EnrollmentProvision of Hospital and Outpatient Care to Veterans

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AJI8

Enrollment--Provision of Hospital and Outpatient Care to Veterans

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: This document amends VA's medical regulations. The Veterans'

Health Care Eligibility Reform Act of 1996 mandates that VA implement a

national enrollment system to manage the delivery of healthcare

services. Accordingly, the medical regulations are amended to establish

provisions consistent with this mandate. Starting October 1, 1998, most

veterans were required to be enrolled in the VA healthcare system as a

condition of receiving VA hospital and outpatient care. Veterans will

be allowed to apply to be enrolled at any time. They will be eligible

to be enrolled based on funding availability and their priority status.

In accordance with statutory provisions, the final rule also states

that some categories of veterans are eligible for VA hospital and

outpatient care even if not enrolled. This document further establishes

a ``medical benefits package'' setting forth, with certain exceptions,

the hospital and outpatient care that will be provided to enrolled

veterans and certain other veterans.

Moreover, this document announces that VA will enroll all 7

priority categories of veterans for the period October 1, 1999 through

September 30, 2000, unless it is necessary to change this determination

by a subsequent rulemaking document.

DATES: Effective Date: November 5, 1999.

FOR FURTHER INFORMATION CONTACT: Roscoe Butler, Health Administration

Service, (10C3), Veterans Health Administration, Department of Veterans

Affairs, 810 Vermont Avenue, NW, Washington, DC 20420, (202) 273-8302.

(This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: In a document published in the Federal

Register on July 10, 1998 (63 FR 37299), we proposed to amend the

medical regulations at 38 CFR part 17. Public Law 104-262, the

Veterans' Health Care Eligibility Reform Act of 1996, mandates that VA

implement a national enrollment system to manage the delivery of

healthcare services. Public Law 104-262 also contains priority

categories for determining eligibility for enrollment. Accordingly, we

proposed

[[Page 54208]]

to amend the medical regulations to establish provisions consistent

with these statutory provisions. Starting October 1, 1998, most

veterans were required to be enrolled in the VA healthcare system as a

condition for receiving VA hospital and outpatient care. The proposal

also stated that these veterans would be allowed to apply to be

enrolled at any time. In accordance with statutory provisions, the

proposal further stated that some categories of veterans would be

eligible for VA hospital and outpatient care even if not enrolled. In

addition, we proposed to establish a ``medical benefits package''

setting forth, with certain exceptions, the hospital and outpatient

care that would be provided to enrolled veterans and certain other

veterans.

We received comments from 10 sources. The comments are discussed

below. Based on the rationale set forth in the proposed rule and in

this document, the provisions of the proposed rule are adopted as a

final rule with certain changes explained below.

Catastrophically Disabled

The priority listing for enrollment in proposed Sec. 17.36 provided

for certain catastrophically disabled veterans to be enrolled in

priority category 4 and for certain other catastrophically disabled

veterans to be enrolled in priority category 7. The proposed provisions

were based on an attempt to reconcile the provisions of 38 U.S.C. 1705

and 1710(a). The provisions of 38 U.S.C. 1705 include in priority

category 4 ``veterans who are catastrophically disabled.'' The

provisions of 38 U.S.C. 1710(a) set forth a preference scheme for

providing VA care first to ``mandatory veterans'' and then to

``discretionary veterans.'' This preference scheme, if controlling,

would place some catastrophically disabled veterans in a lower priority

category than priority category 4. Several commenters asserted that the

provisions of 38 U.S.C. 1705 must be interpreted to require that all

catastrophically disabled veterans be enrolled in priority category 4.

Upon further consideration, we have concluded that the statutory

provisions in question are irreconcilable and that the rules of

statutory construction require that deference be given to the more

specific provisions in 38 U.S.C. 1705. Accordingly, except as discussed

below, the final rule includes all catastrophically disabled veterans

in priority category 4.

Some veterans who are catastrophically disabled must agree to make

the applicable co-payment as a condition of being included in priority

category 4. This is because 38 U.S.C. 1710 imposes co-payments on

certain veterans, including some veterans who are catastrophically

disabled. Accordingly, we amended Sec. 17.36(b)(4) to reflect the co-

payment requirement. We also made corresponding changes to

Sec. 17.36(d)(1) with respect to information to be included in the

application for enrollment in the VA healthcare system.

In Sec. 17.36(e), the definition of the term ``catastrophically

disabled'' includes the requirement that the condition be

``permanent.'' Some commenters opposed the inclusion of this

requirement. Although we have retained the requirement that the

condition be ``permanent,'' we have made clarifying changes.

We believe that a condition causing an individual to be

catastrophically disabled must be a ``permanent'' condition. Under the

provisions of 38 U.S.C. 1705, priority category 4 consists of

``Veterans who are in receipt of increased pension based on a need of

regular aid and attendance or by reason of being permanently housebound

and other veterans who are catastrophically disabled.'' The words

``other veterans who are catastrophically disabled'' indicate that all

veterans in priority category 4 are ``catastrophically disabled'' and

are disabled to a similar extent. To be in receipt of increased pension

based on a need of regular aid and attendance or by reason of being

permanently housebound, a veteran must be permanently disabled (see 38

U.S.C. 1502 and 1521). We have thus construed this statutory priority

category to include only veterans with permanent conditions. Our

interpretation is consistent with other provisions of Pub. L. 104-262,

which, as noted above, includes the mandate that VA implement a

national enrollment system. In this regard, the four examples used to

describe the term ``disabled'' in 38 U.S.C. 1706 are permanent

conditions, i.e., spinal cord dysfunction, blindness, amputations, and

serious mental illness. Moreover, the legislative history of Pub. L.

104-262 refers to a permanent condition, spinal cord injury, to

describe the type of disabilities intended to be covered by the term

``catastrophically disabled'' (House Report No. 690, 104th Cong., 2d

Sess. 7 (1996)) and the Joint Explanatory Statement for H.R. 3118, The

Proposed Veterans' Health Care Eligibility Reform Act of 1996 (142

Cong. Rec. S11642, S11646 (daily ed. Sept. 28, 1996)).

