mobility. The scholarship is de- entation and mobility programs. VA’s signed to increase the supply of quali- determination of the number of fied Blind Rehabilitation Specialists VIOMPSP scholarships to be awarded and Blind Rehabilitation Outpatient in a fiscal year, and the number that Specialists available to VA. The schol- will be awarded to full-time and/or arship will be publicized throughout part-time students, is subject to the educational institutions in the United availability of appropriations. States, with an emphasis on dissemi- (Authority: 38 U.S.C. 7501(a), 7503(c)(2)) nating information to such institutions with high numbers of Hispanic stu- § 17.629 Application for the VIOMPSP. dents and to historically black colleges (a) Application-general. Each indi- and universities. vidual desiring a VIOMPSP scholarship (Authority: 38 U.S.C. 7501) must submit an accurate and complete application, including a signed written § 17.626 Definitions. acceptance agreement. For the definitions that apply to (b) VA’s duties. VA will notify appli- §§ 17.625 through 17.636, see § 17.601. cants prior to acceptance in the VIOMPSP of the following informa- (Authority: 38 U.S.C. 501) tion: § 17.627 Eligibility for the VIOMPSP. (1) A fair summary of the rights and liabilities of an individual whose appli- (a) General. To be eligible for the cation is approved by VA and whose ac- VIOMPSP, an applicant must meet the ceptance agreement is consummated following requirements: by VA; and (1) Be unconditionally accepted for (2) Full description of the terms and enrollment or currently enrolled in a conditions that apply to participation program of study leading to a degree in in the VIOMPSP and service in VA. orientation and mobility, low vision therapy, or vision rehabilitation ther- (Authority: 38 U.S.C. 501(a), 7502(a)(2)) apy, or a dual degree (a program in (The Office of Management and Budget has which an individual becomes certified approved the information collection require- in two of the three professional certifi- ments in this section under control number cations offered by the Academy for 2900–0793.) Certification of Visual Rehabilitation and Education Professionals) at an ac- § 17.630 Selection of VIOMPSP partici- credited educational institution that is pants. in a State; (a) General. In deciding which (2) Be a citizen of the United States; VIOMPSP applications to approve, VA and will first consider applications sub- (3) Submit an application to partici- mitted by applicants entering their pate in the VIOMPSP, as described in final year of education or training. Ap- § 17.629. plicants will be evaluated and selected

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using the criteria specified in para- ments to scholarship participants are graph (b) of this section. If there are a exempt from Federal taxation. larger number of equally qualified ap- (2) The total amount of assistance plicants than there are awards to be provided under the VIOMPSP for an made, then VA will first select vet- academic year to an individual who is erans, and then use a random method a full-time student may not exceed as the basis for further selection. $15,000.00. (b) Selection criteria. In evaluating (3) The total amount of assistance and selecting participants, VA will provided under the VIOMPSP for an take into consideration those factors academic year to a participant who is a determined necessary to assure effec- part-time student shall bear the same tive participation in the VIOMPSP. ratio to the amount that would be paid These factors will include, but are not under paragraph (a)(2) of this section if limited to, the following: the participant were a full-time stu- (1) Academic performance; dent as the coursework carried by the (2) Work/volunteer experience, in- participant to full-time coursework. cluding prior rehabilitation or health (4) The total amount of assistance care employment and VA employment; provided to an individual may not ex- (3) Faculty and employer rec- ceed $45,000.00. ommendations; or (5) In the case of an individual en- (4) Career goals. rolled in a program of study leading to (c) Notification of approval. VA will a dual degree described in § 17.627(a)(1), notify the individual in writing that such tuition and fees will not exceed his or her application has been accept- the amounts necessary for the mined and approved. An individual be- imum number of credit hours to comes a participant in the program achieve such dual degree. upon receipt of such approval by VA. (6) Financial assistance may be pro- (d) Duration of VIOMPSP award. VA vided to an individual under the will award a VIOMPSP scholarship for VIOMPSP to supplement other edu- a period of time equal to the number of cational assistance to the extent that years required to complete a program the total amount of educational assist- of study leading to a degree in orienta- ance received by the individual during tion and mobility, low vision therapy, an academic year does not exceed the or vision rehabilitation therapy, or a total tuition and fees for such aca- dual degree. The number of years cov- demic year. ered by an individual scholarship (7) VA will make arrangements with award will be based on the number of the school in which the participant is school years that the participant has enrolled to issue direct payment for yet to complete his or her degree at the the amount of tuition or fees on behalf time the VIOMPSP scholarship is of the participant. awarded. Subject to the availability of (b) Repeated course work. Additional funds, VA will award the VIOMPSP as costs relating to the repeated course follows: work will not be paid under this pro- (1) Full-time scholarship. A full-time gram. VA will resume any scholarship scholarship is awarded for a minimum payments suspended under this section of 1 school year to a maximum of 4 upon notification by the school that school years; the participant has returned from the (2) Part-time scholarships. A part-time leave-of-absence or has satisfactorily scholarship is awarded for a minimum completed the repeated course work of 1 school year to a maximum of 6 and is pursuing the course of study for school years. which the VIOMPSP was awarded. (Authority: 38 U.S.C. 7504(3)) (Authority: 38 U.S.C. 7503, 7504(3))

§ 17.631 Award procedures. § 17.632 Obligated service. (a) Amount of scholarship. (1) A (a) General provision. Except as pro- VIOMPSP scholarship award will not vided in paragraph (d) of this section, exceed the total tuition and required each participant is obligated to provide fees for the program of study in which service as a full-time clinical VA em- the applicant is enrolled. All such pay- ployee in the rehabilitation practice of

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the participant’s discipline in an as- § 17.634 Failure to comply with terms signment or location determined by and conditions of participation. VA. (a) Participant refuses to accept pay- (b) Beginning of service. A partici- ment of the VIOMPSP. If a participant, pant’s obligated service will begin on other than one described in paragraph the date on which the participant ob- (b) of this section, refuses to accept tains any required applicable creden- payment or instructs the school not to tials and when appointed as a full-time accept payment of the VIOMPSP schol- clinical VA employee in a position for arship provided by VA, the participant which the degree prepared the partici- must, in addition to any obligation in- pant. VA will appoint the participant curred under the agreement, pay to the to such position as soon as possible, United States the amount of $1,500 in but no later than 90 days after the date liquidated damages. Payment of this that the participant receives his or her amount must be made no later than 90 degree, or the date the participant ob- days from the date that the participant tains any required applicable creden- fails to accept payment of the tials, whichever is later. If a partici- VIOMPSP or instructs the school not pant fails to obtain his or her degree, to accept payment. or fails to obtain any required applica- (b) Participant fails to complete course ble credentials within 180 days after re- of study or does not obtain certification. ceiving the degree, the participant is A participant described in paragraphs considered to be in breach of the ac- (b)(1) through (4) of this section must, ceptance agreement. instead of otherwise fulfilling the (c) Duration of service. The partici- terms of his or her acceptance agree- pant will agree to serve as a full-time ment, pay to the United States an clinical VA employee for 3 calendar amount equal to all VIOMPSP funds years which must be completed no awarded under the acceptance agree- later than 6 years after the participant ment. Payment of this amount must be has completed the program for which made no later than 1 year after the the scholarship was awarded and re- date that the participant meets any of ceived a degree referenced in the criteria described in paragraphs § 17.627(a)(1). (b)(1) through (4) of this section, unless (d) Location and assignment of obli- VA determines that a longer period is gated service. VA reserves the right to necessary to avoid hardship. No inter- make final decisions on the location est will be charged on any part of this and assignment of the obligated serv- indebtedness. A participant will pay ice. A participant who receives a schol- such amount if one of the following cri- arship must agree as part of the par- teria is met: ticipant’s mobility agreement that he (1) The participant fails to maintain or she is willing to accept the location an acceptable level of academic stand- and assignment where VA assigns the ing; obligated service. Geographic reloca- (2) The participant is dismissed from tion may be required. the school for disciplinary reasons; (e) Creditability of advanced clinical (3) The participant, for any reason, training. No period of advanced clinical voluntarily terminates the course of training will be credited towards satis- study or program for which the schol- fying the period of obligated service in- arship was awarded including a reduc- curred under the VIOMPSP. tion of course load from full-time to part-time before completing the course (Authority: 38 U.S.C. 7504(2)(D), 7504(3)) of study or program; or § 17.633 Deferment of obligated serv- (4) The participant fails to become ice. certified in the discipline for which the degree prepared the participant, if ap- Deferment of obligated service under plicable, no later than 180 days after the VIOMPSP is treated in the same the date such person becomes eligible manner as deferment of obligated serv- to apply for certification. ice under the HPSP under § 17.608. (c) Participant fails to perform all or (Authority: 38 U.S.C. 7504(3)) any part of their service obligation. (1)

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Participants who breach their agree- PROGRAM FOR REPAYMENT OF EDU- ments by failing to begin or complete CATIONAL LOANS FOR CERTAIN VA their service obligation, for any reason, PSYCHIATRISTS including the loss, revocation, suspension, restriction, or limitation of re- SOURCE: 81 FR 66820, Sept. 29, 2016, unless quired certification, and other than otherwise noted. provided for under paragraph (b) of this § 17.640 Purpose. section, must repay the portion of all VIOMPSP funds paid to or on behalf of The purpose of §§ 17.640 through 17.647 is to establish the requirements for the the participant, adjusted for the serv- program for the repayment of edu- ice that they provided. To calculate cational loans (PREL) obtained by phy- the unearned portion of VIOMPSP sician residents pursuing a certifi- funds, subtract the number of months cation in psychiatry. of obligated service rendered from the total months of obligated service owed, § 17.641 Definitions. divide the remaining months by the The following definitions apply to total obligated service, then multiply §§ 17.640 through 17.647. by the total amount of VIOMPSP funds Acceptance of conditions means a paid to or on behalf of the participant. signed document between VA and a The following formula may be used in participant of the PREL, in which the determining the unearned portion: participant must agree to a period of obligated service, to maintain an ac- A = P((t-s)/t) in which ‘‘A’’ is the amount the United States is enti- ceptable level of performance deter- tled to recover; mined by supervisory review in the po- ‘‘P’’ is the amounts paid under the sition to which VA appoints the partic- VIOMPSP, to or on behalf of the partici- ipant, to terms and amount of pay- pant; ment, and to relocate, if required, to a ‘‘t’’ is the total number of months in the par- location determined by VA at the participant’s period of obligated service; and ticipant’s expense in exchange for edu- ‘‘s’’ is the number of months of obligated cational loan repayments under the service rendered. PREL. VA will provide a list of available locations for the period of obli- (2) The amount that the United gated service in the acceptance of con- States is entitled to recover will be ditions. The applicant will choose the paid no later than 1 year after the date preferred location, in ranking order, the applicant failed to begin or com- for the completion of his or her obli- plete the period of obligated service, as gated service from the locations on determined by VA. this list. However, VA will ultimately (Authority: 38 U.S.C. 7505(a), 7505(b)) make the final determination as to where the applicant will perform his or § 17.635 Bankruptcy. her period of obligated service. A participant of the PREL must agree that Bankruptcy under the VIOMPSP is he or she is willing to accept the loca- treated in the same manner as bank- tion and position to which VA appoints ruptcy for the HPSP under § 17.611. the participant. (Authority: 38 U.S.C. 7505(c), 7505(d)) Educational loan means a loan, government or commercial, made for edu- § 17.636 Cancellation, waiver, or sus- cational purposes by institutions that pension of obligation. are subject to examination and super- Cancellation, waiver, or suspension vision in their capacity as lending institutions by an agency of the United procedures under the VIOMPSP are the States or of the state in which the same as those procedures for the HPSP lender has its principal place of busi- under § 17.612. ness. Loans must be for the actual (Authority: 38 U.S.C. 7505(c)) costs paid for tuition, and other reasonable educational expenses such as living expenses, fees, books, supplies, educational equipment and materials,

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and laboratory expenses. Loans must qualification in psychiatric medicine be obtained from a government entity, or a subspecialty qualification of psy- a private financial institution, a chiatry (the program must be accred- school, or any other authorized entity ited by the Accreditation Council for stated in this definition. The following Graduate Medical Education or the loans do not qualify for the PREL: American Osteopathic Association, (1) Loans obtained from family mem- and, by the time of VA employment, bers, relatives, or friends; must: (2) Loans made prior to, or after, the (i) Have completed all psychiatry individual’s qualifying education; residency training; (3) Any portion of a consolidated loan that is not specifically identified with (ii) Have received a completion cer- the education and purposes for which tificate from the Program Director the PREL may be authorized, such as confirming successful completion of home or auto loans merged with edu- the residency program; and cational loans; (iii) Certify intention to apply for (4) Loans for which an individual in- board certification in the specialty of curred a service obligation for repay- psychiatry (through the American ment or agreed to service for future Board of Medical Specialties or the cancellation; American Osteopathic Association) (5) Credit card debt; within two years after completion of (6) Parent Plus Loans; residency. (7) Loans that have been paid in full; (3) Be licensed or eligible for licen- (8) Loans that are in default, delin- sure to practice medicine by meeting quent, not in a current payment status, the following requirements by the time or have been assumed by a collection of VA employment: agency; (i) Have at least one full, active, cur- (9) Loans not obtained from a bank, rent, and unrestricted license that au- credit union, savings and loan associa- thorizes the licensee to practice in any tion, not-for-profit organization, insurance company, school, and other finan- State, Territory, or possession of the cial or credit institution which is sub- United States, the District of Colum- ject to examination and supervision in bia, or the Commonwealth of Puerto its capacity as a lending institution by Rico; an agency of the United States or of (ii) Document graduation from a the state in which the lender has its school of medicine accredited by the principal place of business; Liaison Committee on Medical Edu- (10) Loans for which supporting docu- cation or the American Osteopathic mentation is not available; Association; or, if an international (11) Loans that have been consoli- medical graduate, verify that require- dated with loans of other individuals, ments for certification by the Edu- such as spouses, children, friends, or cational Commission for Foreign Med- other family member; or ical Graduates have been met. (12) Home equity loans or other non- (b) Simultaneous participation in an- educational loans. other repayment program. Any appli- PREL means the program for the re- cant who, at the time of application, is payment of educational loans for cer- participating in any other program of tain VA psychiatrists established in the Federal Government that repays §§ 17.640 through 17.647. the educational loans of the applicant § 17.642 Eligibility. is not eligible to participate in the PREL. (a) General. To be eligible for the PREL, an applicant must meet all of § 17.643 Application for the PREL. the following requirements: (1) Be a U.S. citizen or permanent (a) General. A complete application resident. for the PREL consists of a completed (2) Be enrolled in the final year of a application form, letters of reference, post-graduate physician residency pro- and personal statement. gram leading to either a specialty

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(b) References. The applicant must contains information collection and record- provide the following letters of ref- keeping requirements and will not become erence and sign a release of informa- effective until approval has been given by tion form for VA to contact such ref- the Office of Management and Budget. erences. The letters of reference should include the following: § 17.644 Selection of participants. (1) One letter of reference from the (a) Selection criteria. In evaluating Program Director of the core psychi- and selecting participants, VA will atry program in which the applicant consider the following factors: trained or is training, or the Program (1) The applicant meets all of the eli- Director of any psychiatry sub- gibility criteria in § 17.642 and has subspecialty program in which the appli- mitted a complete application under cant is training, which indicates that § 17.643; the applicant is in good to excellent (2) The strength of the applicant’s standing; (2) One or more letters of reference letters of reference; from faculty members under which the (3) The applicant is in good to excel- applicant trained; lent standing in the residency program, (3) One letter of reference from a peer as determined from the Program Direc- colleague who is familiar with the psy- tor letter of reference; chiatry practice and character of the (4) The applicant demonstrates a applicant. strong commitment to VA’s mission (c) Personal statement. The personal and core values; statement must include the following (5) The applicant has personal career documentation: goals that match VA needs (i.e., to (1) A cover letter that provides the work with patients suffering from trau- following information: matic brain injury, substance abuse, or (i) Why the applicant is interested in post-traumatic stress disorder); VA employment; (6) The applicant’s expresses a desire (ii) The applicant’s interest in working at a particular VA medical facility; to work at a location that matches (iii) Likely career goals, including with VA needs; and career goals in VA; and (7) The applicant does not have any (iv) A brief summary of past employ- identifiable circumstances relating to ment or training and accomplishments, education, training, licensure, certifi- including any particular clinical areas cation and review of health status, pre- of interest (e.g., substance abuse). vious experience, clinical privileges, (2) The following information must professional references, malpractice be provided on a VA form or online col- history and adverse actions, or crimi- lection system and is subject to VA nal violations that would adversely af- verification: fect the applicant’s credentialing proc- (i) Attestation that the applicant is ess. not participating in any other loan re- (b) Selection. VA will select not less payment program. than 10 individuals who meet the re- (ii) A summary of the applicant’s quirements of this section to partici- educational debt, which includes the pate in the program for the repayment total debt amount and when the debt of educational loans for each year in was acquired. The health professional which VA carries out the program. debt covered the loan must be specific to education that was required, used, (c) Notification of selection. VA will and qualified the applicant for appoint- notify applicants that they have been ment as a psychiatrist. selected in writing. An individual be- (iii) The name of the lending agency comes a participant in the PREL once that provided the educational loan. the participant submits and VA signs (3) A full curriculum vitae. the acceptance of conditions. [81 FR 66820, Sept. 29, 2016, as amended at 82 [81 FR 66820, Sept. 29, 2016, as amended at 82 FR 4795, Jan. 17, 2017] FR 4796, Jan. 17, 2017] EFFECTIVE DATE NOTE: At 81 FR 66820, Sept. 29, 2016, § 17.643 was added. This section

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§ 17.645 Award procedures. (b) Repayment period. The participant (a) Repayment amount. (1) VA may will pay the amount of damages that pay not more than $30,000 in edu- the United States is entitled to recover cational loan repayment for each year under this section in full to the United of obligated service. States no later than 1 year after the (2) An educational loan repayment date of the breach of the agreement. may not exceed the actual amount of principal and interest on an edu- CHAPLAIN SERVICES cational loan or loans. (b) Payment. VA will pay the partici- § 17.655 Ecclesiastical endorsing orga- pant, or the lending institution on be- nizations. half of the participant, directly for the (a) Purpose. This section establishes principal and interest on the partici- the eligibility requirements that an ec- pant’s educational loans. Payments clesiastical endorsing organization will be made monthly or annually for must meet in order to provide ecclesi- each applicable service period, depend- astical endorsements of individuals ing on the terms of the acceptance of who are seeking employment as VA conditions. Participants must provide chaplains or seeking to be engaged by VA documentation that shows the VA under contract or appointed as on- amounts that were credited or posted facility fee basis VA chaplains under 38 by the lending institution to a partici- U.S.C. 7405. Acceptance of an ecclesias- pant’s educational loan during an obligated service period. VA will issue pay- tical endorsement by VA does not ments after the participant commences imply any approval by VA of the the- the period of obligated service. Pay- ology or practices of an ecclesiastical ments are exempt from Federal tax- endorsing organization, nor does it ob- ation. ligate VA to employ the endorsed individual or any other member of the or- § 17.646 Obligated service. ganization. (a) General provision. A participant’s (b) Definitions. The following defini- obligated service will begin on the date tions apply to this section: on which the participant begins full- (1) Ecclesiastical endorsement means a time, permanent employment with VA written statement addressed to VA and in the field of psychiatric medicine in a signed by the designated endorsing offi- location determined by VA. Obligated cial of an ecclesiastical endorsing orga- service must be full-time, permanent nization certifying that an individual employment and does not include any is in good standing with the faith period of temporary or contractual em- group or denomination and, in the ployment. opinion of the endorsing official, is (b) Duration of service. The partici- qualified to perform the full range of pant will agree in the acceptance of conditions to serve for an obligated ministry, including all sacraments, service period of 2 or more calendar rites, ordinances, rituals, and liturgies years. required by members of the faith (c) Location and position of obligated group. Ecclesiastical endorsement is a service. VA reserves the right to make condition of employment as a VA chap- final decisions on the location and po- lain. An individual must obtain and sition of the obligated service. maintain a full and active ecclesiastical endorsement to be employed as a § 17.647 Failure to comply with terms VA chaplain. and conditions of participation. (2) Ecclesiastical endorsing official (a) Participant fails to satisfy obligated means an individual who is authorized service. A participant of the PREL who to provide or withdraw ecclesiastical fails to satisfy the period of obligated endorsements on behalf of an ecclesias- service will be liable to the United tical endorsing organization. States, in lieu of such obligated serv- (3) Ecclesiastical endorsing organization ice, for the full amount of benefit they means an organization that meets the expected to receive in the agreement, eligibility requirements of paragraph pro-rated for completed service days.

