Expansion of Enrollment in the VA Health Care System, 3535-3540 [E9-1024]

Download as PDF mstockstill on PROD1PC66 with PROPOSALS Federal Register / Vol. 74, No. 12 / Wednesday, January 21, 2009 / Proposed Rules to announce the location and date of the public meeting. 73 FR 76296. In this notice, we announce that public meeting to receive comments on this proposed rule. In the NPRM, we proposed to expand the applicability of Notice of Arrival and Departure (NOAD) and Automatic Identification System (AIS) requirements to more commercial vessels, modify NOAD reporting requirements, establish a mandatory method for electronic data submission and establish a separate requirement for certain vessels to submit notices of departure. The proposed rulemaking would also clarify existing AIS requirements and extend the applicability of AIS requirements beyond Vessel Traffic Service areas to all U.S. navigable waters. You may view the NPRM in our online docket, in addition to supporting documents prepared by the Coast Guard (Regulatory Analysis & Initial Regulatory Flexibility Analysis, Valuing Mortality Risk Reductions in Homeland Security Regulatory Analyses—Final Report June 2008, and an Environmental Checklist), and comments submitted thus far by going to https:// www.regulations.gov. Once there, select the Advanced Docket Search option on the right side of the screen, insert USCG–2005–21869 in the Docket ID box, press Enter, and then click on the item in the Docket ID column. If you do not have access to the Internet, you may view the docket online by visiting the Docket Management Facility in Room W12–140 on the ground floor of the Department of Transportation West Building, 1200 New Jersey Avenue, SE., Washington, DC 20590, between 9 a.m. and 5 p.m., Monday through Friday, except Federal holidays. We have an agreement with the Department of Transportation to use the Docket Management Facility. We encourage you to participate in this rulemaking by submitting comments either orally at the meeting or in writing. If you bring written comments to the meeting, you may submit them to Coast Guard personnel specified at the meeting to receive written comments. These comments will be submitted to our online public docket. All comments received will be posted without change to https:// www.regulations.gov and will include any personal information you have provided. Anyone can search the electronic form of comments received into any of our dockets by the name of the individual submitting the comment (or signing the comment, if submitted on behalf of an association, business, labor VerDate Nov<24>2008 16:26 Jan 16, 2009 Jkt 217001 union, etc.). You may review a Privacy Act notice regarding our public dockets in the January 17, 2008 issue of the Federal Register (73 FR 3316). Information on Service for Individuals With Disabilities For information on facilities or services for individuals with disabilities or to request special assistance at the public meeting, contact Lieutenant Sharmine Jones at the telephone number indicated under the FOR FURTHER INFORMATION CONTACT section of this notice. Public Meeting The Coast Guard will hold a public meeting regarding this proposed rulemaking on March 5, 2009, from 12:30 p.m. to 3 p.m., at the United States Coast Guard Headquarters Building, Room 2415, 2100 2nd Street, SW., Washington, DC 20593. A government-issued photo identification (for example, a driver’s license) will be required for entrance to the building. Parking near the building is limited. Public transportation to the building (Bus Route 71) is limited to rush hours, approximately 6 to 9:30 a.m. and 3 to 6 p.m. Contact the Washington Metropolitan Area Transit Authority for additional information at 202–637–7000 or https://www.wmata.com/. We plan to record this meeting using an audio-digital recorder and to make that audio recording available through a link in our online docket. We will also provide a written summary of the meeting and comments and will place that summary in the docket. Dated: January 13, 2009. M.L. Blair, Captain, U.S. Coast Guard, Acting Director of Commercial Regulations and Standards. [FR Doc. E9–1135 Filed 1–16–09; 8:45 am] BILLING CODE 4910–15–P DEPARTMENT OF VETERANS AFFAIRS 38 CFR Part 17 RIN 2900–AN23 Expansion of Enrollment in the VA Health Care System Department of Veterans Affairs. Proposed rule. AGENCY: ACTION: SUMMARY: The Department of Veterans Affairs (VA) proposes to amend its regulations regarding enrollment in the VA health care system. In particular, it proposes to establish additional subpriorities within enrollment priority PO 00000 Frm 00086 Fmt 4702 Sfmt 4702 3535 category 8 and provide that beginning on the effective date of the rule, VA would enroll priority category 8 veterans whose income exceeds the current means test and geographic means test income thresholds by 10 percent or less. DATES: Written comments must be received on or before February 20, 2009. ADDRESSES: Written comments may be submitted through https:// www.Regulations.gov; by mail or handdelivery to the Director, Regulations Management (02REG), Department of Veterans Affairs, 810 Vermont Ave., NW., Room 1068, Washington, DC 20420; or by fax to (202) 273–9026. Comments should indicate that they are submitted in response to ‘‘RIN 2900– AN23—Expansion of Enrollment.’’ Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1063B, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays). Please call (202) 461–4902 for an appointment. In addition, during the comment period, comments may be viewed online through the Federal Docket Management System (FDMS) at https:// www.Regulations.gov. FOR FURTHER INFORMATION CONTACT: Tony Guagliardo, Director, Business Policy, Chief Business Office (163), Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461–1591. (This is not a toll free number.) SUPPLEMENTARY INFORMATION: Public Law 104–262, the Veterans’ Health Care Eligibility Reform Act of 1996, required VA to establish a national enrollment system to manage the delivery of inpatient hospital care and outpatient medical care, within available appropriated resources. It directed that the enrollment system be managed in such a way as ‘‘to ensure that the provision of care to enrollees is timely and acceptable in quality,’’ and authorized such subprioritization of the statutory enrollment categories ‘‘as the Secretary determines necessary.’’ The law also provided that starting October 1, 1998, most veterans had to enroll in the VA health care system as a condition for receiving VA hospital and outpatient care. In a document published in the Federal Register on January 17, 2003 (68 FR 2670), VA published an interim final rule that amended 38 CFR 17.36 to add two new subpriorities to both enrollment priority categories 7 and 8, for a total of four subpriorities in each category. It also announced that E:\FR\FM\21JAP1.SGM 21JAP1 3536 Federal Register / Vol. 74, No. 12 / Wednesday, January 21, 2009 / Proposed Rules beginning January 17, 2003, VA would enroll all priority categories of veterans except that those veterans in priority category 8 who were not in an enrolled status on January 17, 2003, or who requested disenrollment after that date, would not be eligible to be enrolled. The veterans in this priority category are those whose incomes exceed certain income limits and who do not qualify for enrollment in another priority category. Since then, VA has not enrolled veterans in priority category 8 unless they had been enrolled in another priority category and no longer qualified for enrollment in that category. This proposed rule would establish additional subpriorities within enrollment priority category 8 and would provide that beginning on the effective date of the rule, VA would enroll priority category 8 veterans whose income exceeds the current means test and geographic means test income thresholds by 10 percent or less. These veterans would continue enrollment