Veterans Care Agreements, 50856-50861 [2021-19470]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 86, Number 174 (Monday, September 13, 2021)]
[Rules and Regulations]
[Pages 50856-50861]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-19470]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AQ45


Veterans Care Agreements

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: The Department of Veterans Affairs (VA) adopts as final, with 
no substantive changes, an interim final rule revising its medical 
regulations to implement VA's authority under section 102 of the John 
S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining 
Internal Systems and Strengthening Integrated Outside Networks Act of 
2018 (MISSION Act), which authorizes VA to enter into agreements to 
furnish required hospital care, medical services, and extended care 
services in the community when such care and services are not feasibly 
available to certain individuals through a VA facility, a contract, or 
a sharing agreement. As specified in section 1703A and this 
implementing rule, these agreements are called Veterans Care Agreements 
(VCA).

DATES: This rule is effective on October 13, 2021.

FOR FURTHER INFORMATION CONTACT: Joseph Duran, Office of Community Care 
(10D), Veterans Health Administration, Department of Veterans Affairs, 
Ptarmigan at Cherry Creek, Denver, CO 80209; (303) 372-4629. (This is 
not a toll-free number.)

SUPPLEMENTARY INFORMATION: On June 6, 2018, the President signed into 
law the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA 
Maintaining Internal Systems and Strengthening Integrated Outside 
Networks Act of 2018, Public Law 115-182, 132 Stat. 1393 (2018) 
(codified as amended in scattered sections of 38 U.S.C.) (MISSION Act). 
This rule adopts as final, with no substantive changes, an interim 
final rule revising VA medical regulations to implement section 102 of 
the MISSION Act (codified as amended at 38 U.S.C. 1703A), which 
authorizes VA to enter into agreements to furnish required hospital 
care, medical services, and extended care services in the community 
when such care and services are not feasibly available to certain 
individuals through a VA facility, a contract, or a sharing agreement. 
As specified in section 1703A and this implementing rule, these 
agreements are called Veterans Care Agreements (VCA).
    On May 14, 2019, VA published an interim final rule to establish 
the parameters of VCAs authorized under section 1703A, to include: 
Establishing a certification process for entities and providers that 
will seek to enter into a VCA and furnish care or services pursuant to 
that agreement; establishing certain parameters governing the payment 
rates that will be set forth in the terms of each VCA; and establishing 
an administrative process for adjudicating disputes arising under or 
related to VCAs, including those pertaining to claims for payment for 
care or services provided under a VCA. 84 FR 21668. VA received input 
from eight commenters in response to this interim final rule, only 
three of which raised issues relevant to the rule. VA's responses to 
those three commenters are summarized below.
    One commenter that represents a membership consisting of long term 
and post-acute care providers offered four comments that relate to VA's 
implementation and use of VCAs. The comments do not expressly or 
impliedly request any changes to the interim final rule, nor do they 
raise any issues that would necessitate or merit any such changes.
    First, the commenter noted that it wants to ensure its members 
obtain access to information ``available at both the regional and 
national levels'' within VA regarding VA's implementation and use of 
VCAs. Relatedly, the commenter also indicated that it has heard from 
some of its members that they would like VA to establish one or more 
points of contact at the ``national'' level that providers could 
communicate with directly when they have questions that ``regional'' VA 
offices are unable to answer regarding VA's implementation and use of 
VCAs. We interpret the commenter's references to information made 
available and points of contact established at the ``national'' and 
``regional'' levels to constitute references to when such information

[[Page 50857]]

