Expanded Access to Non-VA Care Through the Veterans Choice Program
Final rule.
CFR Part: "38 CFR Part 17"
RIN Number: "RIN 2900-AP24"
Citation: "80 FR 66419"
Page Number: "66419"
"Rules and Regulations"
SUMMARY: This document amends the
DATES: Effective Date: This rule is effective on
FOR FURTHER INFORMATION CONTACT:
SUPPLEMENTARY INFORMATION: On
In response to the November interim final rule,
VA Copayments
The November interim final rule modified 38 CFR 17.108, 17.110, and 17.111 to establish a
As we explained in detail in the November interim final rule, there are administrative difficulties in determining the proper copayment amount for a visit scheduled through the Program that make it inefficient to attempt to charge a copayment amount at the time of visit. In addition, not charging a copayment at the time of the visit was intended to ensure that veterans' experiences under the Program would be as similar as possible to their experiences when provided with non-
Duration and Scope of the Program
The Program is funded with
VA received several comments suggesting that non-
We received comments indicating that the Program should be used to provide unscheduled or emergency care, particularly under extraordinarily dangerous circumstances. We note that under the contract
VA received comments that the Program was implemented too quickly, that staff were not adequately trained, and that there are operational issues that need to be resolved. The Act directed
VA received a comment stating that we should not have sent Choice Cards to veterans who are not eligible to participate in the Program. While this comment is somewhat outside the scope of this rulemaking, which did not address the distribution of Choice Cards because it was not necessary to do so to establish the Program,
Definition of Episode of Care
VA received several comments recommending we adopt different definitions for terms in the rule. Some commenters recommended that
Section 17.1510 Eligible Veterans
We received a number of comments regarding the eligibility criteria for the Program. At the time that the comment periods for both the November and April interim final rules closed, to be eligible to participate in the Program, the veteran must have enrolled in the
Wait-Time Eligibility
Under SEC 17.1510(b)(1), a veteran is eligible if the veteran attempts, or has attempted, to schedule an appointment with a
A commenter suggested that the term "wait-time goals of the
We also received a comment recommending that
Eligibility Based on Distance From a VA Medical Facility
Under SEC 17.1510(b)(2), a veteran is eligible if the veteran resides more than 40 miles from the
The April interim final rule greatly expanded veteran eligibility based on this criterion, representing liberalization similar to what had been suggested by many commenters. However, to the extent that commenters believe that 40-miles driving distance is still an unreasonable calculation, we do not believe that the Act gives us authority to depart from that standard.
VA received a large number of comments recommending that
VA also received a comment recommending that we modify the definition of "
Under SEC 17.1510(b)(3), a veteran is eligible if the veteran's residence is in a state without a full-service
One commenter asked what system
On
Eligibility Based on Burden in Traveling
Under the November interim final rule,
Section 17.1515 Authorizing Non-VA Care
Section 17.1515 describes the process and requirements for authorizing non-
First, we received a comment asking why a patient would be required to travel to a different
Another comment stated that requiring advanced authorization may prevent veterans from receiving timely care.
Several commenters recommended that
VA also received comments offering recommendations for a simpler method for authorizing care. For example, some comments stated that there should be a unique call-in number for providers, and that
Commenters also suggested that authorizations or contracts should be retroactive to the date of an eligible request because this would result in fewer non-health-center providers refusing to care for unauthorized veterans, and fewer uncompensated care costs for health centers. It is unclear how this change would produce that result. Moreover,
Several comments stated that veterans and providers should be notified if care will not be continued past 60 days and that authorizations for care for patients with chronic conditions should cover emergency primary care needs. As we stated in the November interim final rule, we will be working with providers and veterans to notify them in advance if the 60 day authorization period is coming to an end, particularly if such care will not be re-authorized because the veteran or provider is no longer eligible to participate in the Program. For patients with chronic conditions,
Some commenters asserted that requiring authorization for each and every treatment is time consuming and does not produce any benefits, and that
We received several comments raising additional issues concerning authorizations for care. The comments stated that it was sometimes unclear which services were being authorized and who is making the determination, and asked
Finally, one commenter suggested that veterans should not have to contact the vendors administering the Program to verify their eligibility prior to care being authorized. This is not an express requirement in the regulation, and as such is outside the scope of this rulemaking. As a result, we are not making a change based on this comment. However, as a practical matter,
Section 17.1530 Eligible Entities and Providers
Section 17.1530 defines requirements for non-
VA received several comments recommending that other entities, such as rural health clinics, community health centers, women's health centers, essential community providers, and
One commenter recommended that
Under SEC 17.1530(b), an entity or provider must enter into an agreement with
Several comments also stated that existing agreements, including agreements with Tribal and urban health programs among others, should be used to furnish care. Existing contracts and agreements with eligible providers can be used to furnish care, and
Under SEC 17.1530(d), a non-
We also received a recommendation to broaden the language about credentialing and licensing to ensure qualified non-physician practitioners qualify to participate in the Program. Another commenter suggested that
Although not addressed in the regulation,
Section 17.1535 Payment Rates and Methodologies
Section 17.1535 addresses payment rates and payment methodologies.