in these subpriority groups (even if their income exceeds the current tests by more than 10 percent) unless they become eligible for enrollment in a higher category or subpriority; a request for disenrollment is made; or a decision is made to disenroll their particular subpriority or category. This proposed rule would also amend the medical regulations by making a nonsubstantive change to reflect an alternative method to submit VA’s Application for Health Care Benefits (VA Form 10–10EZ). Projections for Increasing Enrollment of Priority Category 8 Veterans Whose Income Exceeds the Current VA Means Test and Geographic Means Test Income Thresholds by 10 Percent or Less An existing regulation (38 CFR 17.36(c)) requires that the Secretary determine which categories of veterans are eligible to be enrolled and that the Secretary notify eligible enrollees of the determination by announcing it in the Federal Register. In making that determination, the Secretary must consider an array of factors including economic information such as available resources, projections of demand for enrollment, and the length of waiting times for appointments for care. The actual number of total enrollees who were enrolled at any time in 2003 was 7,120,347. The corresponding number in 2008 was 7,802,382. The increase in the veterans enrolled in the VA health care system between 2003 and 2008 is, therefore, 682,035. The 2009 Appropriations Act provided funding in VA’s health care appropriation to increase priority category 8 enrollment. The Veterans Health Administration’s (VHA) total FY 2009 medical care appropriation is $40.434 billion. This is supplemented by an additional $3.717 billion from collections for copayments, third-party reimbursements for services, other revenue, and carry-over funds. The sum of these resources is $44.151 billion. The following table shows the projected enrollment for FY 2009 together with the projected expenditures that would be needed to provide the medical benefits package to enrollees under VA’s current enrollment policy: FY 2009 PROJECTIONS UNDER VA’S CURRENT ENROLLMENT POLICY 1 Priority category 1 2 3 4 5 6 7 8 Enrollment Expenditures Cumulative expenditures ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... 1,079,852 595,548 1,090,376 233,153 2,361,166 354,785 1,056,733 1,286,626 $10,552,245,777 2,352,417,015 3,517,387,015 3,461,043,477 11,513,021,012 606,349,476 2,041,244,267 2,692,952,224 $10,552,245,777 12,874,662,792 16,392,050,361 19,853,093,838 31,366,114,850 31,972,464,326 34,013,708,592 36,706,660,817 Total .......................................................................................................................... 8,058,238 36,706,660,817 .............................. 1 This table does not include projections regarding the impact of the proposed regulatory change. The following table shows the projected enrollment and expenditures for FY 2009 if the expanded enrollment as proposed in this document is implemented. The projections are based on reopening enrollment for Priority 8 veterans whose income exceeds the current VA means test (VMT) and geographic means test (GMT) income thresholds by 10 percent or less. The means tests are currently based on Calendar Year (CY) 2007 income. Priority 8 veterans eligible to enroll under VMT/GMT+10 percent are assumed to enroll at higher rates than the average historical rates evidenced in the current Priority 8 enrollee population. Experience shows that veterans in the lower income ranges for Priority 8 veterans are more likely to enroll. The FY 2009 enrollment projections also reflect an expected surge in enrollment when the suspension is lifted and veterans who have not been able to enroll take advantage of this opportunity. The higher enrollment rates for VMT/ GMT+10 percent veterans were increased by 17.5 percent for FY 2009 to reflect the expected surge. In absence of any data to support a different assumption, the projections for VMT/ GMT+10 percent assume the new Priority 8 enrollees will have the same reliance and morbidity as current Priority 8 enrollees. mstockstill on PROD1PC66 with PROPOSALS FY 2009 PROJECTIONS UNDER VA’S CURRENT ENROLLMENT POLICY PLUS GMT/VMT 10 PERCENT SCENARIO 1 Priority category 1 2 3 4 5 Enrollment ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... VerDate Nov<24>2008 16:26 Jan 16, 2009 Jkt 217001 PO 00000 Frm 00087 Fmt 4702 Sfmt 4702 1,079,852 595,548 1,090,376 233,153 2,361,166 E:\FR\FM\21JAP1.SGM Expenditures $10,552,245,777 2,352,417,015 3,517,387,568 3,461,043,477 11,513,021,012 21JAP1 Cumulative expenditures $10,522,245,777 12,874,662,792 16,392,050,361 19,853,093,838 31,366,114,850 3537 Federal Register / Vol. 74, No. 12 / Wednesday, January 21, 2009 / Proposed Rules FY 2009 PROJECTIONS UNDER VA’S CURRENT ENROLLMENT POLICY PLUS GMT/VMT 10 PERCENT SCENARIO 1— Continued Priority category Enrollment Cumulative expenditures Expenditures 6 ....................................................................................................................................... 7 ....................................................................................................................................... 8 ....................................................................................................................................... 354,785 1,056,733 1,545,331 606,349,476 2,041,244,267 3,178,199,353 31,972,464,326 34,013,708,592 37,191,907,945 Total .......................................................................................................................... 8,316,943 37,191,907,945 .............................. 1 FY 2009 Projections in this table include projections under Current Enrollment Policy plus the impact of the proposed regulatory change. The previous tables display 2009 projections based on the 2008 Enrollee Health Care Projection Model, VA’s health care actuarial model. The VA Enrollee Health Care Projection Model (the ‘‘Model’’) supports the VHA health care budget, projects the number of veterans who will be enrolled, the health care services they will choose to get from VHA, and the expenditures associated with that utilization for 20 years. The utilization and expenditure projections are developed based on where enrollees live to support population-based long-term planning. Base year unit costs are based on FY 2007 unit cost data from VA’s financial accounting system—Decision Support System (DSS). The base year unit costs are trended forward using health care cost trends and adjusted for the impact of enrollee aging and changes in VA’s level of health care management over the 20-year projection period. The expenditures projected by this model reflected in these tables exclude services such as Long Term Care, Readjustment Counseling, Spina Bifida, Foreign Medical Programs, Non-Veteran Medical Care, and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). Total expenditures for medical care not included in the model are projected to be $6.959 billion in FY 2009. The following tables show VA’s projections for enrollment through 2019 under the current enrollment policy and how the proposed expansion of enrollment in priority category 8 would affect that. PROJECTED PRIORITY CATEGORY 8 ENROLLMENT: FY 2009–2019 1 Current enrollment policy 2 Fiscal year 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. GMT/VMT 10% scenario 3 1,286,626 1,291,964 1,294,969 1,295,921 1,293,672 1,288,124 1,280,054 1,269,050 1,258,489 1,244,623 1,228,603 258,705 265,571 271,755 281,598 295,772 290,583 294,617 297,001 299,393 300,847 300,798 Total enrollment 1,545,331 1,557,535 1,566,724 1,577,518 1,589,444 1,578,707 1,574,671 1,566,051 1,557,882 1,545,470 1,529,401 1 The enrollment projections begin with VetPop data, 20-year projections of the veteran population that are produced by the VA Office of the Actuary. At this time, VetPop does not provide veteran projections by Priority Levels so VetPop data is combined with other data sources to create VetPop Proxy data, which provides veteran projections by Priority Level. Historical enrollment data are analyzed to develop enrollment rates by Priority Level, Age Band, Geographic Area, and Special Conflict Status. The enrollment rates are then applied to the enrollment pool, which is VetPop minus the enrolled veteran population, to determine projected enrollees for any given year. Mortality rates specific to age, gender, and Priority Level are then applied to the enrollee population, and the enrollment and potential enrollee pool are aged one year at the end of each fiscal year to arrive at the projections for the beginning of the next fiscal year. The process of applying enrollment and mortality rates then repeats for the duration of the enrollment projections. The VA Enrollee Health Care [Projection Model (EHCPM) also accounts for geographic migration and enrollees who transition between enrollment Priority Levels. 