77514 Federal Register / Vol. 88, No. 217 / Monday, November 13, 2023 / Rules and Regulations 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Part 17 

RIN 2900–AR01 

VA Pilot Program on Graduate Medical 

Education and Residency 

AGENCY: Department of Veterans Affairs. 

ACTION: Final rule. 

SUMMARY: The Department of Veterans 

Affairs (VA) adopts as final, with 

changes, a proposed rule amending its 

medical regulations to establish a new 

pilot program on graduate medical 

education and residency, as required by 

section 403 of the John S. McCain III, 

Daniel K. Akaka, and Samuel R. Johnson 

VA Maintaining Internal Systems and 

Strengthening Integrated Outside 

Network Act of 2018. 

DATES: This rule is effective December 

13, 2023. 

FOR FURTHER INFORMATION CONTACT: 

Andrea Bennett, Office of Academic 

Affiliations, Veterans Health 

Administration, Department of Veterans 

Affairs, at (202) 368–0324 or 

VAMission403Help@va.gov. 

SUPPLEMENTARY INFORMATION: On 

February 4, 2022, VA published a 

proposed rule in the Federal Register 

(87 FR 6456) to revise its medical 

regulations to establish the Pilot 

Program on Graduate Medical Education 

and Residency (PPGMER) in §§ 17.243 

through 17.248 of title 38, Code of 

Federal Regulations (CFR). The 

proposed rule provided a framework to 

establish additional medical residency 

positions at certain covered facilities, 

consistent with the John S. McCain III, 

Daniel K. Akaka, and Samuel R. Johnson 

VA Maintaining Internal Systems and 

Strengthening Integrated Outside 

Network Act of 2018 (the Act), Public 

Law (Pub. L.) 115–182. Section 403 of 

the Act, codified as a note to section 

7302 of title 38 United States Code 

(U.S.C.), establishes parameters for VA 

to determine the covered facilities in 

which residents will be placed 

(including prioritization of certain 

covered facilities such as those operated 

by an Indian Tribe or tribal 

organization), and authorizes VA to pay 

resident stipends and benefits as well as 

certain startup costs of new residency 

programs when residents are placed in 

such programs. VA provided a 60-day 

comment period. 

On March 25, 2022, prior to the end 

of the 60-day comment period, VA 

published a second proposed rule (87 

FR 17050) to extend the comment 

period by 90 days to end on July 5, 

2022, to ensure tribal stakeholders were 

aware of the proposed rule and had 

sufficient time to provide meaningful 

input. On March 30, 2022, VA sent a 

letter to tribal leaders and tribal health 

program leadership to inform them of 

the rulemaking and to provide 

information for a virtual information 

session for tribal leaders on April 19, 

2022, and a virtual tribal consultation 

on May 10, 2022. The transcripts from 

those events are available as part of this 

rulemaking docket on 

www.regulations.gov. 

VA received 19 comments on the 

proposed rule from four large 

professional medical organizations, six 

tribes and tribal organizations, and 

numerous members of the public. All 19 

comments were supportive of the rule, 

and we thank the commenters for their 

thoughtful and detailed feedback. We 

address the substantive 

recommendations and clarify certain 

aspects about the program below. We 

adopt the proposed rule as final with 

two substantive changes and one minor 

technical change as described in more 

detail below. 

§ 17.243—Purpose and Scope 

Section 17.243, as proposed, provided 

a broad overview of the authority for the 

PPGMER as well as general description 

of the function and scope of the 

PPGMER. One commenter 

recommended revising § 17.243 to 

include a description from the 

regulatory impact analysis that 

accompanied the proposed rule of the 

‘‘numerous benefits the program will 

offer to both veterans and non-veterans’’ 

and the explanation of how the 

PPGMER will ‘‘fulfill the VA’s broader 

missions.’’ The commenter stated that 

including this information in the 

purpose and scope at 38 CFR 17.243 

would ‘‘strengthen the VA’s argument 

for both the compelling need and the 

statutory authority of this regulation.’’ 

Because the purpose and scope section 

is a broad overview of the authority for 

the PPGMER, not a detailed explanation 

of the many benefits it may provide, we 

make no changes to the rule based on 

this comment. 

§ 17.245—Covered Facilities 

Section 17.245, as proposed, listed the 

covered facilities in which residents 

may be placed under the PPGMER, 

consistent with section 403(a)(2) of the 

Act. Multiple commenters 

recommended VA add additional 

facilities to the covered facilities 

explicitly listed in § 17.245. In 

particular, they suggested the inclusion 

of Rural Health Clinics, rural training 

sites, ‘‘non-VA facilities with ACGMEaccredited GME programs in noncontiguous areas,’’ Urban Indian 

Organization facilities, and consortia of 

Indian Health Service, Tribal, and 

Urban Indian Organization (‘‘I/T/U’’) 

facilities. The commenters stated that 

the inclusion of these additional 

covered facilities would improve access 

to health care for either underserved 

populations and/or individuals in rural 

locations. 

