Reasonable Charges for Outpatient Medical Care or Services; v4.225, Calendar Year (CY) 2022 Update and National Average Administrative Prescription Drug Charge Update, 71707-71708 [2021-27377]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 86, Number 240 (Friday, December 17, 2021)]
[Notices]
[Pages 71707-71708]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-27377]


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DEPARTMENT OF VETERANS AFFAIRS


Reasonable Charges for Outpatient Medical Care or Services; 
v4.225, Calendar Year (CY) 2022 Update and National Average 
Administrative Prescription Drug Charge Update

AGENCY: Department of Veterans Affairs (VA).

ACTION: Notice.

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SUMMARY: This VA notice updates the data for calculating what VA refers 
to as the Reasonable Charges collected or recovered by VA for medical 
care or services provided or furnished by VA to a veteran. This notice 
also updates the National Average Administrative Prescription Costs for 
purposes of calculating VA's charges for prescription drugs that were 
not administered during treatment but provided or furnished by VA to a 
veteran.

DATES: This change is effective January 1, 2022.

FOR FURTHER INFORMATION CONTACT: Debra Vatthauer, Office of Finance, 
Revenue Operations, Payer Relations and Services, Rates and Charges, 
Veterans Health Administration, Department of Veterans Affairs, 128 
Bingham Road, Suite 1000, Asheville, NC 28806; email: 
[email protected]; telephone: 608-821-7346 (This is not a toll-
free number).

SUPPLEMENTARY INFORMATION: 38 CFR 17.101(a)(1) sets forth VA's 
collection or recovery regulations, pursuant to 38 U.S.C. 1729, for 
medical care or services provided or furnished by VA to a Veteran for: 
A nonservice-connected disability for which the veteran is entitled to 
care (or the payment of expenses for care) under a health plan 
contract; a nonservice-connected disability incurred incident to the 
veteran's employment and covered under a worker's compensation law or 
plan that provides reimbursement or indemnification for such care and 
services; or, for a nonservice-connected disability incurred as a 
result of a motor vehicle accident in a state that requires automobile 
accident reparations insurance. VA refers to the charges for services 
as derived under 38 CFR 17.101 as ``reasonable charges.'' Section 
17.101 provides the methodologies for establishing billed amounts for 
several types of charges; however, this notice will only address 
partial hospitalization facility charges; outpatient facility charges; 
physician and other professional charges, including professional 
charges for anesthesia services and dental services; pathology and 
laboratory charges; observation care facility charges; ambulance and 
other emergency transportation charges; and charges for durable medical 
equipment, drugs, injectables, and other medical services, items, and 
supplies identified by Healthcare Common Procedure Coding System 
(HCPCS) Level II codes.
    Section 17.101(a)(2) provides that the actual charge amounts at 
individual VA medical facilities based on these methodologies and the 
data sources used for calculating those actual charge amounts will 
either be published in a notice in the Federal Register (FR) or will be 
posted on VA's website at: https://www.va.gov/communitycare/revenue_ops/payer_rates.asp.
    Certain charges are updated as stated in this notice and will be 
effective on January 1, 2022.
    In cases where VA has not established charges for medical care or 
services provided or furnished at VA expense (by either VA or non-VA 
providers) under other provisions or regulations, the method for 
determining VA's charges is set forth at section 17.101(a)(8).
    Based on the methodologies set forth in section 17.101, this notice 
provides an update to charges for CY 2022 HCPCS Level II and Current 
Procedural Terminology codes. Charges are also being updated based on 
more recent versions of data sources for the following charge types: 
Partial hospitalization facility charges; outpatient facility charges; 
physician and other professional charges, including professional 
charges for anesthesia services and dental services; pathology and 
laboratory charges; observation care facility charges; ambulance and 
other emergency transportation charges; and charges for durable medical 
equipment, drugs, injectables and other medical services, items and 
supplies identified by HCPCS Level II codes. As of the date of this 
notice, the actual charge amounts at individual VA medical facilities 
are based on the methodologies and data sources described in section 
17.101. The nationwide charges will be posted on VA's website at: 
https://www.va.gov/communitycare/revenue_ops/payer_rates.asp under the 
heading ``Reasonable Charges Data Tables'' and identified as ``v4.225 
Data Tables (Outpatient and Professional).''
    Acute inpatient facility charges and skilled nursing facility/sub-
acute inpatient facility charges remain the same as set forth in the 
notice published in the Federal Register on September 13, 2021 (86 FR 
50953).
    We are also updating the list of VA medical facility locations. The 
list of VA medical facility locations, including the first three digits 
of their zip codes will be posted on VA's website under the heading 
``VA Medical Facility Locations'' and identified as ``v4.225 (Jan 
22).''
    Consistent with section 17.101 (a)(2), the updated data and 
supplementary tables containing the changes described in this notice 
will be posted on VA's website at https://www.va.gov/communitycare/revenue_ops/payer_rates.asp under the heading ``Reasonable Charges 
Rules, Notices and Federal Register'' and identified as ``v4.225 
Federal Register Notice 01/01/22 (Outpatient and Professional)''. The 
updated data, and supplementary tables containing the changes described 
will be effective until changed by a subsequent FR notice. Consistent 
with section 17.101(a)(3), the list of data sources used for 
calculating the actual charge amounts listed above also will be posted 
on VA's website under the heading ``Reasonable Charges Data Sources'' 
and identified as ``Reasonable Charges v4.225 Data Sources (Outpatient 
and Professional) (PDF).''
    Section 17.101(m) establishes the charges for prescription drugs 
not administered during treatment, as part of medical care or services 
provided or furnished by VA to a veteran under section 17.101(a)(1) for 
a nonservice-connected disability for which the veteran is entitled to 
care (or the payment of expenses for care) under a health plan 
contract; for a nonservice-connected disability incurred incident to 
the veteran's employment and covered under a worker's compensation law 
or plan that provides reimbursement or indemnification for such care 
and services; or for a nonservice-connected disability incurred as a 
result of a motor vehicle accident in a state that requires automobile 
accident reparations insurance.
    As indicated in section 17.101(m), when VA provides or furnishes 
prescription drugs not administered during treatment, within the scope 
of care described in section 17.101(a)(1), charges billed separately 
for such

[[Page 71708]]

prescription drugs will consist of the amount that equals the total of 
the actual cost to VA for the drugs and the national average of VA 
administrative costs associated with dispensing the drugs for each 
prescription. Section 17.101(m) further describes the methodology for 
calculating the national average administrative cost for prescription 
drug charges not administered during treatment.
    VA determines the amount of the national average administrative 
cost annually for the prior fiscal year (October through September) and 
then applies the charge at the start of the next calendar year.
    Consistent with section 17.101(a)(2), the national average 
administrative cost calculated by VA under section 17.101(m) will be 
posted online on VA's website at: https://www.va.gov/communitycare/revenue_ops/payer_rates.asp under the heading ``Reasonable Charges 
Rules, Notices and Federal Register and identified as CY 22 National 
Average Administrative Cost (PDF)'', to be effective on January 1, 
2022. The national average administrative cost posted will be effective 
until changed by a subsequent FR notice.

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved this 
document on December 10, 2021, 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.

Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy & 
Management, Office of General Counsel, Department of Veterans Affairs.
[FR Doc. 2021-27377 Filed 12-16-21; 8:45 am]
BILLING CODE 8320-01-P