2 FY 2009–2019 Projections under Current Enrollment Policy do not include the impact of the proposed regulatory change. 3 FY 2009–2019 Projections under GMT/VMT 10 percent represent the impact of the proposed regulatory change. PROJECTED TOTAL PRIORITY CATEGORY 1–8 ENROLLMENT: FY 2009–2019 Current enrollment policy 1 mstockstill on PROD1PC66 with PROPOSALS Fiscal year 2009 2010 2011 2012 2013 2014 2015 2016 ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. VerDate Nov<24>2008 16:26 Jan 16, 2009 Jkt 217001 PO 00000 Frm 00088 Fmt 4702 Sfmt 4702 Current enrollment plus GMT/VMT 10% scenario 2 Change from current policy 8,058,238 8,173,270 8,274,706 8,341,713 8,378,061 8,384,127 8,364,224 8,318,496 8,316,943 8,438,842 8,546,461 8,623,310 8,673,833 8,674,710 8,658,841 8,615,497 258,705 265,578 271,755 281,598 295,772 290,583 294,617 297,001 E:\FR\FM\21JAP1.SGM 21JAP1 3538 Federal Register / Vol. 74, No. 12 / Wednesday, January 21, 2009 / Proposed Rules PROJECTED TOTAL PRIORITY CATEGORY 1–8 ENROLLMENT: FY 2009–2019—Continued Current enrollment policy 1 Fiscal year 2017 ............................................................................................................................................. 2018 ............................................................................................................................................. 2019 ............................................................................................................................................. Current enrollment plus GMT/VMT 10% scenario 2 Change from current policy 8,277,135 8,231,823 8,181,196 8,576,528 8,532,671 8,481,994 299,393 300,847 300,798 1 FY 2009–2019 Projections under Current Enrollment Policy do not include the impact of the proposed regulatory change. 2009–2019 Projections in this column include projections under Current Enrollment Policy plus the impact of the proposed regulatory change. 2 FY As can be seen from the FY 2009 medical care appropriation and the tables above, VA projects that available resources to expand enrollment will be adequate to support the proposed expansion of enrollment of Priority 8 veterans. mstockstill on PROD1PC66 with PROPOSALS Previous Interim Final Rules and Responses to Comments This document includes proposed changes in the provisions adopted in the interim final rule published in the Federal Register on January 17, 2003 (68 FR 2669, RIN 2900–AL51). We received five comments on that interim final rule. All of the commenters expressed disagreement with VA’s decision to suspend enrollment of additional veterans in priority category 8. Each of the commenters generally expressed the view that VA should provide care to all veterans seeking care because they had served their country. Thoughtful consideration was given to the comments received. However, as discussed in the preamble accompanying publication of the interim final rule, VA is required to assess available resources and determine the number of veterans it is able to enroll to ensure that medical services provided are both timely and acceptable in quality. An enrollment system is necessary because the provision of VA health care is discretionary and can be provided only to the extent that appropriated resources are available for that purpose. The enrollment decision made in January 2003 was based on available resources, and the comments do not suggest that VA’s assessment of available resources was incorrect. Unfunded Mandates The Unfunded Mandates Reform Act 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 $100 million or more in any given year. This rule would have no such VerDate Nov<24>2008 16:26 Jan 16, 2009 Jkt 217001 effect on State, local, or tribal governments. Paperwork Reduction Act This proposed rule contains no provisions constituting a new collection of information, but would change, merely by adding an option of a new method of submission, a collection of information that has been approved by the Office of Management and Budget (OMB) in accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501–3521). 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. The information collection provisions affected by this proposed rule have been approved under control number 2900– 0091. Executive Order 12866 and Congressional Review Act This is an economically significant regulatory action under Executive Order 12866 and constitutes a major rule under the Congressional Review Act. Executive Order 12866 directs agencies to assess all 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, and other advantages; distributive impacts; and equity). Executive Order 12866 classifies a ‘‘significant regulatory action’’ requiring review by OMB as any regulatory action that is likely to result in a rule that may: (1) Have an annual effect on the economy of $100 million or more, or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities; (2) create a serious inconsistency or interfere with an action taken or planned by another agency; (3) materially alter the budgetary impact of PO 00000 Frm 00089 Fmt 4702 Sfmt 4702 entitlements, grants, user fees, or loan programs or the rights and obligations of entitlement recipients; or (4) raise novel legal or policy issues arising out of legal mandates, the President’s priorities, or the principles set forth in the Executive Order. VA has examined the economic, interagency, budgetary, legal, and policy implications of this proposed rule and has concluded that it is an economically significant regulatory action under Executive Order 12866 because it is likely to result in a rule that may have an annual effect on the economy of $100 million or more and may raise novel legal or policy issues arising out of legal mandates, the President’s priorities, or the principles set forth in the Executive Order. This proposed rule is also a major rule under the Congressional Review Act because it is likely to result in an annual effect on the economy of $100 million or more. VA has attempted to follow OMB circular A–4 to the extent feasible in this analysis. The circular first calls for a discussion of the need for the regulation. The Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009 (Pub. L. 110– 329) was enacted on September 30, 2008. The accompanying report language stated that funding was included to reopen priority category 8 enrollment. The preamble above discusses the need for the regulation in more detail. There are not any alternatives to publishing this proposed rule that will accomplish the stated provisions in the report language of the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009 (Pub. L. 110– 329). VA uses the Enrollee Health Care Projection Model (Model), a health care actuarial model, to project veteran demand for VA health care. To project enrollment and expenditures under this proposed regulatory change, VA first identified the number of non-enrolled veterans whose income exceeds the current VA means test and geographic