§ 16.119 38 CFR Ch. I (7–1–14 Edition)
completion of instruments, prior ani- pended for research involving human mal studies, or purification of com- subjects unless the requirements of pounds. These applications need not be this policy have been satisfied. reviewed by an IRB before an award may be made. However, except for re- § 16.123 Early termination of research search exempted or waived under support: Evaluation of applications § 16.101 (b) or (i), no human subjects and proposals. may be involved in any project sup- (a) The department or agency head ported by these awards until the may require that department or agency project has been reviewed and approved support for any project be terminated by the IRB, as provided in this policy, or suspended in the manner prescribed and certification submitted, by the in- in applicable program requirements, stitution, to the department or agency. when the department or agency head finds an institution has materially § 16.119 Research undertaken without failed to comply with the terms of this the intention of involving human policy. subjects. (b) In making decisions about sup- In the event research is undertaken porting or approving applications or without the intention of involving proposals covered by this policy the de- human subjects, but it is later pro- partment or agency head may take posed to involve human subjects in the into account, in addition to all other research, the research shall first be re- eligibility requirements and program viewed and approved by an IRB, as pro- criteria, factors such as whether the vided in this policy, a certification sub- applicant has been subject to a termi- mitted, by the institution, to the de- nation or suspension under paragarph partment or agency, and final approval (a) of this section and whether the ap- given to the proposed change by the de- plicant or the person or persons who partment or agency. would direct or has have directed the scientific and technical aspects of an § 16.120 Evaluation and disposition of applications and proposals for re- activity has have, in the judgment of search to be conducted or sup- the department or agency head, mate- ported by a Federal Department or rially failed to discharge responsibility Agency. for the protection of the rights and (a) The department or agency head welfare of human subjects (whether or will evaluate all applications and pro- not the research was subject to federal posals involving human subjects sub- regulation). mitted to the department or agency through such officers and employees of § 16.124 Conditions. the department or agency and such ex- With respect to any research project perts and consultants as the depart- or any class of research projects the de- ment or agency head determines to be partment or agency head may impose appropriate. This evaluation will take additional conditions prior to or at the into consideration the risks to the sub- time of approval when in the judgment jects, the adequacy of protection of the department or agency head addi- against these risks, the potential bene- tional conditions are necessary for the fits of the research to the subjects and protection of human subjects. others, and the importance of the knowledge gained or to be gained. PART 17—MEDICAL (b) On the basis of this evaluation, the department or agency head may DEFINITIONS AND ACTIVE DUTY approve or disapprove the application Sec. or proposal, or enter into negotiations 17.1 Incorporation by reference. to develop an approvable one. 17.30 Definitions. 17.31 Duty periods defined. § 16.121 [Reserved] PROTECTION OF PATIENT RIGHTS § 16.122 Use of Federal funds. 17.32 Informed consent and advance care Federal funds administered by a de- planning. partment or agency may not be ex- 17.33 Patients’ rights.
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TENTATIVE ELIGIBILITY DETERMINATIONS at non-departmental facilities and other medical charges associated with non-VA 17.34 Tentative eligibility determinations. outpatient care. HOSPITAL OR NURSING HOME CARE AND USE OF COMMUNITY NURSING HOME CARE MEDICAL SERVICES IN FOREIGN COUNTRIES FACILITIES 17.35 Hospital care and medical services in 17.57 Use of community nursing homes. foreign countries. 17.58 Evacuation of community nursing ENROLLMENT PROVISIONS AND MEDICAL homes. BENEFITS PACKAGE 17.60 Extensions of community nursing home care beyond six months. 17.36 Enrollment—provision of hospital and outpatient care to veterans. COMMUNITY RESIDENTIAL CARE 17.37 Enrollment not required—provision of hospital and outpatient care to veterans. 17.61 Eligibility. 17.38 Medical benefits package. 17.62 Definitions. 17.39 Certain Filipino veterans. 17.63 Approval of community residential 17.40 Additional services for indigents. care facilities. 17.64 [Reserved] EXAMINATIONS AND OBSERVATION AND 17.65 Approvals and provisional approvals of EXAMINATION community residential care facilities. 17.66 Notice of noncompliance with VA 17.41 Persons eligible for hospital observa- standards. tion and physical examination. 17.67 Request for a hearing. 17.42 Examinations on an outpatient basis. 17.68 Notice and conduct of hearing. HOSPITAL, DOMICILIARY AND NURSING HOME 17.69 Waiver of opportunity for hearing. CARE 17.70 Written decision following a hearing. 17.71 Revocation of VA approval. 17.43 Persons entitled to hospital or domi- 17.72 Availability of information. ciliary care. 17.73 Medical foster homes—general. 17.44 Hospital care for certain retirees with 17.74 Standards applicable to medical foster chronic disability (Executive Orders homes. 10122, 10400 and 11733). 17.45 Hospital care for research purposes. USE OF SERVICES OF OTHER FEDERAL 17.46 Eligibility for hospital, domiciliary or AGENCIES nursing home care of persons discharged 17.80 Alcohol and drug dependence or abuse or released from active military, naval, treatment and rehabilitation in residen- or air service. 17.47 Considerations applicable in deter- tial and nonresidential facilities by con- mining eligibility for hospital, nursing tract. home or domiciliary care. 17.81 Contracts for residential treatment 17.48 Compensated Work Therapy/Transi- services for veterans with alcohol or drug tional Residences program. dependence or abuse disabilities. 17.49 Priorities for outpatient medical serv- 17.82 Contracts for outpatient services for ices and inpatient hospital care. veterans with alcohol or drug dependence or abuse disabilities. USE OF DEPARTMENT OF DEFENSE, PUBLIC 17.83 Limitations on payment for alcohol HEALTH SERVICE OR OTHER FEDERAL HOS- and drug dependence or abuse treatment PITALS and rehabilitation.
17.50 Use of Department of Defense, Public RESEARCH-RELATED INJURIES Health Service or other Federal hospitals with beds allocated to the Department of 17.85 Treatment of research-related injuries Veterans Affairs. to human subjects. 17.51 Emergency use of Department of De- CARE DURING CERTAIN DISASTERS AND fense, Public Health Service or other EMERGENCIES Federal hospitals. 17.86 Provision of hospital care and medical USE OF PUBLIC OR PRIVATE HOSPITALS services during certain disasters and 17.52 Hospital care and medical services in emergencies under 38 U.S.C. 1785. non-VA facilities. VOCATIONAL TRAINING AND HEALTH-CARE ELI- 17.53 Limitations on use of public or private GIBILITY PROTECTION FOR PENSION RECIPI- hospitals. ENTS 17.54 Necessity for prior authorization. 17.55 Payment for authorized public or pri- 17.90 Medical care for veterans receiving vo- vate hospital care. cational training under 38 U.S.C. chapter 17.56 VA payment for inpatient and out- 15. patient health care professional services 17.91 Protection of health-care eligibility.
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OUTPATIENT TREATMENT PAYMENT AND REIMBURSEMENT OF THE EX- PENSES OF MEDICAL SERVICES NOT PRE- 17.92 Outpatient care for research purposes. VIOUSLY AUTHORIZED 17.93 Eligibility for outpatient services. 17.94 Outpatient medical services for mili- 17.120 Payment or reimbursement for emer- tary retirees and other beneficiaries. gency treatment furnished by non-VA 17.95 Outpatient medical services for De- providers to certain veterans with serv- partment of Veterans Affairs employees ice-connected disabilities. and others in emergencies. 17.121 Limitations on payment or reim- bursement of the costs of emergency 17.96 Medication prescribed by non-VA phy- treatment not previously authorized. sicians. 17.122 Payment or reimbursement of the ex- 17.97 Prescriptions in Alaska, and terri- penses of repairs to prosthetic appliances tories and possessions. and similar devices furnished without 17.98 Mental health services. prior authorization. 17.123 Claimants. CHARGES, WAIVERS, AND COLLECTIONS 17.124 Preparation of claims. 17.101 Collection or recovery by VA for med- 17.125 Where to file claims. ical care or services provided or fur- 17.126 Timely filing. nished to a veteran for a nonservice-con- 17.127 Date of filing claims. nected disability. 17.128 Allowable rates and fees. 17.102 Charges for care or services. 17.129 Retroactive payments prohibited. 17.103 Referrals of compromise settlement 17.130 Payment for treatment dependent offers. upon preference prohibited. 17.104 Terminations and suspensions. 17.131 Payment of abandoned claims prohib- 17.105 Waivers. ited. 17.132 Appeals. 17.106 VA collection rules; third-party pay- ers. RECONSIDERATION OF DENIED CLAIMS
DISCIPLINARY CONTROL OF BENEFICIARIES RE- 17.133 Procedures. CEIVING HOSPITAL, DOMICILIARY OR NURSING HOME CARE DELEGATIONS OF AUTHORITY 17.107 VA response to disruptive behavior of 17.140 Authority to adjudicate reimburse- ment claims. patients. 17.141 Authority to adjudicate foreign reim- COPAYMENTS bursement claims. 17.142 Authority to approve sharing agree- 17.108 Copayments for inpatient hospital ments, contracts for scarce medical spe- care and outpatient medical care. cialist services and contracts for other 17.109 Presumptive eligibility for psychosis medical services. and mental illness other than psychosis. 17.110 Copayments for medication. PROSTHETIC, SENSORY, AND REHABILITATIVE 17.111 Copayments for extended care serv- AIDS ices. 17.148 Service dogs. 17.149 Sensori-neural aids. CEREMONIES 17.150 Prosthetic and similar appliances. 17.112 Services or ceremonies on Depart- 17.151 Invalid lifts for recipients of aid and ment of Veterans Affairs hospital or cen- attendance allowance or special monthly ter reservations. compensation. 17.152 Devices to assist in overcoming the REIMBURSEMENT FOR LOSS BY NATURAL DIS- handicap of deafness. ASTER OF PERSONAL EFFECTS OF HOSPITAL- 17.153 Training in the use of appliances. IZED OR NURSING HOME PATIENTS 17.154 Equipment for blind veterans.
17.113 Conditions of custody. AUTOMOTIVE EQUIPMENT AND DRIVER 17.114 Submittal of claim for reimburse- TRAINING ment. 17.155 Minimum standards of safety and 17.115 Claims in cases of incompetent pa- quality for automotive adaptive equip- tients. ment. 17.156 Eligibility for automobile adaptive REIMBURSEMENT TO EMPLOYEES FOR THE COST equipment. OF REPAIRING OR REPLACING CERTAIN PER- 17.157 Definition-adaptive equipment. SONAL PROPERTY DAMAGED OR DESTROYED 17.158 Limitations on assistance. BY PATIENTS OR MEMBERS 17.159 Obtaining vehicles for special driver 17.116 Adjudication of claims. training courses.
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DENTAL SERVICES 17.258 Terms and conditions to which awards are subject. 17.160 Authorization of dental examina- 17.259 Direct costs. tions. 17.161 Authorization of outpatient dental 17.260 Patient care costs to be excluded treatment. from direct costs. 17.162 Eligibility for Class II dental treat- 17.261 Indirect costs. ment without rating action. 17.262 Authority to approve applications 17.163 Posthospital outpatient dental treat- discretionary. ment. 17.263 Suspension and termination proce- 17.164 Patient responsibility in making and dures. keeping dental appointments. 17.264 Recoupments and releases. 17.165 Emergency outpatient dental treat- 17.265 Payments. ment. 17.266 Copyrights and patents. 17.166 Dental services for hospital or nurs- CIVILIAN HEALTH AND MEDICAL PROGRAM OF ing home patients and domiciled mem- THE DEPARTMENT OF VETERANS AFFAIRS bers. 17.169 VA Dental Insurance Program for (CHAMPVA)—MEDICAL CARE FOR SUR- veterans and survivors and dependents of VIVORS AND DEPENDENTS OF CERTAIN VET- veterans (VADIP). ERANS 17.270 General provisions. AUTOPSIES 17.271 Eligibility. 17.170 Autopsies. 17.272 Benefit limitations/exclusions. 17.273 Preauthorization. VETERANS CANTEEN SERVICE 17.274 Cost sharing. 17.180 Delegation of authority. 17.275 Claim filing deadline. 17.276 Appeal/review process. AID TO STATES FOR CARE OF VETERANS IN 17.277 Third party liability/medical care STATE HOMES cost recovery. 17.278 Confidentiality of records. 17.190 Recognition of a State home. 17.191 Filing applications. GRANTS TO THE REPUBLIC OF THE PHILIPPINES 17.192 Approval of annexes and new facili- ties. 17.350 The program of assistance to the 17.193 Prerequisites for payments to State Philippines. homes. 17.351 Grants for the replacement and up- 17.194 Aid for domiciliary care. grading of equipment at Veterans Memo- 17.196 Aid for hospital care. rial Medical Center. 17.197 Amount of aid payable. 17.352 Amounts and use of grant funds for 17.198 Department of Veterans Affairs ap- the replacement and upgrading of equip- proval of eligibility required. ment. 17.199 Inspection of recognized State homes. 17.355 Awards procedures. 17.200 Audit of State homes. 17.362 Acceptance of medical supplies as payment. SHARING OF MEDICAL FACILITIES, EQUIPMENT, 17.363 Length of stay. AND INFORMATION 17.364 Eligibility determinations. 17.230 Contingency backup to the Depart- 17.365 Admission priorities. ment of Defense. 17.366 Authorization of emergency admis- 17.240 Sharing specialized medical re- sions. sources. 17.367 Republic of the Philippines to print 17.241 Sharing medical information serv- forms. ices. 17.369 Inspections. 17.242 Coordination of programs with De- 17.370 Termination of payments. partment of Health and Human Services. CONFIDENTIALITY OF HEALTHCARE QUALITY GRANTS FOR EXCHANGE OF INFORMATION ASSURANCE REVIEW RECORDS 17.250 Scope of the grant program. 17.500 General. 17.251 The Subcommittee on Academic Af- 17.501 Confidential and privileged docu- fairs. ments. 17.252 Ex officio member of subcommittee. 17.502 Applicability of other statutes. 17.253 Applicants for grants. 17.503 Improper disclosure. 17.254 Applications. 17.504 Disclosure methods. 17.255 Applications for grants for programs 17.505 Disclosure authorities. which include construction projects. 17.506 Appeal of decision by Veterans 17.256 Amended or supplemental applica- Health Administration to deny disclo- tions. sure. 17.257 Awards procedures. 17.507 Employee responsibilities.
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17.508 Access to quality assurance records HEALTH CARE BENEFITS FOR CERTAIN CHIL- and documents within the agency. DREN OF VIETNAM VETERANS AND VETERANS 17.509 Authorized disclosure: Non-Depart- WITH COVERED SERVICE IN KOREA—SPINA ment of Veterans Affairs requests. BIFIDA AND COVERED BIRTH DEFECTS 17.510 Redisclosure. 17.900 Definitions. 17.511 Penalties for violations. 17.901 Provision of health care. VA HEALTH PROFESSIONAL SCHOLARSHIP 17.902 Preauthorization. PROGRAM 17.903 Payment. 17.904 Review and appeal process. 17.600 Purpose. 17.905 Medical records. 17.601 Definitions. 17.602 Eligibility. PAYMENT OR REIMBURSEMENT FOR EMERGENCY 17.603 Availability of HPSP scholarships. SERVICES FOR NONSERVICE-CONNECTED CON- 17.604 Application for the HPSP. DITIONS IN NON-VA FACILITIES 17.605 Selection of participants. 17.1000 Payment or reimbursement for 17.606 Award procedures. emergency services for nonservice-con- 17.607 Obligated service. nected conditions in non-VA facilities. 17.608 Deferment of obligated service. 17.1001 Definitions. 17.609 Pay during period of obligated serv- 17.1002 Substantive conditions for payment ice. or reimbursement. 17.610 Failure to comply with terms and 17.1003 Emergency transportation. conditions of participation. 17.1004 Filing claims. 17.611 Bankruptcy. 17.1005 Payment limitations. 17.612 Cancellation, waiver, or suspension of 17.1006 Decisionmakers. obligation. 17.1007 Independent right of recovery. VISUAL IMPAIRMENT AND ORIENTATION AND 17.1008 Balance billing prohibited. MOBILITY PROFESSIONAL SCHOLARSHIP PRO- VET CENTERS GRAM 17.2000Vet Center services. 17.625 Purpose. 17.626 Definitions. AUTHORITY: 38 U.S.C. 501, and as noted in 17.627 Eligibility for the VIOMPSP. specific sections. 17.628 Availability of VIOMPSP scholar- ships. DEFINITIONS AND ACTIVE DUTY 17.629 Application for the VIOMPSP. 17.630 Selection of VIOMPSP participants. § 17.1 Incorporation by reference. 17.631 Award procedures. (a) Certain materials are incor- 17.632 Obligated service. porated by reference into this part 17.633 Deferment of obligated service. 17.634 Failure to comply with terms and with the approval of the Director of the conditions of participation. Federal Register under 5 U.S.C. 552(a) 17.635 Bankruptcy. and 1 CFR part 51. To enforce an edi- 17.636 Cancellation, waiver, or suspension of tion of a publication other than that obligation. specified in this section, VA will pro- vide notice of the change in a notice of GRANTS FOR TRANSPORTATION OF VETERANS IN EDERAL HIGHLY RURAL AREAS proposed rulemaking in the F REGISTER and the material will be 17.700 Purpose and scope. made available to the public. All ap- 17.701 Definitions. proved materials are available for in- 17.702 Grants—general. 17.703 Eligibility and application. spection at the Department of Vet- 17.705 Scoring criteria and selection. erans Affairs, Office of Regulation Pol- 17.710 Notice of Fund Availability. icy and Management (02REG), 810 17.715 Grant agreements. Vermont Avenue, NW., Room 1068, 17.720 Payments under the grant. Washington, DC 20420, or at the Na- 17.725 Grantee reporting requirements. tional Archives and Records Adminis- 17.730 Recovery of funds by VA. tration (NARA). For information on TRANSITIONAL HOUSING LOAN PROGRAM the availability of approved materials at NARA, call (202) 741–6030, or go to: 17.800 Purpose. http://www.archives.gov/federallregister/ 17.801 Definitions. 17.802 Application provisions. codeloflfederallregulations/ 17.803 Order of consideration. ibrllocations.html. Copies may be ob- 17.804 Loan approval criteria. tained from the National Fire Protec- 17.805 Additional terms of loans. tion Association, 1 Batterymarch Park,
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Quincy, MA 02269. (For ordering infor- (a) Medical services. The term medical mation, call toll-free 1–800–344–3555.) services includes, in addition to medical (b) The following materials are incor- examination, treatment, and rehabili- porated by reference into this part. tative services: (1) NFPA 10, Standard for Portable (1) Surgical services, dental services Fire Extinguishers (2010 edition), Incor- and appliances as authorized in §§ 17.160 poration by Reference (IBR) approved through 17.166, optometric and for §§ 17.63, 17.74, and 17.81. podiatric services, (in the case of a per- (2) NFPA 101, Life Safety Code (2009 son otherwise receiving care or services edition), IBR approved for §§ 17.63, 17.74 under this chapter) the preventive (chapters 1 through 11, 24, and section health care services set forth in 38 33.7), 17.81, and 17.82. U.S.C. 1762, noninstitutional extended (3) NFPA 101A, Guide on Alternative care, wheelchairs, artificial limbs, Approaches to Life Safety (2010 edi- trusses and similar appliances, special tion), IBR approved for § 17.63. clothing made necessary by the wear- (4) NFPA 13, Standard for the Instal- ing of prosthetic appliances, and such lation of Sprinkler Systems (2010 edi- other supplies or services as are medi- tion), IBR approved for § 17.74. cally determined to be reasonable and (5) NFPA 13D, Standard for the In- necessary. stallation of Sprinkler Systems in One- (Authority: 38 U.S.C. 1701(6)(A)(i)) and Two-Family Dwellings and Manu- factured Homes (2010 edition), IBR ap- (2) Consultation, professional coun- proved for § 17.74. seling, marriage and family counseling, (6) 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, (7) 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- (2008 edition), IBR approved for § 17.74. penses for any person entitled to such (8) NFPA 30, Flammable and Combus- benefits under the provisions of § 17.143. tible Liquids Code (2008 edition), IBR approved for § 17.74. (Authority: 38 U.S.C. 1701(6)) (9) NFPA 72, National Fire Alarm and (b) Domiciliary care. The term domi- Signaling Code (2010 edition), IBR ap- ciliary care means the furnishing of a proved for § 17.74. home to a veteran, embracing the fur- (10) NFPA 720, Standard for the In- nishing of shelter, food, clothing and stallation of Carbon Monoxide (CO) De- other comforts of home, including nec- tection and Warning Equipment (2009 essary medical services. The term fur- edition), IBR approved for § 17.74. ther includes travel and incidental ex- penses pursuant to § 17.143. (Authority: 5 U.S.C. 552(a), 38 U.S.C. 501, 1721.) (Authority: 38 U.S.C. 1701(4)) [76 FR 10248, Feb. 24, 2011, as amended at 77 [23 FR 6498, Aug. 22, 1958] FR 5188, Feb. 2, 2012] EDITORIAL NOTE: For FEDERAL REGISTER ci- EFFECTIVE DATE NOTE: At 76 FR 10248, Feb. tations affecting § 17.30, see the List of CFR 24, 2011, § 17.1 was added. This section con- Sections Affected, which appears in the tains information collection and record- Finding Aids section of the printed volume keeping requirements and will not become and at www.fdsys.gov. effective until approval has been given by the Office of Management and Budget. § 17.31 Duty periods defined. Definitions of duty periods applicable § 17.30 Definitions. to eligibility for medical benefits are When used in Department of Vet- as follows: erans Affairs medical regulations, each (a) Active military, naval, or air service of the following terms shall have the includes: meaning ascribed to it in this section: (1) Active duty.
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(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 Geodetic Survey or the Environmental service in areas of immediate military Science Services Administration, dur- hazard while conducting cooperative ing the following dates: operations with and for the U.S. Armed (i) On or after July 29, 1945; Forces any time during the period De- (ii) Before July 29, 1945, under the fol- cember 7, 1941, to August 15, 1945. lowing circumstances: Qualifying USCGS vessels specified by (A) While on transfer to one of the the Secretary of the Air Force are the Armed Forces; Derickson, Explorer, Gilbert, Hilgard, (B) While, in time of war or national E. Lester Jones, Lydonia, Patton, Sur- emergency declared by the President, veyor, Wainwright, Westdahl, Oceanog- assigned to duty on a project for one of rapher, Hydrographer, or Pathfinder. the Armed Forces in an area deter- Recognized effective April 8, 1991. mined by the Secretary of Defense to (10) Service by Civilian Employees of be of immediate military hazard; or Pacific Naval Air Bases who actively (C) In the Philippine Islands on De- participated in Defense of Wake Island cember 7, 1941, and continuously in during World War II. Recognized effec- such islands thereafter; or tive January 22, 1981. (4) Service as a cadet at the U.S. (11) Service by Civilian Navy Identi- Military, Air Force, or Coast Guard fication Friend or Foe (IFF) Techni- Academy, or as a midshipman at the cians who served in the Combat Areas U.S. Naval Academy. of the Pacific any time during the pe- (5) Service in Women’s Army Auxil- riod December 7, 1941, to August 15, iary Corps (WAAC). Recognized effec- 1945. Recognized effective August 2, tive March 18, 1980. 1988. (6) Service of any person in a group (12) Service by Civilian personnel as- the members of which rendered service signed to the Secret Intelligence Ele- to the Armed Forces of the United ment of the Office of Strategic Services
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(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 with the American Expeditionary Northeast Airlines’ Contract with the Forces in World War II. Recognized ef- Air Transport Command any time dur- fective January 22, 1981. ing the period December 7, 1941, to Au- (20) Service by Quartermaster Corps gust 14, 1945. Recognized effective June Keswick Crew on Corregidor (World 2, 1997. War II). Recognized effective February (29) Service by U.S. Civilian Flight 7, 1984. Crew and Aviation Ground Support (21) Service by Reconstruction Aides Employees of Northwest Airlines, who and Dietitians in World War I. Recog- served overseas as a result of North- nized effective July 6, 1981. west Airlines’ Contract with the Air (22) Service by Signal Corps Female Transport Command any time during Telephone Operators Unit of World War the period December 14, 1941, to August I. Recognized effective May 15, 1979. 14, 1945. Recognized effective December (23) Service by three scouts/guides, 13, 1993. Miguel Tenorio, Penedicto Taisacan, (30) Service by U.S. Civilian Flight and Cristino Dela Cruz, who assisted Crew and Aviation Ground Support the U.S. Marines in the offensive oper- Employees of Pan American World Air- ations against the Japanese on the ways and its Subsidiaries and Affili- Northern Mariana Islands from June ates, who served overseas as a result of 19, 1944, through September 2, 1945. Pan American’s Contract with the Air Recognized effective September 30, Transport Command and Naval Air 1999. Transport Service any time during the (24) Service by U.S. civilian employ- period December 14, 1941, to August 14, ees of American Airlines who served 1945. Recognized effective July 16, 1992. overseas as a result of American Air- (31) Service by U.S. Civilian Flight lines’ Contract with the Air Transport Crew and Aviation Ground Support Command any time during the period Employees of Transcontinental and
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Western Air (TWA), Inc., who served (ii) Female dietetic and physical overseas as a result of TWA’s Contract therapy personnel, excluding students with the Air Transport Command any and apprentices, appointed with rel- time during the period December 14, ative rank after December 21, 1942, or 1941, to August 14, 1945. The ‘‘Flight commissioned after June 21, 1944. Crew’’ includes pursers. Recognized ef- (43) Service by students who were en- fective May 13, 1992. listed men in Aviation camps during (32) Service by U.S. Civilian Flight World War I. Crew and Aviation Ground Support (44) Active service in the Coast Guard Employees of United Air Lines (UAL), after January 28, 1915, while under the who served overseas as a result of jurisdiction of the Treasury Depart- UAL’s Contract with the Air Transport ment, the Navy Department, the De- Command any time during the period partment of Transportation, or the De- December 14, 1941, to August 14, 1945. partment of Homeland Security. This Recognized effective May 13, 1992. does not include temporary members of (33) Service by U.S. civilian volun- the Coast Guard Reserves. teers who actively participated in the (45) Service by contract surgeons if Defense of Bataan. Recognized effec- the disability was the result of injury tive February 7, 1984. or disease contracted in the line of (34) Service by U.S. civilians of the duty during a period of war while actu- American Field Service (AFS) who ally performing the duties of assistant served overseas operationally in World surgeon or acting assistant surgeon War I any time during the period Au- with any military force in the field, or gust 31, 1917, to January 1, 1918. Recog- in transit, or in a hospital. nized effective August 30, 1990. (46) Service by field clerks of the (35) Service by U.S. civilians of the Quartermaster Corps. American Field Service (AFS) who (47) Service by lighthouse service served overseas under U.S. Armies and personnel who were transferred to the U.S. Army Groups in World War II any service and jurisdiction of the War or time during the period December 7, Navy Departments by Executive Order 1941, to May 8, 1945. Recognized effec- under the Act of August 29, 1916. Effec- tive August 30, 1990. tive July 1, 1939, service was consoli- dated with the Coast Guard. (36) Service by U.S. Merchant Sea- (48) Service by male nurses who were men who served on blockships in sup- enlisted in a Medical Corps. port of Operation Mulberry. Recognized (49) Service by persons having a pen- effective October 18, 1985. sionable or compensable status before (37) Service by Wake Island Defend- January 1, 1959. ers from Guam. Recognized effective (50) Service by a Commonwealth April 7, 1982. Army veteran or new Philippine Scout, (38) Service by Women’s Air Forces as defined in 38 U.S.C. 1735, who resides Service Pilots (WASP). Recognized ef- in the United States and is a citizen of fective November 23, 1977. the United States or an alien lawfully (39) Service by persons who were in- admitted to the United States for per- jured while providing aerial transpor- manent residence; service by Regular tation of mail and serving under condi- Philippine Scouts and service in the In- tions set forth in Public Law 73–140. sular Force of the Navy, Samoan Na- (40) Service in the Alaska Territorial tive Guard, or Samoan Native Band of Guard during World War II, for any the Navy. person who the Secretary of Defense (51) Service with the Revenue Cutter determines was honorably discharged. Service while serving under direction (41) Service by Army field clerks. of the Secretary of the Navy in co- (42) Service by Army Nurse Corps, operation with the Navy. Effective Navy Nurse Corps, and female dietetic January 28, 1915, the Revenue Cutter and physical therapy personnel as fol- Service was merged into the Coast lows: Guard. (i) Female Army and Navy nurses on (52) Service during World War I in the active service under order of the serv- Russian Railway Service Corps as cer- ice department; or tified by the Secretary of the Army.
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(53) Service by members of training (ii) Who has been selected or drafted camps authorized by section 54 of the for service in the Armed Forces and National Defense Act (Pub. L. 64–85, 39 has reported pursuant to the call of the Stat. 166), except for members of Stu- person’s local draft board and before dent Army Training Corps Camps at rejection; or the Presidio of San Francisco; (iii) Who has been called into the Plattsburg, New York; Fort Sheridan, Federal service as a member of the Na- Illinois; Howard University, Wash- tional Guard, but has not been enrolled ington, DC; Camp Perry, Ohio; and for the Federal service. Camp Hancock, Georgia, from July 18, Note to paragraph (b)(58): The injury 1918, to September 16, 1918. or disease must be due to some factor (54) Service in the Women’s Army relating to compliance with proper or- Corps (WAC) after June 30, 1943. ders. Draftees and selectees are in- (55) Service in the Women’s Reserve cluded when reporting for preinduction of the Navy, Marine Corps, and Coast examination or for final induction on Guard. active duty. Such persons are not in- (56) Effective July 28, 1959, service by cluded for injury or disease suffered a veteran who was discharged for during the period of inactive duty, or alienage during a period of hostilities period of waiting, after a final physical unless evidence affirmatively shows examination and prior to beginning the the veteran was discharged at his or trip to report for induction. Members her own request. A veteran who was of the National Guard are included discharged for alienage after a period when reporting to a designated ren- of hostilities and whose service was dezvous. honest and faithful is not barred from (59) Authorized travel to or from such benefits if he or she is otherwise enti- duty or service, as described in this tled. A discharge changed prior to Jan- section. uary 7, 1957, to honorable by a board es- (60) The period of time immediately tablished under 10 U.S.C. 1552 and 1553 following the date an individual is dis- will be considered as evidence that the charged or released from a period of ac- discharge was not at the alien’s re- tive duty, as determined by the Sec- quest. retary concerned to have been required (57) Attendance at the preparatory for that individual to proceed to that schools of the United States Air Force individual’s home by the most direct Academy, the United States Military route, and in any event until midnight Academy, or the United States Naval of the date of such discharge or release. Academy for enlisted active duty mem- (c) Active duty for training means: bers who are reassigned to a pre- (1) Full-time duty in the Armed paratory school without a release from Forces performed by Reserves for active duty, and for other individuals training purposes. who have a commitment to active duty (2) Full-time duty for training pur- in the Armed Forces that would be poses performed as a commissioned of- binding upon disenrollment from the ficer of the Reserve Corps of the Public preparatory school. Health service during the period cov- (58) For purposes of providing med- ered in paragraph (b)(2) of this section. ical care under chapter 17 for a service- (3) In the case of members of the connected disability, service by any Army National Guard or Air National person who has suffered an injury or Guard of any State, full-time duty contracted a disease in line of duty under sections 316, 502, 503, 504, or 505 of while en route to or from, or at, a place title 32 U.S.C., or the prior cor- for final acceptance or entry upon ac- responding provisions of law. tive duty and: (4) Duty performed by a member of a (i) Who has applied for enlistment or Senior Reserve Officers’ Training Corps enrollment in the active military, program when ordered to such duty for naval, or air service and has been pro- the purpose of training or a practice visionally accepted and directed or or- cruise under chapter 103 of title 10 dered to report to a place for final ac- U.S.C. for a period of not less than four ceptance into such service; weeks and which must be completed by
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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; (iv) The itinerary; (ii) The hour on which such indi- (v) The manner in which the travel vidual was scheduled to arrive for, or was performed; and on which such individual ceased to per- (vi) The immediate cause of dis- form, such duty; ability. (iii) The method of travel employed; (NOTE TO PARAGRAPH (C)(6): Active (iv) The itinerary; duty for training does not include duty (v) The manner in which the travel performed as a temporary member of was performed; and the Coast Guard Reserve.) (vi) The immediate cause of dis- (d) Inactive duty training means:(1) ability. Duty (other than full-time duty) pre- (Authority: 38 U.S.C. 101, 106, 501, 1734 and scribed for Reserves (including com- 1735.) missioned officers of the Reserve Corps of the Public Health Service) by the [34 FR 9339, June 13, 1969, as amended at 45 Secretary concerned under section 206, FR 6934, Jan. 31, 1980; 45 FR 43169, June 26, 1980; 48 FR 56580, Dec. 22, 1983; 61 FR 21965, title 37 U.S.C., or any other provision May 13, 1996; 75 FR 54497, Sept. 8, 2010; 78 FR of law; 78260, Dec. 26, 2013] (2) Special additional duties author- ized for Reserves (including commis- PROTECTION OF PATIENT RIGHTS sioned officers of the Reserve Corps of the Public Health Service) by an au- § 17.32 Informed consent and advance thority designated by the Secretary care planning. concerned and performed by them on a (a) Definitions: voluntary basis in connection with the Advance Directive. Specific written prescribed training or maintenance ac- statements made by a patient who has
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decision-making capacity regarding fu- to perform the treatment or procedure. ture health care decisions in any of the For the purpose of obtaining informed following: consent for medical treatment, the (i) VA Living Will. A written state- term practitioner includes medical and ment made by a patient on an author- dental residents and other appro- ized VA form which sets forth the pa- priately trained health care profes- tient’s wishes regarding the patient’s sionals designated by VA regardless of health care treatment preferences in- whether they have been granted clin- cluding the withholding and with- ical privileges. drawal of life-sustaining treatment. Signature consent. The patient’s or (ii) VA Durable Power of Attorney for surrogate’s signature on a VA-author- Health Care. A written instruction on a ized consent form. VA form which designates the patient’s choice of health care agent. Special guardian. A person appointed (iii) State-Authorized Advance Direc- by a court of appropriate jurisdiction tive. A non-VA living will, durable for the specific purpose of making power of attorney for health care, or health care decisions. other advance health care planning Surrogate. An individual, organiza- document, the validity of which is de- tion or other body authorized under termined pursuant to applicable State this section to give informed consent law. For the purposes of this paragraph on behalf of a patient who lacks deci- and paragraph (h) of this section, ‘‘ap- sion-making capacity. plicable State law’’ means the law of (b) Policy. Except as otherwise pro- the State where the advance directive vided in this section, all patient care was signed, the State where the patient furnished under title 38 U.S.C. shall be resided when the advance directive was carried out only with the full and in- signed, the State where the patient formed consent of the patient or, in ap- now resides, or the State where the pa- propriate cases, a representative there- tient is receiving treatment. VA will of. In order to give informed consent, resolve any conflict between those the patient must have decision-making State laws regarding the validity of the capacity and be able to communicate advance directive by following the law decisions concerning health care. If the of the State that gives effect to the ex- patient lacks decision-making capacity pressed wishes in the advance direc- tive. or has been declared incompetent, con- Close friend. Any person eighteen sent must be obtained from the pa- years or older who has shown care and tient’s surrogate. Practitioners may concern for the patient’s welfare, who provide necessary medical care in is familiar with the patient’s activi- emergency situations without the pa- ties, health, religious beliefs and val- tient’s or surrogate’s express consent ues, and who has presented a signed when immediate medical care is nec- written statement for the record that essary to preserve life or prevent seri- describes that person’s relationship to ous impairment of the health of the pa- and familiarity with the patient. tient or others and the patient is un- Decision-making capacity. The ability able to consent and the practitioner de- to understand and appreciate the na- termines that the patient has no surro- ture and consequences of health care gate or that waiting to obtain consent treatment decisions. from the patient’s surrogate would in- Health care agent. An individual crease the hazard to the life or health named by the patient in a Durable of the patient or others. In such cir- Power of Attorney for Health Care. cumstances consent is implied. Legal guardian. A person appointed (c) General requirements for informed by a court of appropriate jurisdiction consent. Informed consent is the freely to make decisions for an individual given consent that follows a careful ex- who has been judicially determined to planation by the practitioner to the pa- be incompetent. Practitioner. Any physician, dentist, tient or the patient’s surrogate of the or health care professional who has proposed diagnostic or therapeutic pro- been granted specific clinical privileges cedure or course of treatment. The
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practitioner, who has primary respon- sent discussion and documentation so sibility for the patient or who will per- long as the course of treatment pro- form the particular procedure or pro- ceeds as planned, even if treatment ex- vide the treatment, must explain in tends beyond the 60-day period. If there language understandable to the patient is a change in the patient’s condition or surrogate the nature of a proposed that might alter the diagnostic or procedure or treatment; the expected therapeutic decision, the consent is benefits; reasonably foreseeable associ- automatically rescinded. ated risks, complications or side ef- (3) If it is impractical to consult with fects; reasonable and available alter- the surrogate in person, informed con- natives; and anticipated results if sent may be obtained by mail, fac- nothing is done. The patient or surro- simile, or telephone. A facsimile copy gate must be given the opportunity to of a signed consent form is adequate to ask questions, to indicate comprehen- proceed with treatment. However, the sion of the information provided, and surrogate must agree to submit a to grant permission freely without co- signed consent form to the practi- ercion. The practitioner must advise tioner. If consent is obtained by tele- the patient or surrogate if the proposed phone, the conversation must be treatment is novel or unorthodox. The audiotaped or witnessed by a second patient or surrogate may withhold or VA employee. The name of the person revoke his or her consent at any time. giving consent and his or her authority (d) Documentation of informed consent. to act as surrogate must be adequately (1) The informed consent process must identified for the record. be appropriately documented in the (e) Surrogate consent. If the practi- health record. In addition, signature tioner who has primary responsibility consent is required for all diagnostic for the patient determines that the pa- and therapeutic treatments or proce- tient lacks decision-making capacity dures that: and is unlikely to regain it within a (i) Require the use of sedation; reasonable period of time, informed (ii) Require anesthesia or narcotic consent must be obtained from the pa- analgesia; tient’s surrogate. Patients who are in- (iii) Are considered to produce sig- nificant discomfort to the patient; capable of giving consent as a matter (iv) Have a significant risk of com- of law, i.e., persons judicially deter- plication or morbidity; or mined to be incompetent and minors (v) Require injections of any sub- not otherwise able to provide informed stance into a joint space or body cav- consent, will be deemed to lack deci- ity. sion-making capacity for the purposes (2) A patient or surrogate will sign of this section. If the patient is consid- with an ‘‘X’’ when the patient or surro- ered a minor in the state where the VA gate has a debilitating illness or dis- facility is located and cannot consent ability, i.e., significant physical im- to medical treatment, consent must be pairment and/or difficulty in executing obtained from the patient’s parent or a signature due to an underlying legal guardian. The surrogate generally health condition(s), or is unable to read assumes the same rights and respon- and write. When the patient’s or surro- sibilities as the patient in the informed gate’s signature is indicated by an consent process. The surrogate’s deci- ‘‘X,’’ two adults must witness the act sion must be based on his or her knowl- of signing. By signing, the witnesses edge of what the patient would have are attesting only to the fact that they wanted, i.e., substituted judgment. If saw the patient or surrogate and the the patient’s wishes are unknown, the practitioner sign the form. The signed decision must be based on the patient’s form must be filed in the patient’s best interest. The following persons are health record. A properly executed VA- authorized to consent on behalf of pa- authorized consent form is valid for a tients who lack decision-making capac- period of 60 calendar days. If, however, ity in the following order of priority: the treatment plan involves multiple (1) Health care agent; treatments or procedures, it will not be (2) Legal guardian or special guard- necessary to repeat the informed con- ian;
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(3) Next-of-kin: a close relative of the is initiated, the patient or surrogate patient eighteen years of age or older, must be given adequate opportunity to in the following priority: spouse, child, consult with independent specialists, parent, sibling, grandparent, or grand- legal counsel or other interested par- child; or ties of his or her choosing. The pa- (4) Close friend. tient’s or surrogate’s signature on a (f) Consent for patients without surro- VA authorized consent form must be gates. (1) If none of the surrogates list- witnessed by someone who is not affili- ed in paragraph (e) of this section are ated with the VA health care facility, available, the practitioner may request e.g., spouse, legal guardian, or patient Regional Counsel assistance to obtain advocate. If a surrogate makes the a special guardian for health care or treatment decision, a multi-discipli- follow the procedures outlined in this nary committee, appointed by the fa- paragraph (f). cility Director, must review that deci- (2) Facilities may use the following sion to ensure it is consistent with the process to make treatment decisions patient’s wishes or in his or her best for patients who lack decision-making interest. The committee functions as capacity and have no surrogate. For the patient’s advocate and may not in- treatments or procedures that involve clude members of the treatment team. minimal risk, the practitioner must The committee must submit its find- verify that no authorized surrogate can ings and recommendations in a written be located. The practitioner must at- report to the facility Director. The Di- tempt to explain the nature and pur- rector may authorize treatment con- pose of the proposed treatment to the sistent with the surrogate’s decision or patient and enter this information in request that a special guardian for the health record. For procedures that health care be appointed to make the require signature consent, the practi- treatment decision. tioner must certify that the patient has no surrogate. The attending physi- (2) Administration of psychotropic cian and the Chief of Service (or his or medication to an involuntarily com- her designee) must indicate their ap- mitted patient against his or her will proval of the treatment decision in must meet the following requirements. writing. Any decision to withhold or The patient or surrogate must be al- withdraw life-sustaining treatment for lowed to consult with independent spe- such patients must be reviewed by a cialists, legal counsel or other inter- multi-disciplinary committee ap- ested parties concerning the treatment pointed by the facility Director. The with psychotropic medication. Any rec- committee functions as the patient’s ommendation to administer or con- advocate and may not include members tinue medication against the patient’s of the treatment team. The committee or surrogate’s will must be reviewed by must submit its findings and rec- a multi-disciplinary committee ap- ommendations in a written report to pointed by the facility Director for this the Chief of Staff who must note his or purpose. This committee must include her approval of the report in writing. a psychiatrist or a physician who has After reviewing the record, the facility psychopharmacology privileges. The Director may concur with the decision facility Director must concur with the to withhold or withdraw life support or committee’s recommendation to ad- request further review by Regional minister psychotropic medications Counsel. contrary to the patient’s or surrogate’s (g) Special consent situations. In addi- wishes. Continued therapy with psy- tion to the other requirements of this chotropic medication must be reviewed section, additional protections are re- every 30 days. The patient (or a rep- quired in the following situations. resentative on the patient’s behalf) (1) No patient will undergo any un- may appeal the treatment decision to a usual or extremely hazardous treat- court of appropriate jurisdiction. ment or procedure, e.g., that which (3) If a proposed course of treatment might result in irreversible brain dam- or procedure involves approved medical age or sterilization, except as provided research in whole or in part, the pa- in this paragraph (g). Before treatment tient or representative shall be advised
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of this. Informed consent shall be ob- priate form is not readily available. tained specifically for the administra- The patient’s instructions must have tion or performance of that aspect of been expressed to at least two members the treatment or procedure that in- of the health care team. The substance volves research. Such consent shall be of the patient’s instructions must be in addition to that obtained for the ad- recorded in a progress note in the pa- ministration or performance of the tient’s health record and must be co- nonresearch aspect of the treatment or signed by at least two members of the procedure and must meet the require- health care team who were present and ments for informed consent set forth in can attest to the wishes expressed by 38 CFR Part 16, Protection of Human the patient. These instructions will be Subjects. given effect only if the patient loses (h) Advance health care planning. Sub- decision-making capacity during the ject to the provisions of paragraphs presenting situation. (h)(1) through (h)(4) of this section, VA (3) Revocation. A patient who has de- will follow the wishes of a patient ex- cision-making capacity may revoke an pressed in an Advance Directive when advance directive or instructions in a the attending physician determines critical situation at any time by using and documents in the patient’s health any means expressing the intent to re- record that the patient lacks decision- voke. making capacity and is not expected to (4) VA policy and disputes. Neither the regain it. An advance directive that is treatment team nor surrogate may valid in one or more States under ap- override a patient’s clear instructions plicable State law, as defined in para- in an Advance Directive or in instruc- graph (a) of this section, will be recog- tions in critical situations, except that nized throughout the VA health care those portions of an Advance Directive system. or instructions given in a critical situ- (1) Witnesses. A VA Advance Direc- ation that are not consistent with VA tive: Living Will and Durable Power of policy will not be given effect. Attorney for Health Care must be signed by the patient in the presence of (Authority: 38 U.S.C. 7331–7334) two witnesses. Neither witness may to (The information collection requirements in the witness’ knowledge be named in this section have been approved by the Office the patient’s will, appointed as health of Management and Budget under control care agent in the advance directive, or number 2900–0583) financially responsible for the patient’s [62 FR 53961, Oct. 17, 1997, as amended at 70 care. VA employees of the Chaplain FR 71774, Nov. 30, 2005; 71 FR 68740, Nov. 28, Service, Psychology Service, Social 2006; 72 FR 10366, Mar. 8, 2007; 74 FR 34503, Work Service, or nonclinical employees July 16, 2009] (e.g., Medical Administration Service, § 17.33 Patients’ rights. Voluntary Service, or Environmental Management Service) may serve as (a) General. (1) Patients have a right witnesses. Other individuals employed to be treated with dignity in a humane by the VA facility in which the patient environment that affords them both is being treated may not sign as wit- reasonable protection from harm and nesses to the advance directive. Wit- appropriate privacy with regard to nesses are attesting only to the fact their personal needs. that they saw the patient sign the (2) Patients have a right to receive, form. to the extent of eligibility therefor (2) Instructions in critical situations. under the law, prompt and appropriate VA will follow the unambiguous verbal treatment for any physical or emo- or non-verbal instructions regarding tional disability. future health care decisions of a pa- (3) Patients have the right to the tient who has decision-making capac- least restrictive conditions necessary ity when the patient is admitted to to achieve treatment purposes. care when critically ill and loss of ca- (4) No patient in the Department of pacity may be imminent and the pa- Veterans Affairs medical care system, tient is not physically able to sign an except as otherwise provided by the ap- advance directive form, or the appro- plicable State law, shall be denied legal
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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 (vi) The right to hold a professional, volunteers, sufficient to mail at least occupational, or vehicle operator’s li- one (1) letter each week. cense. (v) All information gained by staff (b) Residents and inpatients. Subject personnel of a medical facility during to paragraphs (c) and (d) of this sec- the course of assisting a patient in tion, patients admitted on a residential writing, reading, or sending mail is to or inpatient care basis to the Depart- be kept strictly confidential except for ment of Veterans Affairs medical care any disclosure required by law. system have the following rights: (2) Clothing. Each patient has the (1) Visitations and communications. right to wear his or her own clothing. Each patient has the right to commu- (3) Personal Possessions. Each patient nicate freely and privately with per- has the right to keep and use his or her sons outside the facility, including gov- own personal possessions consistent ernment officials, attorneys, and cler- with available space, governing fire gymen. To facilitate these communica- safety regulations, restrictions on tions each patient shall be provided the noise, and restrictions on possession of opportunity to meet with visitors dur- contraband material, drugs and medi- ing regularly scheduled visiting hours, cations. convenient and reasonable access to (4) Money. Each patient has the right public telephones for making and re- to keep and spend his or her own ceiving phone calls, and the oppor- money and to have access to funds in tunity to send and receive unopened his or her account in accordance with mail. instructions concerning personal funds (i) Communications with attorneys, of patients published by the Veterans law enforcement agencies, or govern- Health Administration. ment officials and representatives of (5) Social Interaction. Each patient recognized service organizations when has the right to social interaction with the latter are acting as agents for the others. patient in a matter concerning Depart- (6) Exercise. Each patient has the ment of Veterans Affairs benefits, shall right to regular physical exercise and not be reviewed. to be outdoors at regular and frequent (ii) A patient may refuse visitors. intervals. Facilities and equipment for (iii) If a patient’s right to receive un- such exercise shall be provided. opened mail is restricted pursuant to (7) Worship. The opportunity for reli- paragraph (c) of this section, the pa- gious worship shall be made available tient shall be required to open the to each patient who desires such oppor- sealed mail while in the presence of an tunity. No patient will be coerced into appropriate person for the sole purpose engaging in any religious activities of ascertaining whether the mail con- against his or her desires. tains contraband material, i.e., imple- (c) Restrictions. (1) A right set forth in ments which pose significant risk of paragraph (b) of this section may be re- bodily harm to the patient or others or stricted within the patient’s treatment any drugs or medication. Any such ma- plan by written order signed by the ap- terial will be held for the patient or propriate health care professional if—
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(i) It is determined pursuant to para- (iv) of this section that are involved graph (c)(2) of this section that a valid shall be employed. and sufficient reason exists for a re- (4) The patient must be promptly no- striction, and tified of any restriction imposed under (ii) The order imposing the restric- paragraph (c) of this section and the tion and a progress note detailing the reasons therefor. indications therefor are both entered (5) All restricting orders under para- into the patient’s permanent medical graph (c) of this section must be re- record. viewed at least once every 30 days by (2) For the purpose of paragraph (c) the practitioner and must be concurred of this section, a valid and sufficient in by the Chief of Service or Chief of reason exists when, after consideration Staff. of pertinent facts, including the pa- (d) Restraint and seclusion of patients. tient’s history, current condition and (1) Each patient has the right to be free prognosis, a health care professional from physical restraint or seclusion ex- reasonably believes that the full exer- cept in situations in which there is a cise of the specific right would— substantial risk of imminent harm by (i) Adversely affect the patient’s the patient to himself, herself, or oth- physical or mental health, ers and less restrictive means of pre- (ii) Under prevailing community venting such harm have been deter- standards, likely stigmatize the pa- mined to be inappropriate or insuffi- tient’s reputation to a degree that cient. Patients will be physically re- would adversely affect the patient’s re- strained or placed in seclusion only on turn to independent living, the written order of an appropriate li- (iii) Significantly infringe upon the censed health care professional. The rights of or jeopardize the health or reason for any restraint order will be safety of others, or clearly documented in the progress (iv) Have a significant adverse im- notes of the patient’s medical record. pact on the operation of the medical fa- The written order may be entered on cility, to such an extent that the pa- the basis of telephonic authority, but tient’s exercise of the specific right in such an event, an appropriate li- should be restricted. In determining censed health care professional must whether a patient’s specific right examine the patient and sign a written should be restricted, the health care order within an appropriate timeframe professional concerned must determine that is in compliance with current that the likelihood and seriousness of community and/or accreditation stand- the consequences that are expected to ards. In emergency situations, where result from the full exercise of the inability to contact an appropriate li- right are so compelling as to warrant censed health care professional prior to the restriction. The Chief of Service or restraint is likely to result in imme- Chief of Staff, as designated by local diate harm to the patient or others, policy, should concur with the decision the patient may be temporarily re- to impose such restriction. In this con- strained by a member of the staff until nection, it should be noted that there appropriate authorization can be re- is no intention to imply that each of ceived from an appropriate licensed the reasons specified in paragraphs health care professional . Use of re- (c)(2)(i) through (iv) of this section are straints or seclusion may continue for logically relevant to each of the rights a period of time that does not exceed set forth in paragraph (b)(1) of this sec- current community and/or accredita- tion. tion standards, within which time an (3) If it has been determined under appropriate licensed health care profes- paragraph (c)(2) of this section that a sional shall again be consulted to de- valid and sufficient reason exists for termine if continuance of such re- restricting any of the patient’s rights straint or seclusion is required. Re- set forth in paragraph (b) of this sec- straint or seclusion may not be used as tion, the least restrictive method for a punishment, for the convenience of protecting the interest or interests staff, or as a substitute for treatment specified in paragraphs (c)(2)(i) through programs.