We have, however, clarified the criteria for determining when a

condition is permanent. In this regard, we have revised the second

sentence in Sec. 17.36(e) to read as follows: ``This definition is met

if an individual has been found by the Chief of Staff (or equivalent

clinical official) at the VA facility where the individual was examined

to have a permanent condition specified in paragraph (e)(1) of this

section; to meet permanently one of the conditions specified in

paragraph (e)(2) of this section by a clinical evaluation of the

patient's medical records that documents that the patient previously

met the permanent criteria and continues to meet such criteria

(permanently) or would continue to meet such criteria (permanently)

without the continuation of on-going treatment; or to meet permanently

one of the conditions specified in paragraph (e)(2) of this section by

a current medical examination that documents that the patient meets the

permanent criteria and will continue to meet such criteria

(permanently) or would continue to meet such criteria (permanently)

without the continuation of on-going treatment.'' This clarifies that a

veteran who previously met the criteria in Sec. 17.36(e)(2) for

establishing a permanent condition would continue to meet the criteria

even if the condition has improved because of ongoing treatment. In our

view, on-going treatment does not change the finding that the condition

is permanent.

In Sec. 17.36, paragraph (e) defines the term ``catastrophically

disabled'' and includes provisions stating that the definition is met

if certain conditions are met. One commenter argued that in order to be

determined to be ``catastrophically disabled'' a veteran should be

required to meet the definition or the conditions, but not both. No

changes are made based on this comment. Both the definition and the

specific conditions or the functional disability levels that meet the

definition are necessary to ensure that the term ``catastrophically

disabled'' is uniformly applied.

Under the provisions of Sec. 17.36(b)(4), a veteran may be

determined to be catastrophically disabled and thereby included in

priority category 4 only if determined to be catastrophically disabled

by the Chief of Staff (or equivalent clinical official) at the VA

facility where the veteran was examined. One commenter suggested that

VA include in the regulations additional information concerning

examinations for determining whether veterans are catastrophically

disabled, i.e., how a first-time applicant could obtain

catastrophically disabled status, how the examination would be

conducted, and whether records of previous treatment and examination

could be substituted for a current examination. No changes are made

[[Page 54209]]

based on this comment. We will consider a subsequent amendment to this

final rule to include additional procedures as warranted. Currently,

examinations could be provided based on the request of a veteran or VA.

Also, the Chief of Staff (or equivalent clinical official) at the VA

facility where the individual was examined would make decisions based

on the criteria in the final rule for determining whether a veteran is

catastrophically disabled and could use any available records in making

the decision. Further, the decisionmaker could make a decision without

requiring a new examination if the records are sufficient.

One commenter asserted that the determination by the Chief of Staff

(or equivalent clinical official) constitutes an appeal and that the

final rule should include appeal procedures and time limits for this

decision. No changes are made based on this comment. The decision by

the Chief of Staff (or equivalent clinical official) constitutes the

initial decision. It is that decision that could be appealed.

In the proposal, the conditions for determining whether a veteran

is catastrophically disabled included a finding that the veteran is

``[d]ependent in 4 or more Activities of Daily Living (eating,

dressing, bathing, toileting, transferring, incontinence of bowel and/

or bladder), with at least 4 of the dependencies being permanent, using

the Katz scale.'' Commenters argued that the reference to 4 should be

lowered in both places to 3. We have compared the conditions with the

definition of catastrophically disabled and have concluded that the

definition would still be met if the number were changed to 3 in both

places. Accordingly, we have made these changes in the final rule.

In the proposal, the conditions for determining whether a veteran

is catastrophically disabled include a finding that the veteran scored

30 or lower using the Global Assessment of Functioning. Commenters

asserted that the score for the Global Assessment of Functioning should

be raised to 40. No changes are made based on these comments. Patients

above 30 are in a range described as severe but less than catastrophic

in that they do not require personal or mechanical assistance to leave

home or bed or require constant supervision to avoid physical harm to

self or others. Accordingly, they would not meet the definition of

catastrophically disabled.

Commenters recommended that the list of conditions in Sec. 17.36(e)

that would establish that a veteran is ``catastrophically disabled''

should be expanded to include chronic and severe mental illnesses,

Amyotrophic Lateral Sclerosis, Multiple Sclerosis, a score of 5 or

higher on the Kurtzke Expanded Disability Status Scale for Multiple

Sclerosis, and possibly other things. No changes are made based on

these comments. Conditions not specifically mentioned, including those

mentioned by the commenters, would be covered when the criteria in

Sec. 17.36(e) are met. It is impractical to attempt to list all of the

specific conditions that would be covered by the criteria.

The list of conditions for establishing that a veteran is

catastrophically disabled includes a condition resulting from two of

the specified procedures in Sec. 17.36(e)(1) provided the two

procedures were not on the same limb. The proposed procedures included

``Amputation of toe (only if accompanied by V49.71 code for amputated

great toe) (procedure code 84.11).'' These provisions are clarified to

reflect more clearly that the toe amputated must be the great toe.

The proposed list of conditions for establishing that a veteran is

catastrophically disabled included permanent ``unspecified

hemiplegia.'' This is deleted. The final rule provides that a veteran

is catastrophically disabled upon a finding of a score of 2 or lower on

at least 4 of the 13 motor items using the Functional Independence

Measure. This finding necessarily could be made if a veteran had

hemiplegia that would be catastrophically disabling. This Functional

Independence Measure is a more appropriate method of determining

whether hemiplegia constitutes a catastrophic disability.

The proposed list of conditions for establishing that a veteran is

catastrophically disabled included a score of 14 or higher on the

Activities of Daily Living (ADL) Index using Resource Utilizations

Group (RUG) III. This condition is deleted. The ADL section is one part

of a complex multidimensional assessment tool known as the Minimum Data

Set (MDS). All sections in the MDS contribute to the construction of 44

RUGs (RUG III). Therefore isolating one section and attempting to

calculate a numerical score invalidates the purpose for which the

instrument was designed.

Moreover, this should not have any negative effects on veterans.

The category of veterans intended to meet the definition of

catastrophically disabled based on the ADL criteria necessarily would

also meet the definition of catastrophically disabled based on the

criteria in Secs. 17.36(e)(2)(i) or (iii) i.e., dependent in 3 or more

Activities of Daily Living (eating, dressing, bathing, toileting,

transferring, incontinence of bowel and/or bladder), with at least 3 of

the dependencies being permanent, using the Katz scale; or a score of 2

or lower on at least 4 of the 13 motor items using the Functional

Independence Measure. In the ADL provision, ``dependent'' was intended

to mean fully dependent. Being fully dependent is represented by a

rating of 1 on the Katz scale. We have clarified the rule accordingly.