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(c) of this section and has been prop- ‘‘churches’’ from other types of reli- erly designated as an endorsing organi- gious organizations; see IRS Instruc- zation in accordance with paragraph (e) tions for Form 1023 Schedule A). Such of this section. rules stipulate that the particular reli- (c) Eligibility to serve as an ecclesias- gious beliefs of the organization are tical endorsing organization. An ecclesi- truly and sincerely held and that the astical endorsing organization must practices and rituals associated with meet the following requirements before the organization’s religious belief or such organization can endorse an appli- creed are not illegal or contrary to cant for VA chaplaincy: clearly defined public policy. In order (1) Be organized and function exclu- to determine whether a particular reli- sively or substantially to provide religious organization has properly ac- gious ministries to a lay constituency quired, and currently maintains, an and possess authority to both grant IRS tax exempt status and does not en- and withdraw initial and subsequent gage in practices that are illegal or ecclesiastical endorsements; contrary to defined public policy, VA (2) Have tax-exempt status as a reli- shall take appropriate steps to verify gious organization or church under the compliance with these requirements; Internal Revenue Code, section (3) A document verifying that the or- 501(c)(3); ganization shall provide chaplains who (3) Agree to abide by all Federal and shall function in a pluralistic environ- VA laws, regulations, policies, and ment, and who shall support directly issuances on the qualification and en- and indirectly the free exercise of reli- dorsement of persons for service as VA gion by all veterans, their family mem- chaplains; bers, and other persons authorized to (4) Agree to notify VA in writing of be served by VA; any withdrawal of an existing ecclesi- (4) That it agrees to abide by all VA astical endorsement within ten days Directives, Instructions, and other after the date of such withdrawal; guidance, regulations and policies on (5) Provide VA the documents stated the qualification and endorsement of in paragraph (d) of this section; ministers for service as VA chaplains; (6) Notify VA in writing within 30 (5) Documentation that states the days of any change of the name, ad- structure of the organization, includ- dress or contact information of the in- ing copies of the articles of incorpora- dividual that it designates as its eccle- tion, by-laws and constitution, mem- siastical endorsing official; and bership requirements of the organiza- (7) An ecclesiastical endorsing orga- tion, if any, the religious beliefs and nization that is part of an endorsing practices of the organization, and the organization by which its members can organization’s requirements to become be endorsed cannot become a separate clergy; and endorsing organization without the (6) The name and address of the indi- written permission of the larger en- vidual who is applying to become a VA dorsing organization. chaplain. (d) Request to designate ecclesiastical (e) Approval of request to designate an endorser. In order for an ecclesiastical ecclesiastical endorsing official. If an ec- endorsing organization to be recog- clesiastical endorsing organization nized by VA such organization must meets the requirements of paragraph submit the following: (c) of this section and has submitted (1) A complete VA form that requests the documents stated in paragraph (d) the designation of an ecclesiastical en- of this section, VA will notify the orga- dorsing official; nization in writing that such organiza- (2) A copy of an Internal Revenue tion has been designated as an ecclesi- Service document verifying that the astical endorsing organization. The organization currently holds a section designation will be for a period of 3 501(c)(3) exempt status as a church for years from the date of notification. Federal tax purposes from the Internal Once an organization is designated as Revenue Service (IRS) (note ‘‘church’’ an ecclesiastical endorsing organiza- is used by the IRS not to denote a be- tion, VA will accept ecclesiastical en- lief system, but to distinguish dorsements from that organization

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without requiring any further docu- the requirements of paragraph (c) of mentation from the organization dur- this section must resubmit all of the ing the 3 year period, unless VA re- evidence stated in paragraph (d) of this ceives evidence that an organization no section in order to be reconsidered as longer meets the requirements of this an endorsing organization. section. VA will only take action on an (4) If an ecclesiastical endorsing or- initial request to designate an ecclesi- ganization is no longer able to endorse astical endorsing official when VA re- individuals for VA chaplaincy in ac- ceives an application from an indi- cordance with this section, all ecclesi- vidual who is seeking employment as a astical endorsements issued by that or- VA chaplain or is seeking to be en- ganization are considered to be with- gaged under VA contract or appointed drawn. as on-facility fee basis VA chaplains (The Office of Management and Budget has under 38 U.S.C. 7405. approved the information collection require- (f) Reporting requirement. (1) To cer- ments in this section under control number tify that VA chaplains continue to be 2900–0852.) endorsed by an ecclesiastical endorsing [82 FR 51772, Nov. 8, 2017] organization, such organization must provide VA an alphabetical listing of GRANTS FOR TRANSPORTATION OF individuals who are endorsed by that VETERANS IN HIGHLY RURAL AREAS endorsing organization and are employed as VA chaplains or are engaged AUTHORITY: Sec. 307, Pub. L. 111–163; 38 by VA under contract or appointed as U.S.C. 501 and as noted in specific sections. on-facility fee basis VA chaplains SOURCE: 78 FR 19593, Apr. 2, 2013, unless under 38 U.S.C. 7405 by January 1 of otherwise noted. every calendar year. (2) In order for VA to continue to rec- § 17.700 Purpose and scope. ognize an ecclesiastical endorsing orga- This section establishes the Grants nization, such organization must pro- for Transportation of Veterans in High- vide written documentation that it ly Rural Areas program. Under this continues to meet the requirements of program, the Department of Veterans this section every 3 years. Affairs (VA) provides grants to eligible (g) Rescission of ecclesiastical endorsing entities to assist veterans in highly organization. VA may rescind an orga- rural areas through innovative trans- nization’s status as an ecclesiastical portation services to travel to VA med- endorsing organization and refuse to ical centers, and to otherwise assist in accept ecclesiastical endorsements providing transportation services in from such organization if it no longer connection with the provision of VA meets the requirements of paragraph medical care to these veterans. (c) of this section. VA will take the following steps before it rescinds the or- (Authority: Sec. 307, Pub. L. 111–163; 38 ganization’s status: U.S.C. 501) (1) VA will give the ecclesiastical endorsing organization written notice § 17.701 Definitions. stating the reasons for the rescission For the purposes of §§ 17.700–17.730 and and give the organization 60 days to any Notice of Fund Availability issued provide a written reply addressing VA’s pursuant to such sections: concerns. Applicant means an eligible entity (2) VA will notify the ecclesiastical that submits an application for a grant endorsing organization and all VA announced in a Notice of Fund Avail- chaplains endorsed by the organization ability. in writing of its decision after VA re- Eligible entity means: views the evidence provided by the or- (1) A Veterans Service Organization, ganization or after the 60 day time pe- or riod has expired, whichever comes first. (2) A State veterans service agency. (3) Ecclesiastical endorsing organiza- Grantee means an applicant that is tions that are notified that they may awarded a grant under this section. no longer endorse individuals for VA Highly rural area means an area con- chaplaincy because they do not meet sisting of a county or counties having

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a population of less than seven persons ing funds as a condition of receiving per square mile. such grant. Notice of Fund Availability means a (d) Veterans will not be charged. Trans- Notice of Fund Availability published portation services provided to veterans in the FEDERAL REGISTER in accord- through utilization of a grant will be ance with § 17.710. free of charge. Participant means a veteran in a highly rural area who is receiving (Authority: Sec. 307, Pub. L. 111–163; 38 U.S.C. 501) transportation services from a grantee. Provision of VA medical care means § 17.703 Eligibility and application. the provision of hospital or medical services authorized under sections 1710, (a) Eligible entity. The following may 1703, and 8153 of title 38, United States be awarded a grant: Code. (1) A Veterans Service Organization. State veterans service agency means (2) A State veterans service agency. the element of a State government (b) Initial application. To apply for an that has responsibility for programs initial grant, an applicant must submit and activities of that government re- to VA a complete grant application lating to veterans benefits. package, as described in the Notice of Subrecipient means an entity that re- Fund Availability. ceives grant funds from a grantee to (c) Renewal application. Grantees may perform work for the grantee in the ad- apply for one renewal grant per fiscal ministration of all or part of the grant- year, after receiving an initial grant, if ee’s program. the grantee’s program will remain sub- Transportation services means the di- stantially the same. The grantee must rect provision of transportation, or as- submit to VA a complete renewal ap- sistance with providing transportation, plication as described in the Notice of to travel to VA medical centers and Fund Availability. other VA or non-VA facilities in con- (d) Subrecipients. Grantees may pro- nection with the provision of VA med- vide grant funds to other entities, if ical care. such entities are identified as sub- Veteran means a person who served in recipients in grant applications to per- the active military, naval, or air serv- form work for grantees in the adminis- ice, and who was discharged or released tration of all or part of grantees’ pro- therefrom under conditions other than grams. dishonorable. (Authority: Sec. 307, Pub. L. 111–163; 38 Veterans Service Organization means U.S.C. 501) an organization recognized by the Sec- retary of Veterans Affairs for the rep- (The Office of Management and Budget has approved the information collection require- resentation of veterans under section ment in this section under control number 5902 of title 38, United States Code. 2900–0790) (Authority: Sec. 307, Pub. L. 111–163; 38 U.S.C. 501) § 17.705 Scoring criteria and selection. (a) Initial grant scoring. Applications § 17.702 Grants—general. will be scored using the following se- (a) One grant per highly rural area. VA lection criteria: may award one grant per fiscal year to (1) VA will award up to 40 points a grantee for each highly rural area in based on the program’s plan for suc- which the grantee provides transpor- cessful implementation, as dem- tation services. Transportation serv- onstrated by the following: ices may not be simultaneously pro- (i) Program scope is defined, and ap- vided by more than one grantee in any plicant has specifically indicated the single highly rural area. mode(s) or method(s) of transportation (b) Maximum amount. Grant amounts services to be provided by the applicant will be specified in the Notice of Fund- or identified subrecipient. ing Availability, but no grant will ex- (ii) Program budget is defined, and ceed $50,000. applicant has indicated that grant (c) No matching requirement. A grantee funds will be sufficient to completely will not be required to provide match- implement the program.

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(iii) Program staffing plan is defined, highest ranked applications for which and applicant has indicated that there funding is available. will be adequate staffing for delivery of (c) Renewal grant scoring. Renewal ap- transportation services according to plications will be scored using the fol- the program’s scope. lowing selection criteria: (iv) Program timeframe for imple- (1) VA will award up to 55 points mentation is defined, and applicant has based on the success of the grantee’s indicated that the delivery of transpor- program, as demonstrated by the fol- tation services will be timely. lowing: (2) VA will award up to 30 points (i) Application shows that the grant- based on the program’s evaluation ee or identified subrecipient provided plan, as demonstrated by the following: transportation services which allowed (i) Measurable goals for determining participants to be provided medical the success of delivery of transpor- care timely and as scheduled. tation services. (ii) Application shows that partici- (ii) Ongoing assessment of paragraph pants were satisfied with the transpor- (a)(2)(i), with a means of adjusting the tation services provided by the grantee program as required. or identified subrecipient, as described (3) VA will award up to 20 points in the Notice of Fund Availability. based on the applicant’s community re- (2) VA will award up to 35 points lationships in the areas to receive based on the cost effectiveness of the transportation services, as dem- program, as demonstrated by the fol- onstrated by the following: lowing: (i) Applicant has existing relation- (i) The grantee or identified sub- ships with state or local agencies or recipient administered the program on private entities, or will develop such budget. relationships, and has shown these re- (ii) Grant funds were utilized in a lationships will enhance the program’s sensible manner, as interpreted by in- effectiveness. formation provided by the grantee to (ii) Applicant has established past VA under § 17.725(a)(1) through (a)(7). working relationships with state or (3) VA will award up to 15 points local agencies or private entities which based on the extent to which the pro- have provided transportation services gram complied with: similar to those offered by the pro- (i) The grant agreement. gram. (ii) Applicable laws and regulations. (4) VA will award up to 10 points (d) Renewal grant selection. VA will based on the innovative aspects of the use the following process to award re- program, as demonstrated by the fol- newal grants: lowing: (1) VA will rank those applications (i) How program will identify and that receive at least the minimum serve veterans who otherwise would be amount of total points and points per unable to obtain VA medical care category set forth in the Notice of through conventional transportation Fund Availability. The applications resources. will be ranked in order from highest to (ii) How program will use new or al- lowest scores. ternative transportation resources. (2) VA will use the applications’ (b) Initial grant selection. VA will use ranking as the basis for awarding the following process to award initial grants. VA will award grants for the grants: highest ranked applications for which (1) VA will rank those applications funding is available. that receive at least the minimum amount of total points and points per (Authority: Sec. 307, Pub. L. 111–163; 38 category set forth in the Notice of U.S.C. 501) Fund Availability. The applications will be ranked in order from highest to § 17.710 Notice of Fund Availability. lowest scores. When funds are available for grants, (2) VA will use the applications’ VA will publish a Notice of Fund Avail- ranking as the basis for awarding ability in the FEDERAL REGISTER. The grants. VA will award grants for the notice will identify:

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(a) The location for obtaining grant (iv) Vehicles must be safe and main- applications; tained in accordance with the manufac- (b) The date, time, and place for sub- turer’s recommendations. mitting completed grant applications; (v) Vehicles must be operated in ac- (c) The estimated amount and type of cordance with applicable Department grant funding available; of Transportation regulations con- (d) The length of term for the grant cerning transit requirements under the award; Americans with Disabilities Act. (e) The minimum number of total (b) Additional requirements. Grantees points and points per category that an and identified subrecipients are subject applicant or grantee must receive in to the Uniform Administrative Re- order for a supportive grant to be fund- quirements, Cost Principles, and Audit ed; Requirements for Federal Awards (f) The timeframes and manner for under 2 CFR part 200, and subject to 2 payments under the grant; and CFR parts 25 and 170, if applicable. (g) Those areas identified by VA to be (Authority: Sec. 307, Pub. L. 111–163; 38 the ‘‘highly rural areas’’ in which U.S.C. 501) grantees may provide transportation [78 FR 19593, Apr. 2, 2013, as amended at 80 services funded under this rule. FR 43322, July 22, 2015] (Authority: Sec. 307, Pub. L. 111–163; 38 U.S.C. 501) § 17.720 Payments under the grant. Grantees are to be paid in accordance § 17.715 Grant agreements. with the timeframes and manner set (a) General. After a grantee is award- forth in the Notice of Fund Avail- ed a grant in accordance with § 17.705(b) ability. or § 17.705(d), VA will draft a grant (Authority: Sec. 307, Pub. L. 111–163; 38 agreement to be executed by VA and U.S.C. 501) the grantee. Upon execution of the grant agreement, VA will obligate the § 17.725 Grantee reporting require- approved amount to the grantee. The ments. grant agreement will provide that: (a) Program efficacy. All grantees who (1) The grantee must operate the pro- receive either an initial or renewed gram in accordance with the provisions grant must submit to VA quarterly and of this section and the grant applica- annual reports which indicate the fol- tion. lowing information: (2) If a grantee’s application identi- (1) Record of time expended assisting fied a subrecipient, such subrecipient with the provision of transportation must operate the program in accord- services. ance with the provisions of this section (2) Record of grant funds expended and the grant application. assisting with the provision of trans- (3) If a grantee’s application identi- portation services. fied that funds will be used to procure (3) Trips completed. or operate vehicles to directly provide (4) Total distance covered. transportation services, the following (5) Veterans served. requirements must be met: (6) Locations which received trans- (i) Title to the vehicles must vest portation services. solely in the grantee or identified sub- (7) Results of veteran satisfaction recipient, or with leased vehicles in an survey. identified lender. (b) Quarterly fiscal report. All grantees (ii) The grantee or identified sub- who receive either an initial or renewal recipient must, at a minimum, provide grant must submit to VA a quarterly motor vehicle liability insurance for report which identifies the expendi- the vehicles to the same extent they tures of the funds which VA authorized would insure vehicles procured with and obligated. their own funds. (c) Program variations. Any changes in (iii) All vehicle operators must be li- a grantee’s program activities which censed in a U.S. State or Territory to result in deviations from the grant operate such vehicles. agreement must be reported to VA.

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(d) Additional reporting. Additional re- (b) Non-profit organization: A secular porting requirements may be requested or religious organization, no part of by VA to allow VA to fully assess pro- the net earnings of which may inure to gram effectiveness. the benefit of any member, founder, contributor, or individual. The organi- (Authority: Sec. 307, Pub. L. 111–163; 38 U.S.C. 501) zation must include a voluntary board and must either maintain or designate (The Office of Management and Budget has an entity to maintain an accounting approved the information collection require- system which is operated in accordance ments in this section under control numbers 2900–0709 and 2900–0770) with generally accepted accounting principles. If not named in, or approved § 17.730 Recovery of funds by VA. under Title 38 U.S.C. (United States (a) Recovery of funds. VA may recover Code), Section 5902, a non-profit orga- from the grantee any funds that are nization must provide VA with docu- not used in accordance with a grant mentation which demonstrates ap- agreement. If VA decides to recover proval as a non-profit organization funds, VA will issue to the grantee a under Internal Revenue Code, Section notice of intent to recover grant funds, 501.c(3). and grantee will then have 30 days to (c) Recipient: A non-profit organiza- submit documentation demonstrating tion which has received a loan from VA why the grant funds should not be re- under this program. covered. After review of all submitted (d) Veteran: A person who served in documentation, VA will determine the active military, naval, or air serv- whether action will be taken to recover ice, and who was discharged or released the grant funds. therefrom under conditions other than (b) Prohibition of further grants. When dishonorable. VA determines action will be taken to (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat recover grant funds from the grantee, 271, 38 U.S.C. 501) the grantee is then prohibited from receipt of any further grant funds. § 17.802 Application provisions. (Authority: Sec. 307, Pub. L. 111–163; 38 (a) To obtain a loan under these U.S.C. 501) Transitional Housing Loan Program regulations, an application must be TRANSITIONAL HOUSING LOAN PROGRAM submitted by the applicant in the form prescribed by VA in the application SOURCE: 59 FR 49579, Sept. 29, 1994, unless package. The completed application otherwise noted. package must be submitted to the Dep- uty Associate Director for Psychiatric § 17.800 Purpose. Rehabilitation Services, (302/111C), VA The purpose of the Transitional Medical Center, 100 Emancipation Housing Loan Program regulations is Drive, Hampton, VA 23667. An applica- to establish application provisions and tion package may be obtained by writ- selection criteria for loans to non-prof- ing to the proceeding address or tele- it organizations for use in initial start- phoning (804) 722–9961 x3628. (This is not up costs for transitional housing for a toll-free number) veterans who are in (or have recently (b) The application package includes been in) a program for the treatment of exhibits to be prepared and submitted, substance abuse. This program is in- including: tended to increase the amount of tran- (1) Information concerning the appli- sitional housing available for such vet- cant’s income, assets, liabilities and erans who need a period of supportive credit history, housing to encourage sobriety mainte- (2) Information for VA to verify the nance and reestablishment of social applicant’s financial information, and community relationships. (3) Identification of the official(s) authorized to make financial trans- § 17.801 Definitions. actions on behalf of the applicant, (a) Applicant: A non-profit organiza- (4) Information concerning: tion making application for a loan (i) The history, purpose and composi- under this program. tion of the applicant,

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(ii) The applicant’s involvement with § 17.804 Loan approval criteria. recovering substance abusers, includ- Upon consideration of the application ing: package, loan approval will be based on (A) Type of services provided, (B) Number of persons served, the following: (C) Dates during which each type of (a) Favorable financial history and service was provided, status, (D) Names of at least two references (1) A minimum of a two-year credit of government or community groups history, whom the organization has worked (2) No open liens, judgments, and no with in assisting substance abusers, unpaid collection accounts, (iii) The applicant’s plan for the pro- (3) No more than two instances where vision of transitional housing to vet- payments were ever delinquent beyond erans including: 60 days, (A) Means of identifying and screen- (4) Net ratio: (monthly expenses di- ing potential residents, vided by monthly cash flow) that does (B) Number of occupants intended to not exceed 40%, live in the residence for which the loan (5) Gross ratio: (total indebtedness assistance is requested, divided by gross annual cash flow) that (C) Residence operating policies ad- does not exceed 35%, dressing structure for democratic self- (6) At least two favorable credit ref- government, expulsion policies for non- erences, payment, alcohol or illegal drug use or (b) Demonstrated ability to success- disruptive behavior, fully address the needs of substance (D) Type of technical assistance abusers as determined by a minimum available to residents in the event of of one year of successful experience in house management problems, providing services, such as, provision of (E) Anticipated cost of maintaining housing, vocational training, struc- the residence, including rent and utili- tured job seeking assistance, organized ties, relapse prevention services, or similar (F) Anticipated charge, per veteran, activity. Such experience would infor residing in the residence, volve at least twenty-five substance (G) Anticipated means of collecting abusers, and would be experience which rent and utilities payments from resi- could be verified by VA inquiries of dents, government or community groups with (H) A description of the housing unit whom the applicant has worked in pro- for which the loan is sought to support, viding these services. including location, type of neighbor- (c) An acceptable plan for operating a hood, brief floor plan description, etc., residence designed to meet the condi- and why this residence was selected for tions of a loan under this program, this endeavor. which will include: (iv) The applicant’s plans for use of (1) Measures to ensure that residents the loan proceeds. are eligible for residency, i.e., are vet- (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat. erans, are in (or have recently been in) 271, 38 U.S.C. 501) a program for the treatment of substance abuse, are financially able to § 17.803 Order of consideration. pay their share of costs of maintaining Loan applications will be considered the residence, and agree to abide by on a first-come-first-serve basis, sub- house rules and rent/utilities payment ject to availability of funds for loans provisions, and awards will be made on a first- (2) Adequate rent/utilities collections come-first-serve basis to applicants to cover cost of maintaining the resi- who meet the criteria for receiving a dence, loan. If no funds are available for (3) Policies that ensure democratic loans, applications will be retained in self-run government, including expul- the order of receipt for consideration sion policies, and as funds become available. (4) Available technical assistance to (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat. residents in the event of house manage- 271, 38 U.S.C. 501) ment problems.