and resources are made available by national offices of the Veterans 
Health Administration (VHA) as compared to when they are made available 
by Veterans Integrated Service Networks (VISN) or by individual VHA 
medical facilities. In response to the commenter's input in this 
regard, we note that VA currently uses a mix of organizational 
components and points of contact to make information relating to VA's 
implementation and use of VCAs available to entities and providers. 
Certain information, resources, and points of contact are made 
available at the national organizational level through the website of 
VHA's national Office of Community Care.\1\ For example, VA provides 
access to relevant provider educational and training resources (e.g., 
webinars of the type incidentally mentioned in the same comment), and a 
related national point of contact, in this manner.\2\ However, VA also 
currently makes certain information, resources, and points of contact 
available only through the individual VHA medical facilities that enter 
into and administer the specific VCAs to which such information, 
resources, and points of contact relate. Applications for certification 
under section 17.4110 of the interim final rule are processed, and VCAs 
are entered into and administered, by officials at local VHA medical 
facilities. Consequently, those officials and the local facility staff 
are often the most reliable and efficient sources of relevant and 
accurate information for an entity or provider that is considering or 
is currently navigating the processes of applying for certification, 
entering into a VCA with that local facility, and/or furnishing 
hospital care, medical services, or extended care services pursuant to 
a VCA that the entity or provider previously entered into with that 
local facility. Moreover, even in instances where the responsible local 
officials lack certain information requested by an entity or provider 
regarding those matters, it is important that those local officials 
remain the applicable VA points of contact for such entities and 
providers regarding those matters. Local officials possess the 
authority and responsibility for many aspects of the implementation and 
use of VCAs at each local VHA medical facility, so ensuring that they 
are privy to and the source of communications to entities and providers 
regarding those matters (e.g., status of a provider's certification, 
terms of a provider's VCA, or issues pertaining to specific 
authorizations or claims) promotes consistency and efficiency in VA's 
use and administration of VCAs and mitigates risk of conflicting 
communications from those lacking the authority and responsibility for 
those aspects of VA's implementation and use of the specific local VCAs 
and processes that are the subject of such communications. If the 
responsible officials at local VHA facilities lack certain information 
requested by an entity or provider regarding implementation and use of 
VCAs at that facility, those officials can and do utilize established 
internal communication channels to consult with VISN and national VHA 
offices, including the Office of Community Care, as appropriate, in 
identifying such information and formulating an appropriate response.
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    \1\ See https://www.va.gov/communitycare/ (last accessed 9/8/
2021).
    \2\ See https://www.va.gov/communitycare/providers/EDU_Training.asp (last accessed 9/8/2021).
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    In its second comment, the same commenter noted that it wants to 
ensure that the Centers for Medicare & Medicaid Services (CMS) and VA 
communicate how CMS' Patient Driven Payment Model (PDPM), which became 
effective on October 1, 2019, and the VCA reimbursement structures will 
work together. As it pertains to VA, we interpret this comment as 
requesting that VA communicate whether and to what extent the rates 
that VA pays for care and services furnished by nursing facilities 
pursuant to VCAs are based upon or influenced by CMS' PDPM case-mix 
classification methodology for calculating Part A payments under 
Medicare's skilled nursing facility prospective payment system (SNF 
PPS). As established in Sec.  17.4120 of the interim final rule, that 
information (i.e., the nexus between CMS' PDPM methodologies and rates 
and VA payment methodologies and rates, if any), when applicable, will 
be communicated by VA in the price terms set forth in the specific VCA 
pursuant to which VA obtains the care or services at issue. 
Specifically, as established in Sec.  17.4120 of the interim final 
rule, the rates paid by VA for hospital care, medical services, and 
extended care services furnished pursuant to a VCA will be the rates 
set forth in the price terms of that specific VCA, and those price 
terms will be established in compliance with the general parameters set 
forth in Sec.  17.4120(a)-(e). One such parameter of particular 
relevance to this comment regarding CMS' PDPM is contained in Sec.  
17.4120(a), which provides in pertinent part that, subject to the 
caveats and exceptions set forth in Sec.  17.4120(b)-(e), payment rates 
for services furnished pursuant to VCAs will not exceed the applicable 
Medicare prospective payment system amount, if any, for the period in 
which the service was provided (without any changes based on the 
subsequent development of information under Medicare authorities). 
Given that Medicare's SNF PPS is a ``prospective payment system'' 
within the meaning of the foregoing limitation, and given that CMS' 
PDPM currently governs how payment amounts are calculated under the SNF 
PPS, the PDPM will necessarily be factored into VA's calculus when 
formulating certain VCA payment rates that are subject to the general 
limitation set forth in Sec.  17.4120(a). However, while the general 
limitation in Sec.  17.4120(a) can affect how VA formulates pricing for 
care and services obtained pursuant to VCAs, we emphasize that it is 
subject to the caveats and exceptions set forth in Sec.  17.4120(b)-(e) 
and we note that the existence of that general limitation does not 
require or mean that the price terms set forth in any specific VCA for 
care and services furnished by nursing facilities will be the same as 
or based upon the payment rates, if any, for the same services under 
CMS' PDPM. Instead, as previously stated, the nexus between CMS' PDPM 
methodologies and rates and VA payment methodologies and rates, if any, 
will be communicated by VA in the price terms set forth in the specific 
VCA pursuant to which VA obtains the care or services at issue.
    In its third comment, the same commenter indicated that providers 
might be hesitant to enter into VCAs until the U.S. Department of 
Labor's Office of Federal Contract Compliance Programs (OFCCP) issues a 
Notice of Proposed Rulemaking (NPRM) that would revise certain portions 
of 41 CFR subtitle B, chapter 60 that concern the obligations of 
TRICARE and certain other health care providers, as federal contractors 
and/or subcontractors, under the nondiscrimination and affirmative 
action provisions of Executive Order (E.O.) 11246 (as amended), section 
503 of the Rehabilitation Act of 1973 (as amended), and the Vietnam Era 
Veterans' Readjustment Assistance Act of 1974 (as amended). We 
interpret this comment as referring to the NPRM subsequently published 
by OFCCP at 84 FR 59746 (Nov. 6, 2019). That NPRM culminated in a final 
rule, published by OFCCP at 85 FR 39834 (Jul. 2, 2020), that revised 
certain definitions set forth in 41 CFR 60-1.3, 60-300.2, and 60-741.2. 
Given that the rulemaking