means test income thresholds by 10 E:\FR\FM\21JAP1.SGM 21JAP1 Federal Register / Vol. 74, No. 12 / Wednesday, January 21, 2009 / Proposed Rules percent or less. VA then projected the number of those veterans who would enroll based on historical priority category 8 enrollment rates. The projected health care service utilization for these new enrollees was based on the historical morbidity and reliance rates of the current priority category 8 enrollee population. The projected expenditures represent the cost to provide the projected health care services to these new enrollees. Using the 2008 Model, VA projects that this proposed regulatory change would result in an additional 258,705 priority category 8 enrollees in FY 2009. The projected increase in total health care service expenditures associated with this new enrollment is $485 million in FY 2009. The revenues generated by the first- and third-party collections are projected to be $121 million,1 resulting in a $364 million growth in net health service expenditures for FY 2009, and $375 million was provided in the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009 (Pub. L. 110– 329). VA’s expenditures related to this proposed regulatory change are projected to be approximately $2.931 billion for five years.2 These expenditures exclude services such as Long Term Care, Readjustment Counseling, Spina Bifida, Foreign Medical Programs, Non-Veteran Medical Care and CHAMPVA. 1 The first party collections are based on the projected health care service utilization of the new Priority 8 enrollees. In the base year (2007), we applied the appropriate copayment to the projected services. We then balanced the resulting co-payment revenue 3539 projections to the actual collections for 2007 for four categories (inpatient, outpatient, residential rehabilitation, and pharmacy) and by Veterans Integrated Service Network (VISN) to account for the amount actually collected. The resulting first-party revenue per service developed for 2007 is applied to the projected services in future years to project the first-party revenue associated with health care utilization of the new Priority 8 enrollees. Further, the pharmacy co-payment is increased over time based on the legislated Consumer Price Index (CPI) schedule. To develop the third-party collections, we calculated the percentage of third-party revenue collected in 2007 as a percent of 2007 expenditures by VISN, priority level, and two age bands (under and over age 65). We then applied these percentages to the projected expenditures for the new Priority 8 enrollees in future years. For 2010, the percentages were increased to reflect VHA’s initiatives to increase third-party revenue collections. 2 FIVE YEAR PROJECTION TABLE [Present value: (future value)/((1+i¥∧n)] ($ in billions) FY 2009 Future Value (FV) ............................................................ 3% discount rate (i) .......................................................... 7% discount rate (i) .......................................................... Number of Years (n) ........................................................ Present Value (PV) at 3% ............................................... Present Value (PV) at 7% ............................................... VA requests comments on all of these projections. Regulatory Flexibility Act The Secretary hereby certifies that the adoption of this proposed rule would 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 rule would not directly affect any small entities. Only individuals could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this rule is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604. mstockstill on PROD1PC66 with PROPOSALS Catalog of Federal Domestic Assistance The Catalog of Federal Domestic Assistance numbers and titles for the programs affected by this document are 64.005, Grants to States for the Construction of State Homes; 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, VerDate Nov<24>2008 18:29 Jan 16, 2009 Jkt 217001 $0.485 3.00% 7.00% 0 $0.485 $0.485 FY 2010 FY 2011 $0.533 3.00% 7.00% 1 $0.517 $0.498 $0.580 3.00% 7.00% 2 $0.546 $0.506 Veterans State Hospital Care; 64.018, Sharing Specialized Medical Resources; 64.019, Veterans Rehabilitation Alcohol and Drug Dependence; and 64.022, Veterans Home Based Primary Care. 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. Approved: January 13, 2009. James B. Peake, Secretary of Veterans Affairs. For the reasons set out in the preamble, VA proposes to amend 38 CFR part 17 as set forth below: PART 17—MEDICAL 1. The authority citation for part 17 continues to read as follows: PO 00000 Frm 00090 Fmt 4702 Sfmt 4702 FY 2012 $0.631 3.00% 7.00% 3 $0.578 $0.515 FY 2013 $0.702 3.00% 7.00% 4 $0.624 $0.536 5 year $2.931 .................... .................... .................... $2.751 $2.540 Authority: 38 U.S.C. 501, 1721, and as stated in specific sections. 2. Amend § 17.36 by revising paragraphs (b)(8), (c)(1), (c)(2), and (d)(1) and the authority citation to read as follows: § 17.36 Enrollment—provision of hospital and outpatient care to veterans. * * * * * (b) * * * (8) Veterans not included in priority category 4 or 7, who are eligible for care only if they 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 who were in an enrolled status on January 17, 2003, or who are moved from a higher priority category or subcategory due to no longer being eligible for inclusion in such priority category or subcategory and who subsequently do not request disenrollment; (ii) Noncompensable zero percent service-connected veterans not included in paragraph (b)(8)(i) of this section and whose income is not greater than ten percent more than the income that E:\FR\FM\21JAP1.SGM 21JAP1 3540 Federal Register / Vol. 74, No. 12 / Wednesday, January 21, 2009 / Proposed Rules mstockstill on PROD1PC66 with PROPOSALS would permit their enrollment in priority category 5 or priority category 7, whichever is higher; (iii) Nonservice-connected veterans who were in an enrolled status on January 17, 2003, or who are moved from a higher priority category or subcategory due to no longer being eligible for inclusion in such priority category or subcategory and who subsequently do not request disenrollment; (iv) Nonservice-connected veterans not included in paragraph (b)(8)(iii) of this section and whose income is not greater than ten percent more than the income that would permit their enrollment in priority category 5 or priority category 7, whichever is higher; (v) Noncompensable zero percent service-connected veterans not included in paragraph (b)(8)(i) or paragraph (b)(8)(ii) of this section; and (vi) Nonservice-connected veterans not included in paragraph (b)(8)(iii) or paragraph (b)(8)(iv) of this section. (c) * * * VerDate Nov<24>2008 16:26 Jan 16, 2009 Jkt 217001 (1) It is anticipated that each year the Secretary will consider whether to change the categories and subcategories of veterans eligible to be enrolled. The Secretary at any time may revise the categories or subcategories of veterans eligible to be enrolled by amending paragraph (c)(2) of this section. The preamble to a Federal Register document announcing which priority categories and subcategories 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 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 PO 00000 Frm 00091 Fmt 4702 Sfmt 4702 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 the priority categories of veterans set forth in § 17.36(b) beginning [effective date of regulation], except that those veterans in subcategories (v) and (vi) of priority category 8 are not eligible to be enrolled. (d) * * * (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 or via an online submission at https:// www.1010ez.med.va.gov/sec/vha/ 1010ez/. * * * * * (Authority: 38 U.S.C. 101, 501, 1521, 1701, 1705, 1710, 1722) [FR Doc. E9–1024 Filed 1–16–09; 8:45 am] BILLING CODE 8320–01–P E:\FR\FM\21JAP1.SGM 21JAP1

