Caregivers Program, 1357-1378 [2015-00071]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 80, Number 6 (Friday, January 9, 2015)]
[Rules and Regulations]
[Pages 1357-1378]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2015-00071]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Parts 17 and 71

RIN 2900-AN94


Caregivers Program

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: The Department of Veterans Affairs (VA) adopts, with changes, 
the interim final rule concerning VA's Program of Comprehensive 
Assistance for Family Caregivers. VA administers this program to 
provide certain medical, travel, training, and financial benefits to 
caregivers of certain veterans and servicemembers who were seriously 
injured during service on or after September 11, 2001. Also addressed 
in this rulemaking is the Program of General Caregiver Support Services 
that provides support services to caregivers of veterans from all eras 
who are enrolled in the VA health care system. Specifically, changes in 
this final rule include a requirement that Veterans be notified in 
writing should a Family Caregiver request revocation (to no longer be a 
Family Caregiver), an extension of the application timeframe from 30 
days to 45 days for a Family Caregiver, and a change in the stipend 
calculation to ensure that Primary Family Caregivers do not experience 
unexpected decreases in stipend amounts from year to year.

DATES: Effective Date: This rule is effective on January 9, 2015.

FOR FURTHER INFORMATION CONTACT: Michael Kilmer, Chief Consultant, 
Veterans Health Administration, 810 Vermont Avenue, Washington, DC 
20420, 202-461-6780. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: 

Executive Summary

I. Purpose of the Final Rule

    This final rule continues to implement title I of the Caregivers 
and Veterans Omnibus Health Services Act of 2010, Public Law 111-163, 
which was signed into law on May 5, 2010. VA has been administering the 
benefits program under this law continuously since May 5, 2011, under 
an interim final rule published in the Federal Register (76 FR 26148) 
as well as part 71 of title 38, Code of Federal Regulations (CFR). The 
purpose of the benefits program under this law is to provide certain 
medical, travel, training, and financial benefits to caregivers of 
certain veterans and servicemembers who were seriously injured in the 
line of duty on or after September 11, 2001. Among other things, title 
I of the law established 38 U.S.C. 1720G, which requires VA to 
``establish a program of comprehensive assistance for family caregivers 
of eligible veterans,'' as well as a program of ``general caregiver 
support services'' for caregivers of ``veterans who are enrolled in the 
health care system established under [38 U.S.C. 1705(a)] (including 
caregivers who do not reside with such veterans).'' 38 U.S.C. 1720G(a), 
(b).

II. Major Provisions

    VA distinguishes between three types of caregivers based on the 
requirements of the law: Primary Family Caregivers, Secondary Family 
Caregivers, and General Caregivers. A Primary Family Caregiver is an 
individual designated as a ``primary provider of personal care 
services'' for the eligible veteran under 38 U.S.C. 1720G(a)(7)(A), who 
the veteran specifies on the joint application and is approved by VA as 
the primary provider of personal care services for the veteran. A 
Secondary Family Caregiver is an individual approved as a ``provider of 
personal care services'' for the eligible veteran under 38 U.S.C. 
1720G(a)(6)(B), and generally serves as a back-up to the Primary Family 
Caregiver. General Caregivers are ``caregivers of covered veterans'' 
under the program in 38 U.S.C. 1720G(b), and provide personal care 
services to covered veterans, but do not meet the criteria for 
designation or approval as a Primary or Secondary Family Caregiver.
    In general, caregivers receive the following benefits and services:
     General Caregivers--Education and training on caring for 
an enrolled Veteran; use of telehealth technologies; counseling and 
other services under Sec.  71.50; and respite care.
     Secondary Family Caregivers--All benefits and services 
available to General Caregivers; monitoring; veteran-specific 
instruction and training; beneficiary travel under 38 CFR part 70; 
ongoing technical support; and counseling.
     Primary Family Caregivers--All benefits and services 
available to both General Caregivers and Secondary Family Caregivers; 
monthly caregiver stipend; respite care available for at least 30 days 
per year, and may exceed 30 days per year if clinically appropriate and 
if requested by the Primary Family Caregiver; and health care coverage 
(if they are eligible).

Some of these benefits are delivered directly to veterans, such as 
monitoring the quality of the care provided by caregivers to ensure 
that the veteran is able to live in a residential setting without 
unnecessary deterioration of his or her disability, and safe from 
potential abuse or neglect. Other benefits are delivered directly to 
the veteran's caregiver, such as a stipend or enrollment in the 
Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA), which provides health coverage for certain Primary 
Family Caregivers. The fact that caregiver benefits are offered and 
delivered to both the veteran and his or her caregiver makes the 
benefits significantly different from virtually all other benefits 
programs offered through the Veterans Health Administration.

III. Costs and Benefits

Summary of Costs of the Caregiver Program for FY2015 Through FY2017

    In developing the Regulatory Impact Analysis (RIA) for this final 
rule, VA did consider different alternative approaches on how best to 
regulate the statutory provisions of the law. More specifically, VA 
changed the formula and methodology to compute the caregiver stipend 
rate from the interim final rule. Individuals designated as the 
eligible Veteran's primary family caregiver are eligible to receive a 
monthly stipend from VA as an

[[Page 1358]]

acknowledgement of the sacrifices they make to care for seriously 
injured eligible Veterans. The monthly stipend is not intended to 
replace career earnings or be construed to create an employment 
relationship between VA and caregivers. Family caregivers report that 
the stipend is the cornerstone of the Program of Comprehensive 
Assistance for Family Caregivers. The stipend helps to alleviate 
financial distress experienced by many primary family caregivers.
    VA never intended that Primary Family Caregivers should be subject 
to decreased stipend payments from year to year. Therefore, upon 
drafting the final rule and final RIA, VA changed the stipend 
calculation to use the most recent data from the BLS on hourly wage 
rates for home health aides as well as the most recent CPI-U, unless 
using this most recent data for a geographic area would result in an 
overall BLS and CPI-U combined rate that is lower than that applied in 
the previous year for the same geographic area, in which case the BLS 
hourly wage rate and CPI-U that was applied in the previous year for 
that geographic area will be utilized to calculate the Primary Family 
Caregiver stipend. This revision ensures that Primary Family Caregivers 
will not unexpectedly lose monetary assistance upon which they had come 
to rely. VA started applying the new stipend calculation on January 1, 
2013 under the auspices of the interim final rule being finalized with 
this rulemaking.
    The total costs associated with this final rulemaking, including 
the stipend, are estimated to be $477.0 million in FY2015 and $1.67 
billion over a three year period. Estimated costs and revised 
projections are based on actual caseloads, actual obligations and 
historical trends/data since implementation of the Caregiver Program 
(July 2011) and through FY2014. For more specific costing information, 
VA's full RIA can be found as a supporting document at https://www.regulations.gov, usually within 48 hours after the final rulemaking 
document is published. Additionally, a copy of this final rulemaking 
and the RIA are available on VA's Web site at https://www1.va.gov/orpm/, 
by following the link for ``VA Regulations Published.''
    On May 5, 2011, VA published in the Federal Register (76 FR 26148) 
an interim final rule to implement title I of the Caregivers and 
Veterans Omnibus Health Services Act of 2010 (the Caregivers Act), 
Public Law 111-163, codified at 38 U.S.C. 1720G and in other sections 
of title 38, U.S.C. Interested persons were invited to submit comments 
on or before July 5, 2011, and we received 12 comments. All of the 
issues raised by the commenters that opposed at least one portion of 
the rule can be grouped together by similar topic, and we have 
organized our discussion of the comments accordingly. Based on the 
rationale set forth in the interim final rule and in this document, VA 
is adopting the provisions of the interim final rule, including the 
Part 17 amendment, as a final rule except as amended herein.
Distinguishing Levels of Assistance Provided, and To Whom, Under This 
Rule
    To ensure that the varying levels of assistance and accompanying 
eligibility criteria under the rule are appropriately distinguished, we 
amend Sec.  71.10(a) to refer to the ``Program of Comprehensive 
Assistance for Family Caregivers'' where eligibility and assistance of 
both Primary and Secondary Family Caregivers are concerned, and to 
refer to the ``Program of General Caregiver Support Services'' where 
eligibility and support services for General Caregivers are concerned. 
This is consistent with the manner in which these two programs are 
distinguished in 38 U.S.C. 1720G(a) and (b). We similarly amend Sec.  
71.10(b) to refer to ``Family Caregiver benefits'' and ``General 
Caregiver benefits'' authorized by 38 U.S.C. 1720G, and amend the 
definition of ``in the best interest'' in Sec.  71.15 to refer to the 
``Program of Comprehensive Assistance for Family Caregivers,'' instead 
of to the ``Family Caregiver program.'' We also revise the rule in 
multiple places to refer to ``caregiver'' as opposed to ``Caregiver'' 
for consistency in capitalization throughout Part 71. These amendments 
do not create any substantive changes in the application of any of the 
rule's provisions. Throughout this rulemaking, we refer to ``Family 
Caregivers'' as those individuals who may be provided ``Family 
Caregiver benefits'' through the ``Program of Comprehensive Assistance 
for Family Caregivers,'' and refer to ``General Caregivers'' as those 
individuals who may be provided ``General Caregiver benefits'' through 
the ``Program of General Caregiver Support Services.''
    Additionally, we clarify that ``eligible veteran'' by definition 
under Sec.  71.15 includes both a veteran and a servicemember who meet 
the eligibility criteria in Sec.  71.20, and have amended the 
regulations to ensure that the phrase ``eligible veteran'' is used to 
refer to both veterans and servicemembers in any context in which 
eligibility under Sec.  71.20 has been established, and that the terms 
``veterans'' and ``servicemembers'' are used separately in any context 
in which eligibility under Sec.  71.20 has not been established. 
Similarly, in the definition of ``primary care team'' we amend the 
reference to ``veteran'' to instead refer to ``patient'' for 
consistency throughout the definition. These amendments do not create 
any substantive changes in the application of any of the rule's 
provisions, and are made to Sec. Sec.  71.15, and 71.45(b) and (b)(3).
Expanding Eligibility to Veterans Who Served Before September 11, 2001
    Multiple commenters argued that eligibility for Family Caregiver 
benefits should be extended to veterans who served before September 11, 
2001 (``pre-9/11 veterans''). The commenters asserted that pre- and 
post-9/11 veterans may require the same levels of personal care based 
on equally serious injuries, and that dates of service should therefore 
not dictate the level of benefits and services available. The 
eligibility distinction between pre-and post-9/11 veterans was mandated 
by Congress in section 1720G, and we lack authority to make the change 
suggested by these comments. See 38 U.S.C. 1720G(a)(2)(B).
    Commenters emphasized that VA should comply with the Caregivers 
Act's reporting requirements on the feasibility and advisability of 
expanding Family Caregiver benefits to caregivers of pre-9/11 veterans. 
See Pub. L. 111-163, title I, section 101(d)(1). VA has complied with 
these reporting requirements, and on September 4, 2013, transmitted the 
Secretary's recommendations to the Committee on Veterans' Affairs of 
the Senate and the Committee on Veterans' Affairs of the House of 
Representatives. We note that any pre-9/11 veterans who are enrolled in 
the VA health care system, and those veterans' caregivers, are eligible 
to receive benefits and services that are available for General 
Caregivers, pursuant to Sec. Sec.  71.30 and 71.40(a). General 
Caregiver benefits include: instruction, preparation, training, and 
technical support under Sec.  71.40(a)(1); counseling and other 
services described under Sec.  71.50; and respite care for a qualified 
veteran under Sec.  71.40(a)(4). No application or clinical evaluation 
is required to obtain General Caregiver benefits. See 38 CFR 71.30(c).
Causal Link Between a Serious Injury and the Need for Personal Care 
Services
    Family Caregiver eligibility is predicated, under Sec.  71.20(c), 
on the veteran or servicemember having a ``serious injury [incurred or 
aggravated in the line of duty that] renders the individual in need of 
personal care

[[Page 1359]]

services.'' The definition of ``serious injury'' in Sec.  71.15 
similarly requires that the injury render the individual in need of 
personal care services. Commenters argued that this causal link is too 
restrictive because they assert that it excludes from eligibility an 
individual who needs personal care services because of an in-service 
injury that worsens after separation from service, or because of a 
condition that is secondary to a serious injury. To address these 
comments, we will discuss and clarify the meaning and effect of Sec.  
71.20(c); however, no changes to the rule are required.
    Generally, we clarify that under Sec.  71.20(c) a veteran or 
servicemember could qualify for Family Caregiver benefits if the 
veteran or servicemember incurred or aggravated a serious injury in the 
line of duty, even if the need for a Family Caregiver developed due to 
a worsening of that serious injury after separation from service, as 
long as all other Sec.  71.20 criteria are met. Section 71.20 requires 
that a serious injury ``renders the individual in need of personal care 
services,'' but does not require that the injury must have rendered the 
veteran or servicemember in need of personal care services at the time 
of discharge. Therefore, VA does not and will not apply the rule in 
such a restrictive manner. However, we do not believe the definition of 
``serious injury'' may be expanded to include injuries that are 
secondary to a serious injury incurred or aggravated in the line of 
duty, unless the need for personal care services caused by the 
secondary injury is proximately due to or the result of the serious 
injury incurred or aggravated in the line of duty. In the following 
discussion, we respond to specific examples provided by commenters 
concerning serious injuries incurred or aggravated in the line of duty 
that worsen or create a worsening of a condition after discharge from 
service, which the commenters believed should be considered qualifying 
serious injuries. We additionally respond to specific examples of 
injuries that are secondary to the serious injury incurred or 
aggravated in the line of duty, which commenters also believed should 
be considered qualifying serious injuries.
    Commenters provided as examples variations of a scenario concerning 
an individual who sustained fragment wounds in the line of duty that 
did not create the need for personal care services on or before the 
date that the individual was discharged from active military service. 
After separation from service, however, the individual began to 
experience worsening of a condition, as a result of remaining imbedded 
fragments, that created the need for personal care services.
    In one commenter's scenario, for example, the remaining imbedded 
fragments began to leach toxins inside the individual's body, and those 
toxins then caused a worsening of condition that created the need for 
personal care services. Such an individual would likely meet the 
criteria in Sec.  71.20(c) because the fragment injury was a serious 
injury incurred in the line of duty, and this same serious injury 
created a worsening of the condition to render the individual in need 
of personal care services. As clarified above, this scenario fits 
within the criteria of Sec.  71.20(c) because the need for personal 
care services may have developed post-discharge, but the serious injury 
that created the need for personal care services was still incurred or 
aggravated in the line of duty.
    Another example provided by commenters described a scenario where 
an individual with the same type of fragment injury underwent surgery 
after separation from service to remove remaining imbedded fragments, 
but the effects of the surgery created the need for personal care 
services. This scenario is more complex, because the surgery created a 
secondary injury that lead to the need for personal care services. A 
scenario such as this requires a determination of whether the need for 
personal care services, which was created by the surgery after service, 
was proximately due to or the result of the fragment injury incurred in 
the line of duty. If the surgery was medically necessary because of the 
fragment injury, and the need for personal care services was, 
therefore, proximately due to or the result of the serious injury 
sustained by the fragments, the veteran could meet the Sec.  71.20(c) 
criteria.
    However, if surgery to remove such fragments was not medically 
necessary because of the fragment injury, we do not believe it would be 
as clear that the need for personal care services was proximately due 
to or the result of the fragment injury. A clinical assessment would 
have to be completed to determine whether it was the veteran's or 
servicemember's injury incurred in the line of duty that rendered him 
or her in need of personal care services, or whether the surgery caused 
a separate post-service injury without which the veteran or 
servicemember would not require personal care services. In addition, we 
distinguish the situation where the need for personal care services may 
be the result of a clinical provider's negligence in treating the 
qualifying serious injury. While we do not anticipate many of these 
cases occurring, we make this distinction because in one commenter's 
example a ``mishap'' occurred during surgery to remove imbedded 
fragments, which created the need for personal care services. Congress 
and VA did not design the Program of Comprehensive Assistance for 
Family Caregivers to provide benefits to a Family Caregiver based on a 
post-service injury, caused by a provider's negligence or other reasons 
that are not the direct result of the qualifying serious injury. 
Moreover, if a veteran underwent negligent surgery, either at a VA 
medical facility or from a private medical provider, there are other 
remedies designed to provide compensation to the veteran, such as a 
tort action or an award under 38 U.S.C. 1151 (benefits for disability 
or death that results from VA hospital care, medical or surgical 
treatment or examination).
    One commenter provided a final example of a veteran who lost a leg 
during service, and after separation from service experienced a bad 
fall due to loss of balance. This bad fall resulted in a severe head 
injury, and the effects of the head injury, in turn, created the need 
for personal care services. It is similarly unclear in this example 
whether the need for personal care services was proximately due to or 
the result of the veteran's serious injury incurred in the line of 
duty, the loss of the leg. In this example as well, a clinical 
assessment would have to be completed to determine whether the 
veteran's loss of a leg rendered him or her in need of personal care 
services related to the head injury, or whether the head injury was a 
separate post-service injury without which the veteran would not 
require personal care services. We note that the veteran in this 
example could be eligible for caregiver benefits based on the personal 
care services that may be needed due to the loss of the leg, regardless 
of eligibility determinations concerning the fall and resulting need 
for personal care services due to the head injury.
    We emphasize that addressing the specific examples from commenters 
with regards to the causal link in Sec.  71.20(b)-(c) is intended to 
illustrate our general rationale, and that this discussion does not 
encompass all possible scenarios where a veteran with a qualifying 
serious injury may suffer a worsening of that injury after separation 
from service that, in turn, creates the need for personal care 
services. Nor does this discussion establish a required determination 
for or against a particular individual's eligibility for a Family 
Caregiver based on an injury that is secondary to a qualifying serious 
injury.