One commenter questioned how the definition and conditions were

established for determining when an individual is ``catastrophically

disabled''. In this regard, we note that the definition and conditions

were formulated by knowledgeable VA clinical experts.

One commenter asserted that VA form 10-10 EZ should be amended to

specifically ask whether a veteran is requesting an examination to

determine whether the veteran is catastrophically disabled. No changes

are made based on this comment. The issue of whether an individual

should be examined is a complex matter (see Sec. 17.36(e)) that does

not lend itself readily to the form. Further, before a veteran would be

removed from the list of enrollees based on a priority status lower

than priority category 4, the veteran first would be provided a letter

advising of the opportunity to request that action be taken (including

an examination, if needed) to determine whether the veteran is

catastrophically disabled and thereby eligible for inclusion in

priority category 4.

Additional Enrollment Issues

One commenter opposed any enrollment system that could exclude any

categories of veterans from access to medical care. No changes are made

based on this comment. The Veterans' Health Care Eligibility Reform Act

requires that we establish a system for the management of hospital and

outpatient care based on priorities and available funding.

One commenter asserted that nonservice-connected Purple Heart

recipients should be included in priority category 3. No changes are

made based on this comment. The priority categories are established by

statute, and there is no authority to include this category of veterans

in priority category 3.

One commenter asserted that within priority category 7, military

retirees should be given a subpriority based on the further assertion

that military retirement benefits are inadequate. No changes are made

based on this

[[Page 54210]]

comment. This final rule is not an appropriate forum for addressing

military retirement benefits.

One commenter asserted that enrollment status decisions should be

transferable among VA medical facilities. In response, we have added a

note to Sec. 17.36 to clarify that a veteran's enrollment status will

be honored by all VA medical facilities in the United States (care

abroad is covered by 38 U.S.C. 1724).

One commenter asserted that veterans should be given a presumption

of entitlement to medical services when they initially apply or reapply

for enrollment and should receive medical services until an appeal is

decided. No changes are made based on this comment. We have no

authority to include such provisions in the final rule.

One commenter asserted that enrollment should guarantee a veteran

access to the ``medical benefits package'' for a certain period of

time, e.g. until the end of the fiscal year. Commenters also asserted

that after a number of years of receiving VA medical services an

enrollee's right to receive medical services should become permanent.

No changes are made based on these comments. It is our intent under the

provisions of Sec. 17.36 to try to predict accurately for the whole

fiscal year how many priority categories will be funded. However, the

regulations must include provisions for amending the determination at

any time because VA can only provide services insofar as there are

available funds to cover the services. Further, we have no authority to

make permanent an enrollee's right to receive medical services.

Under the provisions of Sec. 17.36(d)(4)(iii), a veteran who had

been enrolled based on inclusion in priority category 5 will be

disenrolled if the veteran does not return to VA a completed form VA

Form 10-10EZ. One commenter asserted that this provision could cause

some of the most vulnerable veterans to lose their medical benefits. No

changes are made based on this comment. This will not disadvantage

veterans who are disenrolled merely because they did not return the

form. Under the provisions of Sec. 17.36 such a veteran may reapply to

be enrolled at any time and thereby supply the information necessary to

determine their enrollment priority category.

One commenter opposed the provisions in Sec. 17.36(d)(4)(i) which

state that a veteran will be removed from the list of enrollees if the

veteran submits to a VA medical center a signed document stating that

the veteran no longer wishes to be enrolled. No changes are made based

on this comment. If a veteran no longer intends to obtain VA care we

would like to be informed so that we can better predict the demand for

VA care. However, this will not disadvantage those who wish to restore

their enrollment status since, as noted above, a veteran may reapply to

be enrolled at any time.

Commenters asserted that the letter that VA sends veterans

concerning their enrollment status should indicate which priority group

the veteran was placed in and all co-payment information. We intend to

provide this information to enrolled veterans as soon as possible.

Under the provisions of Pub. L. 105-368, a veteran enrolled based

on an illness associated with service in combat in a war after the Gulf

War or during a period of hostility after November 11, 1998, is

included in priority category 6 and is eligible for VA hospital and

outpatient care provided in the medical benefits package for the

illness. The final rule is amended to reflect this statutory change.

Hospital and Outpatient Care to Veterans Who are not Enrolled in

the VA Healthcare System

Consistent with the provisions of Pub. L. 104-262, Sec. 17.37

specifies when VA may provide hospital and outpatient care to veterans

who are not enrolled in the VA healthcare system. One commenter

asserted that this should include a statement that a veteran who is not

enrolled in the VA healthcare system may receive an examination to

determine whether the veteran is eligible for inclusion in priority

category 4 based on a finding that the veteran is catastrophically

disabled. We agree and have amended Sec. 17.37 accordingly.

Medical Benefits Package

One commenter argued that the final rule should concern only a

national enrollment system and, accordingly, should not include a

medical benefits package. Although the commenter concluded that VA has

inherent authority to establish a medical benefits package, the

commenter asserted that the proposed rule purportedly was designed

solely ``to implement the Veterans' Health Care Eligibility Reform Act

of 1996'' and that the ``medical benefits package'' went beyond this

statutory authority. The commenter also asserted that the statutory

provisions at 38 U.S.C. 1701 and the regulations at 38 CFR 17.30 are

adequate for determining what care will be provided to enrolled

veterans. The commenter further asserted that we did not provide

sufficient rationale or justification for the establishment of a

``medical benefits package.'' No changes are made based on these

comments. Although the Veterans' Health Care Eligibility Reform Act of

1996 did not direct VA to create a medical benefits package, we believe

that it is necessary under the requirements of the Administrative

Procedure Act to inform affected individuals concerning the care that

would or would not be provided to veterans enrolled in the VA

healthcare system. The definitions of terms in 38 U.S.C. 1701 and 38

CFR 17.30 are not adequate by themselves to allow individuals to make

such determinations. Further, the following statement in the preamble

portion of the proposed rule provided the rational basis for the

medical benefits package: ``The Secretary has authority to provide

healthcare as determined to be medically needed. In our view, medically

needed constitutes care that is determined by appropriate healthcare

professionals to be needed to promote, preserve, or restore the health

of the individual and to be in accord with generally accepted standards

of medical practice. The care included in the proposed `medical

benefits package' is intended to meet these criteria.''