Agencies

DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 74, Number 12 (Wednesday, January 21, 2009)]
[Proposed Rules]
[Pages 3535-3540]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-1024]

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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AN23

Expansion of Enrollment in the VA Health Care System

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend its
regulations regarding enrollment in the VA health care system. In
particular, it proposes to establish additional subpriorities within
enrollment priority category 8 and provide that beginning on the
effective date of the rule, VA would enroll priority category 8
veterans whose income exceeds the current means test and geographic
means test income thresholds by 10 percent or less.

DATES: Written comments must be received on or before February 20,
2009.

ADDRESSES: Written comments may be submitted through https://
www.Regulations.gov; by mail or hand-delivery to the Director,
Regulations Management (02REG), Department of Veterans Affairs, 810
Vermont Ave., NW., Room 1068, Washington, DC 20420; or by fax to (202)
273-9026. Comments should indicate that they are submitted in response
to ``RIN 2900-AN23--Expansion of Enrollment.'' Copies of comments
received will be available for public inspection in the Office of
Regulation Policy and Management, Room 1063B, between the hours of 8
a.m. and 4:30 p.m., Monday through Friday (except holidays). Please
call (202) 461-4902 for an appointment. In addition, during the comment
period, comments may be viewed online through the Federal Docket
Management System (FDMS) at https://www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Tony Guagliardo, Director, Business
Policy, Chief Business Office (163), Veterans Health Administration,
Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC
20420, (202) 461-1591. (This is not a toll free number.)

SUPPLEMENTARY INFORMATION: Public Law 104-262, the Veterans' Health
Care Eligibility Reform Act of 1996, required VA to establish a
national enrollment system to manage the delivery of inpatient hospital
care and outpatient medical care, within available appropriated
resources. It directed that the enrollment system be managed in such a
way as ``to ensure that the provision of care to enrollees is timely
and acceptable in quality,'' and authorized such subprioritization of
the statutory enrollment categories ``as the Secretary determines
necessary.'' The law also provided that starting October 1, 1998, most
veterans had to enroll in the VA health care system as a condition for
receiving VA hospital and outpatient care.
In a document published in the Federal Register on January 17, 2003
(68 FR 2670), VA published an interim final rule that amended 38 CFR
17.36 to add two new subpriorities to both enrollment priority
categories 7 and 8, for a total of four subpriorities in each category.
It also announced that

[[Page 3536]]

beginning January 17, 2003, VA would enroll all priority categories of
veterans except that those veterans in priority category 8 who were not
in an enrolled status on January 17, 2003, or who requested
disenrollment after that date, would not be eligible to be enrolled.
The veterans in this priority category are those whose incomes exceed
certain income limits and who do not qualify for enrollment in another
priority category. Since then, VA has not enrolled veterans in priority
category 8 unless they had been enrolled in another priority category
and no longer qualified for enrollment in that category.
This proposed rule would establish additional subpriorities within
enrollment priority category 8 and would provide that beginning on the
effective date of the rule, VA would enroll priority category 8
veterans whose income exceeds the current means test and geographic
means test income thresholds by 10 percent or less. These veterans
would continue enrollment in these subpriority groups (even if their
income exceeds the current tests by more than 10 percent) unless they
become eligible for enrollment in a higher category or subpriority; a
request for disenrollment is made; or a decision is made to disenroll
their particular subpriority or category. This proposed rule would also
amend the medical regulations by making a nonsubstantive change to
reflect an alternative method to submit VA's Application for Health
Care Benefits (VA Form 10-10EZ).