[[Page 50858]]

referenced in this comment has been completed, the commenter's concern 
that providers might be hesitant to enter into VCAs until the 
completion of that rulemaking process is no longer applicable.
    In its fourth and final comment, the same commenter stated that it 
wants to ensure that ``services covered under VA contracts will 
continue to be covered under VCAs.'' While the intended meaning of this 
comment is unclear to us, we note that, in accordance with the 
statutory authority for VCAs and the interim final rule, VA can use 
VCAs to obtain ``hospital care'' (as defined in 38 U.S.C. 1701(5)), 
``medical services'' (as defined 38 U.S.C. 1701(6)), and ``extended 
care services'' (defined as the services described in 38 U.S.C. 
1710B(a)).\3\ We also note that the circumstances when VA is legally 
authorized to use VCAs to obtain hospital care, medical services, or 
extended care services are specified in 38 U.S.C. 1703A(a) and in Sec.  
17.4115(a) of the interim final rule. Consequently, we do not make any 
changes to the interim final rule based on this comment.
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    \3\ See 38 U.S.C. 1703A(a)(1)(A) (authorizing VA to use VCAs to 
obtain ``hospital care, a medical service, or an extended care 
service'' in certain circumstances); 38 U.S.C. 1701(5)-(6) (defining 
the terms ``hospital care'' and ``medical services'' for purposes of 
38 U.S.C. chapter 17, which includes section 1703A); 38 CFR 17.4100 
(defining the terms ``hospital care,'' ``medical services,'' and 
``extended care services'' for purposes of sections 17.4100-
17.4135).
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    One commenter that represents a membership consisting of hearing 
health care professionals, including licensed hearing aid specialists, 
offered several comments in response to the interim final rule. Some of 
those comments pertain to matters that are outside the scope of this 
rulemaking and which do not implicate any considerations that would 
necessitate or merit any changes to the interim final rule. For 
example, the commenter urged VA to develop and implement the 
qualifications, which VA is authorized to prescribe pursuant to 38 
U.S.C. 7402(b)(14), for hearing aid specialists appointed to positions 
in VHA in accordance with 38 U.S.C. 7401. The commenter also urged VA 
to include hearing aid specialists appointed pursuant to 38 U.S.C. 7401 
in the audiology teams that operate in VHA facilities. The government 
personnel matters raised in these comments, including whether and when 
VA develops qualifications for hearing aid specialists appointed to 
positions in VHA, and how VA utilizes any such specialists in VHA 
facilities, are outside the scope of this rulemaking and implicate no 
issues bearing on the contents of the interim final rule.
    The same commenter also urged VA to prioritize delivery of hearing-
related health care services to veterans, both in VHA facilities and 
through ``the Community Care Program,'' a phrase that we interpret to 
be a reference to the Veterans Community Care Program (VCCP) 
established by section 101 of the MISSION Act (codified as amended at 
38 U.S.C. 1703). The matters raised in this comment, including whether 
and to what extent VA can and does prioritize the provision of certain 
types of hospital care, medical services, and extended care services in 
VHA facilities or through the VCCP, are matters outside the scope of 
this rulemaking. Moreover, to the extent the commenter is concerned 
about VA electing to adopt regulatory parameters that restrict VA's 
ability to provide hearing-related health care services through VCAs, 
we note that the interim final rule contains no such elective 
restrictions. The interim final rule authorizes VA to use VCAs to 
obtain any of the types of hospital care, medical services, and 
extended care services permitted by the underlying statutory authority, 