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(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 bathe at least every twenty-four (24) work with patients will be given a copy hours. of the statement of rights and these (5) Each patient in restraint or seclu- rights will be discussed with them by sion shall be provided nutrition and their immediate supervisor. fluid appropriately. (i) Other rights. The rights described (e) Medication. Patients have a right in this section are in addition to and to be free from unnecessary or exces- not in derogation of any statutory, sive medication. Except in an emer- constitutional or other legal rights. gency, medication will be administered (Authority: 38 U.S.C. 501, 1721) only on a written order of an appro- priate health care professional in that [47 FR 55486, Dec. 10, 1982. Redesignated at 61 FR 21965, May 13, 1996, as amended at 70 FR patient’s medical record. The written 67094, Nov. 4, 2005] order may be entered on the basis of telephonic authority received from an TENTATIVE ELIGIBILITY appropriate health care professional, DETERMINATIONS but in such event, the written order must be countersigned by an appro- § 17.34 Tentative eligibility determina- priate health care professional within tions. 24 hours of the ordering of the medica- Subject to the provisions of §§ 17.36 tion. An appropriate health care pro- through 17.38, when an application for fessional will be responsible for all hospital care or other medical services, medication given or administered to a except outpatient dental care, has been patient. A review by an appropriate filed which requires an adjudication as health care professional of the drug to service connection or a determina- regimen of each inpatient shall take tion as to any other eligibility pre- place at least every thirty (30) days. It requisite which cannot immediately be is recognized that administration of established, the service (including certain medications will be reviewed transportation) may be authorized more frequently. Medication shall not without further delay if it is deter- be used as punishment, for the conven- mined that eligibility for care probably ience of the staff, or in quantities will be established. Tentative eligi- which interfere with the patient’s bility determinations under this sec- treatment program. tion, however, will only be made if: (f) Confidentiality. Information gained (a) In emergencies. The applicant by staff from the patient or the pa- needs hospital care or other medical tient’s medical record will be kept con- services in emergency circumstances, fidential and will not be disclosed ex- or cept in accordance with applicable law. (b) Based on discharge. The applica- (g) Patient grievances. Each patient tion is filed within 6 months after date has the right to present grievances of discharge under conditions other with respect to perceived infringement than dishonorable, and for a veteran of the rights described in this section who seeks eligibility based on a period
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of service that began after September NOTE TO PARAGRAPH (a)(2): A veteran’s en- 7, 1980, the veteran must meet the ap- rollment status will be recognized through- plicable minimum service require- out the United States. ments under 38 U.S.C. 5303A. (3) A veteran enrolled based on hav- (Authority: 38 U.S.C. 501, 5303A) ing a disorder associated with exposure to a toxic substance or radiation, for a [35 FR 6586, Apr. 24, 1970. Redesignated at 61 disorder associated with service in the FR 21965, May 13, 1996, as amended at 64 FR Southwest Asia theater of operations 54212, Oct. 6, 1999; 78 FR 28142, May 14, 2013] during the Gulf War (the period be- HOSPITAL OR NURSING HOME CARE AND tween August 2, 1990, and November 11, MEDICAL SERVICES IN FOREIGN COUN- 1998), or any illness associated with TRIES service in combat in a war after the Gulf War or during a period of hostility § 17.35 Hospital care and medical serv- after November 11, 1998, as provided in ices in foreign countries. 38 U.S.C. 1710(e), is eligible for VA care The Secretary may furnish hospital provided in the ‘‘medical benefits pack- care and medical services to any vet- age’’ set forth in § 17.38 for the disorder. eran sojourning or residing outside the (b) Categories of veterans eligible to be United States, without regard to the enrolled. The Secretary will determine veteran’s citizenship: which categories of veterans are eligi- (a) If necessary for treatment of a ble to be enrolled based on the fol- service-connected disability, or any lowing order of priority: disability associated with and held to (1) Veterans with a singular or com- be aggravating a service-connected dis- bined rating of 50 percent or greater ability; based on one or more service-connected (b) If the care is furnished to a vet- disabilities or unemployability. eran participating in a rehabilitation (2) Veterans with a singular or com- program under 38 U.S.C. chapter 31 who bined rating of 30 percent or 40 percent requires care for the reasons enumer- based on one or more service-connected ated in 38 CFR 17.47(i)(2). disabilities. (3) Veterans who are former prisoners (Authority: 38 U.S.C. 1724) of war; veterans awarded the Medal of [55 FR 11370, Mar. 28, 1990. Redesignated at 61 Honor or Purple Heart; veterans with a FR 21965, May 13, 1996, as amended at 74 FR singular or combined rating of 10 per- 30228, June 25, 2009] cent or 20 percent based on one or more service-connected disabilities; veterans ENROLLMENT PROVISIONS AND MEDICAL who were discharged or released from BENEFITS PACKAGE active military service for a disability § 17.36 Enrollment—provision of hos- incurred or aggravated in the line of pital and outpatient care to vet- duty; veterans who receive disability erans. compensation under 38 U.S.C. 1151; vet- (a) Enrollment requirement for veterans. erans whose entitlement to disability (1) Except as otherwise provided in compensation is suspended pursuant to § 17.37, a veteran must be enrolled in 38 U.S.C. 1151, but only to the extent the VA healthcare system as a condi- that such veterans’ continuing eligi- tion for receiving the ’medical benefits bility for that care is provided for in package’ set forth in § 17.38. the judgment or settlement described in 38 U.S.C. 1151; veterans whose enti- NOTE TO PARAGRAPH (a)(1): A veteran may tlement to disability compensation is apply to be enrolled at any time. (See suspended because of the receipt of § 17.36(d)(1).) military retired pay; and veterans re- (2) Except as provided in paragraph ceiving compensation at the 10 percent (a)(3) of this section, a veteran enrolled rating level based on multiple non- under this section and who, if required compensable service-connected disabil- by law to do so, has agreed to make ities that clearly interfere with normal any applicable copayment is eligible employability. for VA hospital and outpatient care as (4) Veterans who receive increased provided in the ‘‘medical benefits pack- pension based on their need for regular age’’ set forth in § 17.38. aid and attendance or by reason of
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being permanently housebound and purposes of this paragraph. To avoid a other veterans who are determined to hardship to a veteran, VA may use the be catastrophically disabled by the projected income for the current year Chief of Staff (or equivalent clinical of- of the veteran, spouse, and dependent ficial) at the VA facility where they children if the projected income is were examined. below the ‘‘low income’’ income limit (5) Veterans not covered by para- referenced above. This category is fur- graphs (b)(1) through (b)(4) of this sec- ther prioritized into the following sub- tion who are determined to be unable categories: to defray the expenses of necessary (i) Noncompensable zero percent care under 38 U.S.C. 1722(a). service-connected veterans who are in (6) Veterans of the Mexican border an enrolled status on a specified date period or of World War I; veterans sole- announced in a FEDERAL REGISTER doc- ly seeking care for a disorder associ- ument promulgated under paragraph ated with exposure to a toxic substance (c) of this section and who subse- or radiation, for a disorder associated quently do not request disenrollment; with service in the Southwest Asia the- (ii) Nonservice-connected veterans ater of operations during the Gulf War who are in an enrolled status on a spec- (the period between August 2, 1990, and ified date announced in a FEDERAL November 11, 1998), or for any illness REGISTER document promulgated under associated with service in combat in a paragraph (c) of this section and who war after the Gulf War or during a pe- subsequently do not request riod of hostility after November 11, disenrollment; 1998, as provided and limited in 38 (iii) Noncompensable zero percent U.S.C. 1710(e); and veterans with 0 per- service-connected veterans not in- cent service-connected disabilities who cluded in paragraph (b)(7)(i) of this sec- are nevertheless compensated, includ- tion; and ing veterans receiving compensation for inactive tuberculosis. (iv) Nonservice-connected veterans (7) Veterans who agree to pay to the not included in paragraph (b)(7)(ii) of United States the applicable copay- this section. ment determined under 38 U.S.C. 1710(f) (8) Veterans not included in priority and 1710(g) if their income for the pre- category 4 or 7, who are eligible for vious year constitutes ‘‘low income’’ care only if they agree to pay to the under the geographical income limits United States the applicable copay- established by the U.S. Department of ment determined under 38 U.S.C. 1710(f) Housing and Urban Development for and 1710(g). This category is further the fiscal year that ended on Sep- prioritized into the following subcat- tember 30 of the previous calendar egories: year. For purposes of this paragraph, (i) Noncompensable zero percent VA will determine the income of vet- service-connected veterans who were in erans (to include the income of their an enrolled status on January 17, 2003, spouses and dependents) using the rules or who are moved from a higher pri- in §§ 3.271, 3.272, 3.273, and 3.276. After ority category or subcategory due to determining the veterans’ income and no longer being eligible for inclusion in the number of persons in the veterans’ such priority category or subcategory family (including only the spouse and and who subsequently do not request dependent children), VA will compare disenrollment; their income with the current applica- (ii) Noncompensable zero percent ble ‘‘low-income’’ income limit for the service-connected veterans not in- public housing and section 8 programs cluded in paragraph (b)(8)(i) of this sec- in their area that the U.S. Department tion and whose income is not greater of Housing and Urban Development than ten percent more than the income publishes pursuant to 42 U.S.C. that would permit their enrollment in 1437a(b)(2). If the veteran’s income is priority category 5 or priority category below the applicable ‘‘low-income’’ in- 7, whichever is higher; come limits for the area in which the (iii) Nonservice-connected veterans veteran resides, the veteran will be who were in an enrolled status on Jan- considered to have ‘‘low income’’ for uary 17, 2003, or who are moved from a
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higher priority category or sub- categories (v) and (vi) of priority cat- category due to no longer being eligi- egory 8 are not eligible to be enrolled. ble for inclusion in such priority cat- (d) Enrollment and disenrollment proc- egory or subcategory and who subse- ess—(1) Application for enrollment. A vet- quently do not request disenrollment; eran may apply to be enrolled in the (iv) Nonservice-connected veterans VA healthcare system at any time. A not included in paragraph (b)(8)(iii) of veteran who wishes to be enrolled must this section and whose income is not apply by submitting a VA Form 10– greater than ten percent more than the 10EZ to a VA medical facility or via an income that would permit their enroll- Online submission at https:// ment in priority category 5 or priority www.1010ez.med.va.gov/sec/vha/1010ez/. category 7, whichever is higher; (2) Action on application. Upon receipt (v) Noncompensable zero percent of a completed VA Form 10–10EZ, a VA service-connected veterans not in- network or facility director, or the cluded in paragraph (b)(8)(i) or para- Deputy Under Secretary for Health for graph (b)(8)(ii) of this section; and Operations and Management or Chief, (vi) Nonservice-connected veterans Health Administration Service or not included in paragraph (b)(8)(iii) or equivalent official at a VA medical fa- paragraph (b)(8)(iv) of this section. cility, or Director, Health Eligibility (c) FEDERAL REGISTER notification of Center, will accept a veteran as an en- eligible enrollees. (1) It is anticipated rollee upon determining that the vet- that each year the Secretary will con- eran is in a priority category eligible sider whether to change the categories to be enrolled as set forth in and subcategories of veterans eligible § 17.36(c)(2). Upon determining that a to be enrolled. The Secretary at any veteran is not in a priority category el- time may revise the categories or sub- igible to be enrolled, the VA network categories of veterans eligible to be en- or facility director, or the Deputy rolled by amending paragraph (c)(2) of Under Secretary for Health for Oper- this section. The preamble to a FED- ations and Management or Chief, ERAL REGISTER document announcing Health Administration Service or which priority categories and subcat- equivalent official at a VA medical fa- egories are eligible to be enrolled must cility, or Director, Health Eligibility specify the projected number of fiscal Center, will inform the applicant that year applicants for enrollment in each the applicant is ineligible to be en- priority category, projected healthcare rolled. utilization and expenditures for vet- (3) Placement in enrollment categories. erans in each priority category, appro- (i) Veterans will be placed in priority priated funds and other revenue pro- categories whether or not veterans in jected to be available for fiscal year en- that category are eligible to be en- rollees, and projected total expendi- rolled. tures for enrollees by priority cat- (ii) A veteran will be placed in the egory. The determination should in- highest priority category or categories clude consideration of relevant inter- for which the veteran qualifies. nal and external factors, e.g., economic (iii) A veteran may be placed in only changes, changes in medical practices, one priority category, except that a and waiting times to obtain an ap- veteran placed in priority category 6 pointment for care. Consistent with based on a specified disorder or illness these criteria, the Secretary will deter- will also be placed in priority category mine which categories of veterans are 7 or priority category 8, as applicable, eligible to be enrolled based on the if the veteran has previously agreed to order of priority specified in paragraph pay the applicable copayment, for all (b) of this section. matters not covered by priority cat- (2) Unless changed by a rulemaking egory 6. document in accordance with para- (iv) A veteran who had been enrolled graph (c)(1) of this section, VA will en- based on inclusion in priority category roll the priority categories of veterans 5 and became no longer eligible for in- set forth in § 17.36(b) beginning June 15, clusion in priority category 5 due to 2009, except that those veterans in sub- failure to submit to VA a current VA
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Form 10–10EZ will be changed auto- cility, or Director, Health Eligibility matically to enrollment based on in- Center, regarding enrollment status clusion in priority category 6 or 8 (or will be provided to the affected veteran more than one of these categories if by letter and will contain the reasons the previous principle applies), as ap- for the decision. The letter will include plicable, and be considered continu- an effective date for any changes and a ously enrolled. To meet the criteria for statement regarding appeal rights. The priority category 5, a veteran must be decision will be based on all informa- eligible for priority category 5 based on tion available to the decisionmaker, the information submitted to VA in a including the information contained in current VA Form 10–10EZ. To be cur- VA Form 10–10EZ. rent, after VA has sent a form 10–10EZ (e) Catastrophically disabled. For pur- to the veteran at the veteran’s last poses of this section, catastrophically known address, the veteran must re- disabled means to have a permanent se- turn the completed form (including sig- verely disabling injury, disorder, or nature) to the address on the return en- disease that compromises the ability to velope within 60 days from the date VA carry out the activities of daily living sent the form to the veteran. to such a degree that the individual re- (v) Veterans will be disenrolled, and quires personal or mechanical assist- reenrolled, in the order of the priority ance to leave home or bed or requires categories listed with veterans in pri- constant supervision to avoid physical ority category 1 being the last to be harm to self or others. This definition disenrolled and the first to be re- is met if an individual has been found enrolled. Similarly, within priority by the Chief of Staff (or equivalent categories 7 and 8, veterans will be clinical official) at the VA facility disenrolled, and reenrolled, in the order where the individual was examined to of the priority subcategories listed have a permanent condition specified with veterans in subcategory (i) being in paragraph (e)(1) of this section; to the last to be disenrolled and first to be meet permanently one of the condi- reenrolled. tions specified in paragraph (e)(2) of (4) [Reserved] this section by a clinical evaluation of (5) Disenrollment. A veteran enrolled the patient’s medical records that doc- in the VA health care system under uments that the patient previously paragraph (d)(2) of this section will be met the permanent criteria and con- disenrolled only if: tinues to meet such criteria (perma- (i) The veteran submits to a VA Med- nently) or would continue to meet such ical Center or to the VA Health Eligi- criteria (permanently) without the bility Center, 2957 Clairmont Road, continuation of on-going treatment; or NE., Suite 200, Atlanta, Georgia 30329– to meet permanently one of the condi- 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:
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(i) Amputation, detachment, or re- medical center and at https:// amputation of or through the hand; www.1010ez.med.va.gov/sec/vha/1010ez/. (ii) Disarticulation, detachment, or (The Office of Management and Budget has reamputation of or through the wrist; approved the information collection require- (iii) Amputation, detachment, or re- ments in this section under control number amputation of the forearm at or 2900–0091) through the radius and ulna; (Authority: 38 U.S.C 101, 501, 1521, 1701, 1705, (iv) Amputation, detachment, or 1710, 1721, 1722) disarticulation of the forearm at or through the elbow; [64 FR 54212, Oct. 6, 1999, as amended at 67 FR 35039, May 17, 2002; 67 FR 62887, Oct. 9, 2002; (v) Amputation, detachment, or re- 68 FR 2672, Jan. 17, 2003; 74 FR 22834, May 15, amputation of the arm at or through 2009; 74 FR 48012, Sept. 21, 2009; 75 FR 52628, the humerus; Aug. 27, 2010; 76 FR 52274, Aug. 22, 2011; 79 FR (vi) Disarticulation or detachment of 72578, Dec. 3, 2013] the arm at or through the shoulder; (vii) Interthoracoscapular (fore- § 17.37 Enrollment not required—pro- quarter) amputation or detachment; vision of hospital and outpatient care to veterans. (viii) Amputation, detachment, or re- amputation of the leg at or through Even if not enrolled in the VA the tibia and fibula; healthcare system: (ix) Amputation or detachment of or (a) A veteran rated for service-con- through the great toe; nected disabilities at 50 percent or (x) Amputation or detachment of or greater will receive VA care provided through the foot; for in the ‘‘medical benefits package’’ (xi) Disarticulation or detachment of set forth in § 17.38. the foot at or through the ankle; (b) A veteran who has a service-con- (xii) Amputation or detachment of nected disability will receive VA care the foot at or through malleoli of the provided for in the ‘‘medical benefits tibia and fibula; package’’ set forth in § 17.38 for that (xiii) Amputation or detachment of service-connected disability. the lower leg at or through the knee; (c) A veteran who was discharged or (xiv) Amputation, detachment, or re- released from active military service amputation of the leg at or through for a disability incurred or aggravated the femur; in the line of duty will receive VA care (xv) Disarticulation or detachment of provided for in the ‘‘medical benefits the leg at or through the hip; and package’’ set forth in § 17.38 for that (xvi) Interpelviaabdominal (hind- disability for the 12-month period fol- quarter) amputation or detachment. lowing discharge or release. (2)(i) Dependent in 3 or more Activi- (d) When there is a compelling med- ties of Daily Living (eating, dressing, ical need to complete a course of VA bathing, toileting, transferring, incon- treatment started when the veteran tinence of bowel and/or bladder), with was enrolled in the VA healthcare sys- at least 3 of the dependencies being tem, a veteran will receive that treat- permanent with a rating of 1, using the ment. Katz scale. (e) Subject to the provisions of (ii) A score of 2 or lower on at least § 21.240, a veteran participating in VA’s 4 of the 13 motor items using the Func- vocational rehabilitation program de- tional Independence Measure. scribed in §§ 21.1 through 21.430 will re- (iii) A score of 30 or lower using the ceive VA care provided for in the Global Assessment of Functioning. ‘‘medical benefits package’’ set forth in § 17.38. (f) VA Form 10–10EZ. Copies of VA Form 10–10EZ are available at any VA (f) A veteran may receive care pro- vided for in the ’medical benefits pack- age’ based on factors other than vet- eran status (e.g., a veteran who is a private-hospital patient and is referred
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to VA for a diagnostic test by that hos- (iii) Prescription drugs, including pital under a sharing contract; a vet- over-the-counter drugs and medical eran who is a VA employee and is ex- and surgical supplies available under amined to determine physical or men- the VA national formulary system. tal fitness to perform official duties; a (iv) Emergency care in VA facilities; Department of Defense retiree under a and emergency care in non-VA facili- sharing agreement). ties in accordance with sharing con- (g) For care not provided within a tracts or if authorized by §§ 17.52(a)(3), State, a veteran may receive VA care 17.53, 17.54, 17.120–132. provided for in the ‘‘medical benefits (v) Bereavement counseling as au- package’’ set forth in § 17.38 if author- thorized in § 17.98. ized under the provisions of 38 U.S.C. (vi) Comprehensive rehabilitative 1724 and 38 CFR 17.35. services other than vocational services (h) Commonwealth Army veterans provided under 38 U.S.C. chapter 31. and new Philippine Scouts may receive (vii) Consultation, professional coun- care provided for in the ‘‘medical bene- seling, marriage and family counseling, fits package’’ set forth in § 17.38 if au- training, and mental health services thorized under the provisions of 38 for the members of the immediate fam- U.S.C. 1724 and 38 CFR 17.35. ily or legal guardian of the veteran or (i) A veteran may receive certain the individual in whose household the types of VA care not included in the veteran certifies an intention to live, ‘‘medical benefits package’’ set forth in as necessary and appropriate, in con- § 17.38 if authorized by statute or other nection with the veteran’s treatment sections of 38 CFR (e.g., humanitarian as authorized under 38 CFR 71.50. emergency care for which the indi- (viii) Durable medical equipment and vidual will be billed, compensation and prosthetic and orthotic devices, includ- pension examinations, dental care, ing eyeglasses and hearing aids as au- domiciliary care, nursing home care, thorized under § 17.149. readjustment counseling, care as part (ix) Home health services authorized of a VA-approved research project, see- under 38 U.S.C. 1717 and 1720C. ing-eye or guide dogs, sexual trauma (x) Reconstructive (plastic) surgery counseling and treatment, special reg- required as a result of disease or trau- istry examinations). ma, but not including cosmetic surgery (j) A veteran may receive an exam- that is not medically necessary. ination to determine whether the vet- (xi)(A) Hospice care, palliative care, eran is catastrophically disabled and and institutional respite care; and therefore eligible for inclusion in pri- (B) Noninstitutional extended care ority category 4. services, including but not limited to (k) A veteran may receive care for noninstitutional geriatric evaluation, psychosis or mental illness other than noninstitutional adult day health care, psychosis pursuant to 38 CFR 17.109. and noninstitutional respite care. (Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, (xii) Payment of beneficiary travel as 1721, 1722) authorized under 38 CFR part 70. [64 FR 54217, Oct. 6, 1999, as amended at 67 FR (xiii) Pregnancy and delivery serv- 35039, May 17, 2002; 78 FR 28142, May 14, 2013] ices, to the extent authorized by law. (xiv) Newborn care, post delivery, for § 17.38 Medical benefits package. a newborn child for the date of birth (a) Subject to paragraphs (b) and (c) plus seven calendar days after the birth of this section, the following hospital, of the child when the birth mother is a outpatient, and extended care services woman veteran enrolled in VA health constitute the ‘‘medical benefits pack- care and receiving maternity care fur- age’’ (basic care and preventive care): nished by VA or under authorization (1) Basic care. from VA and the child is delivered ei- (i) Outpatient medical, surgical, and ther in a VA facility, or in another fa- mental healthcare, including care for cility pursuant to a VA authorization substance abuse. for maternity care at VA expense. (ii) Inpatient hospital, medical, sur- (xv) Completion of forms (e.g., Fam- gical, and mental healthcare, including ily Medical Leave forms, life insurance care for substance abuse. applications, Department of Education
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forms for loan repayment exemptions functional level of the veteran, prevent based on disability, non-VA disability the progression of disease, cure disease, program forms) by healthcare profes- or extend life span. sionals based on an examination or (3) Restoring health. Care is deemed to knowledge of the veteran’s condition, restore health if the care will restore but not including the completion of the quality of life or daily functional forms for examinations if a third party level that has been lost due to illness customarily will pay health care prac- or injury. titioners for the examination but will (c) In addition to the care specifi- not pay VA. cally excluded from the ‘‘medical bene- (2) Preventive care, as defined in 38 fits package’’ under paragraphs (a) and U.S.C. 1701(9), which includes: (b) of this section, the ‘‘medical bene- (i) Periodic medical exams. fits package’’ does not include the fol- (ii) Health education, including nu- lowing: trition education. (1) Abortions and abortion coun- (iii) Maintenance of drug-use profiles, seling. drug monitoring, and drug use edu- (2) In vitro fertilization. cation. (3) Drugs, biologicals, and medical (iv) Mental health and substance devices not approved by the Food and abuse preventive services. Drug Administration unless the treat- (v) Immunizations against infectious ing medical facility is conducting for- disease. mal clinical trials under an Investiga- (vi) Prevention of musculoskeletal tional Device Exemption (IDE) or an deformity or other gradually devel- Investigational New Drug (IND) appli- oping disabilities of a metabolic or de- cation, or the drugs, biologicals, or generative nature. medical devices are prescribed under a (vii) Genetic counseling concerning compassionate use exemption. inheritance of genetically determined (4) Gender alterations. diseases. (5) Hospital and outpatient care for a (viii) Routine vision testing and eye- veteran who is either a patient or in- care services. mate in an institution of another gov- (ix) Periodic reexamination of mem- ernment agency if that agency has a bers of high-risk groups for selected duty to give the care or services. This diseases and for functional decline of exclusion does not apply to veterans sensory organs, and the services to who are released from incarceration in treat these diseases and functional de- a prison or jail into a temporary hous- clines. ing program (such as a community res- (b) Provision of the ‘‘medical benefits idential re-entry center or halfway package’’. Care referred to in the house). ‘‘medical benefits package’’ will be pro- (6) Membership in spas and health vided to individuals only if it is deter- clubs. mined by appropriate healthcare pro- (Authority 38 U.S.C. 101, 501, 1701, 1705, 1710, fessionals that the care is needed to 1710A, 1721, 1722, 1782, 1786) promote, preserve, or restore the [64 FR 54217, Oct. 6, 1999, as amended at 67 FR health of the individual and is in ac- 35039, May 17, 2002; 73 FR 36798, June 30, 2008; cord with generally accepted standards 75 FR 54030, Sept. 3, 2010; 76 FR 11339, Mar. 2, of medical practice. 1011; 76 FR 26172, May 5, 2011; 76 FR 78571, (1) Promote health. Care is deemed to Dec. 19, 2011] promote health if the care will enhance the quality of life or daily functional § 17.39 Certain Filipino veterans. level of the veteran, identify a pre- (a) Any Filipino Commonwealth disposition for development of a condi- Army veteran, including one who was tion or early onset of disease which can recognized by authority of the U.S. be partly or totally ameliorated by Army as belonging to organized Fili- monitoring or early diagnosis and pino guerilla forces, or any new Phil- treatment, and prevent future disease. ippine Scout is eligible for hospital (2) Preserve health. Care is deemed to care, nursing home care, and out- preserve health if the care will main- patient medical services within the tain the current quality of life or daily United States in the same manner and
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subject to the same terms and condi- (a) Claimants or beneficiaries of VA tions as apply to U.S. veterans, if such for purposes of disability compensa- veteran or scout resides in the United tion, pension, participation in a reha- States and is a citizen or lawfully ad- bilitation program under 38 U.S.C. mitted to the United States for perma- chapter 31, and Government insurance. nent residence. For purposes of these (38 U.S.C. 1711(a)) VA health care benefits, the standards (b) Claimants or beneficiaries re- described in 38 CFR 3.42(c) will be ac- ferred to a diagnostic center for study cepted as proof of U.S. citizenship or to determine the clinical identity of an lawful permanent residence. (b) Commonwealth Army Veterans, obscure disorder. including those who were recognized by (c) Employees of the Department of authority of the U.S. Army as belong- Veterans Affairs when necessary to de- ing to organized Filipino guerilla termine their mental or physical fit- forces, and new Philippine Scouts are ness to perform official duties. not eligible for VA health care benefits (d) Claimants or beneficiaries of if they do not meet the residency and other Federal agencies: citizenship requirements described in (1) Department of Justice—plaintiffs § 3.42(c). in Government insurance suits. (2) United States Civil Service Com- (The Office of Management and Budget has mission—annuitants or applicants for approved the information collection require- ments in this section under control number retirement annuity, and such examina- 2900–0091) tions of prospective appointees as may be requested. (Authority: 38 U.S.C. 501, 1734) (3) Office of Workers’ Compensation [71 FR 6680, Feb. 9, 2006] Programs—to determine identity, se- verity, or persistence of disability. § 17.40 Additional services for (4) Railroad Retirement Board—ap- indigents. plicants for annuity under Public No. In addition to the usual medical serv- 162, 75th Congress. ices agreed upon between the govern- (5) Other Federal agencies. ments of the United States and the Re- (e) Pensioners of nations allied with public of the Philippines to be made available to patients for whom the De- the United States in World War I and partment of Veterans Affairs has au- World War II, upon authorization from thorized care at the Veterans Memorial accredited officials of the respective Medical Center, any such patient deter- governments. mined by the U.S. Department of Vet- [13 FR 7156, Nov. 27, 1948, as amended at 16 erans Affairs to be indigent or without FR 12091, Nov. 30, 1951; 19 FR 6716, Oct. 19, funds may be furnished toilet articles 1954; 32 FR 13813, Oct. 4, 1967; 39 FR 32606, and barber services, including Sept. 10, 1974; 49 FR 5616, Feb. 14, 1984. Redes- haircutting and shaving necessary for ignated and amended at 61 FR 21965, 21966, hygienic reasons. May 13, 1996] [33 FR 5299, Apr. 3, 1968, as amended at 47 FR § 17.42 Examinations on an outpatient 58247, Dec. 30, 1982. Redesignated at 61 FR basis. 21965, May 13, 1996] Physical examinations on an out- EXAMINATIONS AND OBSERVATION AND patient basis may be furnished to ap- EXAMINATION plicants who have been tentatively de- termined to be eligible for Department § 17.41 Persons eligible for hospital ob- of Veterans Affairs hospital or domi- servation and physical examina- tion. ciliary care to determine their need for such care and to the same categories of Hospitalization for observation and persons for whom hospitalization for physical (including mental) examina- observation and examination may be tion may be effected when requested by authorized under § 17.41. an authorized official, or when found necessary in examination of the fol- [35 FR 6586, Apr. 24, 1970. Redesignated and lowing persons: amended at 61 FR 21965, 21966, May 13, 1996]
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HOSPITAL, DOMICILIARY AND NURSING subject to charges as required by HOME CARE § 17.101.
§ 17.43 Persons entitled to hospital or [23 FR 6498, Aug. 22, 1958, as amended at 24 domiciliary care. FR 8327, Oct. 14, 1959; 32 FR 6841, May 4, 1967; 34 FR 9340, June 13, 1969; 35 FR 6586, Apr. 24, Hospital or domiciliary care may be 1970; 39 FR 32606, Sept. 10, 1974. Redesignated provided: and amended at 61 FR 21965, 21966, May 13, (a) Not subject to the eligibility pro- 1996; 64 FR 54218, Oct. 6, 1999] visions of 38 U.S.C. 1710, 1722, and 1729, and 38 CFR 17.44 and 17.45, for: § 17.44 Hospital care for certain retir- (1) Persons in the Armed Forces when ees with chronic disability (Execu- duly referred with authorization there- tive Orders 10122, 10400 and 11733). for, may be furnished hospital care. Hospital care may be furnished when Emergency treatment may be ren- beds are available to members or dered, without obtaining formal au- former members of the uniformed serv- thorization, to such persons upon their ices (Army, Navy, Air Force, Marine own application, when absent from Corps, Coast Guard, Coast and Geodetic their commands. Identification of ac- Survey, now National Oceanic and At- tive duty members of the uniformed mospheric Administration hereinafter services will be made by military iden- referred to as NOAA, and Public Health tification card. Service) temporarily or permanently (2) Hospital care may be provided, retired for physical disability or re- upon authorization, for beneficiaries of ceiving disability retirement pay who the Public Health Service, Office of require hospital care for chronic dis- Workers’ Compensation Programs, and eases and who have no eligibility for other Federal agencies. hospital care under laws governing the (3) Pensioners of nations allied with Department of Veterans Affairs, or who the United States in World War I and having eligibility do not elect hos- World War II may be supplied hospital pitalization as Department of Veterans care when duly authorized. Affairs beneficiaries. Care under this (b) Emergency hospital care may be section is subject to the following con- provided for: ditions: (1) Persons having no eligibility, as a (a) Persons defined in this section humanitarian service. who are members or former members of (2) Persons admitted because of pre- the active military, naval, or air serv- sumed discharge or retirement from ice must agree to pay the subsistence the Armed Forces, but subsequently rate set by the Secretary of Veterans found to be ineligible as such. Affairs, except that no subsistence (3) Employees (not potentially eligi- charge will be made for those persons ble as ex-members of the Armed who are members or former members of Forces) and members of their families, when residing on reservations of field the Public Health Service, Coast facilities of the Department of Vet- Guard, Coast and Geodetic Survey now erans Affairs, and when they cannot NOAA, and enlisted personnel of the feasibly obtain emergency treatment Army, Navy, Marine Corps, and Air from private facilities. Force. (c) Hospital care when incidental to, (b) Under this section, the term and to the extent necessary for, the use chronic diseases shall include chronic of a specialized Department of Vet- arthritis, malignancy, psychiatric dis- erans Affairs medical resource pursu- orders, poliomyelitis with residuals, ant to a sharing agreement entered neurological disabilities, diseases of into under § 17.210, may be authorized the nervous system, severe injuries to for any person designated by the other the nervous system, including quadri- party to the agreement as a patient to plegia, hemiplegia and paraplegia, tu- be benefited under the agreement. berculosis, blindness and deafness re- (d) The authorization of services quiring definitive rehabilitation, dis- under any provision of this section, ex- ability from major amputation, and cept services for eligible veterans, is other diseases as may be agreed upon
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from time to time by the Under Sec- thorized by 38 U.S.C. 1703 and 38 CFR retary for Health and designated offi- 17.52; or cials of the Department of Defense and (2) If the veteran needs non-imme- Department of Health and Human diate hospitalization, schedule the vet- Services. For the purpose of this sec- eran for admission at VA facility where tion, blindness is defined as corrected the veteran applies, if the schedule per- visual acuity of 20/200 or less in the bet- mits, or refer the veteran for admission ter eye, or corrected central visual acu- or scheduling for admission at the ity of more than 20/200 if there is a field nearest VA medical center, or Depart- defect in which the peripheral field has ment of Defense facility with which VA contracted to such an extent that its has a sharing agreement under 38 widest diameter subtends the widest di- U.S.C. 8111. ameter of the field of the better eye at an angle no greater than 20°. (Authority: 38 U.S.C. 1703, 1710; secs. 19011– (c) In the case of persons who are 19012, Pub. L. 99–272) former members of the Coast and Geo- (b) Domiciliary care may be fur- detic Survey, care may be furnished nished when needed to: under this section even though their (1) Any veteran whose annual income retirement for disability was from the does not exceed the maximum annual Environmental Science Services Ad- rate of pension payable to a veteran in ministration or NOAA. need of regular aid and attendance, or [34 FR 9340, June 13, 1969, as amended at 39 (2) Any veteran who the Secretary FR 1841, Jan. 15, 1974; 47 FR 58247, Dec. 30, determines had no adequate means of 1982. Redesignated at 61 FR 21965, May 13, support. An additional requirement for 1996, as amended at 62 FR 17072, Apr. 9, 1997] eligibility for domiciliary care is the § 17.45 Hospital care for research pur- ability of the veteran to perform the poses. following: Subject to the provisions of § 17.62(g), (i) Perform without assistance daily any person who is a bona fide volunteer ablutions, such as brushing teeth; may be admitted to a Department of bathing; combing hair; body elimi- Veterans Affairs hospital when the nations. treatment to be rendered is part of an (ii) Dress self, with a minimum of as- approved Department of Veterans Af- sistance. fairs research project and there are in- (iii) Proceed to and return from the sufficient veteran-patients suitable for dining hall without aid. the project. (iv) Feed Self. (v) Secure medical attention on an [35 FR 11470, July 17, 1970. Redesignated at 61 ambulatory basis or by use of person- FR 21965, May 13, 1996] ally propelled wheelchair. § 17.46 Eligibility for hospital, domi- (vi) Have voluntary control over body ciliary or nursing home care of per- eliminations or control by use of an ap- sons discharged or released from propriate prosthesis. active military, naval, or air serv- (vii) Share in some measure, however ice. slight, in the maintenance and oper- (a) In furnishing hospital care under ation of the facility. 38 U.S.C. 1710(a)(1), VA officials shall: (viii) Make rational and competent (1) If the veteran is in immediate decisions as to his or her desire to re- need of hospitalization, furnish care at main or leave the facility. VA facility where the veteran applies (Authority: 38 U.S.C. 1710(b), sec. 102, Pub. L. or, if that facility is incapable of fur- 100–322) nishing care, arrange to admit the vet- eran to the nearest VA medical center, [24 FR 8328, Oct. 4, 1959, as amended at 30 FR or Department of Defense hospital with 1787, Feb. 9, 1965; 32 FR 13813, Oct. 4, 1967; 34 which VA has a sharing agreement FR 9340, June 13, 1969; 39 FR 1841, Jan. 15, 1974; 45 FR 6935, Jan. 31, 1980; 51 FR 25064, under 38 U.S.C. 8111, which is capable of July 10, 1986; 52 FR 11259, Apr. 8, 1987; 53 FR providing the needed care, or if VA or 9627, Mar. 24, 1988; 53 FR 32391, Aug. 25, 1988; DOD facilities are not available, ar- 56 FR 5757, Feb. 13, 1991. Redesignated and range for care on a contract basis if au- amended at 61 FR 21965, 21966, May 13, 1996]
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§ 17.47 Considerations applicable in ability was incurred or aggravated not determining eligibility for hospital, in line of duty. nursing home or domiciliary care. (2) In those exceptional cases where (a)(1) For applicants discharged or re- the official records of the Armed leased for disability incurred or aggra- Forces show discharge or release under vated in line of duty and who are not in other than dishonorable conditions be- receipt of compensation for service- cause of expiration of period of enlist- connected or service-aggravated dis- ment or any other reason except dis- ability, the official records of the ability, but also show a disability in- Armed Forces relative to findings of curred or aggravated in line of duty line of duty for its purposes will be ac- during the said enlistment; and the dis- cepted in determining eligibility for ability so recorded is considered in hospital care. Where the official medical judgment to be or to have been records of the Armed Forces show a of such character, duration, and degree finding of disability not incurred or ag- as to have justified a discharge or re- lease for disability had the period of gravated in line of duty and evidence is enlistment not expired or other reason submitted to the Department of Vet- for discharge or release been given, the erans Affairs which permits of a dif- Under Secretary for Health, upon con- ferent finding, the decision of the sideration of a clear, full statement of Armed Forces will not be binding upon circumstances, is authorized to ap- the Department of Veterans Affairs, prove admission of the applicant for which will be free to make its own de- hospital care, provided other eligibility termination of line of duty incurrence requirements are met. A typical case of or aggravation upon evidence so sub- this kind will be one where the appli- mitted. It will be incumbent upon the cant was under treatment for the said applicant to present controverting evi- disability recorded during his or her dence and, until such evidence is pre- service at the time discharge or release sented and a determination favorable was given for the reason other than to the applicant is made by the Depart- disability. ment of Veterans Affairs, the finding of (b)(1) Under 38 U.S.C. 1710(a)(1), vet- the Armed Forces will control and hos- erans who are receiving disability com- pital care will not be authorized. Such pensation awarded under § 3.800 of this controverting evidence, when received chapter, where a disease, injury or the from an applicant, will be referred to aggravation of an existing disease or the adjudicating agency which would injury occurs as a result of VA exam- have jurisdiction if the applicant was ination, medical or surgical treatment, filing claim for pension or disability or of hospitalization in a VA health compensation, and the determination care facility or of participation in a re- of such agency as to line of duty, which habilitation program under 38 U.S.C. is promptly to be communicated to the ch. 31, under any law administered by head of the field facility receiving the VA and not the result of his/her own application for hospital care, will gov- willful misconduct. Treatment may be ern the facility Director’s disapproval provided for the disability for which or approval of admission, other eligi- the compensation is being paid or for bility requirements having been met. any other disability. Treatment under Where the official records of the Armed the authority of 38 U.S.C. 1710(a)(1) Forces show that the disability for may not be authorized during any pe- which a veteran was discharged or re- riod when disability compensation leased from the Armed Forces under under § 3.800 of this title is not being other than dishonorable conditions was paid because of the provision of incurred or aggravated in the line of § 3.800(a)(2), except to the extent con- duty, such showing will be accepted for tinuing eligibility for such treatment the purpose of determining his or her is provided for in the judgment for set- eligibility for hospitalization, notwith- tlement described in § 3.800(a)(2) of this standing the fact that the Department title. of Veterans Affairs has made a deter- mination in connection with a claim (Authority: 38 U.S.C. 1710(a); sec. 701, Pub. L. for monetary benefits that the dis- 98–160, Pub. L. 99–272)
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(2) For purposes of eligibility for (ii) The veteran is in receipt of pen- domiciliary care, the phrase no ade- sion under 38 U.S.C. 1521; or quate means of support refers to an ap- (iii) The veteran’s attributable in- plicant for domiciliary care whose an- come does not exceed $15,000 if the vet- nual income exceeds the annual rate of eran has no dependents, $18,000 if the pension for a veteran in receipt of reg- veteran has one dependent, plus $1,000 ular aid and attendance, as defined in for each additional dependent. 38 U.S.C. 1503, but who is able to dem- onstrate to competent VA medical au- (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. thority, on the basis of objective evi- 99–272) dence, that deficits in health and/or (2) For purposes of determining eligi- functional status render the applicant bility for hospital or nursing home care incapable of pursuing substantially under § 17.47(c), a veteran will be deter- gainful employment, as determined by mined eligible for necessary care if the the Chief of Staff, and who is otherwise veteran agrees to provide verifiable without the means to provide ade- evidence, as determined by the Sec- quately for self, or be provided for in retary, that: The veteran’s attributable the community. income does not exceed $20,000 if the veteran has no dependents, $25,000 if (Authority: 38 U.S.C. 1710(a); sec. 701, Pub. L. the veteran has one dependent, plus 98–160, Pub. L. 99–272) $1,000 for each additional dependent. (c) A disability, disease, or defect will comprehend any acute, subacute, or (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. chronic disease (or a general medical, 99–272) tuberculous, or neuropsychiatric type) (3) Effective on January 1 of each of any acute, subacute, or chronic sur- year after calendar year 1986, the gical condition susceptible of cure or amounts set forth in paragraph (d)(1) decided improvement by hospital care; and (2) of this section shall be in- or any condition which does not re- creased by the percentage by which the quire hospital care for an acute or maximum rates of pension were in- chronic condition but requires domi- creased under 38 U.S.C. 1111(a), during ciliary care. Domiciliary care, as the the preceding year. term implies, is the provision of a home, with such ambulant medical (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. care as is needed. To be provided with 99–272) domiciliary care, the applicant must consistently have a disability, disease, (4) Determinations with respect to or defect which is essentially chronic attributable income made under para- in type and is producing disablement of graph (d)(1) and (2) of this section, shall such degree and probable persistency be made in the same manner, including 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 §§ 3.271 and 3.272 of this title. The term (d)(1) For purposes of determining attributable income means income of a eligibility for hospital or nursing home veteran for the calendar year preceding care under § 17.47(a), a veteran will be application for care, determined in the determined unable to defray the ex- same manner as the manner in which a penses of necessary care if the veteran determination is made of the total agrees to provide verifiable evidence, amount of income by which the rate of as determined 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)
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(5) Notwithstanding the attributable eran’s eligibility for hospital care income of a veteran, VA may deter- under 38 U.S.C. 1710(a), fails to pay to mine that such veteran is not eligible the United States the amounts agreed under paragraph (d)(1) and (2) of this to under those sections shall be section if the corpus of the estate of grounds for determining, in accordance the veteran is such that under all the with guidelines promulgated by the circumstances it is reasonable that Under Secretary for Health, that the some part of the corpus of the estate of veteran is not eligible to receive fur- the veteran be consumed for the vet- ther care under those sections until eran’s maintenance. The corpus of the such amounts have been paid in full. estate of a veteran shall be determined in the same manner as determinations (Authority: 38 U.S.C. 1710, 1721; sec. 19011, are made with respect to the deter- Pub. L. 99–272) minations of eligibility for pension (g)(1) Persons hospitalized who have under § 3.275 of this chapter. The term no service-connected disabilities pursu- corpus of the estate of the veteran in- ant to § 17.47, and/or persons receiving cludes the corpus of the estates of the outpatient medical services pursuant veteran’s spouse and dependent chil- to paragraphs (e), (f), (i), (j), and/or (k) dren, if any. of § 17.60 who have no service-connected disabilities who it is believed may be (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. eligible for hospital care and/or med- 99–272) ical services, or reimbursement for the (6) In order to avoid hardship VA expenses of care or services for all or may determine that a veteran is eligi- part of the cost thereof by reason of ble for care notwithstanding that the the following: veteran does not meet the income re- (i) Membership in a union, fraternal quirements established in paragraph or other organization, or (d)(1)(iii) or (d)(2) of this section, if pro- (ii) Coverage under an insurance pol- jections of the veteran’s income for the icy, or contract, medical, or hospital year following application for care are service agreement, membership, or substantially below the income re- subscription contract or similar ar- quirements established in paragraph rangement under which health services (d)(1)(iii) or (d)(2) of this section. for individuals are provided or the ex- penses of such services are paid, will (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. not be furnished hospital care or med- 99–272) ical services without charge therefore (e)(1) If VA determines that an indi- to the extent of the amount for which vidual was incorrectly charged a co- such parties referred to in paragraphs payment, VA will refund the amount of (g)(1)(i) or (g)(1)(ii) of this section, are, any copayment actually paid by that will become, or may be liable. Persons individual. believed entitled to care under any of the plans discussed above will be re- (Authority: 38 U.S.C. 501; sec. 19011, Pub. L. quired to provide such information as 99–272) the Secretary may require. Provisions of this paragraph are effective April 7, (2) In the event a veteran provided in- 1986, except in the case of a health care accurate information on an application policy or contract that was entered and is incorrectly deemed eligible for into before that date, the effective date care under 38 U.S.C. 1710(a)(1) or (a)(2) shall be the day after the plan was rather than 38 U.S.C. 1710(a)(3), VA modified or renewed or on which there shall retroactively bill the veteran for was any change in premium or cov- the applicable copayment. erage and will apply only to care and services provided by VA after the date (Authority: 38 U.S.C. 501 and 1710; sec. 19011, Pub. L. 99–272) the plan was modified, renewed, or on which there was any change in pre- (f) If a veteran who receives hospital mium or coverage. or nursing home care under 38 U.S.C. 1710(a)(2) or outpatient care under 38 (Authority: 38 U.S.C. 1729; sec. 19013, Pub. L. U.S.C. 1712(a)(4) by virtue of the vet- 99–272)
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(2) Persons hospitalized for the treat- nonservice-connected disability of such ment of nonservice-connected disabil- veteran, in addition to treatment inci- ities pursuant to § 17.47, or persons re- dent to the disability for which the ceiving outpatient medical services veteran is hospitalized, if the veteran pursuant to paragraph (e), (f), (h), (i), is willing, and such services are reason- (j), or (k) of § 17.60, and who it is be- ably necessary to protect the health of lieved may be entitled to hospital care such veteran. and/or medical services or to reim- (i) Participating in a rehabilitation pro- bursement for all or part of the cost gram under 38 U.S.C. chapter 31 refers to thereof from any one or more of the any veteran following parties: (1) Who is eligible for and entitled to (i) Workers’ Compensation or employ- participate in a rehabilitation program er’s liability statutes, State or Federal; under chapter 31. (ii) By reason of statutory or other (i) Who is in an extended evaluation relationships with third parties, in- period for the purpose of determining cluding those liable for damages be- feasibility, or cause of negligence or other legal (ii) For whom a rehabilitation objec- wrong; tive has been selected, or (iii) By reason of a statute in a State, (iii) Who is pursuing a rehabilitation or political subdivision of a State; program, or (A) Which requires automobile acci- (iv) Who is pursuing a program of dent reparations or; independent living, or (B) Which provides compensation or (v) Who is being provided employ- payment for medical care to victims ment assistance under 38 U.S.C. chap- suffering personal injuries as the result ter 31, and of a crime of personal violence; (2) Who is medically determined to be (iv) Right to maintenance and cure in in need of hospital care or medical admiralty; services (including dental) for any of will not be furnished hospital care or the following reasons: medical services without charge there- (i) Make possible his or her entrance fore to the extent of the amount for into a rehabilitation program; or which such parties are, will become, or (ii) Achieve the goals of the veteran’s may be liable. Persons believed enti- vocational rehabilitation program; or tled to care under circumstances de- (iii) Prevent interruption of a reha- scribed in paragraph (g)(2)(ii) of this bilitation program; or section will be required to complete (iv) Hasten the return to a rehabilita- such forms as the Secretary may re- tion program of a veteran in inter- quire, such as a power of attorney and rupted or leave status; or assignment. Notice of this assignment (v) Hasten the return to a rehabilita- will be mailed promptly to the party or tion program of a veteran placed in dis- parties believed to be liable. When the continued status because of illness, in- amount of charges is ascertained, a bill jury or a dental condition; or therefore will be mailed to such party (vi) Secure and adjust to employment or parties. Persons believed entitled to during the period of employment as- care under circumstances described in sistance; or paragraph (g)(2)(i) or (g)(2)(iii) of this (vii) To enable the veteran to achieve section will be required to complete maximum independence in daily living. such forms as the Secretary may re- quire. (Authority: 38 U.S.C. 3104(a)(9); Pub. L. 96– 466, sec. 101(a)) (Authority: 38 U.S.C. 1729, sec. 19013, Pub. L. (j) Veterans eligible for treatment 99–272) under chapter 17 of 38 U.S.C. who are (h) Within the limits of Department alcohol or drug abusers or who are in- of Veterans Affairs facilities, any vet- fected with the human immuno- eran who is receiving nursing home deficiency virus (HIV) shall not be dis- care in a hospital under the direct ju- criminated against in admission or risdiction of the Department of Vet- treatment by any Department of Vet- erans Affairs, may be furnished med- erans Affairs health care facility solely ical services to correct or treat any because of their alcohol or drug abuse
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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 takes into account the patient’s im- house manager, must also be in the mune status and/or the infectivity of Compensated Work Therapy program. the HIV or other pathogens (such as tu- (d) Each resident, except for a house berculosis, cytemegalovirus, manager, must bi-weekly, in advance, cryptosporidiosis, etc.). Hospital Direc- pay a fee to VA for living in the hous- tors are responsible for assuring that ing. The local VA program coordinator admission criteria of all programs in will establish the fee for each resident the medical center do not discriminate in accordance with the provisions of solely on the basis of alcohol, drug paragraph (d)(1) of this section. abuse or infection with human im- (1) The total amount of actual oper- munodeficiency virus. Quality Assur- ating expenses of the residence (utili- ance Programs should include indica- ties, maintenance, furnishings, appli- tors and monitors for nondiscrimina- ances, service equipment, all other op- tion. erating costs) for the previous fiscal year plus 15 percent of that amount (Authority: 38 U.S.C. 7333) equals the total operating budget for the current fiscal year. The total oper- (k) In seeking medical care from VA ating budget is to be divided by the av- under 38 U.S.C. 1710 or 1712, a veteran erage number of beds occupied during shall furnish such information and evi- the previous fiscal year and the result- dence as the Secretary may require to ing amount is the average yearly establish eligibility. amount per bed. The bi-weekly fee (Authority: 38 U.S.C. 1722; sec. 19011, Pub. L. shall equal 1/26th of the average yearly 99–272) amount per bed, except that a resident [32 FR 13813, Oct. 4, 1967] shall not, on average, pay more than 30 percent of their gross CWT (Com- EDITORIAL NOTE: For FEDERAL REGISTER ci- pensated Work Therapy) bi-weekly tations affecting § 17.47, see the List of CFR earnings. The VA program manager Sections Affected, which appears in the shall, bi-annually, conduct a review of Finding Aids section of the printed volume and at www.fdsys.gov. the factors in this paragraph for deter- mining resident payments. If he or she § 17.48 Compensated Work Therapy/ determines that the payments are too Transitional Residences program. high or too low by more than 5 percent of the total operating budget, he or she (a) This section sets forth require- shall recalculate resident payments ments for persons residing in housing under the criteria set forth in this under the Compensated Work Therapy/ paragraph, except that the calculations Transitional Residences program. shall be based on the current fiscal (b) House managers shall be respon- year (actual amounts for the elapsed sible for coordinating and supervising portion and projected amounts for the the day-to-day operations of the facili- remainder). ties. The local VA program coordinator (2) If the revenues of a residence do shall select each house manager and not meet the expenses of the residence may give preference to an individual resulting in an inability to pay actual who is a current or past resident of the operating expenses, the medical center facility or the program. A house man- of jurisdiction shall provide the funds ager must have the following qualifica- necessary to return the residence to tions: fiscal solvency in accordance with the (1) A stable, responsible and caring provisions of this section. demeanor; (e) The length of stay in housing (2) Leadership qualities including the under the Compensated Work Therapy/ ability to motivate; Transitional Residences program is (3) Effective communication skills based on the individual needs of each including the ability to interact; resident, as determined by consensus of (4) A willingness to accept feedback; the resident and his/her VA Clinical
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Treatment team. However, the length have dual eligibility under other provi- of stay should not exceed 12 months. sions of § 17.47. (Authority: 38 U.S.C. 1772) [39 FR 1842, Jan. 15, 1974, as amended at 45 FR 6936, Jan. 31, 1980, as amended at 61 FR [70 FR 29627, May 24, 2005] 21966, May 13, 1996]
§ 17.49 Priorities for outpatient med- § 17.51 Emergency use of Department ical services and inpatient hospital of Defense, Public Health Service or care. other Federal hospitals. In scheduling appointments for out- Hospital care in facilities operated patient medical services and admis- by the Department of Defense or the sions for inpatient hospital care, the Public Health Service (or any other Under Secretary for Health shall give agency of the U.S. Government) which priority to: do not have beds allocated for the care (a) Veterans with service-connected of Department of Veterans Affairs pa- disabilities rated 50 percent or greater tients may be authorized subject to the based on one or more disabilities or limitations enumerated in § 17.50 only unemployability; and in emergency circumstances for any (b) Veterans needing care for a serv- veteran otherwise eligible for hospital ice-connected disability. care under 38 U.S.C. 1710 or 38 CFR (Authority: 38 U.S.C. 101, 501, 1705, 1710) 17.46. [67 FR 58529, Sept. 17, 2002] [33 FR 19010, Dec. 20, 1968. Redesignated and amended at 61 FR 21965, 21966, May 13, 1996] USE OF DEPARTMENT OF DEFENSE, PUB- LIC HEALTH SERVICE OR OTHER FED- USE OF PUBLIC OR PRIVATE HOSPITALS ERAL HOSPITALS § 17.52 Hospital care and medical serv- § 17.50 Use of Department of Defense, ices in non-VA facilities. Public Health Service or other Fed- (a) When VA facilities or other gov- eral hospitals with beds allocated to the Department of Veterans Affairs. ernment facilities are not capable of furnishing economical hospital care or Hospital facilities operated by the medical services because of geographic Department of Defense or the Public inaccessibility or are not capable of Health Service (or any other agency of furnishing care or services required, the United States Government) may be VA may contract with non-VA facili- used for the care of Department of Vet- ties for care in accordance with the erans Affairs patients pursuant to provisions of this section. When de- agreements between the Department of mand is only for infrequent use, indi- Veterans Affairs and the department or vidual authorizations may be used. agency operating the facility. When Care in public or private facilities, such an agreement has been entered however, subject to the provisions of into and a bed allocation for Depart- §§ 17.53, 17.54, 17.55 and 17.56, will only ment of Veterans Affairs patients has be authorized, whether under a con- been provided for in a specific hospital tract or an individual authorization, covered by the agreement, care may be for— authorized within the bed allocation for any veteran eligible under 38 U.S.C. (1) Hospital care or medical services 1710 or 38 CFR 17.44. Care in a Federal to a veteran for the treatment of— facility not operated by the Depart- (i) A service-connected disability; or ment of Veterans Affairs, however, (ii) A disability for which a veteran shall not be authorized for any mili- was discharged or released from the ac- tary retiree whose sole basis for eligi- tive military, naval, or air service or bility is under § 17.46b, or, except in (iii) A disability of a veteran who has Alaska and Hawaii, for any retiree of a total disability permanent in nature the uniformed services suffering from a from a service-connected disability, or chronic disability whose entitlement is (iv) For a disability associated with under § 17.46b, § 17.47(b)(2) or § 17.47(c)(2) and held to be aggravating a service- regardless of whether he or she may connected disability, or
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(v) For any disability of a veteran eran can be safely transferred to a VA participating in a rehabilitation pro- facility; gram under 38 U.S.C. ch. 31 and when there is a need for hospital care or (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. medical services for any of the reasons 99–272) enumerated in § 17.48(j). (4) Hospital care for women veterans;
(Authority: 38 U.S.C. 1703, 3104; sec. 101, Pub. (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. L. 96–466; sec. 19012, Pub. L. 99–272) 99–272) (2) Medical services for the treatment (5) Through September 30, 1988, hos- of any disability of— pital care or medical services that will (i) A veteran who has a service-con- obviate the need for hospital admission nected disability rated at 50 percent or for veterans in the Commonwealth of more, Puerto Rico, except that the dollar ex- (ii) A veteran who has been furnished penditure in Fiscal year 1986 cannot ex- hospital care, nursing home care, domi- ceed 85% of the Fiscal year 1985 obliga- ciliary care, or medical services, and tions, in Fiscal year 1987 the dollar ex- requires medical services to complete penditure cannot exceed 50% of the Fis- cal year 1985 obligations and in Fiscal treatment incident to such care or year 1988 the dollar expenditure cannot services (each authorization for non- exceed 25% of the Fiscal year 1985 obli- VA treatment needed to complete gations. treatment may continue for up to 12 months, and new authorizations may (Authority: 38 U.S.C. 1703; sec. 102, Pub. L. be issued by VA as needed), and 99–166; sec. 19012, Pub. L. 99–272) (iii) A veteran of the Mexican border (6) Hospital care or medical services period or World War I or who is in re- that will obviate the need for hospital ceipt of increased pension or additional admission for veterans in Alaska, Ha- compensation based on the need for aid waii, Virgin Islands and other terri- and attendance or housebound benefits tories of the United States except that when it has been determined based on the annually determined hospital pa- an examination by a physician em- tient load and incidence of the fur- ployed by VA (or, in areas where no nishing of medical services to veterans such physician is available, by a physi- hospitalized or treated at the expense cian carrying out such function under of VA in government and non-VA fa- a contract or fee arrangement), that cilities in each such State or territory the medical condition of such veteran shall be consistent with the patient precludes appropriate treatment in VA load or incidence of the provision of facilities; medical services for veterans hospital- ized or treated by VA within the 48 (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. contiguous States. 99–272) (3) Hospital care or medical services (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. for the treatment of medical emer- 99–272) gencies which pose a serious threat to (7) Outpatient dental services and the life or health of a veteran receiving treatment, and related dental appli- hospital care or medical services in a ances, for a veteran who is a former facility over which the Secretary has prisoner of war and was detained or in- direct jurisdiction or government facil- terned for a period of not less that 181 ity with which the Secretary con- days. tracts, and for which the facility is not staffed or equipped to perform, and (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. transfer to a public or private hospital 99–272) which has the necessary staff or equip- (8) Hospital care or medical services ment is the only feasible means of pro- for the treatment of medical emer- viding the necessary treatment, until gencies which pose a serious threat to such time following the furnishing of the life or health of a veteran which de- care in the non-VA facility as the vet- veloped during authorized travel to the
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hospital, or during authorized travel (2) If the veteran agrees to pay the after hospital discharge preventing United States an amount as deter- completion of travel to the originally mined in § 17.48(e). designated point of return (and this (Authority: 38 U.S.C. 1703, 1710 and 1712; sec. will encompass any other medical serv- 19011–19012, Pub. L. 99–272) ices necessitated by the emergency, in- cluding extra ambulance or other [51 FR 25066, July 10, 1986, as amended at 53 FR 32391, Aug. 25, 1988; 54 FR 53057, Dec. 27, transportation which may also be fur- 1989; 58 FR 32446, June 10, 1993. Redesignated nished at VA expense. and amended at 61 FR 21965, 21966, May 13, 1996; 62 FR 17072, Apr. 9, 1997; 75 FR 78915, (Authority: 38 U.S.C. 1701(5)) Dec. 17, 2010; 77 FR 70895, Nov. 28, 2012; 78 FR 76063, Dec. 16, 2013] (9) Diagnostic services necessary for determination of eligibility for, or of § 17.53 Limitations on use of public or the appropriate course of treatment in private hospitals. connection with, furnishing medical The admission of any patient to a services at independent VA outpatient private or public hospital at Depart- clinics to obviate the need for hospital ment of Veterans Affairs expense will admission. only be authorized if a Department of Veterans Affairs medical center or (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. other Federal facility to which the pa- 99–272) tient would otherwise be eligible for (10) For any disability of a veteran admission is not feasibly available. A receiving VA contract nursing home Department of Veterans Affairs facility care. The veteran is receiving contract may be considered as not feasibly nursing home care and requires emer- available when the urgency of the ap- gency treatment in non-VA facilities. plicant’s medical condition, the rel- ative distance of the travel involved, or (Authority: 38 U.S.C. 1703(a)) the nature of the treatment required makes it necessary or economically ad- (11) For completion of evaluation for visable to use public or private facili- observation and examination (O&E) ties. In those instances where care in purposes, clinic directors or their des- public or private hospitals at Depart- ignees will authorize necessary diag- ment of Veterans Affairs expense is au- nostic services at non-VA facilities (on thorized because a Department of Vet- an inpatient or outpatient basis) in erans Affairs or other Federal facility order to complete requests from VA was not feasibly available, as defined Regional Offices for O&E of a person to in this section, the authorization will determine eligibility for VA benefits or be continued after admission only for services. the period of time required to stabilize (b) The Under Secretary for Health or improve the patient’s condition to shall only furnish care and treatment the extent that further care is no under paragraph (a) of this section to longer required to satisfy the purpose veterans described in § 17.47(d). for which it was initiated. (1) To the extent that resources are [39 FR 17223, May 14, 1974, as amended at 47 available and are not otherwise re- FR 58248, Dec. 30, 1982. Redesignated at 61 FR quired to assure that VA can furnish 21965, May 13, 1996] needed care and treatment to veterans described in § 17.47 (a) and (c), and § 17.54 Necessity for prior authoriza- tion. (a) The admission of a veteran to a non-Department of Veterans Affairs hospital at Department of Veterans Af- fairs expense must be authorized in ad- vance. In the case of an emergency which existed at the time of admission, an authorization may be deemed a prior authorization if an application,
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whether formal or informal, by tele- the transferring hospital an amount phone, telegraph or other communica- calculated by the HCFA PRICER for tion, made by the veteran or by others each patient day of care, not to exceed in his or her behalf is dispatched to the the full DRG rate as provided in para- Department of Veterans Affairs (1) for graph (a) of this section. The hospital veterans in the 48 contiguous States that ultimately discharges the patient and Puerto Rico, within 72 hours after will receive the full DRG payment. the hour of admission, including in the (2) In the case of a veteran who has computation of time Saturday, Sunday transferred from a hospital and/or dis- and holidays, or (2) for veterans in a tinct part unit excluded by Medicare noncontiguous State, territory or pos- from the DRG-based prospective pay- session of the United States (not in- ment system or from a hospital that cluding Puerto Rico) if facilities for does not participate in Medicare, the dispatch of application as described in transferring hospital will receive a this section are not available within payment for each patient day of care the 72-hour period, provided the appli- not to exceed the amount provided in cation was filed within 72 hours after paragraph (i) of this section. facilities became available. (c) VA shall pay the providing facil- (b) When an application for admis- ity the full DRG-based rate or reason- sion by a veteran in one of the 48 con- able cost, without regard to any copay- tiguous States in the United States or ments or deductible required by any in Puerto Rico has been made more Federal law that is not applicable to than 72 hours after admission, or more VA. than 72 hours after facilities are avail- (d) If the cost or length of a veteran’s able in a noncontiguous State, terri- care exceeds an applicable threshold tory of possession of the United States, amount, as determined by the HCFA authorization for continued care at De- PRICER program, VA shall pay, in ad- partment of Veterans Affairs expense dition to the amount payable under shall be effective as of the postmark or paragraph (a) of this section, an outlier dispatch date of the application, or the payment calculated by the HCFA date of any telephone call constituting PRICER program, in accordance with an informal application. subpart F of 42 CFR part 412. [42 FR 55212, Oct. 14, 1977. Redesignated at 61 (e) In addition to the amount payable FR 21965, May 13, 1996] under paragraph (a) of this section, VA shall pay, for each discharge, an § 17.55 Payment for authorized public amount to cover the non-Federal hos- or private hospital care. pital’s capital-related costs, kidney, Except as otherwise provided in this heart and liver acquisition costs in- section, payment for public or private curred by hospitals with approved hospital care authorized under 38 transplantation centers, direct costs of U.S.C. 1703 and 38 CFR 17.52 of this part medical education, and the costs of or under 38 U.S.C. 1728 and 38 CFR qualified nonphysician anesthetists in 17.120 of this part shall be based on a small rural hospitals. These amounts prospective payment system similar to will be determined by the Under Sec- that used in the Medicare program for retary for Health on an annual basis paying for similar inpatient hospital and published in the ‘‘Notices’’ section services in the community. Payment of the FEDERAL REGISTER. shall be made using the Health Care Fi- (f) Payment shall be made only for nancing Administration (HCFA) PRIC- those services authorized by VA. ER for each diagnosis-related group (g) Payments made in accordance (DRG) applicable to the episode of care. with this section shall constitute pay- (a) Payment shall be made of the full ment in full and the provider or agent prospective payment amount per dis- for the provider may not impose any charge, as determined according to the additional charge on a veteran or his or methodology in subparts D and G of 42 her health care insurer for any inpa- CFR part 412, as appropriate. tient services for which payment is (b)(1) In the case of a veteran who made by the VA. was transferred to another facility be- (h) Hospitals of distinct part hospital fore completion of care, VA shall pay units excluded from the prospective
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payment system by Medicare and hos- paid under § 17.52 or § 17.120 for health pitals that do not participate in Medi- care professional services, and all other care will be paid at the national cost- medical services associated with non- to-charge ratio times the billed VA outpatient care, using the applica- charges that are reasonable, usual, cus- ble method in this section: tomary, and not in excess of rates or (1) If a specific amount has been ne- fees the hospital charges the general gotiated with a specific provider, VA public for similar services in the com- will pay that amount. munity. (2) If an amount has not been nego- (i) A hospital participating in an al- tiated under paragraph (a)(1) of this ternative payment system that has section, VA will pay the lowest of the been granted a Federal waiver from the prospective payment system under the following amounts: provisions of 42 U.S.C. section (i) The applicable Medicare fee sched- 1395f(b)(3) or 42 U.S.C. section 1395ww(c) ule or prospective payment system for the purposes of Medicare payment amount (‘‘Medicare rate’’) for the pe- shall not be subject to the payment riod in which the service was provided methodology set forth in this section (without any changes based on the sub- so long as such Federal waiver remains sequent development of information in effect. under Medicare authorities), subject to (j) Payments for episodes of hospital the following: care furnished in Alaska that begin (A) In the event of a Medicare waiver, during the period starting on the effec- the payment amount will be calculated tive date of this section through the in accordance with such waiver. 364th day thereafter will be in the (B) In the absence of a Medicare rate amount determined by the HCFA or Medicare waiver, payment will be PRICER plus 50 percent of the dif- the VA Fee Schedule amount for the ference between the amount billed by period in which the service was pro- the hospital and the amount deter- vided. The VA Fee Schedule amount is mined by the PRICER. Claims for serv- determined by the authorizing VA ices provided during that period will be medical facility, which ranks all bil- accepted for payment by VA under this lings (if the facility has had at least paragraph (k) until December 31 of the year following the year in which this eight billings) from non-VA facilities section became effective. under the corresponding procedure (k) Notwithstanding other provisions code during the previous fiscal year, of this section, VA, for public or pri- with billings ranked from the highest vate hospital care covered by this sec- to the lowest. The VA Fee Schedule tion, will pay the lesser of the amount amount is the charge falling at the determined under paragraphs (a) 75th percentile. If the authorizing facil- through (j) of this section or the ity has not had at least eight such bil- amount negotiated with the hospital or lings, then this paragraph does not its agent. apply. (Authority: 38 USC 513, 1703, 1728; § 233 of P. (ii) The amount negotiated by a re- L. 99–576) pricing agent if the provider is partici- pating within the repricing agent’s net- [55 FR 42852, Oct. 24, 1990. Redesignated and amended at 61 FR 21965, 21966, May 13, 1996; 62 work and VA has a contract with that FR 17072, Apr. 9, 1997; 63 FR 39515, July 23, repricing agent. For the purposes of 1998; 65 FR 66637, Nov. 7, 2000] this section, repricing agent means a contractor that seeks to connect VA § 17.56 VA payment for inpatient and with discounted rates from non-VA outpatient health care professional providers as a result of existing con- services at non-departmental facili- ties and other medical charges asso- tracts that the non-VA provider may ciated with non-VA outpatient care. have within the commercial health (a) Except for health care profes- care industry. sional services provided in the state of (iii) The amount that the provider Alaska (see paragraph (b) of this sec- bills the general public for the same tion), VA will determine the amounts service.
