**Enrollment Provisions and Medical Benefits Package**

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

\(a\) *Enrollment requirement for veterans*.

\(1\) Except as otherwise provided in §17.37, a veteran must be enrolled
in the VA healthcare system as a condition for receiving the "medical
benefits package" set forth in §17.38.

> **Note to paragraph (a)(1):** A veteran may apply to be enrolled at
> any time. (See §17.36(d)(1).)

\(2\) Except as provided in paragraph (a)(3) of this section, a veteran
enrolled under this section and who, if required by law to do so, has
agreed to make any applicable copayment is eligible for VA hospital and
outpatient care as provided in the "medical benefits package" set forth
in §17.38.

> **Note to paragraph (a)(2):** A veteran's enrollment status will be
> recognized throughout the United States.

\(3\) A veteran enrolled based on having a disorder associated with
exposure to a toxic substance or radiation, for a disorder associated
with service in the Southwest Asia theater of operations during the Gulf
War, or any illness associated with service in combat in a war after the
Gulf War or during a period of hostility after November 11, 1998, as
provided in 38 U.S.C. 1710(e), is eligible for VA care provided in the
"medical benefits package" set forth in §17.38 for the disorder.

\(b\) *Categories of veterans eligible to be enrolled*. The Secretary
will determine which categories of veterans are eligible to be enrolled
based on the following order of priority:

\(1\) Veterans with a singular or combined rating of 50 percent or
greater based on one or more service-connected disabilities or
unemployability.

\(2\) Veterans with a singular or combined rating of 30 percent or 40
percent based on one or more service-connected disabilities.

\(3\) Veterans who are former prisoners of war; veterans awarded the
Purple Heart; veterans with a singular or combined rating of 10 percent
or 20 percent based on one or more service-connected disabilities;
veterans who were discharged or released from active military service
for a disability incurred or aggravated in the line of duty; veterans
who receive disability compensation under 38 U.S.C. 1151; veterans whose
entitlement to disability compensation is suspended pursuant to 38
U.S.C. 1151, but only to the extent that such veterans' continuing
eligibility for that care is provided for in the judgment or settlement
described in 38 U.S.C. 1151; veterans whose entitlement to disability
compensation is suspended because of the receipt of military retired
pay; and veterans receiving compensation at the 10 percent rating level
based on multiple noncompensable service-connected disabilities that
clearly interfere with normal employability.

\(4\) Veterans who receive increased pension based on their need for
regular aid and attendance or by reason of being permanently housebound
and other veterans who are determined to be catastrophically disabled by
the Chief of Staff (or equivalent clinical official) at the VA facility
where they were examined.

\(5\) Veterans not covered by paragraphs (b)(1) through (b)(4) of this
section who are determined to be unable to defray the expenses of
necessary care under 38 U.S.C. 1722(a).

\(6\) Veterans of the Mexican border period or of World War I; veterans
solely seeking care for a disorder associated with exposure to a toxic
substance or radiation, for a disorder associated with service in the
Southwest Asia theater of operations during the Gulf War, or for any
illness associated with service in combat in a war after the Gulf War or
during a period of hostility after November 11, 1998, as provided and
limited in 38 U.S.C. 1710(e); and veterans with 0 percent
service-connected disabilities who are nevertheless compensated,
including veterans receiving compensation for inactive tuberculosis.

\(7\) Veterans who agree to pay to the United States the applicable
copayment determined under 38 U.S.C. 1710(f) and 1710(g) if their income
for the previous year constitutes "low income" under the geographical
income limits established by the U.S. Department of Housing and Urban
Development for the fiscal year that ended on September 30 of the
previous calendar year. For purposes of this paragraph, VA will
determine the income of veterans (to include the income of their spouses
and dependents) using the rules in §§3.271, 3.272, 3.273, and 3.276.
After determining the veterans' income and the number of persons in the
veterans' family (including only the spouse and dependent children), VA
will compare their income with the current applicable "low-income"
income limit for the public housing and section 8 programs in their area
that the U.S. Department of Housing and Urban Development publishes
pursuant to 42 U.S.C. 1437a(b)(2). If the veteran's income is below the
applicable "low-income" income limits for the area in which the veteran
resides, the veteran will be considered to have "low income" for
purposes of this paragraph. To avoid a hardship to a veteran, VA may use
the projected income for the current year of the veteran, spouse, and
dependent children if the projected income is below the "low income"
income limit referenced above. This category is further prioritized into
the following subcategories:

\(i\) Noncompensable zero percent service-connected veterans who are in
an enrolled status on a specified date announced in a *Federal Register*
document promulgated under paragraph (c) of this section and who
subsequently do not request disenrollment;

\(ii\) Nonservice-connected veterans who are in an enrolled status on a
specified date announced in a *Federal Register* document promulgated
under paragraph (c) of this section and who subsequently do not request
disenrollment;

\(iii\) Noncompensable zero percent service-connected veterans not
included in paragraph (b)(7)(i) of this section; and

\(iv\) Nonservice-connected veterans not included in paragraph
(b)(7)(ii) of this section.