38 U.S.C. 1703A.
    The commenter also recommended that VA use licensed hearing aid 
specialists and audiologists to provide hearing aid evaluations, 
hearing aid fittings, and related services when veterans are receiving 
such services through ``the Community Care Program,'' a phrase that, as 
previously noted, we interpret to be a reference to the VCCP. The 
matters raised in this comment, including whether and to what extent 
certain specific types of providers furnish the care and services that 
VA obtains for covered veterans through the VCCP, are matters outside 
the scope of this rulemaking. Moreover, to the extent the commenter is 
concerned about VA electing to adopt regulatory parameters that 
restrict VA's ability to use VCAs to obtain care and services furnished 
by licensed hearing aid specialists and audiologists, we note that the 
interim final rule contains no such elective restrictions. For example, 
the certification process set forth in Sec.  17.4110 of the interim 
final rule contains no requirements or approval criteria that would 
fundamentally preclude VA from granting certification to licensed 
hearing aid specialists and audiologists or that are any more 
restrictive with regard to those types of providers than they are for 
any other type of provider or entity seeking certification.
    In addition to providing the general comments described above, the 
same commenter also suggested two changes to the text of the interim 
final rule. First, the commenter suggested that VA replace the term 
``medical'' in Sec.  17.4110(b)(1)(i) with the term ``health care'' so 
that the licensure documentation requirement in that subparagraph 
encompasses health care professionals other than physicians. In 
response, we clarify that the requirement in that subparagraph to 
provide documentation of ``applicable medical licenses'' does not 
preclude health care professionals other than physicians from applying 
for and receiving certification under Sec.  17.4110. If the applicant 
does not possess a medical license, then there are no ``applicable 
medical licenses'' of which the applicant must submit documentation 
under that subparagraph. Moreover, we also note that under Sec.  
17.4110(b)(1)(ii), VA can require applicants to submit documentation of 
relevant licenses other than medical licenses. Consequently, because 
the result apparently sought by the commenter--VA's certification 
process accommodating the submission of documentation of licenses from 
health care professionals other than physicians--is already provided 
for in the existing language of the interim final rule, VA does not 
adopt the change recommended in this comment. The commenter also 
indicated that the payment rate parameters set forth in Sec.  
17.4120(a)-(b) of the interim final rule, which are expressly tied to 
Medicare payment models, should be revised to allow for the 
establishment of fee schedules for services that are not within the 
scope of those Medicare-related parameters, such as hearing tests for 
the provision of hearing aids and related hearing aid services. In 
response, VA notes that the payment rate parameters set forth in Sec.  
17.4120 of the interim final rule already permit the very result that 
the commenter is seeking. Under Sec.  17.4120, the rates paid by VA for 
hospital care, medical services, or extended care services furnished 
pursuant to a VCA are the rates set forth in the price terms of that 
specific VCA, and, when the Medicare-related parameters set forth in 
Sec.  17.4120(a)-(b) do not apply to the care or services at issue, VA 
is permitted to establish the payment rates for such care or services 
based on a fee schedule or some other formulation that is unrelated to 
Medicare payment rates and methodologies. Given that the result sought 
by the commenter is already permitted under the existing language of 
the interim final rule, VA makes no changes based on this comment.