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(b) For physician and non-physician USE OF COMMUNITY NURSING HOME CARE professional services rendered in Alas- FACILITIES ka, VA will pay for services in accord- ance with a fee schedule that uses the § 17.57 Use of community nursing Health Insurance Portability and Ac- homes. countability Act mandated national (a) Nursing home care in a contract standard coding sets. VA will pay a public or private nursing home facility specific amount for each service for may be authorized for the following: which there is a corresponding code. Any veteran who has been discharged Under the VA Alaska Fee Schedule, the from a hospital under the direct juris- amount paid in Alaska for each code diction of VA and is currently receiv- will be 90 percent of the average ing VA hospital based home health amount VA actually paid in Alaska for services. the same services in Fiscal Year (FY) 2003. For services that VA provided less (Authority: 38 U.S.C. 1720; sec. 108, Pub. L. 99–166) than eight times in Alaska in FY 2003, for services represented by codes estab- (b) To the extent that resources are lished after FY 2003, and for unit-based available and are not otherwise re- codes prior to FY 2004, VA will take the quired to assure that VA can furnish Centers for Medicare and Medicaid needed care and treatment to veterans Services’ rate for each code and mul- described in 38 U.S.C. 1710(a)(1), the tiply it times the average percentage Under Secretary for Health may fur- paid by VA in Alaska for Centers for nish care under this paragraph to any Medicare and Medicaid Services-like veteran described in 38 U.S.C. 1710(a)(2) codes. VA will increase the amounts on if the veteran agrees to pay the United the VA Alaska Fee Schedule annually States an amount as determined in 38 in accordance with the published na- U.S.C. 1710(f). tional Medicare Economic Index (MEI). (Authority: 38 U.S.C. 1710, 1720; sec. 19011, For those years where the annual aver- Pub. L. 99–272) age is a negative percentage, the fee schedule will remain the same as the (Authority: 38 U.S.C. 1720(b) previous year. Payment for non-VA [51 FR 25067, July 10, 1986. Redesignated and health care professional services in amended at 61 FR 21965, 21966, May 13, 1996 Alaska shall be the lesser of the and further redesignated at 63 FR 39515, July 23, 1998] amount billed or the amount cal- culated under this subpart. § 17.58 Evacuation of community nurs- (c) Payments made by VA to a non- ing homes. VA facility or provider under this sec- When veterans are evacuated from a tion shall be considered payment in community nursing home as the result full. Accordingly, the facility or pro- of an emergency, they may be relo- vider or agent for the facility or pro- cated to another facility that meets vider may not impose any additional certain minimum standards, as set charge for any services for which pay- forth in 38 CFR 51.59(c)(1). ment is made by VA. (d) In a case where a veteran has paid (Authority: 38 U.S.C. 501, 1720) for emergency treatment for which VA [76 FR 55571, Sept. 8, 2011] may reimburse the veteran under § 17.120, VA will reimburse the amount § 17.60 Extensions of community nurs- ing home care beyond six months. that the veteran actually paid. Any amounts due to the provider but un- Directors of health care facilities paid by the veteran will be reimbursed may authorize, for any veteran whose to the provider under paragraphs (a) hospitalization was not primarily for a and (b) of this section. service-connected disability, an exten- sion of nursing care in a public or pri- (Authority: 38 U.S.C. 1703, 1728) vate nursing home care facility at VA [75 FR 78915, Dec. 17, 2010, as amended at 78 expense beyond six months when the FR 26251, May 6, 2013; 78 FR 68364, Nov. 14, need for nursing home care continues 2013; 79 FR 16200, Mar. 25, 2014] to exist and
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(a) Arrangements for payment of (c) The facility has been approved in such care through a public assistance accordance with § 17.63 of this part. program (such as Medicaid) for which (Authority: 38 U.S.C. 1730) the veteran has applied, have been de- layed due to unforeseen eligibility [54 FR 20842, May 15, 1989. Redesignated and problems which can reasonably be ex- amended at 61 FR 21965, 21966, May 13, 1996] pected to be resolved within the exten- sion period, or § 17.62 Definitions. (b) The veteran has made specific ar- For the purpose of §§ 17.61 through rangements for private payment for 17.72: such care, and (a) The term community residential (1) Such arrangements cannot be ef- care means the monitoring, super- fectuated as planned because of vision, and assistance, in accordance unforseen, unavoidable difficulties, with a statement of needed care, of the such as a temporary obstacle to liq- daily living activities of referred vet- uidation of property, and erans in an approved home in the com- (2) Such difficulties can reasonably munity by the facility’s provider. be expected to be resolved within the (b) The term daily living activities in- extension period; or cludes: (c) The veteran is terminally ill and (1) Walking; life expectancy has been medically de- (2) Bathing, shaving, brushing teeth, termined to be less than six months. combing hair; (d) In no case may an extension (3) Dressing; under paragraph (a) or (b) of this sec- (4) Eating; tion exceed 45 days. (5) Getting in or getting out of bed; (Authority: 38 U.S.C. 501, 1720(a)) (6) Laundry; (7) Cleaning room; [53 FR 13121, Apr. 21, 1988. Redesignated at 61 (8) Managing money; FR 21965, May 13, 1996] (9) Shopping; COMMUNITY RESIDENTIAL CARE (10) Using public transportation; (11) Writing letters; SOURCE: 54 FR 20842, May 15, 1989, unless (12) Making telephone calls; otherwise noted. (13) Obtaining appointments; (14) Self-administration of medica- § 17.61 Eligibility. tions; VA health care personnel may assist (15) Recreational and leisure activi- a veteran by referring such veteran for ties; and placement in a privately or publicly- (16) Other similar activities. owned community residential care fa- (c) The term paper hearing means a cility if: review of the written evidence of (a) At the time of initiating the as- record by the hearing official. sistance: (d) The term oral hearing means the (1) The veteran is receiving VA med- in person testimony of representatives ical services on an outpatient basis or of a community residential care facil- VA medical center, domiciliary, or ity and of VA before the hearing offi- nursing home care; or cial and the review of the written evi- (2) Such care or services were fur- dence of record by that official. nished the veteran within the pre- (e) The term approving official means ceding 12 months; the Director or, if designated by the (b) The veteran does not need hos- Director, the Associate Director or pital or nursing home care but is un- Chief of Staff of a Department of Vet- able to live independently because of erans Affairs Medical Center or Out- medical (including psychiatric) condi- patient Clinic which has jurisdiction to tions and has no suitable family re- approve a community residential care sources to provide needed monitoring, facility. supervision, and any necessary assist- (f) The term hearing official means ance in the veteran’s daily living ac- the Director or, if designated by the tivities; and Director, the Associate Director or
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Chief of Staff of a Department of Vet- (b) [Reserved] erans Affairs Medical Center or Out- (c) Interior plan. The facility must: patient Clinic which has jurisdiction to (1) Have comfortable dining areas, approve a community residential care adequate in size for the number of resi- facility. dents; (Authority: 38 U.S.C. 1730) (2) Have confortable living room [54 FR 20842, May 15, 1989. Redesignated and areas, adequate in size to accommodate amended at 61 FR 21965, 21966, May 13, 1996; 74 a reasonable proportion of residents; FR 63308, Dec. 3, 2009] and (3) Maintain at least one functional § 17.63 Approval of community resi- toilet and lavatory, and bathing or dential care facilities. shower facility for every six people liv- The approving official may approve a ing in the facility, including provider community residential care facility, and staff. based on the report of a VA inspection (d) Laundry service. The facility must and on any findings of necessary in- provide or arrange for laundry service. terim monitoring of the facility, if that (e) Residents’ bedrooms. Residents’ facility meets the following standards: bedrooms must: (a) Health and safety standards. The (1) Contain no more than four beds; facility must: (1) Meet all State and local regula- (2) Measure, exclusive of closet space, tions including construction, mainte- at least 100 square feet for a single-resi- nance, and sanitation regulations; dent room, or 80 square feet for each (2) Meet the requirements in the ap- resident in a multiresident room; and plicable provisions of NFPA 101 and (3) Contain a suitable bed for each NFPA 101A (incorporated by reference, resident and appropriate furniture and see § 17.1) and the other publications furnishings. referenced in those provisions. The in- (f) Nutrition. The facility must: stitution shall provide sufficient staff (1) Provide a safe and sanitary food to assist patients in the event of fire or service that meets individual nutri- other emergency. Any equivalencies or tional requirements and residents’ variances to VA requirements must be preferences; approved by the appropriate Veterans (2) Plan menus to meet currently rec- Health Administration Veterans Inte- ommended dietary allowances; grated Service Network (VISN) Direc- (g) Activities. The facility must plan tor; and facilitate appropriate recreational (3) Have safe and functioning systems and leisure activities to meet indi- for heating and/or cooling, as needed (a vidual needs. heating or cooling system is deemed to (h) Residents’ rights. The facility must be needed if VA determines that, in the have written policies and procedures county, parish, or similar jurisdiction that ensure the following rights for where the facility is located, a major- each resident: ity of community residential care fa- (1) Each resident has the right to: cilities or other extended care facilities have one), hot and cold water, elec- (i) Be informed of the rights de- tricity, plumbing, sewage, cooking, scribed in this section; laundry, artificial and natural light, (ii) The confidentiality and non- and ventilation. disclosure of information obtained by (4) Meet the following additional re- community residential care facility quirements, if the provisions for One staff on the residents and the residents’ and Two-Family Dwellings, as defined records subject to the requirements of in NFPA 101, are applicable to the fa- applicable law; cility: (iii) Be able to inspect the residents’ (i) Portable fire extinguishers must own records kept by the community be installed, inspected, and maintained residential care facility; in accordance with NFPA 10 (incor- (iv) Exercise rights as a citizen; and porated by reference, see § 17.1); and (v) Voice grievances and make rec- (ii) The facility must meet the re- ommendations concerning the policies quirements in section 33.7 of NFPA 101. and procedures of the facility.
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(2) Financial affairs. Residents must available to care for the resident and be allowed to manage their own per- ensure the health and safety of each sonal financial affairs, except when the resident. resident has been restricted in this (2) The community residential care right by law. If a resident requests as- provider and staff must have the fol- sistance from the facility in managing lowing qualifications: Adequate edu- personal financial affairs the request cation, training, or experience to main- must be documented. tain the facility. (3) Privacy. Residents must: (k) Cost of community residential care. (i) Be treated with respect, consider- (1) Payment for the charges of commu- ation, and dignity; (ii) Have access, in reasonable pri- nity residential care is not the respon- vacy, to a telephone within the facil- sibility of the United States Govern- ity; ment or VA. (iii) Be able to send and receive mail (2) The resident or an authorized per- unopened and uncensored; and sonal representative and a representa- (iv) Have privacy of self and posses- tive of the community residential care sions. facility must agree upon the charge (4) Work. No resident will perform and payment procedures for commu- household duties, other than personal nity residential care. housekeeping tasks, unless the resident (3) The charges for community resi- receives compensation for these duties dential care must be reasonable: or is told in advance they are vol- (i) For residents in a community resi- untary and the patient agrees to do dential care facility as of June 14, 1989, them. the rates charged for care are pegged to (5) Residents Freedom of association. the facility’s basic rate for care as of have the right to: July 31, 1987. Increases in the pegged (i) Receive visitors and associate freely with persons and groups of their rate during any calendar year cannot own choosing both within and outside exceed the annual percentage increase the facility; in the National Consumer Price Index (ii) Make contacts in the community (CPI) for that year; and achieve the highest level of inde- (ii) For community residential care pendence, autonomy, and interaction facilities approved after July 31, 1987, in the community of which the resi- the rates for care shall not exceed 110 dent is capable; percent of the average rate for ap- (iii) Leave and return freely to the proved facilities in that State as of facility, and March 31, 1987. Increases in this rate (iv) Practice the religion of their own during any calendar year cannot ex- choosing or choose to abstain from re- ceed the annual percentage increase in ligious practice. the National Consumer Price Index (6) Transfer. Residents have the right (CPI) for that year. to transfer to another facility or to an (iii) The approving official may ap- independent living situation. prove a deviation from the require- (i) (1) The facility must Records. ments of paragraphs (k)(3)(i) through maintain records on each resident in a (ii) of this section upon request from a secure place. community residential care facility (2) Facility records must include: (i) Emergency notification proce- representative, a resident in the facil- dures; and ity, or an applicant for residency, if the (ii) A copy of all signed agreements approving official determines that the with the resident. cost of care for the resident will be (3) Records may only be disclosed greater than the average cost of care with the resident’s permission, or when for other residents, or if the resident required by law. (Approved by the Office of Management and Budget under control number 2900–0491) (j) Staff requirements. (1) Sufficient, qualified staff must be on duty and
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chooses to pay more for the care pro- sional approval of the community resi- vided at a facility which exceeds VA dential care facility; and granting the standards. waiver is in the best interests of the veteran in the facility and VA’s com- (Authority: 38 U.S.C. 1730) munity residential care program. In [54 FR 20842, May 15, 1989, as amended at 54 order to reach the above determina- FR 22754, May 26, 1989. Redesignated at 61 FR tions, the VA safety expert may re- 21965, May 13, 1996, as amended at 61 FR quest supporting documentation from 63720, Dec. 2, 1996; 69 FR 18803, Apr. 9, 2004; 74 the community residential care facil- FR 63308, Dec. 3, 2009; 76 FR 10248, Feb. 24, 2011] ity. (2) In those instances where a waiver § 17.64 [Reserved] is granted, the subject standard is 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 (Authority: 38 U.S.C. 1730) agree to a plan of correcting the defi- [74 FR 63308, Dec. 3, 2009, as amended at 78 ciencies in a specified amount of time. FR 32126, May 29, 2013] A provisional approval shall not be for more than 12 months and shall not be § 17.66 Notice of noncompliance with for more time than VA determines is VA standards. reasonable for correcting the specific If the hearing official determines deficiencies. that an approved community residen- (c) An approval may be changed to a tial care facility does not comply with provisional approval or terminated the standards set forth in § 17.63 of this under the provisions of §§ 17.66 through part, the hearing official shall notify 17.71 because of a subsequent failure to the community residential care facil- meet the standards of § 17.63 and a pro- ity in writing of: visional approval may be terminated (a) The standards which have not under the provisions of §§ 17.66 through been met; 17.71 based on failure to meet the plan (b) The date by which the standards of correction or failure otherwise to must be met in order to avoid revoca- meet the standards of § 17.63. tion of VA approval; (d)(1) VA may waive one or more of (c) The community residential care the standards in 38 CFR 17.63 for the facility’s opportunity to request an approval of a particular community oral or paper hearing under § 17.67 of residential care facility, provided that this part before VA approval is re- a VA safety expert certifies that the voked; and deficiency does not endanger the life or (d) The date by which the hearing of- safety of the residents; the deficiency ficial must receive the community res- cannot be corrected as provided in idential care facility’s request for a paragraph (b) of this section for provi- hearing, which shall not be less than 10
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calendar days and not more than 20 (b) Upon the receipt of a community calendar days after the date of VA no- residential care facility’s request for a tice of noncompliance, unless the hear- paper hearing, the hearing official ing official determines that noncompli- shall notify the community residential ance with the standards threatens the care facility operator that written lives of community residential care statements and other evidence must be residents in which case the hearing of- submitted to the hearing official by a ficial must receive the community res- specified date in order to be considered idential care facility’s request for an as part of the record. oral or paper hearing within 36 hours of (c) In all hearings, the community receipt of VA notice. residential care facility operator and (Authority: 38 U.S.C. 1730) VA may be represented by counsel. [54 FR 20842, May 15, 1989. Redesignated and (Authority: 38 U.S.C. 1730) amended at 61 FR 21965, 21967, May 13, 1996; 78 [54 FR 20842, May 15, 1989. Redesignated at 61 FR 32126, May 29, 2013] FR 21965, May 13, 1996]
§ 17.67 Request for a hearing. § 17.69 Waiver of opportunity for hear- The community residential care fa- ing. cility operator must specify in writing If representatives of a community whether an oral or paper hearing is re- residential care facility which receive quested. The request for the hearing a notice of noncompliance under § 17.66 must be sent to the hearing official. of this part fail to appear at an oral Timely receipt of a request for a hear- hearing of which they have been noti- ing will stay the revocation of VA ap- fied or fail to submit written state- proval until the hearing official issues ments for a paper hearing in accord- a written decision on the community ance with § 17.68 of this part, unless the residential care facility’s compliance hearing official determines that their with VA standards. The hearing official failure was due to circumstances be- may accept a request for a hearing re- yond their control, the hearing official ceived after the time limit, if the com- shall: munity residential care facility shows (a) Consider the representatives of that the failure of the request to be re- the community residential care facil- ceived by the hearing official’s office ity to have waived their opportunity by the required date was due to cir- for a hearing; and, cumstances beyond its control. (b) Revoke VA approval of the com- (Authority: 38 U.S.C. 1730) 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] (Authority: 38 U.S.C. 1730) § 17.68 Notice and conduct of hearing. [54 FR 20842, May 15, 1989. Redesignated and (a) Upon receipt of a request for an amended at 61 FR 21965, 21967, May 13, 1996] oral hearing, the hearing official shall: (1) Notify the community residential § 17.70 Written decision following a care facility operator of the date, time, hearing. and location for the hearing; and (a) The hearing official shall issue a (2) Notify the community residential written decision within 20 days of the care facility operator that written completion of the hearing. An oral statements and other evidence for the hearing shall be considered completed record may be submitted to the hear- when the hearing ceases to receive in ing official before the date of the hear- person testimony. A paper hearing ing. An oral hearing shall be informal. shall be considered complete on the The rules of evidence shall not be fol- date by which written statements must lowed. Witnesses shall testify under be submitted to the hearing official in oath or affirmation. A recording or order to be considered as part of the transcript of every oral hearing shall record. be made. The hearing official may ex- (b) The hearing official’s determina- clude irrelevant, immaterial, or unduly tion of a community residential care repetitious testimony. facility’s noncompliance with VA
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standards shall be based on the prepon- the community residential care facil- derance of the evidence. ity. (c) The written decision shall in- (c) If the hearing official determines clude: that a community residential care fa- (1) A statement of the facts; cility fails to comply with the stand- (2) A determination whether the com- ards set forth in § 17.63 of this part and munity residential care facility com- determines that the community resi- plies with the standards set forth in dential care facility shall have an addi- § 17.63 of this part; and tional time period to remedy the non- compliance, the hearing official shall (3) A determination of the time pe- review at the end of the time period riod, if any, the community residential the evidence of the community residen- care facility shall have to remedy any tial care facility’s compliance with the noncompliance with VA standards be- standards which were to have been met fore revocation of VA approval occurs. by the end of that time period and de- (d) The hearing official’s determina- termine if the community residential tion of any time period under para- care facility complies with the stand- graph (c)(3) of this section shall con- ards. If the community residential care sider the safety and health of the resi- facility fails to comply with these or dents of the community residential any other standards, the procedures set care facility and the length of time forth in §§ 17.66–17.71 of this part shall since the community residential care be followed. facility received notice of the non- compliance. (Authority: 38 U.S.C. 1730) [54 FR 20842, May 15, 1989. Redesignated and (Authority: 38 U.S.C. 1730) amended at 61 FR 21965, 21967, May 13, 1996] [54 FR 20842, May 15, 1989. Redesignated and amended at 61 FR 21965, 21967, May 13, 1996] § 17.72 Availability of information. VA standards will be made available § 17.71 Revocation of VA approval. to other Federal, State and local agen- (a) If a hearing official determines cies charged with the responsibility of under § 17.70 of this part that a commu- licensing, or otherwise regulating or nity residential care facility does not inspecting community residential care comply with the standards set forth in facilities. § 17.63 of this part and determines that (Authority: 38 U.S.C. 1730) the community residential care facil- [54 FR 20842, May 15, 1989. Redesignated at 61 ity shall not have further time to rem- FR 21965, May 13, 1996] edy the noncompliance, the hearing of- ficial shall revoke approval of the com- § 17.73 Medical foster homes—general. munity residential care facility and (a) Purpose. Through the medical fos- notify the community residential care ter home program, VA recognizes and facility of this revocation. approves certain medical foster homes (b) Upon revocation of VA approval, for the placement of veterans. The VA health care personnel shall: choice to become a resident of a med- (1) Cease referring veterans to the ical foster home is a voluntary one on community residential care facility; the part of each veteran. VA’s role is and, limited to referring veterans to ap- (2) Notify any veteran residing in the proved medical foster homes. When a community residential care facility of veteran is placed in an approved home, the facility’s disapproval and request VA will provide inspections to ensure permission to assist in the veteran’s re- that the home continues to meet the moval from the facility. If a veteran requirements of this part, as well as has a person or entity authorized by oversight and medical foster home law to give permission on behalf of the caregiver training. If a medical foster veteran, VA health care personnel shall home does not meet VA’s criteria for notify that person or entity of the approval, VA will not refer any veteran community residential care facility’s to the home or provide any of these disapproval and request permission to services. VA may also provide certain assist in removing the veteran from medical benefits to veterans placed in
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medical foster homes, consistent with nator based on the report of a VA in- the VA program in which the veteran spection and on any findings of nec- is enrolled. essary interim monitoring of the med- (b) Definitions. For the purposes of ical foster home, if that home meets this section and § 17.74: the standards established in § 17.74. The Labeled means that the equipment or approval process is governed by the materials have attached to them a process for approving community resi- 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 care- giver 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- (Authority: 38 U.S.C. 501, 1730) ter home. [77 FR 5188, Feb. 2, 2012] Placement refers to the voluntary de- cision by a veteran to become a resi- § 17.74 Standards applicable to med- dent in an approved medical foster ical foster homes. home. Veteran resident means a veteran re- (a) General. A medical foster home siding in an approved medical foster must: home who meets the eligibility criteria (1) Meet all applicable state and local in paragraph (c) of this section. regulations, including construction, (c) Eligibility. VA health care per- maintenance, and sanitation regula- sonnel may assist a veteran by refer- tions. ring such veteran for placement in a (2) Have safe and functioning systems medical foster home if: for heating, hot and cold water, elec- (1) The veteran is unable to live inde- tricity, plumbing, sewage, cooking, pendently safely or is in need of nurs- laundry, artificial and natural light, ing home level care; and ventilation. Ventilation for cook (2) The veteran must be enrolled in, stoves is not required. or agree to be enrolled in, either a VA (3) Except as otherwise provided in Home Based Primary Care or VA Spi- this section, meet the applicable provi- nal Cord Injury Homecare program, or sions of chapters 1 through 11 and 24, a similar VA interdisciplinary program and section 33.7 of NFPA 101 (incor- designed to assist medically complex porated by reference, see § 17.1), and the veterans living in the home; and other codes and chapters identified in (3) The medical foster home has been this section, as applicable. approved in accordance with paragraph (b) Community residential care facility (d) of this section. standards applicable to medical foster (d) Approval of medical foster homes. homes. Medical foster homes must com- Medical foster homes will be approved ply with § 17.63(c), (d), (f), (h), (j) and by a VA Medical Foster Homes Coordi- (k).
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(c) Activities. The facility must plan all smoke alarms within the medical and facilitate appropriate recreational foster home. Smoke detectors or and leisure activities. smoke alarms must not be installed in (d) Residents’ bedrooms. Each veteran the kitchen or any other location sub- resident must have a bedroom: ject to causing false alarms. (1) With a door that closes and (2) CO detectors or CO alarms must latches; be installed in any medical foster home (2) That contains a suitable bed and with a fuel-burning appliance, fire- appropriate furniture; and place, or an attached garage, in accord- (3) That is single occupancy, unless ance with NFPA 720 (incorporated by the veteran agrees to a multi-occupant reference, see § 17.1). bedroom. (3) Combination CO/smoke detectors (e) Windows. VA may grant provi- and combination CO/smoke alarms are sional approval for windows used as a permitted. secondary means of escape that do not (4) Smoke detectors and smoke meet the minimum size and dimensions alarms must initiate a signal to a re- required by chapter 24 of NFPA 101 (in- mote supervising station to notify corporated by reference, see § 17.1) if emergency forces in the event of an the windows are a minimum of 5.0 alarm. square feet (and at least 20 inches wide (5) Smoke and/or CO alarms and and at least 22 inches high). The sec- smoke and/or CO detectors, and all ondary means of escape must be other elements of a fire alarm system, brought into compliance with chapter must be inspected, tested, and main- 24 no later than 60 days after a veteran tained in accordance with NFPA 72 (in- resident is placed in the home. corporated by reference, see § 17.1) and (f) Special locking devices. Special NFPA 720 (incorporated by reference, locking devices that do not comply see § 17.1). with section 7.2.1.5 of NFPA 101 (incor- (h) Sprinkler systems. (1) If a sprinkler porated by reference, see § 17.1) are per- system is installed, it must be in- mitted where the clinical needs of the spected, tested, and maintained in ac- veteran resident require specialized se- cordance with NFPA 25 (incorporated curity measures and with the written by reference, see § 17.1), unless the approval of: sprinkler system is installed in accord- (1) The responsible VA clinician; and ance with NFPA 13D (incorporated by (2) The VA fire/safety specialist or reference, see § 17.1). If a sprinkler sys- the Director of the VA Medical Center tem is installed in accordance with of jurisdiction. NFPA 13D, it must be inspected annu- (g) Smoke and carbon monoxide (CO) ally by a competent person. detectors and smoke and CO alarms. Med- (2) If sprinkler flow or pressure ical foster homes must comply with switches are installed, they must acti- this paragraph (g) no later than 60 days vate notification appliances in the after the first veteran is placed in the medical foster home, and must initiate home. Prior to compliance, VA inspec- a signal to the remote supervising sta- tors will provisionally approve a med- tion. ical foster home for the duration of (i) Fire extinguishers. At least one 2– this 60-day period if the medical foster A:10–B:C rated fire extinguisher must home mitigates risk through the use of be visible and readily accessible on battery-operated single station alarms, each floor, including basements, and provided that the alarms are installed must be maintained in accordance with before any veteran is placed in the the manufacturer’s instructions. Port- home. able fire extinguishers must be in- (1) Smoke detectors or smoke alarms spected, tested, and maintained in ac- must be provided in accordance with cordance with NFPA 10 (incorporated sections 24.3.4.1 or 24.3.4.2 of NFPA 101 by reference, see § 17.1). (incorporated by reference, see § 17.1); (j) Emergency lighting. Each occupied section 24.3.4.3 of NFPA 101 will not be floor must have at least one plug-in re- used. In addition, smoke alarms must chargeable flashlight, operable and be interconnected so that the operation readily accessible, or other approved of any smoke alarm causes an alarm in emergency lighting. Such emergency
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lighting must be tested monthly and spond to a fire alarm and evacuate the replaced if not functioning. medical foster home, unless the vet- (k) Fireplaces. A non-combustible eran resident is unable to participate. hearth, in addition to protective glass (2) The medical foster home caregiver doors or metal mesh screens, is re- must demonstrate the ability to evac- quired for fireplaces. Hearths and pro- uate all occupants within three min- tective devices must meet all applica- utes to a point of safety outside of the ble state and local fire codes. medical foster home that has access to (l) Portable heaters. Portable heaters a public way, as defined in NFPA 101 may be used if they are maintained in (incorporated by reference, see § 17.1). good working condition and: (3) If all occupants are not evacuated (1) The heating elements of such within three minutes or if a veteran heaters do not exceed 212 degrees Fahr- resident is either permanently or tem- enheit (100 degrees Celsius); porarily unable to participate in drills, (2) The heaters are labeled; and then the medical foster home will be (3) The heaters have tip-over protec- given a 60-day provisional approval, tion. after which time the home must have (m) Oxygen safety. Any area where established one of the following reme- oxygen is used or stored must not be dial options or VA will terminate the near an open flame and must have a approval in accordance with § 17.65. posted ‘‘No Smoking’’ sign. Oxygen (i) The home is protected throughout cylinders must be adequately secured with an automatic sprinkler system in or protected to prevent damage to cyl- accordance with section 9.7 of NFPA inders. Whenever possible, transfilling 101 (incorporated by reference, see of liquid oxygen must take place out- § 17.1) and whichever of the following side of the living areas of the home. apply: NFPA 13 (incorporated by ref- (n) Smoking. Smoking must be pro- erence, see § 17.1); NFPA 13R (incor- hibited in all sleeping rooms, including porated by reference, see § 17.1); or sleeping rooms of non-veteran resi- NFPA 13D (incorporated by reference, dents. Ashtrays must be made of non- combustible materials. see § 17.1). (o) Special/other hazards. (1) Extension (ii) Each veteran resident who is per- cords must be three-pronged, grounded, manently or temporarily unable to par- sized properly, and not present a haz- ticipate in a drill or who fails to evac- ard due to inappropriate routing, uate within three minutes must have a pinching, damage to the cord, or risk of bedroom located at the ground level overloading an electrical panel circuit. with direct access to the exterior of the (2) Flammable or combustible liquids home that does not require travel and other hazardous material must be through any other portion of the resi- safely and properly stored in either the dence, and access to the ground level original, labeled container or a safety must meet the requirements of the can as defined by section 3.3.44 of Americans with Disabilities Act. The NFPA 30 (incorporated by reference, medical foster home caregiver’s bed- 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- (Authority: 38 U.S.C. 501, 1730) preservation, the local fire department or response agency must be notified by [77 FR 5189, Feb. 2, 2012] 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 men- tary, 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 treat- ment 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 al- cohol 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 dis- asters 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 de- clared 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(j). 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 of the hospital care or medical services [51 FR 19330, May 29, 1986, as amended at 56 when charges are mandated by Federal FR 3422, Jan. 30, 1991. Redesignated and law (including applicable appropriation amended at 61 FR 21965, 21967, May 13, 1996] acts) or when the cost of care or serv- § 17.91 Protection of health-care eligi- ices is not reimbursed by other-than- bility. VA Federal departments or agencies. 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 [51 FR 19330, May 29, 1986. Redesignated at 61 are not available, VA shall arrange for FR 21965, May 13, 1996] care on a fee basis, but only if the vet- eran is eligible to receive medical serv- OUTPATIENT TREATMENT ices in non-VA facilities under § 17.52. § 17.92 Outpatient care for research If the veteran is not in immediate need purposes. of outpatient medical services, VA Subject to the provisions of § 17.101, shall schedule the veteran for care any person who is a bona fide volunteer where the veteran applied, if the sched- may be furnished outpatient treatment ule there permits, or refer the veteran when the treatment to be rendered is for scheduling to the nearest VA med- part of an approved Department of Vet- ical center or Department of Defense erans Affairs research project and facility (with which VA has a sharing there are insufficient veteran-patients agreement). suitable for the project. (c) VA may furnish on an ambulatory [35 FR 11470, July 17, 1970. Redesignated and or outpatient basis medical services as amended at 61 FR 21965, 21967, May 13, 1996] needed to the following applicants, ex- 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(j). (Authority: 38 U.S.C. 1712) (2) [Reserved] (1) For compensation and pension ex- aminations. A compensation and pen- (Authority: 38 U.S.C. 1717) sion examination shall be performed [55 FR 20150, May 15, 1990, as amended at 58 for any veteran who is directed to have FR 25565, Apr. 27, 1993. Redesignated and such an examination by VA. amended at 61 FR 21965, 21967, May 13, 1996; 64 FR 54218, Oct. 6, 1999] (Authority: 38 U.S.C. 111 and 501) § 17.94 Outpatient medical services for (2) For adjunct treatment. Subject to military retirees and other bene- the provisions of §§ 17.36 through 17.38, ficiaries. 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. 1712 (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 annual income limitation by more than when duly authorized. $ 1,000, and [32 FR 13815, Oct. 4, 1967, as amended at 45 FR (b) The drugs and medicines are pre- 6937, Jan. 31, 1980; 47 FR 58249, Dec. 30, 1982. scribed as specific therapy in the treat- Redesignated and amended at 61 FR 21965, ment of any of the veteran’s illnesses 21967, May 13, 1996] or injuries.
§ 17.95 Outpatient medical services for (Authority 38 U.S.C. 101(11), 1706, 1710, Department of Veterans Affairs em- 1712(d)) ployees and others in emergencies. [68 FR 43929, July 25, 2003, as amended at 74 Outpatient medical services for FR 44291, Aug. 28, 2009; 78 FR 42456, July 16, which charges shall be made as re- 2013] quired by § 17.101 may be authorized for § 17.97 Prescriptions in Alaska, and employees of the Department of Vet- territories and possessions. erans Affairs, their families, and the general public in emergencies, subject In Alaska and territories and posses- to conditions stipulated by the Sec- sions, where there are no Department retary of Veterans Affairs. of Veterans Affairs pharmacies, the ex- penses of any prescriptions filled by a (Authority: 38 U.S.C. 1711(c)(1)) private pharmacist which otherwise [47 FR 58249, Dec. 30, 1982. Redesignated and could have been filled by a Department amended at 61 FR 21965, 21967, May 13, 1996] of Veterans Affairs pharmacy under 38 U.S.C. 1712(h), may be reimbursed. § 17.96 Medication prescribed by non- VA physicians. [32 FR 13816, Oct. 4, 1967. Redesignated and amended at 61 FR 21965, 21967, May 13, 1996] Any prescription, which is not part of authorized Department of Veterans Af- § 17.98 Mental health services. fairs hospital or outpatient care, for drugs and medicines ordered by a pri- (a) Following the death of a veteran, vate or non-Department of Veterans bereavement counseling involving serv- Affairs doctor of medicine or doctor of ices defined in 38 U.S.C. 1701(6)(B), may osteopathy duly licensed to practice in be furnished to persons who were re- the jurisdiction where the prescription ceiving mental health services in con- is written, shall be filled by a Depart- nection with treatment of the veteran ment of Veterans Affairs pharmacy or under 38 U.S.C. 1710, 1712, 1712A, 1713, or a non-VA pharmacy in a state home 1717, or 38 CFR 17.84 of this part, prior under contract with VA for filling pre- to the veteran’s death, but may only be scriptions for patients in state homes, furnished in instances where the vet- provided: eran’s death had been unexpected or (a) The prescription is for: occurred while the veteran was partici- (1) A veteran who by reason of being pating in a VA hospice or similar pro- permanently housebound or in need of gram. Bereavement counseling may be regular aid and attendance is in receipt provided only to assist individuals with of increased compensation under 38 the emotional and psychological stress U.S.C. chapter 11, or increased pension accompanying the veteran’s death, and under § 3.1(u) (Section 306 Pension) or only for a limited period of time, as de- § 3.1(w) (Improved Pension), of this termined by the Medical Center Direc- chapter, as a veteran of a period of war tor, but not to exceed 60 days. The as defined by 38 U.S.C. 101(11) (or, al- Medical Center Director may approve a though eligible for such pension, is in longer period of time when medically receipt of compensation as the greater indicated. benefit), or (b) For purposes of paragraph (a) of (2) A veteran in need of regular aid this section, an unexpected death is and attendance who was formerly in re- one which occurs when in the course of ceipt of increased pension as described an illness the provider of care did not in paragraph (a)(1) of this section or could not have anticipated the tim- whose pension has been discontinued ing of the death. Ordinarily, the pro- solely by reason of excess income, but vider of care can anticipate the pa- only so long as such veteran’s annual tient’s death and can inform the pa- income does not exceed the maximum tient and family of the immediacy and
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certainty of death. If that has not either be published in a notice in the taken place, a death can be described FEDERAL REGISTER or will be posted on as unexpected. the Internet site of the Veterans (Authority: 38 U.S.C. 1701(6)(B)) Health Administration Chief Business Office, currently at http://www.va.gov/ [53 FR 7186, Mar. 7, 1988. Redesignated and cbo, under ‘‘Charge Data.’’ For care for amended at 61 FR 21965, 21967, May 13, 1996] which VA has established a charge, VA CHARGES, WAIVERS, AND COLLECTIONS will bill using its most recent pub- lished 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) Methodologies. Based on the meth- 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 lection of such charges may request services and dental services; pathology that the third party health plan submit and laboratory charges; observation evidence or information to substan- care facility charges; ambulance and tiate the appropriateness of the pay- other emergency transportation ment amount (e.g., health plan or in- charges; and charges for durable med- surance policies, provider agreements, ical equipment, drugs, injectables, and medical evidence, proof of payment to other medical services, items, and sup- other providers in the same geographic plies identified by HCPCS Level II area for the same care and services VA codes. In addition, the charges billed provided). for prescription drugs not administered (5) Definitions. For purposes of this during treatment will be the amount section: determined under paragraph (m) of this APC means Medicare Ambulatory section. Data for calculating actual Payment Classification. charge amounts based on the meth- CMS means the Centers for Medicare odologies set forth in this section will and Medicaid Services.
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CPI-U means Consumer Price Index— etc.) is designated as either provider- All Urban Consumers. based or non-provider-based. Provider- CPT code and CPT procedure code based entities are entitled to bill out- mean Current Procedural Terminology patient facility charges; non-provider- code, a five-digit identifier defined by based entities are not. The charges for the American Medical Association for physician and other professional serv- 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, in- for 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 (i) If a new DRG or CPT/HCPCS code CMS provider-based criteria. Provider- identifier replaces a DRG or CPT/ based entities are entitled to bill out- HCPCS code identifier, the most re- patient facility charges. cently established charge for the iden- RBRVS means Resource-Based Rel- tifier being replaced will continue to be ative Value Scale. used for determining a billing charge RVU means Relative Value Unit. under paragraphs (b), (e), (f), (g), (h), Unlisted procedures mean procedures, (i), (k), or (l) of this section until such services, items, and supplies that have time as VA establishes a charge for the not been defined or specified by the new identifier. American Medical Association or CMS, (ii) If medical care or service is pro- and the CPT and HCPCS codes used to vided or furnished at VA expense by a report such procedures, services, items, non-VA provider and a charge cannot and supplies. be established under paragraph (a)(8)(i) (6) Provider-based and non-provider- of this section, then VA’s billing based entities and charges. Each VA charge for such care or service will be health care entity (medical center, the amount VA paid to the non-VA pro- hospital, community-based outpatient vider without additional calculations clinic, independent outpatient clinic, under this section.
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(iii) If a new CPT/HCPCS code has fier, the interim charge for use in para- been established for a prosthetic device graphs (e), (f), (g), (h), (i), (k), or (l) of or durable medical equipment subject this section will be the charge for the to paragraph (l) of this section and a CPT/HCPCS code that is closest in charge cannot be established under characteristics to the new CPT/HCPCS paragraphs (a)(8)(i) or (ii) of this sec- code. tion, VA’s billing charge for such pros- (viii) If a charge cannot be estab- thetic device or durable medical equip- lished under paragraphs (a)(8)(i) ment will be 1 and 1⁄2 times VA’s aver- through (a)(8)(vii) of this section, then age actual cost without additional cal- VA will not charge under this section culations under this section. for the care or service. (iv) If a new medical identifier DRG (b) Acute inpatient facility charges. code has been assigned to a particular When VA provides or furnishes acute type of medical care or service and a inpatient services within the scope of charge cannot be established under care referred to in paragraph (a)(1) of paragraphs (a)(8)(i) through (iii) of this this section, acute inpatient facility section, then until such time as VA es- charges billed for such services will be tablishes a charge for the new medical determined in accordance with the pro- identifier DRG code, the interim visions of this paragraph. Acute inpa- charge for use in paragraph (b) of this tient facility charges consist of per section will be the average charge of diem charges for room and board and all medical DRG codes that are within for ancillary services that vary by geo- plus or minus 10 of the numerical rel- graphic area and by DRG. These ative weight assigned to the new med- charges are calculated as follows: ical identifier DRG code. (1) Formula. For each acute inpatient (v) If a new surgical identifier DRG stay, or portion thereof, for which a code has been assigned to a particular particular DRG assignment applies, the type 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 (iv) 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 surgical For purposes of this section, standard identifier DRG code, the interim room and board days and ICU room and charge for use in paragraph (b) of this board days are mutually exclusive: VA section will be the average charge of will bill either a standard room and all surgical DRG codes that are within board per diem charge or an ICU room plus or minus 10 of the numerical rel- and board per diem charge, as applica- ative weight assigned to the new sur- ble, for each day of a given acute inpa- gical identifier DRG code. tient stay. (vi) If a new identifier CPT/HCPCS (i) Standard room and board charges. code is assigned to a particular type or Multiply the nationwide standard room item of medical care or service and a and board per diem charge determined charge cannot be established under pursuant to paragraph (b)(2) of this sec- paragraphs (a)(8)(i) through (v) of this tion by the appropriate geographic section, then until such time as VA es- area adjustment factor determined pur- tablishes a charge for the new identi- suant to paragraph (b)(3) of this sec- fier for use in paragraphs (e), (f), (g), tion. The result constitutes the area- (h), (i), (k), or (l) of this section, VA’s specific standard room and board per billing charge will be the Medicare al- diem charge. Multiply this amount by lowable charge multiplied by 1 and 1⁄2, the number of days for which standard without additional calculations under room and board charges apply to ob- this section. tain the total acute inpatient facility (vii) If a new identifier CPT/HCPCS standard room and board charge. code is assigned to a particular type or (ii) ICU room and board charges. Mul- item of medical care or service and a tiply the nationwide ICU room and charge cannot be established under board per diem charge determined pur- paragraphs (a)(8)(i) through (vi) of this suant to paragraph (b)(2) of this section section, then until such time as VA es- by the appropriate geographic area ad- tablishes a charge for the new identi- justment factor determined pursuant
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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 forth in paragraph (b)(2)(iv) of this sec- a medical or surgical problem), then calcula- tion. The results constitute the nation- tions of acute inpatient facility charges will 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 one from the MedStat claims database, room and board compared to the com- a database of nationwide commercial bined total charges for room and board insurance claims. Average per diem and ancillary services, and the percent- charges are calculated based on all age of the total charges for ancillary available charges, except for care re- services compared to the combined ported for emergency room, ambu- total charges for room and board and lance, professional, and observation ancillary services, are calculated by care. These two data sources may re- DRG. port charges for two differing periods (ii) Standard room and board per diem of time; when this occurs, the data charge and ICU room and board per diem source charges with the earlier center charge ratios. Using only those cases date are trended forward to the center from the MedPAR file for which a dis- date of the other data source, based on tinction between room and board and changes to the inpatient hospital serv- ancillary charges can be determined, ices component of the CPI-U. Results overall average per diem room and obtained from these two data sources board charges are calculated by DRG. are then combined into a single weight- Then, using the same cases, an average ed average per diem charge for each standard room and board per diem DRG. The resulting charge for each charge is calculated by dividing total DRG is then separated into its two non-ICU room and board charges by components, a room and board compo- total non-ICU room and board days. nent and an ancillary component, with Similarly, an average ICU room and the per diem charge for each compo- board per diem charge is calculated by
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dividing total ICU room and board per diem charges are obtained from the charges by total ICU room and board MedPAR file, weighted by nationwide days. Finally, ratios of standard room VA discharges and by average lengths and board per diem charges to average of stay from the combined MedPAR file overall room and board per diem and MedStat claims database. Four ge- charges are calculated by DRG, as are ographic area adjustment factors are ratios of ICU room and board per diem then calculated for each geographic charges to average overall room and area by dividing each geographic area board per diem charges. average per diem charge by the cor- (iii) 80th percentile. Using cases from responding national average per diem the MedPAR file with separately iden- charge. tifiable semi-private room rates, the (c) Skilled nursing facility/sub-acute in- ratio of the day-weighted 80th per- patient facility charges. When VA pro- centile semi-private room and board vides or furnishes skilled nursing/sub- per diem charge to the average semi- acute inpatient services within the private room and board per diem scope of care referred to in paragraph charge is obtained for each geographic (a)(1) of this section, skilled nursing fa- area. The geographic area-based ratios cility/sub-acute inpatient facility are averaged to obtain a final 80th per- charges billed for such services will be centile ratio. determined in accordance with the pro- (iv) Trending forward. 80th percentile visions of this paragraph. The skilled charges for each DRG, obtained as de- nursing facility/sub-acute inpatient fa- scribed in paragraph (b)(2) of this sec- cility charges are per diem charges tion, are trended forward based on that vary by geographic area. The fa- changes to the inpatient hospital serv- cility charges cover care, including ices component of the CPI-U. Actual room and board, nursing care, pharma- CPI-U changes are used from the center ceuticals, supplies, and skilled reha- date of the trended data sources bilitation services (e.g., physical ther- through the latest available month as apy, inhalation therapy, occupational of the time the calculations are per- therapy, and speech-language pathol- formed. The three-month average an- ogy), that is provided in a nursing nual trend rate as of the latest avail- home or hospital inpatient setting, is able month is then held constant to the provided under a physician’s orders, midpoint of the calendar year in which and is performed by or under the gen- the charges are primarily expected to eral supervision of professional per- be used. The projected total CPI-U sonnel such as registered nurses, li- change so obtained is then applied to censed practical nurses, physical thera- the 80th percentile charges. pists, occupational therapists, speech- (3) Geographic area adjustment factors. language pathologists, and audiol- For each geographic area, the average ogists. These charges are calculated as per diem room and board charges and follows: ancillary charges from the MedPAR (1) Formula. For each stay, multiply file are calculated for each DRG. The the nationwide per diem charge deter- DRGs are separated into two groups, mined pursuant to paragraph (c)(2) of surgical and non-surgical. For each of this section by the appropriate geo- these groups of DRGs, for each geo- graphic area adjustment factor deter- graphic area, average room and board mined pursuant to paragraph (c)(3) of per diem charges and ancillary per this section. The result constitutes the diem charges are calculated, weighted area-specific per diem charge. Finally, by nationwide VA discharges and by multiply the area-specific per diem average lengths of stay from the com- charge by the number of days of care to bined MedPAR file and MedStat claims obtain the total skilled nursing facil- database. This results in four average ity/sub-acute inpatient facility charge. per diem charges for each geographic (2) Per diem charge. To establish a area: room and board for surgical baseline, a nationwide average per DRGs, ancillary for surgical DRGs, diem billed charge is calculated based room and board for non-surgical DRGs, on charges reported in the MedPAR and ancillary for non-surgical DRGs. skilled nursing facility file. For this Four corresponding national average purpose, the following MedPAR charge
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categories are included: room and (3) Geographic area adjustment factors. board (private, semi-private, and ward), The average billed per diem charge for physical therapy, occupational ther- each geographic area is calculated apy, inhalation therapy, speech-lan- from the MedPAR skilled nursing facil- guage pathology, pharmacy, medical/ ity file. This amount is divided by the surgical supplies, and ‘‘other’’ services. nationwide average billed charge cal- The following MedPAR charge cat- culated in paragraph (c)(2) of this sec- egories are excluded from the calcula- tion. The geographic area adjustment tion of the per diem charge and will be factor for charges for each VA facility billed separately, using the charges de- is the ratio for the geographic area in termined as set forth in other applica- which the facility is located. ble paragraphs of this section, when (d) Partial hospitalization facility these services are provided to skilled charges. When VA provides or furnishes nursing patients or sub-acute inpa- partial hospitalization services that tients: ICU and CCU room and board, are within the scope of care referred to laboratory, radiology, cardiology, di- in paragraph (a)(1) of this section, the alysis, operating room, blood and blood facility charges billed for such services administration, ambulance, MRI, anes- will be determined in accordance with thesia, durable medical equipment, the provisions of this paragraph. Par- emergency room, clinic, outpatient, tial hospitalization facility charges are professional, lithotripsy, and organ ac- per diem charges that vary by geo- quisition services. The resulting aver- graphic area. These charges are cal- age per diem billed charge is then mul- culated as follows: tiplied by the 80th percentile adjust- (1) Formula. For each partial hos- ment factor determined pursuant to pitalization stay, multiply the nation- paragraph (c)(2)(i) of this section to ob- wide per diem charge determined pur- tain a nationwide 80th percentile suant to paragraph (d)(2) of this section charge level. Finally, the resulting by the appropriate geographic area ad- amount is trended forward to the effec- justment factor determined pursuant tive time period for the charges, as set to paragraph (d)(3) of this section. The forth in paragraph (c)(2)(ii) of this sec- result constitutes the area-specific per tion. diem charge. Finally, multiply the (i) 80th percentile adjustment factor. area-specific per diem charge by the Using the MedPAR skilled nursing fa- number of days of care to obtain the cility file, the ratio of the day-weight- total partial hospitalization facility ed 80th percentile room and board per charge. diem charge to the day-weighted aver- (2) Per diem charge. To establish a age room and board per diem charge is baseline, a nationwide median per diem obtained for each geographic area. The billed charge is calculated based on geographic area-based ratios are aver- charges associated with partial hos- aged to obtain the 80th percentile ad- pitalization from the outpatient facil- justment factor. ity component of the Medicare Stand- (ii) Trending forward. The 80th per- ard Analytical File 5 percent Sample. centile charge is trended forward based That median per diem billed charge is on changes to the inpatient hospital then multiplied by the 80th percentile services component of the CPI-U. Ac- adjustment factor determined pursuant tual CPI-U changes are used from the to paragraph (d)(2)(i) of this section to time period of the source data through obtain a nationwide 80th percentile the latest available month as of the charge level. Finally, the resulting time the calculations are performed. amount is trended forward to the effec- The three-month average annual trend tive time period for the charges, as set rate as of the latest available month is forth in paragraph (d)(2)(ii) of this sec- then held constant to the midpoint of tion. the calendar year in which the charges (i) 80th percentile adjustment factor. are primarily expected to be used. The The 80th percentile adjustment factor projected total CPI-U change so ob- for partial hospitalization facility tained is then applied to the 80th per- charges is the same as that computed centile charge. for skilled nursing facility/sub-acute
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inpatient facility charges under para- charge determined pursuant to para- graph (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 and by CPT/HCPCS code. These charges APC. Using this subset of the 5 percent apply in the situations set forth in Sample data, nationwide median paragraph (e)(1) of this section and are charge to Medicare APC payment calculated as set forth in paragraph amount ratios, by APC, and nationwide (e)(2) of this section. 80th percentile to median charge ratios, (1) Settings and circumstances in which by APC, are computed according to the outpatient facility charges apply. Out- methodology set forth in paragraphs patient facility charges consist of facil- (e)(3)(i)(A) and (e)(3)(i)(B) of this sec- ity charges for procedures, diagnostic tion, respectively. The product of these tests, evaluation and management two ratios by APC is then computed, services, and other medical services, resulting in a composite nationwide items, and supplies provided in the fol- 80th percentile charge to Medicare APC lowing settings and circumstances: payment amount ratio. This ratio is (i) Outpatient departments and clin- then compared to the alternate nation- ics at VA medical centers; wide 80th percentile charge to Medicare (ii) Other VA provider-based entities; APC payment amount ratio computed and in paragraph (e)(3)(i)(C) of this section, (iii) VA non-provider-based entities, and the lesser amount is selected and for procedures and tests for which no multiplied by the current Medicare corresponding professional charge is APC payment amount. The resulting established under the provisions of product is the APC-specific nationwide paragraph (f) of this section. 80th percentile charge amount for each (2) Formula. For each outpatient fa- applicable CPT/HCPCS code. cility charge CPT/HCPCS code, mul- (A) Nationwide median charge to Medi- tiply the nationwide 80th percentile care APC payment amount ratios. For
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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 culated for each of the APC categories MDR database, from the MedStat set forth in paragraph (e)(3)(i)(D) of claims database, and from the out- this section, again using the reported 5 patient facility component of the Medi- percent Sample frequencies as weights. care Standard Analytical File 5 percent For APCs where the 5 percent Sample Sample. If the MDR database contains frequencies provide a statistically sufficient data to provide a statis- credible result, the APC-specific tically credible 80th percentile charge, weighted average nationwide 80th per- then that result is retained for this centile to median charge ratio so ob- purpose. If the MDR database does not tained is accepted without further ad- provide a statistically credible 80th justment. However, if the 5 percent percentile charge, then the result from Sample data do not produce statis- the MedStat database is retained for tically credible results for any specific this purpose, provided it is statistically APC, then the APC category-specific credible. If neither the MDR nor the ratio is applied for that APC. MedStat databases provide statis- (C) Alternate nationwide 80th percentile tically credible results, then the na- charge to Medicare APC payment amount tionwide 80th percentile billed charge ratios. A minimum 80th percentile computed from the 5 percent Sample charge to Medicare APC payment data is retained for this purpose. The amount ratio is set at 2.0 for APCs with nationwide 80th percentile charges re- Medicare APC payment amounts of $25 tained from each of these data sources or less. A maximum 80th percentile are trended forward to the effective charge to Medicare APC payment time period for the charges, as set amount ratio is set at 6.5 for APCs with forth in paragraph (e)(3)(iii) of this sec- Medicare APC payment amounts of tion.