Commenters asserted that infertility services, pregnancy and

delivery, surgical implantation of penile prostheses, and membership in

spas and health clubs should be included in the medical benefits

package. As noted above, the medical benefits package would include

``care that is determined by appropriate healthcare professionals to be

needed to promote, preserve, or restore the health of the individual

and to be in accord with generally accepted standards of medical

practice.'' Upon reconsideration, we conclude that pregnancy and

delivery services (to the extent we have legal authority to provide

such services) meet these criteria and should be included in the

medical benefits package. We also conclude that membership in spas and

health clubs does not meet these criteria and should not be included.

Further, under these criteria, we have determined that reproductive

sterilization, surgery to reverse voluntary sterilization, infertility

services (other than in vitro fertilization), and surgical implantation

of penile prostheses should not be excluded. Appropriate changes are

made to the medical benefits package to reflect these determinations.

Commenters asserted that the ``medical benefits package'' should

cover all emergency care for all enrolled veterans. No changes are made

based on these comments. The final rule includes in the ``medical

benefits package'' all of

[[Page 54211]]

the emergency care that VA is authorized to provide to enrolled

veterans (see 38 U.S.C. 1703, 1728).

Priority category 6 includes veterans solely seeking care for a

disorder associated with exposure to a toxic substance or radiation or

for a disorder associated with service in the Southwest Asia theater of

operations during the Gulf War, as provided in 38 U.S.C. 1710(e). One

commenter asserted that these veterans should be eligible to receive

the full ``medical benefits package'' because of such disorders. No

changes are made based on this comment. The restrictions for this

category are required by 38 U.S.C. 1710(e).

One commenter asserted that the final rule should include provision

for ``long-term care services.'' No changes are made based on this

comment. The medical benefits package includes non-institutional long-

term care services, such as home health care. The statutory framework

for the enrollment system does not cover nursing home care.

The medical benefits package includes prescription drugs available

under the VA national formulary system. Commenters argued that this is

inadequate based on the assertion that this would limit drugs only to

those listed and exclude any opportunity for using non-listed drugs. No

changes are made based on these comments. The national formulary system

includes a mechanism for the provision of drugs and medicines not

listed in the formulary.

Commenters recommend that the ``medical benefits package'' include

a statement that VA will maintain its capacity to treat disabled

veterans in accordance with the provisions of 38 U.S.C. 1706. No

changes are made based on these comments. The statutory provisions are

adequate by themselves to provide notice of this requirement.

Commenters asserted that a determination regarding care received

under the ``medical benefits package'' should only be made by a

physician in the appropriate medical specialty and that a veteran

should have direct access to the medical specialist of choice. No

changes are made based on these comments. Consistent with the trends in

industry practice, we believe that generally veterans should first meet

with primary care healthcare professionals and then be referred to

medical specialists, if necessary.

Commenters asserted that the letter that VA sends veterans

concerning their enrollment status should specify what services are

available to enrollees. No changes are made based on these comments.

The enrollment status letter will provide an overview of the services

available and will include a toll-free telephone number for veterans to

call for further information.

We also have made a clarifying change to the medical benefits

package to state that it includes the completion of certain forms

(e.g., Family Medical Leave forms, life insurance applications,

Department of Education forms for loan repayment exemptions based on

disability, non-VA disability program forms) by healthcare

professionals based on an examination or knowledge of the veteran's

condition, but not including the completion of forms for examinations

where payment for such examinations cannot be paid to VA but can be

paid to other health care practitioners. This is a medical service that

generally is provided under customary medical practice.

Notice of Priority Categories Eligible for Enrollment

The proposed rule provided for the Secretary to publish notices in

the notice section of the Federal Register announcing which categories

of veterans are eligible to be enrolled. One commenter asserted that

the determinations made must be published as rules and that such rules

can be made only after prior notice and comment. In response, we have

changed the provisions of the final rule to provide for inclusion of

the announcements by the Secretary in the regulatory material at

Sec. 17.36. Determinations regarding notice and comment will be made in

accordance with the provisions of the Administrative Procedure Act.

Also, the criteria in Sec. 17.36 for determining which categories

of veterans are eligible to be enrolled are clarified to more

accurately reflect the elements necessary for making the determination.

Appeals

Commenters asserted that the proposed rule did not contain

sufficient notice of appeal rights for enrollment determinations. In

response, we have added information to Sec. 17.36(d)(5) stating that

the letter providing notification of enrollment status (enrollment or

disenrollment) will include an effective date for any changes and will

include a statement regarding appeal rights.

As stated in the proposal, veterans may appeal VA decisions

regarding enrollment and disenrollment to the Board of Veterans'

Appeals and the Court of Veterans Appeals. Commenters asserted that

actions on appeals to the Board take too long and that special

intermediate appeal procedures must be established to protect veterans'

access to healthcare. Most of the enrollment determinations will be

based on the ministerial application of determinations made by the VA's

Veterans Benefits Administration. There is already a process for

obtaining reconsideration of these VBA determinations at the Regional

Office level. It would be inappropriate for VA's Veterans Health

Administration (VHA) which administers the National Enrollment System

to provide appellate rights for these VBA issues. Further, although we

are not required to do so, we are in the process of formulating

voluntary intermediate reconsideration procedures for VHA decisions (63

FR 9990). In this regard, we are considering whether to apply such

voluntary intermediate appeal procedures to certain VHA enrollment

issues, such as decisions concerning catastrophic disabilities and

means testing.

One commenter asserted that a veteran should not lose benefits for

at least 90 days or until the completion of an appeal. No changes are

made based on this comment. We have no authority to establish such a

rule.

Commenters asserted that the Presidential Memorandum on Federal

Agency Compliance with the Patient Bill of Rights requires appeal

procedures for enrollment issues. No changes are made based on these

comments. This Memorandum was intended to ensure additional process for

medical determinations not subject to the appellate jurisdiction of the

Board of Veterans Appeals, such as the need for and appropriateness of

specific types of medical care and treatment for an individual.

Further, as noted above, we are taking steps to establish intermediate

appeal procedures as appropriate.

Commenters asserted that the final rule should specifically state

that the Board of Veterans Appeals has appellate jurisdiction of VHA

determinations concerning whether a veteran is catastrophically

disabled. No changes are made based on these comments. We agree that

under 38 CFR 20.101(b) the Board has jurisdiction over these

determinations. Further, we do not believe that there is a need to

include specific provisions in the final rule regarding this matter.