[[Page 50859]]

    A commenter that operates a psychiatric facility raised multiple 
issues. First, the commenter noted that veterans often face specialized 
mental health needs, including ``combat related'' needs such as those 
resulting from post-traumatic stress disorder (PTSD) or traumatic brain 
injury (TBI). In light of VA's specialized experience in those clinical 
areas, the commenter urged VA to share its knowledge of ``combat 
related illnesses'' with mental health providers and indicated that VA 
should require mental health providers furnishing care pursuant to VCAs 
to be adequately trained to handle mental health needs that are unique 
to or more frequently experienced by veterans. In this regard, the 
commenter specifically recommended that the certification process in 
Sec.  17.4110 of the interim final rule should require special training 
in the area of mental health. We interpret this recommendation to mean 
that such training should be required solely for mental health 
providers and should pertain to those clinical areas for which VA has 
special expertise, including PTSD and TBI. In response, we note that VA 
agrees that it is critical for veterans to receive competent care from 
qualified non-VA providers and that VA can contribute to that result in 
certain instances by providing training and/or education to non-VA 
providers in clinical areas for which VA has special expertise, 
including PTSD and TBI. In this regard, we note that VA will take a 
number of actions that will result in the provision of relevant 
training and education to non-VA providers furnishing care and services 
authorized pursuant to VCAs. For example, in accordance with section 
133 of the MISSION Act (codified at 38 U.S.C. 1701 note), VA 
established competency standards and requirements, including training 
requirements, for the provision of care by non-VA providers in clinical 
areas for which VA has special expertise, including PTSD and TBI. Such 
requirements apply to providers furnishing care and services pursuant 
to VCAs. Also, in accordance with section 123 of the MISSION Act 
(codified at 38 U.S.C. 1701 note), VA established a program to provide 
continuing medical education to non-VA medical professionals furnishing 
care to VA beneficiaries, including pursuant to VCAs. Moreover, VA 
provides appropriate oversight of care and services furnished pursuant 
to VCAs as VA administers those agreements. For example, VA established 
and imposed quality standards in accordance with 38 U.S.C. 1703C and 
monitors and assess the quality of the care and services provided 
pursuant to VCAs in accordance with 38 U.S.C. 1703A(g). However, adding 
specific training requirements to the certification process in Sec.  
17.4110 through the regulation process, as opposed through the VCA 
agreements themselves, would not be an appropriate means of 
establishing such training requirements and ensuring that non-VA 
providers fulfill the appropriate training requirements prior to 
furnishing mental health care that VA obtains through VCAs in clinical 
areas for which VA has special expertise, including PTSD and TBI. 
Training requirements for mental health providers furnishing care and 
services pursuant to VCAs may need to be changed over time, potentially 
quickly in certain instances, for reasons including developments in 
clinical practice or new legal requirements with which VA must comply. 
So, establishing training requirements in the terms of VCAs, rather 
than in the certification process set forth in the final rule resulting 
from this rulemaking, will ensure VA retains the flexibility to more 
quickly and efficiently adjust those training requirements as 
appropriate based on evolving circumstances and requirements. For the 
foregoing reasons, we do not adopt the commenter's recommendation to 
add a training requirement to the certification process set forth in 
Sec.  17.4110 of the interim final rule.
    The same commenter also provided recommendations regarding the 
authority set forth in Sec.  17.4020(d) of the interim final rule, 
which authorizes VA to establish payment rates exceeding the applicable 
Medicare-based limitations in Sec.  17.4120(a)-(b) when VA determines 
that it is not practicable to limit payment to those rates. 
Specifically, the commenter recommended that the authority to make the 
determinations referenced in Sec.  17.4120(d) should be delegated to 
officials at individual VHA medical facilities and should not be 
subject to an overly burdensome justification and approval process. In 
response, VA notes that although the authority to generate 
determinations referenced in Sec.  17.4120(d) of the interim final rule 
is delegated to officials at individual VHA medical facilities, that 
authority is circumscribed by a requirement that each such 
determination must be approved by VHA's national Office of Community 
Care. This centralized oversight by the Office of Community Care is 
intended to enhance the effectiveness and integrity of VA's use of 
VCAs, as well as the entire VCCP, by bringing that office's resources, 
data, and enterprise-wide view of VCAs and the VCCP to bear in a manner 
that will promote consistency and quality in how VA interprets and 
applies the impracticability standard in Sec.  17.4120(d) of the 
interim final rule and that will ensure VA is appropriately assessing 
and accounting for the potential impacts, if any, of such 
determinations on the VCCP more broadly. Consequently, VA does not make 
any changes to the interim final rule based on these comments.
    The same commenter also indicated that the non-VA entities and 
providers furnishing care pursuant to VCAs need to be adequately 
compensated on a timely basis for their services. In response, we note 
that VA agrees with this comment and will work to ensure timely 
payments for care and services obtained pursuant to VCAs, as required 
by 38 U.S.C. 1703D. All VCAs contain payment terms that require VA to 
make payment in accordance with the timeframes required by statute, so 
it would serve no relevant purpose to add those same payment timeliness 
requirements to this final rule. Consequently, we do not make any 
changes to the interim final rule based on this comment.
    The same commenter also asserted that VA must develop and partner 
with a network of dedicated providers and that service-disabled veteran 
owned small businesses (SDVOSB), veteran owned small businesses (VOSB), 
and prior VA clinicians should be given priority. The comment indicated 
that the reasons for recommending that VA prioritize utilization of 
SDVOSBs and VOSBs include that veterans (which we presume refers to the 
veteran owners of those businesses) have shared military experience 
that improves the efficacy of counseling services provided to fellow 
veterans and that such veteran owners are highly motivated, dedicated, 
and willing to make sacrifices to help their fellow veterans. As it 
pertains to the subject matter of this rulemaking, VCAs, we interpret 
this comment recommending that VA give ``priority'' to SDVOSBs, VOSBs, 
and prior VA clinicians to mean that when VA is obtaining needed 
hospital care, medical services, or extended care services for a 
veteran through a VCA, in accordance with the legal criteria for doing 
so,\4\ two or more VCAs are feasibly available for that purpose, and 
one or more of those feasibly available VCAs was entered into with an 
entity that's an SDVOSB or a VOSB or with a provider that's a prior