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(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 ad- justed 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 as the ratio of the CPT/HCPCS code Medicare RVUs. The work expense and weighted average charge level for each practice expense RVUs for CPT/HCPCS geographic area to the nationwide CPT/ codes, other than the codes described HCPCS code weighted average charge in paragraphs (f)(2)(ii) and (f)(2)(iii) of level. this section, are compiled using Medi- (5) Multiple surgical procedures. When care Physician Fee Schedule RVUs. multiple surgical procedures are per- The sum of the geographically-adjusted formed during the same outpatient en- work expense RVUs determined pursu- counter by a provider or provider team ant to paragraph (f)(2)(i)(A) of this sec- as indicated by multiple surgical CPT/ tion and the geographically-adjusted HCPCS procedure codes, then each practice expense RVUs determined pur- CPT/HCPCS procedure code will be suant to paragraph (f)(2)(i)(B) of this billed at 100 percent of the charges es- section equals the total geographi- tablished under this section. cally-adjusted RVUs. (f) Physician and other professional (A) Geographically-adjusted work ex- charges except for anesthesia services and pense RVUs. For each CPT/HCPCS code certain dental services. When VA pro- for each geographic area, the Medicare vides or furnishes physician and other Physician Fee Schedule work expense professional services, other than pro- RVUs are multiplied by the work ex- fessional anesthesia services and cer- pense Medicare Geographic Practice tain professional dental services, with- Cost Index. The result constitutes the in the scope of care referred to in para- geographically-adjusted work expense graph (a)(1) of this section, physician RVUs. and other professional charges billed (B) Geographically-adjusted practice ex- for such services will be determined in pense RVUs. For each CPT/HCPCS code
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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 charges are obtained, where statis- 23 CPT/HCPCS code groups: allergy tically credible, from the Prevailing immunotherapy, allergy testing, car- Healthcare Charges System nationwide diovascular, chiropractor, consults, commercial insurance database. For emergency room visits and observation each of these CPT/HCPCS codes, na- care, hearing/speech exams, immuniza- tionwide total RVUs are obtained by tions, inpatient visits, maternity/cesar- taking the nationwide 80th percentile ean deliveries, maternity/non-deliv- billed charges obtained using the pre- eries, maternity/normal deliveries, ceding three databases and dividing by miscellaneous medical, office/home/ur- the untrended nationwide conversion gent care visits, outpatient psychiatry/ factor for the corresponding CPT/ alcohol and drug abuse, pathology, HCPCS code group determined pursu- physical exams, physical medicine, ra- ant to paragraphs (f)(3) and (f)(3)(i) of diology, surgery, therapeutic injec- this section. For any remaining CPT/ tions, vision exams, and well baby HCPCS codes that have not been as- exams. For each of the 23 CPT/HCPCS signed RVUs using the preceding data code groups, representative CPT/ sources, the nationwide total RVUs are HCPCS codes are statistically selected calculated by summing the work ex- and weighted so as to give a weighted pense and non-facility practice expense average RVU comparable to the RVUs found in Ingenix/St. Anthony’s weighted average RVU of the entire RBRVS. The resulting nationwide total CPT/HCPCS code group (the selected RVUs obtained using these four data CPT/HCPCS codes are set forth in the sources are multiplied by the geo- Milliman USA, Inc., Health Cost Guide- graphic area adjustment factors deter- lines fee survey); see paragraph (a)(3) of mined pursuant to paragraph (f)(2)(iv) this section for Data Sources. The 80th
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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 conver- sulting ratios are the geographic area sion factors for each of the 23 CPT/ adjustment factors for the conversion HCPCS code groups are trended for- factors for each of the 23 CPT/HCPCS ward to the effective time period for code groups for each geographic area. the charges, as set forth in paragraph (4) Charge adjustment factors for speci- (f)(3)(ii) of this section. The resulting fied CPT/HCPCS code modifiers. Sur- amounts for each of the 23 groups are charges are calculated in the following multiplied by geographic area adjust- manner: From the Part B component of ment factors determined pursuant to the Medicare Standard Analytical File paragraph (f)(3)(iii) of this section, re- 5 percent Sample, the ratio of weighted sulting in geographically-adjusted 80th average billed charges for CPT/HCPCS percentile conversion factors for each codes with the specified modifier to the geographic area for the 23 CPT/HCPCS weighted average billed charge for code groups for the effective charge pe- CPT/HCPCS codes with no charge riod. modifier is calculated, using the fre- (i) Nationwide conversion factors. quency of procedure codes with the Using the nationwide 80th percentile modifier as weights in both weighted charges for the selected CPT/HCPCS average calculations. The resulting ra- codes from paragraph (f)(3) of this sec- tios constitute the surcharge factors tion, a nationwide conversion factor is for specified charge-significant CPT/ calculated for each of the 23 CPT/ HCPCS code modifiers. HCPCS code groups by dividing the (5) Certain charges for providers other weighted average charge by the weight- than physicians. When services for ed average RVU. which charges are established accord- (ii) Trending forward. The nationwide ing to the preceding provisions of this conversion factors for each of the 23 paragraph (f) are performed by pro- CPT/HCPCS code groups, obtained as viders other than physicians, the described in paragraph (f)(3)(i) of this charges for those services will be as de- section, are trended forward based on termined by the preceding provisions of changes to the physicians’ services this paragraph, except as follows: component of the CPI-U. Actual CPI-U (i) Outpatient facility charges. When changes are used from the time period the services of providers other than of the source data through the latest physicians are furnished in outpatient available month as of the time the cal- facility settings or in other facilities culations are performed. The three- designated as provider-based, and out- month average annual trend rate as of patient facility charges for those serv- the latest available month is then held ices have been established under para- constant to the midpoint of the cal- graph (e) of this section, then the out- endar year in which the charges are patient facility charges established primarily expected to be used. The pro- under paragraph (e) will apply instead jected total CPI-U change so obtained of the charges established under this is then applied to the 23 conversion fac- paragraph (f). tors. (ii) Charges for professional services. (iii) Geographic area adjustment fac- Charges for the professional services of tors. Using the 80th percentile charges the following providers will be 100 per- for the selected CPT/HCPCS codes from cent of the amount that would be paragraph (f)(3) of this section for each charged if the care had been provided geographic area, a geographic area-spe- by a physician: cific conversion factor is calculated for (A) Nurse practitioner. each of the 23 CPT/HCPCS code groups (B) Clinical nurse specialist. by dividing the weighted average (C) Physician Assistant. charge by the weighted average geo- (D) Clinical psychologist. graphically-adjusted RVU. The result- (E) Clinical social worker.
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(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 nurse anesthetists will be 100 percent the MDR database. Then, a preliminary of the charges determined as set forth nationwide weighted-average 80th per- in this paragraph. Professional anes- centile conversion factor is calculated, thesia charges consist of charges for using as weights the population (cen- professional services that vary by geo- sus) frequencies for each geographic graphic area, by CPT/HCPCS code base area as presented in the Milliman USA, units, and by number of time units. Inc., Health Cost Guidelines (see para- These charges are calculated as fol- graph (a)(3) of this section for Data lows: Sources). A nationwide 80th percentile (1) Formula. For each anesthesia CPT/ fee by CPT/HCPCS code is then com- HCPCS code, multiply the total anes- puted by multiplying this conversion thesia RVUs determined pursuant to factor by the MDR base units for each paragraph (g)(2) of this section by the CPT/HCPCS code. An adjusted 80th per- applicable geographically-adjusted con- centile conversion factor by CPT/ version factor (a monetary amount) de- HCPCS code is then calculated by di- termined pursuant to paragraph (g)(3) viding the nationwide 80th percentile of this section to obtain the profes- fee for each procedure code by the an- sional anesthesia charge for each CPT/ esthesia base units (as compiled by HCPCS code in a particular geographic CMS) for that CPT/HCPCS code. Fi- area. nally, a nationwide weighted average (2) Total RVUs for professional anes- 80th percentile conversion factor is cal- thesia services. The total anesthesia culated using combined frequencies for RVUs for each anesthesia CPT/HCPCS billed base units and time units from code are the sum of the base units (as the part B component of the Medicare compiled by CMS) for that CPT/HCPCS Standard Analytical File 5 percent code and the number of time units re- Sample as weights. ported for the anesthesia service, (ii) Trending forward. The nationwide where one time unit equals 15 minutes. conversion factor, obtained as de- For anesthesia CPT/HCPCS codes des- scribed in paragraph (g)(3)(i) of this ignated as unlisted procedures, base section, is trended forward based on units are developed based on the changes to the physicians’ services weighted median base units for anes- component of the CPI-U. Actual CPI-U thesia CPT/HCPCS codes within the se- changes are used from the time period ries in which the unlisted procedure of the source data through the latest
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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 and by HCPCS code. These charges are charges differ from the preliminary calculated as follows: mean charge by more than 50 percent (1) Formula. For each HCPCS dental of the preliminary mean charge, the code, multiply the nationwide 80th per- average charge is calculated as a mean centile charge determined pursuant to of all three reported charges. paragraph (h)(2) of this section by the (ii) Nationwide 80th percentile charges appropriate geographic area adjust- for HCPCS dental codes designated as un- ment factor determined pursuant to listed procedures. For HCPCS dental paragraph (h)(3) of this section. The re- codes designated as unlisted proce- sult constitutes the area-specific den- dures, 80th percentile charges are de- tal charge. veloped based on the weighted median (2) Nationwide 80th percentile charges 80th percentile charge of HCPCS dental by HCPCS code. For each HCPCS dental codes within the series in which the code, 80th percentile charges are ex- unlisted procedure code occurs. The tracted from three independent data distribution of procedures and services sources: Prevailing Healthcare Charges from the Prevailing Healthcare System database; National Dental Ad- Charges System nationwide commer- visory Service nationwide pricing cial insurance database is used for the index; and the Dental UCR Module of purpose of computing the weighted me- the Comprehensive Healthcare Pay- dian. ment System, a release from Ingenix (iii) Trending forward. 80th percentile from a nationwide database of dental charges for each dental procedure code, charges (see paragraph (a)(3) of this sec- obtained as described in paragraph tion for Data Sources). Charges for (h)(2) of this section, are trended for- each database are then trended forward ward based on the dental services com- to a common date, based on actual ponent of the CPI-U. Actual CPI-U changes to the dental services compo- changes are used from the time period
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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- piled by Ingenix, as follows: Using local sons to the 80th percentile derived from and nationwide average charges re- the MDR database. These adjusted pay- ported in the Ingenix data, a local ment amounts are then divided by the weighted average charge for each den- corresponding Medicare conversion fac- tal class of procedure codes is cal- tor to derive RVUs for each CPT/ culated using utilization frequencies HCPCS code. The resulting nationwide from the Milliman USA, Inc., Dental total RVUs are multiplied by the geo- Health Cost Guidelines as weights (see graphic adjustment factors determined paragraph (a)(3) of this section for Data pursuant to paragraph (i)(2)(iv) of this Sources). Similarly, using nationwide section to obtain the area-specific average charge levels, a nationwide av- total RVUs. erage charge by dental class of proce- (ii) RVUs for CPT/HCPCS codes that do dure codes is calculated. The normal- not have Medicare-based RVUs and are ized geographic adjustment factor for not designated as unlisted procedures. each dental class of procedure codes For CPT/HCPCS codes that are not as- and for each geographic area is the signed RVUs in paragraphs (i)(2)(i) or ratio of the local average charge di- (i)(2)(iii) of this section, total RVUs are vided by the corresponding nationwide developed based on various charge data average charge. Finally, the geo- sources. For these CPT/HCPCS codes, graphic area adjustment factor is the the nationwide 80th percentile billed arithmetic average of the cor- charges are obtained, where statis- responding factors from the data tically credible, from the MDR data- sources mentioned in the first sentence base. For any remaining CPT/HCPCS of this paragraph (h)(3). codes, the nationwide 80th percentile (i) Pathology and laboratory charges. billed charges are obtained, where sta- When VA provides or furnishes pathol- tistically credible, from the Part B ogy and laboratory services within the component of the Medicare Standard scope of care referred to in paragraph Analytical File 5 percent Sample. For (a)(1) of this section, charges billed for any remaining CPT/HCPCS codes, the such services will be determined in ac- nationwide 80th percentile billed cordance with the provisions of this charges are obtained, where statis- paragraph. Pathology and laboratory tically credible, from the Prevailing charges consist of charges for services Healthcare Charges System nationwide that vary by geographic area and by commercial insurance database. For
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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 wide total RVUs are multiplied by the of the source data through the latest geographic area adjustment factors de- available month as of the time the cal- termined pursuant to paragraph culations are performed. The three- (i)(2)(iv) of this section to obtain the month average annual trend rate as of area-specific total RVUs. the latest available month is then held (iv) RVU geographic area adjustment constant to the midpoint of the cal- factors for CPT/HCPCS codes that do not endar year in which the charges are have Medicare RVUs, including codes primarily expected to be used. The pro- that are designated as unlisted proce- jected total CPI-U change so obtained dures. The adjustment factor for each is then applied to the pathology/labora- geographic area consists of the weight- tory conversion factor. ed average of the work expense and (iii) Geographic area adjustment factor. practice expense Medicare Geographic Using the 80th percentile charges for Practice Cost Indices for each geo- the selected CPT/HCPCS codes from graphic area using charge data for rep- paragraph (i)(3) of this section for each resentative CPT/HCPCS codes statis- geographic area, a geographic area-spe- tically selected and weighted for work cific conversion factor is calculated by expense and practice expense. dividing the weighted average charge (3) Geographically-adjusted 80th per- by the weighted average geographi- centile conversion factors. Representa- cally-adjusted RVU. The resulting geo- tive CPT/HCPCS codes are statistically graphic area conversion factor is di- selected and weighted so as to give a vided by the corresponding nationwide weighted average RVU comparable to conversion factor determined pursuant the weighted average RVU of the entire to paragraph (i)(3)(i) of this section. pathology/laboratory CPT/HCPCS code The resulting ratios are the geographic group (the selected CPT/HCPCS codes area adjustment factors for pathology
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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 Medicare Standard Analytical File 5 of the number of miles traveled and the percent Sample. Then, using the 80th appropriate HCPCS code mileage percentile observation line item charge determined pursuant to para- charges for each unique hourly length graph (k)(2)(ii) of this section. Then of stay, a standard linear regression multiply this amount by the appro- technique is used to calculate the na- priate geographic area adjustment fac- tionwide 80th percentile base charge tor determined pursuant to paragraph and 80th percentile hourly charge. Fi- (k)(3) of this section. The result con- nally, the resulting amounts are each stitutes the area-specific ambulance or trended forward to the effective time other emergency transportation serv- period for the charges, as set forth in ice charge. paragraph (j)(2)(ii) of this section. The (2)(i) Nationwide 80th percentile all-in- results constitute the nationwide 80th clusive base charge. To calculate a na- percentile base and hourly facility tionwide all-inclusive base charge, all charges for observation care. ambulance and other emergency trans- (ii) Trending forward. The nationwide portation claims are selected from the 80th percentile base and hourly facility outpatient facility component of the charges for observation care, obtained Medicare Standard Analytical File 5 as described in paragraph (j)(2)(i) of percent Sample. Excluding professional this section, are trended forward based and mileage charges, as well as all-in- on changes to the outpatient hospital clusive charges which are reported on services component of the CPI-U. Ac- such claims, the total charge per tual CPI-U changes are used from the claim, including incidental supplies, is time period of the source data through computed. Then, the 80th percentile the latest available month as of the amount for each HCPCS code is com- time the calculations are performed. puted. Finally, the resulting amounts
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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- graphs (k)(2)(i) and (k)(2)(ii) of this sec- (l)(2)(ii) of this section, and this tion, is trended forward based on amount is added to the fixed charge changes to the outpatient hospital amount also determined pursuant to services component of the CPI-U. Ac- paragraph (l)(2)(ii) of this section. tual CPI-U changes are used from the Then, for each HCPCS code, this charge time period of the source data through is multiplied by the appropriate 80th the latest available month as of the percentile to median charge ratio de- time the calculations are performed. termined pursuant to paragraph The three-month average annual trend (l)(2)(iii) of this section. Finally, the rate as of the latest available month is resulting amount is trended forward to then held constant to the midpoint of the effective time period for the the calendar year in which the charges charges, as set forth in paragraph are primarily expected to be used. The (l)(2)(iv) of this section to obtain the projected total CPI-U change so ob- nationwide 80th percentile charge. tained is then applied to the 80th per- (i) RVUs for DME, drugs, injectables, centile charges. and other medical services, items, and (3) Geographic area adjustment factors. supplies. For the purpose of the statis- The geographic area adjustment fac- tical methodology set forth in para- tors for ambulance and other emer- graph (l)(2)(ii) of this section, HCPCS gency transportation charges are the codes are assigned to the following same as those computed for outpatient HCPCS code groups. For the HCPCS facility charges under paragraph (e)(4) codes in each group, the RVUs or of this section. amounts indicated constitute the (l) Charges for durable medical equip- RVUs: ment, drugs, injectables, and other med- (A) Chemotherapy Drugs: Ingenix/St. ical services, items, and supplies identified Anthony’s RBRVS Practice Expense by HCPCS Level II codes. When VA pro- RVUs.
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(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 RVUs. combined Part B and DME components (ii) Charge amounts. Using combined of the Medicare Standard Analytical Part B and DME components of the File 5 percent Sample; and Milliman Medicare Standard Analytical File 5% USA, Inc., Optimized HMO (Health Sample, the median billed charge is Maintenance Organization) Data Sets calculated for each HCPCS code. A (see paragraph (a)(3) of this section for mathematical approximation method- Data Sources). Charges from each data- ology based on least squares techniques base are then trended forward to the ef- is applied to the RVUs specified for fective time period for the charges, as each of the groups set forth in para- set forth in paragraph (l)(3)(i) of this graph (l)(2)(i) of this section, yielding section. Charges for each HCPCS code two charge amounts for each HCPCS from each data source are combined code group: a charge amount per incre- into an average 80th percentile charge mental RVU, and a fixed charge by means of the methodology set forth amount. in paragraph (l)(3)(ii) of this section. (iii) 80th Percentile to median charge The results constitute the nationwide ratios. Two ratios are obtained for each 80th percentile charge for each applica- HCPCS code group set forth in para- ble HCPCS code. graph (l)(2)(i) of this section by divid- (i) Trending forward. The charges ing the weighted average 80th per- from each database for each HCPCS centile charge by the weighted average code, obtained as described in para- median charge derived from two data graph (l)(3) of this section, are trended sources: Medicare data, as represented forward based on changes to the med- by the combined Part B and DME com- ical care commodities component of ponents of the Medicare Standard Ana- the CPI-U. Actual CPI-U changes are lytical File 5% Sample; and the MDR used from the time period of each database. Charge frequencies from the source database through the latest Medicare data are used as weights available month as of the time the cal- when calculating all weighted aver- culations are performed. The three- ages. For each HCPCS code group, the month average annual trend rate as of smaller of the two ratios is selected as the latest available month is then held the adjustment from median to 80th constant to the midpoint of the cal- percentile charges. endar year in which the charges are
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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 (G) DME—Wheelchairs: DME/sup- preliminary mean is removed as an plies. outlier, and the average charge is cal- (H) Other DME: DME/supplies. culated as a mean of the two remaining (I) Enteral/Parenteral Supplies: DME/ charges. In cases where none of the supplies. charges differ from the preliminary (J) Surgical Dressings and Supplies: mean charge by more than 5 times the DME/supplies. preliminary mean charge, or less than (K) Vision Items—Other Than 0.2 times the preliminary mean charge, Lenses: DME/supplies. the average charge is calculated as a (L) Vision Items—Lenses: DME/sup- mean of all three reported charges. plies. (4) Nationwide 80th percentile charges (M) Hearing Items: DME/supplies. for HCPCS codes designated as unlisted or (ii) Area-specific weighted average unspecified. For HCPCS codes des- charges. Using the median charges by ignated as unlisted or unspecified pro- HCPCS code from the MDR database cedures, services, items, or supplies, for each geographic area and utiliza- 80th percentile charges are developed tion frequencies by HCPCS code from based on the weighted median 80th per- the combined Part B and DME compo- centile charges of HCPCS codes within nents of the Medicare Standard Ana- the series in which the unlisted or un- lytical File 5 percent Sample, an area- specified code occurs. A nationwide VA specific weighted average charge is cal- distribution of procedures, services, culated for each combined HCPCS code items, and supplies is used for the pur- group. pose of computing the weighted me- (iii) Nationwide weighted average dian. charges. Using the area-specific weight- (5) Geographic area adjustment factors. ed average charges determined pursu- For the purpose of geographic adjust- ant to paragraph (l)(5)(ii) of this sec- ment, HCPCS codes are combined into tion, a nationwide weighted average two groups: drugs and DME/supplies, as charge is calculated for each combined set forth in paragraph (l)(5)(i) of this HCPCS code group, using as weights section. The geographic area adjust- the population (census) frequencies for ment factor for each of these groups is each geographic area as presented in calculated as the ratio of the area-spe- the Milliman USA, Inc., Health Cost cific weighted average charge deter- Guidelines (see paragraph (a)(3) of this mined pursuant to paragraph (l)(5)(ii) section for Data Sources). of this section divided by the nation- (m) Charges for prescription drugs not wide weighted average charge deter- administered during treatment. Notwith- mined pursuant to paragraph (l)(5)(iii) standing other provisions of this sec- of this section. tion regarding VA charges, when VA (i) Combined HCPCS code groups for ge- provides or furnishes prescription ographic area adjustment factors for drugs not administered during treat- DME, drugs, injectables, and other med- ment, within the scope of care referred
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to in paragraph (a)(1) of this section, by the Under Secretary for Health charges billed separately for such pre- shall be made for inpatient or out- scription drugs will consist of the patient care or services (including amount that equals the total of the ac- domiciliary care) authorized for any tual cost to VA for the drugs and the person on the basis of eligibility as a national average of VA administrative veteran or a tentative eligibility deter- costs associated with dispensing the mination under § 17.34 but he or she was drugs for each prescription. The actual subsequently found to have been ineli- VA cost of a drug will be the actual gible for such care or services as a vet- amount expended by the VA facility for eran because the military service or the purchase of the specific drug. The any other eligibility requirement was administrative cost will be determined not met, or annually using VA’s managerial cost (b) Furnished in a medical emergency. accounting system. Under this ac- Charges at rates prescribed by the counting system, the average adminis- Under Secretary for Health shall be trative cost is determined by adding made for any inpatient or outpatient the total VA national drug general care or services rendered any person in overhead costs (such as costs of build- a medical emergency who was not eli- ings and maintenance, utilities, bill- gible for such care or services as a vet- ing, and collections) to the total VA eran, if: national drug dispensing costs (such as (1) The care or services were rendered costs of the labor of the pharmacy de- as a humanitarian service, under partment, packaging, and mailing) § 17.43(b)(1) or § 17.95 to a person neither with the sum divided by the actual claiming eligibility as a veteran nor number of VA prescriptions filled na- for whom the establishment of eligi- tionally. Based on this accounting sys- bility as a veteran was expected, or tem, VA will determine the amount of (2) The person for whom care or serv- the average administrative cost annu- ices were rendered was a Department of ally for the prior fiscal year (October Veterans Affairs employee or a mem- through September) and then apply the ber of a Department of Veterans Af- charge at the start of the next calendar fairs employee’s family; or year. (c) Furnished beneficiaries of the De- NOTE TO § 17.101: The charges generated by partment of Defense or other Federal the methodology set forth in this section are agencies. Except as provided for in the same charges prescribed by the Office of paragraph (f) of this section and the Management and Budget for use under the second sentence of this paragraph, Federal Medical Care Recovery Act, 42 U.S.C. charges at rates prescribed by the Of- 2651–2653. fice of Management and Budget shall (Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, be made for any inpatient or out- 1721, 1722, 1729) patient care or services authorized for (The Office of Management and Budget has a member of the Armed Forces on ac- approved the information collection require- tive duty or for any beneficiary or des- ments in this section under control number ignee of any other Federal agency. 2900–0606) Charges for services provided a member [68 FR 70715, Dec. 19, 2003, as amended at 69 or former member of a uniformed serv- FR 1061, Jan. 7, 2004; 72 FR 68072, Dec. 4, 2007; ice who is entitled to retired or re- 75 FR 61623, Oct. 6, 2010] tainer pay, or equivalent pay, will be at rates prescribed by the Secretary § 17.102 Charges for care or services. (E.O. 11609, dated July 22, 1971, 36 FR Except as provided in § 17.101, charges 13747), or at the indicated rates shall be made for (d) Furnished pensioners of allied na- Department of Veterans Affairs hos- tions. Charges at rates prescribed by pital care or medical services (includ- the Under Secretary for Health shall be ing, but not limited to, dental services, made for any inpatient or outpatient supplies, medicines, orthopedic and care or services rendered a pensioner of prosthetic appliances, and domiciliary a nation allied with the United States or nursing home care) as follows: in World War I and World War II; or (a) Furnished in error or on tentative (e) Furnished under sharing agree- eligibility. Charges at rates prescribed ments. Charges at rates agreed upon in
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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. 99–272) to a person designated by the other 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. 1982; 52 FR 3010, Jan. 30, 1987. Redesignated and amended ence at rates prescribed by the Under at 61 FR 21965, 21967, May 13, 1996; 62 FR Secretary for Health shall be made for 17072, Apr. 9, 1997. Redesignated and amended the period during which hospital care at 64 FR 22678, 22683, Apr. 27, 1999; 69 FR 1061, is rendered when such care is rendered Jan. 7, 2004; 73 FR 26946, May 12, 2008] to a member or former member of the 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). Any offer to compromise or settle (g) Furnished for research purposes. any charges or claim for $20,000 or less Charges will not be made for medical asserted by the Department of Vet- services, including transportation, fur- erans Affairs in connection with the nished as part of an approved Depart- medical program shall be referred as ment of Veterans Affairs research follows: project, except that if the services are (a) To Chiefs of Fiscal activities. If the furnished to a person who is not eligi- debt represents charges made under ble for the services as a veteran, the § 17.101(a), the compromise offer shall medical care appropriation shall be re- be referred to the Chief of the Fiscal imbursed from the research appropria- activity of the facility for application tion at the same rates used for billings of the collection standards in § 1.900 et under paragraph (b) of this section. seq. of this chapter, provided: (h) Computation of charges. The meth- od for computing the charges under (1) The debt does not exceed $1,000, § 17.86 and under paragraphs (a), (b), (d), and (f), and (g) and the last sentence of (2) There has been a previous denial paragraph (c) of this section is based on of waiver of the debt by a field station the Monthly Program Cost Report Committee on Waivers and Com- (MPCR), which sets forth the actual promises. basic costs and per diem rates by type (b) To Regional Counsel. If the debt in of inpatient care, and actual basic any amount represents charges for costs and rates for outpatient care vis- medical services for which there is or its or prescriptions filled. Factors for may be a claim against a third party depreciation of buildings and equip- tort-feasor or under workers’ com- ment and Central Office overhead are pensation laws or Pub. L. 87–693; 76 added, based on accounting manual in- Stat. 593 (see § 1.903 of this chapter) or structions. Additional factors are involves a claim contemplated by added for interest on capital invest- § 1.902 of this chapter over which the ment and for standard fringe benefit Department of Veterans Affairs lacks costs covering government employee jurisdiction, the compromise offer (or retirement and disability costs. The request for waiver or proposal to termi- current year billing rates are projected nate or suspend collection action) shall on prior year actual rates by applying be promptly referred to the field sta- the budgeted percentage increase. In tion Regional Counsel having jurisdic- addition, based on the detail available tion in the area in which the claim in the MPCR, VA intends to, on each arose, or bill break down the all-inclusive rate (c) To Committee on Waivers and Com- into its three principal components; promises. If one of the following situa- namely, physician cost, ancillary serv- tions contemplated in paragraph (c)(1) ices cost, and nursing, room and board through (3) of this section applies cost. The rates generated by the fore- (1) If the debt represents charges going methodology will be published by made under § 17.101(a), but is not of a
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type contemplated in paragraph (a) of tivity on the basis there is no legal au- this section, or thority to waive debts, unless the ques- (2) If the debt represents charges for tion of waiver should be referred as fol- medical services made under § 17.101(b), lows: or (a) Of charges for medical services. If (3) A claim arising in connection the debt represents charges made under with any transaction of the Veterans § 17.102, the application or request for Health Administration for which the waiver should be referred for disposi- instructions in paragraph (a) or (b) of tion under § 1.900 et seq. of this chapter this section or in § 17.105(c) are not ap- to the field facility Committee on plicable, then, the compromise offer Waivers and Compromises which shall should be referred for disposition under take final action, or § 1.900 et seq. of this chapter to the field (b) Of claims against third persons and station Committee on Waivers and other claims. If the debt is of a type con- Compromises which shall take final ac- templated in § 17.103(b), the waiver tion. question should be referred in accord- [39 FR 26403, July 19, 1974, as amended at 47 ance with the same referral procedures FR 58250, Dec. 30, 1982. Redesignated and for compromise offers in such cat- amended at 61 FR 21966, 21967, May 13, 1996; 62 egories of claims, or FR 17072, Apr. 9, 1997] (c) Of charges for copayments. If the debt represents charges for outpatient § 17.104 Terminations and suspen- medical care, inpatient hospital care, sions. medication or extended care services Any proposal to suspend or terminate copayments made under § 17.108, § 17.110 collection action on any charges or or § 17.111 of this chapter, the claimant claim for $20,000 or less asserted by the must request a waiver by submitting Department of Veterans Affairs in con- VA Form 5655 (Financial Status Re- nection with the medical program shall port) to a Fiscal Officer at a VA med- be referred as follows: ical facility where all or part of the (a) Of charges for medical services. If debt was incurred. The claimant must the debt represents charges made under submit this form within the time pe- § 17.101 (a) or (b) questions concerning riod provided in § 1.963(b) of this chap- suspension or termination of collection ter and may request a hearing under action shall be referred to the Chief of § 1.966(a) of this chapter. The Fiscal Of- the Fiscal activity of the station for ficer may extend the time period for application of the collection standards submitting a claim if the Chairperson in § 1.900 et seq. of this chapter, or of the Committee on Waivers and Com- (b) Of other debts. If the debt is of a promises could do so under § 1.963(b) of type other than those contemplated in this chapter. The Fiscal Officer will paragraph (a) of this section, questions apply the standard ‘‘equity and good concerning suspension or termination conscience’’ in accordance with §§ 1.965 of collection action shall be referred in and 1.966(a) of this chapter, and may accordance with the same referral pro- waive all or part of the claimant’s cedures for compromise offers (except debts. A decision by the Fiscal Officer the Fiscal activity shall make final de- under this provision is final (except terminations in terminations or sus- that the decision may be reversed or pensions involving claims of $150 or modified based on new and material less pursuant to the provisions of § 1.900 evidence, fraud, a change in law or in- et seq. of this chapter.) terpretation of law, or clear and unmis- [34 FR 7807, May 16, 1969, as amended at 39 takable error shown by the evidence in FR 26403, July 19, 1974. Redesignated and the file at the time of the prior deci- amended at 61 FR 21966, 21967, May 13, 1996] sion as provided in § 1.969 of this chap- ter) and may be appealed in accordance § 17.105 Waivers. with 38 CFR parts 19 and 20. Applications or requests for waiver of (d) Other debts. If the debt represents debts or claims asserted by the Depart- any claim or charges other than those ment of Veterans Affairs in connection contemplated in paragraphs (a) and (b) with the medical program generally of this section, and is a debt for which will be denied by the facility Fiscal ac- waiver has been specifically provided
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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. (Authority: 38 U.S.C. 501, 1721, 1722A, 1724) (C) Any Employee Retirement In- [39 FR 26403, July 19, 1974. Redesignated and come and Security Act (ERISA) plan. amended at 61 FR 21966, 21967, May 13, 1996; 69 (D) Any Multiple Employer Trust FR 62204, Oct. 25, 2004] (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. through any VA facility to a veteran (H) Any exclusive provider organiza- who is also a beneficiary under the tion (EPO) plan. third-party payer’s plan. VA’s right to (I) Any physician hospital organiza- recover or collect is limited to the ex- tion (PHO) plan. tent that the beneficiary or a non- (J) Any integrated delivery system government provider of care or services (IDS) plan. would be eligible to receive reimburse- (K) Any management service organi- ment or indemnification from the zation (MSO) plan. third-party payer if the beneficiary were to incur the costs on the bene- (L) Any group or individual medical ficiary’s own behalf. services account. (2) Definitions. For the purposes of (M) Any participating provider orga- this section: nization (PPO) plan or any PPO provi- Automobile liability insurance means sion or option of any third-party payer insurance against legal liability for plan. health and medical expenses resulting (N) Any Medicare supplemental in- from personal injuries arising from op- surance plan. eration of a motor vehicle. Automobile (O) Any automobile liability insur- liability insurance includes: ance plan. (A) Circumstances in which liability (P) Any no fault insurance plan, in- benefits are paid to an injured party cluding any personal injury protection only when the insured party’s tortious plan or medical payments benefit plan acts are the cause of the injuries; and for personal injuries arising from the (B) Uninsured and underinsured cov- operation of a motor vehicle. erage, in which there is a third-party Medicare supplemental insurance plan tortfeasor who caused the injuries (i.e., means an insurance, medical service or benefits are not paid on a no-fault health-plan contract primarily for the basis), but the insured party is not the purpose of supplementing an eligible tortfeasor. person’s benefit under Medicare. The Health-plan contract means any plan, term has the same meaning as ‘‘Medi- policy, program, contract, or liability care supplemental policy’’ in section arrangement that provides compensa- 1882(g)(1) of the Social Security Act (42
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U.S.C. 1395, et seq.) and 42 CFR part 403, beneficiary for healthcare services or subpart B. products. No-fault insurance means an insur- (H) A third-party administrator. ance contract providing compensation (b) Calculating reasonable charges. (1) for medical expenses relating to per- The ‘‘reasonable charges’’ subject to sonal injury arising from the operation recovery or collection by VA under this of a motor vehicle in which the com- section are calculated using the appli- pensation is not premised on who may cable method for such charges estab- have been responsible for causing such lished by VA in 38 CFR 17.101. injury. No-fault insurance includes per- (2) If the third-party payer’s plan in- sonal injury protection and medical cludes a requirement for a deductible payments benefits in cases involving or copayment by the beneficiary of the personal injuries resulting from oper- plan, VA will recover or collect reason- ation of a motor vehicle. able charges less that deductible or co- Participating provider organization payment amount. means any arrangement in a third- (c) VA’s right to recover or collect is ex- party payer plan under which coverage clusive. The only way for a third-party is limited to services provided by a se- payer to satisfy its obligation under lect group of providers who are mem- this section is to pay the VA facility or bers of the PPO or incentives (for ex- other authorized representative of the ample, reduced copayments) are pro- United States. Payment by a third- vided for beneficiaries under the plan party payer to the beneficiary does not to receive health care services from the satisfy the third-party’s obligation members of the PPO rather than from under this section. other providers who, although author- (1) Pursuant to 38 U.S.C. 1729(b)(2), ized to be paid, are not included in the the United States may file a claim or PPO. However, a PPO does not include institute and prosecute legal pro- any organization that is recognized as ceedings against a third-party payer to a health maintenance organization. enforce a right of the United States Third-party payer means an entity, under 38 U.S.C. 1729 and this section. other than the person who received the Such filing or proceedings must be in- medical care or services at issue (first stituted within six years after the last party) and VA who provided the care or day of the provision of the medical care services (second party), responsible for or services for which recovery or col- the payment of medical expenses on be- lection is sought. half of a person through insurance, (2) An authorized representative of agreement or contract. This term in- the United States may compromise, cludes, but is not limited to the fol- settle or waive a claim of the United lowing: States under this section. (3) The remedies authorized for col- (A) State and local governments that lection of indebtedness due the United provide such plans other than Med- States under 31 U.S.C. 3701, et seq., 4 icaid. CFR parts 101 through 104, 28 CFR part (B) Insurance underwriters or car- 11, 31 CFR part 900, and 38 CFR part 1, riers. are available to effect collections (C) Private employers or employer under this section. groups offering self-insured or partially (4) A third-party payer may not, self-insured medical service or health without the consent of a U.S. Govern- plans. ment official authorized to take action (D) Automobile liability insurance under 38 U.S.C. 1729 and this part, off- underwriter or carrier. set or reduce any payment due under 38 (E) No fault insurance underwriter or U.S.C. 1729 or this part on the grounds carrier. that the payer considers itself due a re- (F) Workers’ compensation program fund from a VA facility. A written re- or plan sponsor, underwriter, carrier, quest for a refund must be submitted or self-insurer. and adjudicated separately from any (G) Any other plan or program that is other claims submitted to the third- designed to provide compensation or party payer under 38 U.S.C. 1729 or this coverage for expenses incurred by a part.
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(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 third-party payer that would have the to receive VA medical care and serv- effect of excluding from coverage or ices shall be permissible. limiting payment for any medical care or services for which payment by the (iv) The lack of a participation agree- third-party payer under 38 U.S.C. 1729 ment or the absence of privity of con- or this part is required, is preempted tract between a third-party payer and by 38 U.S.C. 1729(f) and shall have no VA is not a permissible ground for re- force or effect in connection with the fusing or reducing third-party pay- third-party payer’s obligations under ment. 38 U.S.C. 1729 or this part. (v) A provision in a third-party payer (f) Impermissible exclusions by third- plan, other than a Medicare supple- party payers. (1) Statutory requirement. mental plan, that seeks to make Medi- Under 38 U.S.C. 1729(f), no provision of care the primary payer and the plan any third-party payer’s plan having the the secondary payer or that would op- effect of excluding from coverage or erate to carve out of the plan’s cov- limiting payment for certain care if erage an amount equivalent to the that care is provided in or through any Medicare payment that would be made VA facility shall operate to prevent if the services were provided by a pro- collection by the United States. vider to whom payment would be made (2) General rules. The following are under Part A or Part B of Medicare is general rules for the administration of not a permissible ground for refusing 38 U.S.C. 1729 and this part, with exam- or reducing payment as the primary ples provided for clarification. The ex- payer to VA by the third-party payer amples provided are not exclusive. A unless the provision expressly dis- third-party payer may not reduce, off- allows payment as the primary payer set, or request a refund for payments to all providers to whom payment made to VA under the following condi- would not be made under Medicare (in- tions: cluding payment under Part A, Part B, (i) Express exclusions or limitations a Medicare HMO, or a Medicare Advan- in third-party payer plans that are in- tage plan).