\(8\) Veterans not included in priority category 4 or 7, who are
eligible for care only if they agree to pay to the United States the
applicable copayment determined under 38 U.S.C. 1710(f) and 1710(g).
This category is further prioritized into the following subcategories:

\(i\) Noncompensable zero percent service-connected veterans who are in
an enrolled status on a specified date announced in a *Federal Register*
document promulgated under paragraph (c) of this section and who
subsequently do not request disenrollment;

\(ii\) Nonservice-connected veterans who are in an enrolled status on a
specified date announced in a *Federal Register* document promulgated
under paragraph (c) of this section and who subsequently do not request
disenrollment;

\(iii\) Noncompensable zero percent service-connected veterans not
included in paragraph (b)(8)(i) of this section; and

\(iv\) Nonservice-connected veterans not included in paragraph
(b)(8)(ii) of this section.

\(c\) *Federal Register notification of eligible enrollees*.

\(1\) It is anticipated that on or before August 1 of each year the
Secretary will announce in paragraph (c)(2) of this section which
categories of veterans are eligible to be enrolled. As necessary, the
Secretary at any time may revise this determination by further amending
paragraph (c)(2) of this section. The preamble to a *Federal Register*
document announcing which priority categories are eligible to be
enrolled must specify the projected number of fiscal year applicants for
enrollment in each priority category, projected healthcare utilization
and expenditures for veterans in each priority category, appropriated
funds and other revenue projected to be available for fiscal year
enrollees, and results---projected total expenditures for enrollees by
priority category. The determination should include consideration of
relevant internal and external factors, e.g., economic changes, changes
in medical practices, and waiting times to obtain an appointment for
care. Consistent with these criteria, the Secretary will determine which
categories of veterans are eligible to be enrolled based on the order of
priority specified in paragraph (b) of this section.

\(2\) Unless changed by a rulemaking document in accordance with
paragraph (c)(1) of this section, VA will enroll all priority categories
of veterans set forth in §17.36(b) beginning January 17, 2003 except
that those veterans in priority category 8 who were not in an enrolled
status on January 17, 2003 or who requested disenrollment after that
date, are not eligible to be enrolled.

\(d\) *Enrollment and disenrollment process*.

\(1\) *Application for enrollment*. A veteran may apply to be enrolled
in the VA healthcare system at any time. A veteran who wishes to be
enrolled must apply by submitting a VA Form 10-10EZ to a VA medical
facility. Veterans applying based on inclusion in priority categories 1,
2, 3, 6, and 8 do not need to complete section II, but must complete the
rest of the form. Veterans applying based on inclusion in priority
category 4 because of their need for regular aid and attendance or by
being permanently housebound need not complete section II, but must
complete the rest of the form. Veterans applying based on inclusion in
priority category 4 because they are catastrophically disabled need not
complete section II, but must complete the rest of the form, if: they
agree to pay to the United States the applicable copayment determined
under 38 U.S.C. 1710(f) and 1710(g); they are a veteran of the Mexican
border period or of World War I or a veteran with a 0 percent
service-connected disability who is nevertheless compensated; their
catastrophic disability is a disorder associated with exposure to a
toxic substance or radiation, or with service in the Southwest Asia
theater of operations during the Gulf War as provided in 38 U.S.C.
1710(e); or their catastrophic disability is an illness associated with
service in combat in a war after the Gulf War or during a period of
hostility after November 11, 1998, as provided in 38 U.S.C. 1710(e). All
other veterans applying based on inclusion in priority category 4
because they are catastrophically disabled must complete the entire
form. Veterans applying based on inclusion in priority category 5 must
complete the entire form. Veterans applying based on inclusion in
priority category 7 must complete the entire form except for section
IIE. VA form 10-10EZ is set forth in paragraph (f) of this section and
is available from VA medical facilities.

\(2\) *Action on application*. Upon receipt of a completed VA Form
10-10EZ, a VA network or facility director, or the Deputy Under
Secretary for Health for Operations and Management or Chief, Health
Administration Service or equivalent official at a VA medical facility,
or Director, Health Eligibility Center, will accept a veteran as an
enrollee upon determining that the veteran is in a priority category
eligible to be enrolled as set forth in §17.36(c)(2). Upon determining
that a veteran is not in a priority category eligible to be enrolled,
the VA network or facility director, or the Deputy Under Secretary for
Health for Operations and Management or Chief, Health Administration
Service or equivalent official at a VA medical facility, or Director,
Health Eligibility Center, will inform the applicant that the applicant
is ineligible to be enrolled.