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(d) Selection of a suitable housing HEALTH CARE BENEFITS FOR CERTAIN unit for use as a transitional residence CHILDREN OF VIETNAM VETERANS AND in a neighborhood with no known ille- VETERANS WITH COVERED SERVICE IN gal drug activity, and with adequate KOREA—SPINA BIFIDA AND COVERED living space for number of veterans BIRTH DEFECTS planned for residence (at least one large bedroom for every three veterans, SOURCE: 68 FR 1010, Jan. 8, 2003, unless oth- at least one bathroom for every four erwise noted. veterans, adequate common space for entire household) § 17.900 Definitions. (e) Agreements, signed by an official For purposes of §§ 17.900 through authorized to bind the recipient, which 17.905— include: Approved health care provider means a (1) The loan payment schedule in ac- health care provider currently ap- cordance with the requirements of Pub. proved by the Center for Medicare and L. 102–54, with the interest rate being Medicaid Services (CMS), Department the same as the rate the VA is charged of Defense TRICARE Program, Civilian to borrow these funds from the U.S. Health and Medical Program of the De- Department of Treasury and with a partment of Veterans Affairs penalty of 4% of the amount due for (CHAMPVA), The Joint Commission, each failure to pay an installment by or currently approved for providing the date specified in the loan agree- health care under a license or certifi- ment involved, and cate issued by a governmental entity (2) The applicant’s intent to use pro- with jurisdiction. An entity or indi- ceeds of loan only to cover initial vidual will be deemed to be an ap- startup costs associated with the resi- proved health care provider only when dence, such as security deposit, fur- acting within the scope of the ap- nishings, household supplies, and any proval, license, or certificate. other initial startup costs. Child for purposes of spina bifida (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat. means the same as individual as defined 271, 38 U.S.C. 501) at § 3.814(c)(3) or § 3.815(c)(2) of this title and for purposes of covered birth de- § 17.805 Additional terms of loans. fects means the same as individual as In the operation of each residence es- defined at § 3.815(c)(2) of this title. tablished with the assistance of the Covered birth defect means the same loan, the recipient must agree to the as defined at § 3.815(c)(3) of this title following: and also includes complications or (a) The use of alcohol or any illegal medical conditions that are associated drugs in the residence will be prohib- with the covered birth defect(s) accord- ited; ing to the scientific literature. (b) Any resident who violates the Day health care means a therapeutic prohibition of alcohol or any illegal program prescribed by an approved drugs will be expelled from the resi- health care provider that provides nec- dence; essary medical services, rehabilitation, (c) The cost of maintaining the resi- therapeutic activities, socialization, dence, including fees for rent and utili- nutrition, and transportation services ties, will be paid by residents; in a congregate setting. Day health (d) The residents will, through a ma- care may be provided as a component jority vote of the residents, otherwise of outpatient care or respite care. establish policies governing the condi- Habilitative and rehabilitative care tions of the residence, including the means such professional, counseling, manner in which applications for resi- and guidance services and such treat- dence are approved; ment programs (other than vocational (e) The residence will be operated training under 38 U.S.C. 1804 or 1814) as solely as a residence for not less than are necessary to develop, maintain, or six veterans. restore, to the maximum extent prac- (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat. ticable, the functioning of a disabled 271, 38 U.S.C. 501) person.

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Health care means home care, hos- a safe, healthy environment for an in- pital care, long-term care, nursing dividual in the home or other place of home care, outpatient care, preventive residence. Such services contribute to care, habilitative and rehabilitative the prevention, delay, or reduction of care, case management, and respite risk of harm or hospital, nursing home, care; and includes the training of ap- or other institutional care. Home- propriate members of a child’s family maker services include assistance with or household in the care of the child; personal care; home management; com- and the provision of such pharma- pletion of simple household tasks; nu- ceuticals, supplies (including con- trition, including menu planning and tinence-related supplies such as cath- meal preparation; consumer education; eters, pads, and diapers), equipment and hygiene education. Homemaker (including durable medical equipment), services may include assistance with devices, appliances, assistive tech- Instrumental Activities of Daily Liv- nology, direct transportation costs to ing, such as: Light housekeeping; laun- and from approved health care pro- dering; meal preparation; necessary viders (including any necessary costs services to maintain a safe and sani- for meals and lodging en route, and ac- tary environment in the areas of the companiment by an attendant or at- home used by the individual; and serv- tendants), and other materials as the ices essential to the comfort and clean- Secretary determines necessary. liness of the individual and ensuring Health care provider means any entity individual safety. Homemaker services or individual that furnishes health must be provided according to the indi- care, including specialized clinics, vidual’s written plan of care and must health care plans, insurers, organiza- be prescribed by an approved health tions, and institutions. care provider. Health-related services means home- Hospital care means care and treat- maker or home health aide services ment furnished to a child who has been furnished in the individual’s home or admitted to a hospital as a patient. other place of residence to the extent Long-term care means home care, that those services provide assistance nursing home care, and respite care. with Activities of Daily Living and In- Nursing home care means care and strumental Activities of Daily Living treatment furnished to a child who has that have therapeutic value. been admitted to a nursing home as a Home care means medical care, resident. habilitative and rehabilitative care, Other place of residence includes an preventive health services, and health- assisted living facility or residential related services furnished to a child in group home. the child’s home or other place of resi- Outpatient care means care and treat- dence. ment, including day health care and Home health aide services is a compo- preventive health services, furnished to nent of health-related services pro- a child other than hospital care or viding personal care and related sup- nursing home care. port services to an individual in the Preventive care means care and treat- home or other place of residence. Home ment furnished to prevent disability or health aide services may include as- illness, including periodic examina- sistance with Activities of Daily Living tions, immunizations, patient health such as: Bathing; toileting; eating; education, and such other services as dressing; aid in ambulating or trans- the Secretary determines necessary to fers; active and passive exercises; as- provide effective and economical pre- sistance with medical equipment; and ventive health care. routine health monitoring. Home Respite care means care, including health aide services must be provided day health care, furnished by an ap- according to the individual’s written proved health care provider on an plan of care and must be prescribed by intermittent basis for a limited period an approved health care provider. to an individual who resides primarily Homemaker services is a component of in a private residence when such care health-related services encompassing will help the individual continue resid- certain activities that help to maintain ing in such private residence.

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Spina bifida means all forms and (1) The telephone number of the manifestations of spina bifida except Health Administration Center is (888) spina bifida occulta (this includes com- 820–1756; plications or medical conditions that (2) The facsimile number of the are associated with spina bifida accord- Health Administration Center is (303) ing to the scientific literature). 331–7807; Veteran with covered service in Korea (3) The hand-delivery address of the for purposes of spina bifida means the Health Administration Center is 3773 same as defined at § 3.814(c)(2) of this Cherry Creek Drive North, Denver, CO title. 80246; and (4) The mailing address of the Health Vietnam veteran for purposes of spina Administration Center for claims sub- bifida means the same as defined at mitted pursuant to either paragraph § 3.814(c)(1) or § 3.815(c)(1) of this title (a) or (b) of this section is P.O. Box and for purposes of covered birth de- 469065, Denver, CO 80246–9065. fects means the same as defined at § 3.815(c)(1) of this title. (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– 1813, 1831) (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– NOTE TO § 17.901: Under this program, bene- 1813, 1821, 1831) ficiaries with spina bifida will receive com- [68 FR 1010, Jan. 8, 2003, as amended at 76 FR prehensive care through the Department of 4249, Jan. 25, 2011; 79 FR 54616, Sept. 12, 2014; Veterans Affairs. However, the health care 81 FR 19890, Apr. 6, 2016] benefits available under this section to children with other covered birth defects are not § 17.901 Provision of health care. comprehensive, and VA will furnish them only health care services that are related to (a) Spina bifida. VA will provide a their covered birth defects. With respect to Vietnam veteran or veteran with cov- covered children suffering from spina bifida, ered service in Korea’s child who has VA is the exclusive payer for services paid been determined under § 3.814 or § 3.815 under 17.900 through 17.905, regardless of any third party insurer, Medicare, Medicaid, of this title to suffer from spina bifida health plan, or any other plan or program with health care as the Secretary de- providing health care coverage. As to chil- termines is needed. VA may inform dren with other covered birth defects, any spina bifida patients, parents, or guard- third party insurer, Medicare, Medicaid, ians that health care may be available health plan, or any other plan or program at not-for-profit charitable entities. providing health care coverage would be responsible according to its provisions for pay- (b) Covered birth defects. VA will pro- ment for health care not relating to the cov- vide a woman Vietnam veteran’s child ered birth defects. who has been determined under § 3.815 of this title to suffer from covered [68 FR 1010, Jan. 8, 2003, as amended at 76 FR 4249, Jan. 25, 2011] birth defects (other than spina bifida) with such health care as the Secretary § 17.902 Preauthorization. determines is needed by the child for (a) Preauthorization from VA is re- the covered birth defects. However, if quired for the following services or VA has determined for a particular benefits under §§ 17.900 through 17.905: covered birth defect that § 3.815(a)(2) of Rental or purchase of durable medical this title applies (concerning affirma- equipment with a total rental or pur- tive evidence of cause other than the chase price in excess of $300, respec- mother’s service during the Vietnam tively; day health care provided as out- era), no benefits or assistance will be patient care; dental services; home- provided under this section with re- maker services; outpatient mental spect to that particular birth defect. health services in excess of 23 visits in (c) Providers of care. Health care pro- a calendar year; substance abuse treat- vided under this section will be pro- ment; training; transplantation serv- vided directly by VA, by contract with ices; and travel (other than mileage at an approved health care provider, or by the General Services Administration other arrangement with an approved rate for privately owned automobiles). health care provider. Authorization will only be given in (d) Submission of information. For pur- spina bifida cases where it is dem- poses of §§ 17.900 through 17.905: onstrated that the care is medically

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necessary. In cases of other covered mined eligible for benefits under § 3.814 birth defects, authorization will only of this title. be given where it is demonstrated that (ii) For covered birth defects, on or the care is medically necessary and re- after December 1, 2001, and must have lated to the covered birth defects. Re- occurred on or after the date the child quests for provision of health care re- was determined eligible for benefits quiring preauthorization shall be made under § 3.815 of this title. to the Health Administration Center (3) Claims from approved health care and may be made by telephone, fac- providers must be filed with the Health simile, mail, or hand delivery. The ap- Administration Center in writing (fac- plication must contain the following: simile, mail, hand delivery, or elec- (1) Name of child, tronically) no later than: (2) Child’s Social Security number, (i) One year after the date of service; (3) Name of veteran, or (4) Veteran’s Social Security number, (ii) In the case of inpatient care, one (5) Type of service requested, year after the date of discharge; or (6) Medical justification, (iii) In the case of retroactive ap- (7) Estimated cost, and proval for health care, 180 days fol- (8) Name, address, and telephone lowing beneficiary notification of eligi- number of provider. bility. (b) Notwithstanding the provisions of (4) Claims for health care provided paragraph (a) of this section, under the provisions of §§ 17.900 through preauthorization is not required for a 17.905 must contain, as appropriate, the condition for which failure to receive information set forth in paragraphs immediate treatment poses a serious (a)(4)(i) through (a)(4)(v) of this sec- threat to life or health. Such emer- tion. gency care should be reported by tele- (i) Patient identification informa- phone to the Health Administration tion: Center within 72 hours of the emer- (A) Full name, gency. (B) Address, (C) Date of birth, and (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– (D) Social Security number. 1813, 1831) (ii) Provider identification informa- (The Office of Management and Budget has tion (inpatient and outpatient serv- approved the information collection require- ices): ments in this section under control number (A) Full name and address (such as 2900–0219) hospital or physician), [68 FR 1010, Jan. 8, 2003, as amended at 76 FR (B) Remittance address, 4249, Jan. 25, 2011; 81 FR 19890, Apr. 6, 2016] (C) Address where services were rendered, § 17.903 Payment. (D) Individual provider’s professional (a)(1) Payment for services or bene- status (M.D., Ph.D., R.N., etc.), and fits under §§ 17.900 through 17.905 will be (E) Provider tax identification num- determined utilizing the same payment ber (TIN) or Social Security number. methodologies as provided for under (iii) Patient treatment information the Civilian Health and Medical Pro- (long-term care or institutional serv- gram of the Department of Veterans ices): Affairs (CHAMPVA) (see § 17.270). For (A) Dates of service (specific and in- those services or benefits covered by clusive), §§ 17.900 through 17.905 but not covered (B) Summary level itemization (by by CHAMPVA we will use payment revenue code), methodologies the same or similar to (C) Dates of service for all absences those used for equivalent services or from a hospital or other approved insti- benefits provided to veterans. tution during a period for which inpa- (2) As a condition of payment, the tient benefits are being claimed, services must have occurred: (D) Principal diagnosis established, (i) For spina bifida, on or after Octo- after study, to be chiefly responsible ber 1, 1997, and must have occurred on for causing the patient’s hospitaliza- or after the date the child was deter- tion,

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(E) All secondary diagnoses, or agent for the health care provider (F) All procedures performed, may not impose any additional charge (G) Discharge status of the patient, for any services for which payment is and made by VA. (H) Institution’s Medicare provider (d) Explanation of benefits (EOB)—(1) number. When a claim under the provisions of (iv) Patient treatment information §§ 17.900 through 17.905 is adjudicated, for all other health care providers and an EOB will be sent to the beneficiary ancillary outpatient services such as or guardian and the provider. The EOB durable medical equipment, medical provides, at a minimum, the following requisites, and independent labora- information: tories: (i) Name and address of recipient, (A) Diagnosis, (ii) Description of services and/or (B) Procedure code for each proce- supplies provided, dure, service, or supply for each date of (iii) Dates of services or supplies pro- service, and vided, (C) Individual billed charge for each (iv) Amount billed, procedure, service, or supply for each (v) Determined allowable amount, date of service. (vi) To whom payment, if any, was (v) Prescription drugs and medicines made, and and pharmacy supplies: (vii) Reasons for denial (if applica- (A) Name and address of pharmacy ble). where drug was dispensed, (2) [Reserved] (B) Name of drug, (C) National Drug Code (NDC) for (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– drug provided, 1813, 1831) (D) Strength, (The Office of Management and Budget has (E) Quantity, approved the information collection require- (F) Date dispensed, ments in this section under control number (G) Pharmacy receipt for each drug 2900–0219) dispensed (including billed charge), and [68 FR 1010, Jan. 8, 2003, as amended at 76 FR (H) Diagnosis for which each drug is 4249, Jan. 25, 2011; 81 FR 19890, Apr. 6, 2016] prescribed. (b) Health care payment will be pro- § 17.904 Review and appeal process. vided in accordance with the provisions For purposes of §§ 17.900 through of §§ 17.900 through 17.905. However, the 17.905, if a health care provider, child, following are specifically excluded or representative disagrees with a de- from payment: termination concerning provision of (1) Care as part of a grant study or health care or with a determination research program, concerning payment, the person or en- (2) Care considered experimental or tity may request reconsideration. Such investigational, request must be submitted in writing (3) Drugs not approved by the U.S. (by facsimile, mail, or hand delivery) Food and Drug Administration for within one year of the date of the ini- commercial marketing, tial determination to the Health Ad- (4) Services, procedures, or supplies ministration Center (Attention: Chief, for which the beneficiary has no legal Benefit and Provider Services). The re- obligation to pay, such as services ob- quest must state why it is believed tained at a health fair, that the decision is in error and must (5) Services provided outside the include any new and relevant informa- scope of the provider’s license or cer- tion not previously considered. Any re- tification, and quest for reconsideration that does not (6) Services rendered by providers identify the reason for dispute will be suspended or sanctioned by a Federal returned to the sender without further agency. consideration. After reviewing the (c) Payments made in accordance matter, including any relevant sup- with the provisions of §§ 17.900 through porting documentation, a benefits ad- 17.905 shall constitute payment in full. visor will issue a written determina- Accordingly, the health care provider tion (with a statement of findings and