[[Page 1360]]

We stress that all individuals are independently assessed by a clinical 
team to determine eligibility for benefits, and reiterate that 
generally a veteran or servicemember could qualify for Family Caregiver 
benefits if the veteran or servicemember incurred or aggravated a 
serious injury in the line of duty, even if the need for a Family 
Caregiver developed after separation from service, as long as all other 
Sec.  71.20 criteria are met.
Inclusion of the Term ``Illness'' in the Definition of ``Serious 
Injury''
    Under Sec.  71.15, a serious injury is defined as ``any injury, 
including traumatic brain injury, psychological trauma, or other mental 
disorder, incurred or aggravated in the line of duty in the active 
military, naval, or air service on or after September 11, 2001, that 
renders the veteran or servicemember in need of personal care 
services.'' Multiple commenters asserted that VA's definition of 
``serious injury'' should be expanded to refer to and include the term 
``illness'' (or variations of such term) for multiple reasons. We do 
not make any changes to refer to or include the term ``illness,'' as 
explained below.
    First, commenters asserted that Congress intended ``illness'' to be 
considered as a qualifying criterion. However, the definition of 
``serious injury'' is a virtually verbatim recitation of section 
1720G(a)(2)(B) and the requirement in section 1720G(a)(2)(C) that the 
individual be ``in need of personal care services.'' Because section 
1720G does not define the term ``serious injury'' to include illness, 
and the term ``illness'' does not appear elsewhere in title I of the 
Caregivers Act, we do not expand our definition of serious injury to 
include ``illness.''
    Commenters provided examples of legislative history that they 
believe supports the assertion that Congress intended that ``illness'' 
should be considered in relation to eligibility for Family Caregiver 
assistance. We disagree with these interpretations of the legislative 
history. First, commenters correctly stated that the Caregiver 
Assistance and Resource Enhancement Act, H.R. 3155, 111th Congress, 1st 
Session (2009), as reported in the House of Representatives, would have 
established a program to provide specific caregiver benefits for 
certain disabled or ill veterans (certain veterans deemed to have a 
``service-connected disability or illness that is severe''). While H.R. 
3155 was engrossed by the House of Representatives, the bill was never 
considered by the Senate and consequently it failed to pass both houses 
of Congress. Instead, Congress enacted S. 1963, 111th Congress (2009), 
which specifically did not include the term ``illness'' in relation to 
eligibility for caregiver assistance and support services. We do not 
believe that the legislative history of a bill that did not pass must 
be used to inform the text of a bill that actually did pass, 
particularly when the text of both bills differed significantly--in 
particular, on the very point that the commenters wish to prove.
    Multiple commenters cited the Explanatory Statement (joint 
statement) that accompanied the Caregivers Act to indicate that 
Congress intended that ``illness'' be considered in relation to 
eligibility for Family Caregiver assistance. See 156 Cong. Rec. S2566, 
S2567 (2010). Essentially, these commenters asserted that the joint 
statement indicates Congress' intent that the Program of Comprehensive 
Assistance for Family Caregivers should account for ``ill'' as well as 
``injured'' veterans because that statement cited a Center for Naval 
Analyses report that considered the economic impact on caregivers of 
the seriously ill as well as seriously injured veterans. We disagree 
that the mere reference to a report that considered a broader cohort of 
``ill'' individuals necessitates a more expansive interpretation of the 
narrower cohort of ``injured'' individuals actually described in the 
law passed by Congress. Moreover, the joint statement explains that the 
Caregivers Act will limit participation in the Program of Comprehensive 
Assistance for Family Caregivers ``only to `seriously injured or very 
seriously injured' veterans.'' 156 Cong. Rec. S2567. Thus, the joint 
statement clearly expresses Congress' intent, under the Caregivers Act, 
to consider only seriously ``injured'' veterans as eligible for the 
Program of Comprehensive Assistance for Family Caregivers.
    The joint statement explains that the House of Representatives and 
Senate versions of the caregiver program legislation were considered 
prior to enactment of the Caregivers Act. As explained in the joint 
statement, the House version's eligibility criteria accounted for ``OEF 
[Operation Enduring Freedom] or OIF [Operation Iraqi Freedom] veterans 
. . . who have a service-connected disability or illness that is 
severe.'' Id. However, the joint statement goes on to explain that the 
Senate bill's eligibility criteria, which do not account for veterans 
with a serious illness, will be reflected in the Caregivers Act. Id. 
``[W]here the language under question was rejected by the legislature 
and thus not contained in the statute it provides an indication that 
the legislature did not want the issue considered.'' 2A Norman J. 
Singer, Sutherland Statutory Construction, section 48:04 (6th ed. 
2000). Because it is clearly the Senate bill's eligibility criteria 
that became law, we do not agree with the commenters that VA must 
include ``illness'' in the definition of serious injury.
    Commenters also stated that considering ``illness'' within the 
definition of ``serious injury'' is necessary to ensure consistency 
with other Federal government programs for recovering veterans and 
servicemembers which contemplate ``illness'' as a basis for 
eligibility. Examples of such programs, as provided by commenters, 
included the program of monetary compensation for certain 
servicemembers provided by DoD under 37 U.S.C. 439, and the Federal 
Recovery Coordination Program (FRCP). We make no changes based on these 
comments, as we do not believe that these other programs are 
comparable, nor are they intended to be comparable, to the Program of 
Comprehensive Assistance for Family Caregivers.
    The monetary compensation offered by DoD under 37 U.S.C. 439, 
unlike the Program of Comprehensive Assistance for Family Caregivers, 
does not provide mental health services, healthcare, or a monthly 
stipend for eligible Family Caregivers. Instead, DoD pays ``monthly 
special compensation'' directly to qualifying servicemembers. Moreover, 
DoD's eligibility criteria are more stringent than the criteria in the 
Program of Comprehensive Assistance for Family Caregivers. An eligible 
individual under section 439 must have a ``catastrophic'' injury or 
illness, be certified by a licensed physician to be in need of 
assistance from another person, and in the absence of such assistance 
must require ``hospitalization, nursing home care, or other residential 
institutional care.'' 37 U.S.C. 439(b).
    Similarly, the FRCP functions very differently than the Program of 
Comprehensive Assistance for Family Caregivers. The FRCP provides 
oversight and coordination of clinical and non-clinical care for 
eligible severely wounded, ill, or injured servicemembers and veterans 
through recovery, rehabilitation, and reintegration into their home 
community, while Family Caregiver benefits are intended to provide 
support and assistance to designated and approved Family Caregivers to 
enhance the health and well-being of eligible veterans participating in 
the Program of

[[Page 1361]]

Comprehensive Assistance for Family Caregivers.
    Based on the differences between the Program of Comprehensive 
Assistance for Family Caregivers and the programs discussed by the 
commenters, we do not agree that the rule should be amended to match or 
bridge perceived gaps with other Federal government programs.
    Multiple commenters asserted that historical remarks in news 
releases quote the Secretary of Veterans Affairs (Secretary) as being 
in support of including ``illness'' within the definition of ``serious 
injury.'' Specifically, commenters submitted that subsequent to the 
passing of the Caregivers Act, the Secretary stated in a press release 
dated February 9, 2011, that ``[c]aregivers make tremendous sacrifices 
every day to help Veterans of all eras who served this nation. . . . 
They are critical partners with VA in the recovery and comfort of ill 
and injured Veterans, and they deserve our continued training, support 
and gratitude.'' In this statement, the Secretary was referring to 
caregivers for all era veterans, including those pre-9/11 veterans who 
can receive General Caregiver benefits under Sec.  71.30, which covers 
any ``veteran who is enrolled in the VA health care system and needs 
personal care services because the veteran . . . [i]s unable to perform 
an activity of daily living; or . . . [n]eeds supervision or protection 
based on . . . impairment or injury.'' The effects of illness may be 
considered in determining eligibility for General Caregivers benefits 
because the ``serious injury'' requirement is not applicable to Sec.  
71.30.
    One commenter asserted that section 1720G allows for flexibility to 
include the term ``illness'' in our definition of serious injury, 
because section 1720G(a)(2)(C)(ii) includes the phrase ``or other 
impairment.'' See 38 U.S.C. 1720G(a)(2)(C)(i)-(iii) (which premises 
eligibility on the individual being in need of personal care services 
because the individual is unable ``to perform one or more activities of 
daily living;'' has a ``need for supervision or protection based on 
symptoms or residuals of neurological or other impairment or injury;'' 
or ``such other matters as the Secretary considers appropriate.''). 
Although the criteria in section 1720G(a)(2)(C)(i)-(iii), to include 
the phrase ``or other impairment,'' all explain the circumstances for 
which personal care services may be needed, these criteria do not 
define the underlying ``serious injury'' term or the separate 
eligibility requirement that the individual have a serious injury. We 
therefore disagree that section 1720G(a)(2)(C)(ii) permits the 
discretionary inclusion of ``illness'' in the rule.
    Lastly, one commenter argued that VA generally does not 
differentiate between injury and illness as a basis of eligibility for 
VA benefits, and that the Program of Comprehensive Assistance for 
Family Caregivers should similarly not make such a distinction. In 
support of this contention, the commenter cited multiple VA regulations 
primarily related to disability compensation, where eligibility for 
benefits is based on both injury and a disease process or illness, and 
further stated that ``[t]he caregiver provisions should be interpreted 
in harmony with the general principle established in the statutory 
scheme, that veterans with a qualifying disability are entitled to 
benefits whether such disability resulted from an injury or an 
illness.'' We do not agree with the commenter that the statutory scheme 
that supports these other VA regulations may be used to interpret the 
eligibility criteria for the Program of Comprehensive Assistance for 
Family Caregivers for several reasons.
    First, the interpretive relevance of any seemingly related statute 
is outweighed when the subject statute's meaning is clear: ``[I]n line 
with the basic rule on the use of extrinsic aids, other statutes may 
not be resorted to if the statute is clear and unambiguous.'' 2B Norman 
J. Singer, Sutherland Statutory Construction, section 51:01 (6th ed. 
2000). As stated previously, section 1720G is clear that ``illness'' is 
not considered in relation to eligibility under the Program of 
Comprehensive Assistance for Family Caregivers.
    Second, the stipend provided to a caregiver under section 1720G is 
not disability compensation, and is not related to VA's disability 
compensation regulations. The stipend is paid directly to the Family 
Caregiver and not the veteran, and is calculated based on the degree of 
assistance required by the veteran, and not the veteran's rated level 
of disability. Disability compensation schedules are designed to 
measure the effect of disease or injury on a veteran's earning 
capacity, and not the level of personal care services needed by a 
veteran.
    Finally, Congress could easily have linked the Family Caregiver 
stipend to VA disability compensation; however, section 1720G mandates 
that VA create a program that is distinct from virtually all other VA 
benefits programs. In turn, the regulations implementing the stipend 
payments under the Program of Comprehensive Assistance for Family 
Caregivers were specifically established to meet the goals of the 
statute governing the Program of Comprehensive Assistance for Family 
Caregivers. As such, the Family Caregiver stipend is designed to enable 
caregivers to provide certain home-based care--it is not designed to 
supplement, replace, or be dependent in any manner on the level of 
disability compensation received by the veteran.
Use of Global Assessment of Functioning (GAF) Score as an Eligibility 
Criterion
    Multiple commenters argued for the revision or removal of Sec.  
71.20(c)(3), which authorizes eligibility for Family Caregiver benefits 
on the basis that an individual requires personal care services because 
of a ``[p]sychological trauma or a mental disorder that has been scored 
. . . with Global Assessment of Functioning (GAF) test scores of 30 or 
less, continuously during the 90-day period immediately preceding the 
date on which VA initially received the caregiver application.'' 
Commenters interpreted this GAF criterion to be the sole means of 
eligibility for an individual with a psychological trauma or mental 
health disorder, and subsequently asserted that such a criterion was 
arbitrary and too restrictive. We do not make any changes to the rule 
based on these comments; however, we clarify that the GAF score 
criterion in Sec.  71.20(c)(3) is not the sole means to establish 
eligibility based on a psychological trauma or mental health disorder. 
We do not intend, and the rule does not state, that any psychological 
trauma or mental disorder must have an accompanying GAF score of 30 or 
less in order to qualify as a serious injury. In providing the bases 
upon which an individual may require personal care services to 
establish eligibility, the rule states in Sec.  71.20(c) that ``any one 
of the following clinical criteria'' may suffice, to include a GAF 
score of 30 or below in Sec.  71.20(c)(3). The GAF score criterion is 
not a sole eligibility basis for individuals with mental disorders, but 
rather an irrebuttable basis for eligibility under Sec.  71.20(c) when 
an individual presents with a psychological trauma or mental disorder 
that meets the GAF score requirement. A veteran or servicemember with a 
mental health disorder that does not meet the requirements of Sec.  
71.20(c)(3) could still qualify under Sec.  71.20(b)-(c) if that mental 
disorder is a serious injury that renders the individual in need of 
personal care services because of any of the other eligibility criteria 
in Sec.  71.20(c)(1), (c)(2), or (c)(4). For instance, if an individual 
with a psychological trauma or mental disorder requires supervision or 
protection due

[[Page 1362]]