Miscellaneous

Non-substantive changes have been made for purposes of

clarification.

Announcement Regarding Enrollment of Priority Categories

VA will enroll all 7 priority categories of veterans for the period

October 1,

[[Page 54212]]

1999 through September 30, 2000, unless changed by a subsequent

rulemaking document.

OMB

This document has been reviewed by the Office of Management and

Budget under Executive Order 12866.

Paperwork Reduction Act

The collection of information contained in the notice of the

proposed rulemaking was submitted to the Office of Management and

Budget (OMB) for review in accordance with the Paperwork Reduction Act

(44 U.S.C. 3504(h)). The information collection subject to this

rulemaking concerns:

(1) Initial Application for Health Benefits. Under the provisions

of Sec. 17.36(d)(1), a veteran who wishes to be enrolled must apply by

submitting a VA Form 10-10EZ to a VA medical facility. Veterans

applying based on inclusion in categories 1, 2, 3, 6, and 7 do not need

to complete section II, but must complete the rest of the form.

Veterans applying based on inclusion in priority category 4 must

complete all or a portion of VA Form 10-10EZ as set forth in

Sec. 17.36(d)(1). Veterans applying based on inclusion in priority

category 5 must complete the entire form. VA Form 10-10EZ is set forth

in full at Sec. 17.36(f). This information is needed to determine

whether a veteran is eligible to be enrolled in the VA healthcare

system and, consequently, whether the veteran is eligible for VA

hospital and outpatient care;

(2) Yearly Re-application for Health Benefits. Under the provisions

of Sec. 17.36(d)(4)(iii), veterans enrolled based on inclusion in

priority category 5 will be mailed a Form 10-10EZ on a yearly basis.

They will be requested to complete the form and return the form to the

address on the return envelope. VA Form 10-10EZ is set forth in full at

Sec. 17.36(f). This information is needed to determine whether a

veteran is eligible to continue to be enrolled in the VA healthcare

system, and, consequently, whether the veteran is eligible to continue

to receive VA hospital and outpatient care;

(3) Voluntary disenrollment. Under the provisions of

Sec. 17.36(d)(4)(i), a veteran wishing to disenroll and forgo VA

hospital and outpatient care must submit to a VA medical center a

signed document stating that the veteran no longer wishes to be

enrolled. This information is needed to determine the identity of those

veterans wishing to disenroll and forgo VA hospital and outpatient

care. This will help VA determine how to allocate available funding for

hospital and outpatient care.

Interested parties were invited to submit comments on the

collection of information. However, no comments were received. OMB has

approved this information collection under control number 2900-0091.

VA is not authorized to impose a penalty on persons for failure to

comply with information collection requirements which do not display a

current OMB control number, if required.

Regulatory Flexibility Act

The Secretary hereby certifies that this proposed 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 proposed rule would affect only individuals.

Accordingly, pursuant to 5 U.S.C. 605(b), this proposed rule is exempt

from the initial and final regulatory flexibility analysis requirements

of Secs. 603 and 604.

The Catalog of Federal domestic assistance numbers for the programs

affected by this rule 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 recordkeeping requirements, Scholarships and fellowships, Travel

and transportation expenses, Veterans.

Approved: July 16, 1999.

Togo D. West, Jr.,

Secretary of Veterans Affairs.

For the reasons set out in the preamble, 38 CFR part 17 is 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.

Sec. 17.34 [Amended]

2. The first sentence of Sec. 17.34 is amended by removing ``When

an application'' and adding, in its place, ``Subject to the provisions

of Secs. 17.36 through 17.38, when an application''.

3. An undesignated center heading, Sec. 17.36, and a parenthetical

at the end of the section are added to read as follows:

Enrollment Provisions and Medical Benefits Package

Sec. 17.36 Enrollment--provision of hospital and outpatient care to

veterans.

(a) Enrollment requirement for veterans. (1) Except as otherwise

provided in Sec. 17.37, a veteran must be enrolled in the VA healthcare

system as a condition for receiving VA hospital and outpatient care.

Note to paragraph (a)(1): A veteran may apply to be enrolled at

any time. (See Sec. 17.36(d)(1).)

(2) Except as provided in paragraph (a)(3) of this section, a

veteran enrolled under this section is eligible for VA hospital and

outpatient care as provided in the ``medical benefits package'' set

forth in Sec. 17.38.

Note to paragraph (a)(2): A veteran's enrollment status will be

recognized throughout the United States.

(3) A veteran enrolled based on having a disorder associated with

exposure to a toxic substance or radiation, for a disorder associated

with service in the Southwest Asia theater of operations during the

Gulf War, or any illness associated with service in combat in a war

after the Gulf War or during a period of hostility after November 11,

1998, as provided in 38 U.S.C. 1710(e), is eligible for VA hospital and

outpatient care provided in the ``medical benefits package'' set forth

in Sec. 17.38 for the disorder.

(b) Categories of veterans eligible to be enrolled. The Secretary

will determine which categories of veterans are eligible to be enrolled

based on the following order of priority:

(1) Veterans with a singular or combined rating of 50 percent or

greater based on one or more service-connected disabilities or

unemployability.

(2) Veterans with a singular or combined rating of 30 percent or 40

percent based on one or more service-connected disabilities.

(3) Veterans who are former prisoners of war; veterans with a

singular or combined rating of 10 percent or 20 percent based on one or

more service-connected disabilities; veterans who were discharged or

released from active military service for a disability incurred or

aggravated in the line of duty; veterans who receive disability

compensation under 38 U.S.C. 1151; veterans whose entitlement to

disability compensation is suspended pursuant to 38 U.S.C. 1151, but

only to the extent

[[Page 54213]]

that such veterans' continuing eligibility for hospital and outpatient

care is provided for in the judgment or settlement described in 38

U.S.C. 1151; veterans whose entitlement to disability compensation is

suspended because of the receipt of military retired pay; and veterans

receiving compensation at the 10 percent rating level based on multiple

noncompensable service-connected disabilities that clearly interfere

with normal employability.

(4) Veterans who receive increased pension based on their need for

regular aid and attendance or by reason of being permanently housebound

and other veterans who are determined to be catastrophically disabled

by the Chief of Staff (or equivalent clinical official) at the VA

facility where they were examined; except that a veteran who is

catastrophically disabled and who must agree under 38 U.S.C. 1710 to

pay to the United States a co-payment as condition of receiving VA

care, must agree to pay to the United States the applicable co-payment

to be enrolled in priority category 4.