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reasons) to the person or entity seek- § 17.1000 Payment or reimbursement ing reconsideration that affirms, re- for emergency services for non- verses, or modifies the previous deci- service-connected conditions in sion. If the person or entity seeking re- non-VA facilities. consideration is still dissatisfied, with- Sections 17.1000 through 17.1008 con- in 90 days of the date of the decision he stitute the requirements under 38 or she may submit in writing (by fac- U.S.C. 1725 that govern VA payment or simile, mail, or hand delivery) to the reimbursement for non-VA emergency Health Administration Center (Atten- services furnished to a veteran for non- tion: Director) a request for review by service-connected conditions. the Director, Health Administration Center. The Director will review the (Authority: 38 U.S.C. 1725) claim and any relevant supporting doc- NOTE TO § 17.1000: In cases where a patient umentation and issue a decision in is admitted for inpatient care, health care writing (with a statement of findings providers furnishing emergency treatment and reasons) that affirms, reverses, or who believe they may have a basis for filing a claim with VA for payment under 38 U.S.C. modifies the previous decision. An ap- 1725 should contact VA within 48-hours after peal under this section would be con- admission for emergency treatment. Such sidered as filed at the time it was de- contact is not a condition of VA payment. livered to the VA or at the time it was However, the contact will assist the provider released for submission to the VA (for in understanding the conditions for pay- example, this could be evidenced by the ment. The contact may also assist the provider in planning for transfer of the veteran postmark, if mailed). after stabilization. NOTE TO § 17.904: The final decision of the [66 FR 36470, July 12, 2001, as amended at 68 Director will inform the claimant of further FR 3404, Jan. 24, 2003] appellate rights for an appeal to the Board of Veterans’ Appeals. § 17.1001 Definitions. (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– For purposes of §§ 17.1000 through 1813, 1831) 17.1008: (The Office of Management and Budget has (a) The term health-plan contract approved the information collection require- means any of the following: ments in this section under control number (1) An insurance policy or contract, 2900–0219) medical or hospital service agreement, [68 FR 1010, Jan. 8, 2003, as amended at 76 FR membership or subscription contract, 4250, Jan. 25, 2011; 81 FR 19891, Apr. 6, 2016] or similar arrangement under which health services for individuals are pro- § 17.905 Medical records. vided or the expenses of such services are paid; Copies of medical records generated (2) An insurance program described outside VA that relate to activities for in section 1811 of the Social Security which VA is asked to provide payment Act (42 U.S.C. 1395c) or established by or that VA determines are necessary to section 1831 of that Act (42 U.S.C. adjudicate claims under §§ 17.900 1395j); through 17.905 must be provided to VA (3) A State plan for medical assist- at no cost. ance approved under title XIX of the (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– Social Security Act (42 U.S.C. 1396 et 1813, 1831) seq.); [68 FR 1010, Jan. 8, 2003, as amended at 76 FR (4) A workers’ compensation law or 4250, Jan. 25, 2011] plan described in section 38 U.S.C. 1729(a)(2)(A); or PAYMENT OR REIMBURSEMENT FOR (b) The term third party means any of EMERGENCY SERVICES FOR NON- the following: SERVICE-CONNECTED CONDITIONS IN (1) A Federal entity; NON-VA FACILITIES (2) A State or political subdivision of a State; SOURCE: 66 FR 36470, July 12, 2001, unless (3) An employer or an employer’s in- otherwise noted. surance carrier;

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(4) An automobile accident repara- (including severe pain) that a prudent tions insurance carrier; or layperson who possesses an average (5) A person or entity obligated to knowledge of health and medicine provide, or to pay the expenses of, could reasonably expect the absence of health services under a health-plan immediate medical attention to result contract. in placing the health of the individual (c) The term duplicate payment means in serious jeopardy, serious impair- payment made, in whole or in part, for ment to bodily functions, or serious the same emergency services for which dysfunction of any bodily organ or VA reimbursed or made payment. part); (d) The term stabilized means that no (c) A VA or other Federal facility/ material deterioration of the emer- provider that VA has an agreement gency medical condition is likely, with to furnish health care services for within reasonable medical probability, veterans was not feasibly available and to occur if the veteran is discharged or an attempt to use them beforehand transferred to a VA or other Federal would not have been considered reason- facility that VA has an agreement with able by a prudent layperson (as an ex- to furnish health care services for vet- ample, these conditions would be met erans. by evidence establishing that a veteran (e) The term VA medical facility of ju- was brought to a hospital in an ambu- risdiction means the nearest VA med- lance and the ambulance personnel de- ical facility to where the emergency termined the nearest available appro- service was provided. priate level of care was at a non-VA (Authority: 38 U.S.C. 1725) medical center); (d) At the time the emergency treat- [66 FR 36470, July 12, 2001, as amended at 76 FR 79071, Dec. 21, 2011; 77 FR 23617, Apr. 20, ment was furnished, the veteran was 2012] enrolled in the VA health care system and had received medical services § 17.1002 Substantive conditions for under authority of 38 U.S.C. chapter 17 payment or reimbursement. within the 24-month period preceding Payment or reimbursement under 38 the furnishing of such emergency U.S.C. 1725 for emergency treatment treatment; (including medical services, profes- (e) The veteran is financially liable sional services, ambulance services, an- to the provider of emergency treat- cillary care and medication (including ment for that treatment; a short course of medication related to (f) The veteran does not have cov- and necessary for the treatment of the erage under a health-plan contract emergency condition that is provided that would fully extinguish the med- directly to or prescribed for the patient ical liability for the emergency treat- for use after the emergency condition ment (this condition cannot be met if is stabilized and the patient is dis- the veteran has coverage under a charged)) will be made only if all of the health-plan contract but payment is following conditions are met: barred because of a failure by the vet- (a) The emergency services were pro- eran or the provider to comply with vided in a hospital emergency depart- the provisions of that health-plan con- ment or a similar facility held out as tract, e.g., failure to submit a bill or providing emergency care to the pub- medical records within specified time lic; limits, or failure to exhaust appeals of (b) The claim for payment or reim- the denial of payment); bursement for the initial evaluation (g) If the condition for which the and treatment is for a condition of emergency treatment was furnished such a nature that a prudent layperson was caused by an accident or work-re- would have reasonably expected that lated injury, the claimant has ex- delay in seeking immediate medical at- hausted without success all claims and tention would have been hazardous to remedies reasonably available to the life or health (this standard would be veteran or provider against a third met if there were an emergency med- party for payment of such treatment; ical condition manifesting itself by and the veteran has no contractual or acute symptoms of sufficient severity legal recourse against a third party

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that could reasonably be pursued for work-related injury, the claimant has the purpose of extinguishing, in whole, exhausted without success all claims the veteran’s liability to the provider; and remedies reasonably available to and the veteran or provider against a third (h) The veteran is not eligible for re- party for payment of such transpor- imbursement under 38 U.S.C. 1728 for tation; and the veteran has no contrac- the emergency treatment provided (38 tual or legal recourse against a third U.S.C. 1728 authorizes VA payment or party that could reasonably be pursued reimbursement for emergency treat- for the purpose of fully extinguishing ment to a limited group of veterans, the veteran’s liability to the provider; primarily those who receive emergency and treatment for a service-connected dis- (e) If the veteran is not eligible for ability). reimbursement for any emergency (Authority: 38 U.S.C. 1725) treatment expenses under 38 U.S.C. 1728. [66 FR 36470, July 12, 2001, as amended at 68 FR 3404, Jan. 24, 2003; 76 FR 79071, Dec. 21, (Authority: 38 U.S.C. 1725) 2011; 77 FR 23617, Apr. 20, 2012; 80 FR 79484, [66 FR 36470, July 12, 2001, as amended at 83 Dec. 22, 2015; 83 FR 979, Jan. 9, 2018] FR 979, Jan. 9, 2018]

§ 17.1003 Emergency transportation. § 17.1004 Filing claims. Notwithstanding the provisions of (a) A claimant for payment or reim- § 17.1002, payment or reimbursement bursement under 38 U.S.C. 1725 must be under 38 U.S.C. 1725 for ambulance the entity that furnished the treat- services, including air ambulance serv- ment, the veteran who paid for the ices, may be made for transporting a treatment, or the person or organiza- veteran to a facility only if the fol- tion that paid for such treatment on lowing conditions are met: behalf of the veteran. (a) Payment or reimbursement is au- (b) To obtain payment or reimburse- thorized under 38 U.S.C. 1725 for emer- ment for emergency treatment under gency treatment provided at a non-VA 38 U.S.C. 1725, a claimant must submit facility, or payment or reimbursement to the VA medical facility of jurisdic- would have been authorized under 38 tion a completed standard billing form U.S.C. 1725 for emergency treatment had: (such as a UB92 or a CMS 1500). Where (1) The veteran’s personal liability the form used does not contain a false for the emergency treatment not been claims notice, the completed form fully extinguished by payment by a must also be accompanied by a signed, third party, including under a health- written statement declaring that ‘‘I plan contract; or hereby certify that this claim meets (2) Death had not occurred before all of the conditions for payment by emergency treatment could be pro- VA for emergency medical services vided; under 38 CFR 17.1002 (except for para- (b) The veteran is financially liable graph (e)) and 17.1003. I am aware that to the provider of the emergency trans- 38 U.S.C. 6102(b) provides that one who portation; obtains payment without being enti- (c) The veteran does not have cov- tled to it and with intent to defraud erage under a health-plan contract the United States shall be fined in ac- that would fully extinguish the med- cordance with title 18, United States ical liability for the emergency trans- Code, or imprisoned not more than one portation (this condition is not met if year, or both.’’ the veteran has coverage under a NOTE TO § 17.1004(b): These regulations re- health-plan contract but payment is garding payment or reimbursement for barred because of a failure by the vet- emergency services for nonservice-connected eran or the provider to comply with conditions in non-VA facilities also can be the provisions of that health-plan con- found on the internet at http://www.va.gov/ tract); health/elig. (d) If the condition for which the (c) Notwithstanding the provisions of emergency transportation was fur- paragraph (b) of this section, no spe- nished was caused by an accident or cific form is required for a claimant (or

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duly authorized representative) to bursement no later than 1 year after claim payment or reimbursement for May 21, 2012. emergency transportation charges (The Office of Management and Budget has under 38 U.S.C. 1725. The claimant need approved the information collection require- only submit a signed and dated request ments in this section under control number for such payment or reimbursement to 2900–0620.) the VA medical facility of jurisdiction, [66 FR 36470, July 12, 2001, as amended at 68 together with a bill showing the serv- FR 3404, Jan. 24, 2003; 77 FR 23617, Apr. 20, ices provided and charges for which the 2012; 84 FR 26307, June 5, 2019] veteran is personally liable and a § 17.1005 Payment limitations. signed statement explaining who requested such transportation services (a) Payment or reimbursement for and why they were necessary. emergency treatment (including emergency transportation) under 38 U.S.C. (d) To receive payment or reimburse- 1725 will be calculated as follows: ment for emergency services, a claim- (1) If an eligible veteran has personal ant must file a claim within 90 days liability to a provider of emergency after the latest of the following: treatment and no contractual or legal (1) The date that the veteran was dis- recourse against a third party, includ- charged from the facility that fur- ing under a health-plan contract, VA nished the emergency treatment; will pay the lesser of the amount for (2) The date of death, but only if the which the veteran is personally liable death occurred during transportation or 70 percent of the applicable Medi- to a facility for emergency treatment care fee schedule amount for such or if the death occurred during the stay treatment. in the facility that included the provi- (2) If an eligible veteran has personal sion of the emergency treatment; or liability to a provider of emergency (3) The date the veteran finally ex- treatment after payment by a third hausted, without success, action to ob- party, including under a health-plan tain payment or reimbursement for the contract, VA will pay: treatment from a third party. (i) The difference between the amount VA would have paid under (e) If after reviewing a claim the de- paragraph (a)(1) of this section for the cisionmaker determines that addi- cost of the emergency treatment and tional information is needed to make a the amount paid (or payable) by the determination regarding the claim, third party, if that amount would be such official will contact the claimant greater than zero, or; in writing and request additional infor- (ii) If applying paragraph (a)(2)(i) of mation. The additional information this section would result in no pay- must be submitted to the decision- ment by VA, the lesser of the veteran’s maker within 30 days of receipt of the remaining personal liability after such request or the claim will be treated as third-party payment or 70 percent of abandoned, except that if the claimant the applicable Medicare fee schedule within the 30-day period requests in amount for such treatment. writing additional time, the time pe- (3) In the absence of a Medicare fee riod for submission of the information schedule rate for the emergency treat- may be extended as reasonably nec- ment, VA payment will be the lesser of essary for the requested information to the amount for which the veteran is be obtained. personally liable or the amount cal- (f) Notwithstanding paragraph (d) of culated by the VA Fee Schedule in this section, VA will provide retro- § 17.56 (a)(2)(i)(B). active payment or reimbursement for (4) Unless rejected and refunded by the provider within 30 days from the emergency treatment received by the date of receipt, the provider will con- veteran on or after July 19, 2001, but sider VA’s payment made under para- more than 90 days before May 21, 2012, graphs (a)(1), (a)(2), or (a)(3) of this sec- if the claimant files a claim for reim- tion as payment in full and extinguish the veteran’s liability to the provider. (Neither the absence of a contract or

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agreement between the Secretary and (or other Federal facility) and docu- the provider nor any provision of a con- mented such contact in the veteran’s tract, agreement, or assignment to the progress/physicians’ notes, discharge contrary shall operate to modify, limit, summary, or other applicable medical or negate the requirement in the pre- record. ceding sentence.) (d) If a stabilized veteran who re- (5) VA will not reimburse a veteran quires continued non-emergency treat- under this section for any copayment, ment refuses to be transferred to an deductible, coinsurance, or similar available VA facility (or other Federal payment that the veteran owes the facility that VA has an agreement with third party or is obligated to pay under to furnish health care services for vet- a health-plan contract. erans), VA will make payment or reim- (b) Except as provided in paragraph bursement only for the expenses re- (c) of this section, VA will not approve lated to the initial evaluation and the claims for payment or reimbursement emergency treatment furnished to the of the costs of emergency treatment veteran up to the point of refusal of not previously authorized for any pe- transfer by the veteran. riod beyond the date on which the medical emergency ended. For this pur- (Authority: 38 U.S.C. 1725) pose, VA considers that an emergency [66 FR 36470, July 12, 2001, as amended at 68 ends when the designated VA clinician FR 3404, Jan. 24, 2003; 76 FR 79071, Dec. 21, at the VA facility has determined that, 2011; 77 FR 23618, Apr. 20, 2012; 78 FR 36093, based on sound medical judgment, a June 17, 2013; 83 FR 979, Jan. 9, 2018] veteran who received emergency treatment: § 17.1006 Decisionmakers. (1) Could have been transferred from The Chief of the Health Administra- the non-VA facility to a VA medical tion Service or an equivalent official at center (or other Federal facility that the VA medical facility of jurisdiction VA has an agreement with to furnish will make all determinations regarding health care services for veterans) for payment or reimbursement under 38 continuation of treatment, or U.S.C. 1725, except that the designated (2) Could have reported to a VA med- VA clinician at the VA medical facility ical center (or other Federal facility of jurisdiction will make determina- that VA has an agreement with to fur- tions regarding § 17.1002(b), (c), and (d). nish health care services for veterans) Any decision denying a benefit must be for continuation of treatment. in writing and inform the claimant of (c) Claims for payment or reimburse- VA reconsideration and appeal rights. ment of the costs of emergency treat- (Authority: 38 U.S.C. 1725) ment not previously authorized may be approved for continued, non-emergency [66 FR 36470, July 12, 2001, as amended at 76 treatment, only if: FR 79072, Dec. 21, 2011] (1) The non-VA facility notified VA at the time the veteran could be safely § 17.1007 Independent right of recov- transferred to a VA facility (or other ery. Federal facility that VA has an agree- (a) VA has the right to recover its ment with to furnish health care serv- payment under this section when, and ices for veterans) and the transfer of to the extent that, a third party makes the veteran was not accepted, and payment for all or part of the same (2) The non-VA facility made and emergency treatment for which VA re- documented reasonable attempts to reimbursed or made payment under this quest transfer of the veteran to VA (or section. to another Federal facility that VA has (1) Under 38 U.S.C. 1725(d)(4), the vet- an agreement with to furnish health eran (or the veteran’s personal rep- care services for veterans), which resentative, successor, dependents, or means the non-VA facility contacted survivors) or claimant shall ensure either the VA Transfer Coordinator, that the Secretary is promptly notified Administrative Officer of the Day, or of any payment received from any designated staff responsible for accept- third party for emergency treatment ing transfer of patients at a local VA furnished to the veteran. The veteran

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(or the veteran’s personal representa- would conflict with other litigative in- tive, successor, dependents, or sur- terests of the United States. vivors) or claimant shall immediately (Authority: 38 U.S.C. 1725) forward all documents relating to such payment, cooperate with the Secretary § 17.1008 Balance billing prohibited. in the investigation of such payment and assist the Secretary in enforcing Payment by VA under 38 U.S.C. 1725 the United States’ right to recover any on behalf of a veteran to a provider of payment made and accepted under this emergency treatment and any non- section. The required notification and emergency treatment that is authorized under § 17.1005(c) of this part shall, submission of documentation must be unless rejected and refunded by the provided by the veteran or claimant to provider within 30 days of receipt, ex- the VA medical facility of jurisdiction tinguish all liability on the part of the within three working days of receipt of veteran for that emergency treatment notice of the duplicate payment. and any non-emergency treatment that (2) If the Chief Financial Officer or is authorized under § 17.1005(c) of this equivalent official at the VA medical part. Neither the absence of a contract facility of jurisdiction concludes that or agreement between VA and the pro- payment from a third party was made vider nor any provision of a contract, for all or part of the same emergency agreement, or assignment to the con- treatment for which VA reimbursed or trary shall operate to modify, limit, or made payment under this section, such negate this requirement. VA official shall, except as provided in paragraph (c) of this section, initiate (Authority: 38 U.S.C. 1725) action to collect or recover the amount [66 FR 36470, July 12, 2001, as amended at 76 of the duplicate payment in the same FR 79072, Dec. 21, 2011] manner as for any other debt owed the United States. EXPANDED ACCESS TO NON-VA CARE (b)(1) Any amount paid by the United THROUGH THE VETERANS CHOICE PRO- States to the veteran (or the veteran’s GRAM personal representative, successor, dependents, or survivors) or to any other SOURCE: Sections 17.1500 through 17.1540 ap- person or organization paying for such pear at 79 FR 65585, Nov. 5, 2014, unless other- treatment shall constitute a lien in wise noted. favor of the United States against any § 17.1500 Purpose and scope. recovery the payee subsequently receives from a third party for the same (a) Purpose. Sections 17.1500 through treatment. 17.1540 implement the Veterans Choice (2) Any amount paid by the United Program, authorized by section 101 of States, and accepted by the provider the Veterans Access, Choice, and Ac- that furnished the veteran’s emergency countability Act of 2014. treatment, shall constitute a lien (b) Scope. The Veterans Choice Pro- against any subsequent amount the gram authorizes VA to furnish hospital provider receives from a third party for care and medical services to eligible the same emergency treatment for veterans, as defined in § 17.1510, which the United States made pay- through agreements with eligible enti- ment. ties or providers, as defined in § 17.1530. (c) If it is determined that a dupli- (Authority: Sec. 101, Pub. L. 113–146, 128 Stat. cate payment was made, the Chief Fi- 1754) nancial Officer or equivalent official at the VA medical facility of jurisdiction § 17.1505 Definitions. may waive recovery of a VA payment For purposes of the Veterans Choice made under this section to a veteran Program under §§ 17.1500 through upon determining that the veteran has 17.1540: substantially complied with the provi- Appointment means an authorized and sions of paragraph (a)(1) of this section scheduled encounter with a health care and that actions to recover the pay- provider for the delivery of hospital ment would not be cost-effective or care or medical services. A visit to an