to such trauma or disorder, an assessment of their application may show 
they are eligible under Sec.  71.20(c)(2), and that same individual 
will not then be required to submit a GAF score due to their injury 
being related to mental health. Rather than being an undue restriction, 
we consider the GAF score criterion in Sec.  71.20(c)(3) in fact to be 
an expansion of the statutory bases of eligibility, permissible under 
38 U.S.C. 1720G(a)(2)(C)(iii).
    Commenters stated that the requirement that the GAF score be 
continuous for 90 days would necessitate undue repeated testing during 
the 90-day period, and that the 90-day requirement was too lengthy and 
would result in an unreasonable delay of benefits. We do not make any 
changes to the rule based on these comments, because VA does not intend 
to continuously test veterans during the 90-day period in an effort to 
rebut a GAF score of 30 or less. Additionally, 90 days is a reasonable 
and necessary timeframe to determine if an impairment is non-episodic 
to necessitate Family Caregiver benefits. As the rule states, if there 
is a GAF score of 30 or less at the beginning of the 90-day period as 
well as a score of 30 or less at the end of that period, we will apply 
Sec.  71.20(c)(3) unless there is an intervening GAF score of more than 
30 for veterans or servicemembers seeking to qualify for the program on 
this basis. Typically, GAF tests are administered and GAF scores are 
recorded at appropriate clinical intervals during the provision of 
care. Two GAF scores below 30 that are 90 days apart provides a sound 
basis to clinically determine that the servicemember's or veteran's 
injury and need for a Family Caregiver is chronic and not episodic in 
nature, or that the injury is not responsive to treatment such that the 
assistance of a Family Caregiver is required. How many other GAF scores 
might be present in the medical record to be considered intervening 
could depend on multiple individual factors. However, GAF tests will 
not be initiated by VA to develop evidence to rebut the servicemember's 
or veteran's need for a Family Caregiver.
    We further disagree with some commenters' statements that a GAF 
score range of 30 or less, if used as an eligibility criterion in the 
rule, is too restrictive. Commenters argued that the range should be 
higher, including commenters who advocated for scores of up to 50. One 
commenter noted that a score range of 31-40 should be used because it 
indicates ``some impairment in reality testing or communication,'' or 
also indicates ``major impairment in several areas, such as work or 
school, family relations, judgment, thinking or mood.'' However, we 
reiterate from the interim final rule that we find the description for 
a GAF score of 30 and below to be the most appropriate description to 
support the presumption that a Family Caregiver is needed, when a GAF 
score is used as the qualifier. The following description from the 
Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition 
(DSM-IV) of GAF scores in the 21-30 range is the minimum impairment 
standard that VA will require to consider a mental health diagnosis a 
serious injury: ``Behavior is considerably influenced by delusions or 
hallucinations OR serious impairment, in communication or judgment 
(e.g., sometimes incoherent, acts grossly inappropriately, suicidal 
preoccupation) OR inability to function in almost all areas (e.g., 
stays in bed all day, no job, home, or friends).'' At this assessed 
level of impairment, the supervision or protection of a caregiver is 
essential to the individual.
Family Caregiver Eligibility Requirements (Other Than the GAF Score) 
Are Not More Restrictive Than Permitted by Law
    One commenter stated that certain eligibility criteria in Sec.  
71.20(a)-(g) are more restrictive than permitted by a plain reading of 
section 1720G. This commenter argued that VA has created additional, 
unlawful restrictions in the rule that will result in fewer veterans in 
need being deemed eligible for benefits and services. We do not make 
any changes based on this comment. All of the eligibility requirements 
in Sec.  71.20(a)-(g) are either restatements of explicit criteria in 
section 1720G, are additional lawful criteria that are specifically 
authorized by discretionary language in section 1720G, or are supported 
by the clear intent of the law. The following discussion directly 
compares all provisions of the eligibility criteria in Sec.  71.20(a)-
(g) to the express provisions and intent of section 1720G.
    The requirements in Sec.  71.20(a)-(b) restate the requirements in 
section 1720G(a)(2)(A)-(B) that a qualifying individual must be a 
veteran, or servicemember undergoing medical discharge, who has a 
serious injury incurred or aggravated in the line of duty on or after 
September 11, 2001.
    The requirements in Sec.  71.20(c) create additional criteria which 
are not expressly stated in section 1720G, but that are necessary and 
consistent with the overall purpose of the law. Section 71.20(c) 
establishes that there must be a connection between the qualifying 
serious injury and the individual's need for personal care services, 
and that a minimum of six continuous months of care is required. As we 
stated in the interim final rule, we believe that it is reasonable to 
interpret section 1720G, which premises eligibility upon a serious 
injury incurred or aggravated in the line of duty, to require that the 
serious injury form the basis for the individual's need for a Family 
Caregiver. It would not have been reasonable for Congress to have 
authorized VA to provide Family Caregiver services to veterans and 
servicemembers with serious injuries but not to have also required that 
the need for such services be specifically linked with the serious 
injuries. We also interpret section 1720G to provide Family Caregiver 
support and assistance for the benefit of individuals with long-term 
disabilities, and not episodic flare ups that temporarily establish the 
need for a Family Caregiver; this is the basis for the required six-
month period. We reiterate from the interim final rule that this 
requirement meets the intent of the statute to benefit persons with 
longer term care needs. The law contemplates training, payment of 
compensation, and ongoing monitoring of veterans receiving Family 
Caregiver services in their homes, all of which support a framework 
that will benefit those with longer-term care needs.
    The requirements in Sec.  71.20(c)(1)-(2) restate the criteria in 
section 1720G(a)(2)(C)(i)-(ii), that the qualifying individual be in 
need of personal care services because of an inability to perform an 
activity of daily living, or due to the individual needing supervision 
or protection based on symptoms or residuals of neurological or other 
impairment or injury. The requirements in Sec.  71.20(c)(3)-(4) are 
discretionary eligibility criteria expressly permitted by section 
1720G(a)(2)(C)(iii), and allow a veteran or servicemember to be 
considered in need of personal care services through two additional 
means: a qualifying Global Assessment of Functioning score of 30 or 
less; or if the individual is service-connected for a qualifying 
serious injury, is rated as 100 percent disabled for that injury, and 
has been awarded special monthly compensation that includes an aid and 
attendance allowance.
    A veteran or servicemember is not required to meet all requirements 
under Sec.  71.20(c)(1)-(4). Paragraph (c) specifies that an individual 
may be considered to be in need of personal care services ``based on 
any one of the following clinical criteria.'' 38 CFR 71.20(c). We 
further interpret that the law's use of the word ``or'' in section 
1720G(a)(2)(C)

[[Page 1363]]

allows VA to choose, as needed, between the criteria in section 
1720G(a)(2)(C)(i)-(iii) in determining a veteran or servicemember's 
eligibility, to include choosing them all. VA included all explicit 
criteria under section 1720G(a)(2)(C)(i)-(ii) in Sec.  71.20(c)(1)-(2), 
and prescribed additional discretionary criteria in Sec.  71.20(c)(3)-
(4) as permitted by section 1720G(a)(2)(C)(iii).
    The requirement in Sec.  71.20(d) indicates that an individual may 
not be considered eligible unless a clinical determination is made that 
it is in the individual's best interest to participate in the program. 
One commenter suggested that this requirement was unreasonable, as VA's 
``in the best interest'' determination is not analogous to the 
criterion in section 1720G(a)(1)(B), which states that VA ``shall only 
provide support under the [Program of Comprehensive Assistance for 
Family Caregivers] to a family caregiver of an eligible veteran if the 
Secretary determines it is in the best interest of the eligible veteran 
to do so.'' Essentially, the commenter stated that VA incorrectly used 
the ``in the best interest'' criterion for the purposes of determining 
eligibility of the veteran themselves for benefits, instead of for the 
purposes of determining whether to provide benefits to a Family 
Caregiver. We recognize that the language in Sec.  71.20(d) regarding 
the ``in the best interest'' determination is phrased differently than 
in section 1720G(a)(1)(B), but this difference is not contrary to 
section 1720G(a)(1)(B), and does not create more restrictive 
eligibility criteria than permitted by law. Section 1720G does not 
confer benefits to a Family Caregiver independent of a qualifying 
veteran or servicemember, nor are benefits available to a qualifying 
veteran or servicemember under section 1720G, without the designation 
of a Family Caregiver. Therefore, section 1720G(a)(1)(B) and Sec.  
71.20(d) both contemplate the same determination: whether it is in the 
best interest of the veteran or servicemember to receive care and 
services under the Program of Comprehensive Assistance for Family 
Caregivers, and therefore whether the Family Caregiver receives support 
from VA to provide such care and services. It is essential then to 
consider whether it is in the best interest of the veteran or 
servicemember to participate in the Program of Comprehensive Assistance 
for Family Caregivers generally, as part of the initial qualification 
criteria in Sec.  71.20(d). Our use of the phrasing ``in the best 
interest of the individual to participate in the program'' in Sec.  
71.20(d) is not a more restrictive interpretation than permitted by 
law, because a determination that a veteran's or servicemember's 
caregiver should not receive benefits under section 1720G(a)(1)(B) is 
functionally the same as a determination that a veteran or 
servicemember may not participate in the program under Sec.  71.20(d). 
The text of Sec.  71.20(d) maintains the premise under section 
1720G(a)(1)(B) that the determination be based on ``the best interest'' 
of the individual, and merely rephrases to clarify that benefits are 
provided to Family Caregivers only when it is in the best interest of 
the individual to participate in the Program of Comprehensive 
Assistance for Family Caregivers.
    A related argument from the commenter contended further that our 
definition of ``[i]n the best interest'' in Sec.  71.15 creates a 
higher standard than a stated goal of the Program of Comprehensive 
Assistance for Family Caregivers, in that this definition relies upon a 
determination that ``participation in the program significantly 
enhances the eligible veteran's ability to live safely in a home 
setting.'' 38 CFR 71.15. The commenter contrasts this ``significantly 
enhances'' criterion with one of the goals of the Program of 
Comprehensive Assistance for Family Caregivers as discussed in the 
supplementary information in the interim final rule, which is ``to 
ensure that the veteran is able to live in a residential setting 
without unnecessary deterioration of his or her disability, and safe 
from potential abuse or neglect.'' 76 FR 26148, May 5, 2011. In 
addition to asserting that the ``significantly enhances'' criterion in 
Sec.  71.15 is a higher standard than expressed in the supplementary 
information section of the interim final rule, the commenter stated 
that the ``significantly enhances'' criterion is not defined and does 
not have an accompanying scale of measurement to express when it is 
met. Ultimately, the commenter urged VA to revise the rule to include a 
scale of measurement, or to remove the ``significantly enhances'' 
criterion altogether. We do not make any changes based on this comment, 
as the ``significantly enhances'' criterion in the definition of ``[i]n 
the best interest'' in Sec.  71.15 does not create an unreasonable 
standard beyond a goal of the Program of Comprehensive Assistance for 
Family Caregivers. As stated in the rule, VA concludes that 
determinations of ``in the best interest'' must be clinical 
determinations, guided by VA health professionals' judgment as to what 
care will best support the health and well-being of the veteran or 
servicemember--including that which offers the best opportunity for 
recovery and rehabilitation, whenever possible. Consequently, such 
determinations will include clinical considerations of whether 
assistance from a Family Caregiver ``significantly enhances'' the 
individual's ability to live safely in a home setting, where we intend 
the ``significantly enhances'' criterion to be a threshold 
determination that assistance from a caregiver is actually necessary to 
allow a veteran or servicemember to live safely and receive care in a 
non-institutional home environment. This ``significantly enhances'' 
criteria allows health professionals, utilizing clinical judgment, to 
determine that Family Caregiver assistance is needed for an individual 
to live safely in a home setting. We do not interpret section 1720G to 
permit caregiver benefits and services for individuals who, though they 
may benefit from such assistance, can perform tasks safely and 
independently 100 percent of the time without a caregiver, for instance 
by using assistive devices or adaptive equipment. The ``significantly 
enhances'' phrase in the definition of ``[i]n the best interest'' 
therefore does not serve to unduly restrict the provision of Family 
Caregiver benefits, but rather ensures that these benefits are provided 
to only those veterans and servicemembers who actually require them to 
safely live and receive care in the home.
    The requirement in Sec.  71.20(e) bars authorization of a Family 
Caregiver if the services that would be provided would be 
simultaneously and regularly provided by or through another individual 
or entity. Our intent is to ensure that the Family Caregiver is not 
depending on VA or another agency or individual to provide the personal 
care services that the Family Caregiver is expected to provide. This 
requirement is not more restrictive than permitted by law, because 
Congress clearly intended to support Family Caregivers for the personal 
care services that Family Caregivers themselves provide to the veteran 
or servicemember.
    The requirements in Sec.  71.20(f)-(g) state that the individual 
must agree to ``receive care at home'' and ``receive ongoing care from 
a primary care team'' after VA designates a Family Caregiver. The 
consent required by paragraphs (f) and (g) as a prerequisite to an 
award of Family Caregiver benefits enables VA to perform statutorily 
required monitoring and documentation functions. Under section 
1720G(a)(9)(A), VA must

[[Page 1364]]

``monitor the well-being of each eligible veteran receiving personal 
care services'' from a VA-designated caregiver under the Program of 
Comprehensive Assistance for Family Caregivers. We are also required to 
document findings ``pertinent to the appropriate delivery of personal 
care services to an eligible veteran under the program,'' and ensure 
appropriate follow up. See 38 U.S.C. 1720G(a)(9)(B) and (C). In 
addition to meeting statutory requirements, the consent requirements in 
Sec.  71.20(f)-(g) are not unreasonable, given that section 1720G 
generally is premised upon supporting caregivers in the provision of 
assistance to individuals in non-institutional home settings, and those 
individuals must then consent to receive such assistance. Neither of 
the requirements in Sec.  71.20(f)-(g) impose more restrictive criteria 
than permitted by section 1720G.
    As stated above, all of the rule's eligibility requirements in 
Sec.  71.20(a)-(g) that are not restatements of law from section 
1720G(a)(1)-(2) are either discretionary criteria as permitted by law, 
or are required for VA to implement other provisions of section 1720G. 
Section 71.20 merely places all mandatory and permissible eligibility 
requirements from section 1720G(a) in one place to make them apparent 
at the outset. None of the requirements in Sec.  71.20(a)-(g) are more 
restrictive than contemplated by section 1720G(a), and therefore Sec.  
71.20(a)-(g) does not result in fewer veterans in need being deemed 
eligible for benefits and services than contemplated by law.
Servicemember Eligibility
    Section 1720G indicates that servicemembers are eligible for 
benefits under the Program of Comprehensive Assistance for Family 
Caregivers if they are undergoing medical discharge from the Armed 
Forces: ``For purposes of this subsection, an eligible veteran is any 
individual who . . . is a veteran or member of the Armed Forces 
undergoing medical discharge from the Armed Forces.'' 38 U.S.C. 
1720G(a)(2)(A). The rule in turn defines ``undergoing medical 
discharge'' by requiring ``that the servicemember has been found unfit 
for duty due to a medical condition by their Service's Physical 
Evaluation Board, and a date of medical discharge has been issued.'' 38 
CFR 71.15. We received several comments related to the starting time of 
VA Family Caregiver benefits, or when a servicemember may be considered 
eligible for and then apply for benefits. Commenters asserted that a 
servicemember should be eligible to receive Family Caregiver benefits 
before receiving a medical discharge date, and specifically stated that 
a servicemember should be considered eligible at the beginning of the 
medical evaluation process within DoD. These commenters stated that 
allowing a servicemember to be considered eligible at an earlier date 
would ensure that training opportunities would be available to 
caregivers of servicemembers throughout the treatment of the 
servicemember by DoD, which the commenters assert is necessary to 
improve overall care provided to the servicemember. We make some 
changes to the rule based on these comments, as explained below.
    The medical evaluation process that is used by DoD to determine 
whether a servicemember remains medically fit for active duty can take 
several months or more, and some servicemembers referred and evaluated 
will in fact return to active duty or be offered an opportunity to 
train for another military occupational specialty. Section 1720G, 
however, suggests by use of the phrase ``eligible veteran,'' that 
medical discharge and then transition to veteran status must be certain 
in order for a service member to be eligible for such benefits: ``For 
purposes of this subsection, an eligible veteran is any individual who 
. . . is a veteran or member of the Armed Forces undergoing medical 
discharge from the Armed Forces.'' 38 U.S.C. 1720G(a)(2)(A). We 
interpret the phrase ``undergoing medical discharge'' to require then 
that the individual be engaged in a process of actual separation from 
active duty, rather than a process of determining whether to separate 
from active duty. In order to effectuate this statutory requirement, we 
believe it is appropriate to ensure by regulation that the individual 
is far enough along in the medical discharge process that there will 
not be extended overlap between the individual's period of service and 
the time that they achieve veteran status, as well as to attempt to 
ensure that the discharge is essentially inevitable. Therefore, we make 
no change to our definition of ``[u]ndergoing medical discharge.''
    In addition to the reasons stated above, we do not believe Congress 
intended to authorize prolonged VA Family Caregiver benefits for active 
duty servicemembers, particularly because it has authorized DoD to 
provide monthly special compensation, under 37 U.S.C. 439, to active 
duty servicemembers who, due to a catastrophic injury or illness 
incurred or aggravated in the line of duty, require a caregiver in 
order to avoid institutional care. One commenter expressed, however, 
that the special compensation that DoD may pay to these same 
servicemembers under section 439 is not sufficient to ensure that 
actual caregiver training is provided. As noted above, individuals 
receiving section 439 DoD compensation may eventually return to active 
duty. Although VA can and will provide Family Caregiver training for 
servicemembers who have been issued a medical discharge date (and meet 
other requirements to qualify for the Program of Comprehensive 
Assistance for Family Caregivers), for the reasons described above we 
do not believe that section 1720G authorizes VA to provide Family 
Caregiver training before the servicemember is assigned such a date.
    However, we understand the commenters' stated concerns for those 
servicemembers who may be undergoing a lengthy discharge process due to 
multiple hospitalizations and extended recovery times, and their 
caregivers who would benefit from receiving VA Family Caregiver 
training in addition to the servicemember receiving the monetary 
benefit provided by DoD pursuant to 37 U.S.C. 439. In the interest of 
providing compassionate, patient-centric care, we note that VA has 
initiated discussions with DoD to design a caregiver training and 
education program that would be substantially similar to VA's program. 
Although such a program is not currently operationalized, DoD may 
utilize such a program in the future to train caregivers of active duty 
servicemembers.
    Under the interim final rule, Sec.  71.25(d) defined caregiver 
training as ``a program of education and training designed by and 
provided through VA.'' Before an individual is approved as a Family 
Caregiver, Sec.  71.25(c)(2) requires that the individual complete 
caregiver training as defined under Sec.  71.25(d). Based on comments 
concerning the need to allow caregivers to receive training while their 
veterans are still active duty servicemembers, and provided that DoD 
may adopt a training program for caregivers in the future, we amend 
Sec.  71.25(d) to remove the requirement that caregiver training be 
``provided through'' VA, so that Sec.  71.25(d) will define Family 
Caregiver training as ``a program of education and training designed 
and approved by VA.'' Consequently, VA will approve and accept 
participation by a caregiver of an active duty servicemember in DoD 
caregiver training that is modeled after VA's caregiver training to 
satisfy the training requirements under Sec.  71.25(c)(2). Recognition 
of such training that may be offered by DoD in