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(vi) A third-party payer may not (b) Response to disruptive patients. The refuse or reduce third-party payment time, place, and/or manner of the pro- to VA because VA’s claim form did not vision of a patient’s medical care may report hospital acquired conditions be restricted by written order of the (HAC) or present on admission condi- Chief of Staff of the VA Medical Center tions (POA). VA is exempt from the of jurisdiction or his or her designee if: Medicare Inpatient prospective pay- (1) The Chief of Staff or designee de- ment system and the Medicare rules termines pursuant to paragraph (c) of for reporting POA or HAC information this section that the patient’s behavior to third-party payers. at a VA medical facility has jeopard- (vii) Health Maintenance Organiza- ized or could jeopardize the health or tions (HMOs) may not exclude claims safety of other patients, VA staff, or or refuse to certify emergent and ur- guests at the facility, or otherwise gent services provided within the interfere with the delivery of safe med- HMO’s service area or otherwise cov- ical care to another patient at the fa- ered non-emergency services provided cility; out of the HMO’s service area. In addi- (2) The order is narrowly tailored to tion, opt-out or point-of-service op- address the patient’s disruptive behav- tions available under an HMO plan may ior and avoid undue interference with not exclude services otherwise payable the patient’s care; under 38 U.S.C. 1729 or this part. (3) The order is signed by the Chief of (g) Records. Pursuant to 38 U.S.C. Staff or designee, and a copy is entered 1729(h), VA shall make available for in- into the patient’s permanent medical spection and review to representatives record; of third-party payers, from which the (4) The patient receives a copy of the United States seeks payment, recov- order and written notice of the proce- ery, or collection under 38 U.S.C. 1729, dure for appealing the order to the Net- appropriate health care records (or cop- work Director of jurisdiction as soon as ies of such records) of patients. How- possible after issuance; and ever, the appropriate records will be (5) The order contains an effective made available only for the purposes of date and any appropriate limits on the verifying the care and services which duration of or conditions for con- are the subject of the claim(s) for pay- tinuing the restrictions. The Chief of ment under 38 U.S.C. 1729, and for Staff or designee may order restric- verifying that the care and services tions for a definite period or until the met the permissible criteria of the conditions for removing conditions terms and conditions of the third-party specified in the order are satisfied. Un- payer’s plan. Patient care records will less otherwise stated, the restrictions not be made available under any other imposed by an order will take effect circumstances to any other entity. VA upon issuance by the Chief of Staff or will not make available to a third- designee. Any order issued by the Chief party payer any other patient or VA of Staff or designee shall include a records. summary of the pertinent facts and the bases for the Chief of Staff’s or des- (Authority: 31 U.S.C. 3711, 38 U.S.C. 501, 1729, ignee’s determination regarding the 42 U.S.C. 2651) need for restrictions. [76 FR 37204, June 24, 2011] (c) Evaluation of disruptive behavior. In making determinations under para- DISCIPLINARY CONTROL OF BENE- graph (b) of this section, the Chief of FICIARIES RECEIVING HOSPITAL, DOMI- Staff or designee must consider all per- CILIARY OR NURSING HOME CARE tinent facts, including any prior coun- seling of the patient regarding his or § 17.107 VA response to disruptive be- her disruptive behavior or any pattern havior of patients. of such behavior, and whether the dis- (a) Definition. For the purposes of ruptive behavior is a result of the pa- this section: tient’s individual fears, preferences, or VA medical facility means VA medical perceived needs. A patient’s disruptive centers, outpatient clinics, and domi- behavior must be assessed in connec- ciliaries. tion with VA’s duty to provide good
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quality care, including care designed to inpatient hospital care and outpatient reduce or otherwise clinically address medical care provided to veterans by the patient’s behavior. VA. (d) Restrictions. The restrictions on (b) Copayments for inpatient hospital care imposed under this section may care. (1) Except as provided in para- include but are not limited to: graphs (d) or (e) of this section, a vet- (1) Specifying the hours in which eran, as a condition of receiving inpa- nonemergent outpatient care will be tient hospital care provided by VA provided; (provided either directly by VA or ob- (2) Arranging for medical and any tained by VA by contract), must agree other services to be provided in a par- to pay VA (and is obligated to pay VA) ticular patient care area (e.g., private the applicable copayment, as set forth exam room near an exit); in paragraph (b)(2) or (b)(3) of this sec- (3) Arranging for medical and any tion. other services to be provided at a spe- (2) The copayment for inpatient hos- cific site of care; pital care shall be, during any 365-day (4) Specifying the health care pro- period, a copayment equaling the sum vider, and related personnel, who will of: be involved with the patient’s care; (i) $10 for every day the veteran re- (5) Requiring police escort; or ceives inpatient hospital care, and (6) Authorizing VA providers to ter- minate an encounter immediately if (ii) The lesser of: certain behaviors occur. (A) The sum of the inpatient Medi- (e) Review of restrictions. The patient care deductible for the first 90 days of may request the Network Director’s re- care and one-half of the inpatient view of any order issued under this sec- Medicare deductible for each subse- tion within 30 days of the effective date quent 90 days of care (or fraction there- of the order by submitting a written of) after the first 90 days of such care request to the Chief of Staff. The Chief during such 365-day period, or of Staff shall forward the order and the (B) VA’s cost of providing the care. patient’s request to the Network Direc- (3) The copayment for inpatient hos- tor for a final decision. The Network pital care for veterans enrolled in pri- Director shall issue a final decision on ority category 7 shall be 20 percent of this matter within 30 days. VA will en- the amount computed under paragraph force the order while it is under review (b)(2) of this section. by the Network Director. The Chief of Staff will provide the patient who NOTE TO § 17.108(b): The requirement that a veteran agree to pay the copayment would made the request written notice of the be met by submitting to VA a signed VA Network Director’s final decision. Form 10–10EZ. This is the application form NOTE TO § 17.106: Although VA may restrict for enrollment in the VA healthcare system the time, place, and/or manner of care under and also is the document used for providing this section, VA will continue to offer the means-test information annually. full range of needed medical care to which a (c) Copayments for outpatient medical patient is eligible under title 38 of the United care. (1) Except as provided in para- States Code or Code of Federal Regulations. Patients have the right to accept or refuse graphs (d), (e) or (f) of this section, a treatments or procedures, and such refusal veteran, as a condition of receiving by a patient is not a basis for restricting the outpatient medical care provided by provision of care under this section. VA, must agree to pay VA (and is obli- (Authority: 38 U.S.C. 501, 901, 1721) gated to pay VA) a copayment as set forth in paragraph (c)(2) of this section. [75 FR 69883, Nov. 16, 2010. Redesignated at 76 FR 37204, June 24, 2011] (2) The copayment for outpatient medical care is $15 for a primary care COPAYMENTS outpatient visit and $50 for a specialty care outpatient visit. If a veteran has § 17.108 Copayments for inpatient hos- more than one primary care encounter pital care and outpatient medical on the same day and no specialty care care. encounter on that day, the copayment (a) General. This section sets forth re- amount is the copayment for one pri- quirements regarding copayments for mary care outpatient visit. If a veteran
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has one or more primary care encoun- (4) A veteran who was discharged or ters and one or more specialty care en- released from active military service counters on the same day, the copay- for a disability incurred or aggravated ment amount is the copayment for one in the line of duty; specialty care outpatient visit. (5) A veteran who receives disability (3) For purposes of this section, a pri- compensation under 38 U.S.C. 1151. mary care visit is an episode of care (6) A veteran whose entitlement to furnished in a clinic that provides inte- disability compensation is suspended grated, accessible healthcare services pursuant to 38 U.S.C. 1151, but only to by clinicians who are accountable for the extent that the veteran’s con- addressing a large majority of personal tinuing eligibility for care is provided healthcare needs, developing a sus- for in the judgment or settlement de- tained partnership with patients, and scribed in 38 U.S.C. 1151. practicing in the context of family and community. Primary care includes, but (7) A veteran whose entitlement to is not limited to, diagnosis and man- disability compensation is suspended agement of acute and chronic bio- because of the receipt of military re- psychosocial conditions, health pro- tirement pay. motion, disease prevention, overall (8) A veteran of the Mexican border care management, and patient and period or of World War I. caregiver education. Each patient’s (9) A military retiree provided care identified primary care clinician deliv- under an interagency agreement as de- ers services in the context of a larger fined in section 113 of Public Law 106– interdisciplinary primary care team. 117, 113 Stat. 1545. Patients have access to the primary (10) A veteran who VA determines to care clinician and much of the primary be unable to defray the expenses of nec- care team without need of a referral. In essary care under 38 U.S.C. 1722(a). contrast, specialty care is generally (11) A veteran who VA determines to provided through referral. A specialty be catastrophically disabled, as defined care outpatient visit is an episode of in 38 CFR 17.36(e). care furnished in a clinic that does not (12) A veteran receiving care for psy- provide primary care, and is only pro- chosis or a mental illness other than vided through a referral. Some exam- psychosis pursuant to § 17.109. ples of specialty care provided at a spe- (e) Services not subject to copayment re- cialty care clinic are radiology services quirements for inpatient hospital care or requiring the immediate presence of a outpatient medical care. The following physician, audiology, optometry, mag- are not subject to the copayment re- netic resonance imagery (MRI), com- quirements under this section: puterized axial tomography (CAT) scan, nuclear medicine studies, sur- (1) Care provided to a veteran for a gical consultative services, and ambu- noncompensable zero percent service- latory surgery. connected disability; (2) Care authorized under 38 U.S.C. NOTE TO § 17.108(c): The requirement that a 1710(e) for Vietnam-era herbicide-ex- veteran agree to pay the copayment would posed veterans, radiation-exposed vet- be met by submitting to VA a signed VA Form 10–10EZ. This is the application form erans, Gulf War veterans, or post-Gulf for enrollment in the VA healthcare system War combat-exposed veterans; and also is the document used for providing (3) Special registry examinations (in- means-test information annually. cluding any follow-up examinations or (d) Veterans not subject to copayment testing ordered as part of the special requirements for inpatient hospital care or registry examination) offered by VA to outpatient medical care. The following evaluate possible health risks associ- veterans are not subject to the copay- ated with military service; ment requirements of this section: (4) Counseling and care for sexual (1) A veteran with a compensable trauma as authorized under 38 U.S.C service-connected disability. 1720D. (2) A veteran who is a former pris- (5) Compensation and pension exami- oner of war. nations requested by the Veterans Ben- (3) A veteran awarded a Purple Heart. efits Administration;
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(6) Care provided as part of a VA-ap- chosis, and such condition is exempted proved research project authorized by from copayments under §§ 17.108, 17.110, 38 U.S.C. 7303; and 17.111 for any veteran of World War (7) Outpatient dental care provided II, the Korean conflict, the Vietnam under 38 U.S.C. 1712; era, or the Persian Gulf War who devel- (8) Readjustment counseling and re- oped such psychosis: lated mental health services author- (1) Within 2 years after discharge or ized under 38 U.S.C 1712A; release from the active military, naval, (9) Emergency treatment paid for or air service; and under 38 U.S.C. 1725 or 1728; (2) Before the following date associ- (10) Care or services authorized under ated with the war or conflict in which 38 U.S.C. 1720E for certain veterans re- he or she served: garding cancer of the head or neck; (i) World War II: July 26, 1949. (11) Publicly announced VA public (ii) Korean conflict: February 1, 1957. health initiatives (e.g., health fairs) or (iii) Vietnam era: May 8, 1977. an outpatient visit solely consisting of (iv) Persian Gulf War: The end of the preventive screening and immuniza- 2-year period beginning on the last day tions (e.g., influenza immunization, of the Persian Gulf War. pneumonococcal immunization, hyper- (b) Mental illness (other than psy- tension screening, hepatitis C screen- chosis). Eligibility under this part is es- ing, tobacco screening, alcohol screen- tablished by this section for treatment ing, hyperlipidemia screening, breast of an active mental illness (other than cancer screening, cervical cancer psychosis), and such condition is ex- screening, screening for colorectal can- empted from copayments under cer by fecal occult blood testing, and §§ 17.108, 17.110, and 17.111 for any vet- education about the risks and benefits eran of the Persian Gulf War who de- of prostate cancer screening); veloped such mental illness other than (12) Weight management counseling psychosis: (individual and group); (1) Within 2 years after discharge or (13) Smoking cessation counseling release from the active military, naval, (individual and group); or air service; and (14) Laboratory services, flat film ra- (2) Before the end of the 2-year period diology services, and electrocardio- beginning on the last day of the Per- grams; and sian Gulf War. (15) Hospice care. (c) No minimum service required. Eligi- (16) In-home video telehealth care. bility for care and waiver of copay- (f) Additional care not subject to out- ments will be established under this patient copayment. Outpatient care is section without regard to the veteran’s not subject to the outpatient copay- length of active-duty service. ment requirements under this section when provided to a veteran during a (Authority: 38 U.S.C. 501, 1702, 5303A) day for which the veteran is required [78 FR 28143, May 14, 2013] to make a copayment for extended care 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 (Authority: 38 U.S.C. 501, 1710, 1730A) medications provided to veterans by VA. [66 FR 63448, Dec. 6, 2001, as amended at 68 (b) Copayments. (1) Copayment amount. FR 60854, Oct. 24, 2003; 70 FR 22596, May 2, 2005; 73 FR 20532, Apr. 16, 2008; 75 FR 54030, Unless exempted under paragraph (c) of Sept. 3, 2010; 76 FR 52274, Aug. 22, 2011; 77 FR this section, a veteran is obligated to 13198, Mar. 6, 2012; 78 FR 28143, May 14, 2013] pay VA a copayment for each 30-day or less supply of medication provided by § 17.109 Presumptive eligibility for VA on an outpatient basis (other than psychosis and mental illness other medication administered during treat- than psychosis. ment). (a) Psychosis. Eligibility for benefits (i) For the period from July 1, 2010, under this part is established by this through December 31, 2014, the copay- section for treatment of an active psy- ment amount for veterans in priority
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categories 2 through 6 of VA’s health 50% or more based on a service-con- care system (see § 17.36) is $8. nected disability or unemployability. (ii) For veterans in priority cat- (2) Medication for a veteran’s service- egories 7 and 8 of VA’s health care sys- connected disability. tem (see § 17.36), the copayment (3) Medication for a veteran whose amount from July 1, 2010, through De- annual income (as determined under 38 cember 31, 2014, is $9. U.S.C. 1503) does not exceed the max- (iii) The copayment amount for all imum annual rate of VA pension which affected veterans for each calendar would be payable to such veteran if year after December 31, 2014, will be es- such veteran were eligible for pension tablished by using the prescription under 38 U.S.C. 1521. drug component of the Medical Con- (4) Medication authorized under 38 sumer Price Index as follows: For each U.S.C. 1710(e) for Vietnam-era herbi- calendar year, the Index as of the pre- cide-exposed veterans, radiation-ex- vious September 30 will be divided by posed veterans, Persian Gulf War vet- the Index as of September 30, 2001 erans, or post-Persian Gulf War com- which was 304.8. The ratio so obtained bat-exposed veterans. will be multiplied by the original co- (5) Medication for treatment of sex- payment amount of $7. The copayment ual trauma as authorized under 38 amount for the new calendar year will U.S.C. 1720D. be this result, rounded down to the (6) Medication for treatment of can- whole dollar amount. cer of the head or neck authorized NOTE TO PARAGRAPH (b)(1)(iii): Example for under 38 U.S.C. 1720E. determining copayment amount. The ratio of (7) Medications provided as part of a the prescription drug component of the Med- VA approved research project author- ical Consumer Price Index for September 30, ized by 38 U.S.C. 7303. 2005, to the corresponding Index for Sep- (8) Medication for a veteran who is a tember 30, 2001 (304.8) was 1.1542. This ratio, former prisoner of war. when multiplied by the original copayment amount of $7 equals $8.08, and the copayment (9) A veteran who VA determines to amount beginning in calendar year 2006, be catastrophically disabled, as defined rounded down to the whole dollar amount, in 38 CFR 17.36(e). was set at $8. (10) A veteran receiving care for psy- (2) The total amount of copayments chosis or a mental illness other than in a calendar year for a veteran en- psychosis pursuant to § 17.109. rolled in one of the priority categories (Authority: 38 U.S.C. 501, 1710, 1720D, 1722A, 2 through 6 of VA’s health care system 1730A) (see § 17.36) shall not exceed the cap es- [66 FR 63451, Dec. 6, 2001, as amended at 74 tablished for the calendar year. During FR 69285, Dec. 31, 2009; 75 FR 32672, June 9, the period from January 1, 2010 through 2010; 75 FR 54030, Sept. 3, 2010; 76 FR 52274, December 31, 2014, the cap will be $960. Aug. 22, 2011; 76 FR 78826, Dec. 20, 2011; 77 FR If the copayment amount increases 76867, Dec. 31, 2012; 78 FR 28143, May 14, 2013; after December 31, 2014, the cap of $960 78 FR 79317, Dec. 30, 2013] shall be increased by $120 for each $1 increase in the copayment amount. § 17.111 Copayments for extended care (3) Information on copayment/cap services. amounts. Current copayment and cap (a) General. This section sets forth re- amounts are available at any VA Med- quirements regarding copayments for ical Center and on our Web site, http:// extended care services provided to vet- www.va.gov. Notice of any increases to erans by VA (either directly by VA or the copayment and corresponding in- paid for by VA). creases to annual cap amount will be (b) Copayments. (1) Unless exempted published in the FEDERAL REGISTER. under paragraph (f) of this section, as a (c) Medication not subject to the copay- condition of receiving extended care ment requirements. The following are ex- services from VA, a veteran must agree empt from the copayment require- to pay VA and is obligated to pay VA ments of this section: a copayment as specified by this sec- (1) Medication for a veteran who has tion. A veteran has no obligation to a service-connected disability rated pay a copayment for the first 21 days of
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extended care services that VA pro- comprehensive assessment, care plan, vided the veteran in any 12-month pe- and extended care service recommenda- riod (the 12-month period begins on the tions. date that VA first provided extended (5) Institutional means a setting in a care services to the veteran). However, hospital, domiciliary, or nursing home for each day that extended care serv- of overnight stays of one or more days. ices are provided beyond the first 21 (6) Noninstitutional means a service days, a veteran is obligated to pay VA that does not include an overnight the copayment amount set forth below stay. to the extent the veteran has available (7) Nursing home care means the ac- resources. Available resources are based on monthly calculations, as de- commodation of convalescents or other termined under paragraph (d) of this persons who are not acutely ill and not section. The following sets forth the in need of hospital care, but who re- extended care services provided by VA quire nursing care and related medical and the corresponding copayment services, if such nursing care and med- amount per day: ical services are prescribed by, or are (i) Adult day health care—$15. performed under the general direction (ii) Domiciliary care—$5. of, persons duly licensed to provide (iii) Institutional respite care—$97. such care (nursing services must be (iv) Institutional geriatric evalua- provided 24 hours a day). Such term in- tion—$97. cludes services furnished in skilled (v) Non-institutional geriatric eval- nursing care facilities. Such term ex- uation—$15. cludes hospice care. (vi) Non-institutional respite care— (8) Respite care means care which is of $15. limited duration, is furnished on an (vii) Nursing home care—$97. intermittent basis to a veteran who is (2) For purposes of counting the num- suffering from a chronic illness and ber of days for which a veteran is obli- who resides primarily at home, and is gated to make a copayment under this furnished for the purpose of helping the section, VA will count each day that veteran to continue residing primarily adult day health care, non-institu- at home. (Respite providers tempo- tional geriatric evaluation, and non-in- rarily replace the caregivers to provide stitutional respite care are provided and will count each full day and partial services ranging from supervision to day for each inpatient stay except for skilled care needs.) the day of discharge. (d) Effect of the veteran’s financial re- (c) Definitions. For purposes of this sources on obligation to pay copayment. section: (1) A veteran is obligated to pay the co- (1) Adult day health care is a thera- payment to the extent the veteran and peutic outpatient care program that the veteran’s spouse have available re- provides medical services, rehabilita- sources. For veterans who have been tion, therapeutic activities, socializa- receiving extended care services for 180 tion, nutrition and transportation days or less, their available resources services to disabled veterans in a con- are the sum of the income of the vet- gregate setting. eran and the veteran’s spouse, minus (2) Domiciliary care is defined in the sum of the veterans allowance, the § 17.30(b). spousal allowance, and expenses. For (3) Extended care services means adult veterans who have been receiving ex- day health care, domiciliary care, in- tended care services for 181 days or stitutional geriatric evaluation, non- more, their available resources are the institutional geriatric evaluation, sum of the value of the liquid assets, nursing home care, institutional res- the fixed assets, and the income of the pite care, and noninstitutional respite veteran and the veteran’s spouse, care. minus the sum of the veterans allow- (4) Geriatric evaluation is a special- ized, diagnostic/consultative service ance, the spousal allowance, the spous- provided by an interdisciplinary team al resource protection amount, and that is for the purpose of providing a (but only if the veteran—has a spouse
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or dependents residing in the commu- ents (if the veteran does not have a nity who is not institutionalized) ex- spouse) if the veteran is receiving in- penses. When a veteran is legally sepa- stitutional extended care service. rated from a spouse, available re- (3) A vehicle if the vehicle is: sources do not include spousal income, (i) The vehicle of the veteran and the expenses, and assets or a spousal allow- veteran is receiving only noninstitu- ance. tional extended care service; or (2) For purposes of determining avail- (ii) The vehicle of the veteran’s able resources under this section: spouse or the veteran’s dependents (if (i) Income means current income (in- the veteran does not have a spouse) if cluding, but not limited to, wages and the veteran is receiving institutional income from a business (minus busi- extended care service. ness expenses), bonuses, tips, severance (B) [Reserved] pay, accrued benefits, cash gifts, inher- (iv) Liquid assets means cash, stocks, itance amounts, interest income, dividends received from IRA, 401K’s standard dividend income from non tax and other tax deferred annuities, deferred annuities, retirement income, bonds, mutual funds, retirement ac- 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 med- (3) The maximum amount of a copay- ical care costs not otherwise covered ment for any month equals the copay- by health insurance; health insurance ment amount specified in paragraph premiums for the veteran, veteran’s (b)(1) of this section multiplied by the spouse, and veteran’s dependents; and number of days in the month. The co- taxes paid on income and personal payment for any month may be less property. than the amount specified in paragraph (iii) Fixed Assets means: (b)(1) of this section if the veteran pro- (A) Real property and other non-liq- vides information in accordance with uid assets; except that this does not in- this section to establish that the co- clude— payment should be reduced or elimi- (1) Burial plots; nated. (2) A residence if the residence is: (e) Requirement to submit information. (i) The primary residence of the vet- (1) Unless exempted under paragraph (f) eran and the veteran is receiving only of this section, a veteran must submit noninstitutional extended care service; to a VA medical facility a completed or VA Form 10–10EC and documentation (ii) The primary residence of the vet- requested by the Form at the following eran’s spouse or the veteran’s depend- times:
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(i) At the time of initial request for (9) A veteran receiving care for psy- an episode of extended care services; chosis or a mental illness other than (ii) At the time of request for ex- psychosis pursuant to § 17.109. tended care services after a break in (Authority: 38 U.S.C. 101(28), 501, 1701(7), 1710, provision of extended care services for 1710B, 1720B, 1720D, 1722A) more than 30 days; and (iii) Each year at the time of submis- [67 FR 35040, May 17, 2002; as amended at 69 FR 39846, July 1, 2004; 76 FR 52274, Aug. 22, sion to VA of VA Form 10–10EZ. 2011; 78 FR 28143, May 14, 2013; 78 FR 70864, (2) When there are changes that Nov. 27, 2013] might change the copayment obliga- tion (i.e., changes regarding marital CEREMONIES status, fixed assets, liquid assets, ex- penses, income (when received), or § 17.112 Services or ceremonies on De- whether the veteran has a spouse or de- partment of Veterans Affairs hos- pendents residing in the community), pital or center reservations. the veteran must report those changes (a) Services or ceremonies on Depart- to a VA medical facility within 10 days ment of Veterans Affairs hospital or of the change. center reservations are subject to the (f) Veterans and care that are not sub- following limitations: ject to the copayment requirements. The (1) All activities must be conducted following veterans and care are not with proper decorum, and not interfere subject to the copayment requirements with the care and treatment of pa- of this section: tients. Organizations must provide as- (1) A veteran with a compensable surance that their members will obey service-connected disability. all rules in effect at the hospital or (2) A veteran whose annual income center involved, and act in a dignified (determined under 38 U.S.C. 1503) is less and proper manner; than the amount in effect under 38 (2) Partisan activities are inappro- U.S.C. 1521(b). priate and all activities must be non- (3) Care for a veteran’s noncompen- partisan in nature. An activity will be sable zero percent service-connected considered partisan and therefore inap- disability. propriate if it includes commentary in (4) An episode of extended care serv- support of, or in opposition to, or at- ices that began on or before November tempts to influence, any current policy 30, 1999. of the Government of the United States or any State of the United States. If (5) Care authorized under 38 U.S.C. the activity is closely related to par- 1710(e) for Vietnam-era herbicide-ex- tisan activities being conducted out- posed veterans, radiation-exposed vet- side the hospital or center reserva- erans, Persian Gulf War veterans, or tions, it will be considered partisan and post-Persian Gulf War combat-exposed therefore inappropriate. veterans. (b) Requests for permission to hold (6) Care for treatment of sexual trau- services or ceremonies will be ad- ma as authorized under 38 U.S.C. 1720D. dressed to the Secretary, or the Direc- (7) Care or services authorized under tor of the Department of Veterans Af- 38 U.S.C. 1720E for certain veterans re- fairs hospital or center involved. Such garding cancer of the head or neck. applications will describe the proposed (8) A veteran who VA determines to activity in sufficient detail to enable a be catastrophically disabled, as defined determination as to whether it meets in 38 CFR 17.36(e), is exempt from co- the standards set forth in paragraph (a) payments for adult day health care, of this section. If permission is grant- non-institutional respite care, and non- ed, the Director of the hospital or cen- institutional geriatric care. ter involved will assign an appropriate time, and render assistance where ap- propriate. No organization will be given exclusive permission to use the hospital or center reservation on any
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particular occasion. Where several re- pared in triplicate, signed by the re- quests are received for separate activi- sponsible officer who made it, and ties, the Director will schedule each so countersigned by the Director of the as to avoid overlapping or interference, medical center. After the above papers or require appropriate modifications in have been secured, voucher will be pre- the scope or timing of the activity. pared, signed, and certified, and for- [35 FR 2389, Feb. 3, 1970. Redesignated at 61 warded to the Fiscal Officer for ap- FR 21966, May 13, 1996, and further redesig- proval, payment to be made in accord- nated at 67 FR 35040, May 17, 2002] ance with fiscal procedure. The origi- nal list of property and certificate are REIMBURSEMENT FOR LOSS BY NATURAL to be attached to voucher. DISASTER OF PERSONAL EFFECTS OF [39 FR 1843, Jan. 15, 1974, as amended at 49 HOSPITALIZED OR NURSING HOME PA- FR 5616, Feb. 14, 1984. Redesignated at 61 FR TIENTS 21966, May 13, 1996, and further redesignated at 67 FR 35039, May 17, 2002] § 17.113 Conditions of custody. When the personal effects of a pa- § 17.115 Claims in cases of incom- tient who has been or is hospitalized or petent patients. receiving nursing home care in a De- Where the patient is insane and in- partment of Veterans Affairs hospital competent, the patient will not be re- or center were or are duly delivered to quired to make claim for reimburse- a designated location for custody and ment for personal effects lost by fire, 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- tor for custody. § 17.114 Submittal of claim for reim- bursement. [39 FR 1843, Jan. 15, 1974, as amended at 49 FR 5616, Feb. 14, 1984. Redesignated and The claim for reimbursement for per- amended at 61 FR 21966, 21967, May 13, 1996, sonal effects damaged or destroyed will and further redesignated at 67 FR 35039, May be submitted by the patient to the Di- 17, 2002] rector. The patient will separately list and evaluate each article with a nota- REIMBURSEMENT TO EMPLOYEES FOR THE tion as to its condition at the time of COST OF REPAIRING OR REPLACING the fire, earthquake, or other natural CERTAIN PERSONAL PROPERTY DAM- disaster i.e., whether new, worn, etc. AGED OR DESTROYED BY PATIENTS OR The date of the fire, earthquake, or MEMBERS other natural disaster will be stated. It will be certified by a responsible offi- § 17.116 Adjudication of claims. cial that each article listed was stored Claims comprehended. Claims for reim- in a designated location at the time of bursing Department of Veterans Af- loss by fire, earthquake, or other nat- fairs employees for cost of repairing or ural disaster or was in process of laun- replacing their personal property dam- dering. The patient will further state aged or destroyed by patients or mem- whether the loss of each article was bers while such employees are engaged complete or partial, permitting of in the performance of their official du- some further use of the article. The re- ties will be adjudicated by the Director sponsible official will certify that the of the medical center concerned. Such amount of reimbursement claimed on claims will be considered under the fol- each article of personal effects is not in lowing conditions, both of which must excess of the fair value thereof at time have existed and, if either one is lack- of loss. The certification will be pre- ing, reimbursement or payment for the
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cost or repair of the damaged article disability (does not apply outside of will not be authorized: the States, Territories, and possessions (a) The claim must be for an item of of the United States, the District of personal property normally used by the Columbia, and the Commonwealth of employee in his or her day to day em- Puerto Rico); or ployment, e.g., eyeglasses, hearing (4) For any illness, injury or dental aids, clothing, etc., and, condition in the case of a veteran who (b) Such personal property was dam- is participating in a rehabilitation pro- aged or destroyed by a patient or domi- gram under 38 U.S.C. ch. 31 and who is ciliary member while the employee was engaged in the performance of official medically determined to be in need of duties. hospital care or medical services for any of the reasons enumerated in Reimbursement or payment as pro- § 17.47(i)(2); and vided in this paragraph will be made in a fair and reasonable amount, taking into consideration the condition and (Authority: 38 U.S.C. 1724, 1728) reasonable value of the article at the (b) In a medical emergency. Emergency time it was damaged or destroyed. treatment not previously authorized [28 FR 5083, May 22, 1963, as amended at 39 including medical services, profes- 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 PAYMENT AND REIMBURSEMENT OF THE emergency condition that is provided EXPENSES OF MEDICAL SERVICES NOT directly to the patient for use after the PREVIOUSLY AUTHORIZED emergency condition is stabilized and the patient is discharged) was rendered § 17.120 Payment or reimbursement in a medical emergency of such nature for emergency treatment furnished that a prudent layperson would have by non-VA providers to certain vet- erans with service-connected dis- reasonably expected that delay in seek- abilities. ing immediate medical attention would To the extent allowable, payment or have been hazardous to life or health. reimbursement of the expenses of This standard is met by an emergency emergency treatment, not previously medical condition manifesting itself by authorized, in a private or public (or acute symptoms of sufficient severity Federal) hospital not operated by the (including severe pain) that a prudent Department of Veterans Affairs, or of layperson who possesses an average any emergency treatment not pre- knowledge of health and medicine viously authorized including transpor- could reasonably expect the absence of tation (except prosthetic appliances, immediate medical attention to result similar devices, and repairs) will be in placing the health of the individual paid on the basis of a claim timely in serious jeopardy, serious impair- filed, under the following cir- ment to bodily functions, or serious cumstances: dysfunction of any bodily organ or (a) For veterans with service connected part. And, disabilities. Emergency treatment not (c) When Federal facilities are unavail- previously authorized was rendered to able. VA or other Federal facilities that a veteran in need of such emergency VA has an agreement with to furnish treatment: health care services for veterans were (1) For an adjudicated service-con- nected disability; not feasibly available, and an attempt (2) For nonservice-connected disabil- to use them beforehand or obtain prior ities associated with and held to be ag- VA authorization for the services re- gravating an adjudicated service-con- quired would not have been reasonable, nected disability; (3) For any disability of a veteran who has a total disability permanent in na- ture resulting from a service-connected
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sound, wise, or practicable, or treat- nator, Administrative Officer of the ment had been or would have been re- Day, or designated staff responsible for fused. accepting transfer of patients, at a (Authority: 38 U.S.C. 1724, 1728, 7304) local VA (or other Federal facility) and documented such contact in the vet- [39 FR 1844, Jan. 15, 1974, as amended at 49 eran’s progress/physicians’ notes, dis- FR 5616, Feb. 14, 1984; 51 FR 8672, Mar. 13, 1986; 56 FR 3422, Jan. 30, 1991. Redesignated at charge summary, or other applicable 61 FR 21966, May 13, 1996; 76 FR 79070, Dec. 21, medical record. 2011] (c) Refusal of transfer. If a stabilized veteran who requires continued non- § 17.121 Limitations on payment or re- emergency treatment refuses to be imbursement of the costs of emer- gency treatment not previously au- transferred to an available VA facility thorized. (or other Federal facility that VA has (a) Emergency Treatment. Except as an agreement with to furnish health provided in paragraph (b) of this sec- care services for veterans), VA will tion, VA will not approve claims for make payment or reimbursement only payment or reimbursement of the costs for the expenses related to the initial of emergency treatment not previously evaluation and the emergency treat- authorized for any period beyond the ment furnished to the veteran up to date on which the medical emergency the point of refusal of transfer by the ended. For this purpose, VA considers veteran. that an emergency ends when the des- (Authority: 38 U.S.C. 1724, 1728, 7304) ignated VA clinician at the VA facility has determined that, based on sound [76 FR 79071, Dec. 21, 2011] medical judgment, the veteran who re- ceived emergency treatment: § 17.122 Payment or reimbursement of (1) Could have been transferred from 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- thorization. VA has an agreement with to furnish 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 Federal facility that VA has an agree- (a) Obtaining the repairs locally was ment with to furnish health care serv- necessary, expedient, and not a matter ices for veterans), and the transfer of of preference to using authorized the veteran was not accepted; and sources, and (2) The non-VA facility made and (b) The costs were reasonable, except documented reasonable attempts to re- that where it is determined the costs quest transfer of the veteran to a VA were excessive or unreasonable, the facility (or to another Federal facility claim may be allowed to the extent the that VA has an agreement with to fur- costs were deemed reasonable and dis- nish health care services for veterans), allowed as to the remainder. In no cir- which means the non-VA facility con- cumstances will any claim for repairs tacted either the VA Transfer Coordi-
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be allowed to the extent the costs ex- ignated as a clinic or jurisdiction ceed $125. which serves the region in which the care or services were rendered. (Authority: 38 U.S.C. 1728, 7304) [33 FR 19011, Dec. 20, 1968, as amended at 49 (Authority: 38 U.S.C. 7304) FR 5616, Feb. 14, 1984; 51 FR 8672, Mar. 13, 1986. Redesignated and amended at 61 FR (b) For services rendered in the Phil- 21966, 21967, May 13, 1996] ippines. Claims for the expenses of care or services rendered in the Republic of § 17.123 Claimants. the Philippines should be filed with the A claim for payment or reimburse- Department of Veterans Affairs Out- ment of services not previously author- patient Clinic (358/00), 2201 Roxas Blvd., ized may be filed by the veteran who Pasay City, 1300, Republic of the Phil- received the services (or his/her guard- ippines. ian) or by the hospital, clinic, or com- (c) For services rendered in other for- munity resource which provided the eign countries. Claims for the expenses services, or by a person other than the of care or services rendered in other veteran who paid for the services. foreign countries must be mailed to the Health Administration Center, P.O. [39 FR 1844, Jan. 15, 1974, as amended at 45 FR 53807, Aug. 13, 1980. Redesignated at 61 FR Box 469063, Denver, CO 80246–9063. 21966, May 13, 1996] (Authority: 38 U.S.C. 7304) § 17.124 Preparation of claims. (d) For services rendered in Puerto Rico. Claims for costs of services not pre- Claims for the expenses of care or serv- viously authorized shall be on such ices rendered in the Commonwealth of forms as shall be prescribed and shall Puerto Rico should be filed with the include the following: Department of Veterans Affairs Med- (a) The claimant shall specify the ical and Regional Office Center, San amount claimed and furnish bills, Juan, PR. vouchers, invoices, or receipts or other [33 FR 19011, Dec. 20, 1968, as amended at 39 documentary evidence establishing FR 1844, Jan. 15, 1974; 45 FR 53807, Aug. 13, that such amount was paid or is owed, 1980; 51 FR 8673, Mar. 13, 1986. Redesignated and and amended at 61 FR 21966, 21967, May 13, (b) The claimant shall provide an ex- 1996; 74 FR 30228, June 25, 2009] planation of the circumstances necessi- tating the use of community medical § 17.126 Timely filing. care, services, or supplies instead of Claims for payment or reimburse- Department of Veterans Affairs care, ment of the expenses of medical care or services, or supplies, and services not previously authorized (c) The claimant shall furnish such must be filed within the following time other evidence or statements as are limits: deemed necessary and requested for ad- (a) A claim must be filed within 2 judication of the claim. years after the date the care or serv- [33 FR 19011, Dec. 20, 1968, as amended at 39 ices were rendered (and in the case of FR 1844, Jan. 15, 1974. Redesignated at 61 FR continuous care, payment will not be 21966, May 13, 1996] made for any part of the care rendered more than 2 years prior to filing § 17.125 Where to file claims. claim), or Claims for payment or reimburse- (b) In the case of case or services ren- ment of the expenses of services not dered prior to a VA adjudication allow- previously authorized should be filed as ing service-connection: follows: (1) The claim must be filed within 2 (a) For services rendered in the U.S. years of the date the veteran was noti- Claims for the expenses of care or serv- fied by VA of the allowance of the ices rendered in the United States, in- award of service-connection. cluding the Territories or possessions (2) VA payment may be made for care of the United States, should be filed related to the service-connected dis- with the Chief, Outpatient Service, or ability received only within a 2-year Clinic Director of the VA facility des- period prior to the date the veteran
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filed the original or reopened claim Department of Veterans Affairs ex- which resulted in the award of service- pense has been established. connection but never prior to the effec- [39 FR 1844, Jan. 15, 1974. Redesignated and tive date of the award of service-con- amended at 61 FR 21966, 21968, May 13, 1996] nection within that 2-year period. (3) VA payment will never be made § 17.130 Payment for treatment de- for any care received beyond this 2- pendent upon preference prohib- year period whether service connected ited. or not. No reimbursement or payment of (Authority: 38 U.S.C. 7304) services not previously authorized will be made when such treatment was pro- [33 FR 19012, Dec. 20, 1968, as amended at 39 cured through private sources in pref- FR 1844, Jan. 15, 1974; 45 FR 53807, Aug. 13, 1980; 51 FR 8673, Mar. 13, 1986. Redesignated erence to available Government facili- at 61 FR 21966, May 13, 1996] ties. [39 FR 1844, Jan. 15, 1974. Redesignated at 61 § 17.127 Date of filing claims. FR 21966, May 13, 1996] The date of filing any claim for pay- ment or reimbursement of the expenses § 17.131 Payment of abandoned claims of medical care and services not pre- prohibited. viously authorized shall be the post- Any informal claim for the payment mark date of a formal claim, or the or reimbursement of medical expenses date of any preceding telephone call, which is not followed by a formal telegram, or other communication con- claim, or any formal claim which is not stituting an informal claim. followed by necessary supporting evi- dence, within 1 year from the date of [39 FR 1844, Jan. 15, 1974. Redesignated at 61 FR 21966, May 13, 1996] the request for a formal claim or sup- porting evidence shall be deemed aban- § 17.128 Allowable rates and fees. doned, and payment or reimbursement shall not be authorized on the basis of When it has been determined that a such abandoned claim or any future veteran has received public or private claim for the same expenses. For the hospital care or outpatient medical purpose of this section, time limita- services, the expenses of which may be tions shall be computed from the date paid under § 17.120 of this part, the pay- following the date of request for a for- ment of such expenses shall be paid in mal claim or supporting evidence. accordance with §§ 17.55 and 17.56 of this part. [33 FR 19012, Dec. 20, 1968. Redesignated at 61 FR 21966, May 13, 1996] (Authority: Section 233, Pub. L. 99–576) [63 FR 39515, July 23, 1998] § 17.132 Appeals. When any claim for payment or reim- § 17.129 Retroactive payments prohib- bursement of expenses of medical care ited. or services rendered in non-Department When a claim for payment or reim- of Veterans Affairs facilities or from bursement of expenses of services not non-Department of Veterans Affairs re- previously authorized has not been sources has been disallowed, the claim- timely filed in accordance with the ant shall be notified of the reasons for provisions of § 17.126, the expenses of the disallowance and of the right to any such care or services rendered initiate an appeal to the Board of Vet- prior to the date of filing the claim erans Appeals by filing a Notice of Dis- shall not be paid or reimbursed. In no agreement, and shall be furnished such event will a bill or claim be paid or al- other notices or statements as are re- lowed for any care or services rendered quired by part 19 of this chapter, gov- prior to the effective date of any law, erning appeals. or amendment to the law, under which eligibility for the medical services at [33 FR 19012, Dec. 20, 1968. Redesignated at 61 FR 21966, May 13, 1996]
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RECONSIDERATION OF DENIED CLAIMS sion-maker, the claimant, and the claimant’s representative (if the claim- § 17.133 Procedures. ant wishes to have a representative (a) Scope. This section sets forth re- present). Such a meeting shall only be consideration procedures regarding for the purpose of discussing the issues claims for benefits administered by the and shall not include formal procedures Veterans Health Administration (e.g., presentation, cross-examination (VHA). These procedures apply to of witnesses, etc.). The meeting will be claims for VHA benefits regarding deci- taped and transcribed by VA if re- sions that are appealable to the Board quested by the claimant and a copy of of Veterans’ Appeals (e.g., reimburse- the transcription shall be provided to ment for non-VA care not authorized in the claimant. After reviewing the mat- advance, reimbursement for bene- ter, the immediate supervisor of the ficiary travel expenses, reimbursement initial VA decision-maker shall issue a for home improvements or structural alterations, etc.). These procedures do written decision that affirms, reverses, not apply when other regulations pro- or modifies the initial decision. viding reconsideration procedures do NOTE TO § 17.133: The final decision of the apply (this includes CHAMPVA (38 CFR immediate supervisor of the initial VA deci- 17.270 through 17.278) and spina bifida sion-maker will inform the claimant of fur- (38 CFR 17.904) and any other regula- ther appellate rights for an appeal to the tions that contain reconsideration pro- Board of Veterans’ Appeals. cedures). Also, these procedures do not (The Office of Management and Budget has apply to decisions made outside of approved the information collection require- VHA, such as decisions made by the ments in this section under control number Veterans Benefits Administration and 2900–0600) adopted by VHA for decisionmaking. These procedures are not mandatory, (Authority: 38 U.S.C. 511, 38 U.S.C. 7105) and a claimant may choose to appeal [64 FR 44660, Aug. 17, 1999] the denied claim to the Board of Vet- erans’ Appeals pursuant to 38 U.S.C. DELEGATIONS OF AUTHORITY 7105 without utilizing the provisions of this section. Submitting a request for § 17.140 Authority to adjudicate reim- reconsideration shall constitute a no- bursement claims. tice of disagreement for purposes of fil- The Department of Veterans Affairs ing a timely notice of disagreement medical installation having responsi- under 38 U.S.C. 7105(b). bility for the fee basis program in the (b) Process. An individual who dis- region or territory (including the Re- agrees with the initial decision denying public of the Philippines) served by the claim in whole or in part may ob- such medical installation shall adju- tain reconsideration under this section dicate all claims for the payment or re- by submitting a reconsideration re- imbursement of the expenses of serv- quest in writing to the Director of the ices not previously authorized rendered healthcare facility of jurisdiction with- in the region or territory. in one year of the date of the initial de- cision. The reconsideration decision [39 FR 1844, Jan. 15, 1974. Redesignated at 61 will be made by the immediate super- FR 21966, May 13, 1996] visor of the initial VA decision-maker. The request must state why it is con- § 17.141 Authority to adjudicate for- cluded that the decision is in error and eign reimbursement claims. must include any new and relevant in- The Health Administration Center in formation not previously considered. Denver, CO, shall adjudicate claims for Any request for reconsideration that the payment or reimbursement of the does not identify the reason for the dis- pute will be returned to the sender without further consideration. The re- quest for reconsideration may include a request for a meeting with the imme- diate supervisor of the initial VA deci-
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expenses of services not previously au- PROSTHETIC, SENSORY, AND thorized rendered in any foreign coun- REHABILITATIVE AIDS try except the Republic of the Phil- ippines which will be referred to the § 17.148 Service dogs. VA Outpatient Clinic in Pasay City. (a) Definitions. For the purposes of this section: [39 FR 1844, Jan. 15, 1974, as amended at 45 FR 6938, Jan. 31, 1980. Redesignated and Service dogs are guide or service dogs amended at 61 FR 21966, 21968, May 13, 1996; 74 prescribed for a disabled veteran under FR 30228, June 25, 2009] this section. (b) Clinical requirements. VA will pro- § 17.142 Authority to approve sharing vide benefits under this section to a agreements, contracts for scarce veteran with a service dog only if: medical specialist services and con- (1) The veteran is diagnosed as hav- tracts for other medical services. ing a visual, hearing, or substantial The Under Secretary for Health is mobility impairment; and delegated authority to enter into (2) The VA clinical team that is (a) Sharing agreements authorized treating the veteran for such impair- under the provisions of 38 U.S.C. 8153 ment determines based upon medical and § 17.210 and which may be nego- judgment that it is optimal for the vet- tiated pursuant to the provisions of 41 eran to manage the impairment and CFR 8–3.204(c); live independently through the assist- (b) Contracts with schools and col- ance of a trained service dog. Note: If leges of medicine, osteopathy, den- other means (such as technological de- tistry, podiatry, optometry, and nurs- vices or rehabilitative therapy) will provide the same level of independence, ing, clinics, and any other group or in- then VA will not authorize benefits dividual capable of furnishing such under this section. services to provide scarce medical spe- (3) For the purposes of this section, cialist services at Department of Vet- substantial mobility impairment erans Affairs health care facilities (in- means a spinal cord injury or dysfunc- cluding, but not limited to, services of tion or other chronic impairment that physicians, dentists, podiatrists, op- substantially limits mobility. A chron- tometrists, nurses, physicians’ assist- ic impairment that substantially lim- ants, expanded function dental auxil- its mobility includes but is not limited iaries, technicians, and other medical to a traumatic brain injury that com- support personnel); and promises a veteran’s ability to make (c) When a sharing agreement or con- appropriate decisions based on environ- tract for scarce medical specialist serv- mental cues (i.e., traffic lights or dan- ices is not warranted, contracts au- gerous obstacles) or a seizure disorder thorized under the provisions of 38 that causes a veteran to become immo- U.S.C. 513 for medical and ancillary bile during and after a seizure event. services. The authority under this sec- (c) Recognized service dogs. VA will tion generally will be exercised by ap- recognize, for the purpose of paying proval of proposed contracts or agree- benefits under this section, the fol- ments negotiated at the health care fa- lowing service dogs: cility level. Such approval, however, (1) The dog and veteran must have will not be necessary in the case of any successfully completed a training pro- purchase order or individual authoriza- gram offered by an organization ac- tion for which authority has been dele- credited by Assistance Dogs Inter- gated in § 17.99. All such contracts and national or the International Guide agreements will be negotiated pursuant Dog Federation, or both (for dogs that to 41 CFR chapters 1 and 8. perform both service- and guide-dog as- sistance). The veteran must provide to (Authority: 38 U.S.C. 512, 513, 7409, 8153) VA a certificate showing successful [45 FR 6938, Jan. 31, 1980. Redesignated at 61 completion issued by the accredited or- FR 21966, May 13, 1996, as amended at 62 FR ganization that provided such program. 17072, Apr. 9, 1997] (2) Dogs obtained before September 5, 2012 will be recognized if a guide or
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service dog training organization in ex- Sensory Aids Service at his or her local istence before September 5, 2012 cer- VA medical facility and request the tifies that the veteran and dog, as a items needed. team, successfully completed, no later (3) Payments for travel expenses as- than September 5, 2013, a training pro- sociated with obtaining a dog under gram offered by that training organiza- paragraph (c)(1) of this section. Travel tion. The veteran must provide to VA a costs will be provided only to a veteran certificate showing successful comple- who has been prescribed a service dog tion issued by the organization that by a VA clinical team under paragraph provided such program. Alternatively, (b) of this section. Payments will be the veteran and dog will be recognized made as if the veteran is an eligible if they comply with paragraph (c)(1) of beneficiary under 38 U.S.C. 111 and 38 this section. (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 or deductibles associated with the pol- items such as license tags, nonprescrip- icy; however, the veteran will be re- tion food, grooming, insurance for per- sponsible for any cost of care that ex- sonal injury, non-sedated dental ceeds the maximum amount authorized cleanings, nail trimming, boarding, by the policy for a particular proce- pet-sitting or dog-walking services, dure, course of treatment, or policy over-the-counter medications, or other year. If a dog requires care that may goods and services not covered by the exceed the policy’s limit, the insurer policy. The dog is not the property of will, whenever reasonably possible VA; VA will never assume responsi- under the circumstances, provide ad- vance notice to the veteran. bility for, or take possession of, any (ii) The policy will guarantee cov- service dog. erage for all treatment (and associated (e) Dog must maintain ability to func- prescription medications), subject to tion as a service dog. To continue to re- premiums, copayments, deductibles or ceive benefits under this section, the annual caps, determined to be medi- service dog must maintain its ability cally necessary, including euthanasia, to function as a service dog. If at any by any veterinarian who meets the re- time VA learns from any source that quirements of the insurer. The veteran the dog is medically unable to main- will not be billed for these covered tain that role, or VA makes a clinical costs, and the insurer will directly re- determination that the veteran no imburse the provider. longer requires the dog, VA will pro- (iii) The policy will not exclude dogs vide at least 30 days notice to the vet- with preexisting conditions that do not eran before benefits will no longer be prevent the dog from being a service authorized. dog. (2) Hardware, or repairs or replace- (Authority: 38 U.S.C. 501, 1714) ments for hardware, that are clinically (The Office of Management and Budget has determined to be required by the dog to approved the information collection require- perform the tasks necessary to assist ments in this section under control number the veteran with his or her impair- 2900–0785.) ment. To obtain such devices, the vet- [77 FR 54381, Sept. 5, 2012] eran must contact the Prosthetic and
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§ 17.149 Sensori-neural aids. § 17.150 Prosthetic and similar appli- ances. (a) Notwithstanding any other provi- sion 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- pliances or repairs are a necessary part connected disability; of outpatient care for which the vet- (2) Those who are former prisoners of eran is eligible under 38 U.S.C. 1712 and war; 38 CFR 17.93 (or a necessary part of out- (3) Those awarded a Purple Heart; patient care authorized under § 17.94) or (4) Those in receipt of benefits under (b) As part of hospital care. The appli- 38 U.S.C. 1151; ances or repairs are a necessary part of (5) Those in receipt of increased pen- inpatient care for any service-con- sion based on the need for regular aid nected disability or any nonservice- and attendance or by reason of being connected disability, if: permanently housebound; (1) The nonservice-connected dis- (6) Those who have a visual or hear- ability is associated with an aggra- ing impairment that resulted from the vating a service-connected disability, existence of another medical condition or for which the veteran is receiving VA (2) The nonservice-connected dis- care, or which resulted from treatment ability is one for which hospital admis- of that medical condition; sion was authorized, or (7) Those with a significant func- (3) The nonservice-connected dis- tional or cognitive impairment evi- ability is associated with and aggra- denced by deficiencies in activities of vating a nonservice-connected dis- daily living, but not including nor- ability for which hospital admission mally occurring visual or hearing im- was authorized, or pairments; and (4) The nonservice-connected dis- (8) Those visually or hearing im- ability is one for which treatment may paired so severely that the provision of be authorized under the provisions of sensori-neural aids is necessary to per- § 17.48(f), or mit active participation in their own (c) As part of domiciliary care. The ap- medical treatment. pliances or repairs are necessary for (c) VA will furnish needed hearing continued domiciliary care, or are nec- aids to those veterans who have serv- essary to treat a member’s service-con- ice-connected hearing disabilities rated nected disability, or nonservice-con- 0 percent if there is organic conductive, nected disability associated with and mixed, or sensory hearing impairment, aggravating a service-connected dis- and loss of pure tone hearing sensi- ability, or tivity in the low, mid, or high-fre- (d) As part of nursing home care. The quency range or a combination of fre- appliances or repairs are a necessary quency ranges which contribute to a part of nursing home care furnished in loss of communication ability; how- facilities under the direct and exclu- ever, hearing aids are to be provided sive jurisdiction of the Department of only as needed for the service-con- Veterans Affairs. nected hearing disability. [32 FR 13816, Oct. 4, 1967, as amended at 33 FR (Authority: 38 U.S.C. 501,1707(b) 12315, Aug. 31, 1968; 34 FR 9341, June 13, 1969; 35 FR 17948, Nov. 21, 1970; 54 FR 34983, Aug. [62 FR 30242, June 3, 1997, as amended at 69 23, 1989. Redesignated and amended at 61 FR FR 33575, June 16, 2004] 21966, 21968, May 13, 1996]
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§ 17.151 Invalid lifts for recipients of entitled to compensation on account of aid and attendance allowance or such hearing impairment. special monthly compensation. (Authority: 38 U.S.C. 3902) An invalid lift may be furnished if: [53 FR 46607, Nov. 18, 1988. Redesignated at 61 (a) The applicant is a veteran who is FR 21966, May 13, 1996] receiving (1) special monthly com- pensation (including special monthly § 17.153 Training in the use of appli- compensation based on the need for aid ances. and attendance) under the provisions of Beneficiaries supplied prosthetic and 38 U.S.C. 1114(r), or (2) comparable com- similar appliances will be additionally pensation benefits at the rates pre- entitled to fitting and training in the scribed under 38 U.S.C. 1134, or (3) in- use of the appliances. Such training creased pension based on the need for will usually be given in Department of aid and attendance or a greater com- Veterans Affairs facilities and by De- 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 el- igible; and [26 FR 5871, June 30, 1961. Redesignated at 61 (b) The veteran has loss, or loss of FR 21966, May 13, 1996] use, of both lower extremities and at § 17.154 Equipment for blind veterans. least one upper extremity (loss of use VA may furnish mechanical and/or may result from paralysis or other im- electronic equipment considered nec- pairment to muscle power and includes essary as aids to overcoming the handi- all cases in which the veteran cannot cap of blindness to blind veterans enti- use his or her extremities or is medi- tled to disability compensation for a cally prohibited from doing so because service-connected disability. of a serious disease or disability); and (c) The veteran has been medically (Authority: 38 U.S.C. 1714) determined incapable of moving him- [77 FR 54382, Sept. 5, 2012] self or herself from his or her bed to a AUTOMOTIVE EQUIPMENT AND DRIVER wheelchair, or from his or her wheel- TRAINING chair to his or her bed, without the aid of an attendant, because of the dis- § 17.155 Minimum standards of safety ability involving the use of his or her and quality for automotive adaptive extremities; and equipment. (d) An invalid lift would be a feasible (a) The Under Secretary for Health or means by which the veteran could ac- designee is authorized to develop and complish the necessary maneuvers be- establish minimum standards of safety tween bed and wheelchair, and is medi- and quality for adaptive equipment cally determined necessary. provided under 38 U.S.C. chapter 39. (b) In the performance of this func- [33 FR 12315, Aug. 31, 1968, as amended at 36 tion, the following considerations will FR 3117, Feb. 13, 1971; 54 FR 34983, Aug. 23, apply: 1989. Redesignated at 61 FR 21966, May 13, (1) Minimum standards of safety and 1996] quality will be developed and promul- § 17.152 Devices to assist in over- gated for basic adaptive equipment spe- coming the handicap of deafness. cifically designed to facilitate oper- ation and use of standard passenger Devices for assisting in overcoming motor vehicles by persons who have the handicap of deafness (including specified types of disablement and for telecaptioning television decoders) the installation of such equipment. may be furnished to any veteran who is (2) In those instances where custom- profoundly deaf (rated 80% or more dis- built adaptive equipment is designed abled for hearing impairment by the and installed to meet the peculiar Department of Veterans Affairs) and is needs of uniquely disabled persons and where the incidence of probable usage is not such as to justify development of
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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] items, authorization of suitable adapt- ive equipment will not be delayed. Ap- § 17.157 Definition-adaptive equip- proval of such adaptive equipment, ment. however, shall be subject to the judg- The term, adaptive equipment, ment of designated certifying officials means equipment which must be part that it meets implicit standards of of or added to a conveyance manufac- safety and quality adopted by the in- tured for sale to the general public to dustry or as later developed by the De- make it safe for use by the claimant, partment of Veterans Affairs. and enable that person to meet the ap- [40 FR 8819, Mar. 3, 1975. Redesignated at 61 plicable standards of licensure. Adapt- FR 21966, May 13, 1996, as amended at 62 FR ive equipment includes any term speci- 17072, Apr. 9, 1997] fied by the Under Secretary for Health or designee as ordinarily necessary for § 17.156 Eligibility for automobile any of the classes of losses or combina- adaptive equipment. tion of such losses specified in § 17.156 Automobile adaptive equipment may of this part, or as deemed necessary in be authorized if the Under Secretary an individual case. Adaptive equipment for Health or designee determines that includes, but is not limited to, a basic such equipment is deemed necessary to automatic transmission, power steer- insure that the eligible person will be ing, power brakes, power window lifts, able to operate the automobile or other power seats, air-conditioning equip- conveyance in a manner consistent ment when necessary for the health with such person’s safety and so as to and safety of the veteran, and special satisfy the applicable standards of li- equipment necessary to assist the eligi- censure established by the State of ble person into or out of the auto- such person’s residency or other proper mobile or other conveyance, regardless licensing authority. of whether the automobile or other (a) Persons eligible for adaptive conveyance is to be operated by the eli- equipment are: gible person or is to be operated for (1) Veterans who are entitled to re- such person by another person; and any ceive compensation for the loss or per- modification of the interior space of manent loss of use of one or both feet; the automobile or other conveyance if or the loss or permanent loss of use of needed because of the physical condi- one or both hands; or ankylosis of one tion of such person in order for such or both knees, or one of both hips if the person to enter or operate the vehicle. disability is the result of injury in- curred or disease contracted in or ag- (Authority: 38 U.S.C. 3901, 3902) gravated by active military, naval or [53 FR 46608, Nov. 18, 1988. Redesignated and air service. amended at 61 FR 21966, 21968, May 13, 1996]
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§ 17.158 Limitations on assistance. § 17.159 Obtaining vehicles for special driver training courses. (a) An eligible person shall not be en- 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 automobile, vehicle or conveyance to four-year period is no longer available which the Department of Veterans Af- for the use of such person. fairs holds title for such price or under (1) Circumstances beyond the control such terms deemed appropriate by the of the eligible person are those where Secretary. Any proceeds received from the vehicle was lost due to fire, theft, such disposition shall be credited to accident, court action, or when repairs the applicable Department of Veterans are so costly as to be prohibitive or a Affairs appropriation. different vehicle is required due to a change in the eligible person’s physical (Authority: 38 U.S.C. 3903(e)(3)) condition. [45 FR 6939, Jan. 31, 1980. Redesignated at 54 (2) For purposes of paragraph (a)(1) of FR 46607, Nov. 18, 1988, and further redesig- this section, an eligible person shall be nated at 61 FR 21966, May 13, 1996] deemed to have access to and use of an DENTAL SERVICES automobile or other conveyance for which the Department of Veterans Af- § 17.160 Authorization of dental exami- fairs has provided adaptive equipment nations. if that person has sold, given or trans- When a detailed report of dental ex- ferred the vehicle to a spouse, family amination is essential for a determina- member or other person residing in the tion of eligibility for benefits, dental same household as the eligible person, examinations may be authorized for or to a business owned by such person. the following classes of claimants or beneficiaries: (Authority: 38 U.S.C. 3903) (a) Those having a dental disability (b) Eligible persons may be reim- adjudicated as incurred or aggravated bursed for the actual cost of adaptive in active military, naval, or air service equipment subject to a dollar amount or those requiring examination to de- for specific items established from termine whether the dental disability time to time by the Under Secretary is service connected. for Health. (b) Those having disability from dis- ease or injury other than dental, adju- (Authority: 38 U.S.C. 3902) dicated as incurred or aggravated in active military, naval, or air service (c) Reimbursement for a repair to an but with an associated dental condition item of adaptive equipment is limited that is considered to be aggravating to the current vehicles of record and the basic service-connected disorder. only to the basic components author- (c) Those for whom a dental examina- ized as automobile adaptive equipment. tion is ordered as a part of a general Reimbursable amounts for repairs are physical examination. limited to the cost of parts and labor (d) Those requiring dental examina- based on the amounts published in gen- tion during hospital, nursing home, or erally acceptable commercial esti- domiciliary care. mating guides for domestic auto- (e) Those held to have suffered dental mobiles. injury or aggravation of an existing dental injury, as the result of examina- (Authority: 38 U.S.C. 3902) tion, hospitalization, or medical or sur- [53 FR 46608, Nov. 18, 1988. Redesignated and gical (including dental) treatment that amended at 61 FR 21966, 21968, May 13, 1996] had been awarded.
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(f) Veterans who are participating in discharged or released under conditions a rehabilitation program under 38 other than dishonorable, from any U.S.C. chapter 31 are entitled to such other period of active military, naval, dental services as are professionally or air service of not less than 180 days; determined necessary for any of the (B) Application for treatment is reasons enumerated in § 17.47(g). made within 180 days after such dis- charge or release. (Authority: 38 U.S.C. 1712(b); ch. 31) (C) The certificate of discharge or re- (g) Those for whom a special dental lease does not bear a certification that examination is authorized by the the veteran was provided, within the Under Secretary for Health or the As- 90-day period immediately before such sistant Chief Medical Director for Den- discharge or release, a complete dental tistry. examination (including dental X-rays) (h) Persons defined in § 17.60(d). and all appropriate dental treatment indicated by the examination to be [13 FR 7162, Nov. 27, 1948, as amended at 21 FR 10388, Dec. 28, 1956; 23 FR 6503, Aug. 22, needed, and 1958; 27 FR 11424, Nov. 20, 1962; 29 FR 1463, (D) Department of Veterans Affairs Jan. 29, 1964; 30 FR 1789, Feb. 9, 1965; 32 FR dental examination is completed with- 13817, Oct. 4, 1967; 33 FR 5300, Apr. 3, 1968; 35 in six months after discharge or re- FR 6586, Apr. 24, 1970; 49 FR 5617, Feb. 14, lease, unless delayed through no fault 1984. Redesignated and amended at 61 FR of the veteran. 21966, 21968, May 13, 1996] (ii) Those veterans discharged from § 17.161 Authorization of outpatient their final period of service after Au- dental treatment. gust 12, 1981, who had reentered active Outpatient dental treatment may be military service within 90 days after authorized by the Chief, Dental Serv- the date of a discharge or release from ice, for beneficiaries defined in 38 a prior period of active military serv- U.S.C. 1712(b) and 38 CFR 17.93 to the ice, may apply for treatment of serv- extent prescribed and in accordance ice-connected noncompensable dental with the applicable classification and conditions relating to any such periods provisions set forth in this section. of service within 180 days from the date of their final discharge or release. (a) Class I. Those having a service- connected compensable dental dis- (iii) If a disqualifying discharge or re- ability or condition, may be authorized lease has been corrected by competent any dental treatment indicated as rea- authority, application may be made sonably necessary to maintain oral within 180 days after the date of correc- health and masticatory function. There tion. is no time limitation for making appli- (2)(i) Those having a service-con- cation for treatment and no restriction nected noncompensable dental condi- as to the number of repeat episodes of tion or disability shown to have been treatment. in existence at time of discharge or re- (b) Class II. (1)(i) Those having a serv- lease from active service, which took ice-connected noncompensable dental place before October 1, 1981, may be au- condition or disability shown to have thorized any treatment indicated as been in existence at time of discharge reasonably necessary for the one-time or release from active service, which correction of the service-connected took place after September 30, 1981, noncompensable condition, but only if: may be authorized any treatment indi- (A) They were discharged or released, cated as reasonably necessary for the under conditions other than dishonor- one-time correction of the service-con- able, from a period of active military, nected noncompensable condition, but naval or air service of not less than 180 only if: days. (A) They served on active duty dur- (B) Application for treatment is ing the Persian Gulf War and were dis- made within one year after such dis- charged or released, under conditions charge or release. other than dishonorable, from a period (C) Department of Veterans Affairs of active military, naval, or air service dental examination is completed with- of not less than 90 days, or they were in 14 months after discharge or release,
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unless delayed through no fault of the (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- All Class IIR (Retroactive) treatment gust 13, 1981, who had reentered active authorized will be completed on a fee military service within one year from basis status. the date of a prior discharge or release, may apply for treatment of service- (Authority: 38 U.S.C. 1712) connected noncompensable dental con- 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 authority, application may be made treatment for only those dental condi- within one year after the date of cor- tions which, in sound professional judg- rection. ment, are having a direct and material detrimental effect upon the associated (Authority: 38 U.S.C. 1712) basic condition or disability. (c) Class II (a). Those having a serv- (h) Class IV. Those whose service-con- ice-connected noncompensable dental nected disabilities are rated at 100% by condition or disability adjudicated as schedular evaluation or who are enti- resulting from combat wounds or serv- tled to the 100% rate by reason of indi- ice trauma may be authorized any vidual unemployability may be author- treatment indicated as reasonably nec- ized any needed dental treatment. essary for the correction of such serv- ice-connected noncompensable condi- (Authority: 38 U.S.C. 1712) tion or disability. (i) Class V. A veteran who is partici- pating in a rehabilitation program (Authority: 38 U.S.C. 501; 1712(a)(1)(C)) under 38 U.S.C. chapter 31 may be au- (d) Class II(b). Certain homeless and thorized such dental services as are other enrolled veterans eligible for a professionally determined necessary one-time course of dental care under 38 for any of the reasons enumerated in U.S.C. 2062. § 17.47(g).
(Authority: 38 U.S.C. 2062; 38 U.S.C. (Authority: 38 U.S.C. 1712(b); chapter 31) 1712(a)(1)(H)) (j) Class VI. Any veterans scheduled (e) Class II(c). Those who were pris- for admission or otherwise receiving oners of war, as determined by the con- care and services under chapter 17 of 38 cerned military service department, U.S.C. may receive outpatient dental may be authorized any needed out- care which is medically necessary, i.e., patient dental treatment. is for dental condition clinically deter- (Authority: Pub. L. 100–322; Pub. L. 108–170; mined to be complicating a medical 38 U.S.C. 1712(b)(1)(F)) condition currently under treatment. (f) Class IIR (Retroactive). Any veteran (Authority: 38 U.S.C. 1712) who had made prior application for and received dental treatment from the De- [20 FR 9505, Dec. 20, 1955] partment of Veterans Affairs for non- EDITORIAL NOTE: For FEDERAL REGISTER ci- compensable dental conditions, but was tations affecting § 17.161, see the List of CFR denied replacement of missing teeth Sections Affected, which appears in the which were lost during any period of Finding Aids section of the printed volume service prior to his/her last period of and at www.fdsys.gov. service may be authorized such pre- viously denied benefits under the fol- § 17.162 Eligibility for Class II dental lowing conditions: treatment without rating action. (1) Application for such retroactive When an application has been made benefits is made within one year of for class II dental treatment under April 5, 1983. § 17.161(b), the applicant may be deemed
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eligible and dental treatment author- have abandoned the claim for dental ized on a one-time basis without rating treatment. action if: [45 FR 6939, Jan. 31, 1980. Redesignated at 61 (a) The examination to determine the FR 21966, May 13, 1996] need for dental care has been accom- plished within the specified time limit § 17.165 Emergency outpatient dental after date of discharge or release unless treatment. delayed through no fault of the vet- When outpatient emergency dental eran, and sound dental judgment war- care is provided, as a humanitarian rants a conclusion the condition origi- service, to individuals who have no es- nated in or was aggravated during serv- tablished eligibility for outpatient den- ice and the condition existed at the tal care, the treatment will be re- time of discharge or release from ac- stricted to the alleviation of pain or tive service, and extreme discomfort, or the remediation of a dental condition which is deter- (Authority: 38 U.S.C. 1712) mined to be endangering life or health. The provision of emergency treatment (b) The treatment will not involve re- to persons found ineligible for dental placement of a missing tooth noted at care will not entitle the applicant to the time of Department of Veterans Af- further dental treatment. Individuals fairs examination except: provided emergency dental care who (1) In conjunction with authorized ex- are found to be ineligible for such care traction replacement, or will be billed. (2) When a determination can be made on the basis of sound professional (Authority: 38 U.S.C. 501) judgment that a tooth was extracted or [50 FR 14704, Apr. 15, 1985; 50 FR 21604, May lost on active duty. 28, 1985. Redesignated at 61 FR 21966, May 13, (c) Individuals whose entire tour of 1996] duty consisted of active or inactive § 17.166 Dental services for hospital or duty for training shall not be eligible nursing home patients and domi- for treatment under this section. ciled members. [37 FR 6847, Apr. 5, 1972, as amended at 48 FR Persons receiving hospital, nursing 16682, Apr. 19, 1983. Redesignated and amend- home, or domiciliary care pursuant to ed at 61 FR 21966, 21968, May 13, 1996] the provisions of §§ 17.46 and 17.47, will be furnished such dental services as are § 17.163 Posthospital outpatient dental professionally determined necessary to treatment. the patients’ or members’ overall hos- The Chief, Dental Service may au- pital, nursing home, or domiciliary thorize outpatient dental care which is care. reasonably necessary to complete [30 FR 1790, Feb. 9, 1965. Redesignated at 61 treatment of a nonservice-connected FR 21966, May 13, 1996] dental condition which was begun while the veteran was receiving De- § 17.169 VA Dental Insurance Program partment of Veterans Affairs author- for veterans and survivors and de- ized hospital care. pendents of veterans (VADIP). (a) General. (1) The VA Dental Insur- (Authority: 38 U.S.C. 1712(b)(5)) ance Program (VADIP) provides pre- [45 FR 6939, Jan. 31, 1980. Redesignated at 61 mium-based dental insurance coverage FR 21966, May 13, 1996] through which individuals eligible under paragraph (b) of this section may § 17.164 Patient responsibility in mak- choose to obtain dental insurance from ing and keeping dental appoint- a participating insurer. Enrollment in ments. VADIP does not affect the insured’s Any veteran eligible for dental treat- eligibility for outpatient dental serv- ment on a one-time completion basis ices and treatment, and related dental only and who has not received such appliances, under 38 U.S.C. 1712. treatment within 3 years after filing (2) The following definitions apply to the application shall be presumed to this section:
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Insured means an individual, identi- (E) Apicoectomy and periradicular fied in paragraph (b) of this section, services. who has enrolled in an insurance plan (v) Periodontic services. through VADIP. (A) Surgical services. Participating insurer means an insur- (B) Periodontal services. ance company that has contracted with (vi) Oral surgery. VA to offer a premium-based dental in- (A) Extractions. surance plan to veterans, survivors, (B) Surgical extractions. and dependents through VADIP. There may be more than one participating in- (C) Alveoloplasty. surer. (D) Biopsy. (b) Covered veterans and survivors and (vii) Other services. dependents. A participating insurer (A) Palliative (emergency) treatment must offer coverage to the following of dental pain. persons: (B) Therapeutic drug injection. (1) Any veteran who is enrolled under (C) Other drugs and/or medications. 38 U.S.C. 1705 in accordance with 38 (D) Treatment of postsurgical com- CFR 17.36. plications. (2) Any survivor or dependent of a (E) Crowns. veteran who is eligible for medical care (F) Bridges. under 38 U.S.C. 1781 and 38 CFR 17.271. (G) Dentures. (c) Premiums, coverage, and selection of (3) Selection of participating insurer. participating insurer. (1) Premiums. Pre- VA will use the Federal competitive miums and copayments will be paid by contracting process to select a partici- the insured in accordance with the pating insurer, and the insurer will be terms of the insurance plan. Premiums responsible for the administration of and copayments will be determined by VADIP. VA through the contracting process, (d) Enrollment. (1) VA, in connection and will be adjusted on an annual with the participating insurer, will basis. The participating insurer will market VADIP through existing VA notify all insureds in writing of the communication channels to notify all amount and effective date of such ad- eligible persons of their right to volun- justment. tarily enroll in VADIP. The partici- (2) Benefits. Participating insurers pating insurer will prescribe all further must offer, at a minimum, coverage for enrollment procedures, and VA will be the following dental care and services: responsible for confirming that a per- (i) Diagnostic services. son is eligible under paragraph (b) of (A) Clinical oral examinations. this section. (B) Radiographs and diagnostic imag- (2) The initial period of enrollment ing. will be for a period of 12 calendar (C) Tests and laboratory examina- months, followed by month-to-month tions. enrollment, subject to paragraph (e)(5) (ii) Preventive services. of this section, as long as the insured (A) Dental prophylaxis. remains eligible for coverage under (B) Topical fluoride treatment (office paragraph (b) of this section and choos- procedure). es to continue enrollment, so long as (C) Sealants. VA continues to authorize VADIP. (D) Space maintenance. (3) The participating insurer will (iii) Restorative services. agree to continue to provide coverage (A) Amalgam restorations. to an insured who ceases to be eligible (B) Resin-based composite restora- under paragraphs (b)(1) through (2) of tions. this section for at least 30 calendar (iv) Endodontic services. days after eligibility ceased. The in- (A) Pulp capping. sured must pay any premiums due dur- (B) Pulpotomy and pulpectomy. ing this 30-day period. This 30-day cov- (C) Root canal therapy. erage does not apply to an insured who (D) Apexification and recalcification is disenrolled under paragraph (e) of procedures. this section.