[[Page 50860]]

VA clinician, that VA should automatically obtain the needed care or 
services through one of the VCAs entered into with the entities and 
providers in those classes in lieu of using any other VCAs that are 
feasibly available. In response, we note that when the needed care or 
services at issue are being obtained through the VCCP, the veteran is 
legally permitted to select the eligible entity or provider from which 
the veteran receives such care or services.\5\ So, implementing the 
commenter's recommendation would not be legally feasible in that 
context if the veteran opts to select the eligible entity or provider. 
Moreover, if and when VA finds itself in the position of selecting from 
among multiple VCAs that are feasibly available for purposes of 
obtaining needed care or services, VA's determination of the 
appropriate VCA to utilize will be driven by clinical considerations, 
including those bearing on ensuring VA obtains timely and quality care 
and services most appropriate to the specific needs of the beneficiary. 
In some instances, the involvement of veterans or prior VA clinicians 
in the delivery of care and services by certain entities and providers 
could prove relevant to such individualized and clinically driven 
determinations. However, selecting the VCA that VA will use based upon 
whether the VCA was entered into with an SDVOSB, a VOSB, or a prior VA 
clinician, rather than based upon a holistic and individualized 
assessment of all relevant clinical considerations, including those 
bearing on ensuring VA obtains timely and quality care and services 
most appropriate to the specific needs of the veteran, could result in 
adverse consequences, including worse health outcomes, for the veteran. 
Consequently, we decline to adopt such an approach, and, for the 
foregoing reasons, we make no changes to the interim final rule based 
on this comment.
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    \4\ As previously noted, the circumstances when VA is legally 
authorized to use VCAs to obtain hospital care, medical services, or 
extended care services are specified in 38 U.S.C. 1703A(a) and in 
Sec.  17.4115(a) of the interim final rule.
    \5\ See 38 U.S.C. 1703(g)(2) (``[VA] shall not prioritize 
providers in a tier over providers in any other tier in a manner 
that limits the choice of a covered veteran in selecting a health 
care provider specified in subsection (c) for receipt of hospital 
care, medical services, or extended care services under [the 
VCCP]''); 38 CFR 17.4030 (``[a] covered veteran may specify a 
particular eligible entity or provider'').
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Administrative Procedure Act