(5) Veterans not covered by paragraphs (b)(1) through (b)(4) of

this section who are determined to be unable to defray the expenses of

necessary care under 38 U.S.C. 1722(a).

(6) Veterans of the Mexican border period or of World War I;

veterans solely seeking care for a disorder associated with exposure to

a toxic substance or radiation, for a disorder associated with service

in the Southwest Asia theater of operations during the Gulf War, or for

any illness associated with service in combat in a war after the Gulf

War or during a period of hostility after November 11, 1998, as

provided and limited in 38 U.S.C. 1710(e); and veterans with 0 percent

service-connected disabilities who are nevertheless compensated,

including veterans receiving compensation for inactive tuberculosis.

(7) Veterans who agree to pay to the United States the applicable

copayment determined under 38 U.S.C. 1710(f) and 1710(g). This category

is further prioritized into the following subcategories:

(i) Noncompensable zero percent service-connected veterans; and

(ii) All other priority category 7 veterans.

(c) Federal Register notification of eligible enrollees. (1) It is

anticipated that on or before August 1 of each year the Secretary will

announce in paragraph (c)(2) of this section which categories of

veterans are eligible to be enrolled. As necessary, the Secretary at

any time may revise this determination by further amending paragraph

(c)(2) of this section. The preamble to a Federal Register document

announcing which priority categories are eligible to be enrolled must

specify the projected number of fiscal year applicants for enrollment

in each priority category, projected healthcare utilization and

expenditures for veterans in each priority category, appropriated funds

and other revenue projected to be available for fiscal year enrollees,

and results--projected total expenditures for enrollees by priority

category. The determination should include consideration of relevant

internal and external factors, e.g., economic changes, changes in

medical practices, and waiting times to obtain an appointment for care.

Consistent with these criteria, the Secretary will determine which

categories of veterans are eligible to be enrolled based on the order

of priority specified in paragraph (b) of this section.

(2) Unless changed by a rulemaking document in accordance with

paragraph (c)(1) of this section, VA will enroll all priority

categories of veterans set forth in Sec. 17.36(b) for the period from

October 1, 1999 through September 30, 2000.

(d) Enrollment and disenrollment process--(1) Application for

enrollment. A veteran may apply to be enrolled in the VA healthcare

system at any time. A veteran who wishes to be enrolled must apply by

submitting a VA Form 10-10EZ to a VA medical facility. Veterans

applying based on inclusion in priority categories 1, 2, 3, 6, and 7 do

not need to complete section II, but must complete the rest of the

form. Veterans applying based on inclusion in priority category 4

because of their need for regular aid and attendance or by being

permanently housebound need not complete section II, but must complete

the rest of the form. Veterans applying based on inclusion in priority

category 4 because they are catastrophically disabled need not complete

section II, but must complete the rest of the form, if: they agree to

pay to the United States the applicable copayment determined under 38

U.S.C. 1710(f) and 1710(g); they are a veteran of the Mexican border

period or of World War I or a veteran with a 0 percent service-

connected disability who is nevertheless compensated; their

catastrophic disability is a disorder associated with exposure to a

toxic substance or radiation, or with service in the Southwest Asia

theater of operations during the Gulf War as provided in 38 U.S.C.

1710(e); or their catastrophic disability is an illness associated with

service in combat in a war after the Gulf War or during a period of

hostility after November 11, 1998, as provided in 38 U.S.C. 1710(e).

All other veterans applying based on inclusion in priority category 4

because they are catastrophically disabled must complete the entire

form. Veterans applying based on inclusion in priority category 5 must

complete the entire form. VA Form 10-10EZ is set forth in paragraph (f)

of this section and is available from VA medical facilities.

Note to paragraph (d)(1): To remain enrolled based on inclusion

in priority category 5, a veteran annually must return information

to VA on a VA Form 10-10EZ as provided in paragraph (d)(4)(iii) of

this section and otherwise meet the requirements for enrollment.

(2) Action on application. Upon receipt of a completed VA Form 10-

10EZ, a VA network or facility director, or the Chief Network Officer,

will accept a veteran as an enrollee upon determining that the veteran

is in a priority category eligible to be enrolled as set forth in

Sec. 17.36(c)(2). Upon determining that a veteran is not in a priority

category eligible to be enrolled, the VA network or facility director,

or the Chief Network Officer, will inform the applicant that the

applicant is ineligible to be enrolled.

(3) Automatic enrollment. Notwithstanding other provisions of this

section, veterans who were notified by VA letter that they were

enrolled in the VA healthcare system under the trial VA enrollment

program prior to October 1, 1998, automatically will be enrolled in the

VA healthcare system under this section if determined by a VA network

or facility director, or the Chief Network Officer, that the veteran is

in a priority category eligible to be enrolled as set forth in

Sec. 17.36(c)(2). Upon determining that a veteran is not in a priority

category eligible to be enrolled, the VA network or facility director,

or the Chief Network Officer, will inform the veteran that the veteran

is ineligible to be enrolled.

(4) Disenrollment. A veteran enrolled under paragraph (d)(2) or

(d)(3) of this section will be disenrolled only if:

(i) The veteran submits to a VA medical center a signed document

stating that the veteran no longer wishes to be enrolled;

(ii) A VA network or facility director, or the Chief Network

Officer, determines that the veteran is no longer in a priority

category eligible to be enrolled, as set forth in Sec. 17.36(c)(2); or

(iii) A VA network or facility director, or the Chief Network

Officer, determines that the veteran has been enrolled based on

inclusion in priority category 5; determines that the veteran was sent

by mail a VA Form 10-10EZ; and determines that the veteran failed to

[[Page 54214]]

return the completed form to the address on the return envelope within

60 days from receipt of the form. VA Form 10-10EZ is set forth in

paragraph (f) of this section.

(5) Notification of enrollment status. Notice of a decision by a VA

network or facility director, or the Chief Network Officer, regarding

enrollment status will be provided to the affected veteran by letter

and will contain the reasons for the decision. The letter will include

an effective date for any changes and a statement regarding appeal

rights. The decision will be based on all information available to the

decisionmaker, including the information contained in VA Form 10-10EZ.