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(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 in- voluntarily 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. that prevents the use of the benefits (f) Other appeals procedures. Partici- under the plan. pating insurers will establish and be re- (iii) If the insured is prevented by se- sponsible for determination and appeal rious medical condition from being procedures for all issues other than able to obtain benefits under the plan. voluntary disenrollment. (iv) If the insured would suffer severe (g) Limited preemption of State and financial hardship by continuing in local law. To achieve important Federal VADIP. interests, including but not limited to (v) For any reason during the month- the assurance of the uniform delivery to-month coverage period, after the of benefits under VADIP and to ensure initial 12-month enrollment period. the operation of VADIP plans at the (3) All insured requests for voluntary lowest possible cost to VADIP enroll- disenrollment must be submitted to ees, paragraphs (b), (c)(1), (c)(2), (d), the insurer for determination of wheth- and (e)(2) through (5) of this section er the insured qualifies for preempt conflicting State and local disenrollment under the criteria in laws, including laws relating to the paragraphs (e)(2)(i) through (v) of this business of insurance. Any State or section. Requests for disenrollment due local law, or regulation pursuant to to a serious medical condition or finan- such law, is without any force or effect cial hardship must include submission on, and State or local governments of written documentation that verifies have no legal authority to enforce the existence of a serious medical con- them in relation to, the paragraphs ref- dition or financial hardship. The writ- erenced in this paragraph or decisions ten documentation submitted to the made by VA or a participating insurer insurer must show that circumstances under these paragraphs. leading to a serious medical condition (Authority: Sec. 510, Pub. L. 111–163) or financial hardship originated after (The Office of Management and Budget has the effective date coverage began, and approved the information collection require- will prevent the insured from main- ment in this section under control number taining the insurance benefits. 2900–0789.) (4) If the participating insurer denies [78 FR 32130, May 29, 2013, as amended at 78 a request for voluntary disenrollment FR 62443, Oct. 22, 2013] because the insured does not meet any criterion under paragraphs (e)(2)(i) AUTOPSIES through (v) of this section, the partici- pating insurer must issue a written de- § 17.170 Autopsies. cision and notify the insured of the (a) General. (1) Except as otherwise basis for the denial and how to appeal. provided in this section, the Director of The participating insurer will establish a VA facility may order an autopsy on the form of such appeals whether oral- a decedent who died while undergoing ly, in writing, or both. The decision VA care authorized by § 17.38 or § 17.52, and notification of appellate rights if the Director determines that an au- must be issued to the insured no later topsy is required for VA purposes for than 30 days after the request for vol- the following reasons:
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(i) Completion of official records; or person who is authorized to grant VA (ii) Advancement of medical knowl- permission to perform the autopsy and, edge. if more than one person is identified, (2) VA may order an autopsy to be the order of precedence among such performed only if consent is first ob- persons. tained under one of the following cir- (2) When the next of kin, as defined cumstances: by the laws of the state where the au- (i) Consent is granted by the sur- topsy will be performed, consists of a viving spouse or next of kin of the de- number of persons such as children, cedent; parents, brothers and sisters, etc., per- (ii) Consent is implied where a known mission to perform an autopsy may be surviving spouse or next of kin does accepted when granted by the person in not respond within a specified period of the appropriate class who assumes the time to VA’s request for permission to right and duty of burial. conduct an autopsy; (e) Death outside a VA facility. The Di- (iii) Consent is implied where a rector of a VA facility may order an known surviving spouse or next of kin autopsy on a veteran who was under- does not inquire after the well-being of going VA care authorized by § 17.38 or the deceased veteran for a period of at § 17.52, and whose death did not occur in least 6 months before the date of the a VA facility. Such authority also in- veteran’s death; or cludes transporting the body at VA’s (iv) Consent is implied where there is expense to the facility where the au- no known surviving spouse or next of topsy will be performed, and the return kin of the deceased veteran. of the body. Consent for the autopsy (b) Death resulting from crime. If it is will be obtained as stated in paragraph suspected that death resulted from (d) of this section. The Director must crime and if the United States has ju- determine that such autopsy is reason- risdiction over the area where the body ably required for VA purposes for the is found, the Director of the Depart- following reasons: ment of Veterans Affairs facility will (1) The completion of official records; inform the Office of Inspector General or of the known facts concerning the (2) Advancement of medical knowl- death. Thereupon the Office of Inspec- edge. tor General will transmit all such in- (Authority: 38 U.S.C. 501, 1703, 1710) formation to the United States Attor- ney for such action as may be deemed [16 FR 5701, June 15, 1951, as amended at 18 appropriate and will inquire whether FR 2414, Apr. 24, 1953; 24 FR 8330, Oct. 14, 1959; the United States Attorney objects to 35 FR 6586, Apr. 24, 1970; 36 FR 23386, Dec. 9, 1971; 45 FR 6939, Jan. 31, 1980. Redesignated an autopsy if otherwise it be appro- and amended at 61 FR 21966, 21968, May 13, priate. If the United States Attorney 1996; 61 FR 29294, June 10, 1996; 68 FR 17551, has no objection, the procedure as to Apr. 10, 2003; 77 FR 38181, June 27, 2012] autopsy will be the same as if the death had not been reported to him or VETERANS CANTEEN SERVICE her. (c) Jurisdiction. If the United States § 17.180 Delegation of authority. does not have exclusive jurisdiction In connection with the Veterans Can- over the area where the body is found teen Service, the Under Secretary for the local medical examiner/coroner Health is hereby delegated authority as will be informed. If the local medical follows: examiner/coroner declines to assume (a) To exercise the powers and func- jurisdiction the procedure will be the tions of the Secretary with respect to same as is provided in paragraph (b) of the maintenance and operation of the this section. If a Federal crime is indi- Veterans Canteen Service. cated by the evidence, the procedure of (b) To designate the Assistant Chief paragraph (b) of this section will also Medical Director for Administration to be followed. administer the overall operation of the (d) Applicable law. (1) The laws of the Veterans Canteen Service and to des- state where the autopsy will be per- ignate selected employees of the Vet- formed are to be used to identify the erans Canteen Service to perform the
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functions described in the enabling erans Affairs. After arranging for an statute, 38 U.S.C. ch. 75, so as to effec- inspection of the State home’s facili- tively maintain and operate the Vet- ties for furnishing domiciliary or hos- erans Canteen Service. pital care, the Under Secretary for [20 FR 337, Jan. 14, 1955, as amended at 36 FR Health will make a recommendation to 23386, Dec. 9, 1971; 45 FR 6939, Jan. 3l, 1980. the Secretary who will notify the State Redesignated at 61 FR 21966, May 13, 1996, as official in writing of a decision. amended at 62 FR 17072, Apr. 9, 1997] [35 FR 3166, Feb. 19, 1970, as amended at 45 AID TO STATES FOR CARE OF VETERANS FR 6939, Jan. 31, 1980. Redesignated and IN STATE HOMES amended at 61 FR 21966, 21968, May 13, 1996; 65 FR 968, Jan. 6, 2000] NOTE: Sections 17.190 through 17.200 do not apply to nursing home care in State homes. § 17.192 Approval of annexes and new The provisions for nursing home care in facilities. State homes are set forth in 38 CFR part 51. Separate applications for recognition § 17.190 Recognition of a State home. must be filed for any annex, branch, A State-operated facility which pro- enlargement, expansion, or relocation vides hospital or domiciliary care to of a recognized home which is not on veterans must be formally recognized the same or contiguous grounds on by the Secretary as a State home be- which the parent facility is located. fore Federal aid payments can be made When a recognized State home estab- for the care of such veterans. Any lishes hospital care facilities which agency of a State (exclusive of a terri- have not been inspected and approved tory or possession) responsible for the by the Department of Veterans Affairs, maintenance or administration of a a request for separate approval of such State home may apply for recognition facilities must be made. by the Department of Veterans Affairs (Authority: 38 U.S.C. 1741, 501) for the purpose of receiving aid for the care of veterans in such State home. A [35 FR 3166, Feb. 19, 1970, as amended at 45 State home may be recognized if: FR 6939, Jan. 31, 1980. Redesignated and amended at 61 FR 21966, 21968, May 13, 1996; 65 (Authority: 38 U.S.C. 501, 1741) FR 968, Jan. 6, 2000] (a) The State home is a facility § 17.193 Prerequisites for payments to which exists primarily for the accom- State homes. modation of veterans incapable of earning a living and who are in need of No payment or grant may be made to domiciliary, and any State home unless the State home (b) The majority of such veterans meets the standards prescribed by the who are domiciliary members in the Secretary. home are veterans who may be in- (Authority: 38 U.S.C. 1742(a)) cluded in the computation of the amount of aid payable from the De- [45 FR 6939, Jan. 31, 1980. Redesignated at 61 partment of Veterans Affairs, and FR 21966, May 13, 1996; 65 FR 968, Jan. 6, 2000] (c) The personnel, building and other § 17.194 Aid for domiciliary care. facilities and improvements at the home are devoted primarily to the care Aid may be paid to the designated of veterans. State official for domiciliary care fur- nished in a recognized State home for [35 FR 3166, Feb. 19, 1970, as amended at 45 FR 6939, Jan. 31, 1980. Redesignated and any veteran if the veteran is eligible amended at 61 FR 21966, 21968, May 13, 1996; 65 for domiciliary care in a Department of FR 968, Jan. 6, 2000; 72 FR 18128, Apr. 11, 2007] Veterans Affairs facility.
§ 17.191 Filing applications. (Authority: 38 U.S.C. 1741) Applications for Department of Vet- [45 FR 6939, Jan. 31, 1980. Redesignated at 61 erans Affairs recognition of a State FR 21966, May 13, 1996] home may be filed with the Under Sec- retary for Health, Department of Vet-
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§ 17.196 Aid for hospital care. of jurisdiction within 10 days after the Aid may be paid to the designated beginning of the care of such veteran State official for hospital care fur- for which he or she is determined to be nished in a recognized State home for eligible, payment shall be made on ac- any veteran if: count of such veteran from the date (a) The veteran is eligible for hos- care began. pital care in a Department of Veterans (Authority: 38 U.S.C. 1743) Affairs facility, and [35 FR 3167, Feb. 19, 1970, as amended at 45 (b) The quarters in which the hos- FR 6940, Jan. 31, 1980. Redesignated at 61 FR pital care is carried out are in an area 21966, May 13, 1996; 65 FR 968, Jan. 6, 2000] clearly designated for such care, spe- cifically established, staffed and § 17.199 Inspection of recognized State equipped to provide hospital type care, homes. are not intermingled with the quarters Representatives of the Department of of nursing home care patients or domi- Veterans Affairs may inspect any State ciliary members, and meet such other home at such times as are deemed nec- minimum standards as the Department essary. Such inspections shall be con- of Veterans Affairs may prescribe. cerned with the physical plant; records [45 FR 6940, Jan. 31, 1980. Redesignated at 61 relating to admissions, discharges and FR 21966, May 13, 1996] occupancy; fiscal records; and all other areas of interest necessary to a deter- § 17.197 Amount of aid payable. mination of compliance with applicable The amount of aid payable to a rec- laws and regulations relating to the ognized State home shall be at the per payment of Federal aid. The authority diem rates established by title 38 to inspect carries with it no authority U.S.C., section 1741(a)(1) for domi- over the management or control of any ciliary care; and section 1741(a)(3) for State home. hospital care. In no case shall the pay- (Authority: 38 U.S.C. 1742) ments made with respect to any vet- [30 FR 221, Jan. 8, 1965, as amended at 35 FR eran exceed one-half of the cost of the 3167, Feb. 19, 1970. Redesignated at 61 FR veteran’s care in the State home. VA 21966, May 13, 1996] will publish the actual per diem rates, whenever they change, in a FEDERAL § 17.200 Audit of State homes. REGISTER notice. The State must comply with the Sin- (Authority: 38 U.S.C. 1741) gle Audit Act of 1984 (part 41 of this chapter). [50 FR 32568, Aug. 13, 1985. Redesignated at 61 FR 21966, May 13, 1996; 65 FR 968, Jan. 6, 2000] (Authority: 31 U.S.C. 7501–7507)
§ 17.198 Department of Veterans Af- [52 FR 23825, June 25, 1987. Redesignated at 61 fairs approval of eligibility re- FR 21966, May 13, 1996] quired. SHARING OF MEDICAL FACILITIES, Federal aid will be paid only for the EQUIPMENT, AND INFORMATION care of veterans whose separate eligi- bility for hospital or domiciliary care § 17.230 Contingency backup to the has been approved by the Department Department of Defense. of Veterans Affairs. To obtain such ap- (a) Priority care to active duty per- proval, State homes will complete a sonnel. The Secretary, during and/or Department of Veterans Affairs appli- immediately following a period of war cation form for each veteran for the or national emergency declared by the type of care to be provided and submit Congress or the President that involves it to the Department of Veterans Af- the use of United States Armed Forces fairs office of jurisdiction for deter- in armed conflict, is authorized to fur- mination of eligibility. Payments shall nish hospital care, nursing home care, be made only from the date the Depart- and medical services to members of the ment of Veterans Affairs office of juris- Armed Forces on active duty. The Sec- diction receives such application; how- retary may give higher priority in the ever, if such request is received by the furnishing of such care and services in Department of Veterans Affairs office VA facilities to members of the Armed
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Forces on active duty than to any mutual use or exchange of use of spe- other group of persons eligible for such cialized medical resources when such care and services with the exception of an agreement will obviate the need for veterans with service-connected dis- a similar resource to be installed or abilities. provided at a facility operated by the Department of Veterans Affairs, or (Authority: 38 U.S.C. 8111A, Pub. L. 97–174) (2) It will secure effective use of De- (b) Contract authority. During a period partment of Veterans Affairs special- in which the Secretary is authorized to ized medical resources by providing for furnish care and services to members of the mutual use, or exchange of use, of the Armed Forces under paragraph (a) specialized medical resources in a facil- of this section, the Secretary, to the ity operated by the Department of Vet- extent authorized by the President and erans Affairs, which have been justified subject to the availability of appro- on the basis of veterans’ care, but priations or reimbursements, may au- which are not utilized to their max- thorize VA facilities to enter into con- imum effective capacity; and tracts with private facilities for the (b) The agreement is determined to provision during such period of hos- be in the best interest of the prevailing pital care and medical services for cer- standards of the Department of Vet- tain veterans. These veterans include erans Affairs Medical Program; and only those who are receiving hospital (c) The agreement provides for recip- care under 38 U.S.C. 1710 or, in emer- rocal reimbursement based on a charge gencies, for those who are eligible for which covers the full cost of the use of treatment under that section, or who specialized medical resources, inci- are receiving care under 38 U.S.C. 1712 dental hospital care or other needed (f) and (g). This authorization pertains services, supplies used, and normal de- only to circumstances in which VA fa- preciation and amortization costs of cilities are not capable of furnishing or equipment. continuing to furnish the care or serv- ices required because of the furnishing (d) Reimbursement for medical care of care and services to members of the rendered to an individual who is enti- Armed Forces. tled to hospital or medical services (Medicare) under subchapter XVIII of (Authority: 38 U.S.C. 8111A) chapter 7 of title 42 U.S.C., and who has (Authority: Sec. 501 and 1720(a) of Title 38, no entitlement to medical care from U.S.C.) the Department of Veterans Affairs, [49 FR 5617, Feb. 14, 1984. Redesignated at 61 will be made to such facility, or if the FR 21966, May 13, 1996] contract or agreement so provides, to the community health care facility § 17.240 Sharing specialized medical which is party to the agreement, in ac- resources. cordance with: Subject to such terms and conditions (1) Rates prescribed by the Secretary as the Under Secretary for Health shall of Health and Human Services, after prescribe, agreements may be entered consultation with the Secretary of Vet- into for sharing medical resources with erans Affairs, and other hospitals, including State or (2) Procedures jointly prescribed by local, public or private hospitals or the Secretary of Health and Human other medical installations having hos- Services and the Secretary of Veterans pital facilities or organ banks, blood Affairs to assure reasonable quality of banks, or similar institutions, or med- care and service and efficient and eco- ical schools or clinics in a medical nomical utilization of resources. community with geographical limita- tions determined by the Under Sec- (Authority: 38 U.S.C. 8153) retary for Health, provided: [32 FR 6841, May 4, 1967, as amended at 35 FR (a) The agreement will achieve one of 18198, Nov. 28, 1970; 39 FR 1846, Jan. 15, 1974; the following purposes: (1) It will se- 45 FR 6940, Jan. 31, 1980; 47 FR 58250, Dec. 30, cure the use of a specialized medical 1982; 54 FR 34983, Aug. 23, 1989. Redesignated resource which otherwise might not be at 61 FR 21966, May 13, 1996, as amended at 62 feasibly available by providing for the FR 17072, Apr. 9, 1997]
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§ 17.241 Sharing medical information Health shall prescribe, Directors of De- services. partment of Veterans Affairs medical (a) Agreements for exchange of informa- centers shall charge for information tion. Subject to such terms and condi- and educational facilities and services tions as the Under Secretary for Health made available under paragraph (d) of shall prescribe, Directors of Depart- this section. The fee may be on an an- ment of Veterans Affairs medical cen- nual or other periodic basis, at rates ters, may enter into agreements with determined, after appropriate study, to medical schools, Federal, State or be fair and equitable. The financial sta- local, public or private hospitals, re- tus of any user of such services shall be search centers, and individual members taken into consideration in estab- of the medical profession, under which lishing the amount of the fee to be medical information and techniques paid. will be freely exchanged and the med- ical information services of all parties [32 FR 6841, May 4, 1967, as amended at 47 FR to the agreement will be available for 58250, Dec. 30, 1982. Redesignated at 61 FR use by any party to the agreement 21966, May 13, 1996, as amended at 62 FR under conditions specified in the agree- 17072, Apr. 9, 1997] ment. (b) Purpose of sharing agreements. § 17.242 Coordination of programs Agreements for the exchange of infor- with Department of Health and mation shall be used to the maximum Human Services. extent practicable to create at each Programs for sharing specialized Department of Veterans Affairs med- medical resources or medical informa- ical center which has entered into such tion services shall be coordinated to a an agreement, an environment of aca- maximum extent practicable, with pro- demic medicine which will help the grams carried out under part F, title hospital attract and retain highly XVI of the Public Health Service Act trained and qualified members of the under the jurisdiction of the Depart- medical profession. ment of Health and Human Services. (c) Use of electronic equipment. Recent developments in electronic equipment [32 FR 6842, May 4, 1967, as amended at 45 FR shall be utilized under information 6940, Jan. 31, 1980; 47 FR 58250, Dec. 30, 1982. sharing programs to provide a close Redesignated at 61 FR 21966, May 13, 1996] educational, scientific, and profes- sional link between Department of Vet- GRANTS FOR EXCHANGE OF INFORMATION erans Affairs medical centers and § 17.250 Scope of the grant program. major medical centers. (d) Furnishing information services on a The provisions of § 17.250 through fee basis. The educational facilities and § 17.266 are applicable to grants under programs established at Department of 38 U.S.C. 8155 for programs for the ex- Veterans Affairs Medical Centers and change of medical information. The the electronic link to medical centers purpose of these grants is to assist shall be made available for use by med- medical schools, hospitals, and re- ical entities in the surrounding med- search centers in planning and car- ical community which have not en- rying out agreements for the exchange tered into sharing agreements with the of medical information, techniques, Department of Veterans Affairs, in and information services. The grant order to bring about utilization of all funds may be used for the employment medical information in the sur- of personnel, the construction of facili- rounding medical community, particu- ties, the purchasing of equipment, re- larly in remote areas, and to foster and search, training or demonstration ac- encourage the widest possible coopera- tivities when necessary to implement tion and consultation among all mem- exchange of information agreements. bers of the medical profession in the surrounding medical community. [33 FR 6011, Apr. 19, 1968. Redesignated and (e) Establishing fees for information amended at 61 FR 21966, 21968, May 13, 1996] services. Subject to such terms and con- ditions as the Under Secretary for
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§ 17.251 The Subcommittee on Aca- which the grant funds applied for will demic Affairs. implement, and There is established within the Spe- (c) To include descriptions and plans. cial Medical Advisory Group author- Each application shall include a de- ized under the provisions of 38 U.S.C. scription of the use to which the grant 7312 a Subcommittee on Academic Af- funds will be applied in sufficient de- fairs, and the Subcommittee shall ad- tail to show need, purpose, and jus- vise the Secretary, through the Under tifications, and shall be illustrated by Secretary for Health, in matters perti- financial and budgetary data, and nent to achieving the objectives of pro- (d) To include cost participation infor- grams for exchange of medical infor- mation. Each application shall show the mation. The Subcommittee shall re- amount of the grant requested to be view each application for a grant and used for direct expenses by category of prepare a written report setting forth direct expenses, the amount requested recommendations as to the final action for indirect expenses related to the di- to be taken on the application. rect expenses, any additional amounts [42 FR 54804, Oct. 11, 1977. Redesignated at 61 which will be applied to the program or FR 21966, May 13, 1996, as amended at 62 FR planning from other Federal agencies, 17072, Apr. 9, 1997] and from other sources, and amounts or expenses which will be borne by the § 17.252 Ex officio member of sub- applicant, and committee. (e) To include assurance records will be The Assistant Chief Medical Director kept. Each application shall include for Academic Affairs shall be an ex sufficient assurances that the appli- officio member of the Subcommittee cant shall keep records which fully dis- on Academic Affairs. close the amount and disposition of the [42 FR 54804, Oct. 11, 1977. Redesignated at 61 proceeds of the grant, the total cost of FR 21966, May 13, 1996] the project or undertaking in connec- tion with which the grant is made or § 17.253 Applicants for grants. used, the portion of the costs supplied Applicants for grants generally will by non-Federal sources, and such other be persons authorized to represent a records as will facilitate an effective medical school, hospital, or research audit. All such records shall be re- center which has in effect or has ten- tained by the applicant (grantee) for a tatively approved an agreement with period of 3 years after the submission the Department of Veterans Affairs to of the final expenditure report, or if exchange medical information. litigation, claim or audit is started be- fore the expiration of the 3-year period, [33 FR 6011, Apr. 19, 1968. Redesignated at 61 FR 21966, May 13, 1996] the records shall be retained until all litigation, claims or audit findings in- § 17.254 Applications. volving the records have been resolved, Each application for a grant shall be and submitted to the Under Secretary for (f) To include assurance records will be Health on such forms as shall be pre- made available. Each application shall scribed and shall include the following include sufficient assurances the appli- evidence, assurances, and supporting cant will give the Secretary and the documents: Comptroller General of the United (a) To specify amount. Each applica- States, or any of their authorized rep- tion shall show the amount of the resentatives, access to its books, docu- grant requested, and if the grant is to ments, papers, and records which are be for more than one objective, the pertinent to the grant for the purposes amounts allocated to each objective of audit and examination, and (e.g., to training, demonstrations, or (g) To include assurance progress re- construction) shall be specified, and ports will be made. Each application (b) To include copy of agreement. Each shall include sufficient assurances the application shall be accompanied by a applicant will furnish the Under Sec- copy of the agreement for the exchange retary for Health periodic progress re- of information or information services ports in sufficient detail showing the
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status of the project, planning, pro- be considered either before or after gram, or system funded by the grant final action has been taken on the for which application is made, and the original application. Amended applica- extent to which the stated objectives tions and applications for supplemental will have been achieved, and grants shall be subject to the same (h) To include civil rights assurances. terms, conditions and requirements Each application shall include suffi- necessary for original applications. cient assurances that no part of the [33 FR 6012, Apr. 19, 1968. Redesignated at 61 grant funds will be used either by the FR 21966, May 13, 1996] grantee or by any contractor or sub- contractor to be paid from grant funds § 17.257 Awards procedures. for any purpose which is inconsistent Applications for grants for planning with regulations promulgated by the or implementing agreements for the Secretary (part 18 of this chapter) im- exchange of medical information or in- plementing title VI of the Civil Rights formation facilities shall be reviewed Act of 1964, or inconsistent with Execu- by the Under Secretary for Health or tive Order 11246 (30 FR 12319) and any designee. If it is determined approval implementing regulations the Sec- of the grant is warranted, rec- retary of Labor may promulgate. ommendations to that effect shall be [33 FR 6011, Apr. 19, 1968, as amended at 36 made to the Secretary in writing and FR 320, Jan. 9, 1971; 42 FR 54804, Oct. 11, 1977. shall be accompanied by the following: Redesignated and amended at 61 FR 21966, (a) The recommendation for approval 21969, May 13, 1996] shall be accompanied by the written recommendation of the Subcommittee § 17.255 Applications for grants for on Academic Affairs, and programs which include construc- tion projects. (b) The recommendation for approval shall be accompanied by the written In addition to the documents and evi- draft of the certificate of award stating dence required by § 17.254, any applica- all conditions which the grantee is re- tion for a grant for the construction of quired to agree to under the provisions any facility, structure or system which of § 17.258 and all other conditions to is part of an exchange of information which it has been determined the grant program shall include the following: will be subject, and (a) Each application shall include (c) The recommendation shall in- complete descriptions, maps, and sur- clude a certification that sufficient ap- veys of the construction site, and docu- propriated funds are available, and mentary evidence and explanations that the application for the grant is showing ownership, and sufficient in all details as specified in (b) Each application shall include §§ 17.254 through 17.256. complete plans and specifications for the construction project, and where ap- [33 FR 6012, Apr. 19, 1968, as amended at 42 FR 54805, Oct. 11, 1977. Redesignated and plicable, sufficient explanations of amended at 61 FR 21966, 21969, May 13, 1996] technical applications so that they may be understood by the layman, and § 17.258 Terms and conditions to (c) Each application shall contain as- which awards are subject. surance that the rates of pay for labor- Each certificate of award of a grant ers and mechanics engaged in construc- for planning or implementing an agree- tion activities will not be less than the ment for the exchange of information prevailing local wage rates for similar or information facilities shall specify work as determined in accordance with that the grant is subject to the fol- the provisions of 40 U.S.C. 276a—276a–5 lowing terms and conditions: (The Davis-Bacon Act). (a) Grants subject to terms of agreement [33 FR 6012, Apr. 19, 1968. Redesignated and for exchange of information. Each grant amended at 61 FR 21966, 21969, May 13, 1996] 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
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(b) Grants subject to assurances in ap- basis of a negotiated lump-sum allow- plication. Each grant shall be subject to ance. In the method of computation all assurances made by the grantee in used, only indirect costs shall be in- its application for the grant as re- cluded which bear a reasonable rela- quired by §§ 17.254 through 17.256, and tionship to the planning or program (c) Grants subject to limitations on use funded by the grant and shall not ex- of funds. Each grant shall be subject to ceed a percentage greater than the per- the limitations on the use of grant centage the total institutional indirect funds, either for direct or indirect cost is of the total direct salaries and costs, as prescribed in §§ 17.259 through wages paid by the institution. 17.261, and [33 FR 6012, Apr. 19, 1968. Redesignated at 61 (d) Grants subject to special provisions. FR 21966, May 13, 1996] Each grant shall be subject to any spe- cial terms or conditions which may be § 17.262 Authority to approve applica- warranted by circumstances applicable tions discretionary. to individual applications, and speci- Notwithstanding any recommenda- fied in the certificate of award. tion by the Subcommittee on Aca- [33 FR 6012, Apr. 19, 1968. Redesignated and demic Affairs of the Special Medical amended at 61 FR 21966, 21969, May 13, 1996] Advisory Group, or any recommenda- tion by the Under Secretary for Health § 17.259 Direct costs. or designee, the final determination on Direct costs to which grant funds any application for a grant rests solely may be applied may include in propor- with the Secretary. tion to time and effort spent, but are [42 FR 54805, Oct. 11, 1977. Redesignated and not limited to, fees and costs directly amended at 61 FR 21966, 21969, May 13, 1996] paid to personnel or for fringe benefits, rent, publications, educational pro- § 17.263 Suspension and termination grams, training, research, demonstra- procedures. tion activities, or construction carried Termination of a grant means the out in connection with pilot programs cancellation of Department of Veterans for planning or exchange of informa- Affairs sponsorship, in whole or in tion. part, under an agreement at any time prior to the date of completion. Sus- [33 FR 6012, Apr. 19, 1968. Redesignated at 61 FR 21966, May 13, 1996] pension of a grant is an action by the Department of Veterans Affairs which § 17.260 Patient care costs to be ex- temporarily suspends Department of cluded from direct costs. Veterans Affairs sponsorship under the Grant funds for planning or imple- grant pending corrective action by the menting agreements for the exchange grantee or pending a decision to termi- of medical information shall not be nate the grant by the Department of available for the payment of any hos- Veterans Affairs. (a) The fol- pital, medical, or other costs involving Posttermination appeal. lowing procedures are applicable for re- the care of patients except to the ex- viewing postaward disputes which may tent that such costs are determined to arise in the administration of or car- be incident to research, training, or rying out of the Exchange of Medical demonstration activities carried out in Information Grant Program. connection with an exchange of infor- (1) Reviewable decisions. The Depart- mation program. ment of Veterans Affairs reserves the [33 FR 6012, Apr. 19, 1968. Redesignated at 61 right to terminate any grant in whole FR 21966, May 13, 1996] or in part at any time before the date of completion, whenever it determines § 17.261 Indirect costs. that the grantee has failed to comply The grantee shall allocate expendi- with conditions of the agreement, or tures as between direct and indirect otherwise failed to comply with any costs according to generally accepted law, regulation, assurance, term, or accounting procedures. The amount al- condition applicable to the grant. located for indirect costs may be com- (2) Notice. The Department of Vet- puted on a percentage basis or on the erans Affairs shall promptly notify the
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grantee in writing of the determina- (7) Presentation of case. If the Assist- tion. The notice shall set forth the rea- ant Chief Medical Director for Aca- son for the determination in sufficient demic Affairs believes there is no dis- detail to enable the grantee to respond, pute as to material fact, the resolution and shall inform the grantee of his or of which would be materially assisted her opportunity for review by the As- by oral testimony, both parties shall be sistant Chief Medical Director as pro- notified of the issues to be considered, vided in this section. and take steps to afford both parties (3) Request for appeal. A grantee with the opportunity for presenting their respect to whom a determination de- cases, at the option of the Assistant scribed in paragraph (a)(1) of this sec- Chief Medical Director for Academic tion has been made, and who desires re- Affairs, in whole or in part in writing, view, may file with the Assistant Chief or in an informal conference. Where it Medical Director for Academic Affairs is concluded that oral testimony is re- an application for review of such deter- quired to resolve a dispute over a mate- mination. The grantee’s application for rial fact, both parties shall be afforded review must be post-marked no later an opportunity to present and cross-ex- than 30 days after the postmarked date amine witnesses at a hearing. of notification provided pursuant to (8) Decision. After both parties have paragraph (a)(2) of this section. presented their cases, the Assistant (4) Contents of request. The applica- Chief Medical Director for Academic tion for review must clearly identify Affairs shall prepare an initial written decision which shall include findings of the question or questions in dispute, fact and conclusions based thereon. contain a full statement of the grant- Copies of the decision shall be mailed ee’s position in respect to such ques- promptly to each of the parties to- tion or questions, and provide perti- gether with a notice informing them of nent facts and reasons in support of his their right to appeal the decision of the or her position. The Assistant Chief Secretary, or to the officer or em- Medical Director for Academic Affairs ployee to whom the Secretary has dele- will promptly send a copy of the grant- gated such authority, by submitting ee’s application to the Department of written comments thereon within a Veterans Affairs official responsible for specified reasonable time. the determination which is to be re- (9) Final decision. Upon filing com- viewed. ments with the Secretary, or des- (5) Effect of submission. When an appli- ignated officer or employee, the review cation for review has been filed no ac- of the initial decision shall be con- tion may be taken by the Department ducted on the basis of the decision, the of Veterans Affairs pursuant to such hearing record, if any, and written determination until such application comments submitted by both parties. has been disposed of, except that the The decision shall be final. filing of the application shall not affect (10) Participation by a party. Either the authority which the constituent party may participate in person, or by agency may have to suspend the sys- counsel pursuant to the procedure set tem under a grant during proceedings forth in this section. under this section or otherwise to (b) Termination for convenience. The withhold or defer payments under the Department of Veterans Affairs or the grant. grantee may terminate a grant in (6) Consideration of request. When an whole or in part when both parties application for review has been filed agree that the continuation of the with the Assistant Chief Medical Direc- project would not produce beneficial tor for Academic Affairs, and it has results commensurate with the further been determined that the application expenditure of funds. The two parties meets the requirements stated in this shall agree upon the termination con- paragraph, all background material of ditions, including the effective date the issues shall be reviewed. If the ap- 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
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the effective date, and shall cancel as ical Director for Academic Affairs for a many outstanding obligations as pos- final determination. sible. The Department of Veterans Af- [42 FR 54805, Oct. 11, 1977. Redesignated at 61 fairs shall allow full credit to the FR 21966, May 13, 1996] grantee for the Department of Vet- erans Affairs share of the § 17.265 Payments. noncancellable obligations, properly incurred by the grantee prior to termi- Payments of grant funds are made to nation. grantees through a letter-of-credit, an advance by Treasury check, or a reim- (c) Suspension procedures. When a bursement by Treasury check, as ap- grantee has failed to comply with the propriate. A letter-of-credit is an in- terms of the grant agreement and con- strument certified by an authorized of- ditions or standards, the Department ficial of the Department of Veterans of Veterans Affairs may, on reasonable Affairs which authorizes the grantee to notice to the grantee, suspend the draw funds when needed from the grant and withhold further payments, Treasury, through a Federal Reserve prohibit the grantee from incurring ad- bank and the grantee’s commercial ditional obligations of funds, pending bank and shall be used by the Depart- corrective action by the grantee, or ment of Veterans Affairs where all the make a decision to terminate as de- following conditions exist: scribed in paragraph (a) of this section. (a) When there is or will be a con- The Department of Veterans Affairs tinuing relationship between the grant- shall allow all necessary and proper ee and the Department of Veterans Af- costs that the grantee could not rea- fairs for at least a 12-month period and sonably avoid during the period of sus- the total amount of advance payments pension provided that they meet the expected to be received within that pe- provisions of the applicable Federal riod is $250,000, or more; cost principles. (b) When the grantee has established [42 FR 54805, Oct. 11, 1977. Redesignated at 61 or demonstrated the willingness and FR 21966, May 13, 1996] ability to maintain procedures that will minimize the time elapsing be- § 17.264 Recoupments and releases. tween the transfer of funds and their In any case where the Department of disbursement by the grantee; and Veterans Affairs or a grantee’s obliga- (c) When the grantee’s financial man- tions under an exchange of information agement meets the standards for fund agreement implemented by grant funds control and accountability. An advance are terminated, or where grant-fi- by Treasury check is a payment made nanced equipment or facilities cease to to a grantee upon its request before be used for the purposes for which outlays are made by the grantee, or grant support was given, or when through use of predetermined payment grant-financed property is transferred, schedules and shall be used by the De- the grantee shall return the propor- partment of Veterans Affairs when the tionate value of such equipment or fa- grantee meets all of the above require- cility as was financed by the grant. ments of this section except that ad- When it is determined the Department vances will be less than $250,000, or for of Veterans Affairs equitable interest a period less than 12 months. Reim- is greater that proportionate value, bursement by Treasury check is a pay- then a claim in such greater amount ment made to a grantee upon request shall be asserted. If it is determined an for reimbursement from the grantee amount less than proportionate value and shall be the preferred method when or less than the Department of Vet- the grantee does not meet the require- erans Affairs equitable interest should ments of paragraphs (b) and (c) of this be recouped, or that the Department of section. This method may be used on Veterans Affairs should execute any re- any construction agreement, or if the leases, then a proposal concerning such major portion of the program is accom- a settlement or releases complete with plished through private market financ- explanations and justifications shall be ing or Federal loans, and the Federal submitted to the Assistant Chief Med- assistance constitutes a minor portion
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of the program. When the reimburse- in 38 U.S.C. 101. The term ‘‘fiscal year’’ ment method is used, the Department refers to October 1, through September of Veterans Affairs shall make pay- 30. ment within 30 days after receipt of the (Authority: 38 U.S.C. 501, 1781) billing, unless billing is improper. Un- less otherwise required by law, pay- [63 FR 48102, Sept. 9, 1998, as amended at 73 ments shall not be withheld for proper FR 65553, Nov. 4, 2008] charges at any time during the grant § 17.271 Eligibility. period unless a grantee has failed to comply with the program objectives, (a) General entitlement. The following award conditions, or Federal reporting persons are eligible for CHAMPVA ben- requirements; or the grantee is in- efits provided that they are not eligible debted. under Title 10 for the TRICARE Pro- gram or Part A of Title XVIII of the [42 FR 54806, Oct. 11, 1977. Redesignated at 61 Social Security Act (Medicare) except FR 21966, May 13, 1996] as provided in paragraph (b) of this sec- § 17.266 Copyrights and patents. tion. (1) The spouse or child of a veteran If a grant-supported program results who has been adjudicated by VA as in copyrightable material or patent- having a permanent and total service- able inventions or discoveries, the connected disability; United States Government shall have (2) The surviving spouse or child of a the right to use such publications or veteran who died as a result of an adju- inventions on a royalty-free basis. dicated service-connected condition(s); [33 FR 6013, Apr. 19, 1968. Redesignated at 61 or who at the time of death was adju- FR 21966, May 13, 1996] dicated permanently and totally dis- abled from a service-connected condi- CIVILIAN HEALTH AND MEDICAL PRO- tion(s); GRAM OF THE DEPARTMENT OF VET- (3) The surviving spouse or child of a ERANS AFFAIRS (CHAMPVA)—MED- person who died on active military ICAL CARE FOR SURVIVORS AND DE- service and in the line of duty and not PENDENTS OF CERTAIN VETERANS due to such person’s own misconduct; and SOURCE: 63 FR 48102, Sept. 9, 1998, unless otherwise noted. (4) An eligible child who is pursuing a full-time course of instruction ap- § 17.270 General provisions. proved under 38 U.S.C. Chapter 36, and (a) CHAMPVA is the Civilian Health who incurs a disabling illness or injury and Medical Program of the Depart- while pursuing such course (between ment of Veterans Affairs and is admin- terms, semesters or quarters; or during istered by the Health Administration a vacation or holiday period) that is Center, Denver, Colorado. Pursuant to not the result of his or her own willful 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 sup- (iii) The twenty-third birthday of the plies for eligible beneficiaries as set child, whichever occurs first. forth in §§ 17.271 through 17.278. (b) For purposes of §§ 17.270 through (Authority: 38 U.S.C. 501, 1781) 17.278, the definitions of ‘‘child,’’ (b) CHAMPVA and Medicare entitle- ‘‘service-connected condition/dis- ment. (1) Individuals under age 65 who ability,’’ ‘‘spouse,’’ and ‘‘surviving are entitled to Medicare Part A and en- spouse’’ must be those set forth further rolled in Medicare Part B, retain
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CHAMPVA eligibility as secondary fits may have limitations. The fact payer to Medicare Parts A and B, Medi- that a physician may prescribe, order, care supplemental insurance plans, and recommend, or approve a service or Medicare HMO plans. supply does not, of itself, make it (2) Individuals age 65 or older, and medically necessary or make the not entitled to Medicare Part A, retain charge an allowable expense, even CHAMPVA eligibility. though it is not listed specifically as an exclusion. The following are specifi- NOTE TO PARAGRAPH (b)(2): If the person is not eligible for Part A of Medicare, a Social cally excluded from program coverage: Security Administration ‘‘Notice of Dis- (1) Services, procedures or supplies allowance’’ certifying that fact must be sub- for which the beneficiary has no legal mitted. Additionally, if the individual is en- obligation to pay, or for which no titled to only Part B of Medicare, but not charge would be made in the absence of Part A, or Part A through the Premium HI coverage under a health benefits plan. provisions, a copy of the individual’s Medi- (2) Services and supplies required as a care card or other official documentation result of an occupational disease or in- noting this must be provided. jury for which benefits are payable (3) Individuals age 65 on or after June under workers’ compensation or simi- 5, 2001, who are entitled to Medicare lar protection plan (whether or not Part A and enrolled in Medicare Part such benefits have been applied for or B, are eligible for CHAMPVA as sec- paid) except when such benefits are ex- ondary payer to Medicare Parts A and hausted and are otherwise not excluded B, Medicare supplemental insurance from CHAMPVA coverage. plans, and Medicare HMO plans for (3) Services and supplies that are services received on or after October 1, paid directly or indirectly by a local, 2001. State or Federal government agency (4) Individuals age 65 or older prior to (Medicaid excluded), including court- June 5, 2001, who are entitled to Medi- ordered treatment. In the case of the care Part A and who have not pur- following exceptions, CHAMPVA as- chased Medicare Part B, are eligible for sumes primary payer status: CHAMPVA as secondary payer to Medi- (i) Medicaid. care Part A and any other health insur- (ii) State Victims of Crime Com- ance for services received on or after pensation Programs. October 1, 2001. (4) Services and supplies that are not (5) Individuals age 65 or older prior to medically or psychologically necessary June 5, 2001, who are entitled to Medi- for the diagnosis or treatment of a cov- care Part A and who have purchased ered condition (including mental dis- Medicare Part B must continue to order) or injury. 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
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primarily for purposes of remaining (ii) Dental care required in prepara- with the mother when the mother (but tion for, or as a result of, radiation not the newborn infant) requires ex- therapy for oral or facial cancer. tended postpartum inpatient stay. (iii) Gingival Hyperplasia. (9) Therapeutic absences from an in- (iv) Loss of jaw substance due to di- patient facility or residential treat- rect trauma to the jaw or due to treat- ment center (RTC). ment of neoplasm. (10) Custodial care. (v) Intraoral abscess when it extends (11) Inpatient stays primarily for beyond the dental alveolus. domiciliary care purposes. (12) Inpatient stays primarily for rest (vi) Extraoral abscess. or rest cures. (vii) Cellulitis and osteitis which is (13) Services and supplies provided as clearly exacerbating and directly af- a part of, or under, a scientific or med- fecting a medical condition currently ical study, grant, or research program. under treatment. (14) Services and supplies not pro- (viii) Repair of fracture, dislocation, vided in accordance with accepted pro- and other injuries of the jaw, to in- fessional medical standards or related clude removal of teeth and tooth frag- to experimental or investigational pro- ments only when such removal is inci- cedures or treatment regimens. dental to the repair of the jaw. (15) Services or supplies prescribed or (ix) Treatment for stabilization of provided by a member of the bene- myofascial pain dysfunction syndrome, ficiary’s immediate family, or a person also referred to as temporomandibular living in the beneficiary’s or sponsor’s joint (TMJ) syndrome. Authorization is household. limited to initial radiographs, up to (16) Services and supplies that are (or four office visits, and the construction are eligible to be) payable under an- of an occlusal splint. other medical insurance or program, (x) Total or complete ankyloglossia. either private or governmental, such as coverage through employment or Medi- (xi) Adjunctive dental and ortho- care. dontic support for cleft palate. (17) Services or supplies subject to (xii) Prosthetic replacement of jaw preauthorization (see § 17.273) that were due to trauma or cancer. obtained without the required (22) Nonsurgical treatment of obesity preauthorization; and services and sup- or morbid obesity for dietary control plies that were not provided according or weight reduction (with the excep- to the terms of the preauthorization. tion of gastric bypass, gastric stapling, (18) Inpatient stays primarily to con- or gastroplasty procedures in connec- trol or detain a runaway child, whether tion with morbid obesity when deter- or not admission is to an authorized in- mined to be medically necessary) in- stitution. cluding prescription medications. (19) Services and supplies (to include (23) Services and supplies related to prescription medications) in connec- transsexualism or other similar condi- tion with cosmetic surgery which is tions such as gender dysphoria (includ- performed to primarily improve phys- ing, but not limited to, intersex sur- ical appearance or for psychological gery and psychotherapy, except for am- purposes or to restore form without biguous genitalia which was docu- correcting or materially improving a mented to be present at birth). bodily function. (20) Electrolysis. (24) Sex therapy, sexual advice, sex- (21) Dental care with the following ual counseling, sex behavior modifica- exceptions: tion, psychotherapy for mental dis- (i) Dental care that is medically nec- orders involving sexual deviations (e.g., essary in the treatment of an otherwise transvestic fetish), or other similar covered medical condition, is an inte- services, and any supplies provided in gral part of the treatment of such med- connection with therapy for sexual ical condition, and is essential to the dysfunctions or inadequacies. control of the primary medical condi- (25) Removal of corns or calluses or tion. trimming of toenails and other routine
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foot care services, except those re- (CDC) and Prevention Advisory Com- quired as a result of a diagnosed sys- mittee on Immunization Practices. temic medical disease affecting the (5) Pediatric blood lead level test. lower limbs, such as severe diabetes. (6) Tuberculosis screening. (26) Services and supplies, to include (7) Blood pressure screening. psychological testing, provided in con- (8) Measurement of hemoglobin and nection with a specific developmental hematocrit for anemia. disorder. The following exception ap- (9) Urinalysis. plies: Diagnostic and evaluative serv- (C) Additional services or visits re- ices required to arrive at a differential quired because of specific findings or diagnosis for an otherwise eligible because the particular circumstances child unless the state is required to of the individual case are covered if provide those services under Public medically necessary and otherwise au- Law 94–142, Education for All Handi- thorized for benefits under CHAMPVA. capped Children Act of 1975 as amended, see 20 U.S.C. chapter 33. (ii) Rabies vaccine following an ani- (27) Surgery to reverse voluntary sur- mal bite. gical sterilization procedures. (iii) Tetanus vaccine following an ac- (28) Services and supplies related to cidental injury. artificial insemination (including (iv) Rh immune globulin. semen donors and semen banks), in (v) Pap smears. vitro fertilization, gamete (vi) Mammography tests. intrafallopian transfer and all other (vii) Genetic testing and counseling noncoital reproductive technologies. determined to be medically necessary. (29) Nonprescription contraceptives. (viii) Chromosome analysis in cases (30) Diagnostic tests to establish pa- of habitual abortion or infertility. ternity of a child; or tests to determine (ix) Gamma globulin. sex of an unborn child. (x) School-required physical exami- (31) Preventive care (such as routine, nations for beneficiaries through age 17 annual, or employment-requested phys- that are provided on or after October 1, ical examinations; routine screening 2001. procedures; and immunizations). The (32) Chiropractic and naturopathic following exceptions apply: services. (i) Well-child care from birth to age (33) Counseling services that are not six. Periodic health examinations de- medically necessary in the treatment signed for prevention, early detection, of a diagnosed medical condition (such and treatment of disease are covered to as educational counseling; vocational include screening procedures, immuni- counseling; and counseling for socio- zations, and risk counseling. The fol- economic purposes, stress manage- lowing services are payable when re- ment, life style modification, etc.). quired as part of a well-child care pro- (34) Acupuncture, whether used as a gram and when rendered by the attend- therapeutic agent or as an anesthetic. ing pediatrician, family physician, or a (35) Hair transplants, wigs, or pediatric nurse practitioner. hairpieces, except that benefits may be (A) Newborn examination, heredity extended for one wig or hairpiece per and metabolic screening, and newborn beneficiary (lifetime maximum) when circumcision. the attending physician certifies that (B) Periodic health supervision visits alopecia has resulted from treatment intended to promote optimal health for of malignant disease and the bene- infants and children to include the fol- ficiary certifies that a wig or hairpiece lowing services: has not been obtained previously (1) History and physical examination. through the U.S. Government (includ- (2) Vision, hearing, and dental ing the Department of Veterans Af- screening. fairs). The wig or hairpiece benefit does (3) Developmental appraisal to in- not include coverage for the following: clude body measurement. (i) Maintenance, wig or hairpiece (4) Immunizations as recommended supplies, or replacement of the wig or by the Centers for Disease Control hairpiece.
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(ii) Hair transplant or any other sur- condition, benefits may be extended for gical procedure involving the attach- a second set of lenses, subject to med- ment of hair or a wig or hairpiece to ical review. the scalp. (43) Hearing aids or other auditory (iii) Any diagnostic or therapeutic sensory enhancing devices. method or supply intended to encour- (44) Prostheses with the following ex- age hair growth. ceptions: (36) Self-help, academic education or (i) Dental prostheses specifically re- vocational training services and sup- quired in connection with otherwise plies. covered orthodontia directly related to (37) Exercise equipment, spas, whirl- the surgical correction of a cleft palate pools, hot tubs, swimming pools, anomaly. health club membership or other such (ii) Any prostheses, other than dental charges or items. prostheses, determined to be medically (38) General exercise programs, even necessary because of significant condi- if recommended by a physician. tions resulting from trauma, con- (39) Services of an audiologist or genital anomalies, or disease, includ- speech therapist, except when pre- ing, but not limited to: scribed by a physician and rendered as (A) Artificial limbs. a part of treatment addressed to the (B) Voice prostheses. physical defect itself and not to any (C) Eyes. educational or occupational deficit. (D) Items surgically inserted in the (40) Eye exercises or visual training body as an integral part of a surgical (orthoptics). procedure. (41) Eye and hearing examinations (E) Ears, noses, and fingers. except when rendered in connection (45) Orthopedic shoes, arch supports, with medical or surgical treatment of a shoe inserts, and other supportive de- covered illness or injury or in connec- vices for the feet, including special or- tion with well-child care. dered, custom-made built-up shoes, or (42) Eyeglasses, spectacles, contact regular shoes later built up with the lenses, or other optical devices with following exceptions: the following exceptions: (i) Shoes that are an integral part of (i) When necessary to perform the an orthopedic brace, and which cannot function of the human lens, lost as a be used separately from the brace. result of intraocular surgery, ocular in- (ii) Extra-depth shoes with inserts or jury or congenital absence. custom molded shoes with inserts for (ii) Pinhole glasses prescribed for use individuals with diabetes. after surgery for detached retina. (46) Services or advice rendered by (iii) Lenses prescribed as ‘‘treat- telephone are excluded except that a ment’’ instead of surgery for the fol- diagnostic or monitoring procedure lowing conditions: which incorporates electronic trans- (A) Contact lenses used for treatment mission of data or remote detection of infantile glaucoma. and measurement of a condition, activ- (B) Corneal or scleral lenses pre- ity, or function (biotelemetry) is cov- scribed in connection with treatment ered when: of keratoconus. (i) The procedure, without electronic (C) Scleral lenses prescribed to retain data transmission, is a covered benefit; moisture when normal tearing is not and present or is inadequate. (ii) The addition of electronic data (D) Corneal or scleral lenses pre- transmission or biotelemetry improves scribed to reduce a corneal irregularity the management of a clinical condition other than astigmatism. in defined circumstances; and (iv) The specified benefits are limited (iii) The electronic data or biotelem- to one set of lenses related to one etry device has been classified by the qualifying eye condition as set forth in U.S. Food and Drug Administration, ei- paragraphs (a)(42)(iii)(A) through (D) of ther separately or as part of a system, this section. If there is a prescription for use consistent with the medical change requiring a new set of lenses, condition and clinical management of but still related to the qualifying eye such condition.
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(47) Air conditioners, humidifiers, de- (62) Institutional services for partial humidifiers, and purifiers. hospitalization in excess of 60 treat- (48) Elevators. ment days in any fiscal year (or in an (49) Alterations to living spaces or admission) unless a waiver for extended permanent features attached thereto, coverage is granted in advance. even when necessary to accommodate (63) Detoxification in a hospital set- installation of covered durable medical ting or rehabilitation facility in excess equipment or to facilitate entrance or of seven days. exit. (64) Outpatient substance abuse serv- (50) Items of clothing, even if re- ices in excess of 60 visits during a ben- quired by virtue of an allergy (such as efit period. A benefit period begins cotton fabric versus synthetic fabric with the first date of covered service and vegetable-dyed shoes). and ends 365 days later. (51) Food, food substitutes, vitamins (65) Family therapy for substance or other nutritional supplements, in- abuse in excess of 15 visits during a cluding those related to prenatal care benefit period. A benefit period begins for a home patient whose condition with the first date of covered service permits oral feeding. and ends 365 days later. (52) Enuretic (bed-wetting) condi- (66) Services that are provided to a tioning programs. beneficiary who is referred to a pro- (53) Autopsy and post-mortem exami- vider of such services by a provider nations. who has an economic interest in the fa- (54) All camping, even when orga- cility to which the patient is referred, nized for a specific therapeutic purpose unless a waiver is granted. (such as diabetic camp or a camp for (67) Abortion except when a physi- emotionally disturbed children), or cian certifies that the life of the moth- when offered as a part of an otherwise er would be endangered if the fetus covered treatment plan. were carried to term. (55) Housekeeping, homemaker, or at- (68) Abortion counseling. tendant services, including a sitter or (69) Aversion therapy. companion. (70) Rental or purchase of bio- (56) Personal comfort or convenience feedback equipment. items, such as beauty and barber serv- ices, radio, television, and telephone. (71) Biofeedback therapy for treat- (57) Smoking cessation services and ment of ordinary muscle tension states supplies. (including tension headaches) or for (58) Megavitamin psychiatric ther- psychosomatic conditions. apy; orthomolecular psychiatric ther- (72) Drug maintenance programs apy. where one addictive drug is substituted (59) All transportation except for spe- for another, such as methadone sub- cialized transportation with life sus- stituted for heroin. taining equipment, when medically re- (73) Immunotherapy for malignant quired for the treatment of a covered diseases except for treatment of Stage condition. O and Stage A carcinoma of the blad- (60) Inpatient mental health services der. in excess of 30 days in any fiscal year (74) Services and supplies provided by (or in an admission), in the case of a other than a hospital, such as non- patient nineteen years of age or older; skilled nursing homes, intermediate 45 days in any fiscal year (or in an ad- care facilities, halfway houses, homes mission), in the case of a patient under for the aged, or other institutions of 19 years of age; or 150 days of residen- similar purpose. tial treatment care in any fiscal year (75) Services performed when the pa- (or in an admission) unless a waiver for tient is not physically present. extended coverage is granted in ad- (76) Medical photography. vance. (77) Special tutoring. (61) Outpatient mental health serv- (78) Surgery for psychological rea- ices in excess of 23 visits in a fiscal sons. year unless a waiver for extended cov- (79) Treatment of premenstrual syn- erage is granted in advance. drome (PMS).