[[Page 1365]]

the future, that is substantially similar to that offered by VA, will 
prevent Family Caregivers from having to undertake the same training 
more than once, unless necessary.
    We also amend Sec.  71.25(e) to require that VA visit the veteran 
at home and assess the Family Caregiver's competence to provide 
personal care services within 10 business days after VA certifies 
completion of training, rather than within 10 business days of training 
completion. As noted above, the training may be provided by DoD to 
caregivers of active duty servicemembers who are not at that time 
eligible for Family Caregiver benefits; therefore, we cannot visit the 
home within 10 days after completion of such training. Thus, Sec.  
71.25(e) now provides that a home-care assessment must be conducted by 
VA not later than 10 business days after VA certifies completion of 
Family Caregiver training, versus not later than 10 business days after 
completion of the training. In practice, VA will certify that previous 
DoD training has been completed when the caregiver presents 
documentation showing completion to VA, after a joint application has 
been submitted and all eligibility and approval criteria are otherwise 
met under Sec. Sec.  71.20-71.25. This amendment of Sec.  71.25(e) will 
not have any adverse effect on caregivers of eligible veterans who 
complete Family Caregiver training provided through VA, as VA will 
continue to schedule the home visit within 10 days of training 
completion.
Procedures for Clinical Ratings
    One commenter stated that the rule failed to clearly articulate how 
VA makes clinical determinations. Specifically, the commenter suggested 
that the phrase ``clinical rating'' be defined to describe procedures 
that would ensure that clinical determinations are made by an 
interdisciplinary team (and not one individual), and that would ensure 
that the perspectives of the caregiver are considered when determining 
need for personal care services. The commenter suggested that the 
caregiver be interviewed to capture the caregiver's assessment of the 
veteran's or servicemember's need for personal care services, as well 
as to assess the level of distress potentially experienced by the 
caregiver. The commenter lastly urged that eligibility evaluations 
concerning a need for ``supervision or protection'' specifically should 
account for how the individual veteran or servicemember functions at 
home and in his or her community to properly evaluate the individual's 
need for protection or supervision.
    The rule states in Sec.  71.25(f) that ``if the eligible veteran 
and at least one applicant meet the requirements of this part, VA will 
approve the application and designate Primary and/or Secondary Family 
Caregivers, as appropriate. This approval and designation will be a 
clinical determination authorized by the eligible veteran's primary 
care team.'' We intend that the clinical determinations made under 
Sec.  71.20 regarding the veteran's or servicemember's initial 
eligibility as well be authorized by a primary care team versus a 
single individual, and agree with the commenter that Sec.  71.20 be so 
amended. Section 71.20(c) will now similarly states that ``such serious 
injury renders the individual in need of personal care services for a 
minimum of 6 continuous months (based on a clinical determination 
authorized by the individual's primary care team), based on any one of 
the following clinical criteria.'' Section 71.20(d) will now state that 
``a clinical determination (authorized by the individual's primary care 
team) has been made that it is in the best interest of the individual 
to participate in the program.'' We believe Sec.  71.20(c) otherwise 
clearly specifies the criteria by which personal care services are 
determined to be needed.
    We additionally make one change to the definition of ``Primary care 
team'' as that term is defined in Sec.  71.15 to indicate that we are 
referring to a group of medical professionals who care for a patient 
and who are selected ``by VA.'' We do not believe this is a substantive 
change, as the rule clearly states that VA is responsible for 
conducting all clinical assessments and determinations in the process 
of assessing and approving Family Caregivers. See Sec.  71.25(a)(2), 
(b)(3), (c), (c)(1), (e), and (f).
    Section 71.25(c) further mandates that during the application 
process, the primary care team will screen the family member to ensure 
the family member meets criteria to complete caregiver education and 
training, and thereby is deemed able to provide caregiver assistance. 
We believe that this caregiver screening is consistent with law, and we 
do not find that an additional, individual interview with the 
caregiver, or required inclusion of the caregiver in the veteran's or 
servicemember's assessment, should be a formal part of the current 
clinical process in determining the level of personal care services 
needed by every veteran or servicemember. However, it is not VA 
practice to bar a caregiver from being present during the veteran's or 
servicemember's assessment. The regulation at Sec.  71.40(c)(4) 
similarly does not restrict the presence of a caregiver during a 
veteran's or servicemember's assessment, nor does it restrict a primary 
care team from considering the input of a caregiver. It is likely then 
that in many cases the caregiver will be present during the clinical 
assessment of the veteran or servicemember and that the primary care 
team will have discussions with that caregiver as needed to assist in 
determining the level of personal care services needed by the veteran 
or servicemember. As to the commenter's request for an assessment of a 
caregiver's level of distress, we recognize that it is important that 
caregivers be adequately trained so as not to experience undue levels 
of distress. In determining whether a particular caregiver should be 
approved and designated, VA will apply the objective criteria in Sec.  
71.25(b) and then assess the prospective caregiver in accordance with 
Sec.  71.25(c). It is at that time that the clinical team will be able 
to determine whether the individual can perform the duties of a Family 
Caregiver and, in making that determination, the clinical team will 
consider ``any relevant information specific to the needs of the 
eligible veteran. . . .'' 38 CFR 71.25(c)(1). Information that a family 
member experiences too much stress to provide personal care services 
would be considered at such time. To the extent that a family member 
may be designated as a Family Caregiver and then, subsequently, find 
the responsibility to be stressful, we note that respite care will be 
available under Sec.  71.40, and revocation of Family Caregiver status 
is available under Sec.  71.45.
    Lastly, we believe that initial eligibility determinations for 
individuals who may require supervision or protection do take into 
account how each individual functions in his or her home and community. 
The current evaluation process captures whether the veteran or 
servicemember is experiencing symptoms that necessitate supervision or 
protection, as those symptoms are described in Sec.  71.15. We do, 
however, make changes to Sec.  71.25(e) to facilitate ease of 
understanding related to home visits, and to clarify that an eligible 
veteran's well-being is independently assessed to determine if any 
additional training is needed for the caregiver to meet the eligible 
veteran's personal care needs. We believe this addresses the 
commenter's concern that VA assess a veteran's or servicemember's 
functionality in his or her home as appropriate. Section 71.25(e) is 
amended to make clear that

[[Page 1366]]

the purpose of the home visit is for the VA clinician or clinical team 
to assess the caregiver's completion of training and competence to 
provide personal care services to the eligible veteran, and to measure 
the eligible veteran's well-being.
    We believe the evaluation process as discussed above appropriately 
describes an interdisciplinary clinical assessment process that 
involves the caregiver, without being overly prescriptive beyond the 
requirements of the law. We make one last non-substantive change to 
Sec.  71.25(c)(1)(i) to clarify that accommodation for language or 
hearing impairment during an initial assessment of the application will 
be made ``to the extent possible and'' as appropriate.
Appeals
    Multiple commenters stated that the rule should address a 
veteran's, servicemember's, or caregiver's right to appeal decisions 
made in connection with the Program of Comprehensive Assistance for 
Family Caregivers. In response, we first note that medical 
determinations are not subject to the jurisdiction of the Board of 
Veterans' Appeals under 38 U.S.C. 7104, or pursuant to our implementing 
regulation, which states that ``medical determinations, such as 
determinations of the need for and appropriateness of specific types of 
medical care and treatment for an individual, are not adjudicative 
matters and are beyond the [Board of Veterans' Appeals'] 
jurisdiction.'' 38 CFR 20.101(b). We additionally note that the 
Caregivers Act expressly states that ``[a] decision by the Secretary 
under [the Program of Comprehensive Assistance for Family Caregivers or 
the Program of General Caregiver Support Services] affecting the 
furnishing of assistance or support shall be considered a medical 
determination.'' 38 U.S.C. 1720G(c)(1). Therefore, all determinations 
that affect the furnishing of assistance or support through the 
programs under 38 U.S.C. 1720G are medical determinations as a matter 
of law, and as such may not be adjudicated in the standard manner as 
claims associated with veterans' benefits. We consequently do not make 
any changes to the rule.
    Commenters asserted nonetheless that not all decisions under these 
regulations are medical in nature, and as such VA must distinguish in 
the rule those determinations that are not medical and that therefore 
may be appealed through the current processes associated with 
adjudicating veterans' benefits claims. Commenters also advocated that 
this rule must further prescribe an appellate mechanism for medical 
determinations. We disagree, and do not make any changes based on these 
comments.
    Though the commenters recognize the clear mandate that all 
decisions regarding benefits under the rule are medical determinations 
and therefore are not appealable to the Board of Veterans' Appeals, 
commenters assert that Congress could not have intended to make 
decisions related specifically to eligibility determinations exempt 
from appellate review. In support of this contention, commenters cited 
38 CFR 20.101(b), which states that ``[t]he [Board of Veterans' 
Appeals'] appellate jurisdiction extends to questions of eligibility.'' 
To illustrate their point, commenters argued that Congress could not 
have intended to deny an administrative right to appeal, for example, a 
nonmedical decision that a veteran's or servicemember's injury was 
incurred in the line of duty, or was incurred on or after September 11, 
2001. The plain language of section 1720G(c)(1) removes any doubt that 
Congress intended to insulate even decisions of eligibility from 
appellate review under the Program of Comprehensive Assistance for 
Family Caregivers, and VA's regulation at Sec.  20.101(b) cannot 
circumvent a statutory requirement. ``If the intent of Congress is 
clear, that is the end of the matter; for the court, as well as the 
agency, must give effect to the unambiguously expressed intent of 
Congress.'' Chevron, U.S.A., Inc. v. Natural Res. Def. Council, Inc., 
467 U.S. 837, 842-43 (1984). Further, Congress is presumed to know what 
laws and regulations exist when it enacts new legislation, and it is 
reasonable to infer that Congress knew that medical determinations were 
not appealable under Sec.  20.101, and subsequently used that precise 
phrase in the statute to limit appeals of decisions in the Program of 
Comprehensive Assistance for Family Caregivers. See California Indus. 
Products, Inc. v. United States, 436 F.3d 1341, 1354 (Fed. Cir. 2006) 
(``These regulations are appropriately considered in the construction 
of [this particular statute] because Congress is presumed to be aware 
of pertinent existing law.'').
    We recognize the seeming incongruence of the statutory mandate; for 
instance, a determination under the Program of Comprehensive Assistance 
for Family Caregivers that a veteran's or servicemember's military 
record did not support eligibility because he or she was discharged 
from active duty before September 11, 2001, is deemed a ``medical 
determination'' because it affects the provision of Family Caregiver 
benefits. However, if a veteran or servicemember believes that his or 
her military records are incorrect, he or she may seek correction of 
those records through his or her service department. If VA errs in 
applying these types of non-discretionary criteria, the error should be 
clear on the face of the evidence presented, or could be rectified with 
the presentation of alternate or corrected evidence. Such decisions 
would not create a situation in which the expertise of the Board of 
Veterans' Appeals at interpreting legal and regulatory provisions would 
be required. Instead, VHA has a clinical appeals process that will be 
sufficient to resolve such conflict. Under the VHA appeals process, 
patients or their representatives have access to a fair and impartial 
review of disputes regarding clinical determinations or services that 
are not resolved at the facility level. This process is intended to 
resolve conflicts about whether an appropriate clinical decision has 
been made, and the process certainly can resolve whether the adverse 
decision was based, for example, on a misreading of a date in a 
military record. Other issues that are being resolved through the VHA 
clinical appeals process include basic eligibility, determination of 
``illness'' or ``injury,'' and the tier level assigned for stipend 
payment. This appeals process does not defy the statutory restriction 
at 38 U.S.C. 1720G(c)(1) against appeals to the Board of Veterans' 
Appeals because it is specifically designed to resolve conflicts based 
upon medical determinations.
    We note, however, that not all benefits provided to caregivers are 
provided under 38 U.S.C. 1720G. Certain benefits afforded to caregivers 
by 38 U.S.C. 1720G are provided through other statutory authorities, 
and decisions regarding those benefits are therefore not made under 38 
U.S.C. 1720G. For example, decisions by the Secretary affecting the 
payment of beneficiary travel (under 38 U.S.C. 111(e)(2) as authorized 
by 38 U.S.C. 1720G(a)(3)(A)(i)(IV)), the provision of CHAMPVA (under 38 
U.S.C. 1781 as authorized by 38 U.S.C. 1720G(a)(3)(A)(ii)(IV)), and 
debt collection and waiver (under 31 U.S.C. 3711 and 38 U.S.C. 5302) 
are examples of matters decided under statutory authorities other than 
38 U.S.C. 1720G. Appeal processes associated with those decisions, 
under applicable statutes and regulations, may be pursued by caregivers 
who disagree with a VA decision made under those authorities. See e.g., 
38 CFR 70.40, 17.276, 1.900-1.970.

[[Page 1367]]

Expansion of ``Activities of Daily Living'' in Stipend Calculation
    Under Sec.  71.40(c)(4), VA calculates the monthly stipend 
available to Primary Family Caregivers based on clinical ratings of 
both the eligible veteran's level of dependence in performing 
activities of daily living (ADLs) listed in the definition of the term 
``[i]nability to perform an activity of daily living'' in Sec.  71.15, 
and his or her ``[n]eed for supervision or protection based on symptoms 
or residuals of neurological or other impairment or injury'' under 
Sec.  71.15. The ADLs designated in Sec.  71.15 are: Dressing; bathing; 
grooming; frequent need of adjustment of special prosthetic or 
orthopedic appliance that, by reason of the particular disability, 
cannot be done without assistance; toileting; feeding oneself; and 
mobility.
    Several commenters sought to include additional activities in the 
list of ADLs in Sec.  71.15, because a Primary Family Caregiver may 
assist with activities that maintain an individual's quality of life 
but that are not listed as ADLs in Sec.  71.15 and, therefore, are not 
accounted for in the stipend calculation. Examples of such activities 
included meal preparation, housework, shopping, transportation, laundry 
services, medication management, and using a telephone or other 
communication device. Multiple commenters referred to these activities 
as ``instrumental activities of daily living'' to distinguish them from 
the self-care ADLs already described in Sec.  71.15. We do not make any 
changes to the rule based on these comments, and do not expand the 
listed ADLs in Sec.  71.15 that are considered in calculating the 
stipend.
    We believe that Congress specifically considered and rejected the 
use of the term ``instrumental activities of daily living'' in the 
Caregivers Act, as made apparent in the joint statement which 
accompanied the law. To reiterate our rationale from earlier in this 
rulemaking, it is clear from the joint statement that the eligibility 
criteria in the Senate bill (S. 1963, 111th Cong. (2009)), and not 
those in the House of Representatives bill (H.R. 3155, 111th Cong. 
(2009)), are generally reflected in the Caregivers Act, including the 
eligibility criteria and language regarding activities of daily living. 
In describing the eligibility criteria in the Senate bill, the joint 
statement states that ``[s]everely injured veterans are defined as 
those who need personal care services because they are unable to 
perform one or more independent activities of daily living.'' 156 Cong. 
Rec. S2567. This is in contrast to the eligibility criteria in the 
House of Representatives bill, which would have accounted for veterans 
``unable to carry out activities (including instrumental activities) of 
daily living.'' Id. The Senate bill's eligibility criteria language 
most closely resembles that which was adopted in the Caregivers Act. 
See 38 U.S.C. 1720G(d)(4)(A) (which defines ``personal care services'' 
to include services that provide assistance with one or more 
``independent activities of daily living''). ``[W]here the language 
under question was rejected by the legislature and thus not contained 
in the statute it provides an indication that the legislature did not 
want the issue considered.'' 2A Norman J. Singer, Sutherland Statutory 
Construction, section 48:04 (6th ed. 2000). Because it is clearly the 
Senate provision and its characterization of ADLs as ``independent'' 
and not ``instrumental'' that became law, we do not agree with the 
commenters that VA must expand the ADL listing in Sec.  71.15 to 
include ``instrumental'' ADLs.
    We clarify that some activities commenters wanted to add to the ADL 
listing in Sec.  71.15 are already specifically considered in Sec.  
71.15, or elsewhere in the rule. An individual who has difficulty with 
``medication management'' for instance, may be eligible if he or she is 
considered under Sec.  71.15 as having ``[d]ifficulty with planning and 
organizing (such as the ability to adhere to medication regimen).'' 
Additionally, the costs involved in traveling to and from and for the 
duration of the eligible veteran's medical examination, treatment, or 
care may be compensable through the beneficiary travel program pursuant 
to Sec.  71.40(b)(6) and section 104 of the Caregivers Act. To consider 
such costs in calculation of the stipend would amount to duplicative 
compensation. However, caregiver services consisting solely of common 
housekeeping activities (housecleaning, laundry, meal preparation, 
shopping, or other chores), as well as assistance with financial 
management and operating communication devices, should not be 
compensable as part of the stipend unless these deficiencies relate to 
a need for supervision or protection or inability to perform ADLs, 
pursuant to the explicit requirements of the Caregivers Act. Section 
1720G(a)(3)(C)(i) states that VA must base the stipend amount on ``the 
amount and degree of personal care services provided,'' and section 
1720G(a)(2)(C)(i)-(iii) predicates the need for personal care services 
on the individual being unable ``to perform one or more activities of 
daily living;'' having a ``need for supervision or protection based on 
symptoms or residuals of neurological or other impairment or injury;'' 
or ``such other matters as the Secretary considers appropriate.'' 
Because the law premises the need for personal care services on 
specific ADL needs or supervision and protection needs, the calculation 
of the stipend amount is based upon the amount and degree of assistance 
an individual requires to perform one or more activities of daily 
living (ADL), or the amount and degree to which the individual is in 
need of supervision or protection based on symptoms or residuals of 
neurological or other impairment or injury. The stipend is calculated, 
therefore, based on the personal care needs of each individual, not 
specific duties as performed by caregivers that are not directly 
related to assistance with ADLs or providing supervision or protection 
in the home. For instance, while housecleaning and shopping may be 
common activities in daily living, completion of these activities by 
the caregiver may not be for the exclusive benefit of the eligible 
veteran, but rather for the benefit of the entire household to 
potentially include the Primary Family Caregiver--these activities are 
not related to the eligible veteran's specific need for ADL assistance 
or need for protection or supervision.
    While we do not amend the rule to add ADLs to Sec.  71.15 as 
suggested by commenters, we do believe changes to Sec.  
71.40(c)(4)(iv)(A)-(C) would clarify the intent of the assessment of an 
eligible veteran's need for personal care services, with relation to 
calculating the monthly stipend for Primary Family Caregivers. Section 
71.40(c)(4)(iv) currently equates the sum of a veteran's ratings under 
Sec.  71.40(c)(4)(iii) with the number of caregiver assistance hours 
the veteran is presumed to need. See 38 CFR 71.40(c)(4)(iv) (explaining 
that the sum of ratings indicates that ``the eligible veteran is 
presumed to require'' a certain number of hours of caregiver assistance 
per week). Because the stipend amount must be based on the amount of 
personal care services needed, we will emphasize that an eligible 
veteran's rating under Sec.  71.40(c)(4)(iii) will be the basis for the 
stipend the Family Caregiver will receive. We therefore amend Sec.  
71.40(c)(4)(iv)(A)-(C) to indicate that the sum of an eligible 
veteran's ratings under Sec.  71.40(c)(4)(iii) will be the basis for 
the stipend payment the Family Caregiver will receive, equivalent to 
the eligible veteran requiring a designated number of hours of 
caregiver assistance. This change in the regulation text does