(e) Catastrophically disabled. For purposes of this section,

catastrophically disabled means to have a permanent severely disabling

injury, disorder, or disease that compromises the ability to carry out

the activities of daily living to such a degree that the individual

requires personal or mechanical assistance to leave home or bed or

requires constant supervision to avoid physical harm to self or others.

This definition is met if an individual has been found by the Chief of

Staff (or equivalent clinical official) at the VA facility where the

individual was examined to have a permanent condition specified in

paragraph (e)(1) of this section; to meet permanently one of the

conditions specified in paragraph (e)(2) of this section by a clinical

evaluation of the patient's medical records that documents that the

patient previously met the permanent criteria and continues to meet

such criteria (permanently) or would continue to meet such criteria

(permanently) without the continuation of on-going treatment; or to

meet permanently one of the conditions specified in paragraph (e)(2) of

this section by a current medical examination that documents that the

patient meets the permanent criteria and will continue to meet such

criteria (permanently) or would continue to meet such criteria

(permanently) without the continuation of on-going treatment.

(1) Quadriplegia and quadriparesis (ICD-9-CM Code 344.0x: 344.00,

344.01, 344.02, 344.03, 344.04, 3.44.09), paraplegia (ICD-9-CM Code

344.1), blindness (ICD-9-CM Code 369.4), persistent vegetative state

(ICD-9-CM Code 780.03), or a condition resulting from two of the

following procedures (ICD-9-CM Code 84.x or associated V Codes when

available or Current Procedural Terminology (CPT) Codes) provided the

two procedures were not on the same limb:

(i) Amputation through hand (ICD-9-CM Code 84.03 or V Code V49.63

or CPT Code 25927);

(ii) Disarticulation of wrist (ICD-9-CM Code 84.04 or V Code V49.64

or CPT Code 25920);

(iii) Amputation through forearm (ICD-9-CM Code 84.05 or V Code

V49.65 or CPT Codes 25900, 25905);

(iv) Disarticulation of forearm (ICD-9-CM Code 84.05 or V Code

V49.66 or CPT Codes 25900, 25905);

(v) Amputation or disarticulation through elbow. (ICD-9-CM Code

84.06 or V Code V49.66 or CPT 24999);

(vi) Amputation through humerus (ICD-9-CM Code 84.07 or V Code

V49.66 or CPT Codes 24900, 24920);

(vii) Shoulder disarticulation (ICD-9-CM Code 84.08 or V Code

V49.67 or CPT Code 23920);

(viii) Forequarter amputation (ICD-9-CM Code 84.09 or CPT Code

23900);

(ix) Lower limb amputation not otherwise specified (ICD-9-CM Code

84.10 or V Code V49.70 or CPT Codes 27880, 27882);

(x) Amputation of great toe (ICD-9-CM Code 84.11 or V Code V49.71

or CPT Codes 28810, 28820);

(xi) Amputation through foot (ICD-9-CM Code 84.12 or V Code V49.73

or CPT Codes 28800, 28805);

(xii) Disarticulation of ankle (ICD-9-CM Code 84.13 or V Code

V49.74 or CPT 27889);

(xiii) Amputation through malleoli (ICD-9-CM Code 84.14 or V Code

V49.75 or CPT Code 27888);

(xiv) Other amputation below knee (ICD-9-CM Code 84.15 or V Code

V49.75 or CPT Codes 27880, 27882);

(xv) Disarticulation of knee (ICD-9-CM Code 84.16 or V Code V49.76

or CPT Code 27598);

(xvi) Above knee amputation (ICD-9-CM Code 84.17 or V Code V49.76

or CPT Code 27598);

(xvii) Disarticulation of hip (ICD-9-CM Code 84.18 or V Code V49.77

or CPT Code 27295); and

(xviii) Hindquarter amputation (ICD-9-CM Code 84.19 or CPT Code

27290).

(2)(i) Dependent in 3 or more Activities of Daily Living (eating,

dressing, bathing, toileting, transferring, incontinence of bowel and/

or bladder), with at least 3 of the dependencies being permanent with a

rating of 1, using the Katz scale.

(ii) A score of 10 or lower using the Folstein Mini-Mental State

Examination.

(iii) A score of 2 or lower on at least 4 of the 13 motor items

using the Functional Independence Measure.

(iv) A score of 30 or lower using the Global Assessment of

Functioning.

(f) VA Form 10-10EZ. [insert actual photocopy of VA Form 10-10EZ]

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(The Office of Management and Budget has approved the information

collection requirements in this section under control number 2900-

0091.)

Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, 1721, 1722.

4. A new Sec. 17.37 is added to read as follows:

Sec. 17.37 Enrollment not required--provision of hospital and

outpatient care to veterans.

Even if not enrolled in the VA healthcare system:

(a) A veteran rated for service-connected disabilities at 50

percent or greater will receive VA hospital and outpatient care

provided for in the ``medical benefits package'' set forth in

Sec. 17.38.

(b) A veteran who has a service-connected disability will receive

VA hospital and outpatient care provided for in the ``medical benefits

package'' set forth in Sec. 17.38 for that service-connected

disability.

(c) A veteran who was discharged or released from active military

service for a disability incurred or aggravated in the line of duty

will receive VA hospital and outpatient care provided for in the

``medical benefits package'' set forth in Sec. 17.38 for that

disability for the 12-month period following discharge or release.

(d) When there is a compelling medical need to complete a course of

VA treatment started when the veteran was enrolled in the VA healthcare

system, a veteran will receive that treatment.

(e) Subject to the provisions of Sec. 21.240, a veteran

participating in VA's vocational rehabilitation program described in

Secs. 21.1 through 21.430 will receive VA hospital and outpatient care

provided for in the ``medical benefits package'' set forth in

Sec. 17.38.

(f) A veteran may receive VA hospital and outpatient care based on

factors other than veteran status (e.g., a veteran who is a private-

hospital patient and is referred to VA for a diagnostic test by that

hospital under a sharing contract; a veteran who is a VA employee and

is examined to determine physical or mental fitness to perform official

duties; a Department of Defense retiree under a sharing agreement).

(g) For care not provided within a State, a veteran may receive VA

hospital and outpatient care provided for in the ``medical benefits

package'' set forth in Sec. 17.38 if authorized under the provisions of

38 U.S.C. 1724 and 38 CFR 17.35.

(h) Commonwealth Army veterans and new Philippine Scouts may

receive hospital and outpatient care provided for in the ``medical

benefits package'' set forth in Sec. 17.38 if authorized under the

provisions of 38 U.S.C. 1724 and 38 CFR 17.35.