We make no changes to the rule based 

on these comments. As proposed, the 

language in § 17.245(f) already allows 

VA to consider those types of facilities 

as covered facilities for the purposes of 

the PPGMER. The language proposed by 

VA to describe the six categories of 

covered facilities in § 17.245(a) through 

(f) is almost identical to the language 

Congress used to describe the covered 

facilities in section 403(a)(2)(A) through 

(F) of the Act. The first five paragraphs 

of both the statute and the regulation 

enumerate five specific categories of 

health care facilities that are considered 

covered facilities for purposes of the 

PPGMER. Both authorities then provide 

a sixth and final category allowing VA 

to consider any other health care 

facilities deemed by VA to be 

appropriate for participation. 

As stated in the proposed rule, the 

language of 38 CFR 17.245(f) provides 

VA the ability to place residents in a 

variety of facilities without curtailing 

the discretion given to VA in section 

403(a)(2)(F) of the Act. Explicitly listing 

the five facilities suggested by the 

commenters as additional covered 

facilities in 38 CFR 17.245 does not 

provide additional flexibility beyond 

what is provided in paragraph (f). VA 

intends to use the inclusive authority of 

paragraph (f) to the maximum extent 

possible, which will allow for potential 

resident placements at all facilities 

meeting the intent of the pilot program; 

we do not anticipate placing limitations 

on which facilities may be considered. 

Therefore, further specificity in the 

regulation does not substantively impact 

whether these five additional categories 

of facilities may be deemed appropriate 

covered facilities by VA. 

Placement of Residents 

Prior to addressing certain comments 

on proposed §§ 17.246 through 17.248 

that concern the placement of residents 

under the PPGMER, we first clarify VA’s 

role in such placements under both its 

traditional graduate medical education 

(GME) programming and the new 

PPGMER. In administering traditional 

GME programming, VA forms 

relationships with non-VA institutions 

that sponsor GME programs (most often 

medical schools or teaching hospitals), 


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and it is those sponsoring institutions 

that provide the residents that would be 

available for placement in VA facilities. 

The same would be true for the 

PPGMER. 

VA, therefore, does not control the 

pool of participating educational 

programs or available residents, 

although VA does assess the 

requirements for traditional GME 

placements under 3 U.S.C. 7302(e) to 

determine the best placement locations 

for such residents in VA facilities, and 

VA will do similarly for the PPGMER in 

accordance with the provisions in 38 

CFR 17.246 and 17.247. VA in effect 

then does not place residents but does 

provide for resident positions to be 

filled in VA facilities under its 

traditional GME programming and will 

similarly provide for resident positions 

to be filled in covered facilities as 

defined in § 17.245 under the PPGMER. 

§ 17.246(a)—Placement of Residents 

Section 17.246, as proposed, 

established factors that VA would 

consider when determining in which 

covered facilities residents would be 

placed under the pilot, consistent with 

section 403(a)(4) of the Act. We received 

multiple comments requesting 

modifications and additions to the 

consideration factors for placement of 

residents found in 38 CFR 17.246(a). 

Paragraphs (a)(1) through (6) of § 17.246 

enumerate six specific factors VA will 

consider in determining the clinical 

need for health care providers before 

determining resident placements. These 

six factors use almost identical language 

to the language used in section 

403(a)(4)(A) through (G) of the Act. 

Additionally, the final factor listed in 38 

CFR 17.246(a)(7) gives VA the ability to 

consider any other criteria important in 

determining which covered facilities are 

not adequately serving area veterans, 

consistent with section 403(a)(4)(G) of 

the Act. 

We considered each comment related 

to 38 CFR 17.246(a) and address each 

individually below. However, we make 

no changes to 38 CFR 17.246(a) due to 

the flexibility provided in paragraph 

(a)(7), which equips VA to consider all 

other important criteria not otherwise 

specifically listed in paragraphs (a)(1) 

through (a)(6) when determining 

resident placement (and further 

provides a non-exhaustive list of such 

other criteria as examples in (a)(7)(i) and 

(ii)). VA intends to use the broad 

consideration permitted by paragraph 

(a)(7), along with the six specific factors 

in paragraphs (a)(1) through (6), to 

ensure that every covered entity 

submitting a proposal for resident 

placement receives consideration to the 

maximum extent authorized by section 

403(a)(4) of the Act. 

