Medical Benefits Package; Copayments for Extended Care Services

AGENCY:

Department of Veterans Affairs.

ACTION:

Proposed rule.

SUMMARY:

We propose to amend VA's medical regulations by adding the following extended care services to the medical benefits package: noninstitutional adult day health care, noninstitutional geriatric evaluation, and noninstitutional respite care. Also, we propose to amend VA's medical regulations to establish provisions regarding copayments for extended care services. These actions would implement provisions of the Veterans Millennium Health Care and Benefits Act.

DATES:

Comments must be received on or before December 3, 2001.

ADDRESSES:

Mail or hand-deliver written comments to: Director, Office of Regulations Management (02D), Department of Veterans Affairs, 810 Vermont Ave., NW., Room 1154, Washington, DC 20420; or fax comments to (202) 273-9289; or e-mail comments to OGCRegulations@mail.va.gov. Comments should indicate that they are submitted in response to “RIN 2900-AK32.” All comments received will be available for public inspection in the Office of Regulations Management, Room 1158, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays).

FOR FURTHER INFORMATION CONTACT:

Marsha Goodwin, Geriatrics and Extended Care (114), at (202) 273-8540 for issues regarding the medical benefits package, and Nancy Howard, Revenue Office (174), at (202) 273-8198 for issues regarding copayments for extended care services. Both are officials in the Veterans Health Administration, 810 Vermont Avenue NW., Washington, DC 20420.

SUPPLEMENTARY INFORMATION:

Medical Benefits Package

We propose to amend VA's medical regulations at 38 CFR 17.38 concerning VA's medical benefits package which sets forth what care is provided to veterans enrolled in the VA healthcare system. More specifically, we propose to add the following extended care services to the medical benefits package: noninstitutional adult day health care, noninstitutional geriatric evaluation, and noninstitutional respite care. This implements amendments to 38 U.S.C. 1701(10) and 1710B(a)(5) added by the Veterans Millennium Health Care and Benefits Act (section 101(b) and (c) of Public Law 106-117).

The medical benefits package already specifically includes respite care that is provided as hospital or outpatient care. To avoid confusion, we note that with the adoption of the proposed changes, the medical benefits package would include both institutional (hospital and outpatient) and noninstitutional respite care.

Copayments for Extended Care Services

The Veterans Millennium Health Care and Benefits Act (Pub. L. 106-117) also established provisions regarding copayments for extended care services provided to veterans by VA. These provisions are set forth at 38 U.S.C. 1710B. This document proposes to establish requirements at 38 CFR 17.111 regarding copayments for such extended care services provided either directly by VA or obtained by contract.

The proposed rule states that, with certain exceptions, as a condition of receiving extended care services, a veteran must agree to pay VA a copayment. This restates statutory provisions at 38 U.S.C. 1710B.

The proposed rule sets forth a mechanism for calculating the copayment amount. This is intended to implement the following statutory criteria set forth at 38 U.S.C. 1710B(d)(2) that states:

The Secretary shall develop a methodology for establishing the amount of the copayment for which a veteran [receiving extended care services] is liable. That methodology shall provide for:

(A) Establishing a maximum monthly copayment (based on all income and assets of the veteran and the spouse of such veteran);

(B) Protecting the spouse of a veteran from financial hardship by not counting all of the income and assets of the veteran and spouse (in the case of a spouse who resides in the community) as available for determining the copayment obligation; and

(C) Allowing the veteran to retain a monthly personal allowance.

The proposed rule states that a veteran has no copayment obligation for the first 21 days of extended care services in any 12-month period from the date extended care services began. It further states that for each day that extended care services are provided beyond the first 21 days, unless an exemption applies, a veteran is obligated to pay VA a copayment amount for each day that extended care services are provided to the extent the veteran has available resources. This reflects statutory provisions at 38 U.S.C. 1710B.

The proposed rule provides that the following extended care services are subject to the corresponding copayment amount per day:

(i) Adult day health care—$15.

(ii) Domiciliary care—$5.

(iii) Institutional respite care—$97.

(iv) Institutional geriatric evaluation—$97.

(v) Non-institutional geriatric evaluation—$15.

(vi) Non-institutional respite care—$15.

(vii) Nursing home care—$97.