\(3\) *Placement in enrollment categories*.

\(i\) Veterans will be placed in priority categories whether or not
veterans in that category are eligible to be enrolled.

\(ii\) A veteran will be placed in the highest priority category or
categories for which the veteran qualifies.

\(iii\) A veteran may be placed in only one priority category, except
that a veteran placed in priority category 6 based on a specified
disorder or illness will also be placed in priority category 7 or
priority category 8, as applicable, if the veteran has previously agreed
to pay the applicable copayment, for all matters not covered by priority
category 6.

\(iv\) A veteran who had been enrolled based on inclusion in priority
category 5 and became no longer eligible for inclusion in priority
category 5 due to failure to submit to VA a current VA Form 10-10EZ will
be changed automatically to enrollment based on inclusion in priority
category 6 or 8 (or more than one of these categories if the previous
principle applies), as applicable, and be considered continuously
enrolled. To meet the criteria for priority category 5, a veteran must
be eligible for priority category 5 based on the information submitted
to VA in a current VA Form 10-10EZ. To be current, after VA has sent a
form 10-10EZ to the veteran at the veteran\'s last known address, the
veteran must return the completed form (including signature) to the
address on the return envelope within 60 days from the date VA sent the
form to the veteran.

\(v\) Veterans will be disenrolled, and reenrolled, in the order of the
priority categories listed with veterans in priority category 1 being
the last to be disenrolled and the first to be reenrolled. Similarly,
within priority categories 7 and 8, veterans will be disenrolled, and
reenrolled, in the order of the priority subcategories listed with
veterans in subcategory (i) being the last to be disenrolled and first
to be reenrolled.

\(4\) *Automatic enrollment*. Notwithstanding other provisions of this
section, veterans who were notified by VA letter that they were enrolled
in the VA healthcare system under the trial VA enrollment program prior
to October 1, 1998, automatically will be enrolled in the VA healthcare
system under this section if determined by a VA network or facility
director, or the Deputy Under Secretary for Health for Operations and
Management or Chief, Health Administration Service or equivalent
official at a VA medical facility, or Director, Health Eligibility
Center, that the veteran is in a priority category eligible to be
enrolled as set forth in §17.36(c)(2). Upon determining that a veteran
is not in a priority category eligible to be enrolled, the VA network or
facility director, or the Deputy Under Secretary for Health for
Operations and Management or Chief, Health Administration Service or
equivalent official at a VA medical facility, or Director, Health
Eligibility Center, will inform the veteran that the veteran is
ineligible to be enrolled.

\(5\) *Disenrollment*. A veteran enrolled in the VA health care system
under paragraph (d)(2) or (d)(4) of this section will be disenrolled
only if:

\(i\) The veteran submits to a VA medical center or the VA Health
Eligibility Center, 1644 Tullie Circle, Atlanta, Georgia 30329, a signed
document stating that the veteran no longer wishes to be enrolled; or

\(ii\) A VA network or facility director, or the Deputy Under Secretary
for Health for Operations and Management or Chief, Health Administration
Service or equivalent official at a VA medical facility, or Director,
Health Eligibility Center, determines that the veteran is no longer in a
priority category eligible to be enrolled, as set forth in §17.36(c)(2);
or

\(iii\) A VA network or facility director, or the Deputy Under Secretary
for Health for Operations and Management or Chief, Health Administration
Service or equivalent official at a VA medical facility, or Director,
Health Eligibility Center, determines that the veteran has been enrolled
based on inclusion in priority category 5 or priority category 7;
determines that the veteran was sent by mail a VA Form 10-10EZ; and
determines that the veteran failed to return the completed form to the
address on the return envelope within 60 days from receipt of the form.
VA Form 10-10EZ is set forth in paragraph (f) of this section.

\(6\) *Notification of enrollment status*. Notice of a decision by a VA
network or facility director, or the Deputy Under Secretary for Health
for Operations and Management or Chief, Health Administration Service or
equivalent official at a VA medical facility, or Director, Health
Eligibility Center, regarding enrollment status will be provided to the
affected veteran by letter and will contain the reasons for the
decision. The letter will include an effective date for any changes and
a statement regarding appeal rights. The decision will be based on all
information available to the decisionmaker, including the information
contained in VA Form 10-10EZ.