Several commenters stated that
The vendors administering the Program also operate the Patient-Centered Community Care (PC3) contract, which can pay rates lower than the
However, we are adding two additional exceptions to
One commenter suggested that
Section 17.1535(b) details payment responsibilities. One comment stated that
Section 17.1540 Claims Processing System
Section 17.1540 provides general requirements for a
We received comments stating the processing system should be simple, and that it should be easy for providers and entities to submit information. We also received comments suggesting that
Miscellaneous Comments
In addition to the areas above,
Several comments asked about other non-
VA received comments that it should address late payment claims for care authorized under other authorities so that community providers would be more likely to participate in the Program. This is outside the scope of the rulemaking, but we are working to pay promptly claims under any authority, including the Program, and if there are specific claims that are late, we encourage the providers to contact us so we can rectify the situation. We are not making any changes as a result of these comments.
We also received a number of comments about other issues. One comment stated that
Another comment stated that
Several comments recommended better communication with the public about the Program. For example, some suggested outreach to medical societies and physician associations to increase awareness, some suggested better education materials for eligible veterans and providers, and some recommended better coordination and consistency with the vendors administering the Program to clarify the requirements of the Program. Although these comments are outside the scope of the rulemaking, we appreciate this feedback and are working with all of these populations to increase awareness of the Program. For example, when we initially launched the Program, we mailed explanatory letters to over eight million veterans, and we completed an outbound call campaign to those veterans who were initially eligible under the wait-time criterion. We have prepared and updated fact sheets for veterans that can be accessed online or at a facility, and we have worked with provider groups and Veterans Service Organizations to support further outreach. Earlier this year,
One comment recommended that non-
One comment recommended that
We also received several comments that Tribes and Tribal organizations can contribute to the Program. As we stated in the November interim final rule, outpatient health programs or facilities operated by a Tribe or Tribal organization under the Indian Self-Determination and Education Assistance Act or by an urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act are defined as Federally-qualified health centers in section 1905(l)(2)(B) of the Social Security Act and can be eligible providers under section 101(a)(1)(B) of the Act. The comments urged
Administrative Procedure Act
In accordance with 5 U.S.C. 553(b)(B) and (d)(3), the Secretary of
Effect of Rulemaking
Title 38 of the Code of Federal Regulations, as revised by this final rule, represents
Paperwork Reduction Act
The Paperwork Reduction Act of 1995 (44 U.S.C. 3507) requires that
This final rule will impose the following new information collection requirements. Section 17.1515 requires eligible veterans to notify
As required by the Paperwork Reduction Act of 1995 (at 44 U.S.C. 3507(d)),
Executive Orders 12866 and 13563
Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages; distributive impacts; and equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 12866 (Regulatory Planning and Review) defines a "significant regulatory action," requiring review by OMB, unless OMB waives such review, as "any regulatory action that is likely to result in a rule that may: (1) Have an annual effect on the economy of
The economic, interagency, budgetary, legal, and policy implications of this regulatory action have been examined, and it has been determined that this is an economically significant regulatory action under Executive Order 12866.
Congressional Review Act
This regulatory action is a major rule under the Congressional Review Act, 5 U.S.C. 801-08, because it may result in an annual effect on the economy of
Unfunded Mandates
The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of
Regulatory Flexibility Act
The Secretary hereby certifies that this final rule will not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. This final rule will not have a significant economic impact on participating eligible entities and providers who enter into agreements with
Catalog of Federal Domestic Assistance
The Catalog of Federal Domestic Assistance numbers and titles for the programs affected by this document are as follows: 64.007, Blind Rehabilitation Centers; 64.008, Veterans Domiciliary Care; 64.009, Veterans Medical Care Benefits; 64.010, Veterans Nursing Home Care; 64.011, Veterans Dental Care; 64.012, Veterans Prescription Service; 64.013, Veterans Prosthetic Appliances; 64.014, Veterans State Domiciliary Care; 64.015, Veterans State Nursing Home Care; 64.016, Veterans State Hospital Care; 64.018, Sharing Specialized Medical Resources; 64.019, Veterans Rehabilitation Alcohol and Drug Dependence; 64.022, Veterans Home Based Primary Care; and 64.024, VA Homeless Providers Grant and Per Diem Program.
Signing Authority
The Secretary of
List of Subjects in 38 CFR Part 17
Administrative practice and procedure, Alcohol abuse, Alcoholism, Claims, Day care, Dental health, Drug abuse, Government contracts, Grant programs-health, Grant programs-veterans, Health care, Health facilities, Health professions, Health records, Homeless, Mental health programs, Nursing homes, Reporting and recordkeeping requirements, Travel and transportation expenses, Veterans.
Dated:
Chief Impact Analyst,
For the reasons stated in the preamble,
PART 17--MEDICAL
1. The authority citation for part 17 continues to read as follows:
Authority: 38 U.S.C. 501, and as noted in specific sections.
2. In
(a) * * *
(3) For eligible entities or providers in
(4) For eligible entities or providers in a State with an All-Payer Model Agreement under the Social Security Act that became effective on
* * * * *
[FR Doc. 2015-27481 Filed 10-28-15;
BILLING CODE 8320-01-P
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