(i) A veteran may receive certain types of VA hospital and

outpatient care not included in the ``medical benefits package'' set

forth in Sec. 17.38 if authorized by statute or other sections of 38

CFR (e.g., humanitarian emergency care for which the individual will be

billed, compensation and pension examinations, dental care, domiciliary

care, nursing home care, readjustment counseling, care as part of a VA-

approved research project, seeing-eye or guide dogs, sexual trauma

counseling and treatment, special registry examinations).

(j) A veteran may receive an examination to determine whether the

veteran is catastrophically disabled and therefore eligible for

inclusion in priority category 4.

Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, 1721, 1722.

5. A new Sec. 17.38 is added to read as follows:

Sec. 17.38 Medical benefits package.

(a) Subject to paragraphs (b) and (c) of this section, the

following hospital and outpatient care constitutes the ``medical

benefits package'' (basic care and preventive care):

(1) Basic care.

(i) Outpatient medical, surgical, and mental healthcare, including

care for substance abuse.

(ii) Inpatient hospital, medical, surgical, and mental healthcare,

including care for substance abuse.

(iii) Prescription drugs, including over-the-counter drugs and

medical and surgical supplies available under the VA national formulary

system.

(iv) Emergency care in VA facilities; and emergency care in non-VA

facilities in accordance with sharing contracts or if authorized by

Secs. 17.52(a)(3), 17.53, 17.54, 17.120-132.

(v) Bereavement counseling as authorized in Sec. 17.98.

(vi) Comprehensive rehabilitative services other than vocational

services provided under 38 U.S.C. chapter 31.

(vii) Consultation, professional counseling, training, and mental

health services for the members of the immediate family or legal

guardian of the veteran or the individual in whose household the

veteran certifies an intention to live, if needed to treat:

(A) The service-connected disability of a veteran; or

(B) The nonservice-connected disability of a veteran where these

services were first given during the veteran's hospitalization and

continuing them is essential to permit the veteran's release from

inpatient care.

(viii) Durable medical equipment and prosthetic and orthotic

devices, including eyeglasses and hearing aids as authorized under

Sec. 17.149.

(ix) Home health services authorized under 38 U.S.C. 1717 and

1720C.

(x) Reconstructive (plastic) surgery required as a result of

disease or trauma, but not including cosmetic surgery that is not

medically necessary.

(xi) Respite, hospice, and palliative care.

(xii) Payment of travel and travel expenses for veterans eligible

under Sec. 17.143 if authorized by that section.

(xiii) Pregnancy and delivery services, to the extent authorized by

law.

(xiv) Completion of forms (e.g., Family Medical Leave forms, life

insurance applications, Department of Education forms for loan

repayment exemptions based on disability, non-VA disability program

forms) by healthcare professionals based on an examination or knowledge

of the veteran's condition, but not including the completion of forms

for examinations if a third party customarily will pay health care

practitioners for the examination but will not pay VA.

(2) Preventive care, as defined in 38 U.S.C. 1701(9), which

includes:

(i) Periodic medical exams.

(ii) Health education, including nutrition education.

(iii) Maintenance of drug-use profiles, drug monitoring, and drug

use education.

(iv) Mental health and substance abuse preventive services.

(v) Immunizations against infectious disease.

(vi) Prevention of musculoskeletal deformity or other gradually

developing disabilities of a metabolic or degenerative nature.

(vii) Genetic counseling concerning inheritance of genetically

determined diseases.

(viii) Routine vision testing and eye-care services.

(ix) Periodic reexamination of members of high-risk groups for

selected diseases and for functional decline of sensory organs, and the

services to treat these diseases and functional declines.

(b) Provision of the ``medical benefits package''. Care referred to

in the ``medical benefits package'' will be provided to individuals

only if it is determined by appropriate healthcare professionals that

the care is needed to promote, preserve, or restore the health of the

individual and is in accord with generally accepted standards of

medical practice.

[[Page 54218]]

(1) Promote health. Care is deemed to promote health if the care

will enhance the quality of life or daily functional level of the

veteran, identify a predisposition for development of a condition or

early onset of disease which can be partly or totally ameliorated by

monitoring or early diagnosis and treatment, and prevent future

disease.

(2) Preserve health. Care is deemed to preserve health if the care

will maintain the current quality of life or daily functional level of

the veteran, prevent the progression of disease, cure disease, or

extend life span.

(3) Restoring health. Care is deemed to restore health if the care

will restore the quality of life or daily functional level that has

been lost due to illness or injury.

(c) In addition to the care specifically excluded from the

``medical benefits package'' under paragraphs (a) and (b) of this

section, the ``medical benefits package'' does not include the

following:

(1) Abortions and abortion counseling.

(2) In vitro fertilization.

(3) Drugs, biologicals, and medical devices not approved by the

Food and Drug Administration unless the treating medical facility is

conducting formal clinical trials under an Investigational Device

Exemption (IDE) or an Investigational New Drug (IND) application, or

the drugs, biologicals, or medical devices are prescribed under a

compassionate use exemption.

(4) Gender alterations.

(5) Hospital and outpatient care for a veteran who is either a

patient or inmate in an institution of another government agency if

that agency has a duty to give the care or services.

(6) Membership in spas and health clubs.

Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, 1721, 1722.

Sec. 17.43 [Amended]

6. In Sec. 17.43, paragraph (a) is removed and paragraphs (b)

through (e) are redesignated as paragraphs (a) through (d),

respectively.

Sec. 17.47 [Amended]

7. In Sec. 17.47, paragraph (h) is removed; paragraphs (i) through

(l) are redesignated as paragraphs (h) through (k), respectively; and

newly redesignated paragraph (h) is amended by removing ``hospital or''

and by removing ``or hospital care in a Federal hospital under

agreement,''.

Sec. 17.93 [Amended]

8. In Sec. 17.93, paragraph (a)(2) is amended by removing ``Medical

services'' and adding, in its place, ``Subject to the provisions of

Secs. 17.36 through 17.38, medical services''.

Sec. 17.99 [Removed]

9. Section 17.99 is removed.

Sec. 17.100 [Amended]

10. In Sec. 17.100, the third sentence is amended by removing ``a

new application is filed, and''.

[FR Doc. 99-25871 Filed 10-5-99; 8:45 am]

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