[[Page 1368]]

not create any substantive change in the calculation of the stipend.
    Multiple commenters asserted that other VA statutory or regulatory 
authority supported the expansion of listed ADLs in Sec.  71.15. One 
commenter asserted that the rule does not consider as eligible those 
veterans or servicemembers with residuals of traumatic brain injury 
(TBI) who are able to perform ADLs as listed in Sec.  71.15, but not 
``instrumental activities of daily living'' (IADLs) as that term is 
used in 38 CFR 4.124a, Schedule of ratings--neurological conditions and 
convulsive disorders. While the commenter cited 38 CFR 4.123, we assume 
that the commenter was referring to Sec.  4.124a and that regulation's 
use of the term IADL to suggest that the rule should be consistent with 
VA's means of rating TBI for purposes of determining disability 
compensation. We disagree for several reasons. First, we reiterate that 
the stipend provided to a caregiver under section 1720G is not 
disability compensation, and is not related to disability compensation. 
The stipend is paid directly to the Primary Family Caregiver and is 
calculated based on the degree of assistance required by the eligible 
veteran. Congress could easily have linked the caregiver stipend to 
disability compensation; however, section 1720G instead mandates that 
VA create a program that is distinct from virtually all other VA 
benefits programs. The caregiver stipend is designed to assist eligible 
veterans by enabling Primary Family Caregivers to provide certain home-
based care. It is not designed to supplement, replace, or be dependent 
on the level of disability compensation received by the veteran. The 
regulations implementing the Program of Comprehensive Assistance for 
Family Caregivers, in particular the criteria for calculating the 
stipend amount, were specifically established to meet the goals of the 
Caregivers Act governing the Program of Comprehensive Assistance for 
Family Caregivers. These regulations are not, and need not be, designed 
to complement the rating schedule in 38 CFR part 4.
    Another commenter stated, ``Section 1115 of title 38 of the United 
States Code provides compensation to the veteran only when the spouse 
cannot perform the duties of a caregiver. This same level of stipend 
should be applied to non-medical care services provided by caregivers 
to service members and veterans.'' The meaning of this comment is 
unclear. First, it is not clear to what ``[t]his same level of 
stipend'' refers. Section 1115 of title 38, United States Code, does 
not provide a stipend; rather, it authorizes additional compensation 
for certain dependents to a veteran entitled to compensation at the 
rates provided under 38 U.S.C. 1114, and whose disability is rated at 
least 30 percent. Nothing in 38 U.S.C. 1115, or in VA's implementing 
regulation at 38 CFR 3.4(b)(2), suggests that a veteran's receipt of 
additional compensation for dependents is based on the veteran's 
dependent spouse being unable to serve as the veteran's caregiver. 
Section 1115 compensation is available to a veteran for a dependent 
spouse, regardless of the spouses' caregiver status, and the payment of 
section 1115 compensation to a veteran for a dependent spouse does not 
equate to VA paying for ``non-medical'' services provided to the 
veteran or to the dependent spouse. Rather, the payment of additional 
compensation for dependents is intended to assist a disabled veteran to 
continue to support certain dependents. Additionally, a veteran's 
receipt of additional compensation under section 1115 is not affected 
by a dependent spouse's receipt of the stipend under Sec.  71.40(c)(4). 
Generally, we reiterate our rationale that the stipend provided to a 
Primary Family Caregiver under Sec.  71.40(c)(4) is not disability 
compensation, and is not related to VA's disability compensation 
authorities, to include section 1115. The stipend is paid directly to 
the Primary Family Caregiver and not the veteran, and is calculated 
based on of the degree of assistance required by the veteran, and not 
the veteran's rated level of disability.
    It is possible that the commenter intended to discuss the 
additional compensation payable based on a veteran's need for aid and 
attendance and a ``higher level of care'' (under 38 U.S.C. 1114(r)(2)), 
which is payable only if personal health care services must be provided 
by, or provided under the supervision of, a licensed provider in the 
veteran's home. 38 U.S.C. 1114(r)(2). Assuming that the commenter was 
referring to payments under section 1114(r)(2), we find the commenter's 
analogy between payments under that section and the stipend payments 
under this rule inapplicable. The duties provided by a Primary Family 
Caregiver are not exclusively personal health care services that must 
be performed by a person who is licensed to provide such services or 
under the regular supervision of a licensed health care professional, 
unlike the services required by a veteran under section 1114(r)(2). All 
assistance that is compensable under the stipend calculation in the 
rule, such as helping the eligible veteran with dressing, eating, 
grooming, using the toilet, etc., requires no special license and only 
a designated level of training as specified in Sec.  71.25(d). Payments 
under section 1114(r)(2) would be even less comparable to stipend 
payments under the rule, in fact, if non-medical IADL services that 
clearly do not require licensure (e.g., laundry, meal preparation) were 
considered in the calculation of the stipend. We additionally clarify 
that participation in the Program of Comprehensive Assistance for 
Family Caregivers would not bar a veteran from receiving aid and 
attendance compensation under section 1114(r), as Sec.  71.20(c)(4) 
makes clear that one of the means of establishing a need for personal 
care services is the veteran having been rated 100 percent disabled for 
a service connected qualifying serious injury, where the individual has 
been awarded special monthly compensation that includes an aid and 
attendance allowance.
    Lastly, one commenter stated that VA should expand the listing of 
ADLs in Sec.  71.15, because VA is not limited by section 
1720G(d)(4)(B) to only consider 38 U.S.C. 1701(6)(E) as its authority 
to define non-institutional extended care under the rule. In turn, as 
asserted by the commenter, VA is not so limited in defining ``personal 
care services'' in Sec.  71.15. We do not make any changes based on 
this comment, as we believe we are so limited by the clear language of 
the law. The rule elaborates upon the statutory definition of 
``personal care services'' set forth in 38 U.S.C. 1720G(d)(4). There, 
personal care services means services that provide the eligible veteran 
with ``[a]ssistance with one or more independent activities of daily 
living [and] . . . [a]ny other non-institutional extended care (as such 
term is used in section 1701(6)(E) of [title 38]).'' Non-institutional 
extended care services are not defined in 38 U.S.C. 1701(6)(E) in a 
manner that delineates the types of non-institutional extended care 
that constitute ``personal care services,'' but rather only authorizes 
the Secretary of VA to provide non-institutional extended care. See 38 
U.S.C. 1701(6)(E) (explaining that the term ``medical services'' 
includes ``[n]oninstitutional extended care services, including 
alternatives to institutional extended care that the Secretary may 
furnish directly, by contract, or through provision of case management 
by another provider or payer.''). VA provides noninstitutional extended 
care services to veterans through VA's medical benefits package,

[[Page 1369]]

which includes but is not limited to ``noninstitutional geriatric 
evaluation, noninstitutional adult day health care, and 
noninstitutional respite care.'' 38 CFR 17.38(a)(1)(xi)(B). The clear 
language of 38 U.S.C. 1720G(d)(4)(B) requires that VA apply the term 
``non-institutional extended care'' according to this established 
framework, ``as such term is used in section 1701(6)(E) of [title 
38].'' 38 U.S.C. 1720G(d)(4)(B). We do not agree, therefore, with the 
commenter's assertions that we may rely on statutory authorities other 
than section 1701(6)(E), and in turn the implementing regulation at 38 
CFR 17.38(a)(1)(xi)(B), to provide non-institutional care under the 
rule or otherwise as support for expanding the definition of ``personal 
care services'' in Sec.  71.15. Moreover, the other authorities the 
commenter suggested we utilize to define non-institutional care and 
thus, personal care services under the rule specifically relate to the 
delivery of home health services, extended care services, and similar 
treatment by an interdisciplinary health team, not the provision of 
personal care services by a Family Caregiver as intended by section 
1720G. See 38 U.S.C. 1710B, 1717, 1720C.
40-Hour Cap on Compensable Personal Care Services
    A commenter contended that the cap of 40 hours of compensable 
caregiver assistance under Sec.  71.40(c)(4)(iv) is insufficient 
because the personal care needs of some eligible veterans may exceed 
that limit. Specifically, this commenter argued that the rationale for 
such a cap should be articulated in the rule, and that the rule must 
allow the caregiver a reasonable opportunity to rebut the presumption 
that a veteran requires no more than 40 hours of assistance a week. We 
do not make any changes based on this comment. As previously stated, 
the stipend is calculated based on the personal care needs of each 
veteran, and may not directly correlate with all of the activities a 
caregiver completes, and subsequently may not directly correlate with 
the actual number of hours that a caregiver spends completing such 
activities.
    Moreover, we believe that it could jeopardize the health and 
welfare of the eligible veteran to require or expect a Primary Family 
Caregiver to work more than 40 hours per week. A significant factor in 
the passage of the Caregivers Act was the amount of work and stress 
that caregiver's experience. The Program of Comprehensive Assistance 
for Family Caregivers includes supplemental home-based care and respite 
care as resources for an eligible veteran who requires more than 40 
hours per week of care. Neither the law, nor sound VA policy, 
contemplates overburdening caregivers by expecting them to provide care 
for more than 40 hours per week.
Hourly Wage Rate
    A commenter stated that setting of the hourly wage rate at the 75th 
percentile of the rate established by the Bureau of Labor Statistics 
(BLS) for a home health aide (varying by geography) is inadequate 
compensation. Specifically, the commenter argued that a wage rate at 
the 90th percentile would more appropriately reflect the degree of 
complex services caregivers provide. As stated by the commenter, ``the 
caregiving needs of many within the population of young severely 
wounded veterans are far more extensive than the kind of routine care 
described by BLS, and often cannot be met by a home health aide. In 
describing her role as a caregiver, one [caregiver] explained, `I am my 
husband's accountant; occupational therapist; physical therapist; 
driver; mental health counselor; and life coach.' '' We do not make any 
changes based on this comment. First, the commenter urges VA to provide 
compensation for services that are beyond the scope of expertise of a 
home health aide and should not otherwise be provided by a home health 
aide (e.g. physical and occupational therapy, mental health 
counseling), despite the mandate in the Caregivers Act that, ``to the 
extent practicable,'' VA must ensure that the stipend amount ``is not 
less than the monthly amount a commercial home health care entity would 
pay an individual in the geographic area of the eligible veteran to 
provide equivalent personal care services to the eligible veteran.'' 38 
U.S.C. 1720G(a)(3)(C)(ii). We interpret section 1720G(a)(3)(C)(ii) to 
clearly mandate that stipend amounts should be relative to what a 
typical home health aide is paid, and subsequently that Family 
Caregivers should not be expected to provide services that home health 
aides do not typically provide. We do not find that the law can 
reasonably be interpreted to require stipend compensation for the 
provision of specialty clinical care or rehabilitative treatment, or 
any other care beyond that which can be provided by a typical home 
health aide, or by a Family Caregiver who may have no additional 
training beyond that provided by VA under Sec.  71.25(d).
    Second, we believe Family Caregivers provide assistance within a 
range of complexity, given the level of assistance the individual 
veteran or servicemember is assessed to need and the moderate level of 
training and prequalification required before VA will designate a 
family member as a Family Caregiver. Consequently, the wage rate was 
set at the 75th percentile, which we continue to believe most 
accurately reflects the hourly rate of a home health aide for providing 
assistance with ADLs and supervision/protection needs, as they are 
defined in Sec.  71.15. As we stated in the interim final rule, wage 
rates vary for home health aides depending on their experience and 
education, as well as economic factors in each geographic area. We 
believe the 75th percentile most accurately meets the intent of section 
1720G given this range of wage rates, and is reasonable as a middle 
point between the 50th and 90th percentiles as identified by BLS for 
geographic areas. We do not believe the setting of the rate at the 75th 
percentile significantly hinders an eligible veteran's opportunities to 
receive the assistance they require.
    The regulation text in the interim final rule at Sec.  
71.40(c)(4)(v), however, did not make clear that VA uses this 75th 
percentile per geographic area as a factor in calculating the stipend. 
We therefore make changes to Sec.  71.15 and Sec.  71.40(c)(4)(v) to 
clarify this point.
    We also make clarifying changes to Sec.  71.15 and Sec.  
71.40(c)(4)(v) unrelated to public comments to better describe how the 
Bureau of Labor Statistics (BLS) wage rates and Consumer Price Index 
(CPI) are used in calculating stipend amounts. Because BLS wage rates 
are generally based on the previous year's data, the interim final rule 
factored in a cost of living adjustment based on the CPI to calculate 
the current year's hourly wage rate. At the time the interim final rule 
was drafted, BLS provided 2009 wage rates. Shortly thereafter, BLS 
published its 2010 wage rates, and VA began issuing stipends based on 
the 2010 BLS wage rates adjusted by the CPI. The BLS's 2011 wage rates, 
however, reflected some dramatic decreases in the hourly wages of home 
health aides in various geographic areas of the United States. 
Application of the 2011 BLS hourly wage rate for all Primary Family 
Caregivers' stipends would have resulted in decreases in monthly 
stipend payments for 34% of approved Primary Family Caregivers, the 
largest decrease being over $6.00 per hour. We never intended that 
Primary Family Caregivers should be subject to decreased stipend 
payments from year to year due to decreased BLS rates or a decreased 
CPI rate. Therefore, we clarify in this final rule that VA's intent is 
to use the most recent data from the BLS