Projections for Increasing Enrollment of Priority Category 8 Veterans
Whose Income Exceeds the Current VA Means Test and Geographic Means
Test Income Thresholds by 10 Percent or Less

An existing regulation (38 CFR 17.36(c)) requires that the
Secretary determine which categories of veterans are eligible to be
enrolled and that the Secretary notify eligible enrollees of the
determination by announcing it in the Federal Register. In making that
determination, the Secretary must consider an array of factors
including economic information such as available resources, projections
of demand for enrollment, and the length of waiting times for
appointments for care.
The actual number of total enrollees who were enrolled at any time
in 2003 was 7,120,347. The corresponding number in 2008 was 7,802,382.
The increase in the veterans enrolled in the VA health care system
between 2003 and 2008 is, therefore, 682,035.
The 2009 Appropriations Act provided funding in VA's health care
appropriation to increase priority category 8 enrollment. The Veterans
Health Administration's (VHA) total FY 2009 medical care appropriation
is $40.434 billion. This is supplemented by an additional $3.717
billion from collections for copayments, third-party reimbursements for
services, other revenue, and carry-over funds. The sum of these
resources is $44.151 billion. The following table shows the projected
enrollment for FY 2009 together with the projected expenditures that
would be needed to provide the medical benefits package to enrollees
under VA's current enrollment policy:

FY 2009 Projections Under VA's Current Enrollment Policy \1\
----------------------------------------------------------------------------------------------------------------
Cumulative
Priority category Enrollment Expenditures expenditures
----------------------------------------------------------------------------------------------------------------
1......................................................... 1,079,852 $10,552,245,777 $10,552,245,777
2......................................................... 595,548 2,352,417,015 12,874,662,792
3......................................................... 1,090,376 3,517,387,015 16,392,050,361
4......................................................... 233,153 3,461,043,477 19,853,093,838
5......................................................... 2,361,166 11,513,021,012 31,366,114,850
6......................................................... 354,785 606,349,476 31,972,464,326
7......................................................... 1,056,733 2,041,244,267 34,013,708,592
8......................................................... 1,286,626 2,692,952,224 36,706,660,817
=================
Total................................................. 8,058,238 36,706,660,817 .................
----------------------------------------------------------------------------------------------------------------
\1\ This table does not include projections regarding the impact of the proposed regulatory change.

The following table shows the projected enrollment and expenditures
for FY 2009 if the expanded enrollment as proposed in this document is
implemented. The projections are based on reopening enrollment for
Priority 8 veterans whose income exceeds the current VA means test
(VMT) and geographic means test (GMT) income thresholds by 10 percent
or less. The means tests are currently based on Calendar Year (CY) 2007
income.
Priority 8 veterans eligible to enroll under VMT/GMT+10 percent are
assumed to enroll at higher rates than the average historical rates
evidenced in the current Priority 8 enrollee population. Experience
shows that veterans in the lower income ranges for Priority 8 veterans
are more likely to enroll. The FY 2009 enrollment projections also
reflect an expected surge in enrollment when the suspension is lifted
and veterans who have not been able to enroll take advantage of this
opportunity. The higher enrollment rates for VMT/GMT+10 percent
veterans were increased by 17.5 percent for FY 2009 to reflect the
expected surge. In absence of any data to support a different
assumption, the projections for VMT/GMT+10 percent assume the new
Priority 8 enrollees will have the same reliance and morbidity as
current Priority 8 enrollees.

FY 2009 Projections Under VA's Current Enrollment Policy Plus GMT/VMT 10 Percent Scenario \1\
----------------------------------------------------------------------------------------------------------------
Cumulative
Priority category Enrollment Expenditures expenditures
----------------------------------------------------------------------------------------------------------------
1......................................................... 1,079,852 $10,552,245,777 $10,522,245,777
2......................................................... 595,548 2,352,417,015 12,874,662,792
3......................................................... 1,090,376 3,517,387,568 16,392,050,361
4......................................................... 233,153 3,461,043,477 19,853,093,838
5......................................................... 2,361,166 11,513,021,012 31,366,114,850

[[Page 3537]]

6......................................................... 354,785 606,349,476 31,972,464,326
7......................................................... 1,056,733 2,041,244,267 34,013,708,592
8......................................................... 1,545,331 3,178,199,353 37,191,907,945
-----------------------------------------------------
Total................................................. 8,316,943 37,191,907,945 .................
----------------------------------------------------------------------------------------------------------------
\1\ FY 2009 Projections in this table include projections under Current Enrollment Policy plus the impact of the
proposed regulatory change.

The previous tables display 2009 projections based on the 2008
Enrollee Health Care Projection Model, VA's health care actuarial
model. The VA Enrollee Health Care Projection Model (the ``Model'')
supports the VHA health care budget, projects the number of veterans
who will be enrolled, the health care services they will choose to get
from VHA, and the expenditures associated with that utilization for 20
years. The utilization and expenditure projections are developed based
on where enrollees live to support population-based long-term planning.
Base year unit costs are based on FY 2007 unit cost data from VA's
financial accounting system--Decision Support System (DSS). The base
year unit costs are trended forward using health care cost trends and
adjusted for the impact of enrollee aging and changes in VA's level of
health care management over the 20-year projection period. The
expenditures projected by this model reflected in these tables exclude
services such as Long Term Care, Readjustment Counseling, Spina Bifida,
Foreign Medical Programs, Non-Veteran Medical Care, and the Civilian
Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA). Total expenditures for medical care not included in the
model are projected to be $6.959 billion in FY 2009. The following
tables show VA's projections for enrollment through 2019 under the
current enrollment policy and how the proposed expansion of enrollment
in priority category 8 would affect that.

Projected Priority Category 8 Enrollment: FY 2009-2019 \1\
----------------------------------------------------------------------------------------------------------------
Current
Fiscal year enrollment GMT/VMT 10% Total
policy \2\ scenario \3\ enrollment
----------------------------------------------------------------------------------------------------------------
2009............................................................ 1,286,626 258,705 1,545,331
2010............................................................ 1,291,964 265,571 1,557,535
2011............................................................ 1,294,969 271,755 1,566,724
2012............................................................ 1,295,921 281,598 1,577,518
2013............................................................ 1,293,672 295,772 1,589,444
2014............................................................ 1,288,124 290,583 1,578,707
2015............................................................ 1,280,054 294,617 1,574,671
2016............................................................ 1,269,050 297,001 1,566,051
2017............................................................ 1,258,489 299,393 1,557,882
2018............................................................ 1,244,623 300,847 1,545,470
2019............................................................ 1,228,603 300,798 1,529,401
----------------------------------------------------------------------------------------------------------------
\1\ The enrollment projections begin with VetPop data, 20-year projections of the veteran population that are
produced by the VA Office of the Actuary. At this time, VetPop does not provide veteran projections by
Priority Levels so VetPop data is combined with other data sources to create VetPop Proxy data, which provides
veteran projections by Priority Level.
Historical enrollment data are analyzed to develop enrollment rates by Priority Level, Age Band, Geographic
Area, and Special Conflict Status. The enrollment rates are then applied to the enrollment pool, which is
VetPop minus the enrolled veteran population, to determine projected enrollees for any given year.
Mortality rates specific to age, gender, and Priority Level are then applied to the enrollee population, and the
enrollment and potential enrollee pool are aged one year at the end of each fiscal year to arrive at the
projections for the beginning of the next fiscal year. The process of applying enrollment and mortality rates
then repeats for the duration of the enrollment projections.
The VA Enrollee Health Care [Projection Model (EHCPM) also accounts for geographic migration and enrollees who
transition between enrollment Priority Levels.
\2\ FY 2009-2019 Projections under Current Enrollment Policy do not include the impact of the proposed
regulatory change.
\3\ FY 2009-2019 Projections under GMT/VMT 10 percent represent the impact of the proposed regulatory change.