\(e\) *Catastrophically disabled*. For purposes of this section,
catastrophically disabled means to have a permanent severely disabling
injury, disorder, or disease that compromises the ability to carry out
the activities of daily living to such a degree that the individual
requires personal or mechanical assistance to leave home or bed or
requires constant supervision to avoid physical harm to self or others.
This definition is met if an individual has been found by the Chief of
Staff (or equivalent clinical official) at the VA facility where the
individual was examined to have a permanent condition specified in
paragraph (e)(1) of this section; to meet permanently one of the
conditions specified in paragraph (e)(2) of this section by a clinical
evaluation of the patient's medical records that documents that the
patient previously met the permanent criteria and continues to meet such
criteria (permanently) or would continue to meet such criteria
(permanently) without the continuation of on-going treatment; or to meet
permanently one of the conditions specified in paragraph (e)(2) of this
section by a current medical examination that documents that the patient
meets the permanent criteria and will continue to meet such criteria
(permanently) or would continue to meet such criteria (permanently)
without the continuation of on-going treatment.

\(1\) Quadriplegia and quadriparesis (ICD-9-CM Code 344.0x: 344.00,
344.01, 344.02, 344.03, 344.04, 3.44.09), paraplegia (ICD-9-CM Code
344.1), blindness (ICD-9-CM Code 369.4), persistent vegetative state
(ICD-9-CM Code 780.03), or a condition resulting from two of the
following procedures (ICD-9-CM Code 84.x or associated V Codes when
available or Current Procedural Terminology (CPT) Codes) provided the
two procedures were not on the same limb:

> \(i\) Amputation through hand (ICD-9-CM Code 84.03 or V Code V49.63 or
> CPT Code 25927);
>
> \(ii\) Disarticulation of wrist (ICD-9-CM Code 84.04 or V Code V49.64
> or CPT Code 25920);
>
> \(iii\) Amputation through forearm (ICD-9-CM Code 84.05 or V Code
> V49.65 or CPT Codes 25900, 25905);
>
> \(iv\) Disarticulation of forearm (ICD-9-CM Code 84.05 or V Code
> V49.66 or CPT Codes 25900, 25905);
>
> \(v\) Amputation or disarticulation through elbow. (ICD-9-CM Code
> 84.06 or V Code V49.66 or CPT 24999);
>
> \(vi\) Amputation through humerus (ICD-9-CM Code 84.07 or V Code
> V49.66 or CPT Codes 24900, 24920);
>
> \(vii\) Shoulder disarticulation (ICD-9-CM Code 84.08 or V Code V49.67
> or CPT Code 23920);
>
> \(viii\) Forequarter amputation (ICD-9-CM Code 84.09 or CPT Code
> 23900);
>
> \(ix\) Lower limb amputation not otherwise specified (ICD-9-CM Code
> 84.10 or V Code V49.70 or CPT Codes 27880, 27882);
>
> \(x\) Amputation of great toe (ICD-9-CM Code 84.11 or V Code V49.71 or
> CPT Codes 28810, 28820);
>
> \(xi\) Amputation through foot (ICD-9-CM Code 84.12 or V Code V49.73
> or CPT Codes 28800, 28805);
>
> \(xii\) Disarticulation of ankle (ICD-9-CM Code 84.13 or V Code V49.74
> or CPT 27889);
>
> \(xiii\) Amputation through malleoli (ICD-9-CM Code 84.14 or V Code
> V49.75 or CPT Code 27888);
>
> \(xiv\) Other amputation below knee (ICD-9-CM Code 84.15 or V Code
> V49.75 or CPT Codes 27880, 27882);
>
> \(xv\) Disarticulation of knee (ICD-9-CM Code 84.16 or V Code V49.76
> or CPT Code 27598);
>
> \(xvi\) Above knee amputation (ICD-9-CM Code 84.17 or V Code V49.76 or
> CPT Code 27598);
>
> \(xvii\) Disarticulation of hip (ICD-9-CM Code 84.18 or V Code V49.77
> or CPT Code 27295); and
>
> \(xviii\) Hindquarter amputation (ICD-9-CM Code 84.19 or CPT Code
> 27290).

\(2\) (i) Dependent in 3 or more Activities of Daily Living (eating,
dressing, bathing, toileting, transferring, incontinence of bowel and/or
bladder), with at least 3 of the dependencies being permanent with a
rating of 1, using the Katz scale.

> \(ii\) A score of 10 or lower using the Folstein Mini-Mental State
> Examination.
>
> \(iii\) A score of 2 or lower on at least 4 of the 13 motor items
> using the Functional Independence Measure.
>
> \(iv\) A score of 30 or lower using the Global Assessment of
> Functioning.

\(f\) *VA Form 10-10EZ*. \[See pages 17.36-9 and 10\]

(Authority: 38 U.S.C 101, 501, 1521, 1701, 1705, 1710, 1721, 1722).

(The Office of Management and Budget has approved the information
collection requirements in this section under control number 2900-0091.)

\[64 FR 54212, Oct. 6, 1999, as amended at 67 FR 35039, May 17, 2002; 67
FR 62887, Oct. 9, 2002; 68 FR 2672, Jan. 17, 2003\]

**Supplement *Highlights* references**: 37(1). Book I, 9(1), 12(1),
13(2).