    VA has considered all relevant input and information contained in 
the comments submitted in response to the interim final rule (84 FR 
21668) and, for the reasons set forth in the foregoing responses to 
those comments, has concluded that no changes to the interim final rule 
are warranted. Accordingly, based upon the authorities and reasons set 
forth in the interim final rule (84 FR 21668), as supplemented by the 
additional reasons provided in this document in response to comments 
received, VA is adopting the provisions of the interim final rule as a 
final rule with no substantive changes.

Paperwork Reduction Act

    The Paperwork Reduction Act of 1995 (44 U.S.C. 3507) requires that 
VA consider the impact of paperwork and other information collection 
burdens imposed on the public. Except for emergency approvals under 44 
U.S.C. 3507(j), VA may not conduct or sponsor, and a person is not 
required to respond to, a collection of information unless it displays 
a currently valid OMB control number. The interim final rule included 
provisions constituting new collections of information under the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521) that require 
approval by the Office of Management and Budget (OMB) (the provisions 
in the interim final rule are Sec. Sec.  17.4110, 17.4130, and 
17.4135). Accordingly, under 44 U.S.C. 3507(d), VA submitted a copy of 
the interim final rule to OMB for review, and VA requested that OMB 
approve the collections of information on an emergency basis. VA did 
not receive any comments on the collections of information contained in 
the interim final rule. OMB approved the collections of information 
under control number 2900-0872.

Regulatory Flexibility Act

    The Secretary hereby certifies that this rule will not have a 
significant economic impact on a substantial number of small entities 
as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-
612. Therefore, pursuant to 5 U.S.C. 605(b), the initial and final 
regulatory flexibility analysis requirements of 5 U.S.C. 603 and 604 do 
not apply.

Executive Orders 12866 and 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
OMB's Office of Information and Regulatory Affairs (OIRA) has 
determined that this rule is not a significant regulatory action under 
Executive Order 12866. The Regulatory Impact Analysis associated with 
this rulemaking can be found as a supporting document at 
www.regulations.gov.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of anticipated costs and 
benefits before issuing any rule that may result in the expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any one year. This final rule will have no such effect on 
State, local, and tribal governments, or on the private sector.

Congressional Review Act

    Pursuant to the Congressional Review Act (5 U.S.C. 801 et seq.), 
OIRA designated this rule as not a major rule, as defined by 5 U.S.C. 
804(2).

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are as follows: 64.009, Veterans 
Medical Care Benefits; and 64.018, Sharing Specialized Medical 
Resources.

List of Subjects in 38 CFR Part 17

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

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved this 
document on July 27, 2021, and authorized the undersigned to sign and 
submit the document to the Office of the Federal Register for 
publication

[[Page 50861]]

electronically as an official document of the Department of Veterans 
Affairs.

Michael P. Shores,
Director, Office of Regulation Policy & Management, Office of General 
Counsel, Department of Veterans Affairs.

    Accordingly, the interim final rule amending 38 CFR part 17, which 
was published at 84 FR 21668 on May 14, 2019, is adopted as final with 
the following technical amendments:

PART 17--MEDICAL

0
1. The general authority citation for part 17 continues to read as 
follows:

    Authority:  38 U.S.C. 501, and as noted in specific sections
* * * * *


Sec.  Sec.  17.4110, 17.4130, and 17.4135   [Amended]

0
2. In Sec. Sec.  17.4110, 17.4130, and 17.4135, remove the OMB 
statement ``(The information collection requirements have been 
submitted to the Office of Management and Budget (OMB) and are pending 
OMB approval.)'' and add in its place ``(Office of Management and 
Budget approved the collection of information under control number 
2900-0872.)''.

[FR Doc. 2021-19470 Filed 9-10-21; 8:45 am]
BILLING CODE 8320-01-P