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emergency room or an unscheduled one full-time primary care physician. visit to a clinic is not an appointment. A Vet Center, or Readjustment Coun- Attempt to schedule means contact seling Service Center, is not a VA med- with a VA scheduler or VA health care ical facility. provider in which a stated request by Wait-time goals of the Veterans Health the veteran for an appointment is Administration means, unless changed made. by further notice in the FEDERAL REG- Episode of care means a necessary ISTER, a date not more than 30 days course of treatment, including follow- from either: up appointments and ancillary and spe- (1) The date that an appointment is cialty services, which lasts no longer deemed clinically appropriate by a VA than 1 calendar year from the date of health care provider. In the event a VA the first appointment with a non-VA health care provider identifies a time health care provider. range when care must be provided (e.g., Full-time primary care physician means within the next 2 months), VA will use a single VA physician whose workload, the last clinically appropriate date for or multiple VA physicians whose com- determining whether or not such care bined workload, equates to 0.9 full time is timely. equivalent employee working at least (2) Or, if no such clinical determina- 36 clinical hours a week at the VA med- tion has been made, the date that a ical facility and who provides primary veteran prefers to be seen for hospital care as defined by their privileges or care or medical services. scope of practice and licensure. (Authority: Sec. 101, Pub. L. 113–146, 128 Stat. Health-care plan means an insurance 1754; Sec. 4005, Pub. L. 114–41, 129 Stat. 443) policy or contract, medical or hospital [79 FR 65585, Nov. 5, 2014, as amended at 80 service agreement, membership or sub- FR 74995, Dec. 1, 2015] scription contract, or similar arrangement not administered by the Sec- § 17.1510 Eligible veterans. retary of Veterans Affairs, under which A veteran must meet the eligibility health services for individuals are pro- criteria under both paragraphs (a) and vided or the expenses of such services (b) of this section to be eligible for care are paid; and does not include any such through the Veterans Choice Program. policy, contract, agreement, or similar A veteran must also provide the infor- arrangement pursuant to title XVIII or mation required by paragraphs (c) and XIX of the Social Security Act (42 (d) of this section. U.S.C. 1395 et seq.) or chapter 55 of title (a) A veteran must be enrolled in the 10, United States Code. VA health care system under § 17.36. Residence means a legal residence or (b) A veteran must also meet at least personal domicile, even if such resi- one of the following criteria: dence is seasonal. A person may main- (1) The veteran attempts, or has at- tain more than one residence but may tempted, to schedule an appointment only have one residence at a time. If a with a VA health care provider, but VA veteran lives in more than one location is unable to schedule an appointment during a year, the veteran’s residence for the veteran within: is the residence or domicile where the (i) The wait-time goals of the Vet- person is staying at the time the veterans Health Administration; or eran wants to receive hospital care or (ii) With respect to such care or serv- medical services through the Program. ices that are clinically necessary, the A post office box or other non-residen- period VA determines necessary for tial point of delivery does not con- such care or services if such period is stitute a residence. shorter than the wait-time goals of the Schedule means identifying and con- Veterans Health Administration. firming a date, time, location, and en- (2) The veteran’s residence is more tity or health care provider for an ap- than 40 miles from the VA medical fa- pointment. cility that is closest to the veteran’s VA medical facility means a VA hos- residence. pital, a VA community-based out- (3) The veteran’s residence is both: patient clinic, or a VA health care cen- (i) In a state without a VA medical ter, any of which must have at least facility that provides hospital care,

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emergency medical services, and sur- under this section, VA will use the gical care having a surgical complexity driving distance between the nearest of standard (VA maintains a Web site VA medical facility and a veteran’s with a list of the facilities that have residence. VA will calculate a veteran’s been designated with at least a surgical driving distance using geographic in- complexity of standard. That Web site formation system software. can be accessed here: www.va.gov/ (Authority: Sec. 101, Pub. L. 113–146, 128 Stat. health/surgery); and 1754; Section 3(a)(2) of Pub. L. 114–19, 129 (ii) More than 20 miles from a med- Stat. 215) ical facility described in paragraph (The information collection requirements (b)(3)(i) of this section. have been submitted to the Office of Manage- (4) The veteran’s residence is in a lo- ment and Budget and are pending OMB ap- cation, other than one in Guam, Amer- proval.) ican Samoa, or the Republic of the [79 FR 65585, Nov. 5, 2014, as amended at 80 Philippines, which is 40 miles or less FR 22909, Apr. 24, 2015; 80 FR 74996, Dec. 1, from a VA medical facility and the vet- 2015] eran: (i) Must travel by air, boat, or ferry § 17.1515 Authorizing non-VA care. to reach such a VA medical facility; or (a) Electing non-VA care. A veteran el- (ii) Faces an unusual or excessive igible for the Veterans Choice Program burden in traveling to such a VA med- under § 17.1510 may choose to schedule ical facility based on geographical an appointment with a VA health care challenges, such as the presence of a provider, be placed on an electronic body of water (including moving water waiting list for VA care, or have VA and still water) or a geologic formation authorize the veteran to receive an epi- that cannot be crossed by road; envi- sode of care for hospital care or med- ronmental factors, such as roads that ical services under 38 CFR 17.38 from an are not accessible to the general pub- eligible entity or provider. lic, traffic, or hazardous weather; a medical condition that affects the abil- (b) Selecting a non-VA provider. An eli- ity to travel; or other factors, as deter- gible veteran may specify a particular mined by VA, including but not limited non-VA entity or health care provider, to: if that entity or health care provider (A) The nature or simplicity of the meets the requirements of § 17.1530. If hospital care or medical services the an eligible veteran does not specify a veteran requires; particular eligible entity or provider, (B) The frequency that such hospital VA will refer the veteran to a specific care or medical services need to be fur- eligible entity or provider. nished to the veteran; and (Authority: Sec. 101, Pub. L. 113–146, 128 Stat. (C) The need for an attendant, which 1754) is defined as a person who provides re- (The information collection requirements quired aid and/or physical assistance to have been submitted to the Office of Manage- the veteran, for a veteran to travel to ment and Budget and are pending OMB ap- a VA medical facility for hospital care proval.) or medical services. (c) If the veteran changes his or her § 17.1520 Effect on other provisions. residence, the veteran must update VA (a) General. In general, eligibility about the change within 60 days. under the Veterans Choice Program (d) A veteran must provide to VA in- does not affect a veteran’s eligibility formation on any health-care plan for hospital care or medical services under which the veteran is covered under the medical benefits package, as prior to obtaining authorization for defined in § 17.38, or other benefits ad- care under the Veterans Choice Pro- dressed in this part. Notwithstanding gram. If the veteran changes health- any other provision of this part, VA care plans, the veteran must update will pay for and fill prescriptions writ- VA about the change within 60 days. ten by eligible providers under § 17.1530 (e) For purposes of calculating the for eligible veterans under § 17.1510, in- distance between a veteran’s residence cluding prescriptions for drugs, includ- and the nearest VA medical facility ing over-the-counter drugs and medical

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and surgical supplies available under be executed by a duly authorized De- the VA national formulary system. partment official. (b) Copayments. VA will be liable for (c) Accessibility. An entity or provider any deductibles, cost-shares, or copay- may only furnish hospital care or med- ments required by an eligible veteran’s ical services to an eligible veteran if health-care plan for hospital care and the entity or provider is accessible to medical services furnished under this the eligible veteran. VA will determine Program, to the extent that such reim- accessibility by considering the fol- bursement does not result in expendi- lowing factors: tures by VA for the furnished care or (1) The length of time the eligible services in excess of the rate estab- veteran would have to wait to receive lished under § 17.1535. Veterans are also hospital care or medical services from liable for a VA copayment for care fur- the entity or provider; nished under this Program, as required (2) The qualifications of the entity or by §§ 17.108(b)(4), 17.108(c)(4), 17.110(b)(4), provider to furnish the hospital care or and 17.111(b)(3). medical services to the eligible vet- (c) Beneficiary travel. For veterans eran; and who are eligible for beneficiary travel (3) The distance between the eligible benefits under part 70 of this chapter, veteran’s residence and the entity or VA will provide beneficiary travel ben- provider. efits for travel to and from the location (d) Requirements for health care proof the eligible entity or provider who viders. (1) To be eligible to furnish care furnishes hospital care or medical serv- or services under the Veterans Choice ices for an authorized appointment Program, a health care provider must: under the Veterans Choice Program (i) Maintain at least the same or without regard to the limitations in similar credentials and licenses as § 70.30(b)(2) of this chapter. those required of VA’s health care pro- (Authority: 38 U.S.C. 111; Sec. 101, Pub. L. viders, as determined by the Secretary. 113–146, 128 Stat. 1754) The agreement reached under paragraph (b) of this section will clarify § 17.1525 [Reserved] these requirements. Eligible health care providers must submit § 17.1530 Eligible entities and pro- verification of such licenses and cre- viders. dentials maintained by the provider to (a) General. An entity or provider is VA at least once per 12-month period. eligible to deliver care under the Vet- (ii) Not be excluded from participa- erans Choice Program if, in accordance tion in a Federal health care program with paragraph (c) of this section, it is (as defined in section 1128B(f) of the So- accessible to the veteran and is an en- cial Security Act (42 U.S.C. 1320a–7b(f)) tity or provider identified in section under section 1128 or 1128A of such Act 101(a)(1)(B)(i)–(iv) of the Veterans Ac- (42 U.S.C. 1320a–7 and 1320a–7a)), not be cess, Choice, and Accountability Act of identified as an excluded source on the 2014 or is an entity identified in para- list maintained in the System for graph (e) of this section, and is either: Award Management or any successor (1) Not a part of, or an employee of, system, and not be identified on the VA; or List of Excluded Individuals and Enti- (2) If the provider is an employee of ties that is maintained by the Office of VA, is not acting within the scope of the Inspector General of the U.S. De- such employment while providing hos- partment of Health and Human Serv- pital care or medical services through ices. the Veterans Choice Program. (2) Any entities that are eligible to (b) Agreement. An entity or provider provide care through the Program must enter into an agreement with VA must ensure that any of their providers to provide non-VA hospital care or furnishing care and services through medical services to eligible veterans the Program meet the standards iden- through one of the following types of tified in paragraph (d)(1) of this sec- agreements: contracts, intergovern- tion. An eligible entity may submit mental agreements, or provider agree- this information on behalf of its pro- ments. Each form of agreement must viders.

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(e) Other eligible entities and providers. et seq.) for the same care or services. In accordance with sections These rates are known as the ‘‘Medi- 101(a)(1)(B)(v) and 101(d)(5) of the Vet- care Fee Schedule’’ for VA purposes. erans Access, Choice, and Account- (2) For eligible entities or providers ability Act of 2014 (as amended), the in highly rural areas, the Secretary following entities or providers are eli- may enter into an agreement that in- gible to deliver care under the Vet- cludes a rate greater than the rate de- erans Choice Program, subject to the fined paragraph (a)(1) of this section additional criteria established in this for hospital care or medical services, so section. long as such rate is still determined by (1) A health care provider that is par- VA to be fair and reasonable. The term ticipating in a State Medicaid plan ‘‘highly rural area’’ means an area lo- under title XIX of the Social Security cated in a county that has fewer than Act (42 U.S.C. 1396 et seq.), including seven individuals residing in that coun- any physician furnishing services ty per square mile. under such program, if the health care (3) For eligible entities or providers provider has an agreement under a in Alaska, the Secretary may enter State plan under title XIX of such Act into agreements at rates established (42 U.S.C. 1396 et seq.) or a waiver of under §§ 17.55(j) and 17.56(b). such a plan; (4) For eligible entities or providers (2) An Aging and Disability Resource in a State with an All-Payer Model Center, an area agency on aging, or a Agreement under the Social Security State agency (as defined in section 102 Act that became effective on January of the Older Americans Act of 1965 (42 1, 2014, payment rates will be cal- U.S.C. 3002)), or a center for inde- culated based on the payment rates pendent living (as defined in section 702 under such agreement. of the Rehabilitation Act of 1973 (29 (5) When there are no available rates U.S.C. 796a)). as described in paragraph (a)(1) of this (3) A health care provider that is not section, the Secretary shall, to the ex- identified in paragraph (e)(1) or (2) of tent consistent with the Veterans Ac- this section, if that provider meets all cess, Choice, and Accountability Act of requirements under paragraph (d) of 2014, follow the process and method- this section. ology outlined in §§ 17.55 and 17.56 and pay the resulting rate. (Authority: Sec. 101, Pub. L. 113–146, 128 Stat. 1754; Sec. 4005, Pub. L. 114–41, 129 Stat. 443) (b) Payment responsibilities. Responsi- (The information collection requirements bility for payments will be as follows. have been submitted to the Office of Manage- (1) For a nonservice-connected dis- ment and Budget and are pending OMB ap- ability, as that term is defined at proval.) § 3.1(l) of this chapter, a health-care [79 FR 65585, Nov. 5, 2014, as amended at 80 plan of an eligible veteran is primarily FR 74996, Dec. 1, 2015; 81 FR 24027, Apr. 25, responsible, to the extent such care or 2016] services is covered by the health-care plan, for paying the eligible entity or § 17.1535 Payment rates and meth- provider for such hospital care or med- odologies. ical services as are authorized under (a) Payment rates. Payment rates will §§ 17.1500 through 17.1540 and furnished be negotiated and set forth in an agree- to an eligible veteran. VA shall be re- ment between the Secretary and an eli- sponsible for promptly paying only for gible entity or provider. costs of the VA-authorized service not (1) Except as otherwise provided in covered by such health-care plan, in- this section, payment rates may not cluding a payment made by the vet- exceed the rates paid by the United eran, except that such payment may States to a provider of services (as de- not exceed the rate determined for fined in section 1861(u) of the Social such care or services pursuant to para- Security Act (42 U.S.C. 1395x(u)) or a graph (a) of this section. supplier (as defined in section 1861(d) of (2) For hospital care or medical serv- such Act (42 U.S.C. 1395x(d)) under the ices furnished for a service-connected Medicare program under title XVIII of disability, as that term is defined at the Social Security Act (42 U.S.C. 1395 § 3.1(k) of this chapter, or pursuant to

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38 U.S.C. 1710(e), 1720D, or 1720E, VA is VET CENTERS solely responsible for paying the eligible entity or provider for such hospital § 17.2000 Vet Center services. care or medical services as are author- (a) Eligibility for readjustment coun- ized under §§ 17.1500 through 17.1540 and seling. Upon request, VA will provide furnished to an eligible veteran. readjustment counseling to any indi- (c) Authorized care. VA will only pay vidual who: for an episode of care for hospital care (1) Is a veteran or member of the or medical services authorized by VA. Armed Forces, including a member of a The eligible entity or provider must reserve component of the Armed contact VA to receive authorization Forces, who: prior to providing any hospital care or (i) Served on active duty in a theater medical services the eligible non-VA of combat operations or an area of hos- entity or provider believes are nec- tilities (i.e., an area at a time during essary that are not identified in the au- which hostilities occurred in that thorization VA submits to the eligible area); or entity or provider. VA will only pay for (ii) Provided direct emergency med- the hospital care or medical services ical or mental health care, or mortuary that are furnished by an eligible entity services, to the causalities of combat or provider. There must be an actual operations or hostilities, but who at encounter with a health care provider, the time was located outside the the- who is either an employee of an entity ater of combat operations or area of in an agreement with VA or who is fur- hostilities; or nishing care through an agreement the (iii) Engaged in combat with an health care provider has entered into enemy of the United States or against with VA, and such encounter must an opposing military force in a theater occur after an election is made by an of combat operations or an area at a eligible veteran. time during which hostilities occurred in that area by remotely controlling an (Authority: Secs. 101, 105, Pub. L. 113–146, 128 unmanned aerial vehicle operations, Stat. 1754) notwithstanding whether the physical [79 FR 65585, Nov. 5, 2014, as amended at 80 location of such veteran or member FR 66428, Oct. 29, 2015] during such combat was within such theater of combat operations or area. § 17.1540 Claims processing system. Individuals who remotely control un- (a) There is established within the manned aerial vehicles includes, but is Chief Business Office of the Veterans not limited to, individuals who pilot Health Administration a nationwide the unmanned aerial vehicle as well as claims processing system for proc- individuals who are crew members of essing and paying bills or claims for the unmanned aerial vehicle and par- authorized hospital care and medical ticipate in combat related missions. services furnished to eligible veterans The crew members include, but are not under §§ 17.1500 through 17.1540. limited to, intelligence analysts or weapons specialists who control the (b) The Chief Business Office is re- cameras, engage the weapon systems, sponsible for overseeing the implemen- as well as those individuals who are di- tation and maintenance of such sys- rectly responsible for the mission of tem. the unmanned aerial vehicle. (c) The claims processing system will (2) Received counseling under this receive requests for payment from eli- section before January 2, 2013. gible entities and providers for hospital (3) Is a family member of a veteran or care or medical services furnished to member of the Armed Forces, includ- eligible veterans. The claims proc- ing a member of a reserve component essing system will provide accurate, of the Armed Forces, who is eligible for timely payments for claims received in readjustment counseling under para- accordance with §§ 17.1500 through graphs (a)(1) or (a)(2) of this section. 17.1540. For purposes of this section, family (Authority: Secs. 101, 105, Pub. L. 113–146, 128 member includes, but is not limited to, Stat. 1754) the spouse, parent, child, step-family

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member, extended family member, and (ii) VA for a VA benefits eligibility any individual who lives with the vet- determination under 38 CFR 3.12. eran or member of the Armed Forces, (d) Readjustment counseling defined. including a member of a reserve com- For the purposes of this section, read- ponent of the Armed Forces, but is not justment counseling includes, but is a member of the veteran’s or member’s not limited to: Psychosocial assess- family. ment, individual counseling, group (b) Proof of eligibility. With the vet- counseling, marital and family coun- eran’s or member’s of the Armed seling for military-related readjust- Forces, including a member of a re- ment issues, substance abuse assess- serve component of the Armed Forces, ments, medical referrals, referral for consent, VA will assist in obtaining additional VA benefits, employment proof of eligibility. For the purposes of assessment and referral, military sex- this section, proof of service in a the- ual trauma counseling and referral, be- ater of combat operations or in an area reavement counseling, and outreach. A during a period of hostilities in that ‘‘psychosocial assessment’’ under this area will be established by: paragraph means the holistic assessing (1) A DD Form 214 (Certificate of Re- of an individual’s psychological, social, lease or Discharge from Active Duty) and functional capacities as it relates containing notations of service in a to their readjustment from combat designated theater of combat oper- theaters. Readjustment counseling is ations; or provided to: (2) Receipt of one of the following (1) Veterans and members of the medals: The Armed Forces Expedi- Armed Forces, including a member of a tionary Medal, Service Specific Expedi- reserve component of the Armed tionary Medal (e.g., Navy Expedi- Forces, for the purpose of readjusting tionary Medal), Combat Era Specific to civilian life or readjustment to con- Expeditionary Medal (e.g., the Global tinued military service following par- War on Terrorism Expeditionary ticipation in or in support of oper- Medal), Campaign Specific Medal (e.g., ations in a combat theater or area of Vietnam Service Medal or Iraq Cam- hostility. paign Medal), or other combat theater (2) A family member of a member of awards established by public law or ex- the Armed Forces, including a member ecutive order; or of a reserve component of the Armed (3) Proof of receipt of Hostile Fire or Forces, for the purpose of coping with Imminent Danger Pay (commonly re- such member’s deployment. ferred to as ‘‘combat pay’’) or combat (3) A family member of a veteran or tax exemption after November 11, 1998. member of the Armed Forces, includ- (c) Referral and advice. Upon request, ing a member of a reserve component VA will provide an individual who does of the Armed Forces, to aid in a vet- not meet the eligibility requirements eran’s or member’s readjustment to ci- of paragraph (a) of this section, solely vilian or continued military service because the individual was discharged following participation in or in support under dishonorable conditions from ac- of operations in a combat theater or tive military, naval, or air service, the area of hostility, only as it relates to following: the veteran’s or member’s military ex- (1) Referral services to assist such in- perience. dividual, to the maximum extent prac- (e) Confidentiality. Benefits under this ticable, in obtaining mental health section are furnished solely by VA Vet care and services from sources outside Centers, which maintain confidential VA; and records independent from any other VA (2) If pertinent, advice to such indi- or Department of Defense medical vidual concerning such individual’s records and which will not disclose rights to apply to: such records without either the vet- (i) The appropriate military, naval or eran’s or member’s of the Armed air service for review of such individ- Forces, including a member of a re- ual’s discharge or release from such serve component of the Armed Forces, service; and voluntary, signed authorization, or a

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specific exception permitting their re- home to at least one bedroom and es- lease. For more information, see 5 sential lavatory and sanitary facilities. U.S.C. 552a, 38 U.S.C. 5701 and 7332, 45 Beneficiary means a veteran or serv- CFR parts 160 and 164, and VA’s System icemember who is awarded or who is el- of Records 64VA15, ‘‘Readjustment igible to receive HISA benefits. Counseling Service Vet Center Pro- Essential lavatory and sanitary facili- gram.’’ The term Vet Center means a ties means one bathroom equipped with facility that is operated by VA for the a toilet and a shower or bath, one provision of services under this section kitchen, and one laundry facility. and that is situated apart from a VA HISA benefits means a monetary pay- general health care facility. ment by VA to be used for improve- (Authority: 38 U.S.C. 501, 1712A, 1782, and ments and structural alterations to the 1783) home of a beneficiary in accordance with §§ 17.3100 through 17.3130. [78 FR 57073, Sept. 17, 2013, as amended at 80 Home means the primary place where FR 46200, Aug. 4, 2015] the beneficiary resides or, in the case HOME IMPROVEMENTS AND STRUCTURAL of a servicemember, where the bene- ALTERATIONS (HISA) PROGRAM ficiary intends to reside after discharge from service.