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(80) Medications not requiring a pre- cluding admission of emotionally dis- scription, except for insulin and related turbed children and adolescents to resi- diabetic testing supplies and syringes. dential treatment centers. (81) Thermography. (b) All admissions to a partial hos- (82) Removal of tattoos. pitalization program (including alcohol (83) Penile implant/testicular pros- rehabilitation). thesis procedures and related supplies (c) Outpatient mental health visits in for psychological impotence. excess of 23 per calendar year and/or (84) Dermabrasion of the face except more than two (2) sessions per week. in those cases where coverage has been (d) Dental care. authorized for reconstructive or plastic surgery required to restore body form (e) Durable medical equipment with a following an accidental injury or to re- purchase or total rental price in excess vise disfiguring and extensive scars re- of $2,000. sulting from neoplastic surgery. (f) Organ transplants. (85) Chemical peeling for facial wrin- (Authority: 38 U.S.C. 501, 1781) kles. (86) Panniculectomy, body sculpting [63 FR 48102, Sept. 9, 1998, as amended at 74 procedures. FR 31374, July 1, 2009] (b) CHAMPVA-determined allowable amount. § 17.274 Cost sharing. (1) The term allowable amount is the (a) With the exception of services ob- maximum CHAMPVA-determined level tained through VA facilities, of payment to a hospital or other au- CHAMPVA is a cost-sharing program thorized institutional provider, a phy- in which the cost of covered services is sician or other authorized individual shared with the beneficiary. professional provider, or other author- CHAMPVA pays the CHAMPVA-deter- ized provider for covered services. The mined allowable amount less the de- CHAMPVA-allowable amount is deter- ductible, if applicable, and less the ben- mined prior to cost sharing and the ap- eficiary cost share. plication of deductibles and/or other (b) In addition to the beneficiary cost health insurance. share, an annual (calendar year) out- (2) A Medicare-participating hospital patient deductible requirement ($50 per must accept the CHAMPVA-deter- beneficiary or $100 per family) must be mined allowable amount for inpatient satisfied prior to the payment of out- services as payment-in-full. (Reference patient benefits. There is no deductible 42 CFR parts 489 and 1003). requirement for inpatient services or (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. (4) A provider who has collected and against the impact of a long-term ill- not made appropriate refund, or at- ness or injury, a calendar year cost tempts to collect from the beneficiary, limit or ‘‘catastrophic cap’’ has been any amount in excess of the placed on the beneficiary cost-share CHAMPVA-determined allowable amount for covered services and sup- amount may be subject to exclusion plies. Credits to the annual cata- from Federal benefit programs. strophic cap are limited to the applied annual deductible(s) and the bene- (Authority: 38 U.S.C. 501, 1781) ficiary cost-share amount. Costs above [63 FR 48102, Sept. 9, 1998, as amended at 67 the CHAMPVA-allowable amount, as FR 4359, Jan. 30, 2002; 73 FR 65553, Nov. 4, well as costs associated with non-cov- 2008] ered services are not credited to the catastrophic cap computation. After a § 17.273 Preauthorization. family has paid the maximum cost- Preauthorization or advance ap- share and deductible amounts for a cal- proval is required for any of the fol- endar year, CHAMPVA will pay allow- lowing: able amounts for the remaining cov- (a) Non-emergent inpatient mental ered services through the end of that health and substance abuse care in- calendar year.
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(i) Through December 31, 2001, the an- dures do not constitute a valid basis nual cap on cost sharing is $7,500 per for an exception. CHAMPVA-eligible family. (ii) Effective January 1, 2002, the cap (Authority: 38 U.S.C. 501, 1781) on cost sharing is $3,000 per [63 FR 48102, Sept. 9, 1998, as amended at 73 CHAMPVA-eligible family. FR 65553, Nov. 4, 2008] (d) If the CHAMPVA benefit payment is under $1.00, payment will not be § 17.276 Appeal/review process. issued. Catastrophic cap and deductible Notice of the initial determination will, however, be credited. regarding payment of CHAMPVA bene- (Authority: 38 U.S.C. 501, 1781) fits will be provided to the beneficiary on a CHAMPVA Explanation of Bene- [67 FR 4359, Jan. 30, 2002, as amended at 67 FR 6875, Feb. 14, 2002] fits (EOB) form. The EOB form is gen- erated by the CHAMPVA automated § 17.275 Claim filing deadline. payment processing system. If a bene- (a) Unless an exception is granted ficiary disagrees with the determina- under paragraph (b) of this section, tion concerning covered services or cal- claims for medical services and sup- culation of benefits, he or she may re- plies must be filed with the Center no quest reconsideration. Such requests later than: must be submitted to the Center in (1) One year after the date of service; writing within one year of the date of or the initial determination. The request (2) In the case of inpatient care, one must state why the beneficiary be- year after the date of discharge; or lieves the decision is in error and must (3) In the case of retroactive approval include any new and relevant informa- for medical services/supplies, 180 days tion not previously considered. Any re- following beneficiary notification of quest for reconsideration that does not authorization; or identify the reason for dispute will be (4) In the case of retroactive approval returned to the claimant without fur- of CHAMPVA eligibility, 180 days fol- ther consideration. After reviewing the lowing notification to the beneficiary claim and any relevant supporting doc- of authorization for services occurring umentation, a CHAMPVA benefits ad- on or after the date of first eligibility. visor will issue a written determina- (b) Requests for an exception to the tion to the beneficiary that affirms, re- claim filing deadline must be sub- verses or modifies the previous deci- mitted, in writing, to the Center and sion. If the beneficiary is still dissatis- include a complete explanation of the fied, within 90 days of the date of the circumstances resulting in late filing decision he or she may make a written along with all available supporting request for review by the Director, documentation. Each request for an ex- ception to the claim filing deadline Health Administration Center, or his willbe reviewed individually and con- or her designee. The Director, Health sidered on its own merit. The Director, Administration Center, or his or her Health Administration Center, or his designee will review the claim, and any or her designee may grant exceptions relevant supporting documentation, to the requirements in paragraph (a) of and issue a decision in writing that af- this section if he or she determines firms, reverses or modifies the previous that there was good cause for missing decision. The decision of the Director, the filing deadline. For example, when Health Administration Center, or his dual coverage exists CHAMPVA pay- or her designee with respect to benefit ment, if any, cannot be determined coverage and computation of benefits until after the primary insurance car- is final. rier has adjudicated the claim. In such circumstances an exception may be (Authority: 38 U.S.C. 501, 1781) granted provided that the delay on the NOTE TO § 17.276: Denial of CHAMPVA bene- part of the primary insurance carrier is fits based on legal eligibility requirements not attributable to the beneficiary. may be appealed to the Board of Veterans’ Delays due to provider billing proce- Appeals in accordance with 38 CFR part 20.
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Medical determinations are not appealable § 17.351 Grants for the replacement to the Board. 38 CFR 20.101. and upgrading of equipment at Vet- [63 FR 48102, Sept. 9, 1998, as amended at 73 erans Memorial Medical Center. FR 65553, Nov. 4, 2008] Grants to assist the Republic of the Philippines in the replacement and up- § 17.277 Third-party liability/medical grading of equipment and in rehabili- care cost recovery. tating the physical plant and facilities The Center will actively pursue of the Veterans Memorial Medical Cen- third-party liability/medical care cost ter, which the Secretary may make recovery in accordance with applicable under the authority cited in § 17.350, law. shall be subject to such terms and con- ditions as the Secretary may prescribe. (Authority: 28 U.S.C. 2651; 38 U.S.C. 501, 1781) Among such terms and conditions to which the grants will be subject, will § 17.278 Confidentiality of records. be advance approval by the U.S. De- Confidentiality of records will be partment of Veterans Affairs of equip- maintained in accordance with 38 CFR ment purchases, maintenance or repair 1.460 through 1.582. projects. The awarding of such grants is further subject to the limitations on (Authority: 5 U.S.C. 552, 552a; 38 U.S.C. 501, available funds in § 17.352. 1781, 5701, 7332) (Authority: 38 U.S.C. 1732, as amended by GRANTS TO THE REPUBLIC OF THE Pub. L. 97–72, sec. 107(c)(1)) PHILIPPINES [33 FR 5300, Apr. 3, 1968, as amended at 45 FR 47680, July 16, 1980; 47 FR 58250, Dec. 30, 1982] § 17.350 The program of assistance to the Philippines. § 17.352 Amounts and use of grant funds for the replacement and up- The provisions of this section grading of equipment. through § 17.370 are applicable to grants Grants awarded under § 17.351 shall to the Republic of the Philippines and not exceed the amounts provided by to furnishing medical services under 38 the appropriation acts of the Congress U.S.C. 1724 and 1732, and 38 CFR 17.36 of the United States for the purpose. through 17.40, and implement the Funds appropriated for the upgrading ‘‘Agreement between the Government and replacement of equipment at the of the United States of America and Veterans Memorial Medical Center, or the Government of the Republic of the for rehabilitating its equipment, shall Philippines on the Use of the Veterans remain available in consecutive fiscal Memorial Medical Center and the Pro- years until expanded, but in no event vision of Inpatient and Outpatient shall exceed the amount of $500,000 per Medical Care and Treatment of Vet- year. It is not intended that such funds erans by the Government of the Phil- will be utilized to expand the medical ippines and Furnishing of Grants-in- center facilities. Upgrading of equip- Aid Thereof by the Government of the ment, however, would permit purchase United States of America,’’ dated April of new and additional equipment not 25, 1967 (Treaties and Other Inter- now possessed by the medical center. national Acts Series 6248), and a sub- (Authority: 38 U.S.C. 1732) sidiary agreement of the same date, [47 FR 58250, Dec. 30, 1982] both of which were entered into pursu- ant to the provisions of 38 U.S.C. 1731– § 17.355 Awards procedures. 1734. All such implementing regula- All applications for grants to the Re- tions have been approved by the Direc- public of the Philippines under the pro- tor of the Office of Management and visions of § 17.351 shall be submitted to Budget. the Under Secretary for Health or a [33 FR 5300, Apr. 3, 1968, as amended at 45 FR designee for consideration. 47680, July 16, 1980; 47 FR 58250, Dec. 30, 1982; (Authority: 38 U.S.C. 1732) 61 FR 21969, May 13, 1996] [47 FR 58250, Dec. 30, 1982, as amended at 61 FR 21969, May 13, 1996]
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§ 17.362 Acceptance of medical sup- tions by the Department of Defense of plies as payment. the United States as to military serv- Upon request of the Government of ice shall be accepted. In those cases in the Republic of the Philippines, pay- which the United States Department of ment for medical and nursing home Veterans Affairs shall have informa- services provided to eligible United tion which it deems reliable and in con- States veterans may consist in whole flict with the information upon which or in part, of available medicines, med- the Department of Defense determina- ical supplies, or equipment furnished tion was made, the conflicting infor- by the Department of Veterans Affairs mation shall be referred to the Depart- to the Veterans Memorial Medical Cen- ment of Defense for reconsideration ter at valuations determined by the and redetermination. Such determina- Secretary. Such valuations shall not be tions and redeterminations as to mili- less than the cost of the items and tary service shall be conclusive. shall include the cost of transpor- tation, arrastre, brokerage, shipping (Authority: 38 U.S.C. 1712) and handling charges. [47 FR 58250, Dec. 30, 1982, as amended at 61 FR 21969, May 13, 1996] (Authority: 38 U.S.C. 1732(a)(2)) [47 FR 58250, Dec. 30, 1982] § 17.365 Admission priorities. § 17.363 Length of stay. Appropriate provisions of § 17.49 apply. In computing the length of stay for which payment will be made, the day (Authority: 38 U.S.C. 1712) of admission will be counted, but not [47 FR 58251, Dec. 30, 1982] the day of discharge, death, or transfer. Where a veteran for whom hospitaliza- § 17.366 Authorization of emergency tion has been authorized in Veterans admissions. Memorial Medical Center or a contract facility, is absent from the hospital for The Secretary of National Defense of a period longer than 24 hours, no pay- the Republic of the Philippines shall ment will be made for hospital care make determinations as to whether during that absence. any patient should be admitted in emergency circumstances before the (Authority: 38 U.S.C. 1732) U.S. Department of Veterans Affairs [47 FR 58250, Dec. 30, 1982] has made a legal determination of eli- gibility, except that liability for pay- § 17.364 Eligibility determinations. ment will not accrue to the United Determinations of legal eligibility States until such eligibility determina- and medical need for hospitalization of tion has been made. Eligibility deter- United States veterans for treatment minations will be given effect retro- rest exclusively with the United States actively to the date of admission when Department of Veterans Affairs. Deter- the U.S. Department of Veterans Af- minations as to various factors upon fairs has been notified by telephone, which eligibility may depend shall be telegram, letter, or other communica- made as follows: tion of the emergency admission with- (a) Determinations of service connec- in 72 hours of the hour of admission. tion. For the purpose of meeting any The Clinic Director of the VA Regional requirement in 38 U.S.C. 1724 and 1732, Office, Manila, may make an exception and 38 CFR 17.36 through 17.37 for serv- to the 72-hour limitation when it is de- ice-connected disability, the United termined that the delay in notification States Department of Veterans Affairs was fully justified. When any author- shall determine that under laws it ad- ization cannot be made effective retro- ministers the disability in question actively to the date of admission, it was incurred in or aggravated by serv- shall be effective from the date of re- ice, and ceipt of notification. (b) Determinations of valid service. For the purpose of determining the nec- [33 FR 5301, Apr. 3, 1968, as amended at 47 FR essary prerequisite service, determina- 58251, Dec. 30, 1982]
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§ 17.367 Republic of the Philippines to advance written notice of intent to print forms. stop payments. The Secretary of National Defense of (Authority: 38 U.S.C. 1732) the Republic of the Philippines will, [33 FR 5301, Apr. 3, 1968, as amended at 47 FR with the concurrence of the Secretary 58251, Dec. 30, 1982] of Veterans Affairs, print all forms for applications for hospitalization, forms CONFIDENTIALITY OF HEALTHCARE for physical examination reports, QUALITY ASSURANCE REVIEW RECORDS forms for billings for services rendered, and such other forms as may be nec- AUTHORITY: 38 U.S.C. 5705. essary and incident to the efficient SOURCE: 59 FR 53355, Oct. 24, 1994, unless execution of the program governed by otherwise noted. the provisions of 38 U.S.C. 1724 and 1732, and 38 CFR 17.36 through 17.40 and § 17.500 General. §§ 17.350 through 17.370. The forms will (a) Section 5705, title 38, United be used whenever applicable in the gen- States Code was enacted to protect the eral operation of the program. integrity of the VA’s medical quality [33 FR 5301, Apr. 3, 1968, as amended at 61 FR assurance program by making con- 21969, May 13, 1996] fidential and privileged certain records and documents generated by this pro- § 17.369 Inspections. gram and information contained there- The U.S. Department of Veterans Af- in. Disclosure of quality assurance fairs, through authorized representa- records and documents made confiden- tives, has the right under the agree- tial and privileged by 38 U.S.C. 5705 and ments cited in § 17.350, to inspect the the regulations in §§ 17.500 through 17.511 may only be made in accordance Veterans Memorial Medical Center, its with the provisions of 38 U.S.C. 5705 premises and all appurtenances and and those regulations. records to determine completeness and (b) The purpose of the regulations in correctness of such records, and to de- §§ 17.500 through 17.511 is to specify and termine according to the provisions of provide for the limited disclosure of the cited agreements whether stand- those quality assurance documents ards maintained conform to the nec- which are confidential under the provi- essary requirements. sions of 38 U.S.C. 5705. [33 FR 5301, Apr. 3, 1968, as amended at 47 FR (c) For purposes of the regulations in 58251, Dec. 30, 1982] §§ 17.500 through 17.511, the VA’s med- ical quality assurance program con- § 17.370 Termination of payments. sists of systematic healthcare reviews Payments may be terminated if the carried out by or for VA for the pur- U.S. Department of Veterans Affairs pose of improving the quality of med- determines the Veterans Memorial ical care or improving the utilization Medical Center has not replaced and of healthcare resources in VA medical upgraded as needed equipment during facilities. These review activities may the period in which the agreements involve continuous or periodic data cited in § 17.50 are in effect or has not collection and may relate to either the structure, process, or outcome of rehabilitated the existing physical health care provided in the VA. plant and facilities to place the med- (d) Nothing in the regulations in ical center on a sound and effective op- §§ 17.500 through 17.511 shall be con- erating basis, or has not maintained strued as authority to withhold any the medical center in a well-equipped record or document from a committee and effective operating condition. Pay- or subcommittee of either House of ments, however, will not be stopped un- Congress or any joint committee or less the Veterans Memorial Medical subcommittee of Congress, if such Center has been given at least 60 days record or document pertains to any matter within the jurisdiction of such committee or joint committee.
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(e) The regulations in §§ 17.500 at the outset of the review as protected through 17.511 do not waive the sov- by 38 U.S.C. 5705 and the regulations in ereign immunity of the United States, §§ 17.500 through 17.511; focused reviews and do not waive the confidentiality may be either: provisions and disclosure restrictions (i) Facility focused reviews; of 38 U.S.C. 5705. (ii) VA Central Office or Regional fo- (Authority: 38 U.S.C. 5705) cused reviews; (3) VA Central Office or Regional § 17.501 Confidential and privileged general oversight reviews to assess fa- documents. cility compliance with VA program re- (a) Documents and parts of docu- quirements if the reviews are des- ments are considered confidential and ignated by the reviewing office at the privileged if they were produced by or outset of the review as protected by 38 for the VA in the process of conducting U.S.C. 5705 and the regulations in systematic healthcare reviews for the §§ 17.500 through 17.511; and purpose of improving the quality of (4) Contracted external reviews of health care or improving the utiliza- care, specifically designated in the con- tion of healthcare resources in VA tract or agreement as reviews pro- healthcare facilities and meet the cri- tected by 38 U.S.C. 5705 and the regula- teria in paragraphs (b) and (c) of this tions in §§ 17.500 through 17.511. section. The four classes of healthcare (b) The Under Secretary for Health, quality assurance reviews with exam- Regional Director or facility Director ples are: will describe in advance in writing (1) Monitoring and evaluation re- those quality assurance activities in- views conducted by a facility: cluded under the classes of healthcare (i) Medical records reviews, quality assurance reviews listed in (ii) Drug usage evaluations, paragraph (a) of this section. Only doc- (iii) Blood usage reviews, uments and parts of documents result- (iv) Surgical case/invasive procedure ing from those activities which have reviews, been so described are protected by 38 (v) Service and program monitoring U.S.C. 5705 and the regulations in including monitoring performed by in- §§ 17.500 through 17.511. If an activity is dividual services or programs, several not described in a VA Central Office or services or programs working together, Regional policy document, this re- or individuals from several services or quirement may be satisfied at the fa- programs working together as a team, cility level by description in advance of (vi) Mortality and morbidity reviews, the activity and its designation as pro- (vii) Infection control review and sur- tected in the facility quality assurance veillance, plan or other policy document. (viii) Occurrence screening, (c) Documents and parts of docu- (ix) Tort claims peer reviews (except ments generated by activities which reviews performed to satisfy the re- meet the criteria in paragraphs (a) and quirements of a governmental body or (b) of this section shall be confidential a professional health care organization and privileged only if they: which is licensing practitioners or (1) Identify, either implicitly or ex- monitoring their professional perform- plicitly, individual practitioners, pa- ance), tients, or reviewers except as provided (x) Admission and continued stay re- in paragraph (g)(6) of this section; or views, (2) Contain discussions relating to (xi) Diagnostic studies utilization re- the quality of VA medical care or utili- views, zation of VA medical resources by (xii) Reports of special incidents (VA healthcare evaluators during the Form 10-2633 or similar forms) and fol- course of a review of quality assurance low-up documents unless developed information or data, even if they do during or as a result of a Board of In- not identify practitioners, patients, or vestigation; reviewers; or (2) Focused reviews which address (3) Are individual committee, service, specific issues or incidents and which or study team minutes, notes, reports, are designated by the reviewing office memoranda, or other documents either
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produced by healthcare evaluators in (3) The contents of Credentialing and deliberating on the findings of Privileging folders as described in healthcare reviews, or prepared for pur- VACO policy documents (38 U.S.C. 5705- poses of discussion or consideration by protected records shall not be filed in healthcare evaluators during a quality Credentialing and Privileging folders); assurance review; or (4) Records and documents developed (4) Are memoranda, letters, or other during or as a result of Boards of Inves- documents from the medical facility to tigations; the Regional Director or VA Central (5) Completed patient satisfaction Office which contain information gen- survey questionnaires and findings erated by a quality assurance activity from patient satisfaction surveys; meeting the criteria in § 17.501 (a) and (6) Records and documents which (b); or only indicate the number of patients (5) Are memoranda, letters, or other treated by a practitioner, either by di- documents produced by the Regional agnosis or in aggregate, or number of Director or VA Central Office which ei- procedures performed by a practi- ther respond to or contain information tioner, either by procedure or in aggre- generated by a quality assurance activ- gate; ity meeting the criteria in § 17.501 (a) (7) Records and documents developed and (b). during or as a result of reviews per- (d) Documents which meet the cri- formed to satisfy the requirements of a teria in this section are confidential governmental body or a professional and privileged whether they are pro- healthcare organization which is li- duced at the medical facility, Regional censing practitioners or monitoring or VA Central Office levels, or by ex- their professional performance, e.g., ternal contractors performing National Practitioner Data Bank, Fed- healthcare quality assurance reviews. eration of State Medical Boards, and (e) Documents which are confidential National Council of State Boards of and privileged may be in written, com- Nursing; puter, electronic, photographic or any (8) Documents and reports developed other form. during or as a result of site visits by (f) Documents which contain con- the Office of the Medical Inspector ex- fidential and privileged material in one cept to the extent that the documents part, but not in others, such as Clinical and reports contain information that Executive Board minutes, should be meets the criteria described in this sec- filed and maintained as if the entire tion and are produced by or for VA by document was protected by 38 U.S.C. other than the Office of Medical In- 5705. This is not required if the con- spector; fidential and privileged material is de- (9) External reviews conducted by VA leted. Central Office or a Region other than (g) The following records and docu- those designated by the reviewing of- ments and parts of records and docu- fice under paragraph (a)(2) or (a)(3) of ments are not confidential even if they this section as protected by 38 U.S.C. meet the criteria in paragraphs (a) 5705 and the regulations in §§ 17.500 through (c) of this section: through 17.511; (1) Statistical information regarding (10) Documents and reports of Profes- VA healthcare programs or activities sional Standards Boards, Credentialing that does not implicitly or explicitly Committees, Executive Committees of identify individual VA patients or VA Medical Staff, and similar bodies, inso- employees or individuals involved in far as the documents relate to the the quality assurance process; credentialing and privileging of practi- (2) Summary documents or records tioners; which only identify study topics, the (11) Documents and reports developed period of time covered by the study, during or as a result of data validation criteria, norms, and/or major overall activities; findings, but which do not identify in- (12) Documents and reports developed dividual healthcare practitioners, even during or as a result of occupational by implication; health monitoring;
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(13) Documents and reports developed § 17.503 Improper disclosure. during or as a result of safety moni- (a) Improper disclosure is the disclo- toring not directly related to the care sure of confidential and privileged of specified individual patients; healthcare quality assurance review (14) Documents and reports developed records or documents (or information during or as a result of resource man- contained therein), as defined in agement activities not directly related § 17.501, to any person who is not au- to the care of specified individual pa- thorized access to the records or docu- tients; and ments under the statute and the regu- (15) Information and records derived lations in §§ 17.500 through 17.511. from patient medical records or facil- (b) ‘‘Disclosure’’ means the commu- ity administrative records, which are nication, transmission, or conveyance not protected by 38 U.S.C. 5705 and the in any way of any confidential and regulations in §§ 17.500 through 17.511, privileged quality assurance records or may be sent or communicated to a documents or information contained in third party payor who has asked for them to any individual or organization this information in response to a VA in any form by any means. request for reimbursement based on (Authority: 38 U.S.C. 5705) Public Law 99–272 and Public Law 101– 508. Reviews conducted at the request § 17.504 Disclosure methods. of the third party payor do not gen- (a) Disclosure of confidential and erate records protected by 38 U.S.C. privileged quality assurance records 5705 and the regulations in §§ 17.500 and documents or the information con- through 17.511 since the reviews are not tained therein outside VA, where per- undertaken as part of the VA’s quality mitted by the statute and the regula- assurance program. tions in §§ 17.500 through 17.511, will al- (Authority: 38 U.S.C. 5705) ways be by copies, abstracts, sum- maries, or similar records or docu- § 17.502 Applicability of other statutes. ments prepared by the Department of Veterans Affairs and released to the re- (a) Disclosure of quality assurance questor. The original confidential and records and documents which are not privileged quality assurance records confidential and privileged under 38 and documents will not be removed U.S.C. 5705 and the confidentiality reg- from the VA facility by any person, VA ulations in §§ 17.500 through 17.511 will employee or otherwise, except in ac- be governed by the provisions of the cordance with § 17.508(c) or where oth- Freedom of Information Act, and, if ap- erwise legally required. plicable, the Privacy Act and any other (b) Disclosure of confidential and VA or federal confidentiality statutes. privileged quality assurance records (b) When included in a quality assur- and documents to authorized individ- ance review, confidential records pro- uals under either § 17.508 or § 17.509 shall tected by other confidentiality stat- bear the following statement: ‘‘These utes such as 5 U.S.C. 552a (the Privacy documents or records (or information Act), 38 U.S.C. 7332 (drug and alcohol contained herein) are confidential and abuse, sickle cell anemia, HIV infec- privileged under the provisions of 38 tion), and 38 U.S.C. 5701 (veterans’ U.S.C. 5705, which provide for fines up names and addresses) retain whatever to $20,000 for unauthorized disclosures confidentiality protection they have thereof, and the implementing regula- under these laws and applicable regula- tions. This material shall not be dis- tions and will be handled accordingly. closed to anyone without authorization To the extent that information pro- as provided for by that law or the regu- tected by 38 U.S.C. 5701 or 7332 or the lations in §§ 17.500 through 17.511.’’ Privacy Act is incorporated into qual- (Authority: 38 U.S.C. 5705) ity assurance records, the information in the quality assurance records is still § 17.505 Disclosure authorities. protected by these statutes. The VA medical facility Director, (Authority: 38 U.S.C. 5705) Regional Director, Under Secretary for
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Health, or their designees are author- and contractors of VA) who have a ized to disclose any confidential and need for such information to perform privileged quality assurance records or their government duties or contractual documents under their control to other responsibilities and who are authorized agencies, organizations, or individuals access by the VA medical facility Di- where 38 U.S.C. 5705 or the regulations rector, Regional Director, the Under in §§ 17.500 through 17.511 expressly pro- Secretary for Health, or their designees vide for disclosure. or by the regulations in §§ 17.500 (Authority: 38 U.S.C. 5705) through 17.511. (b) To foster continuous quality im- § 17.506 Appeal of decision by Vet- provement, practitioners on VA rolls, erans Health Administration to whether paid or not, will have access to deny disclosure. confidential and privileged quality as- When a request for records or docu- surance records and documents relat- ments subject to the regulations in ing to evaluation of the care they pro- §§ 17.500 through 17.511 is denied in vided. whole or in part by the VA medical fa- (c) Any quality assurance record or cility Director, Regional Director or Under Secretary for Health, the VA of- document, whether confidential and ficial denying the request in whole or privileged or not, may be provided to in part will notify the requestor in the General Counsel or any attorney writing of the right to appeal this deci- within the Office of General Counsel, sion to the General Counsel of the De- wherever located. These documents partment of Veterans Affairs within 60 may also be provided to a Department days of the date of the denial letter. of Justice (DOJ) attorney who is inves- The final Department decision will be tigating a claim or potential claim made by the General Counsel or the against the VA or who is preparing for Deputy General Counsel. litigation involving the VA. If nec- (Authority: 38 U.S.C. 5705) essary, such a record or document may be removed from the VA medical facil- § 17.507 Employee responsibilities. ity to the site where the General Coun- (a) All VA employees and other indi- sel or any attorney within the Office of viduals who have access to records des- General Counsel or the DOJ attorney is ignated as confidential and privileged conducting an investigation or pre- under 38 U.S.C. 5705 and the regulations paring for litigation. in §§ 17.500 through 17.511 will treat the (d) Any quality assurance record or findings, views, and actions relating to document or the information contained quality assurance in a confidential therein, whether confidential and privi- manner. leged or not, will be provided to the De- (b) All individuals who have had ac- partment of Veterans Affairs Office of cess to records designated as confiden- Inspector General upon request. A tial and privileged under 38 U.S.C. 5705 written request is not required. and the regulations in §§ 17.500 through (e) To the extent practicable, docu- 17.511 will not disclose such records or ments accessed under paragraph (b) of information therein to any person or this section will not include the iden- organization after voluntary or invol- tity of peer reviewers. Reasonable ef- untary termination of their relation- forts will be made to edit documents so ship to the VA. as to protect the identities of review- (Authority: 38 U.S.C. 5705) ers, but the inability to completely do so will not bar access under paragraph § 17.508 Access to quality assurance (b). records and documents within the agency. (f) No individual shall be permitted access to confidential and privileged (a) Access to confidential and privi- quality assurance records and docu- leged quality assurance records and documents within the Department pur- ments identified in § 17.501 unless such suant to this section is restricted to individual has been informed of the VA employees (including consultants penalties for unauthorized disclosure.
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Any misuse of confidential and privi- engaged in healthcare program activi- leged quality assurance records or doc- ties shall, upon request to and approval uments shall be reported to the appro- by the Under Secretary for Health, Re- priate VHA official, e.g., Service Chief, gional Director, medical facility Direc- Medical Center Director. tor, or their designees, have access to (g) In general, confidential and privi- confidential and privileged medical leged quality assurance records and quality assurance records and docu- documents will be maintained for a ments to permit VA participation in a minimum of 3 years and may be held healthcare activity with the requestor, longer if needed for research studies or provided that no records or documents quality assurance or legal purposes. are removed from the VA facility in (Authority: 38 U.S.C. 5705) possession of the records. (d) When a request under paragraphs § 17.509 Authorized disclosure: Non- (b) or (c) of this section concerns access Department of Veterans Affairs re- for research purposes, the request, to- quests. gether with the research plan or pro- (a) Requests for confidential and tocol, shall first be submitted to and privileged quality assurance records approved by an appropriate VA medical and documents from organizations or facility Research and Development individuals outside VA must be made Committee and then approved by the to the Department and must specify Director of the VA medical facility. the nature and content of the informa- The VA medical facility staff together tion requested, to whom the informa- with the qualified person(s) conducting tion should be transmitted or dis- the research shall be responsible for closed, and the purpose listed in para- the preservation of the anonymity of graphs (b) through (j) of this section the patients, clients, and providers and for which the information requested shall not disseminate any records or will be used. In addition, the requestor documents which identify such individ- will specify to the extent possible the uals directly or indirectly without the beginning and final dates of the period individual’s consent. This applies to for which disclosure or access is re- the handling of data or information as quested. The request must be in writ- well as reporting or publication of find- ing and signed by the requestor. Except ings. These requirements are in addi- as specified in paragraphs (b) and (c) of tion to other applicable protections for this section, these requests should be the research. forwarded to the Director of the facil- (e) Individually identified patient ity in possession of the records or docu- medical record information which is ments for response. The procedures protected by another statute as pro- outlined in 38 CFR 1.500 through 1.584 vided in § 17.502 may not be disclosed to will be followed where applicable. a non-VA person or organization, in- (b) Disclosure shall be made to Fed- cluding disclosures for research pur- eral agencies upon their written re- poses under paragraph (d), except as quest to permit VA’s participation in provided in that statute. healthcare programs including (f) Under paragraph (b), the Under healthcare delivery, research, plan- Secretary for Health or designee or ning, and related activities with the re- under paragraph (c), the Under Sec- questing agencies. Any Federal agency retary for Health, Regional Director, may apply to the Under Secretary for medical facility Director, or their des- Health for approval. If the VA decides ignees may approve a written request if to participate in the healthcare pro- it meets the following criteria: gram with the requestor, the request- (1) Participation by VA will benefit ing agency will enter into an agree- VA patient care; or ment with VA to ensure that the agen- (2) Participation by VA will enhance cy and its staff will ensure the con- VA medical research; or fidentiality of any quality assurance (3) Participation by VA will enhance records or documents shared with the VA health services research; or agency. (4) Participation by VA will enhance (c) Qualified persons or organiza- VA healthcare planning or program de- tions, including academic institutions, velopment activities; or
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(5) Participation by VA will enhance (1) Accreditation agencies which are related VA healthcare program activi- charged with assessing all aspects of ties; and medical facility patient care, e.g., (6) Access to the record by the re- JCAHO, may have access to all con- quester is required for VA to partici- fidential and privileged quality assur- pate in a healthcare program with the ance records and documents. requester. (2) Accreditation agencies charged (g) Protected quality assurance with more narrowly focused review records or documents, including (e.g., College of American Pathologists, records pertaining to a specific indi- American Association of Blood Banks, vidual, will for purposes authorized Nuclear Regulatory Commission, etc.) may have access only to such confiden- under law be disclosed to a civil or tial and privileged records and docu- criminal law enforcement govern- ments as are relevant to their respec- mental agency or instrumentality tive focus. charged under applicable law with the (j) Confidential and privileged qual- protection of public health or safety, ity assurance records and documents including state licensing and discipli- shall be released to the General Ac- nary agencies, if a written request for counting Office if such records or docu- such records or documents is received ments pertain to any matter within its from an official of such an organiza- jurisdiction. tion. The request must state the pur- (k) Confidential and privileged qual- pose authorized by law for which the ity assurance records and documents records will be used. The Under Sec- shall be released to both VA and non- retary for Health, Regional Director, VA healthcare personnel upon request medical facility Director, or their des- to the extent necessary to meet a med- ignees will determine the extent to ical emergency affecting the health or which the information is disclosable. safety of any individual. (h) Federal agencies charged with (l) For any disclosure made under protecting the public health and wel- paragraphs (a) through (i) of this sec- fare, federal and private agencies tion, the name of and other identifying which engage in various monitoring information regarding any individual and quality control activities, agencies VA patient, employee, or other indi- responsible for licensure of individual vidual associated with VA shall be de- health care facilities or programs, and leted from any confidential and privi- similar organizations will be provided leged quality assurance record or docu- confidential and privileged quality as- ment before any disclosure under these surance records and documents if a quality assurance regulations in written request for such records or doc- §§ 17.500 through 17.511 is made, if dis- uments is received from an official of closure of such name and identifying such an organization. The request must information would constitute a clearly state the purpose for which the records unwarranted invasion of personal pri- will be used. The Under Secretary for vacy. Health, Regional Director, medical fa- (m) Disclosure of the confidential cility Director, or their designees will and privileged quality assurance determine the extent to which the in- records and documents identified in formation is disclosable. § 17.501 will not be made to any indi- (i) JCAHO (Joint Commission on Ac- vidual or agency until that individual creditation of Healthcare Organiza- or agency has been informed of the tions) survey teams and similar na- penalties for unauthorized disclosure tional accreditation agencies or boards or redisclosure. and other organizations requested by (Authority: 38 U.S.C. 5705) VA to assess the effectiveness of qual- ity assurance program activities or to § 17.510 Redisclosure. consult regarding these programs are No person or entity to whom a qual- entitled to disclosure of confidential ity assurance record or document has and privileged quality assurance docu- been disclosed under § 17.508 or § 17.509 ments with the following qualifica- shall make further disclosure of such tions: record or document except as provided
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for in 38 U.S.C. 5705 and the regulations ticipant of the HPSP or VIOMPSP that in §§ 17.500 through 17.511. specifies the obligations of VA and the (Authority: 38 U.S.C. 5705) participant upon acceptance to the HPSP or VIOMPSP. An acceptance § 17.511 Penalties for violations. agreement must incorporate by ref- Any person who knows that a docu- erence, and cannot be inconsistent ment or record is a confidential and with, §§ 17.600 through 17.612 (for HPSP privileged quality assurance document agreements) or §§ 17.626 through 17.636 or record described in §§ 17.500 through (for VIOMPSP agreements), and must 17.511 and willfully discloses such con- include: fidential and privileged quality assur- (1) A mobility agreement. ance record or document or informa- (2) Agreement to accept payment of tion contained therein, except as au- the scholarship. thorized by 38 U.S.C. 5705 or the regula- (3) Agreement to perform obligated tions in §§ 17.500 through 17.511, shall be service. fined not more than $5,000 in the case (4) Agreement to maintain enroll- of a first offense and not more than ment and attendance in the course of $20,000 in the case of each subsequent study for which the scholarship was offense. awarded, and to maintain an accept- (Authority: 38 U.S.C. 5705) able level of academic standing. Affiliation agreement means a legal VA HEALTH PROFESSIONAL SCHOLARSHIP document that enables the clinical PROGRAM education of trainees at a VA or non- VA medical facility. An affiliation AUTHORITY: 38 U.S.C. 7601–7619, 7633, 7634, agreement is required for all education and 7636. or training that involves direct patient contact, or contact with patient infor- § 17.600 Purpose. mation, by trainees from a non-VA in- The purpose of §§ 17.600 through 17.612 stitution. is to establish the requirements for the Citizen of the United States means any award of scholarships under the VA person born, or lawfully naturalized, in Health Professional Scholarship Pro- the United States, subject to its juris- gram (HPSP) to students pursuing a diction and protection, and owing alle- course of study leading to a degree in giance thereto. certain health care occupations, listed Credential means the licensure, reg- in 38 U.S.C. 7401(1) and (3), to assist in istration, certification, required edu- providing an adequate supply of such cation, relevant training and experi- personnel for VA. The HPSP allows VA ence, and current competence nec- to provide scholarship awards to facili- essary to meet VA’s qualification tate recruitment and retention of em- standards for employment in certain ployees in several hard-to-fill health health care occupations. care occupations. Degree represents the successful com- (Authority: 38 U.S.C. 7601(b)) pletion of the course of study for which [78 FR 51069, Aug. 20, 2013] a scholarship was awarded. (1) HPSP. For the purposes of the § 17.601 Definitions. HPSP, VA recognizes the following de- The following definitions apply to grees: a doctor of medicine; doctor of §§ 17.600 through 17.636: osteopathy; doctor of dentistry; doctor Acceptable level of academic standing of optometry; doctor of podiatry; or an means the level at which a participant associate, baccalaureate, master’s, or may continue to attend school under doctorate degree in another health care the standards and practices of the discipline needed by VA. school at which a participant is en- (2) VIOMPSP. For the purposes of the rolled in a course of study for which an VIOMPSP, VA recognizes a bachelor’s, HPSP or VIOMPSP scholarship was master’s, education specialist or doc- awarded. torate that meets the core curriculum Acceptance agreement means a signed and supervised practice requirements legal document between VA and a par- in visual impairment and blindness.
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Full-time student means an individual U.S. Department of Education or by who meets the requirements for full the Council for Higher Education Ac- time attendance as defined by the creditation (CHEA), and that meets the school in which they are enrolled. following requirements: HPSP means the VA Health Profes- (1) For the purposes of the HPSP, of- sional Scholarship Program authorized fers a course of study leading to a de- by 38 U.S.C. 7601 through 7619. gree in a health care service discipline Mobility agreement means a signed needed by VA. legal document between VA and a par- (2) For the purposes of the VIOMPSP, ticipant of the HPSP or VIOMPSP, in offers a course of study leading to a de- which the participant agrees to accept gree in visual impairment or orienta- assignment at a VA facility selected by tion and mobility. VA where he or she will fulfill the obli- School year means for purposes of the gated service requirement. A mobility HPSP and its stipend payment, and the agreement must be included in the par- VIOMPSP, all or part of the 12-month ticipant’s acceptance agreement. Relo- period that starts on the date the par- cation to another geographic location ticipant begins school as a full-time may be required. student. Obligated service means the period of Secretary means the Secretary of Vet- time during which the HPSP or erans Affairs or designee. VIOMPSP participant must be em- State means one of the several States, ployed by VA in a full-time clinical oc- Territories and possessions of the cupation for which the degree prepared United States, the District of Columbia the participant as a requirement of the and the Commonwealth of Puerto Rico. acceptance agreement. Under Secretary for Health means the Part-time student—(1) HPSP. For the Under Secretary for Health of the De- purposes of the HPSP, part-time stu- partment of Veterans Affairs or des- dent means an individual who is a VA ignee. employee, and who has been accepted VA means the Department of Vet- for enrollment or enrolled for study erans Affairs. leading to a degree on a less than full- VA employee means an individual per- time basis but no less than half-time manently employed by VA. A VA em- basis. ployee does not include an individual (2) VIOMPSP. For the purposes of the who is employed temporarily or on a VIOMPSP, part-time student means an contractual basis. individual who has been accepted for VA health care facility means a VA enrollment or enrolled for study lead- medical center, independent outpatient ing to a degree on a less than full-time clinic, domiciliary, nursing home (com- basis but no less than half-time basis. munity living center), residential Participant or scholarship program par- treatment program, and any of a vari- ticipant means an individual whose ap- ety of community based clinics (includ- plication to the HPSP or VIOMPSP has ing community based outpatient clin- been approved, whose acceptance ics, rural health resource centers, pri- agreement has been consummated by mary care telehealth clinics, and Vet VA, and who has yet to complete the Centers), consolidated mail outpatient period of obligated service or otherwise pharmacies, and research centers. satisfy the obligation or financial li- VIOMPSP means the Visual Impair- abilities of such agreement. ment and Orientation and Mobility Required fees means those fees which Professional Scholarship Program au- are charged by the school to all stu- thorized by 38 U.S.C. 7501 through 7505. dents pursuing a similar curriculum in the same school. (Authority: 38 U.S.C. 301, 7501(a)(1), 7504, Scholarship Program means the VA 7602(a), 7604(1)(B), 7633) Health Professional Scholarship Pro- [78 FR 51069, Aug. 20, 2013] gram (HPSP) authorized by 38 U.S.C. 7601 through 7619. § 17.602 Eligibility. School means an academic institution (a) To be eligible for a scholarship that is accredited by a body or bodies under this program an applicant recognized for accreditation by the must—
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(1) Be unconditionally accepted for § 17.603 Availability of HPSP scholar- enrollment or be enrolled as a full-time ships. student in an accredited school located (a) General. A HPSP scholarship will in a State; be awarded only when necessary to as- (2) Be pursuing a degree annually sist VA in alleviating shortages or an- designated by the Secretary for partici- ticipated shortages of personnel in the pation in the Scholarship Program; health professions stated in paragraph (b) of this section. VA will determine (Authority: 38 U.S.C. 7602(a)(1), 7612(b)(1)) the existence of shortage of personnel (3) Be in a discipline or program an- in accordance with specific criteria for each health care profession. VA has the nually designated by the Secretary for authority to establish the number of participation in the Scholarship Pro- scholarships to be awarded in a fiscal gram; year, and the number that will be (4) Be a citizen of the United States; awarded to full-time and part-time stu- and dents. (5) Submit an application to partici- (b) Qualifying fields of education. VA pate in the Scholarship Program to- will grant HPSP scholarships in a gether with a signed contract. course of study in those disciplines or (6) Clinical tours. An applicant for a programs where recruitment is nec- scholarship under the HPSP must essary for the improvement of health agree to perform clinical tours while care of veterans. Those disciplines or enrolled in the course of education or programs are listed in 38 U.S.C. 7401(1) training for which the scholarship is and (3). provided. VA will determine the assign- (Authority: 38 U.S.C. 7401(1), (3), 7612(b)(2), ments and locations of the clinical 7612(b)(4), and 7603(b)(1)) tour. [78 FR 51070, Aug. 20, 2013] (Authority: 38 U.S.C. 7618(b)) § 17.604 Application for the HPSP. (b) To be eligible for a scholarship as An applicant for the HPSP must sub- a part-time student under this pro- mit an accurate and complete applica- gram, an applicant must satisfy re- tion, including a signed written accept- quirements of paragraph (a) of this sec- ance agreement. tion and in addition must— (Authority: 38 U.S.C. 7612(c)(1)(B)) (1) Be a full-time VA employee per- manently assigned to a VA health care (The Office of Management and Budget has facility at the time of application and approved the information collection require- on the date when the scholarship is ments in this section under control number 2900–0793.) awarded; (2) Remain a VA employee for the du- [78 FR 51070, Aug. 20, 2013] ration of the scholarship award. § 17.605 Selection of participants. (Authority: 38 U.S.C. 7612(c)(3)(B)) (a) General. In deciding which HPSP application to approve, VA will first (c) Any applicant who, at the time of consider applications submitted by ap- application, owes a service obligation plicants entering their final year of to any other entity to perform service education or training and applicants after completion of the course of study who previously received HPSP scholar- is ineligible to receive a scholarship ships and who meet the conditions of under the Department of Veterans Af- paragraph (f) of this section. Except for fairs Scholarship Program. paragraph (f) of this section, applicants will be evaluated and selected using (Authority: 38 U.S.C. 7602(b)) the criteria specified in paragraph (b) (Approved by the Office of Management and of this section. If there are a larger Budget under control number 2900–0352) number of equally qualified applicants [47 FR 10810, Mar. 12, 1982, as amended at 48 than there are awards to be made, then FR 37399, Aug. 18, 1983; 54 FR 28674, July 7, VA will first select veterans, and then 1989; 78 FR 51070, Aug. 20, 2013] use a random method as the basis for
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further selection. In selecting partici- Scholarship Program, the Secretary pants to receive awards as part-time will award a participant a full-time students, VA may, at VA’s discretion— scholarship under these regulations for a period of from 1 to 4 school years and (Authority: 38 U.S.C. 7612(b)(5)) a participant of a part-time scholarship (1) Award scholarships geographi- for a period of 1 to 6 school years. cally to part-time students so that available scholarships may be distrib- (Authority: 38 U.S.C. 7612(c)(1)(A) and 7614(3)) uted on a relatively equal basis to stu- (f) Continuation awards. Subject to dents working throughout the VA the availability of funds for the Schol- health care system, and/or arship Program and selection, the Sec- (2) Award scholarships on the basis of retary will award a continuation schol- retention needs within the VA health arship for completion of the degree for care system. which the scholarship was awarded if— (1) The award will not extend the (Authority: 38 U.S.C. 7603(d)) total period of Scholarship Program (b) Selection. In evaluating and select- support beyond 4 years for a full-time ing participants, the Secretary will scholarship, and beyond 6 years for a take into consideration those factors part-time scholarship; and determined necessary to assure effec- (2) The participant remains eligible tive participation in the Scholarship for continued participation in the Program. The factors may include, but Scholarship Program. not be limited to— (Authority: 38 U.S.C. 7603(d)) (1) Work/volunteer experience, in- (Approved by the Office of Management and cluding prior health care employment Budget under control number 2900–0352) and Department of Veterans Affairs employment; [48 FR 37399, Aug. 18, 1983, as amended at 54 (2) Faculty and employer rec- FR 28674, July 7, 1989; 78 FR 51070, Aug. 20, 2013] ommendations; (3) Academic performance; and § 17.606 Award procedures. (4) Career goals. (a) Amount of scholarship. (1) A schol- (Authority: 38 U.S.C. 7633) arship award will consist of (i) tuition and required fees, (ii) other educational (c) Selection of part-time students. Fac- expenses, including books and labora- tors in addition to those specified in tory equipment, and (iii) except as pro- paragraph (b) of this section, which vided in paragraph (a)(2) of this sec- may be considered in awarding scholar- tion, a monthly stipend, for the dura- ships to part-time students may in- tion of the scholarship award. All such clude, but are not limited to: payments to scholarship participants (1) Length of service of a VA em- are exempt from Federal taxation. ployee in a health care facility; (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 ac- (e) Duration of scholarship award. Sub- cordance with the proportion that the ject to the availability of funds for the number of credit hours carried by such participant bears to the number of
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credit hours required to be carried by a (b) Beginning of service. (1)(i) Date of full-time student in the course of train- employment. Except as provided in para- ing being pursued by the participant. graph (b)(2) of this section, a partici- (5) A full stipend may be paid only pant’s obligated service will begin on for the months the part-time student is the date VA appoints the participant attending classes. as a full-time VA employee in a clin- ical occupation for which the degree (Authority: 38 U.S.C. 7614(2)) prepared the participant. VA will ap- point the participant to such position (6) The Secretary may make arrange- as soon as possible, but no later than 90 ments with the school in which the days after the date that the participant participant is enrolled for the direct receives his or her degree, or the date payment of the amount of tuition and/ the participant becomes licensed in a or reasonable educational expenses on State or becomes certified, whichever the participant’s behalf. is later. VA will actively assist and monitor participants to ensure State (Authority: 38 U.S.C. 7613(c)) licenses or certificates are obtained in a minimal amount of time following (7) A participant’s eligibility for a graduation. If a participant fails to ob- stipend ends at the close of the month tain his or her degree, or fails to be- in which degree requirements are met. come licensed in a State or become cer- (b) Leave-of-absence, repeated course tified no later than 180 days after re- work. The Secretary may suspend ceiving the degree, the participant is scholarship payments to or on behalf of considered to be in breach of the ac- a participant if the school (1) approves ceptance agreement. a leave-of-absence for the participant (ii) Notification. VA will notify the for health, personal, or other reasons, participant of the work assignment and or (2) requires the participant to repeat its location no later than 60 days be- course work for which the Secretary fore the date on which the participant previously has made payments under must begin work. the Scholarship Program. Additional (iii) VA mentor. VA will ensure that costs relating to the repeated course the participant is assigned a mentor work will not be paid under this pro- who is employed at the same facility gram. Any scholarship payments sus- where the participant performs his or pended under this section will be re- her obligated service at the commence- sumed by the Secretary upon notifica- ment of such service. tion by the school that the participant (2) Obligated service shall begin on has returned from the leave-of-absense the degree completion date for a par- or has satisfactorily completed the re- ticipant who, on that date, is a full- peated course work and is proceeding time VA employee working in a capac- as a full-time student in the course of ity for which the degree program pre- study for which the scholarship was pared the participant. awarded. (Authority: 38 U.S.C. 7616(b), 7616(c), 7618(a)) (Authority: 38 U.S.C. 7633) (c) Duration of service—(1) Full-time [48 FR 37400, Aug. 18, 1983, as amended at 55 student. A participant who attended FR 40170, Oct. 2, 1990] school as a full-time student will agree to serve as a full-time clinical em- § 17.607 Obligated service. ployee in the Veterans Health Adminis- (a) General. Except as provided in tration for 1 calendar year for each paragraph (d) of this section, each par- school year or part thereof for which a ticipant is obligated to provide service scholarship was awarded, but for no as a Department of Veterans Affairs less than 2 years. employee in full-time clinical practice (2) Part-time student. Obligated serv- in the participant’s discipline in an as- ice to VA for a participant who at- signment or location determined by tended school as a part-time student the Secretary. must be satisfied by full-time clinical employment. The period of obligated (Authority: 38 U.S.C. 7616(a)) service will be reduced from that which
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a full-time student must serve under (b) Deferment requirements. Any par- paragraph (c)(1) of this section in ac- ticipant whose period of obligated serv- cordance with the proportion that the ice is deferred shall be required to take number of credit hours carried by the all or part of the advanced clinical part-time student in any school year training in an accredited program in an bears to the number of credit hours re- educational institution having an Af- quired to be carried by a full-time stu- filiation Agreement with a Department dent who is pursuing the same degree; of Veterans Affairs health care facility, however, the period of obligated serv- and such training will be undertaken in ice will not be for less than 1 year. a Department of Veterans Affairs (Authority: 38 U.S.C. 7612(c)(1)(B), health-care facility. 7612(c)(3)(A), 7618(c)) (d) Location for service. VA reserves (Authority: 38 U.S.C. 7616(b)(4)) the right to make final decisions on (c) Additional service obligation. A par- the location for service obligation. A ticipant who has requested and re- participant who receives a scholarship ceived deferment for approved ad- as a full-time student must be willing vanced clinical training may, at the to relocate to another geographic loca- 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 mo- cialty determined to be necessary to bility agreement at that facility. meet health care requirements of the Veterans Health Administration; De- (Authority: 38 U.S.C. 7616(a)) 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 calendar year for each year of approved training will be credited toward satis- graduate training (or a proportionate fying the period of obligated service in- ratio thereof) if the training is in a curred under the Scholarship Program. 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] meet the health care requirements of 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, op- tometry, or podiatry, may request (Authority: 38 U.S.C. 7616(b)(4)(B)) deferment of obligated service to com- plete an approved program of advanced (d) Altering deferment. Before altering clinical training. The Secretary may the length or type of approved ad- defer the beginning date of the obli- vanced clinical training for which the gated service to allow the participant period of obligated service was deferred 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(a)(A)(i)) (Authority: 38 U.S.C. 7633)
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(e) Beginning of service after deferment. scholarship award or instructs the Any participant whose period of obli- school not to accept payment. gated service has been deferred under paragraph (a) or (b) of this section (Authority: 38 U.S.C. 7617(a)) must begin the obligated service effec- (b) If a participant: tive on the date of appointment under (1) Fails to maintain an acceptable title 38 in full-time clinical practice in level of academic standing; an assignment or location in a Depart- (2) Is dismissed from the school for ment of Veterans Affairs health care disciplinary reasons; facility as determined by the Sec- (3) Voluntarily terminates the course retary. The assignment will be made by of study or program for which the the Secretary within 120 days prior to scholarship was awarded including in or no later than 30 days following the the case of a full-time student, a reduc- completion of the requested graduate tion of course load from full-time to training for which the deferment was part-time before completing the course granted. Travel and relocation regula- of study or program; tions will apply. (4) Fails to become licensed to prac- (Authority: 38 U.S.C. 7616(b)(2)) tice in the discipline for which the de- gree program prepared the participant, [47 FR 10810, Mar. 12, 1982; 47 FR 13523, Mar. if applicable, in a State within 1 year 31, 1982, as amended at 54 FR 28675, July 7, 1989; 61 FR 21969, May 13, 1996] from the date such person becomes eli- gible to apply for State licensure; or § 17.609 Pay during period of obligated service. (Authority: 38 U.S.C. 7617(b)(4)) The initial appointment of physi- (5) Is a part-time student and fails to cians for obligated service will be made maintain employment in a permanent in a grade commensurate with quali- assignment in a VA health care facility fications as determined in section while enrolled in the course of training 7404(b)(1) of title 38 U.S.C. A physician being pursued; the participant must in- serving a period of obligated service is stead of performing any service obliga- not eligible for incentive special pay tion, pay to the United States an during the first three years of such ob- amount equal to all scholarship funds ligated service. A physician may be awarded under the written contract ex- paid primary special pay at the discre- ecuted in accordance with § 17.602. Pay- tion of the Secretary upon the rec- ment of this amount must be made ommendation of the Under Secretary within 1 year from the date academic for Health. training terminates unless a longer pe- riod is necessary to avoid hardship. No (Authority: Pub. L. 96–330, Sec. 202; 38 U.S.C. 7431–7440) interest will be charged on any part of this indebtedness. [47 FR 10810, Mar. 12, 1982, as amended at 54 FR 28676, July 7, 1989; 61 FR 21969, May 13, (Authority: 38 U.S.C. 7617(b)) 1996] (c) Participants who breach their § 17.610 Failure to comply with terms contracts by failing to begin or com- and conditions of participation. plete their service obligation (for any (a) If a participant, other than one reason) other than as provided for described in paragraph (b) of this sec- under paragraph (b) of this section are tion fails to accept payment or in- liable to repay the amount of all schol- structs the school not to accept pay- arship funds paid to them and to the ment of the scholarship provided by school on their behalf, plus interest, the Secretary, the participant must, in multiplied by three, minus months of addition to any service or other obliga- service obligation satisfied, as deter- tion incurred under the contract, pay mined by the following formula: to the United States the amount of $1,500 liquidated damages. Payment of this amount must be made within 90 days of the date on which the partici- pant fails to accept payment of the in which:
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‘A’ is the amount the United States is enti- the date VA notifies the participant tled to recover; that he or she is in breach of his or her ‘j’ is the sum of the amounts paid to or on acceptance agreement. A participant behalf of the applicant and the interest on such amounts which would be payable if, seeking a waiver or suspension must at the time the amounts were paid, they comply with requests for additional in- were loans bearing interest at the max- formation from VA no later than 30 imum legal prevailing rate, as determined days after the date of any such request. by the Treasurer of the United States; (i) Waivers. A waiver is a permanent ‘t’ is the total number of months in the ap- release by VA of the obligation either plicant’s period of obligated service; and ‘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 of the participant, or to fulfill any The amount which the United States is other acceptance agreement require- entitled to recover shall be paid within ment. If a waiver is granted, then the 1 year of the date on which the appli- waived amount of scholarship funds cant failed to begin or complete the pe- may be considered taxable income. riod of obligated service, as determined (ii) Suspensions. VA may approve an by the Secretary. 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 will be in breach of his or her accept- [47 FR 10810, Mar. 12, 1982; 47 FR 13523, Mar. 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] (A) VA will temporarily discontinue providing any scholarship funds to or § 17.611 Bankruptcy. on behalf of the participant while the Any payment obligation incurred participant’s scholarship is in a sus- may not be discharged in bankruptcy pended status; or under title 11 U.S.C. until 5 years after (B) VA will temporarily delay the en- the date on which the payment obliga- forcement of acceptance agreement re- tion is due. This section applies to par- quirements. ticipants in the HPSP and the (2) The Secretary may waive or sus- VIOMPSP. pend any service or payment obligation (Authority: 38 U.S.C. 7505(d), 7634(c)) incurred by a participant whenever compliance by the participant (i) is im- [78 FR 51071, Aug. 20, 2013] possible, due to circumstances beyond § 17.612 Cancellation, waiver, or sus- the control of the participant or (ii) pension of obligation. whenever the Secretary concludes that 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 VIOMPSP. partment of Veterans Affairs. (2) Any obligation of a participant for service or payment will be cancelled (Authority: 38 U.S.C. 7634(b)) upon the death of the participant. (c) Compliance by a participant with a service or payment obligation will be (Authority: 38 U.S.C. 7634(a)) considered impossible due to cir- (b) Waivers or suspensions. (1) A par- cumstances beyond the control of the ticipant may seek a waiver or suspen- participant if the Secretary deter- sion of the obligated service or pay- mines, on the basis of such information ment obligation incurred under this and documentation as may be required, program by submitting a written re- that the participant suffers from a quest to VA setting forth the basis, cir- physical or mental disability resulting cumstances, and causes which support in permanent inability to perform the the requested action. Requests for service or other activities which would waivers or suspensions must be sub- be necessary to comply with the obli- mitted to VA no later than 1 year after gation.