[[Page 1370]]

on hourly wage rates for home health aides as well as the most recent 
Consumer Price Index for All Urban Consumers (CPI-U), unless using this 
most recent data for a geographic area would result in an overall BLS 
and CPI-U combined rate that is lower than that applied in the previous 
year for the same geographic area. If using this most recent data would 
result in a BLS and CPI-U combined rate for a geographic area that is 
lower than that applied in the previous year, the BLS hourly wage rate 
and CPI-U that was applied in the previous year for that geographic 
area will be utilized to calculate the Primary Family Caregiver 
stipend. We note that the CPI-U has been and will continue to be used 
in the stipend calculation because its representative population 
coverage is more comprehensive than that of the Consumer Price Index 
for Urban Wage Earners and Clerical Workers (CPI-W), and therefore the 
CPI-U is more representative of Primary Family Caregivers around the 
country. (The CPI-U covers approximately 87 percent of the total 
population, and the CPI-W covers approximately 32 percent of the 
population and is a subset of the CPI-U population). More specifically, 
the annual CPI-U as used in the stipend calculation is a national 
average, based on a U.S. city average for the expenditure category 
``care of invalids and elderly at home.'' This expenditure category is 
most representative, within the more general ``medical care'' 
expenditure category, of the type of care provided by most Family 
Caregivers.
    To clarify this calculation methodology, we add a new definition of 
the term ``combined rate'' to Sec.  71.15, to refer to the BLS hourly 
wage rate for home health aides at the 75th percentile in the eligible 
veteran's geographic area of residence, multiplied by the CPI-U. This 
definition will further clarify that the combined rate will be 
determined for each geographic area on an annual basis by comparing (1) 
the product of the most recent BLS hourly wage rate for home health 
aides at the 75th percentile in the geographic area and the most recent 
CPI-U, with (2) the combined rate applied for the geographic area in 
the previous year. Whichever of these is higher will represent the 
combined rate for that geographic area that year. We make corresponding 
revisions to the text of Sec.  71.40(c)(4)(v) to reference the term 
``combined rate'' as it is defined in Sec.  71.15.
    The combined rate will apply for the entire affected geographic 
area, such that existing Primary Family Caregivers and new Primary 
Family Caregivers in a geographic area will receive a stipend 
calculated with the same combined rate, even though new Primary Family 
Caregivers would not be adversely affected by a lower BLS hourly wage 
rate or a lower CPI-U than the previous year. Using one combined rate 
for both new and existing Primary Family Caregivers in the same 
geographic area will ensure equity in stipend payments between Primary 
Family Caregivers of eligible veterans requiring the same number of 
hours of personal care services, and permits VA to avoid costly and 
cumbersome adjustments that would be required if we allowed multiple, 
different combined rates to apply in the same geographic area--costs 
that were not considered in the impact analysis associated with this 
regulation, and burdens that were never intended to be a consequence of 
the interim final rule. Under this methodology, the number of hours of 
caregiver assistance required would be the only basis for different 
stipend amounts in each particular geographic area, and no Primary 
Family Caregiver will see downward fluctuations in their stipend amount 
from year to year unless the number of required hours of assistance 
decreases or the eligible veteran moves to a geographic area with a 
lower combined rate. This revision ensures that Primary Family 
Caregivers will not unexpectedly lose monetary assistance upon which 
they had come to rely based on their participation in the Program of 
Comprehensive Assistance for Family Caregivers. This is the fairest 
result for all Family Caregivers, and best effectuates our original 
intent. Moreover, this revision is consistent with the statutory 
requirement at 38 U.S.C. 1720G(a)(3)(C)(ii) to ensure that stipends are 
``not less than'' the monthly amount a commercial home health entity 
would pay in the geographic area.
    We are publishing this revision as part of this final rulemaking 
because prior notice and comment is not required. This revision is 
consistent with the calculation methodology set forth in the interim 
final rule because VA still uses the BLS rate per geographic area and 
multiplies that rate by the CPI-U (among other factors) to calculate 
the stipend amount. This revision merely ensures that Primary Family 
Caregivers' stipends will not decrease simply because the BLS wage rate 
for their geographic area or the CPI-U has decreased. Because these 
changes effectuate our original intent, are consistent with the 
governing statutory authority, serve only to benefit both Primary 
Family Caregivers and VA, and cannot be applied in a manner detrimental 
to the public, a new notice and comment period is not necessary.
Expansion of Symptoms Considered in ``Supervision or Protection'' 
Categories in Sec.  71.15
    One commenter argued that VA should expand the listed reasons an 
individual may require supervision or protection in Sec.  71.15 (in the 
definition of ``[n]eed for supervision or protection based on symptoms 
or residuals of neurological or other impairment or injury''), to 
ensure that symptoms of depression, anxiety disorder, and post-
traumatic stress disorder (PTSD) were included, and thereby to ensure 
that these disorders were considered as qualifying injuries under this 
rule. The commenter acknowledged that the current criteria of ``[s]elf 
regulation,'' ``[d]ifficulty with sleep regulation,'' and ``[s]afety 
risks'' in Sec.  71.15 are criteria that may be met by veterans 
suffering from PTSD or severe depression, and thus that such veterans 
could be eligible for a Family Caregiver (assuming all other 
eligibility requirements are met). However, the commenter also 
advocated for additional criteria such as ``significant avoidant 
behaviors'' for someone with PTSD, or ``fear of leaving the home'' and 
related fearfulness symptoms experienced in conjunction with anxiety 
disorders.
    We acknowledge that a significant number of post-9/11 veterans 
suffer from PTSD, anxiety disorders, and depression, which may create a 
need for personal care services. We also acknowledge that the behaviors 
described by the commenter may be present in this veteran population. 
However, we disagree that the current regulation does not adequately 
account for these veterans and servicemembers in the existing 
eligibility criteria. We therefore do not make any substantive changes.
    The currently listed symptoms in Sec.  71.15 pertaining to the need 
for ``supervision or protection'' are adequate to ensure eligibility 
for veterans and servicemembers with these disorders and to ensure that 
Primary Family Caregivers of eligible individuals with these disorders 
receive a monthly stipend comparable to the stipend paid to Primary 
Family Caregivers of eligible individuals whose need is based on other 
types of injuries. As discussed in the interim final rule and as is 
clear by the regulations themselves, the Program of Comprehensive 
Assistance for Family Caregivers seeks to train Family Caregivers to 
provide specific services to seriously injured eligible veterans in a 
home environment. It is not designed to compensate caregivers of 
veterans

[[Page 1371]]

and servicemembers simply because the veteran or servicemember has been 
injured or suffers from lasting effects of an injury that, while 
serious and disruptive, does not rise to the level of creating a need 
for protection or supervision. We do not minimize the impact of any 
symptoms suggested by the commenter. However, we cannot agree that a 
veteran or servicemember should be eligible for a Family Caregiver, or 
that a Family Caregiver's stipend should be increased, based on the 
veteran or servicemember having symptoms like avoidant behavior, unless 
those symptoms establish impairment that meets the statutory criterion 
of a need for protection or supervision. For example, a veteran or 
servicemember whose psychological disorder produces significant 
avoidant behavior requires mental health care but does not require a 
compensated caregiver, unless that avoidant behavior poses a safety 
risk, affects the veteran's or servicemember's ability to plan or 
organize, causes delusions, or results in one of the other criteria 
under ``[n]eed for supervision or protection . . .'' in Sec.  71.15 (or 
if it affects the veteran's or servicemember's ability to perform 
ADLs). All of the symptoms listed under ``[n]eed for supervision or 
protection . . .'' in Sec.  71.15 strongly indicate that an individual 
actually requires supervision or protection, and the list should not be 
expanded to include symptoms that are serious and that may require 
medical intervention, but do not require assistance from a Family 
Caregiver to provide supervision or protection.
    We make one minor non-substantive correction to the regulation text 
in the definition of ``[n]eed for supervision or protection based on 
symptoms or residuals of neurological or other impairment or injury'' 
in Sec.  71.15, by removing the word ``and'' in paragraph (6) of the 
definition, and replacing it with the word ``or.'' This clarifies that 
a need for supervision or protection may be based on ``any of the 
following reasons'' under paragraphs (1)-(7) in that definition. See 38 
CFR 71.15. This clarification is consistent with the clear language of 
Sec.  71.15, and does not create any new restrictions.
Validity and Reliability of the Criteria in Sec.  71.15 as an 
Assessment Instrument, and of the Scoring Methodology in Sec.  
71.40(c)(4)(iii)
    We received several comments that the activities and symptoms 
listed in Sec.  71.15 do not accurately assess the number of caregiver 
hours required for provision of personal care services. There were 
several bases offered for these comments; however, we do not make any 
changes.
    First, commenters stated that the listed activities and symptoms do 
not comprise a reliable or valid clinical assessment because they are 
derived from three different clinical assessments, the Katz Basic 
Activities of Daily Living Scale (Katz), the UK Functional Independence 
Measure and Functional Assessment Measure (FIM+FAM), and the 
Neuropsychiatric Inventory (NPI). Commenters asserted that though each 
of these assessments separately are known to be valid and reliable 
measuring instruments, taking portions from each to create a new scale 
does not then make VA's criteria in Sec.  71.15 reliable or valid. 
Instead, it was suggested by a commenter that VA administer each of 
these three assessments separately.
    These comments may be based on a misunderstanding of the purposes 
of the applicable definitions in Sec.  71.15. The criteria listed as 
ADLs or as establishing the need for supervision or protection serve 
two purposes. First, if any one of those criteria are met, a veteran or 
servicemember may be found under Sec.  71.20(c)(1) or (2) to be in need 
of personal care services and thus, to be eligible for a Family 
Caregiver (if other eligibility criteria are met). Second, meeting one 
or more of those criteria establishes that the Primary Family Caregiver 
of an eligible veteran will be eligible to receive a stipend in 
recognition that the caregiver may in fact be providing services for 
which VA would otherwise need to hire a professional home health aide. 
It is unclear whether the commenters assert that the criteria under 
these definitions in Sec.  71.15 are inappropriate for the first, 
second, or both of these purposes.
    We use criteria from the three assessment tools described above 
because these are criteria that are typically used in considering a 
patient's level of impairment; we are not suggesting that our 
regulations be used as a substitute for these tools when the tools are 
being used for their intended purposes in the context of the treatment 
provided to an eligible veteran. At the same time, none of these three 
assessment tools are designed to identify or measure dependence in 
activities that would specifically render a veteran or servicemember in 
need of a caregiver who is not a medical professional. Nor are any of 
the three assessment tools designed to determine those activities for 
which a stipend ought to be provided to a Primary Family Caregiver 
providing certain care in the home. Using the three assessment tools in 
their original design would not, therefore, serve either of the 
purposes of the criteria listed in Sec.  71.15 (i.e., to determine 
which veterans and servicemembers are in need personal care services 
and level of dependence), and we make no changes based on these 
comments. We note that there were many comments concerning the addition 
of new criteria, and we have addressed these comments elsewhere in this 
rulemaking.
    In addition, the commenters argued that VA has not adequately 
tested the scoring methodology in Sec.  71.40(c)(4)(iii) to ensure that 
the actual amount and degree of personal care services will be captured 
for purposes of the stipend calculation. Specifically, commenters 
asserted that the aggregate scoring in Sec.  71.40(c)(4)(iii)-(iv) 
inaccurately creates a presumption of an individual's need, and does 
not appropriately account for the actual time required to provide 
caregiver assistance. We concede that we did not have an opportunity to 
field test this formula prior to implementation of the interim final 
rule. If, in the future, we determine that the formula is inadequate, 
we will make necessary regulatory changes. At this time, we do not 
believe that changes are required. The current scoring methodology is 
broadly designed to ensure that an eligible veteran does not have to be 
rated as fully dependent in a majority of the 14 criteria in Sec.  
71.15 to receive the full stipend amount. In fact, an eligible 
veteran's need for personal care services can be relatively minor, and 
yet a stipend amount will still be provided. For example, the Primary 
Family Caregiver of an eligible veteran who scores a ``1'' in the 
category of dressing, which means that the eligible veteran can perform 
75 percent or more of that task independently, and who scores a ``0'' 
in all other categories would receive, under Sec.  71.40(c)(4)(iv)(C), 
a stipend amount based on the eligible veteran requiring 10 hours of 
caregiver assistance per week--which is one fourth of the total number 
of hours that can be authorized under Sec.  71.40(c)(4)(iv).
    One commenter additionally asserted that the aggregate scoring 
system in Sec.  71.40(c)(4)(iii) is unfair to those eligible veterans 
who may only rate in a few ``supervision and protection'' categories, 
but who nonetheless may require a full time caregiver. The commenter 
further suggested that the ``supervision and protection'' categories 
should be weighed more heavily in the aggregate scoring, so that an 
eligible veteran who may rate in only one of these categories could 
qualify for a full time caregiver. The commenter

[[Page 1372]]

provided examples in support of this assertion. For instance, one 
example described a veteran diagnosed with severe depression who was 
able to perform all ADLs, and whose symptoms included ``utter lack of 
energy, difficulty in even getting out of bed or concentrating on 
tasks, and feelings of hopelessness.'' This example further posited 
that because the veteran's symptoms were not controlled by medication 
the veteran in turn required ``virtually full time watch'' from his 
family members to ensure he did not ``attempt to harm himself.'' In 
this scenario, the commenter surmised that the veteran would rate as a 
``4'' (needing total assistance) for three protection/supervision 
categories under Sec.  71.15: safety risk, self regulation, and 
difficulty with planning and organizing. The commenter stated that the 
overall rating of ``12'' only presumes 10 hours per week of caregiver 
assistance, and that the stipend amount for 10 hours was too low to 
support a caregiver who must provide ``virtually full time watch'' to 
protect the veteran. While the commenter would use this scenario to 
show that a full time caregiver is needed, we do not agree that the 
protection or supervision categories should be weighted differently 
than the ADL categories, such that dependence in three supervision or 
protection categories (or even in a single protection or supervision 
category as used in another example by the commenter) would presume the 
full stipend amount. In fact, we find that the circumstances described 
in the commenter's example above in support of this assertion depict a 
scenario that is arguably unsafe for the veteran. If a veteran requires 
``virtually full time watch'' to ensure that they do not harm 
themselves, an in-home care setting may not be the most appropriate 
level of care. The Program of Comprehensive Assistance for Family 
Caregivers is not designed to train Family Caregivers to the same 
levels as professional clinical care providers who provide continuous 
24-hour, seven day a week support, and such providers with expertise in 
mental health would be the only individuals qualified to attempt to 
prevent self-harm. Additionally, we believe that weighing the 
supervision/protection categories more heavily than the ADL categories 
is unfair for those eligible veterans whose stipend amounts would be 
based solely on their need for assistance with ADLs.
Retroactive Provision of Benefits
    Multiple commenters asserted that VA unnecessarily delayed the 
implementation of the Program of Comprehensive Assistance for Family 
Caregivers, which placed undue stress on an already strained 
population. These commenters argued that VA could mitigate this delay 
by retroactively providing Family Caregiver benefits. Particularly, one 
commenter asserted that VA should make all applicable Family Caregiver 
benefits effective retroactive to May 5, 2010. We do not have the 
authority to make this change. The Caregivers Act specifically provided 
for an effective date for the caregiver programs under 38 U.S.C. 1720G 
of January 30, 2011. See Pub. L. 111-163, title I, section 101(a)(3)(A) 
(stating that the amendments made by this subsection shall take effect 
``270 days after the date of the enactment'').
    Another commenter stated that stipend payments specifically should 
be retroactively provided to Family Caregivers from the intended 
effective date of the 38 U.S.C. 1720G, January 30, 2011. We regret that 
our program, while authorized as of January 2011, did not actually 
become operational until May 2011. The Caregivers Act established an 
unprecedented set of benefits to be administered to eligible veterans 
and non-veterans, as well as intricate eligibility criteria which 
required VA to promulgate regulations, a time intensive process, before 
we could legally provide stipend payments.
    Currently, the stipend is paid monthly for personal care services 
that the Primary Family Caregiver provided in the prior month. Benefits 
due prior to designation of the Primary Family Caregiver, based on the 
date of application, will be paid retroactive to the date that the 
joint application is received by VA or the date on which the eligible 
veteran begins receiving care at home, whichever is later. While we 
acknowledge that the earliest date VA began accepting caregiver 
applications was after the effective date of 38 U.S.C. 1720G, we cannot 
provide stipend payments retroactive to that effective date for all 
current Primary Family Caregivers. This would create an unfair 
advantage for those who filed applications later than others, between 
the period of May 5, 2011, and the present.
Revocation of a Family Caregiver
    Under Sec.  71.45(a), a Family Caregiver may request a revocation 
of caregiver status in writing which provides the date of revocation, 
and all Family Caregiver benefits will continue until the date of 
revocation. VA may further assist the revoking Family Caregiver in 
transitioning to alternative health care and mental health coverage, if 
requested and applicable. 38 CFR 71.45(a). One commenter stated that 
the rule should also require that the revoking caregiver provide notice 
to the eligible veteran, and should specify an amount of time in which 
the Family Caregiver must continue to provide assistance after such 
notice is provided (with the exception of cases where the revoking 
caregiver may be abusing or neglecting the veteran). As stated in the 
interim final rule, participation in the Program of Comprehensive 
Assistance for Family Caregivers is purely voluntary. Accordingly, VA 
may not compel a Family Caregiver to continue providing assistance 
beyond the date provided in the written notice to VA, nor may VA compel 
a Family Caregiver to provide notice to the eligible veteran. However, 
we do amend Sec.  71.45(a) to provide that VA will notify the eligible 
veteran verbally and in writing when the Family Caregiver requests 
revocation. We make an additional change to Sec.  71.45(b)(2) to remove 
the word ``removal'' and replace it with the word ``revocation,'' for 
consistency and ease of understanding. We also amend Sec.  71.45(b)(3) 
to be consistent with Sec.  71.45(c), regarding VA's actions prior to 
making a formal revocation. The portion of Sec.  71.45(b)(3) concerning 
VA actions in suspending Family Caregiver responsibilities now state 
that ``if VA suspects that the safety of the eligible veteran is at 
risk, then VA may suspend the caregiver's responsibilities, and remove 
the eligible veteran from the home if requested by the eligible 
veteran, or take other appropriate action to ensure the welfare of the 
eligible veteran, prior to making a formal revocation.'' We did not 
intend to limit VA's ability to ``take other appropriate action to 
ensure the welfare of the eligible veteran'' to Sec.  71.45(c) only, 
when Sec.  71.45(b)(3) also discusses what may occur if VA suspects 
that the safety of the eligible veteran is at risk. This is not a 
substantive change to Sec.  71.45(b)(3), and does not create any new 
restrictions or criteria.
    We further amend Sec.  71.45(b)(4)(ii) and (b)(4)(iii) because they 
may be misconstrued to prohibit the provision of benefits for a revoked 
Family Caregiver for any portion of the 30 days after the date of 
revocation, if another Family Caregiver is designated within that 30 
days. The intent of Sec.  71.45(b)(4)(ii) is that there should not be 
any overlap in the provision of benefits for a revoked Primary Family 
Caregiver and newly designated Primary Family Caregiver of an eligible 
veteran, and the intent of Sec.  71.45(b)(4)(iii) is that a maximum of 
three Family Caregivers for an eligible veteran may be designated and 
receiving benefits at one time. We additionally clarify that the