SOURCE: Sections 17.3100 through 17.3130 ap- Improvement or structural alteration pear at 79 FR 71660, Dec. 3, 2014, unless other- means a modification to a home or to wise noted. an existing feature or fixture of a home, including repairs to or replace- § 17.3100 Purpose and scope. ment of previously improved or altered (a) Purpose. The purpose of §§ 17.3100 features or fixtures. through 17.3130 is to implement the Undergoing medical discharge means Home Improvements and Structural that a servicemember has been found Alterations (HISA) program. The pur- unfit for duty due to a medical condi- pose of the HISA benefits program is to tion by their Service’s Physical Eval- provide eligible beneficiaries monetary uation Board, and a date of medical benefits for improvements and struc- discharge has been issued. tural alterations to their homes when (Authority: 38 U.S.C. 501, 1717) such improvements and structural alterations: § 17.3102 Eligibility. (1) Are necessary for the continu- The following individuals are eligible ation of the provision of home health for HISA benefits: treatment of the beneficiary’s dis- (a) A veteran who is eligible for med- ability; or ical services under 38 U.S.C. 1710(a). (2) Provide the beneficiary with ac- (b) A servicemember who is under- cess to the home or to essential lava- going medical discharge from the tory and sanitary facilities. Armed Forces for a permanent dis- (b) Scope. 38 CFR 17.3100 through ability that was incurred or aggravated 17.3130 apply only to the administra- in the line of duty in the active mili- tion of the HISA benefits program, untary, naval, or air service. A service- less specifically provided otherwise. member would be eligible for HISA (Authority: 38 U.S.C. 501, 1717(a)(2)) benefits while hospitalized or receiving outpatient medical care, services, or § 17.3101 Definitions. treatment for such permanent disability. For the purposes of the HISA benefits program (§§ 17.3100 through 17.3130): (Authority: 38 U.S.C. 501, 1717) Access to essential lavatory and sanitary facilities means having normal use §§ 17.3103–17.3104 [Reserved] of the standard structural components of those facilities. § 17.3105 HISA benefit lifetime limits. Access to the home means the ability (a) General. Except as provided in of the beneficiary to enter and exit the paragraph (e) of this section, a bene- home and to maneuver within the ficiary’s HISA benefit is limited to the

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lifetime amount established in para- (2) On or after May 5, 2010, then the graph (b), (c), or (d) of this section, as servicemember’s HISA benefit lifetime applicable. A beneficiary may use limit is $6,800. HISA benefits to pay for more than one (e) Increases to HISA benefit lifetime home alteration, until the beneficiary limit. (1) A veteran who received HISA exhausts his or her lifetime benefit. benefits under paragraph (c) of this sec- HISA benefits approved by VA for use tion, and who subsequently qualifies in a particular home alteration but un- for HISA benefits under paragraph used by the beneficiary will remain (b)(1) of this section on or after May 5, available for future use. 2010, due to a new award of disability (b) HISA benefits for a service-con- compensation based on service connec- nected disability, a disability treated ‘‘as tion or an increased disability rating, if’’ it were service connected, or for veterans with a service-connected disability may apply for the increased lifetime rated 50 percent or more. (1) If a veteran: benefit amount under paragraph (i) Applies for HISA benefits to ad- (b)(2)(ii) of this section. The increased dress a service-connected disability; amount that will be available is $6,800 (ii) Applies for HISA benefits to ad- minus the amount of HISA benefits dress a compensable disability treated previously used by the beneficiary. ‘‘as if’’ it is a service-connected dis- (2) A veteran who previously received ability and for which the veteran is en- HISA benefits as a servicemember is titled to medical services under 38 not eligible for a new lifetime HISA U.S.C. 1710(a)(2)(C) (e.g., a disability ac- benefit amount based on his or her at- quired through treatment or voca- taining veteran status, but the veteran tional rehabilitation provided by VA); may file a HISA claim for any HISA or benefit amounts not used prior to dis- (iii) Applies for HISA benefits to ad- charge. The veteran’s subsequent HISA dress a nonservice-connected dis- award cannot exceed the applicable ability, if the beneficiary has a service- award amount under paragraphs (b), connected disability rated at least 50 (c), or (e)(1) of this section, as applica- percent disabling; and ble, minus the amount of HISA benefits (2) The veteran first applies for HISA awarded to the veteran while the vet- benefits: eran was a servicemember. (i) Before May 5, 2010, then the veteran’s lifetime HISA benefit limit is (Authority: 38 U.S.C. 501, 1717) $4,100. (ii) On or after May 5, 2010, then the §§ 17.3106–17.3119 [Reserved] veteran’s lifetime HISA benefit limit is $6,800. § 17.3120 Application for HISA bene- (c) HISA benefits for any other disabil- fits. ities. If a veteran who is eligible for (a) Application package. To apply for medical services under 38 U.S.C. 1710(a) HISA benefits, the beneficiary must applies for HISA benefits to address a submit to VA a complete HISA benefits disability that is not covered under application package. A complete HISA paragraph (b) of this section, and the benefits application package includes veteran first applies for HISA benefits: all of the following: (1) Before May 5, 2010, then the vet- (1) A prescription, which VA may ob- eran’s lifetime HISA benefit limit is tain on the beneficiary’s behalf, writ- $1,200; or ten or approved by a VA physician that (2) On or after May 5, 2010, then the includes all of the following: veteran’s lifetime HISA benefit limit is $2,000. (i) The beneficiary’s name, address, (d) Servicemembers. If a servicemem- and telephone number. ber is eligible for HISA benefits under (ii) Identification of the prescribed § 17.3102(b), and the servicemember first improvement or structural alteration. applies: (iii) The diagnosis and medical jus- (1) Before May 5, 2010, then the tification for the prescribed improve- servicemember’s HISA benefit lifetime ment or structural alteration. limit is $4,100; or

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(2) A completed and signed VA Form (1) The application is consistent with 10–0103, Veterans Application for As- §§ 17.3100 through 17.3130, and sistance in Acquiring Home Improve- (2) VA determines that the proposed ment and Structural Alterations, in- improvement or structural alteration cluding, if desired, a request for ad- is reasonably designed to address the vance payment of HISA benefits. needs of the beneficiary and is appro- (3) A signed statement from the priate for the beneficiary’s home, based owner of the property authorizing the on documentation provided and/or improvement or structural alteration through a pre-award inspection of the to the property. The statement must home. be notarized if the beneficiary submit- (b) Notification of approval. No later ting the HISA benefits application is than 30 days after a beneficiary sub- not the owner of the property. mits a complete application, VA will (4) A written itemized estimate of notify the beneficiary whether an ap- costs for labor, materials, permits, and plication is approved. The notification inspections for the home improvement will: or structural alteration. (1) State the total benefit amount authorized for the improvement or struc- (5) A color photograph of the unim- tural alteration. proved area. (2) State the amount of any advance (b) Pre-award inspection of site. The payment, if requested by the bene- beneficiary must allow VA to inspect ficiary, and state that the advance pay- the site of the proposed improvement ment must be used for the improve- or structural alteration. VA will not ments or structural alterations de- approve a HISA application unless VA tailed in the application. The notifica- has either conducted a pre-award in- tion will also remind beneficiaries re- spection or has determined that no ceiving advance payment of the obliga- such inspection is needed. No later tion to submit the request for final than 30 days after receiving a complete payment upon completion of the con- HISA benefits application, VA will construction. duct the inspection or determine that (3) Provide the beneficiary with the no inspection is required. notice of the right to appeal if they do (c) Incomplete applications. If VA re- not agree with VA’s decision regarding ceives an incomplete HISA benefits ap- the award. plication, VA will notify the applicant of the missing documentation. If the (Authority: 38 U.S.C. 501, 1717, 7104) missing documentation is not received § 17.3126 Disapproving HISA benefits by VA within 30 days after such notifi- applications. cation, VA will close the application VA will disapprove a HISA benefits and notify the applicant that the appli- application if the complete HISA bene- cation has been closed. The closure no- fits application does not meet all of the tice will indicate that the application criteria outlined in § 17.3125(a). Notifi- may be re-opened by submitting the re- cation of the decision provided to the quested documentation and updating beneficiary will include the basis for any outdated information from the the disapproval and notice to the bene- original application. ficiary of his or her right to appeal. (Authority: 38 U.S.C. 501, 1717) (Authority: 38 U.S.C. 501, 7104) (The Office of Management and Budget has approved the information collection require- §§ 17.3127–17.3129 [Reserved] ments in this section under control number 2900–0188.) § 17.3130 HISA benefits payment procedures. §§ 17.3121–17.3124 [Reserved] (a) Advance payment. If the beneficiary has requested advance payment § 17.3125 Approving HISA benefits ap- of HISA benefits in VA Form 10–0103, as plications. provided in § 17.3120(a)(2), VA will make (a) Approval of application. VA will an advance payment to the beneficiary approve the HISA benefits application equal to 50 percent of the total benefit if: authorized for the improvement or

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structural alteration. VA will make less the amount of any advance pay- the advance payment no later than 30 ment. days after the HISA benefits applica- (3) If the total actual cost of the im- tion is approved. The beneficiary may provement or structural alteration is receive only one advance payment for less than the amount paid to the bene- each approved HISA benefits applica- ficiary as an advance payment, the tion. A beneficiary must use the ad- beneficiary will reimburse VA for the vance payment only for the improve- difference between the advance payment or structural alteration described ment and the total actual costs. in the application and must submit a (4) After final payment is made on a final payment request, as defined in HISA benefits application, the applica- paragraph (b) of this section, to docu- tion file will be closed and no future ment such use after the construction is HISA benefits will be furnished to the finished. beneficiary for that application. If the (b) Final payment request. No later total actual cost of the improvement than 60 days after the application is ap- or structural alteration is less than the proved or, if VA approved an advance approved HISA benefit, the balance of payment, no later than 60 days after the approved amount will be credited the advance payment was made, the to the beneficiary’s remaining HISA beneficiary must submit a complete benefits lifetime balance. final payment request to VA for pay- (d) Failure to submit a final payment ment. The complete final payment re- request. (1) If an advance payment was quest must include: made to the beneficiary, but the bene- (1) A statement by the beneficiary ficiary fails to submit a final payment that the improvement or structural al- request in accordance with paragraph teration, as indicated in the applica- (b) of this section within 60 days of the tion, was completed; date of the advance payment, VA will send a notice to remind the beneficiary (2) A color photograph of the com- of the obligation to submit the final pleted work; and payment request. If the beneficiary (3) Documentation of the itemized fails to submit the final payment re- actual costs for material, labor, per- quest or to provide a suitable update mits, and inspections. and explanation of delay within 30 days (c) VA action on final payment request. of this notice, VA may take appro- (1) Prior to approving and remitting priate action to collect the amount of the final payment, VA may inspect the advance payment from the bene- (within 30 days after receiving the final ficiary. payment request) the beneficiary’s (2) If an advance payment was not home to determine that the improve- made to the beneficiary and the bene- ment or structural alteration was com- ficiary does not submit a final payment pleted as indicated in the application. request in accordance with paragraph No payment will be made if the im- (b) of this section within 60 days of the provement or structural alteration has date the application was approved, the not been completed. application will be closed and no future (2) No later than 30 days after receipt HISA benefits will be furnished to the of a complete final payment request, beneficiary for that application. Before or, if VA conducts an inspection of the closing the application, VA will send a home under paragraph (c)(1) of this sec- notice to the beneficiary of the intent tion, no later than 30 days after the in- to close the file. If the beneficiary does spection, VA will make a determina- not respond with a suitable update and tion on the final payment request. If explanation for the delay within 30 approved, VA will remit a final pay- days, VA will close the file and provide ment to the beneficiary equal to the a final notice of closure. The notice lesser of: will include information about the (i) The approved HISA benefit right to appeal the decision. amount, less the amount of any ad- (e) Failure to make approved improve- vance payment, or ments or structural alterations. If an in- (ii) The total actual cost of the im- spection conducted pursuant to para- provement or structural alteration, graph (c)(1) of this section reveals that

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the improvement or structural alter- Eligible entity or provider means a ation has not been completed as indi- health care entity or provider that cated in the final payment request, VA meets the requirements of § 17.4030. may take appropriate action to collect Episode of care means a necessary the amount of the advance payment course of treatment, including follow- from the beneficiary. VA will not seek up appointments and ancillary and spe- to collect the amount of the advance cialty services, which lasts no longer payment from the beneficiary if the than 1 calendar year. beneficiary provides documentation in- Extended care services include the dicating that the project was not com- same services as described in 38 U.S.C. pleted due to the fault of the con- 1710B(a). tractor, including bankruptcy or mis- Full-service VA medical facility means conduct of the contractor. a VA medical facility that provides (Authority: 38 U.S.C. 501, 1717) hospital care, emergency medical services, and surgical care and having a (The Office of Management and Budget has surgical complexity designation of at approved the information collection requirement in this section under control number least ‘‘standard.’’ 2900–0188.) Note 1 to the definition of ‘‘full-service VA medical facility’’: VA maintains VETERANS COMMUNITY CARE PROGRAM a website with a list of the facilities that have been designated with at least SOURCE: Sections 17.4000 through 17.4040, a surgical complexity of ‘‘standard,’’ appear as 84 FR 26307, June 5, 2019, unless which can be accessed on VA’s website. otherwise noted. Hospital care has the same meaning as defined in 38 U.S.C. 1701(5). § 17.4000 Purpose and scope. Medical services have the same mean- (a) Purpose. Sections 17.4000 through ing as defined in 38 U.S.C. 1701(6). 17.4040 implement the Veterans Com- Other health-care plan contract means munity Care Program, authorized by 38 an insurance policy or contract, med- U.S.C. 1703. ical or hospital service agreement, (b) Scope. The Veterans Community membership or subscription contract, Care Program establishes when a cov- or similar arrangement not adminis- ered veteran may elect to have VA au- tered by the Secretary of Veterans Af- thorize an episode of care for hospital fairs, under which health services for care, medical services, or extended care individuals are provided or the ex- services from an eligible entity or pro- penses of such services are paid; and vider. Sections 17.4000 through 17.4040 does not include any such policy, con- do not affect eligibility for non-VA tract, agreement, or similar arrange- care under sections 1724, 1725, 1725A, or ment pursuant to title XVIII or XIX of 1728 of title 38, United States Code. the Social Security Act (42 U.S.C. 1395 et seq.) or chapter 55 of title 10, United § 17.4005 Definitions. States Code. For purposes of the Veterans Com- Residence means a legal residence or munity Care Program under §§ 17.4000 personal domicile, even if such resi- through 17.4040: dence is seasonal. A covered veteran Appointment means an authorized and may maintain more than one residence scheduled encounter, including tele- but may only have one residence at a health and same-day encounters, with time. If a covered veteran lives in more a health care provider for the delivery than one location during a year, the of hospital care, medical services, or covered veteran’s residence is the resi- extended care services. dence or domicile where they are stay- Covered veteran means a veteran en- ing at the time they want to receive rolled under the system of patient en- hospital care, medical services, or ex- rollment in § 17.36, or a veteran who tended care services through the Vet- otherwise meets the criteria to receive erans Community Care Program. A care and services notwithstanding his post office box or other non-residential or her failure to enroll in § 17.37(a) point of delivery does not constitute a through (c). residence.

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Schedule means identifying and con- of this section, but received care or firming a date, time, location, and en- services under title 38 U.S.C. between tity or health care provider for an ap- June 6, 2017, and June 6, 2018, and is pointment in advance of such appoint- seeking care before June 6, 2020. ment. (4) Has contacted an authorized VA Note 1 to the definition of ‘‘sched- official to request the care or services ule’’: A VA telehealth encounter and a the veteran requires, but VA has deter- same-day care encounter are consid- mined it is not able to furnish such ered to be scheduled even if such an en- care or services in a manner that com- counter is conducted on an ad hoc plies with designated access standards basis. established in § 17.4040. VA facility means a VA facility that (5) The veteran and the veteran’s re- offers hospital care, medical services, ferring clinician determine it is in the or extended care services. best medical interest of the veteran, VA medical service line means a spe- for the purpose of achieving improved cific medical service or set of services clinical outcomes, to access the care or delivered in a VA facility. services the veteran requires from an § 17.4010 Veteran eligibility. eligible entity or provider, based on one or more of the following factors, as Section 1703(d) of title 38, U.S.C., es- applicable: tablishes the conditions under which, at the election of the veteran and sub- (i) The distance between the veteran ject to the availability of appropria- and the facility or facilities that could tions, VA must furnish care in the provide the required care or services; community through eligible entities (ii) The nature of the care or services and providers. VA has regulated these required by the veteran; conditions under paragraphs (a)(1) (iii) The frequency the veteran re- through (5) of this section. If VA deter- quires the care or services; mines that a covered veteran meets at (iv) The timeliness of available ap- least one or more of the conditions in pointments for the required care or paragraph (a) of this section and has services; provided information required by para- (v) The potential for improved con- graphs (b) and (c) of this section, the tinuity of care; covered veteran may elect to receive (vi) The quality of the care provided; authorized non-VA care under § 17.4020. or (a) The covered veteran requires hos- (vii) Whether the veteran faces an pital care, medical services, or ex- unusual or excessive burden in access- tended care services and: ing a VA facility based on consider- (1) No VA facility offers the hospital ation of the following: care, medical services, or extended care (A) Excessive driving distance; geo- services the veteran requires. graphical challenges, such as the pres- (2) VA does not operate a full-service ence of a body of water (including mov- VA medical facility in the State in ing water and still water) or a geologic which the veteran resides. (3) The veteran was eligible to re- formation that cannot be crossed by ceive care and services from an eligible road; or environmental factors, such as entity or provider under section roads that are not accessible to the 101(b)(2)(B) of the Veterans Access, general public, traffic, or hazardous Choice, and Accountability Act of 2014 weather. (Pub. L. 113–146, sec. 101, as amended; 38 (B) Whether care and services are U.S.C. 1701 note) as of June 5, 2018, and available from a VA facility that is continues to reside in a location that reasonably accessible. would qualify the veteran under that (C) Whether a medical condition of provision, and: the veteran affects the ability to trav- (i) Resides in Alaska, Montana, el. North Dakota, South Dakota, or Wyo- (D) Whether there is a compelling ming; or reason the veteran needs to receive (ii) Does not reside in one of the care and services from a non-VA facil- States described in paragraph (a)(3)(i) ity.