The proposed copayment amount for institutional extended care is comparable to the copayment amount for nursing home services under the Medicare program and copayments at State homes that provide similar services. The proposed copayment amount for outpatient care is comparable to industry standards.

The proposed copayment amount for domiciliary care is lower, in part, because of the lower level of care provided. Further, although Public Law 106-117 included domiciliary care in the extended care service package, the eligibility criteria for this level of medical care did not change. To be eligible for domiciliary care, veterans must have a very low income, usually an amount that does not exceed the maximum annual rate of VA pension that would be applicable to the veteran if the veteran were eligible for VA pension based on the need for regular aid and attendance. Accordingly, we believe it is appropriate for the copayment amount to be low.

Under the proposal, a veteran would be obligated to pay the copayment only to the extent the veteran and the veteran's spouse have available resources. Available resources would mean the sum of the value of the liquid assets, fixed assets, and income of the veteran and the veteran's spouse minus the sum of the veteran allowance and the spousal allowance. Liquid assets and fixed assets are included in the calculations only if the veteran has been receiving extended care services for 181 days or more. Expenses are included in the veterans allowance calculations only if the veteran has been receiving extended care services for 180 days or less, the veteran is receiving only adult day health care or other noninstitutional care, or the veteran has a spouse or dependents residing in the community (not institutionalized). This formula is designed to allow the veteran and the veteran's spouse and dependents to have minimum amenities while allowing the retention of some of their possessions to help them maintain, to a degree, a similar standard of living as they had in the past. Also, this formula is intended to help ensure that veterans institutionalized for 180 days or less would have the means to return home.

The proposed rule states that, for purposes of counting the number of days for which a veteran is obligated to make a copayment, VA would count each day that outpatient services are provided and would count each full day and partial day for each inpatient stay except for the day of discharge. This formula is not only administratively feasible, but it appears to be a fair and reasonable method for counting days for charging copayments.

The proposed rule sets forth definitions of adult day health care, domiciliary care, extended care services, geriatric evaluation, institutional, noninstitutional, nursing home care, and respite care. These definitions reflect the common meaning of their terms in the context of extended care services.

The proposed rule provides that, unless exempted, a veteran must submit to a VA medical facility a completed VA Form 10-10EC and documentation requested by the form at the following times:

(i) At the time of initial request for an episode of extended care services.

(ii) At the time of request for extended care services after having a break in provision of extended care services for more than 30 days.

(iii) Each year at the time of submission to VA of VA Form 10-10EZ.

The proposed rule also states that when there are changes to the veteran's or spouse's situation that would change the copayment obligation (i.e., changes regarding fixed assets, liquid assets, expenses, income, or whether the veteran has a spouse or dependents residing in the community), the veteran must report those changes to a VA medical facility within 10 days of the change. Further, the proposed rule sets forth in full VA Form 10-10EC. These provisions appear to be adequate to allow VA to make the determinations required to be made under the proposed rule.

The proposed rule sets forth the following categories of veterans and care that would not be subject to the copayment requirements:

(1) A veteran with a compensable service-connected disability,

(2) A veteran whose annual income (determined under 38 U.S.C. 1503) is less than the amount in effect under 38 U.S.C. 1521(b),

(3) Care for a veteran's noncompensable zero percent service-connected disability,

(4) An episode of extended care services that began on or before November 30, 1999,

(5) Care authorized under 38 U.S.C. 1710(e) for Vietnam-era herbicide-exposed veterans, radiation-exposed veterans, Persian Gulf War veterans, or post-Persian Gulf War combat-exposed veterans,

(6) Care for treatment of sexual trauma as authorized under 38 U.S.C. 1720D, or

(7) Care or services authorized under 38 U.S.C. 1720E for certain veterans regarding cancer of the head or neck.

The first four categories are specifically excluded from the copayment provisions by statute (38 U.S.C. 1710B). Also, VA can charge a copayment for extended care services only for care provided to nonservice-connected veterans (38 U.S.C. 1710B). Categories (5) through (7) reflect circumstances in which the extended cares services would be for other than a “nonservice-connected disability.”