[[Page 1373]]

intent of Sec.  71.45(b)(4)(i) remains that benefits should be 
immediately terminated after the revocation date when VA determines the 
Family Caregiver has committed fraud or abused or neglected the 
eligible veteran. Similarly, we clarify that the intent of Sec.  
71.45(b)(4)(iv) remains that benefits should be immediately terminated 
after the revocation date when the revoked individual had been living 
with the eligible veteran and moves out, or the revoked individual 
abandons or terminates his or her relationship with the eligible 
veteran. We note that we also amend Sec.  71.45(b)(4)(ii) and 
(b)(4)(iii) to use the word ``designated'' versus ``assigned'' when 
referring to new replacement Family Caregivers. Our regulations do not 
define the word ``assigned,'' and we did not intend to create any 
ambiguity with regards to the process whereby Family Caregivers are 
approved and designated as such by VA. We amend Sec.  71.45(b)(4)(i)-
(iv) to reflect these clarifications. These are not substantive 
revisions, and they do not create any new restrictions or 
interpretations. Corresponding revisions are made to Sec.  71.45(b)(4) 
and Sec.  71.45(c).
    Finally, we make clarifying edits to Sec.  71.45 to clarify that VA 
will, if requested and applicable, assist revoked Family Caregivers in 
transitioning to alternative health care coverage and mental health 
services. The word ``with'' before the phrase ``mental health 
services'' in Sec. Sec.  71.45(a), (b)(4), and (c) is extraneous and is 
removed for clarity. In addition, we clarify the phrase ``fraud or 
abuse or neglect of the eligible veteran'' in Sec.  71.45(b)(4)(i). We 
amend Sec. Sec.  71.45(a), (b)(4), (b)(4)(i), and (c) to reflect these 
clarifications. These are not substantive revisions, and they do not 
create any new restrictions or interpretations.
CHAMPVA Benefits
    Commenters raised issues related to the Civilian Health and Medical 
Program of the Department of Veterans Affairs (CHAMPVA) benefits 
available to Primary Family Caregivers under this rule. One commenter 
asserted that a Primary Family Caregiver who is the spouse of a veteran 
with a service-connected disability rated at 100 percent, who becomes 
eligible for CHAMPVA benefits under this rule, should be able to retain 
CHAMPVA benefits despite revocation of caregiver status if the spouse 
otherwise would qualify for CHAMPVA due to a veteran's 100 percent 
service-connected disability rating. We believe this comment argued for 
the retention of CHAMPVA benefits for this group of spouses, based on 
the independent eligibility criterion for CHAMPVA benefits for a spouse 
of a veteran who has been adjudicated by VA as having a permanent and 
total service-connected disability. See 38 CFR 17.271(a)(1) 
(identifying as eligible for CHAMPVA benefits ``[t]he spouse or child 
of a veteran who has been adjudicated by VA as having a permanent and 
total service-connected disability''). We do not make any changes based 
on this assertion. If a Primary Family Caregiver is independently 
eligible for CHAMPVA benefits--irrespective of his or her status as a 
caregiver--then that caregiver's revocation will not affect his or her 
eligibility for CHAMPVA on that other basis. In order to maintain 
CHAMPVA coverage post-revocation, VA would need to adjudicate such 
independent eligibility. We would, of course, assist the revoked family 
member in this process during the applicable grace period or as 
otherwise provided by Sec.  71.45. However, we note that a veteran's 
``100 percent'' disability rating does not necessarily make that 
veteran's spouse eligible for CHAMPVA benefits under Sec.  
17.271(a)(1). Though a veteran's 100 percent disability rating is 
considered a ``total'' disability rating, it is not necessarily 
considered a ``permanent'' disability rating. We clarify this due to 
the commenter's example of a ``100 percent'' disability rating.
    To the extent that the commenter may believe that Family Caregivers 
who are eligible solely based on their status as a caregiver should 
retain eligibility for CHAMPVA even after their status is revoked, we 
disagree. Under 38 U.S.C. 1720G(a)(3)(A)(ii)(IV), VA must provide 
certain Primary Family Caregivers with medical care under 38 U.S.C. 
1781. VA administers section 1781 through the CHAMPVA program and its 
implementing regulations. Section 102 of the Caregivers Act added 
paragraph (4) under subsection (a) of section 1781 to expand CHAMPVA 
eligibility to any ``individual designated as a primary provider of 
personal care services under [38 U.S.C. 1720G(a)(7)(A)] . . . who is 
not entitled to care or services under a health-plan contract (as 
defined in [38 U.S.C. 1725(f)]) . . . [who is] not otherwise eligible 
for medical care under chapter 55 of title 10.'' Thus, for individuals 
eligible for CHAMPVA based solely on their status as a Primary Family 
Caregiver, VA is authorized to provide CHAMPVA only for the family 
member's duration as a Primary Family Caregiver.
    An additional comment was that CHAMPVA benefits should be 
retroactive, first to January 31, 2011, for all currently designated 
Primary Family Caregivers, and then to the date a caregiver application 
was submitted for all future Primary Family Caregivers. First, we note 
that all Primary Family Caregiver benefits are effective as of the date 
the signed joint application is received by VA (or the date on which 
the eligible veteran begins receiving care at home, if later), if the 
application is approved, to include CHAMPVA benefits. This means that, 
in practice, an individual who receives private medical care prior to 
being designated as a Primary Family Caregiver after his or her joint 
application is received by VA, and who was not already entitled to care 
or services under a health-plan contract or eligible for medical care 
under chapter 55 of title 10, will, once approved and designated and 
determined eligible for CHAMPVA, be able to request reimbursement for 
that medical care retroactive to the date the joint application was 
received by VA. Claims from Primary Family Caregivers for such 
retroactive reimbursement for medical care are subject to the same 
procedural requirements imposed by CHAMPVA regulations for all CHAMPVA 
beneficiaries. See 38 CFR 17.272 et seq.
    However, VA cannot provide such reimbursement for private medical 
care retroactive to January 30, 2011, for the same reasons that we will 
not provide stipend payments retroactive to any date that is prior to 
the actual date the joint application is received by VA.
    One commenter stated that a Primary Family Caregiver's eligibility 
for CHAMPVA should not only be considered when they are first 
designated as a caregiver, but that a Primary Family Caregiver may 
enroll in CHAMPVA at any time after having begun to serve as a Primary 
Family Caregiver, for example, should they lose other health coverage 
after designation as a Primary Family Caregiver. This is the correct 
interpretation of Sec.  71.40(c)(3), which states that ``Primary Family 
Caregivers are to be considered eligible for enrollment in the Civilian 
Health and Medical Program of the Department of Veterans Affairs 
(CHAMPVA), unless they are entitled to care or services under a health-
plan contract.'' We do not make any changes based on this comment 
because the commenter properly interpreted the rule and we do not see 
any inherent ambiguity. We note, however, that the commenter's 
additional assertion that the wording of Sec.  71.40(c)(3) is vague and 
weakens the CHAMPVA eligibility provision by including the phrase ``to 
be considered'' is addressed by the removal of that phrase from the 
rule. Section 71.40(c)(3) is further clarified by adding

[[Page 1374]]

reference to the statutory authority for CHAMPVA (38 U.S.C. 1781), 
which specifically identifies Primary Family Caregivers as eligible for 
CHAMPVA.
Mental Health Services
    One commenter expressed confusion related to counseling and other 
mental health services available to Family Caregivers, and further 
requested that it be more clearly stated in the rule that Family 
Caregivers may receive counseling and other services independent of 
whether those services are provided in connection with the treatment of 
a disability for which the veteran is receiving treatment from VA. 
Under Sec. Sec.  71.40(b)(5) and 71.40(c)(1), all Family Caregivers may 
receive ``[c]ounseling, which . . . includes individual and group 
therapy, individual counseling, and peer support groups.'' We do not 
specify in Sec. Sec.  71.40(b)(5) or 71.40(c)(1) that such counseling 
must be ``in connection with the treatment of a disability for which 
the veteran is receiving treatment through VA,'' which is the criteria 
that General Caregivers must meet to receive certain counseling and 
other mental health services under Sec.  71.50(a). As explained in the 
interim final rulemaking, counseling for Family Caregivers may be 
provided for reasons not in connection with the treatment of a veteran, 
unlike the ``[c]ounseling and other services'' provided to General 
Caregivers under Sec. Sec.  71.40(a)(3) and 71.50(a). See 76 FR 26153, 
May 5, 2011 (explaining the differences in statutory authorities to 
provide counseling to Family Caregivers versus to General Caregivers, 
and the subsequent differences in eligibility requirements). We amend 
Sec.  71.40(b)(5) to make clear that counseling provided to Family 
Caregivers does not have to be in connection with the treatment of a 
disability for which the eligible veteran is receiving treatment from 
VA. The commenter must understand as well that because all General 
Caregiver benefits in Sec.  71.40(a) are generally incorporated into 
the benefits listed for Secondary Family Caregivers by Sec.  
71.40(b)(1) and for Primary Family Caregivers by Sec.  71.40(c)(1), 
Family Caregivers could receive both counseling services defined in 
Sec.  71.40(b)(5), as well as those defined for General Caregivers in 
Sec.  71.40(a)(3) (under Sec.  71.50).
Mandatory Family Caregiver Training To Provide Specific Treatment
    One commenter stated that VA should consider requiring that Family 
Caregivers, who provide personal care services for veterans with PTSD, 
receive training in the specific treatment modalities of eye movement 
desensitization and reprogramming, and myofascial release, to assist 
veterans with anger management and pain management issues. We do not 
make any changes to the rule based on these comments. Caregiver 
training as set forth in Sec.  71.25(d) is designed to cover the 
essential components of home-based care (called ``core competencies'' 
in the rule), and prepare the caregiver to provide assistance with 
``personal care services'' as that term is defined in section 
1720G(d)(4) and Sec.  71.15. We believe that all of these identified 
competencies are present to at least some degree in virtually all 
situations in which we will find a veteran or servicemember eligible 
for a Family Caregiver. If a particular eligible veteran presents 
complex challenges in any or all of the competencies in Sec.  71.25(d), 
we will provide more specific training to the Family Caregiver. 
However, we cannot mandate by regulation training in very specific 
treatment modalities that may not be applicable or beneficial to all 
eligible veterans.
Respite Care
    One commenter expressed concern that the rule did not clearly state 
that respite care provided for Primary Family Caregivers ``shall be 
medically and age-appropriate and include in-home care,'' as is 
required by 38 U.S.C. 1720G(a)(3)(B). The commenter further stated that 
if the statutory requirement that respite care be ``age-appropriate and 
include in-home care'' is not explicitly stated in the rule, then VA 
personnel may erroneously advise caregivers that respite options are 
limited to VA nursing home placement. We note that the analysis of 
respite care costs in the rule assumes that ``respite care will be 
primarily in-home care for 24 hours per day,'' and VA does not intend 
to educate its personnel contrary to the rule and statutory 
requirements. 76 FR 26162, May 5, 2011. However, we agree that Sec.  
71.40(c)(2) should be clarified to conform to the requirements in 
section 1720G(a)(3)(B), and therefore we have revised Sec.  71.40(c)(2) 
to indicate that respite care provided for Primary Family Caregivers 
``shall be medically and age-appropriate and include in-home care.''
Beneficiary Travel
    Commenters stated that the rule does not clearly specify that 
Family Caregivers are eligible for beneficiary travel benefits, and 
does not clearly specify the scope of those travel benefits. 
Beneficiary travel under 38 CFR part 70 is authorized for Family 
Caregivers in Sec.  71.25(d) and Sec.  71.40(b)(6). Section 71.40(b)(6) 
states that Family Caregivers ``are to be considered eligible for 
beneficiary travel under 38 CFR part 70.'' Commenters expressed concern 
that the phrase ``are to be considered'' is vague and ambiguous and 
suggested that the phrase could be used to exclude Family Caregivers 
who are eligible for beneficiary travel under section 104 of Public Law 
111-163. This is not VA's intent; Sec.  71.40(b)(6) is therefore 
amended to remove the phrase ``to be considered.''
    In addition, we believe the language in Sec.  71.40(b)(6) should be 
revised to clarify the scope of benefits authorized under 38 U.S.C. 
111(e)(2), as added by section 104 of Public Law 111-163. Section 
111(e)(2) of title 38, U.S.C., states: ``Without regard to whether an 
eligible veteran entitled to mileage under this section for travel to a 
Department facility for the purpose of medical examination, treatment, 
or care requires an attendant in order to perform such travel, an 
attendant of such veteran described in subparagraph (B) may be allowed 
expenses of travel (including lodging and subsistence) upon the same 
basis as such veteran.'' 38 U.S.C. 111(e)(2)(A) (emphasis added). This 
means that a veteran must be eligible for mileage under 38 U.S.C. 111 
in order for his or her family caregivers to receive travel benefits 
during the period of time in which the eligible veteran is traveling to 
or from a VA facility for and throughout the duration of the eligible 
veteran's examination, treatment or care episode. We note that Family 
Caregivers may receive travel benefits for training purposes under 
Sec.  71.25(d) without respect to the veteran's eligibility for 
beneficiary travel based on the authority in 38 U.S.C. 1720G(a)(6)(C), 
which is not tied to 38 U.S.C. 111(e). We have revised the text of 
Sec.  71.40(b)(6) so it states that ``Primary and Secondary Family 
Caregivers are eligible for beneficiary travel under 38 CFR part 70 if 
the eligible veteran is eligible for beneficiary travel under 38 CFR 
part 70.''
    Commenters also expressed concern that Family Caregivers would be 
denied benefits based on language in the supplementary information to 
the interim final rule that beneficiary travel would be available 
``subject to any limitations or exclusions under [38 CFR] part 70,'' 
the regulations governing VA's beneficiary travel benefits (76 FR 
26152, May 5, 2011), and that VA has not revised its beneficiary travel 
regulations to include Family Caregivers among those who are eligible 
persons under

[[Page 1375]]