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(E) The need for an attendant, which REGISTER. Such document will identify is defined as a person who provides re- and describe the standards for quality quired aid and/or physical assistance to VA used to inform the determination the veteran, for a veteran to travel to under paragraph (a), as well as how the a VA medical facility for hospital care data described in paragraph (a) and fac- or medical services. tors identified in paragraph (e) of this (6) In accordance with § 17.4015, VA section were used to make the deter- has determined that a VA medical minations. Such document will also service line that would furnish the care identify limitations, if any, concerning or services the veteran requires is not when and where covered veterans can providing such care or services in a receive qualifying care and services at manner that complies with VA’s stand- their election in the community based ards for quality. on this section. Such limitations may (b) If the covered veteran changes his include a defined timeframe, a defined or her residence, the covered veteran geographic area, and a defined scope of must update VA about the change services. VA will also take reasonable within 60 days. steps to provide direct notice to cov- (c) A covered veteran must provide to ered veterans affected under this sec- VA information on any other health- tion. care plan contract under which the vet- (d) VA will identify no more than 3 eran is covered prior to obtaining au- VA medical services lines in a single thorization for care and services the VA facility under this section, and no veteran requires. If the veteran more than 36 VA medical service lines changes such other health-care plan nationally under this section. contract, the veteran must update VA (e) In determining whether a VA about the change within 60 days. medical service line should be identi- (d) Review of veteran eligibility de- fied under paragraph (a) of this section, terminations. The review of any deci- and to comply with paragraph (c) of sions under paragraph (a) of this sec- this section, VA will consider: tion are subject to VA’s clinical ap- (1) Whether the differences between peals process, and such decisions may performance of individual VA medical not be appealed to the Board of Vet- service lines, and between performance erans’ Appeals. of VA medical service lines and non-VA (The information collection is pending Office medical service lines, is clinically sig- of Management and Budget approval.) nificant. (2) Likelihood and ease of remedi- § 17.4015 Designated VA medical service lines. ation of the VA medical service line within a short timeframe. (a) VA may identify VA medical serv- (3) Recent trends concerning the VA ice lines that are underperforming medical service line or non-VA medical based on the timeliness of care when service line. compared with the same medical serv- (4) The number of covered veterans ice line at other VA facilities and based served by the medical service line or on data related to two or more distinct that could be affected by the designa- and appropriate quality measures of tion. VA’s standards for quality when compared with non-VA medical service (5) The potential impact on patient lines. outcomes. (b) VA will make determinations re- (6) The effect that designating one garding VA medical service lines under VA medical service line would have on this section using data described in other VA medical service lines. paragraph (a) of this section, VA standards for quality, and based on factors § 17.4020 Authorized non-VA care. identified in paragraph (e) of this sec- (a) Electing non-VA care. Except as tion. provided for in paragraph (d) of this (c) VA will announce annually any section, a covered veteran eligible for VA medical service lines identified the Veterans Community Care Pro- under paragraph (a) of this section by gram under § 17.4010 may choose to publishing a document in the FEDERAL schedule an appointment with a VA

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health care provider, or have VA au- (i) Be made to the appropriate VA of- thorize the veteran to receive an epi- ficial at the nearest VA facility; sode of care for hospital care, medical (ii) Identify the covered veteran; and services, or extended care services from (iii) Identify the eligible entity or an eligible entity or provider when VA provider. determines such care or services are (d) Organ and bone marrow transplant clinically necessary. care. (1) In the case of a covered vet- (b) Selecting an eligible entity or pro- eran described in paragraph (d)(3) of vider. A covered veteran may specify a this section, the Secretary will deter- particular eligible entity or provider. If mine whether to authorize an organ or a covered veteran does not specify a bone marrow transplant for the cov- particular eligible entity or provider, ered veteran through an eligible entity VA will refer the veteran to a specific or provider. eligible entity or provider. (2) The Secretary will make deter- (c) Authorizing emergency treatment. minations under paragraph (d)(1) of This paragraph (c) applies only to this section, and the primary care pro- emergency treatment furnished to a vider of the veteran will make deter- covered veteran by an eligible entity or minations concerning whether there is provider when such treatment was not a medically compelling reason to trav- the subject of an election by a veteran el outside the region of the Organ Pro- under paragraph (a) of this section. curement and Transplantation Net- This paragraph (c) does not affect eligi- work in which the veteran resides to bility for, or create any new rules or receive a transplant, in consideration conditions affecting, reimbursement of, but not limited to, the following for emergency treatment under section factors: 1725 or 1728 of title 38, United States (i) Specific patient factors. Code. (ii) Which facilities meet VA’s stand- (1) Under the conditions set forth in ards for quality, including quality this paragraph (c), VA may authorize metrics and outcomes, for the required emergency treatment after it has been transplant. furnished to a covered veteran. For (iii) The travel burden on covered purposes of this paragraph (c), ‘‘emer- veterans based upon their medical con- gency treatment’’ has the meaning de- ditions and the geographic location of fined in section 1725(f)(1) of title 38, eligible transplant centers. United States Code. (iv) The timeliness of transplant cen- (2) VA may only authorize emergency ter evaluations and management. treatment under this paragraph (c) if (3) This paragraph (d) applies to cov- the covered veteran, someone acting on ered veterans who meet one or more the covered veteran’s behalf, or the eli- conditions of eligibility under gible entity or provider notifies VA § 17.4010(a) and: within 72-hours of such care or services (i) Require an organ or bone marrow being furnished and VA approves the transplant as determined by VA based furnishing of such care or services upon generally-accepted medical cri- under paragraph (c)(3) of this section. teria; and (3) VA may approve emergency treat- (ii) Have, in the opinion of the pri- ment of a covered veteran under this mary care provider of the veteran, a paragraph (c) only if: medically compelling reason, as deter- (i) The veteran is receiving emer- mined in consideration of the factors gency treatment from an eligible enti- described in paragraph (d)(2) of this ty or provider. section, to travel outside the region of (ii) The notice to VA complies with the Organ Procurement and Transplan- the provisions of paragraph (c)(4) of tation Network in which the veteran this section and is submitted within 72 resides, to receive such transplant. hours of the beginning of such treatment. § 17.4025 Effect on other provisions. (iii) The emergency treatment only (a) General. No provision in this sec- includes services covered by VA’s med- tion may be construed to alter or mod- ical benefits package in § 17.38. ify any other provision of law estab- (4) Notice to VA must: lishing specific eligibility criteria for

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certain hospital care, medical services, erans Community Care Program under or extended care services. §§ 17.4000 through 17.4040. (b) Prescriptions. Notwithstanding (c) Must be accessible to the covered any other provision of this part, VA veteran. VA will determine accessi- will: bility by considering the following fac- (1) Pay for prescriptions no longer tors: than 14 days written by eligible enti- (1) The length of time the covered ties or providers for covered veterans, veteran would have to wait to receive including over-the-counter drugs and hospital care, medical services, or ex- medical and surgical supplies, avail- tended care services from the entity or able under the VA national formulary provider; system to cover a course of treatment (2) The qualifications of the entity or for an urgent or emergent condition. provider to furnish the hospital care, (2) Fill prescriptions written by eligi- medical services, or extended care serv- ble entities or providers for covered ices from the entity or provider; and veterans, including over-the-counter (3) The distance between the covered drugs and medical and surgical sup- veteran’s residence and the entity or plies, available under the VA national provider. formulary system. (3) Pay for prescriptions written by § 17.4035 Payment rates. eligible entities or providers for cov- The rates paid by VA for hospital ered veterans that have an immediate care, medical services, or extended care need for durable medical equipment services (hereafter referred to as and medical devices that are required ‘‘services’’) furnished pursuant to a for urgent or emergent conditions (e.g., procurement contract or an agreement splints, crutches, manual wheelchairs). authorized by §§ 17.4100 through 17.4135 (4) Fill prescriptions written by eligi- will be the rates set forth in the terms ble entities or providers for covered of such contract or agreement. Such veterans for durable medical equip- payment rates will comply with the ment and medical devices that are not following parameters: required for urgent or emergent condi- (a) Except as otherwise provided in tions. this section, payment rates will not ex- (c) Copayments. Covered veterans are ceed the applicable Medicare fee sched- liable for a VA copayment for care or ule (including but not limited to allow- services furnished under the Veterans able rates under 42 U.S.C. 1395m) or Community Care Program, if required prospective payment system amount by § 17.108(b)(4) or (c)(4), § 17.110(b)(4), or (hereafter ‘‘Medicare rate’’), if any, for § 17.111(b)(3). the period in which the service was provided (without any changes based § 17.4030 Eligible entities and pro- on the subsequent development of in- viders. formation under Medicare authorities). To be eligible to furnish care and (b) With respect to services furnished services under the Veterans Commu- in a State with an All-Payer Model nity Care Program, entities or pro- Agreement under section 1814(b)(3) of viders: the Social Security Act (42 U.S.C. (a) Must enter into a contract, agree- 1395f(b)(3)) that became effective on or ment, or other arrangement to furnish after January 1, 2014, the Medicare pay- care and services under the Veterans ment rates under paragraph (a) of this Community Care Program under section will be calculated based on the §§ 17.4000 through 17.4040. payment rates under such agreement. (b) Must either: (c) Payment rates for services fur- (1) Not be a part of, or an employee nished in a highly rural area may ex- of, VA; or ceed the limitations set forth in para- (2) If the provider is an employee of graphs (a) and (b) of this section. The VA, not be acting within the scope of term ‘‘highly rural area’’ means an such employment while providing hos- area located in a county that has fewer pital care, medical services, or ex- than seven individuals residing in that tended care services through the Vet- county per square mile.

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(d) Payment rates may deviate from VETERANS CARE AGREEMENTS the parameters set forth in paragraphs (a) through (c) of this section when VA SOURCE: Sections 17.4100 through 17.4135 ap- determines, based on patient needs, pear at 84 FR 21678, May 14, 2019, unless oth- market analyses, health care provider erwise noted. qualifications, or other factors, that it is not practicable to limit payment for § 17.4100 Definitions. services to the rates available under For the purposes of §§ 17.4100 through paragraphs (a) through (c). 17.4135, the following definitions apply: (e) Payment rates for services fur- Contract is any of the following: Fed- nished in Alaska are not subject to eral procurement agreements regulated paragraphs (a) through (d) of this sec- by the Federal Acquisition Regulation; tion and will be set forth in the terms common law contracts; other trans- of the procurement contract or agree- actions; or any other instrument. Vet- ment authorized by §§ 17.4100 through erans Care Agreements are excluded 17.4135, pursuant to which such services from this definition. are furnished. If no payment rate is set Covered individual is an individual forth in the terms of such a contract or who is eligible to receive hospital care, agreement pursuant to which such medical services, or extended care serv- services are furnished, payment rates ices from a non-VA provider under title for services furnished in Alaska will 38 U.S.C. and title 38 CFR. follow the Alaska Fee Schedule of the Extended care services are the services Department of Veterans Affairs. described in 38 U.S.C. 1710B(a). Hospital care is defined in 38 U.S.C. § 17.4040 Designated access standards. 1701(5). Medical services is defined in 38 U.S.C. (a) The following access standards 1701(6). have been designated to apply for pur- Sharing agreement is an agreement, poses of eligibility determinations to under statutory authority other than access care in the community through 38 U.S.C. 1703A, by which VA can ob- the Veterans Community Care Pro- tain hospital care, medical services, or gram under § 17.4010(a)(4). extended care services for a covered in- (1) Primary care, mental health care, dividual. and non-institutional extended care serv- VA facility is a point of VA care ices. VA cannot schedule an appoint- where covered individuals can receive ment for the covered veteran with a hospital care, medical services, or ex- VA health care provider for the re- tended care services, to include a VA quired care or service: medical center, a VA community-based (i) Within 30 minutes average driving outpatient clinic, a VA health care time of the veteran’s residence; and center, a VA community living center, (ii) Within 20 days of the date of re- a VA independent outpatient clinic, quest unless a later date has been and other VA outpatient services sites. agreed to by the veteran in consulta- Veterans Care Agreement is an agree- tion with the VA health care provider. ment authorized under 38 U.S.C. 1703A (2) Specialty care. VA cannot schedule for the furnishing of hospital care, an appointment for the covered veteran medical services, or extended care serv- with a VA health care provider for the ices to covered individuals. required care or service: (i) Within 60 minutes average driving § 17.4105 Purpose and Scope. time of the veteran’s residence; and (a) Purpose. Sections 17.4100 through (ii) Within 28 days of the date of re- 17.4135 implement 38 U.S.C. 1703A, as quest unless a later date has been required under section 1703A(j). Section agreed to by the veteran in consulta- 1703A authorizes VA to enter into and tion with the VA health care provider. utilize Veterans Care Agreements to (b) For purposes of calculating aver- furnish hospital care, medical services, age driving time from the veteran’s and extended care services to a covered residence in paragraph (a) of this sec- individual when such individual is eli- tion, VA will use geographic informa- gible for and requires such care or serv- tion system software. ices that are not feasibly available to

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the covered individual through a VA and as submitted by the applicant, and facility, a contract, or a sharing agree- will determine eligibility for certifi- ment. cation. (b) Scope. Sections 17.4100 through (ii) An applicant must submit all in- 17.4135 contain procedures, require- formation required under paragraph ments, obligations, and limitations for: (b)(1) of this section. The process of certifying entities or (iii) VA will deny an application for providers under 38 U.S.C. 1703A; enter- certification if VA determines that the ing into, administering, furnishing care entity or provider is excluded from par- or services pursuant to, and dis- ticipation in a Federal health care pro- continuing Veterans Care Agreements; gram (as defined in section 1128B(f) of and all disputes arising under or re- the Social Security Act (42 U.S.C. lated to Veterans Care Agreements. 1320a–7b(f)) under section 1128 or 1128A Sections 17.4100 through 17.4135 apply of such Act (42 U.S.C. 1320a–7 and 1320a– to all entities and providers, where ap- 7a) or is identified as an excluded plicable, that are parties to a Veterans source on the System for Award Man- Care Agreement, participate in the cer- agement Exclusions list described in tification process, or furnish hospital part 9 of title 48, Code of Federal Regu- care, medical services, or extended care lations, and part 180 of title 2 of such services pursuant to a Veterans Care Code, or successor regulations. Agreement. (iv) VA will deny an application for certification if VA determines that the § 17.4110 Entity or provider certifi- applicant is already barred from fur- cation. nishing hospital care, medical services, (a) General. To be eligible to enter and extended care services under chap- into a Veterans Care Agreement, an enter 17 of title 38, U.S.C., because VA tity or provider must be certified by has previously determined the appli- VA in accordance with the process and cant submitted to VA a fraudulent criteria established in paragraph (b) of claim, as that term is defined in 38 this section. Additionally, an entity or U.S.C. 1703D(i)(4), for payment for hos- provider must be actively certified pital care, medical services, or ex- while furnishing hospital care, medical tended care services. services, or extended care services pur- (v) VA may deny an application for suant to a Veterans Care Agreement certification if VA determines that that the entity or provider has entered based on programmatic considerations, into with VA. VA is unlikely to seek to enter into a (b) Process and criteria—(1) Application Veterans Care Agreement with the ap- for certification. An entity or provider plicant. must apply for certification by submit- (vi) VA will issue a decision approv- ting the following information and doc- ing or denying an application for cer- umentation to VA: tification within 120 calendar days of (i) Documentation of applicable med- receipt of such application, if prac- ical licenses; and ticable. Notices of approval will set (ii) All other information and docu- forth the effective date and duration of mentation required by VA. This infor- the certification. Notices of denial will mation and documentation may in- set forth the specific grounds for denial clude, but is not limited to, provider and supporting evidence. A denial con- first and last names, legal business stitutes VA’s final decision on the ap- names, National Provider Identifier plication. (NPI), NPI type, provider identifier (3) Duration of certification and appli- type (e.g., individual or group practice), cation for recertification. (i) An entity or tax identification number, specialty provider’s certification under this sec- (taxonomy code), business address, bill- tion lasts for a three-year period, un- ing address, phone number, and care less VA revokes certification during site address. that three-year period pursuant to (2) Approval or denial of certification. paragraph (b)(4) of this section. (i) VA will review all information ob- (ii) A certified entity or provider tained by VA, including through appli- must maintain its eligibility through- cable federal and state records systems out the period in which it is certified

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and must inform VA of any changes or (A) Documenting compliance and events that would affect its eligibility proving any grounds false, or within 30 calendar days of the change (B) Providing information and docu- or event. mentation that demonstrates the enti- (iii) A certified entity or provider ty or provider has, subsequent to the seeking certification after the end of notice of proposed revocation, achieved its current three-year certification compliance with all criteria for certifi- must apply for recertification at least cation set forth in paragraph (b)(2) of 60 calendar days prior to the expiration this section. of its current certification; otherwise, (iii) Decision to revoke. Following the the procedures set forth in paragraph 30-day response period, VA will con- (b)(3)(iv) of this section will apply. sider any information and documenta- Upon application for recertification by tion submitted by the entity or pro- the entity or provider, including sub- vider and will, within 30 calendar days, determine whether revocation is war- mitting any new or updated informa- ranted. If VA determines that revocation within the scope of paragraph tion is not warranted, VA will notify (b)(1) of this section that VA requests the entity or provider of that deter- in conjunction with such application mination in writing. If VA determines for recertification, VA will reassess the that revocation is warranted, the enti- entity or provider under the criteria in ty or provider will immediately lose paragraph (b)(2) of this section. VA will certified status, and VA will issue a no- issue a decision approving or denying tice of revocation to the entity or pro- the application for recertification vider. Notices of revocation will set within 60 calendar days of receiving the forth the specific facts and grounds for, application, if practicable. Notice of and the effective date of, such revoca- the decision will be furnished to the ap- tion. A notice of revocation constitutes plicant in writing. Notices of recertifi- VA’s final decision. cation will set forth the effective date (iv) Effect of revocation. Revocation of and duration of the certification. No- certification results in such status tices of denial will set forth the spe- being rendered void, and the provider cific grounds for denial and supporting or entity may not furnish services or evidence. A denial constitutes VA’s care to a covered individual under a final decision on the application for re- Veterans Care Agreement prior to ap- certification. plying for and obtaining certified VCA (iv) If a certified entity or provider status. applies for recertification after the (The information collection require- deadline in paragraph (b)(3)(iii) of this ments have been submitted to the Of- section, such application will con- fice of Management and Budget (OMB) stitute a new application for certifi- and are pending OMB approval.) cation and will be processed in accordance with paragraphs (b)(1) and (2) of § 17.4115 VA use of Veterans Care this section. Agreements. (4) Revocation of certification—(i) (a) Criteria for using. VA may furnish Standard for revocation. VA may revoke hospital care, medical services, or ex- an entity’s or provider’s certification tended care services through a Vet- in accordance with paragraphs (b)(2)(ii) erans Care Agreement only if: through (v) of this section. (1) Such care or services are fur- (ii) Notice of proposed revocation. nished to a covered individual who is When VA determines revocation is ap- eligible for such care or services under propriate, VA will notify the entity or 38 U.S.C. chapter 17 and requires such provider in writing of the proposed rev- care or services; and ocation. The notice of proposed revoca- (2) Such care or services are not fea- tion will set forth the specific grounds sibly available to that covered indi- for the action and will notify the enti- vidual through a VA facility, contract, ty or provider that it has 30 calendar or sharing agreement. For purposes of days from the date of issuance to sub- this subparagraph, hospital care, med- mit a written response addressing ei- ical services, or extended care services ther of the following: are not feasibly available through a VA

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facility, contract, or sharing agree- applicable disqualification requirement when VA determines that the ments of 5 CFR 2635.604 and 2635.606. medical condition of the covered indi- The statutory prohibition in 18 U.S.C. vidual, the travel involved, the nature 208 also may require an employee’s dis- of the care or services, or a combina- qualification from participation in tion of these factors make the use of a matters pertaining to the certification VA facility, contract, or sharing agree- of an entity or provider or a entering ment impracticable or inadvisable. into and administering a Veterans Care (b) Standards of conduct and improper Agreement with an entity or provider business practices—(1) General. (i) Gov- even if the employee’s duties may not ernment business shall be conducted in be considered ‘‘participating personally a manner above reproach and, except and substantially’’; as authorized by statute or regulation, (C) Post-employment restrictions are with complete impartiality and with covered by 18 U.S.C. 207 and 5 CFR part preferential treatment for none. Trans- 2641, that prohibit certain activities by actions relating to the expenditure of former Government employees, includ- public funds require the highest degree ing representation of an entity or proof public trust and an impeccable vider before the Government in rela- standard of conduct. The general rule tion to any particular matter involving is to avoid strictly any conflict of in- specific parties on which the former terest or even the appearance of a con- employee participated personally and flict of interest in Government-con- substantially while employed by the tractor relationships. The conduct of Government. Additional restrictions Government personnel must be such apply to certain senior Government that they would have no reluctance to employees and for particular matters make a full public disclosure of their under an employee’s official responsi- actions. bility; and (ii) VA officials and employees are (D) Using nonpublic information to reminded that there are other statutes further an employee’s private interest and regulations that deal with prohib- or that of another and engaging in a fi- ited conduct, including: nancial transaction using nonpublic in- (A) The offer or acceptance of a bribe formation are prohibited by 5 CFR or gratuity is prohibited by 18 U.S.C. 2635.703. 201. The acceptance of a gift, under cer- (2) Standards and requirements for enti- tain circumstances, is prohibited by 5 ties or providers that enter into Veterans U.S.C. 7353, and 5 CFR part 2635; Care Agreements. An entity or provider (B)(1) Certain financial conflicts of that enters into a Veterans Care Agree- interest are prohibited by 18 U.S.C. 208 ment must comply with the following and regulations at 5 CFR part 2635. standards and requirements through- (2) Contacts with an entity or pro- out the term of the Veterans Care vider that is seeking or receives certifi- Agreement: cation under section 17.4110 of this part (i) Must have a satisfactory perform- or is seeking, enters into, and/or fur- ance record. nishes services or care under a Vet- (ii) Must have a satisfactory record erans Care Agreement may constitute of integrity and business ethics. ‘‘seeking employment,’’ (see Subpart F (iii) Must notify VA within 30 cal- of 5 CFR part 2635). Government offi- endar days of the existence of an in- cers and employees (employees) are dictment, charge, conviction, or civil prohibited by 18 U.S.C. 208 and 5 CFR judgment, or Federal tax delinquency part 2635 from participating personally in an amount that exceeds $3,500. and substantially in any particular (iv) Must not engage in any of the matter that would affect the financial following: interests of any person from whom the (A) Commission of fraud or a crimi- employee is seeking employment. An nal offense in connection with— employee who engages in negotiations (1) Obtaining; or is otherwise seeking employment (2) Attempting to obtain; or with an offeror or who has an arrange- (3) Performing a public contract or ment concerning future employment subcontract, or a Veterans Care Agree- with an offeror must comply with the ment;