This regulation will use a means test income threshold equal to the amount of basic pension VA provides to a single veteran eligible for pension benefits. The threshold differs from other means-test income thresholds established by other statutory provisions that VA uses to determine whether a veteran must pay copayments for inpatient and outpatient care and for medications because this threshold is specifically established by law at 38 U.S.C. 1710B(c)(2)(A) as added by the Millennium Act. Additionally, the copayment amounts established under this rule differ from other copayment amounts that VA must charge for inpatient and outpatient care and for medications. The copayment amounts are different due to the statutory requirements set forth at 38 U.S.C. 1710B(d)(2).

Paperwork Reduction Act

Proposed 38 CFR 17.111(f) contains collections of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). Accordingly, under section 3507(d) of the Act, VA has submitted a copy of this rulemaking action to OMB for its review of the collections of information.

OMB assigns a control number for each collection of information it approves. VA may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Comments on the proposed collections of information should be submitted to the Office of Management and Budget, Attention: Desk Officer for the Department of Veterans Affairs, Office of Information and Regulatory Affairs, Washington, DC 20503, with copies mailed or hand-delivered to: Director, Office of Regulations Management (02D), Department of Veterans Affairs, 810 Vermont Ave., NW., Room 1154, Washington, DC 20420. Comments should indicate that they are submitted in response to “RIN 2900-AK32.”

Title: Application for extended care services.

Summary of collection of information: In proposed § 17.111(f), VA requests information from veterans so that VA can determine the financial circumstances of veterans receiving extended care services.

Description of the need for information and proposed use of information: The information is necessary to determine the amount of copayment owed to VA by veterans receiving extended care services.

Description of likely respondents: Estimated number of respondents: 8,600.

Estimated frequency of responses: 1.

Estimated total annual reporting and record keeping burden: 12,900 hours.

Estimated annual burden per collection: 90 minutes.

The Department considers comments by the public on proposed collections of information in—

• Evaluating whether the proposed collections of information are necessary for the proper performance of the functions of the Department, including whether the information will have practical utility;
• Evaluating the accuracy of the Department's estimate of the burden of the proposed collections of information, including the validity of the methodology and assumptions used;
• Enhancing the quality, usefulness, and clarity of the information to be collected; and
• Minimizing the burden of the collections of information on those who are to respond, including responses through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses.

OMB is required to make a decision concerning the collections of information contained in this proposed rule between 30 and 60 days after publication of this document in the Federal Register. Therefore, a comment to OMB is best assured of having its full effect if OMB receives it within 30 days of publication. This does not affect the deadline for the public to comment on the proposed rule.

Unfunded Mandates

The Unfunded Mandates Reform Act requires (in section 202) that agencies prepare an assessment of anticipated costs and benefits before developing any rule that may result in an expenditure by State, local, or tribal governments, in the aggregate, or by the private sector of $100 million or more in any given year. This rule would have no consequential effect on State, local, or tribal governments.

OMB Review

This document has been reviewed by the Office of Management and Budget under Executive Order 12866. VA has not yet completed a cost estimate for this rule but expects it to be significantly less than $100 million per year. VA will present a cost estimate in the final rule.

Regulatory Flexibility Act

The Secretary hereby certifies that this regulatory amendment will not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act (RFA), 5 U.S.C. 601-612. This amendment would not directly affect any small entities. Only individuals could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this amendment is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604.

Catalog of Federal Domestic Assistance Numbers

The Catalog of Federal Domestic Assistance numbers for the programs affected by this document are 64.005, 64.007, 64.008, 64,009, 64.010, 64.011, 64.012, 64.013, 64.014, 64.015, 64.016, 64.018, 64.019, 64.022, and 64.025.

List of Subjects in 38 CFR Part 17

• Administrative practice and procedure
• Alcohol abuse
• Alcoholism
• Claims
• Day care
• Dental health
• Drug abuse
• Foreign relations
• Government contracts
• Grant programs-health
• Grant programs-veterans
• Health care
• Health facilities
• Health professions
• Health records
• Homeless
• Medical and dental schools
• Medical devices
• Medical research
• Mental health programs
• Nursing homes
• Philippines
• Reporting and record-keeping requirements
• Scholarships and fellowships
• Travel and transportation expenses
• Veterans

For the reasons set out in the preamble, 38 CFR part 17 is proposed to be amended as set forth below:

PART 17—MEDICAL

1. The authority citation for part 17 continues to read as follows:

Authority: 38 U.S.C. 501, 1721, unless otherwise noted.