Projected Total Priority Category 1-8 Enrollment: FY 2009-2019
----------------------------------------------------------------------------------------------------------------
Current
Current enrollment
Fiscal year enrollment plus GMT/VMT Change from
policy \1\ 10% scenario current policy
\2\
----------------------------------------------------------------------------------------------------------------
2009............................................................ 8,058,238 8,316,943 258,705
2010............................................................ 8,173,270 8,438,842 265,578
2011............................................................ 8,274,706 8,546,461 271,755
2012............................................................ 8,341,713 8,623,310 281,598
2013............................................................ 8,378,061 8,673,833 295,772
2014............................................................ 8,384,127 8,674,710 290,583
2015............................................................ 8,364,224 8,658,841 294,617
2016............................................................ 8,318,496 8,615,497 297,001

[[Page 3538]]

2017............................................................ 8,277,135 8,576,528 299,393
2018............................................................ 8,231,823 8,532,671 300,847
2019............................................................ 8,181,196 8,481,994 300,798
----------------------------------------------------------------------------------------------------------------
\1\ FY 2009-2019 Projections under Current Enrollment Policy do not include the impact of the proposed
regulatory change.
\2\ FY 2009-2019 Projections in this column include projections under Current Enrollment Policy plus the impact
of the proposed regulatory change.

As can be seen from the FY 2009 medical care appropriation and the
tables above, VA projects that available resources to expand enrollment
will be adequate to support the proposed expansion of enrollment of
Priority 8 veterans.

Previous Interim Final Rules and Responses to Comments

This document includes proposed changes in the provisions adopted
in the interim final rule published in the Federal Register on January
17, 2003 (68 FR 2669, RIN 2900-AL51). We received five comments on that
interim final rule. All of the commenters expressed disagreement with
VA's decision to suspend enrollment of additional veterans in priority
category 8. Each of the commenters generally expressed the view that VA
should provide care to all veterans seeking care because they had
served their country. Thoughtful consideration was given to the
comments received. However, as discussed in the preamble accompanying
publication of the interim final rule, VA is required to assess
available resources and determine the number of veterans it is able to
enroll to ensure that medical services provided are both timely and
acceptable in quality. An enrollment system is necessary because the
provision of VA health care is discretionary and can be provided only
to the extent that appropriated resources are available for that
purpose. The enrollment decision made in January 2003 was based on
available resources, and the comments do not suggest that VA's
assessment of available resources was incorrect.

Unfunded Mandates

The Unfunded Mandates Reform Act 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
$100 million or more in any given year. This rule would have no such
effect on State, local, or tribal governments.

Paperwork Reduction Act

This proposed rule contains no provisions constituting a new
collection of information, but would change, merely by adding an option
of a new method of submission, a collection of information that has
been approved by the Office of Management and Budget (OMB) in
accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521). 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. The information collection
provisions affected by this proposed rule have been approved under
control number 2900-0091.

Executive Order 12866 and Congressional Review Act

This is an economically significant regulatory action under
Executive Order 12866 and constitutes a major rule under the
Congressional Review Act.
Executive Order 12866 directs agencies to assess all 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,
and other advantages; distributive impacts; and equity). Executive
Order 12866 classifies a ``significant regulatory action'' requiring
review by OMB as any regulatory action that is likely to result in a
rule that may: (1) Have an annual effect on the economy of $100 million
or more, or adversely affect in a material way the economy, a sector of
the economy, productivity, competition, jobs, the environment, public
health or safety, or State, local, or tribal governments or
communities; (2) create a serious inconsistency or interfere with an
action taken or planned by another agency; (3) materially alter the
budgetary impact of entitlements, grants, user fees, or loan programs
or the rights and obligations of entitlement recipients; or (4) raise
novel legal or policy issues arising out of legal mandates, the
President's priorities, or the principles set forth in the Executive
Order.
VA has examined the economic, interagency, budgetary, legal, and
policy implications of this proposed rule and has concluded that it is
an economically significant regulatory action under Executive Order
12866 because it is likely to result in a rule that may have an annual
effect on the economy of $100 million or more and may raise novel legal
or policy issues arising out of legal mandates, the President's
priorities, or the principles set forth in the Executive Order. This
proposed rule is also a major rule under the Congressional Review Act
because it is likely to result in an annual effect on the economy of
$100 million or more.
VA has attempted to follow OMB circular A-4 to the extent feasible
in this analysis. The circular first calls for a discussion of the need
for the regulation. The Consolidated Security, Disaster Assistance, and
Continuing Appropriations Act, 2009 (Pub. L. 110-329) was enacted on
September 30, 2008. The accompanying report language stated that
funding was included to reopen priority category 8 enrollment. The
preamble above discusses the need for the regulation in more detail.
There are not any alternatives to publishing this proposed rule that
will accomplish the stated provisions in the report language of the
Consolidated Security, Disaster Assistance, and Continuing
Appropriations Act, 2009 (Pub. L. 110-329).
VA uses the Enrollee Health Care Projection Model (Model), a health
care actuarial model, to project veteran demand for VA health care. To
project enrollment and expenditures under this proposed regulatory
change, VA first identified the number of non-enrolled veterans whose
income exceeds the current VA means test and geographic means test
income thresholds by 10