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(B) Violation of Federal or State (v) Must not submit to VA a fraudu- antitrust statutes relating to the sub- lent claim, as that term is defined in 38 mission of offers; U.S.C. 1703D(i)(4), for payment for hos- (C) Commission of embezzlement, pital care, medical services, or ex- theft, forgery, bribery, falsification or tended care services. destruction of records, making false statements, tax evasion, violating Fed- § 17.4120 Payment rates. eral criminal tax laws, or receiving The rates paid by VA for hospital stolen property; care, medical services, and extended (D) Delinquent Federal taxes in an care services (hereafter in this section amount that exceeds $3,500. Federal referred to as ‘‘services’’) furnished taxes are considered delinquent for pursuant to a Veterans Care Agree- purposes of this provision if both of the ment will be the rates set forth in the following criteria apply: price terms of the Veterans Care (1) The tax liability is finally deter- Agreement. Each Veterans Care Agree- mined. The liability is finally deter- ment will contain price terms for all mined if it has been assessed and all services within its scope. Such pay- available administrative remedies and ment rates will comply with the fol- rights to judicial review have been ex- lowing parameters: hausted or have lapsed. (a) Except as otherwise provided in this section, payment rates will not ex- (2) The taxpayer is delinquent in ceed the applicable Medicare fee sched- making payment. A taxpayer is delin- ule or prospective payment system quent if the taxpayer has failed to pay amount (hereafter in this section re- the tax liability when full payment was ferred to as ‘‘Medicare rate’’), if any, due and required. A taxpayer is not de- for the period in which the service was linquent in cases where enforced col- provided (without any changes based lection action is precluded. on the subsequent development of in- (E) Knowing failure by a principal, formation under Medicare authorities). until 3 years after final payment on (b) With respect to services furnished any Government contract awarded to in a State with an All-Payer Model the contractor (or any Veterans Care Agreement under section 1814(b)(3) of Agreement entered into with the enti- the Social Security Act (42 U.S.C. ty or provider), to timely disclose to 1395f(b)(3)) that became effective on or the Government, in connection with after January 1, 2014, the Medicare rate the award or agreement, performance, under paragraph (a) will be calculated or closeout of the contract or agree- based on the payment rates under such ment or a subcontract thereunder, agreement. credible evidence of— (c) Payment rates for services fur- (1) Violation of Federal criminal law nished in a highly rural area may ex- involving fraud, conflict of interest, ceed the limitations set forth in para- bribery, or gratuity violations found in graphs (a) and (b) of this section. The Title 18 of the United States Code; term ‘‘highly rural area’’ means an (2) Violation of the civil False Claims area located in a county that has fewer Act (31 U.S.C. 3729–3733); or than seven individuals residing in that (3) Significant overpayment(s) on the county per square mile. contract or Veterans Care Agreement, (d) Payment rates may deviate from other than overpayments resulting the parameters set forth in paragraphs from contract financing payments. (a) through (c) of this section when VA Contract financing payments means an determines, based on patient needs, authorized Government disbursement market analyses, health care provider of monies to a contractor prior to ac- qualifications, or other factors, that it ceptance of supplies or services by the is not practicable to limit payment for Government; or services to the rates available under (F) Commission of any other offense paragraphs (a) through (c). indicating a lack of business integrity (e) Payment rates for services fur- or business honesty that seriously and nished in Alaska are not subject to directly affects the present responsi- paragraphs (a) through (d) of this sec- bility of an entity or provider. tion.

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§ 17.4125 Review of Veterans Care (2) Notice will be delivered to the en- Agreements. tity or provider in accordance with the terms of the Veterans Care Agreement. VA will periodically review each Vet- erans Care Agreement that exceeds (3) VA may discontinue a Veterans Care Agreement for the following rea- $5,000,000 annually, to determine if it is sons: feasible and advisable to furnish the (i) If VA determines the entity or hospital care, medical services, and ex- provider failed to comply substantially tended care services that VA has fur- with the provisions of 38 U.S.C. 1703A nished or anticipates furnishing under or 38 CFR 17.4100–17.4135 such Veterans Care Agreements (ii) If VA determines the entity or through a VA facility, contract, or provider failed to comply substantially sharing agreement instead. If VA de- with the provisions, terms, or condi- termines it is feasible and advisable to tions of the Veterans Care Agreement; provide any such hospital care, medical (iii) If VA determines the entity or services, or extended care services in a provider is excluded from participation VA facility or by contract or sharing in a Federal health care program (as agreement, it will take action to do so. defined in section 1128B(f) of the Social Security Act (42 U.S.C. 1320a–7b(f)) § 17.4130 Discontinuation of Veterans Care Agreements. under section 1128 or 1128A of such Act (42 U.S.C. 1320a–7 and 1320a–7a), or is (a) Discontinuation of the agreement identified as an excluded source on the by the entity or provider requires a System for Award Management Exclu- written notice of request to dis- sions list described in part 9 of title 48, continue, in accordance with the terms Code of Federal Regulations, and part of the Veterans Care Agreement and 180 of title 2 of such Code, or successor the following notice requirements: regulations; (1) Written notice must be received (iv) If VA ascertains that the entity by VA at least 45 calendar days before or provider has been convicted of a fel- the discontinuation date and must ony or other serious offense under fed- specify the discontinuation date; and eral or state law and determines that (2) Such notice must be delivered to discontinuation of the Veterans Care the designated VA official to which Agreement would be in the best inter- such notice must be submitted under est of a covered individual or VA; or the terms of the Veterans Care Agree- (v) If VA determines it is reasonable ment, and the notice and delivery must to discontinue the Veterans Care comply with all terms of the Veterans Agreement based on the health care Care Agreement. needs of a covered individual. (b)(1) Discontinuation of the agree- (The information collection requirement by VA requires a written notice ments have been submitted to the Of- of discontinuation to the entity or pro- fice of Management and Budget (OMB) vider in accordance with the terms of and are pending OMB approval.) the Veterans Care Agreement and the following notice standards: § 17.4135 Disputes. (i) Written notice of discontinuation (a) General. (1) This section estab- will be issued at least 45 calendar days lishes the administrative procedures before the discontinuation date, except and requirements for asserting and re- as provided in subparagraph (ii). solving disputes arising under or re- (ii) Notice may be issued fewer than lated to a Veterans Care Agreement. 45 calendar days before the discontinu- For purposes of this section, a dispute ation date, including notice that is ef- means a disagreement, between VA and fective immediately upon issuance, the entity or provider that entered into when VA determines such abbreviated the subject Veterans Care Agreement or immediate notice is necessary to with VA, that meets the following cri- protect the health of covered individ- teria: uals or when such abbreviated or im- (i) Pertains to one of the subject mediate notice is permitted under the matters set forth in paragraph (b) of terms of the Veterans Care Agreement. this section;

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(ii) Is not resolved informally by mu- all facts pertinent to the dispute, any tual agreement of the parties; and specific resolutions or relief sought, (iii) Culminates in one of the parties and all information and documentation demanding or asserting, as a matter of necessary to review and adjudicate the right, the payment of money in a sum dispute. certain under the Veterans Care Agree- (iii) The notice of dispute must be re- ment, the interpretation of the terms ceived by the designated VA official to of the Veterans Care Agreement or a which such notice must be submitted, specific authorization thereunder, or in accordance with the terms of the other relief arising under or relating to Veterans Care Agreement, within 90 the Veterans Care Agreement. How- calendar days after the accrual of the ever, a dispute does not encompass any dispute. For purposes of this para- demand or assertion, as a matter of graph, the accrual of the dispute is the right, for penalties or forfeitures pre- date when all events, that fix the al- scribed by a statute or regulation that leged liability of either VA or the enti- another federal agency is specifically ty or provider and permit the applica- authorized to administer, settle, or de- ble demand(s) and assertion(s), were termine. known or should have been known. The (2) The procedures established in this term ‘‘accrual of the dispute,’’ as de- section should only be used when the fined, has the following meanings in parties to a Veterans Care Agreement each of the two specific circumstances have failed to resolve an issue in con- that follow: troversy by mutual agreement. (A) When a dispute consists of an en- (3) The procedures established in this tity or provider asserting that VA has section constitute an entity’s or pro- made payment in an incorrect amount, vider’s exclusive administrative rem- under circumstances where VA has edy for disputes under this section. issued a corresponding payment notice (4) Disputes under this section are and the entity or provider has received not considered claims for the purposes such notice, the accrual of the dispute of laws that would otherwise require is the date such notice was received by the application of sections 7101 through the entity or provider. 7109 of title 41 U.S.C. (B) When a dispute consists of an en- (5) An entity or provider must first tity or provider asserting that VA has exhaust the procedures established in improperly denied payment to which it this section before seeking judicial re- is entitled, under circumstances where view under section 1346 of title 28 VA has issued a corresponding denial of U.S.C. payment notice and the entity or pro- (b) Subject matter of disputes. Disputes vider has received such notice, the ac- under this section must pertain to: crual of the dispute is the date such no- (1) The scope of one or more specific tice was received by the entity or pro- authorizations under the applicable vider. Veterans Care Agreement; or (2) VA authority to decide and resolve (2) Claims for payment under the ap- disputes arising under or relating to Vet- plicable Veterans Care Agreement. erans Care Agreements. (i) A VA official (c) Procedures—(1) Initiation of dispute. acting within the scope of authority Disputes under this section must be delegated by the Secretary of Veterans initiated in accordance with the fol- Affairs (hereafter referred to in this lowing procedures and requirements: section as the ‘‘responsible VA offi- (i) Disputes must be initiated by sub- cial’’) will decide and resolve disputes mitting a notice of dispute, in writing, under this section. to the designated VA official to which (ii) The authority to decide or resolve notice must be submitted under the disputes under this section does not ex- terms of the Veterans Care Agreement. tend to the settlement, compromise, The notice of dispute must comply payment, or adjustment of any claim with, and be submitted in accordance for payment that involves fraud or mis- with, applicable terms of the Veterans representation of fact. For purposes of Care Agreement. this paragraph, ‘‘misrepresentation of (ii) The notice of dispute must con- fact’’ means a false statement of sub- tain all specific assertions or demands, stantive fact, or any conduct which

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leads to the belief of a substantive fact (B) Upon a determination that addi- material to proper understanding of tional time is reasonably required to the matter in hand, made with intent issue a decision, the responsible VA of- to deceive or mislead. If the respon- ficial will provide written notice to sible VA official encounters evidence of both parties, in accordance with the misrepresentation of fact or fraud on notice provisions of the Veterans Care the part of the entity or provider, the Agreement, of such determination and responsible VA official shall refer the the time within which a decision will matter to the agency official respon- be issued. The time within which a de- sible for investigating fraud and may cision will be issued must be reason- refer the matter to other federal enti- able, taking into account the com- ties as necessary. plexity of the dispute and any other (3) Review of dispute and written deci- relevant factors, and must not exceed sion. (i) Upon receipt of a notice of dis- 150 calendar days after receipt of a no- pute, the responsible VA official will tice of dispute that conforms to the re- review the dispute and all facts perti- quirements of paragraph (c)(1) of this nent to the dispute. section and all information and docu- (ii) If the responsible VA official de- mentation necessary to review and ad- termines additional information or judicate the dispute. The responsible documentation is required for review VA official will subsequently issue a and adjudication of the dispute, the of- written decision in accordance with ficial will, within 90 calendar days of paragraph (c)(3)(iii)(A) of this section. VA’s receipt of the notice of dispute, (4) Issuance of decision. VA will fur- provide written notice to both parties, nish the decision to the entity or pro- in accordance with the notice provi- vider by any method that provides evi- sions of the Veterans Care Agreement, dence of receipt. that additional information or docu- (5) Effect of decision. A written deci- mentation is required for review and sion issued by the responsible VA offi- adjudication of the dispute. Such no- cial constitutes the agency’s final deci- tice will identify and request the addi- sion on the dispute. tional information and documentation deemed necessary to review and adju- (The information collection require- dicate the dispute. ments have been submitted to the Of- (iii) Upon VA receipt of a notice of fice of Management and Budget (OMB) dispute that conforms to the require- and are pending OMB approval.) ments of paragraph (c)(1) of this sec- § 17.4600 Urgent care. tion (including containing all information and documentation necessary to (a) Purpose. The purpose of this sec- review and adjudicate the dispute), the tion is to establish procedures for ac- responsible VA official will take one of cessing urgent care. Eligible veterans the following actions within 90 cal- may obtain urgent care, in accordance endar days: with the requirements and processes (A) Issue a written decision, in ac- set forth in this section, from quali- cordance with the notice provisions of fying non-VA entities or providers in the Veterans Care Agreement, to both VA’s network that are identified by VA parties. The written decision will in- in accordance with paragraph (c)(2) of clude: this section. (1) A description of the dispute; (b) Definitions. The following defini- (2) A reference to the pertinent terms tions apply to this section. of the Veterans Care Agreement and (1) Eligible veteran means a veteran any relevant authorizations; described in 38 U.S.C. 1725A(b). (3) A statement of the factual areas (2) Episodic care means care or serv- of agreement and disagreement; ices provided in a single visit to an eli- (4) A statement of the responsible of- gible veteran for a particular health ficial’s decision, with supporting ra- condition, or a limited set of particular tionale; and health conditions, without an ongoing (5) A statement that the decision relationship being established between constitutes the final agency decision the eligible veteran and qualifying on the matter in dispute. non-VA entities or providers.

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(3) Longitudinal management of condi- (iv) If VA determines that the provi- tions means outpatient care that ad- sion of additional services is in the in- dresses important disease prevention terest of eligible veterans, based upon and treatment goals and is dependent identified health needs, VA may offer upon bidirectional communications such additional services under this sec- that are ongoing over an extended pe- tion as VA determines appropriate. riod of time. For purposes of this sec- Such services may be limited in duration, the term ‘‘longitudinal manage- tion and location. VA will inform the ment of conditions’’ and ‘‘longitudinal public through a FEDERAL REGISTER care’’ are synonymous. document, published as soon as prac- (4) Qualifying non-VA entity or pro- ticable, and other communications, as vider means a non-VA entity or pro- appropriate. vider, including Federally-qualified (c) Procedures. (1)(i)(A) Eligible vet- health centers as defined in 42 U.S.C. erans may receive urgent care under 1396d(l)(2)(B), that has entered into a this section without prior approval contract, agreement, or other arrange- from VA. ment with the Secretary to furnish ur- (B) Eligible veterans must declare at gent care under this section, or has en- each episode of care if they are using tered into an agreement with a third- this benefit prior to receiving urgent party administrator with whom VA has care under this section. a contract to furnish such care. (2) VA will publish a website pro- (5) Urgent care means services providing information on urgent care, in- vided by a qualifying non-VA entity or cluding the names, locations, and con- provider, and as further defined in tact information for qualifying non-VA paragraphs (b)(5)(i) through (iv) of this entities or providers from which urgent section. care is available under this section. (3) In general, eligibility under this (i) Urgent care includes service avail- section does not affect eligibility for able from entities or providers submit- hospital care or medical services under ting claims for payment as a walk-in the medical benefits package, as de- retail health clinic (Centers for Medi- fined in § 17.38, or other benefits ad- care and Medicaid Services (CMS) dressed in this title. Nothing in this Place of Service code 17) or urgent care section waives the eligibility require- facility (CMS Place of Service code 20); ments established in other statutes or (ii)(A) Except as provided in para- regulations. graph (b)(5)(ii)(B) or (b)(5)(iv) of this (4) Urgent care furnished under this section, urgent care does not include section must meet VA’s standards for preventive health services, as defined quality established under 38 U.S.C. in section 1701(9) of title 38, United 1703C, as applicable. States Code, dental care, or chronic (d) Copayment. (1) Except as provided disease management. in paragraphs (d)(2) and (3) of this sec- (B) Urgent care includes immunization, an eligible veteran, as a condition tion against influenza (flu shots), as for receiving urgent care provided by well as therapeutic vaccines that are VA under this section, must agree to necessary in the course of treatment of pay VA (and is obligated to pay VA) a an otherwise included service and copayment of $30: screenings related to the treatment of (i) After three visits in a calendar symptoms associated with an imme- year if such eligible veteran is enrolled diate illness or exposure. under § 17.36(b)(1) through (6), except (iii) Urgent care may only be fur- those veterans described in nished as episodic care for eligible vet- § 17.36(d)(3)(iii) for all matters not cov- erans needing immediate non-emergent ered by priority category 6. medical attention, and it does not in- (ii) If such eligible veteran is enrolled clude longitudinal care. Veterans re- under § 17.36(b)(7) or (8), including vet- quiring follow-up care as a result of an erans described in § 17.36(d)(3)(iii). urgent care visit under this section (2) An eligible veteran who receives must contact VA or their VA-author- urgent care under paragraph (b)(5)(iv) ized primary care provider to arrange of this section or urgent care con- such care. sisting solely of an immunization

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against influenza (flu shot) is not sub- medical and surgical supplies, avail- ject to a copayment under paragraph able under the VA national formulary (d)(1) of this section and such a visit system. shall not count as a visit for purposes (3) Pay for prescriptions written by of paragraph (d)(1)(i) of this section. qualifying non-VA entities or providers (3) If an eligible veteran would be re- for eligible veterans that have an im- quired to pay more than one copay- mediate need for durable medical ment under this section, or a copay- equipment and medical devices that ment under this section and a copay- are required for urgent conditions (e.g., ment under § 17.108 or § 17.111, on the splints, crutches, manual wheelchairs). same day, the eligible veteran will only (f) Payments. Payments made for ur- be charged the higher copayment. gent care constitute payment in full (e) Prescriptions. Notwithstanding any and shall extinguish the veteran’s li- other provision of this part, VA will: ability to the qualifying non-VA entity (1) Pay for prescriptions written by or provider. The qualifying non-VA en- qualifying non-VA entities or providers tity or provider may not impose any for eligible veterans, including over- additional charge on a veteran or his or the-counter drugs and medical and sur- her health care insurer for any urgent gical supplies, available under the VA care service for which payment is made national formulary system to cover a by VA. This section does not abrogate course of treatment for urgent care no VA’s right, under 38 U.S.C. 1729, to re- longer than 14 days. cover or collect from a third party the (2) Fill prescriptions for urgent care reasonable charges of the care or serv- written by qualifying non-VA entities ices provided under this section. or providers for eligible veterans, including over-the-counter drugs and [84 FR 26018, June 5, 2019]

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