Sec.  70.10. Our statement that the provision of beneficiary travel is 
subject to the limitations in part 70 does not appear in regulation, 
and we do not make any changes based on this comment. However, we 
clarify that the purpose of that statement was to express that Family 
Caregivers receiving beneficiary travel must comply with the procedural 
requirements and restrictions in part 70, not to impose new 
restrictions that do not apply to any other applicants for beneficiary 
travel benefits. Section 111(e)(2) of title 38, U.S.C., as amended by 
section 104 of the Caregivers Act, states that Family Caregivers ``may 
be allowed expenses of travel . . . upon the same basis as [the] 
veteran'' who is traveling for purposes of medical examination, 
treatment, or care; it does not provide an independent right to 
beneficiary travel benefits that would not be subject to the procedures 
established in 38 CFR part 70, which are applicable to all individuals 
seeking beneficiary travel benefits. Travel benefits under 38 U.S.C. 
1720G(a)(6)(C) for purposes of Family Caregiver training were also 
linked to 38 CFR part 70 for ease of administering the benefits--
instead of establishing a separate program of travel benefits for 
training purposes. However, we reiterate that for purposes of Family 
Caregiver training, a veteran's independent eligibility under 38 CFR 
part 70 is not relevant.
    Another commenter cited anecdotal reports that some VA personnel 
have not properly understood the scope of beneficiary travel benefits 
offered to Family Caregivers. We note that this is a new legal 
provision, and concede that some beneficiary travel authorizers may not 
have been adequately trained at the time that the commenter received 
the anecdotal reports. We regret this, but note that we are currently 
conducting formal trainings in VA facilities to educate VA personnel on 
Family Caregiver eligibility for beneficiary travel benefits, 
consistent with section 104 of Public Law 111-163. Training, and not 
regulatory revision, is required to address this problem.
    Finally, we note that we are currently in the process of drafting 
amendments to part 70 that will clearly state that Family Caregivers 
may receive beneficiary travel benefits (under 38 U.S.C. 111(e)(2) and 
under 38 U.S.C. 1720G(a)(6)(C)) in the same manner, and subject to the 
same procedural requirements and limitations, as any individual 
currently identified as eligible in 38 CFR 70.10. In the interim, 38 
U.S.C. 111(e), as amended by section 104 of the Caregiver Act, 
authorizes VA to provide to Family Caregivers the ``expenses of travel 
(including lodging and subsistence)'' during the period of time in 
which the eligible veteran is traveling to and from a VA facility for 
the purpose of medical examination, treatment, or care, and the 
duration of the medical examination, treatment, or care episode for the 
eligible veteran. VA will rely upon that statutory authority as well as 
38 U.S.C. 1720G(a)(6)(C) and our regulations in part 70 as authority to 
provide beneficiary travel benefits to eligible Family Caregivers.
Effective Date of Benefits
    Section 71.40(d)(1) indicates that Family Caregiver benefits are 
effective as of the date that the signed joint application is received 
by VA or the date the eligible veteran begins receiving care at home 
(whichever is later), but that these benefits are not provided until a 
Family Caregiver has been designated. Family Caregivers must complete 
all required training and instruction to become so designated no later 
than 30 days after the date the joint application was submitted or, if 
the application was placed on hold for a GAF assessment, 30 days after 
the hold has been lifted.
    Through implementing Sec.  71.40(d)(1), VA has discovered that the 
30-day timeframe is in many instances too brief to allow Family 
Caregivers to complete all required training. To avoid the delay that 
starting a new application would create, we are amending Sec.  
71.40(d)(1) to extend this timeframe to 45 days, and to include a 
mechanism to waive the need for a new application beyond 45 days in 
certain instances. VA may extend the 45-day period for up to 90 days 
after the date the joint application was submitted or, if the 
application has been placed on hold for a GAF assessment, for up to 90 
days after the hold has been lifted. Such an extension may either be 
based on training identified under 38 CFR 71.25(d) that is still 
pending completion, or hospitalization of the eligible veteran. This 
regulatory change is a liberalization of a requirement, and does not 
add any restrictions for those otherwise eligible veterans and Family 
Caregivers with regards to the effective date of benefits.
Non-Substantive Change to Sec.  71.30(b)(2)
    Section 71.30(b)(2) provides that a ``covered veteran'' for 
purposes of the Program of General Caregiver Support Services is a 
veteran who is enrolled in the VA health care system and needs personal 
care services because the veteran ``[n]eeds supervision or protection 
based on symptoms or residuals of neurological care or other impairment 
or injury.'' The word ``care'' in Sec.  71.30(b)(2) is extraneous and 
is removed to be consistent with the relevant statutory provision 
related to covered veterans in the Program of General Caregiver Support 
Services, 38 U.S.C. 1720G(b)(2)(B).

Administrative Procedure Act

    In accordance with 5 U.S.C. 553(d)(3), the Secretary of Veterans 
Affairs concluded that there was good cause to publish this rule with 
an immediate effective date. Under the interim final rule, Caregiver 
benefits have been provided continuously since May 5, 2011. A delayed 
effective date for this final rule could confuse current Caregivers or 
VA employees, possibly leading to the misperception that existing 
Caregiver benefits will be interrupted during the 30-day period between 
publication of this final rule and the effective date. Therefore, there 
is good cause to publish this rule with an immediate effective date.

Effect of Rulemaking

    Title 38 of the Code of Federal Regulations, as revised by this 
rulemaking, represents VA's implementation of its legal authority on 
this subject. Other than future amendments to this regulation or 
governing statutes, no contrary guidance or procedures are authorized. 
All existing or subsequent VA guidance must be read to conform with 
this rulemaking if possible or, if not possible, such guidance is 
superseded by this rulemaking.

Paperwork Reduction Act

    The interim final rule included a collection of information under 
the Paperwork Reduction Act (44 U.S.C. 3501-3521) that requires 
approval by the Office of Management and Budget (OMB). Accordingly, 
under section 3507(d) of the Act, VA submitted a copy of that 
rulemaking to OMB for review. 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.
    In the interim final rule, we stated that Sec.  71.25(a) contained 
collection of information provisions under the Paperwork Reduction Act 
of 1995, and we requested public comment on those provisions in the 
document published in the Federal Register on May 5, 2011 (76 FR 
26158).
    We did not receive any comments on the collection of information 
contained in the interim final rule, and this final rule does not 
change the burden and

[[Page 1376]]

number of respondents because eligibility criteria did not change. OMB 
approved these new information collection requirements associated with 
the interim final rule and assigned OMB control number 2900-0768.

Regulatory Flexibility Act

    The Acting Secretary hereby certifies that this regulatory 
amendment will not have a significant economic impact on a substantial 
number of small entities as they are defined in the Regulatory 
Flexibility Act, 5 U.S.C. 601-612. This regulatory action affects 
individuals and will not affect any small entities. Therefore, under 5 
U.S.C. 605(b), this rulemaking is exempt from the initial and final 
regulatory flexibility analysis requirements of 5 U.S.C. 603 and 604.

Executive Order 12866 and Executive Order 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
Executive Order 12866 (Regulatory Planning and Review) defines a 
``significant regulatory action,'' which requires 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 otherwise 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 recipients thereof; or (4) Raise novel legal 
or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in this Executive Order.
    The economic, interagency, budgetary, legal, and policy 
implications of this regulatory action have been examined, and it has 
been determined that it is an economically significant regulatory 
action under Executive Order 12866. VA's impact analysis can be found 
as a supporting document at https://www.regulations.gov, usually within 
48 hours after the rulemaking document is published. Additionally, a 
copy of the rulemaking and its impact analysis are available on VA's 
Web site at https://www1.va.gov/orpm/, by following the link for ``VA 
Regulations Published.''

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 
developing 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 (adjusted annually for inflation) in any given 
year. This rule will have no such effect on State, local, and tribal 
governments, or on the private sector.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are 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, Pension for Non-Service-Connected 
Disability for Veterans; 64.015, Sharing Specialized Medical Resources; 
64.019, Veterans Rehabilitation Alcohol and Drug Dependence; and 
64.022, Veterans Home Based Primary Care.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Jose D. 
Riojas, Chief of Staff, Department of Veterans Affairs, approved this 
document on June 30, 2014, for publication.

List of Subjects

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.

38 CFR Part 71

    Administrative practice and procedure, Caregivers program, Claims, 
Health care, Health facilities, Health professions, Mental health 
programs, Travel and transportation expenses, Veterans.

    Dated: January 5, 2015.
William F. Russo,
Acting Director, Office of Regulation Policy & Management, Office of 
the General Counsel, U.S. Department of Veterans Affairs.

    For the reasons set forth in the preamble, the interim final rule 
amending 38 CFR 17.38(a)(1)(vii) and 38 CFR part 71, that was published 
at 76 FR 26148 on May 5, 2011, is adopted as a final rule with the 
following changes:

PART 71--CAREGIVERS BENEFITS AND CERTAIN MEDICAL BENEFITS OFFERED 
TO FAMILY MEMBERS OF VETERANS

0
1. The authority citation for part 71 continues to read as follows:

    Authority:  38 U.S.C. 501, 1720G, unless otherwise noted.


0
2. Amend Sec.  71.10 by revising paragraphs (a) and (b) to read as 
follows:


Sec.  71.10  Purpose and scope.

    (a) Purpose. This part implements the Program of Comprehensive 
Assistance for Family Caregivers, which, among other things, provides 
certain benefits to eligible veterans who have incurred or aggravated 
serious injuries during military service, and to their caregivers. This 
part also implements the Program of General Caregiver Support Services, 
which provides support services to caregivers of covered veterans from 
all eras who are enrolled in the VA health care system.
    (b) Scope. This part regulates the provision of Family Caregiver 
benefits and General Caregiver benefits authorized by 38 U.S.C. 1720G. 
Persons eligible for such benefits may be eligible for other VA 
benefits based on other laws or other parts of this title.
* * * * *

0
3. Amend Sec.  71.15 by:
0
a. Adding the definition for ``Combined rate'' in alphabetical order.
0
b. In the definition for ``In the best interest'', removing all 
references to ``eligible veteran'' and adding, in each place, ``veteran 
or servicemember'', and removing ``Family Caregiver program'' and 
adding, in its place, ``Program of Comprehensive Assistance for Family 
Caregivers''.

[[Page 1377]]

0
c. In the definition for ``Need for supervision or protection based on 
symptoms or residuals of neurological or other impairment or injury'', 
removing ``and'' at the end of paragraph (6) and adding, in its place, 
``or''.
0
d. Revising the definition for ``Primary care team''.
    The addition and revision read as follows:


Sec.  71.15  Definitions.

    Combined rate refers to the Bureau of Labor Statistics (BLS) hourly 
wage rate for home health aides at the 75th percentile in the eligible 
veteran's geographic area of residence, multiplied by the Consumer 
Price Index for All Urban Consumers (CPI-U). The combined rate will be 
determined for each geographic area on an annual basis. For each 
geographic area, the combined rate will be the higher of:
    (1) The most recent BLS hourly wage rate for home health aides at 
the 75th percentile in the geographic area multiplied by the most 
recent CPI-U; or
    (2) The combined rate applied for the geographic area in the 
previous year.
* * * * *
    Primary care team means a group of medical professionals who care 
for a patient and who are selected by VA based on the clinical needs of 
the patient. The team must include a primary care provider who 
coordinates the care, and may include clinical specialists (e.g., a 
neurologist, psychiatrist, etc.), resident physicians, nurses, 
physicians' assistants, nurse practitioners, occupational or 
rehabilitation therapists, social workers, etc., as indicated by the 
needs of the particular patient.
* * * * *


Sec.  71.20  [Amended]

0
4. Amend Sec.  71.20 by:
0
a. In paragraph (c), removing ``(based on a clinical determination)'' 
and adding, in its place, ``(based on a clinical determination 
authorized by the individual's primary care team)''.
0
b. In paragraph (d), immediately following ``A clinical 
determination'', adding ``(authorized by the individual's primary care 
team)''.

0
5. Amend Sec.  71.25 by:
0
a. In paragraph (c)(1)(i) parenthetical, immediately before ``as 
appropriate'', adding ``to the extent possible and''.
0
b. In paragraph (d), removing ``designed by and provided through'' and 
adding, in its place, ``designed and approved by'' .
0
c. Revising paragraph (e).
    The revision reads as follows:


Sec.  71.25  Approval and designation of Primary and Secondary Family 
Caregivers.

* * * * *
    (e) Initial home-care assessment. No later than 10 business days 
after VA certifies completion of caregiver education and training, or 
should an eligible veteran be hospitalized during this process, no 
later than 10 days from the date the eligible veteran returns home, a 
VA clinician or a clinical team will visit the eligible veteran's home 
to assess the caregiver's completion of training and competence to 
provide personal care services at the eligible veteran's home, and to 
measure the eligible veteran's well being.
* * * * *


Sec.  71.30  [Amended]

0
6. Amend Sec.  71.30(b)(2) by removing ``care''.
0
7. Amend Sec.  71.40 by:

0
a. In paragraphs (b)(4), (c)(4)(iv)(A) through (C), and (c)(4)(v), 
removing all references to ``Caregiver'' and adding, in each place, 
``caregiver''.
0
b. In paragraph (b)(5), adding, at the end of the paragraph, 
``Counseling does not have to be in connection with the treatment of a 
disability for which the eligible veteran is receiving treatment from 
VA.''
0
c. In paragraph (b)(6), removing ``to be considered'', and adding, at 
the end of the sentence, ``if the eligible veteran is eligible for 
beneficiary travel under 38 CFR part 70.''
0
d. In paragraph (c)(2), adding, at the end of the paragraph, ``Respite 
care provided shall be medically and age-appropriate and include in-
home care.''
0
e. Revising paragraph (c)(3).
0
f. In paragraphs (c)(4)(iv)(A) through (C), removing all references to 
``then the eligible veteran is presumed to require'' and adding, in 
each place, ``then the caregiver will receive a stipend equivalent to 
the eligible veteran requiring''.
0
g. In paragraph (c)(4)(v), removing ``Bureau of Labor Statistics hourly 
wage for home health aides in the geographic area by the Consumer Price 
Index and then multiplying that total'' and adding, in its place, 
``combined rate''.
0
h. Revising paragraph (d)(1).
    The revisions read as follows:


Sec.  71.40  Caregiver benefits.

* * * * *
    (c) * * *
    (3) Primary Family Caregivers are eligible for enrollment in the 
Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA) pursuant to 38 U.S.C. 1781, unless they are entitled 
to care or services under a health-plan contract (as defined in 38 
U.S.C. 1725(f)).
* * * * *
    (d) * * *
    (1) Effective date. Caregiver benefits are effective as of the date 
that the signed joint application is received by VA or the date on 
which the eligible veteran begins receiving care at home, whichever is 
later. However, benefits will not be provided until the individual is 
designated as a Family Caregiver. Individuals who apply to be Family 
Caregivers must complete all necessary education, instruction, and 
training so that VA can complete the designation process no later than 
45 days after the date that the joint application was submitted or, if 
the application has been placed on hold for a GAF assessment, 45 days 
after the hold has been lifted, or a new joint application will be 
required to serve as the date of application for payment purposes. VA 
may extend the 45-day period for up to 90 days after the date the joint 
application was submitted or, if the application has been placed on 
hold for a GAF assessment, for up to 90 days after the hold has been 
lifted. Such an extension may either be based on training identified 
under Sec.  71.25(d) that is still pending completion, or 
hospitalization of the eligible veteran.
* * * * *
    8. Revising Sec.  71.45 to read as follows:


Sec.  71.45  Revocation.

    (a) Revocation by the Family Caregiver. The Family Caregiver may 
request a revocation of caregiver status in writing and provide the 
present or future date of revocation. All caregiver benefits will 
continue to be provided to the Family Caregiver until the date of 
revocation. VA will, if requested and applicable, assist the Family 
Caregiver in transitioning to alternative health care coverage and 
mental health services. VA will notify the eligible veteran verbally 
and in writing of the request for revocation.
    (b) Revocation by the eligible veteran or surrogate. The eligible 
veteran or the eligible veteran's surrogate may initiate revocation of 
a Primary or Secondary Family Caregiver.
    (1) The revocation request must be in writing and must express an 
intent to remove the Family Caregiver.
    (2) VA will notify the Family Caregiver verbally and in writing of 
the request for revocation.
    (3) VA will review the request for revocation and determine whether 
there is a possibility for remediation. This review will take no longer 
than 30 days. During such review, the eligible veteran

[[Page 1378]]

or surrogate may rescind the request for revocation. If VA suspects 
that the safety of the eligible veteran is at risk, then VA may suspend 
the caregiver's responsibilities, and remove the eligible veteran from 
the home if requested by the eligible veteran, or take other 
appropriate action to ensure the welfare of the eligible veteran, prior 
to making a formal revocation.
    (4) Caregiver benefits will continue for 30 days after the date of 
revocation, and VA will, if requested by the Family Caregiver, assist 
the individual with transitioning to alternative health care coverage 
and mental health services, unless one of the following is true:
    (i) VA determines that the Family Caregiver committed fraud or 
abused or neglected the eligible veteran, in which case benefits will 
terminate immediately.
    (ii) If the revoked individual was the Primary Family Caregiver, 
and another Primary Family Caregiver is designated within 30 days after 
the date of revocation, in which case benefits for the revoked Primary 
Family Caregiver will terminate the day before the date the new Primary 
Family Caregiver is designated.
    (iii) If another individual is designated to be a Family Caregiver 
within 30 days after the date of revocation, such that there are three 
Family Caregivers assigned to the eligible veteran, in which case 
benefits for the revoked Family Caregiver will terminate the day before 
the date the new Family Caregiver is designated.
    (iv) The revoked individual had been living with the eligible 
veteran and moves out, or the revoked individual abandons or terminates 
his or her relationship with the eligible veteran, in which case 
benefits will terminate immediately.
    (c) Revocation by VA. VA may immediately revoke the designation of 
a Family Caregiver if the eligible veteran or individual designated as 
a Family Caregiver no longer meets the requirements of this part, or if 
VA makes the clinical determination that having the Family Caregiver is 
no longer in the best interest of the eligible veteran. VA will, if 
requested by the Family Caregiver, assist him or her in transitioning 
to alternative health care coverage and mental health services. If 
revocation is due to improvement in the eligible veteran's condition, 
death, or permanent institutionalization, the Family Caregiver will 
continue to receive caregiver benefits for 90 days, unless any of the 
conditions described in paragraphs (b)(4)(i) through (iv) of this 
section apply, in which case benefits will terminate as specified. In 
addition, bereavement counseling may be available under 38 U.S.C. 1783. 
If VA suspects that the safety of the eligible veteran is at risk, then 
VA may suspend the caregiver's responsibilities, and remove the 
eligible veteran from the home if requested by the eligible veteran or 
take other appropriate action to ensure the welfare of the eligible 
veteran, prior to making a formal revocation.

[FR Doc. 2015-00071 Filed 1-8-15; 8:45 am]
BILLING CODE 8320-01-P