[[Page 3539]]

percent or less. VA then projected the number of those veterans who
would enroll based on historical priority category 8 enrollment rates.
The projected health care service utilization for these new enrollees
was based on the historical morbidity and reliance rates of the current
priority category 8 enrollee population. The projected expenditures
represent the cost to provide the projected health care services to
these new enrollees.
Using the 2008 Model, VA projects that this proposed regulatory
change would result in an additional 258,705 priority category 8
enrollees in FY 2009. The projected increase in total health care
service expenditures associated with this new enrollment is $485
million in FY 2009. The revenues generated by the first- and third-
party collections are projected to be $121 million,\1\ resulting in a
$364 million growth in net health service expenditures for FY 2009, and
$375 million was provided in the Consolidated Security, Disaster
Assistance, and Continuing Appropriations Act, 2009 (Pub. L. 110-329).
VA's expenditures related to this proposed regulatory change are
projected to be approximately $2.931 billion for five years.\2\ These
expenditures exclude services such as Long Term Care, Readjustment
Counseling, Spina Bifida, Foreign Medical Programs, Non-Veteran Medical
Care and CHAMPVA.

\1\ The first party collections are based on the projected
health care service utilization of the new Priority 8 enrollees. In
the base year (2007), we applied the appropriate co-payment to the
projected services. We then balanced the resulting co-payment
revenue projections to the actual collections for 2007 for four
categories (inpatient, outpatient, residential rehabilitation, and
pharmacy) and by Veterans Integrated Service Network (VISN) to
account for the amount actually collected. The resulting first-party
revenue per service developed for 2007 is applied to the projected
services in future years to project the first-party revenue
associated with health care utilization of the new Priority 8
enrollees. Further, the pharmacy co-payment is increased over time
based on the legislated Consumer Price Index (CPI) schedule.
To develop the third-party collections, we calculated the
percentage of third-party revenue collected in 2007 as a percent of
2007 expenditures by VISN, priority level, and two age bands (under
and over age 65). We then applied these percentages to the projected
expenditures for the new Priority 8 enrollees in future years. For
2010, the percentages were increased to reflect VHA's initiatives to
increase third-party revenue collections.

\2\ Five Year Projection Table
[Present value: (future value)/((1+i-[supcaret]n)]
----------------------------------------------------------------------------------------------------------------
($ in billions) FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 5 year
----------------------------------------------------------------------------------------------------------------
Future Value (FV)................. $0.485 $0.533 $0.580 $0.631 $0.702 $2.931
3% discount rate (i).............. 3.00% 3.00% 3.00% 3.00% 3.00% ...........
7% discount rate (i).............. 7.00% 7.00% 7.00% 7.00% 7.00% ...........
Number of Years (n)............... 0 1 2 3 4 ...........
Present Value (PV) at 3%.......... $0.485 $0.517 $0.546 $0.578 $0.624 $2.751
Present Value (PV) at 7%.......... $0.485 $0.498 $0.506 $0.515 $0.536 $2.540
----------------------------------------------------------------------------------------------------------------

VA requests comments on all of these projections.

Regulatory Flexibility Act

The Secretary hereby certifies that the adoption of this proposed
rule would 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 rule would not directly affect
any small entities. Only individuals could be directly affected.
Therefore, pursuant to 5 U.S.C. 605(b), this rule is exempt from the
initial and final regulatory flexibility analysis requirements of
sections 603 and 604.

Catalog of Federal Domestic Assistance

The Catalog of Federal Domestic Assistance numbers and titles for
the programs affected by this document are 64.005, Grants to States for
the Construction of State Homes; 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; and 64.022, Veterans Home
Based Primary Care.

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.

Approved: January 13, 2009.
James B. Peake,
Secretary of Veterans Affairs.

For the reasons set out in the preamble, VA proposes to amend 38
CFR part 17 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, and as stated in specific
sections.

2. Amend Sec. 17.36 by revising paragraphs (b)(8), (c)(1), (c)(2),
and (d)(1) and the authority citation to read as follows:

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

* * * * *
(b) * * *
(8) Veterans not included in priority category 4 or 7, who are
eligible for care only if they 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 who were
in an enrolled status on January 17, 2003, or who are moved from a
higher priority category or subcategory due to no longer being eligible
for inclusion in such priority category or subcategory and who
subsequently do not request disenrollment;
(ii) Noncompensable zero percent service-connected veterans not
included in paragraph (b)(8)(i) of this section and whose income is not
greater than ten percent more than the income that

[[Page 3540]]

would permit their enrollment in priority category 5 or priority
category 7, whichever is higher;
(iii) Nonservice-connected veterans who were in an enrolled status
on January 17, 2003, or who are moved from a higher priority category
or subcategory due to no longer being eligible for inclusion in such
priority category or subcategory and who subsequently do not request
disenrollment;
(iv) Nonservice-connected veterans not included in paragraph
(b)(8)(iii) of this section and whose income is not greater than ten
percent more than the income that would permit their enrollment in
priority category 5 or priority category 7, whichever is higher;
(v) Noncompensable zero percent service-connected veterans not
included in paragraph (b)(8)(i) or paragraph (b)(8)(ii) of this
section; and
(vi) Nonservice-connected veterans not included in paragraph
(b)(8)(iii) or paragraph (b)(8)(iv) of this section.
(c) * * *
(1) It is anticipated that each year the Secretary will consider
whether to change the categories and subcategories of veterans eligible
to be enrolled. The Secretary at any time may revise the categories or
subcategories of veterans eligible to be enrolled by amending paragraph
(c)(2) of this section. The preamble to a Federal Register document
announcing which priority categories and subcategories 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 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 the priority
categories of veterans set forth in Sec. 17.36(b) beginning [effective
date of regulation], except that those veterans in subcategories (v)
and (vi) of priority category 8 are not eligible to be enrolled.
(d) * * *
(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 or via an online submission at https://www.1010ez.med.va.gov/
sec/vha/1010ez/.
* * * * *
(Authority: 38 U.S.C. 101, 501, 1521, 1701, 1705, 1710, 1722)

[FR Doc. E9-1024 Filed 1-16-09; 8:45 am]
BILLING CODE 8320-01-P

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