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(d) Waivers or suspensions of service § 17.626 Definitions. or payment obligations, when not re- For the definitions that apply to lated to paragraph (c) of this section, §§ 17.625 through 17.636, see § 17.601. and when considered in the best inter- est of the Department of Veterans Af- (Authority: 38 U.S.C. 501) fairs, will be determined by the Sec- retary on an individual basis. § 17.627 Eligibility for the VIOMPSP. (e) Eligibility to reapply for award. Any (a) General. To be eligible for the previous participant of any federally VIOMPSP, an applicant must meet the sponsored scholarship program who following requirements: breached his or her acceptance agree- (1) Be unconditionally accepted for ment or similar agreement in such enrollment or currently enrolled in a scholarship program is not eligible to program of study leading to a degree in apply for a HPSP or VIOMPSP. This orientation and mobility, low vision includes participants who previously therapy, or vision rehabilitation ther- applied for, and received, a waiver apy, or a dual degree (a program in under this section. which an individual becomes certified (f) Finality of decisions. Decisions to in two of the three professional certifi- approve or disapprove waiver requests cations offered by the Academy for are final and binding determinations. Certification of Visual Rehabilitation Such determinations are not subject to and Education Professionals) at an ac- reconsideration or appeal. credited educational institution that is in a State; (Authority: 38 U.S.C. 7505(c), 7634(a), 7634(b)) (2) Be a citizen of the United States; [47 FR 10810, Mar. 12, 1982, as amended at 78 and FR 51071, Aug. 20, 2013] (3) Submit an application to partici- pate in the VIOMPSP, as described in VISUAL IMPAIRMENT AND ORIENTATION § 17.629. AND MOBILITY PROFESSIONAL SCHOL- (b) Obligated service to another entity. ARSHIP PROGRAM Any applicant who, at the time of ap- plication, owes a service obligation to SOURCE: Sections 17.625 through 17.636 ap- any other entity to perform service pear at 78 FR 51071, Aug. 20, 2013, unless oth- after completion of the course of study erwise noted. is ineligible to receive a VIOMPSP scholarship. § 17.625 Purpose. (Authority: 38 U.S.C. 7501(a), 7502(a), 7504(3)) The purpose of §§ 17.625 through 17.636 is to establish the requirements for the § 17.628 Availability of VIOMPSP award of scholarships under the Visual scholarships. 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
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application, including a signed written of study leading to a degree in orienta- acceptance agreement. tion and mobility, low vision therapy, (b) VA’s duties. VA will notify appli- or vision rehabilitation therapy, or a cants prior to acceptance in the dual degree. The number of years cov- VIOMPSP of the following informa- ered by an individual scholarship tion: award will be based on the number of (1) A fair summary of the rights and school years that the participant has liabilities of an individual whose appli- yet to complete his or her degree at the cation is approved by VA and whose ac- time the VIOMPSP scholarship is ceptance agreement is consummated awarded. Subject to the availability of by VA; and funds, VA will award the VIOMPSP as (2) Full description of the terms and follows: conditions that apply to participation (1) Full-time scholarship. A full-time in the VIOMPSP and service in VA. scholarship is awarded for a minimum (Authority: 38 U.S.C. 501(a), 7502(a)(2)) of 1 school year to a maximum of 4 school years; (The Office of Management and Budget has approved the information collection require- (2) Part-time scholarships. A part-time ments in this section under control number scholarship is awarded for a minimum 2900–0793.) of 1 school year to a maximum of 6 school years. § 17.630 Selection of VIOMPSP partici- pants. (Authority: 38 U.S.C. 7504(3)) (a) General. In deciding which § 17.631 Award procedures. VIOMPSP applications to approve, VA will first consider applications sub- (a) Amount of scholarship. (1) A mitted by applicants entering their VIOMPSP scholarship award will not final year of education or training. Ap- exceed the total tuition and required plicants will be evaluated and selected fees for the program of study in which using the criteria specified in para- the applicant is enrolled. All such pay- graph (b) of this section. If there are a ments to scholarship participants are larger number of equally qualified ap- exempt from Federal taxation. plicants than there are awards to be (2) The total amount of assistance made, then VA will first select vet- provided under the VIOMPSP for an erans, and then use a random method academic year to an individual who is as the basis for further selection. a full-time student may not exceed (b) Selection criteria. In evaluating $15,000.00. and selecting participants, VA will (3) The total amount of assistance take into consideration those factors provided under the VIOMPSP for an determined necessary to assure effec- academic year to a participant who is a tive participation in the VIOMPSP. part-time student shall bear the same These factors will include, but are not ratio to the amount that would be paid limited to, the following: under paragraph (a)(2) of this section if (1) Academic performance; the participant were a full-time stu- (2) Work/volunteer experience, in- dent as the coursework carried by the cluding prior rehabilitation or health participant to full-time coursework. care employment and VA employment; (4) The total amount of assistance (3) Faculty and employer rec- provided to an individual may not ex- ommendations; or ceed $45,000.00. (4) Career goals. (5) In the case of an individual en- (c) Notification of approval. VA will rolled in a program of study leading to notify the individual in writing that a dual degree described in § 17.627(a)(1), his or her application has been accept- such tuition and fees will not exceed ed and approved. An individual be- the amounts necessary for the min- comes a participant in the program imum number of credit hours to upon receipt of such approval by VA. achieve such dual degree. (d) Duration of VIOMPSP award. VA (6) Financial assistance may be pro- will award a VIOMPSP scholarship for vided to an individual under the a period of time equal to the number of VIOMPSP to supplement other edu- years required to complete a program cational assistance to the extent that
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the total amount of educational assist- ceived a degree referenced in ance received by the individual during § 17.627(a)(1). an academic year does not exceed the (d) Location and assignment of obli- total tuition and fees for such aca- gated service. VA reserves the right to demic year. make final decisions on the location (7) VA will make arrangements with and assignment of the obligated serv- the school in which the participant is ice. A participant who receives a schol- enrolled to issue direct payment for arship must agree as part of the par- the amount of tuition or fees on behalf ticipant’s mobility agreement that he of the participant. or she is willing to accept the location (b) Repeated course work. Additional and assignment where VA assigns the costs relating to the repeated course obligated service. Geographic reloca- work will not be paid under this pro- tion may be required. gram. VA will resume any scholarship (e) Creditability of advanced clinical payments suspended under this section training. No period of advanced clinical upon notification by the school that training will be credited towards satis- the participant has returned from the fying the period of obligated service in- leave-of-absence or has satisfactorily curred under the VIOMPSP. completed the repeated course work and is pursuing the course of study for (Authority: 38 U.S.C. 7504(2)(D), 7504(3)) which the VIOMPSP was awarded. § 17.633 Deferment of obligated serv- (Authority: 38 U.S.C. 7503, 7504(3)) ice. Deferment of obligated service under § 17.632 Obligated service. the VIOMPSP is treated in the same (a) General provision. Except as pro- manner as deferment of obligated serv- vided in paragraph (d) of this section, ice under the HPSP under § 17.608. each participant is obligated to provide service as a full-time clinical VA em- (Authority: 38 U.S.C. 7504(3)) ployee in the rehabilitation practice of the participant’s discipline in an as- § 17.634 Failure to comply with terms and conditions of participation. signment or location determined by 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
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the criteria described in paragraphs (2) The amount that the United (b)(1) through (4) of this section, unless States is entitled to recover will be VA determines that a longer period is paid no later than 1 year after the date necessary to avoid hardship. No inter- the applicant failed to begin or com- est will be charged on any part of this plete the period of obligated service, as indebtedness. A participant will pay determined by VA. such amount if one of the following cri- (Authority: 38 U.S.C. 7505(a), 7505(b)) teria is met: (1) The participant fails to maintain § 17.635 Bankruptcy. an acceptable level of academic stand- Bankruptcy under the VIOMPSP is ing; treated in the same manner as bank- (2) The participant is dismissed from ruptcy for the HPSP under § 17.611. the school for disciplinary reasons; (3) The participant, for any reason, (Authority: 38 U.S.C. 7505(c), 7505(d)) voluntarily terminates the course of study or program for which the schol- § 17.636 Cancellation, waiver, or sus- arship was awarded including a reduc- pension of obligation. tion of course load from full-time to Cancellation, waiver, or suspension part-time before completing the course procedures under the VIOMPSP are the of study or program; or same as those procedures for the HPSP (4) The participant fails to become under § 17.612. certified in the discipline for which the (Authority: 38 U.S.C. 7505(c)) degree prepared the participant, if ap- plicable, no later than 180 days after GRANTS FOR TRANSPORTATION OF the date such person becomes eligible VETERANS IN HIGHLY RURAL AREAS to apply for certification. (c) Participant fails to perform all or AUTHORITY: Sec. 307, Pub. L. 111–163; 38 any part of their service obligation. (1) U.S.C. 501 and as noted in specific sections. Participants who breach their agree- SOURCE: 78 FR 19593, Apr. 2, 2013, unless ments by failing to begin or complete otherwise noted. their service obligation, for any reason, including the loss, revocation, suspen- § 17.700 Purpose and scope. sion, restriction, or limitation of re- This section establishes the Grants quired certification, and other than for Transportation of Veterans in High- provided for under paragraph (b) of this ly Rural Areas program. Under this section, must repay the portion of all program, the Department of Veterans VIOMPSP funds paid to or on behalf of Affairs (VA) provides grants to eligible the participant, adjusted for the serv- entities to assist veterans in highly ice that they provided. To calculate rural areas through innovative trans- the unearned portion of VIOMPSP portation services to travel to VA med- funds, subtract the number of months ical centers, and to otherwise assist in of obligated service rendered from the providing transportation services in total months of obligated service owed, connection with the provision of VA divide the remaining months by the medical care to these veterans. total obligated service, then multiply by the total amount of VIOMPSP funds (Authority: Sec. 307, Pub. L. 111–163; 38 paid to or on behalf of the participant. U.S.C. 501) The following formula may be used in § 17.701 Definitions. determining the unearned portion: For the purposes of §§ 17.700–17.730 and A = P((t-s)/t) in which any Notice of Fund Availability issued ‘‘A’’ is the amount the United States is enti- pursuant to such sections: tled to recover; Applicant means an eligible entity ‘‘P’’ is the amounts paid under the that submits an application for a grant VIOMPSP, to or on behalf of the partici- pant; announced in a Notice of Fund Avail- ‘‘t’’ is the total number of months in the par- ability. ticipant’s period of obligated service; and Eligible entity means: ‘‘s’’ is the number of months of obligated (1) A Veterans Service Organization, service rendered. or
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(2) A State veterans service agency. (b) Maximum amount. Grant amounts Grantee means an applicant that is will be specified in the Notice of Fund- awarded a grant under this section. ing Availability, but no grant will ex- Highly rural area means an area con- ceed $50,000. sisting of a county or counties having (c) No matching requirement. A grantee a population of less than seven persons will not be required to provide match- per square mile. ing funds as a condition of receiving Notice of Fund Availability means a such grant. Notice of Fund Availability published (d) Veterans will not be charged. Trans- in the FEDERAL REGISTER in accord- portation services provided to veterans ance with § 17.710. through utilization of a grant will be Participant means a veteran in a free of charge. highly rural area who is receiving (Authority: Sec. 307, Pub. L. 111–163; 38 transportation services from a grantee. U.S.C. 501) Provision of VA medical care means the provision of hospital or medical § 17.703 Eligibility and application. 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. Veterans Service Organization means (Authority: Sec. 307, Pub. L. 111–163; 38 U.S.C. 501) an organization recognized by the Sec- retary of Veterans Affairs for the rep- (The Office of Management and Budget has resentation of veterans under section approved the information collection require- 5902 of title 38, United States Code. ment in this section under control number 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
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services to be provided by the applicant Fund Availability. The applications or identified subrecipient. will be ranked in order from highest to (ii) Program budget is defined, and lowest scores. applicant has indicated that grant (2) VA will use the applications’ funds will be sufficient to completely ranking as the basis for awarding implement the program. grants. VA will award grants for the (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: (i) How program will identify and (1) VA will rank those applications serve veterans who otherwise would be that receive at least the minimum unable to obtain VA medical care amount of total points and points per through conventional transportation category set forth in the Notice of resources. Fund Availability. The applications (ii) How program will use new or al- will be ranked in order from highest to ternative transportation resources. lowest scores. (b) Initial grant selection. VA will use (2) VA will use the applications’ the following process to award initial ranking as the basis for awarding grants: grants. VA will award grants for the (1) VA will rank those applications highest ranked applications for which that receive at least the minimum funding is available. 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)
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§ 17.710 Notice of Fund Availability. would insure vehicles procured with their own funds. When funds are available for grants, VA will publish a Notice of Fund Avail- (iii) All vehicle operators must be li- censed in a U.S. State or Territory to ability in the FEDERAL REGISTER. The notice will identify: operate such vehicles. (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 following additional require- order for a supportive grant to be fund- ments: ed; (1) State veterans service agencies (f) The timeframes and manner for and identified subrecipients in the payments under the grant; and grant agreement are subject to the (g) Those areas identified by VA to be Uniform Administrative Requirements the ‘‘highly rural areas’’ in which for Grants and Cooperative Agreements grantees may provide transportation to State and Local Governments under services funded under this rule. 38 CFR part 43, as well as to OMB Cir- cular A–87, Cost Principles for State, (Authority: Sec. 307, Pub. L. 111–163; 38 Local, and Indian Tribal Governments, U.S.C. 501) and 2 CFR parts 25 and 170, if applica- ble. § 17.715 Grant agreements. (2) Veterans Service Organizations (a) General. After a grantee is award- and identified subrecipients in the ed a grant in accordance with § 17.705(b) grant agreement are subject to the or § 17.705(d), VA will draft a grant Uniform Administrative Requirements agreement to be executed by VA and for Grants and Agreements With Insti- the grantee. Upon execution of the tutions of Higher Education, Hospitals, grant agreement, VA will obligate the and Other Non-Profit Organizations approved amount to the grantee. The under 38 CFR part 49, as well as to OMB grant agreement will provide that: Circular A–122, Cost Principles for Non- (1) The grantee must operate the pro- Profit Organizations, codified at 2 CFR gram in accordance with the provisions part 230, and 2 CFR parts 25 and 170, if of this section and the grant applica- applicable. tion. (2) If a grantee’s application identi- (Authority: Sec. 307, Pub. L. 111–163; 38 U.S.C. 501) fied a subrecipient, such subrecipient must operate the program in accord- § 17.720 Payments under the grant. ance with the provisions of this section and the grant application. Grantees are to be paid in accordance (3) If a grantee’s application identi- with the timeframes and manner set fied that funds will be used to procure forth in the Notice of Fund Avail- or operate vehicles to directly provide ability. transportation services, the following (Authority: Sec. 307, Pub. L. 111–163; 38 requirements must be met: U.S.C. 501) (i) Title to the vehicles must vest solely in the grantee or identified sub- § 17.725 Grantee reporting require- recipient, or with leased vehicles in an ments. identified lender. (a) Program efficacy. All grantees who (ii) The grantee or identified sub- receive either an initial or renewed recipient must, at a minimum, provide grant must submit to VA quarterly and motor vehicle liability insurance for annual reports which indicate the fol- the vehicles to the same extent they lowing information:
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(1) Record of time expended assisting TRANSITIONAL HOUSING LOAN PROGRAM with the provision of transportation services. SOURCE: 59 FR 49579, Sept. 29, 1994, unless (2) Record of grant funds expended otherwise noted. assisting with the provision of trans- § 17.800 Purpose. portation services. (3) Trips completed. The purpose of the Transitional Housing Loan Program regulations is (4) Total distance covered. to establish application provisions and (5) Veterans served. selection criteria for loans to non-prof- (6) Locations which received trans- it organizations for use in initial start- portation services. up costs for transitional housing for (7) Results of veteran satisfaction veterans who are in (or have recently survey. been in) a program for the treatment of (b) Quarterly fiscal report. All grantees substance abuse. This program is in- who receive either an initial or renewal tended to increase the amount of tran- grant must submit to VA a quarterly sitional housing available for such vet- report which identifies the expendi- erans who need a period of supportive tures of the funds which VA authorized housing to encourage sobriety mainte- and obligated. nance and reestablishment of social (c) Program variations. Any changes in and community relationships. a grantee’s program activities which § 17.801 Definitions. result in deviations from the grant (a) Applicant: A non-profit organiza- agreement must be reported to VA. tion making application for a loan (d) Additional reporting. Additional re- under this program. porting requirements may be requested (b) Non-profit organization: A secular by VA to allow VA to fully assess pro- or religious organization, no part of gram effectiveness. the net earnings of which may inure to (Authority: Sec. 307, Pub. L. 111–163; 38 the benefit of any member, founder, U.S.C. 501) contributor, or individual. The organi- zation must include a voluntary board (The Office of Management and Budget has and must either maintain or designate approved the information collection require- an entity to maintain an accounting ments in this section under control numbers system which is operated in accordance 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 dishonorable. (b) Prohibition of further grants. When 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 re- § 17.802 Application provisions. ceipt of any further grant funds. (a) To obtain a loan under these (Authority: Sec. 307, Pub. L. 111–163; 38 Transitional Housing Loan Program U.S.C. 501) regulations, an application must be
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submitted by the applicant in the form (G) Anticipated means of collecting prescribed by VA in the application rent and utilities payments from resi- package. The completed application dents, package must be submitted to the Dep- (H) A description of the housing unit uty Associate Director for Psychiatric for which the loan is sought to support, Rehabilitation Services, (302/111C), VA including location, type of neighbor- Medical Center, 100 Emancipation hood, brief floor plan description, etc., Drive, Hampton, VA 23667. An applica- and why this residence was selected for tion package may be obtained by writ- this endeavor. ing to the proceeding address or tele- (iv) The applicant’s plans for use of phoning (804) 722–9961 x3628. (This is not the loan proceeds. a toll-free number) (b) The application package includes (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat. 271, 38 U.S.C. 501) exhibits to be prepared and submitted, including: § 17.803 Order of consideration. (1) Information concerning the appli- cant’s income, assets, liabilities and Loan applications will be considered credit history, on a first-come-first-serve basis, sub- (2) Information for VA to verify the ject to availability of funds for loans applicant’s financial information, and awards will be made on a first- (3) Identification of the official(s) au- come-first-serve basis to applicants thorized to make financial trans- who meet the criteria for receiving a actions on behalf of the applicant, loan. If no funds are available for loans, applications will be retained in (4) Information concerning: the order of receipt for consideration (i) The history, purpose and composi- as funds become available. tion of the applicant, (ii) The applicant’s involvement with (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat. recovering substance abusers, includ- 271, 38 U.S.C. 501) ing: (A) Type of services provided, § 17.804 Loan approval criteria. (B) Number of persons served, Upon consideration of the application (C) Dates during which each type of package, loan approval will be based on service was provided, the following: (D) Names of at least two references (a) Favorable financial history and of government or community groups status, whom the organization has worked (1) A minimum of a two-year credit with in assisting substance abusers, history, (iii) The applicant’s plan for the pro- (2) No open liens, judgments, and no vision of transitional housing to vet- unpaid collection accounts, erans including: (3) No more than two instances where (A) Means of identifying and screen- payments were ever delinquent beyond ing potential residents, 60 days, (B) Number of occupants intended to (4) Net ratio: (monthly expenses di- live in the residence for which the loan vided by monthly cash flow) that does assistance is requested, not exceed 40%, (C) Residence operating policies ad- (5) Gross ratio: (total indebtedness dressing structure for democratic self- divided by gross annual cash flow) that government, expulsion policies for non- does not exceed 35%, payment, alcohol or illegal drug use or (6) At least two favorable credit ref- disruptive behavior, erences, (D) Type of technical assistance (b) Demonstrated ability to success- available to residents in the event of fully address the needs of substance house management problems, abusers as determined by a minimum (E) Anticipated cost of maintaining of one year of successful experience in the residence, including rent and utili- providing services, such as, provision of ties, housing, vocational training, struc- (F) Anticipated charge, per veteran, tured job seeking assistance, organized for residing in the residence, relapse prevention services, or similar
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activity. Such experience would in- nishings, household supplies, and any volve at least twenty-five substance other initial startup costs. abusers, and would be experience which (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat. could be verified by VA inquiries of 271, 38 U.S.C. 501) government or community groups with whom the applicant has worked in pro- § 17.805 Additional terms of loans. viding these services. In the operation of each residence es- (c) An acceptable plan for operating a tablished with the assistance of the residence designed to meet the condi- loan, the recipient must agree to the tions of a loan under this program, following: which will include: (a) The use of alcohol or any illegal (1) Measures to ensure that residents drugs in the residence will be prohib- are eligible for residency, i.e., are vet- ited; erans, are in (or have recently been in) (b) Any resident who violates the prohibition of alcohol or any illegal a program for the treatment of sub- drugs will be expelled from the resi- stance abuse, are financially able to dence; pay their share of costs of maintaining (c) The cost of maintaining the resi- the residence, and agree to abide by dence, including fees for rent and utili- house rules and rent/utilities payment ties, will be paid by residents; provisions, (d) The residents will, through a ma- (2) Adequate rent/utilities collections jority vote of the residents, otherwise to cover cost of maintaining the resi- establish policies governing the condi- dence, tions of the residence, including the (3) Policies that ensure democratic manner in which applications for resi- self-run government, including expul- dence are approved; sion policies, and (e) The residence will be operated (4) Available technical assistance to solely as a residence for not less than residents in the event of house manage- six veterans. ment problems. (Authority: Sec. 8 of Pub. L. 102–54, 105 Stat. (d) Selection of a suitable housing 271, 38 U.S.C. 501) unit for use as a transitional residence HEALTH CARE BENEFITS FOR CERTAIN in a neighborhood with no known ille- CHILDREN OF VIETNAM VETERANS AND gal drug activity, and with adequate VETERANS WITH COVERED SERVICE IN living space for number of veterans KOREA—SPINA BIFIDA AND COVERED planned for residence (at least one BIRTH DEFECTS large bedroom for every three veterans, at least one bathroom for every four SOURCE: 68 FR 1010, Jan. 8, 2003, unless oth- veterans, adequate common space for erwise noted. entire household) (e) Agreements, signed by an official § 17.900 Definitions. authorized to bind the recipient, which For purposes of §§ 17.900 through include: 17.905— (1) The loan payment schedule in ac- Approved health care provider means a cordance with the requirements of Pub. health care provider currently ap- L. 102–54, with the interest rate being proved by the Center for Medicare and the same as the rate the VA is charged Medicaid Services (CMS), Department to borrow these funds from the U.S. of Defense TRICARE Program, Civilian 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), Joint Commission on Ac- each failure to pay an installment by creditation of Health Care Organiza- the date specified in the loan agree- tions (JCAHO), or currently approved ment involved, and for providing health care under a li- (2) The applicant’s intent to use pro- cense or certificate issued by a govern- ceeds of loan only to cover initial mental entity with jurisdiction. An en- startup costs associated with the resi- tity or individual will be deemed to be dence, such as security deposit, fur- an approved health care provider only
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when acting within the scope of the ap- Nursing home care means care and proval, license, or certificate. treatment furnished to a child who has Child for purposes of spina bifida been admitted to a nursing home as a means the same as individual as defined resident. at § 3.814(c)(2) or § 3.815(c)(2) of this title Outpatient care means care and treat- and for purposes of covered birth de- ment, including preventive health serv- fects means the same as individual as ices, furnished to a child other than defined at § 3.815(c)(2) of this title. hospital care or nursing home care. Covered birth defect means the same Preventive care means care and treat- as defined at § 3.815(c)(3) of this title ment furnished to prevent disability or and also includes complications or illness, including periodic examina- medical conditions that are associated tions, immunizations, patient health with the covered birth defect(s) accord- education, and such other services as the Secretary determines necessary to ing to the scientific literature. provide effective and economical pre- Habilitative and rehabilitative care ventive health care. means such professional, counseling, Respite care means care furnished by and guidance services and such treat- an approved health care provider on an ment programs (other than vocational intermittent basis for a limited period training under 38 U.S.C. 1804 or 1814) as to an individual who resides primarily are necessary to develop, maintain, or in a private residence when such care restore, to the maximum extent prac- will help the individual continue resid- ticable, the functioning of a disabled ing in such private residence. person. Spina bifida means all forms and Health care means home care, hos- manifestations of spina bifida except pital care, nursing home care, out- spina bifida occulta (this includes com- patient care, preventive care, plications or medical conditions that habilitative and rehabilitative care, are associated with spina bifida accord- case management, and respite care; ing to the scientific literature). and includes the training of appro- Veteran with covered service in Korea priate members of a child’s family or for purposes of spina bifida means the household in the care of the child; and same as defined at § 3.814(c)(2) of this the provision of such pharmaceuticals, title. supplies (including continence-related Vietnam veteran for purposes of spina supplies such as catheters, pads, and bifida means the same as defined at diapers), equipment (including durable § 3.814(c)(1) or § 3.815(c)(1) of this title medical equipment), devices, appli- and for purposes of covered birth de- ances, assistive technology, direct fects means the same as defined at transportation costs to and from ap- § 3.815(c)(1) of this title. proved health care providers (including (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– any necessary costs for meals and lodg- 1813, 1821, 1831) ing en route, and accompaniment by an [68 FR 1010, Jan. 8, 2003, as amended at 76 FR attendant or attendants), and other 4249, Jan. 25, 2011] materials as the Secretary determines necessary. § 17.901 Provision of health care. Health care provider means any entity (a) Spina bifida. VA will provide a or individual that furnishes health Vietnam veteran or veteran with cov- care, including specialized clinics, ered service in Korea’s child who has health care plans, insurers, organiza- been determined under § 3.814 or § 3.815 tions, and institutions. of this title to suffer from spina bifida Home care means medical care, with health care as the Secretary de- habilitative and rehabilitative care, termines is needed. VA may inform preventive health services, and health- spina bifida patients, parents, or guard- related services furnished to a child in ians that health care may be available the child’s home or other place of resi- at not-for-profit charitable entities. dence. (b) Covered birth defects. VA will pro- Hospital care means care and treat- vide a woman Vietnam veteran’s child ment furnished to a child who has been who has been determined under § 3.815 admitted to a hospital as a patient. of this title to suffer from covered
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birth defects (other than spina bifida) § 17.902 Preauthorization. with such health care as the Secretary (a) Preauthorization from a customer determines is needed by the child for service representative of the Health the covered birth defects. However, if Administration Center is required for VA has determined for a particular the following services or benefits under covered birth defect that § 3.815(a)(2) of §§ 17.900 through 17.905: rental or pur- this title applies (concerning affirma- chase of durable medical equipment tive evidence of cause other than the with a total rental or purchase price in mother’s service during the Vietnam excess of $300, respectively; transplan- era), no benefits or assistance will be tation services; mental health services; provided under this section with re- spect to that particular birth defect. training; substance abuse treatment; (c) Providers of care. Health care pro- dental services; and travel (other than vided under this section will be pro- mileage at the General Services Ad- vided directly by VA, by contract with ministration rate for privately owned an approved health care provider, or by automobiles). Authorization will only other arrangement with an approved be given in spina bifida cases where health care provider. there is a demonstrated medical need. (d) Submission of information. For pur- In cases of other covered birth defects, poses of §§ 17.900 through 17.905: authorization will only be given where (1) The telephone number of the there is a demonstrated medical need Health Administration Center is (888) related to the covered birth defects. 820–1756; Requests for provision of health care (2) The facsimile number of the requiring preauthorization shall be Health Administration Center is (303) made to the Health Administration 331–7807; Center and may be made by telephone, (3) The hand-delivery address of the facsimile, mail, or hand delivery. The Health Administration Center is 3773 application must contain the following: Cherry Creek Drive North, Denver, CO (1) Name of child, 80246; and (2) Child’s Social Security number, (4) The mailing address of the Health (3) Name of veteran, Administration Center for claims sub- (4) Veteran’s Social Security number, mitted pursuant to either paragraph (5) Type of service requested, (a) or (b) of this section is P.O. Box (6) Medical justification, 469065, Denver, CO 80246–9065. (7) Estimated cost, and (8) Name, address, and telephone (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– number of provider. 1813, 1831) (b) Notwithstanding the provisions of NOTE TO § 17.901: Under this program, bene- paragraph (a) of this section, ficiaries with spina bifida will receive com- preauthorization is not required for a prehensive care through the Department of condition for which failure to receive Veterans Affairs. However, the health care benefits available under this section to chil- immediate treatment poses a serious dren with other covered birth defects are not threat to life or health. Such emer- comprehensive, and VA will furnish them gency care should be reported by tele- only health care services that are related to phone to the Health Administration their covered birth defects. With respect to Center within 72 hours of the emer- covered children suffering from spina bifida, gency. VA is the exclusive payer for services paid under 17.900 through 17.905, regardless of any (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– third party insurer, Medicare, Medicaid, 1813, 1831) health plan, or any other plan or program (The Office of Management and Budget has providing health care coverage. As to chil- approved the information collection require- dren with other covered birth defects, any ments in this section under control number third party insurer, Medicare, Medicaid, 2900–0578) health plan, or any other plan or program providing health care coverage would be re- [68 FR 1010, Jan. 8, 2003, as amended at 76 FR sponsible according to its provisions for pay- 4249, Jan. 25, 2011] ment for health care not relating to the cov- ered birth defects. § 17.903 Payment. [68 FR 1010, Jan. 8, 2003, as amended at 76 FR (a)(1) Payment for services or bene- 4249, Jan. 25, 2011] fits under §§ 17.900 through 17.905 will be
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determined utilizing the same payment (B) Summary level itemization (by methodologies as provided for under revenue code), the Civilian Health and Medical Pro- (C) Dates of service for all absences gram of the Department of Veterans from a hospital or other approved insti- Affairs (CHAMPVA) (see § 17.270). 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, mined eligible for benefits under § 3.814 (E) All secondary diagnoses, of this title. (F) All procedures performed, (ii) For covered birth defects, on or (G) Discharge status of the patient, after December 1, 2001, and must have and occurred on or after the date the child (H) Institution’s Medicare provider was determined eligible for benefits number. under § 3.815 of this title. (iv) Patient treatment information (3) Claims from approved health care for all other health care providers and providers must be filed with the Health ancillary outpatient services such as Administration Center in writing (fac- durable medical equipment, medical simile, mail, hand delivery, or elec- requisites, and independent labora- tronically) no later than: tories: (i) One year after the date of service; (A) Diagnosis, or (B) Procedure code for each proce- (ii) In the case of inpatient care, one dure, service, or supply for each date of year after the date of discharge; or service, and (iii) In the case of retroactive ap- (C) Individual billed charge for each proval for health care, 180 days fol- procedure, service, or supply for each lowing beneficiary notification of eligi- date of service. bility. (v) Prescription drugs and medicines (4) Claims for health care provided and pharmacy supplies: under the provisions of §§ 17.900 through (A) Name and address of pharmacy 17.905 must contain, as appropriate, the where drug was dispensed, information set forth in paragraphs (B) Name of drug, (a)(4)(i) through (a)(4)(v) of this sec- (C) National Drug Code (NDC) for tion. drug provided, (i) Patient identification informa- (D) Strength, tion: (E) Quantity, (A) Full name, (F) Date dispensed, (B) Address, (G) Pharmacy receipt for each drug (C) Date of birth, and dispensed (including billed charge), and (D) Social Security number. (H) Diagnosis for which each drug is (ii) Provider identification informa- prescribed. tion (inpatient and outpatient serv- (b) Health care payment will be pro- ices): vided in accordance with the provisions (A) Full name and address (such as of §§ 17.900 through 17.905. However, the hospital or physician), following are specifically excluded (B) Remittance address, from payment: (C) Address where services were ren- (1) Care as part of a grant study or dered, research program, (D) Individual provider’s professional (2) Care considered experimental or status (M.D., Ph.D., R.N., etc.), and investigational, (E) Provider tax identification num- (3) Drugs not approved by the U.S. ber (TIN) or Social Security number. Food and Drug Administration for (iii) Patient treatment information commercial marketing, (long-term care or institutional serv- (4) Services, procedures, or supplies ices): for which the beneficiary has no legal (A) Dates of service (specific and in- obligation to pay, such as services ob- clusive), tained at a health fair,
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(5) Services provided outside the tion not previously considered. Any re- scope of the provider’s license or cer- quest for reconsideration that does not tification, and identify the reason for dispute will be (6) Services rendered by providers returned to the sender without further suspended or sanctioned by a Federal consideration. After reviewing the agency. matter, including any relevant sup- (c) Payments made in accordance porting documentation, a benefits ad- with the provisions of §§ 17.900 through visor will issue a written determina- 17.905 shall constitute payment in full. tion (with a statement of findings and Accordingly, the health care provider reasons) to the person or entity seek- or agent for the health care provider ing reconsideration that affirms, re- may not impose any additional charge verses, or modifies the previous deci- for any services for which payment is sion. If the person or entity seeking re- made by VA. consideration is still dissatisfied, with- (d) Explanation of benefits (EOB)—(1) in 90 days of the date of the decision he When a claim under the provisions of or she may submit in writing (by fac- §§ 17.900 through 17.905 is adjudicated, simile, mail, or hand delivery) to the an EOB will be sent to the beneficiary Health Administration Center (Atten- or guardian and the provider. The EOB tion: Director) a request for review by provides, at a minimum, the following the Director, Health Administration information: Center. The Director will review the (i) Name and address of recipient, claim and any relevant supporting doc- (ii) Description of services and/or umentation and issue a decision in supplies provided, writing (with a statement of findings (iii) Dates of services or supplies pro- and reasons) that affirms, reverses, or vided, modifies the previous decision. An ap- (iv) Amount billed, peal under this section would be con- (v) Determined allowable amount, sidered as filed at the time it was de- (vi) To whom payment, if any, was livered to the VA or at the time it was made, and released for submission to the VA (for (vii) Reasons for denial (if applica- example, this could be evidenced by the ble). postmark, if mailed). (2) [Reserved] (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– NOTE TO § 17.904: The final decision of the 1813, 1831) Director will inform the claimant of further appellate rights for an appeal to the Board of (The Office of Management and Budget has Veterans’ Appeals. approved the information collection require- ments in this section under control number (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– 2900–0578) 1813, 1831) [68 FR 1010, Jan. 8, 2003, as amended at 76 FR (The Office of Management and Budget has 4249, Jan. 25, 2011] approved the information collection require- ments in this section under control number § 17.904 Review and appeal process. 2900–0578) For purposes of §§ 17.900 through [68 FR 1010, Jan. 8, 2003, as amended at 76 FR 17.905, if a health care provider, child, 4250, Jan. 25, 2011] or representative disagrees with a de- termination concerning provision of § 17.905 Medical records. health care or with a determination Copies of medical records generated concerning payment, the person or en- outside VA that relate to activities for tity may request reconsideration. Such which VA is asked to provide payment request must be submitted in writing or that VA determines are necessary to (by facsimile, mail, or hand delivery) adjudicate claims under §§ 17.900 within one year of the date of the ini- through 17.905 must be provided to VA tial determination to the Health Ad- at no cost. ministration Center (Attention: Chief, Benefit and Provider Services). The re- (Authority: 38 U.S.C. 101(2), 1802–1803, 1811– quest must state why it is believed 1813, 1831) that the decision is in error and must [68 FR 1010, Jan. 8, 2003, as amended at 76 FR include any new and relevant informa- 4250, Jan. 25, 2011]
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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; (4) An automobile accident repara- § 17.1000 Payment or reimbursement tions insurance carrier; or for emergency services for non- (5) A person or entity obligated to service-connected conditions in provide, or to pay the expenses of, non-VA facilities. health services under a health-plan Sections 17.1000 through 17.1008 con- contract. stitute the requirements under 38 (c) The term duplicate payment means U.S.C. 1725 that govern VA payment or payment made, in whole or in part, for reimbursement for non-VA emergency the same emergency services for which services furnished to a veteran for non- VA reimbursed or made payment. service-connected conditions. (d) The term stabilized means that no material deterioration of the emer- (Authority: 38 U.S.C. 1725) gency medical condition is likely, NOTE TO § 17.1000: In cases where a patient within reasonable medical probability, is admitted for inpatient care, health care to occur if the veteran is discharged or providers furnishing emergency treatment transferred to a VA or other Federal who believe they may have a basis for filing facility that VA has an agreement with a claim with VA for payment under 38 U.S.C. to furnish health care services for vet- 1725 should contact VA within 48-hours after admission for emergency treatment. Such erans. contact is not a condition of VA payment. (e) The term VA medical facility of ju- However, the contact will assist the provider risdiction means the nearest VA med- in understanding the conditions for pay- ical facility to where the emergency ment. The contact may also assist the pro- service was provided. vider in planning for transfer of the veteran after stabilization. (Authority: 38 U.S.C. 1725) [66 FR 36470, July 12, 2001, as amended at 76 [66 FR 36470, July 12, 2001, as amended at 68 FR 79071, Dec. 21, 2011; 77 FR 23617, Apr. 20, FR 3404, Jan. 24, 2003] 2012]
§ 17.1001 Definitions. § 17.1002 Substantive conditions for For purposes of §§ 17.1000 through payment or reimbursement. 17.1008: Payment or reimbursement under 38 (a) The term health-plan contract U.S.C. 1725 for emergency treatment means any of the following: (including medical services, profes- (1) An insurance policy or contract, sional services, ambulance services, an- medical or hospital service agreement, cillary care and medication (including membership or subscription contract, a short course of medication related to or similar arrangement under which and necessary for the treatment of the health services for individuals are pro- emergency condition that is provided vided or the expenses of such services directly to the patient for use after the are paid; emergency condition is stabilized and (2) An insurance program described the patient is discharged)) will be made in section 1811 of the Social Security only if all of the following conditions Act (42 U.S.C. 1395c) or established by are met: section 1831 of that Act (42 U.S.C. (a) The emergency services were pro- 1395j); vided in a hospital emergency depart- (3) A State plan for medical assist- ment or a similar facility held out as ance approved under title XIX of the providing emergency care to the pub- Social Security Act (42 U.S.C. 1396 et lic; seq.); (b) The claim for payment or reim- (4) A workers’ compensation law or bursement for the initial evaluation plan described in section 38 U.S.C. and treatment is for a condition of 1729(a)(2)(A); or such a nature that a prudent layperson
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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 (including severe pain) that a prudent that could reasonably be pursued for layperson who possesses an average the purpose of extinguishing, in whole, knowledge of health and medicine the veteran’s liability to the provider; could reasonably expect the absence of and immediate medical attention to result (h) The veteran is not eligible for re- in placing the health of the individual imbursement under 38 U.S.C. 1728 for in serious jeopardy, serious impair- the emergency treatment provided (38 ment to bodily functions, or serious U.S.C. 1728 authorizes VA payment or dysfunction of any bodily organ or reimbursement for emergency treat- part); ment to a limited group of veterans, (c) A VA or other Federal facility/ primarily those who receive emergency provider that VA has an agreement treatment for a service-connected dis- with to furnish health care services for ability). veterans was not feasibly available and (Authority: 38 U.S.C. 1725) an attempt to use them beforehand [66 FR 36470, July 12, 2001, as amended at 68 would not have been considered reason- FR 3404, Jan. 24, 2003; 76 FR 79071, Dec. 21, able by a prudent layperson (as an ex- 2011; 77 FR 23617, Apr. 20, 2012] ample, these conditions would be met by evidence establishing that a veteran § 17.1003 Emergency transportation. was brought to a hospital in an ambu- Notwithstanding the provisions of lance and the ambulance personnel de- § 17.1002, payment or reimbursement termined the nearest available appro- under 38 U.S.C. 1725 for ambulance priate level of care was at a non-VA services, including air ambulance serv- medical center); ices, may be made for transporting a (d) At the time the emergency treat- veteran to a facility only if the fol- ment was furnished, the veteran was lowing conditions are met: enrolled in the VA health care system (a) Payment or reimbursement is au- and had received medical services thorized under 38 U.S.C. 1725 for emer- under authority of 38 U.S.C. chapter 17 gency treatment provided at such facil- within the 24-month period preceding ity (or payment or reimbursement the furnishing of such emergency could have been authorized under 38 treatment; U.S.C. 1725 for emergency treatment if (e) The veteran is financially liable death had not occurred before emer- to the provider of emergency treat- gency treatment could be provided); ment for that treatment; (b) The veteran is financially liable (f) The veteran has no coverage under to the provider of the emergency trans- a health-plan contract for payment or portation; reimbursement, in whole or in part, for (c) The veteran has no coverage the emergency treatment (this condi- under a health-plan contract for reim- tion cannot be met if the veteran has bursement or payment, in whole or in coverage under a health-plan contract part, for the emergency transportation but payment is barred because of a fail- or any emergency treatment author- ure by the veteran or the provider to ized under 38 U.S.C. 1728 (this condition comply with the provisions of that is not met if the veteran has coverage health-plan contract, e.g., failure to under a health-plan contract but pay- submit a bill or medical records within ment is barred because of a failure by specified time limits, or failure to ex- the veteran or the provider to comply haust appeals of the denial of pay- with the provisions of that health-plan ment); contract); and (g) If the condition for which the (d) If the condition for which the emergency treatment was furnished emergency transportation was fur- was caused by an accident or work-re- nished was caused by an accident or
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work-related injury, the claimant has the VA medical facility of jurisdiction, exhausted without success all claims together with a bill showing the serv- and remedies reasonably available to ices provided and charges for which the the veteran or provider against a third veteran is personally liable and a party for payment of such transpor- signed statement explaining who re- tation; and the veteran has no contrac- quested such transportation services tual or legal recourse against a third and why they were necessary. party that could reasonably be pursued (d) To receive payment or reimburse- for the purpose of extinguishing, in ment for emergency services, a claim- whole or in part, the veteran’s liability ant must file a claim within 90 days to the provider. after the latest of the following: (Authority: 38 U.S.C. 1725) (1) The date that the veteran was dis- charged from the facility that fur- § 17.1004 Filing claims. nished the emergency treatment; (2) The date of death, but only if the (a) A claimant for payment or reim- death occurred during transportation bursement under 38 U.S.C. 1725 must be to a facility for emergency treatment the entity that furnished the treat- or if the death occurred during the stay ment, the veteran who paid for the in the facility that included the provi- treatment, or the person or organiza- sion of the emergency treatment; or tion that paid for such treatment on behalf of the veteran. (3) The date the veteran finally ex- (b) To obtain payment or reimburse- hausted, without success, action to ob- ment for emergency treatment under tain payment or reimbursement for the 38 U.S.C. 1725, a claimant must submit treatment from a third party. to the VA medical facility of jurisdic- (e) If after reviewing a claim the de- tion a completed standard billing form cisionmaker determines that addi- (such as a UB92 or a HCFA 1500). Where tional information is needed to make a the form used does not contain a false determination regarding the claim, claims notice, the completed form such official will contact the claimant must also be accompanied by a signed, in writing and request additional infor- written statement declaring that ‘‘I mation. The additional information hereby certify that this claim meets must be submitted to the decision- all of the conditions for payment by maker within 30 days of receipt of the VA for emergency medical services request or the claim will be treated as under 38 CFR 17.1002 (except for para- abandoned, except that if the claimant graph (e)) and 17.1003. I am aware that within the 30-day period requests in 38 U.S.C. 6102(b) provides that one who writing additional time, the time pe- obtains payment without being enti- riod for submission of the information tled to it and with intent to defraud may be extended as reasonably nec- the United States shall be fined in ac- essary for the requested information to cordance with title 18, United States be obtained. Code, or imprisoned not more than one (f) Notwithstanding paragraph (d) of year, or both.’’ this section, VA will provide retro- active payment or reimbursement for NOTE TO § 17.1004(b): These regulations re- emergency treatment received by the garding payment or reimbursement for veteran on or after July 19, 2001, but emergency services for nonservice-connected more than 90 days before May 21, 2012, conditions in non-VA facilities also can be found on the internet at http://www.va.gov/ if the claimant files a claim for reim- health/elig. bursement no later than 1 year after May 21, 2012. (c) Notwithstanding the provisions of paragraph (b) of this section, no spe- (Authority: 38 U.S.C. 1725) cific form is required for a claimant (or (The Office of Management and Budget has duly authorized representative) to approved the information collection require- claim payment or reimbursement for ments in this section under control number emergency transportation charges 2900–0620.) under 38 U.S.C. 1725. The claimant need [66 FR 36470, July 12, 2001, as amended at 68 only submit a signed and dated request FR 3404, Jan. 24, 2003; 77 FR 23617, Apr. 20, for such payment or reimbursement to 2012]
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§ 17.1005 Payment limitations. summary, or other applicable medical record. (a) Payment or reimbursement for emergency treatment under 38 U.S.C. (d) If a stabilized veteran who re- 1725 shall be the lesser of the amount quires continued non-emergency treat- for which the veteran is personally lia- ment refuses to be transferred to an ble or 70 percent of the amount under available VA facility (or other Federal the applicable Medicare fee schedule facility that VA has an agreement with for such treatment. to furnish health care services for vet- (b) Except as provided in paragraph erans), VA will make payment or reim- (c) of this section, VA will not approve bursement only for the expenses re- claims for payment or reimbursement lated to the initial evaluation and the of the costs of emergency treatment emergency treatment furnished to the not previously authorized for any pe- veteran up to the point of refusal of riod beyond the date on which the med- transfer by the veteran. ical emergency ended. For this pur- (e) If an eligible veteran under pose, VA considers that an emergency § 17.1002 has contractual or legal re- ends when the designated VA clinician course against a third party that would at the VA facility has determined that, only partially extinguish the veteran’s based on sound medical judgment, a liability to the provider of emergency veteran who received emergency treat- treatment, then: ment: (1) VA will be the secondary payer; (1) Could have been transferred from (2) Subject to the limitations of this the non-VA facility to a VA medical section, VA will pay the difference be- center (or other Federal facility that tween the amount VA would have paid VA has an agreement with to furnish under this section for the cost of the health care services for veterans) for continuation of treatment, or emergency treatment and the amount (2) Could have reported to a VA med- paid (or payable) by the third party; ical center (or other Federal facility and that VA has an agreement with to fur- (3) The provider will consider the nish health care services for veterans) combined payment under paragraph for continuation of treatment. (e)(2) of this section as payment in full (c) Claims for payment or reimburse- and extinguish the veteran’s liability ment of the costs of emergency treat- to the provider. ment not previously authorized may be (f) VA will not reimburse a claimant approved for continued, non-emergency under this section for any deductible, treatment, only if: copayment or similar payment that (1) The non-VA facility notified VA the veteran owes the third party. at the time the veteran could be safely (Authority: 38 U.S.C. 1725) transferred to a VA facility (or other Federal facility that VA has an agree- [66 FR 36470, July 12, 2001, as amended at 68 ment with to furnish health care serv- FR 3404, Jan. 24, 2003; 76 FR 79071, Dec. 21, ices for veterans) and the transfer of 2011; 77 FR 23618, Apr. 20, 2012; 78 FR 36093, the veteran was not accepted, and June 17, 2013] (2) The non-VA facility made and § 17.1006 Decisionmakers. documented reasonable attempts to re- quest transfer of the veteran to VA (or The Chief of the Health Administra- to another Federal facility that VA has tion Service or an equivalent official at an agreement with to furnish health the VA medical facility of jurisdiction care services for veterans), which will make all determinations regarding means the non-VA facility contacted payment or reimbursement under 38 either the VA Transfer Coordinator, U.S.C. 1725, except that the designated Administrative Officer of the Day, or VA clinician at the VA medical facility designated staff responsible for accept- of jurisdiction will make determina- ing transfer of patients at a local VA tions regarding § 17.1002(b), (c), and (d). (or other Federal facility) and docu- Any decision denying a benefit must be mented such contact in the veteran’s progress/physicians’ notes, discharge
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in writing and inform the claimant of ceives from a third party for the same VA reconsideration and appeal rights. treatment. (2) Any amount paid by the United (Authority: 38 U.S.C. 1725) States, and accepted by the provider [66 FR 36470, July 12, 2001, as amended at 76 that furnished the veteran’s emergency FR 79072, Dec. 21, 2011] treatment, shall constitute a lien § 17.1007 Independent right of recov- against any subsequent amount the ery. provider receives from a third party for the same emergency treatment for (a) VA has the right to recover its which the United States made pay- payment under this section when, and ment. to the extent that, a third party makes (c) If it is determined that a dupli- payment for all or part of the same cate payment was made, the Chief Fi- emergency treatment for which VA re- nancial Officer or equivalent official at imbursed or made payment under this the VA medical facility of jurisdiction section. may waive recovery of a VA payment (1) Under 38 U.S.C. 1725(d)(4), the vet- made under this section to a veteran eran (or the veteran’s personal rep- upon determining that the veteran has resentative, successor, dependents, or substantially complied with the provi- survivors) or claimant shall ensure that the Secretary is promptly notified sions of paragraph (a)(1) of this section of any payment received from any and that actions to recover the pay- third party for emergency treatment ment would not be cost-effective or furnished to the veteran. The veteran would conflict with other litigative in- (or the veteran’s personal representa- terests of the United States. tive, successor, dependents, or sur- (Authority: 38 U.S.C. 1725) vivors) or claimant shall immediately forward all documents relating to such § 17.1008 Balance billing prohibited. payment, cooperate with the Secretary Payment by VA under 38 U.S.C. 1725 in the investigation of such payment on behalf of a veteran to a provider of and assist the Secretary in enforcing emergency treatment and any non- the United States’ right to recover any emergency treatment that is author- payment made and accepted under this ized under § 17.1005(c) of this part shall, section. The required notification and unless rejected and refunded by the submission of documentation must be provider within 30 days of receipt, ex- provided by the veteran or claimant to tinguish all liability on the part of the the VA medical facility of jurisdiction veteran for that emergency treatment within three working days of receipt of and any non-emergency treatment that notice of the duplicate payment. is authorized under § 17.1005(c) of this (2) If the Chief Financial Officer or part. Neither the absence of a contract equivalent official at the VA medical or agreement between VA and the pro- facility of jurisdiction concludes that vider nor any provision of a contract, payment from a third party was made agreement, or assignment to the con- for all or part of the same emergency trary shall operate to modify, limit, or treatment for which VA reimbursed or negate this requirement. made payment under this section, such VA official shall, except as provided in (Authority: 38 U.S.C. 1725) paragraph (c) of this section, initiate [66 FR 36470, July 12, 2001, as amended at 76 action to collect or recover the amount FR 79072, Dec. 21, 2011] of the duplicate payment in the same manner as for any other debt owed the VET CENTERS United States. (b)(1) Any amount paid by the United § 17.2000 Vet Center services. States to the veteran (or the veteran’s (a) Eligibility for readjustment coun- personal representative, successor, de- seling. Upon request, VA will provide pendents, or survivors) or to any other readjustment counseling to the fol- person or organization paying for such lowing individuals: treatment shall constitute a lien in (1) A veteran who served on active favor of the United States against any duty in a theater of combat operations recovery the payee subsequently re- during a period of war.
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(2) A veteran who served on active of paragraph (a) of this section, solely duty in an area in which hostilities oc- because the individual was discharged curred, or in combat against a hostile under dishonorable conditions from ac- force during a period of hostilities. tive military, naval, or air service, the (3) A veteran who served on active following: duty during the Vietnam era who (1) Referral services to assist such in- sought or was provided counseling dividual, to the maximum extent prac- under 38 U.S.C. 1712A before January 1, ticable, in obtaining mental health 2004. care and services from sources outside (4) Any member of the Armed Forces, VA; and including a member of the National (2) If pertinent, advice to such indi- Guard or reserve, who served on active vidual concerning such individual’s duty in the Armed Forces in Operation rights to apply to: Enduring Freedom, Operation Iraqi Freedom or Operation New Dawn. (i) The appropriate military, naval or (5) A family member of a veteran or air service for review of such individ- servicemember who is eligible for read- ual’s discharge or release from such justment counseling under paragraphs service; and (a)(1) through (a)(4) of this section. For (ii) VA for a VA benefits eligibility purposes of this section, family mem- determination under 38 CFR 3.12. ber includes, but is not limited to, the (d) Readjustment counseling defined. spouse, parent, child, step-family mem- For the purposes of this section, read- ber, extended family member, and any justment counseling includes, but is individual who lives with the veteran not limited to: psychosocial assess- or servicemember but is not a member ment, individual counseling, group of the family of the veteran or service- counseling, marital and family coun- member. seling for military-related readjust- (b) Proof of eligibility. With the vet- ment issues, substance abuse assess- eran’s or servicemember’s consent, VA ments, medical referrals, referral for will assist in obtaining proof of eligi- additional VA benefits, employment bility. For the purposes of this section, assessment and referral, military sex- proof of service in a theater of combat ual trauma counseling and referral, be- operations or in an area during a pe- reavement counseling, and outreach. A riod of hostilities in that area will be ‘‘psychosocial assessment’’ under this 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 individuals listed in para- (2) Receipt of one of the following medals: The Armed Forces Expedi- graphs (a)(1) through (a)(4) of this sec- tionary Medal, Service Specific Expedi- tion, and to family members under tionary Medal (e.g., Navy Expedi- paragraph (a)(5) of this section, when it tionary Medal), Combat Era Specific would aid in the readjustment of a vet- Expeditionary Medal (e.g., the Global eran or servicemember. War on Terrorism Expeditionary (e) Confidentiality. Benefits under this Medal), Campaign Specific Medal (e.g., section are furnished solely by VA Vet Vietnam Service Medal or Iraq Cam- Centers, which maintain confidential paign Medal), or other combat theater records independent from any other VA awards established by public law or ex- or Department of Defense medical ecutive order; or records and which will not disclose (3) Proof of receipt of Hostile Fire or such records without either the vet- Imminent Danger Pay (commonly re- eran or servicemember’s voluntary, ferred to as ‘‘combat pay’’) or combat signed authorization, or a specific ex- tax exemption after November 11, 1998. ception permitting their release. For (c) Referral and advice. Upon request, more information, see 5 U.S.C. 552a, 38 VA will provide an individual who does U.S.C. 5701 and 7332, 45 CFR parts 160 not meet the eligibility requirements and 164, and VA’s System of Records
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64VA15, ‘‘Readjustment Counseling Service Vet Center Program.’’ (Authority: 38 U.S.C. 501, 1712A, 1782, and 1783; Pub. L. 111–163, sec. 304, 401, and 402) [78 FR 57073, Sept. 17, 2013]
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