§ 17.246(a)(1). One commenter 

recommended that the term ‘‘general 

practitioners and specialists’’ be 

changed to ‘‘primary care physicians 

and other specialists.’’ This commenter 

also requested that, when determining 

the ratio of veterans to VA providers 

under this paragraph, VA calculate 

separate ratios for internal medicine and 

for family medicine. The commenter 

stated that the term ‘‘primary care 

physicians and specialists’’ would be 

inclusive of family medicine 

practitioners who provide women’s 

health care and young adult care and are 

well-positioned to serve the entire 

veteran population, while internal 

medicine focuses exclusively on adult 

medicine. We do not make changes 

based on this comment. We believe the 

term ‘‘general practitioners’’ captures 

the category of ‘‘primary care 

physicians’’ suggested by the 

commenter, and further, we would not 

want to unduly restrict consideration 

only to ‘‘primary care physicians,’’ 

which would be in conflict with the 

clear language of the statute as stated in 

section 403(a)(4)(A) of the Act. We also 

do not believe that further 

distinguishing the ratios of primary care 

providers between internal medicine 

and family medicine will have a 

significant impact on the success of the 

PPGMER, although any important 

criteria related to these distinctions may 

be considered under 38 CFR 

17.246(a)(7). 

§ 17.246(a)(1)(i). Two commenters 

expressed concern with VA’s decision 

to use ‘‘county’’ to define a 

‘‘standardized geographic area’’ for the 

placement factors enumerated in 

§ 17.246(a)(1) and (2). One commenter 

believed that using ‘‘county’’ as the 

standard would not account for ‘‘truly 

remote areas such as non-contiguous 

states.’’ This commenter did not offer a 

recommendation for an alternate 

standard, but emphasized that Hawaii 

has unique healthcare challenges in a 

non-contiguous area with a high 

population of Native Hawaiians and 

Pacific Islanders and would like VA to 

include them to the extent authorized 

by law. Another commenter asked VA to 

apply a standard similar to the one used 

to designate a health professional 

shortage area (HPSA) under 42 U.S.C. 

254e(a)(1), ‘‘which need not conform to 

the geographic boundaries of a political 

subdivision and which is a rational area 

for the delivery of health services,’’ as 

justification for removing the 

requirement to rely on geographic area 

based on county in this paragraph. 

VA believes that a ‘‘county’’ can both 

account for truly remote areas and serve 

as a ‘‘rational area for the delivery of 

health services’’ in line with the 

standard established in 42 U.S.C. 

254e(a)(1). Further, a ‘‘county’’ is a 

simple standard in the context of 

§ 17.246(a)(1) and (2) to provide clarity 

to covered facilities submitting 

proposals as well as to VA in evaluating 

proposals. As stated in the proposed 

rule, the factors in 38 CFR 17.246(a)(1) 

and (2) that use the ‘‘county’’ standard 

are only two of six enumerated factors 

VA will consider in determining the 

clinical need for health care providers 

in an area. VA may therefore consider 

all other important criteria using the 

authority in paragraph (a)(7) to ensure 

consideration of these commenters’ 

concerns, to include being in a noncontiguous State. We make no change to 

the rule based on these comments. 

§ 17.246(a)(3). One commenter 

requested that VA ‘‘draw upon a 

combination of resources beyond the 

OIG [Office of Inspector General] 

report’’ to assess whether the specialty 

of a provider is included in the most 

recent staffing shortage determination in 

38 CFR 17.246(a)(3). We make no 

changes to the rule based on this 

comment. The language used in the 

regulation for this factor is almost 

identical to the language in section 

403(a)(4)(C) of the Act. Additionally, the 

OIG report has consistently been the 

manner in which VA determines its 

yearly staffing shortages and we have no 

reason to believe this data will be 

insufficient. VA may further consider all 

other important criteria using the 

authority of 38 CFR 17.246(a)(7), 

including any relevant information 

derived from sources beyond the OIG 

report. 

§ 17.246(a)(5). One commenter stated 

that HPSA designations may not be an 

adequate measure of the clinical need 

for health care providers in a noncontiguous area. The commenter 

specifically requested that VA use its 

authority under section 403(a)(4)(G) of 

the Act to grant special allowance for 

non-contiguous areas to be considered 

as an important criterion for 

determining resident placement. We 

make no change to the rule based on 

this comment. The HPSA standard used 

in 38 CFR 17.246(a)(5) is directed by 

section 403(a)(4)(E) of the Act. However, 

as mentioned previously, 38 CFR 

17.246(a)(7) provides VA the ability to 

consider the unique situation of all 

covered facilities submitting proposals, 

including the clinical need for health 

care providers in a non-contiguous area. 

The HPSA standard in § 17.246(a)(7) 

will not limit VA’s ability to consider 


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non-contiguous areas when determining 

resident placement. 

Additional Specific Criteria. Two 

commenters suggested VA add 

additional consideration factors when 

determining the placement of residents. 

One commenter recommended that VA 

explicitly include ‘‘the accessibility of 

gender and sexual orientation services’’ 

to the ‘‘other criteria’’ in § 17.246(a)(7). 

Another commenter recommended we 

add ‘‘availability of culturally sensitive 

healthcare options’’ and ‘‘ongoing 

healthcare shortages at a covered 

facility.’’ Because these factors may be 

considered using the authority in 38 

CFR 17.246(a)(7), we make no changes 

to the rule to explicitly include them. 

§ 17.246(b)—Priority in Placements 

Consistent with section 403(a)(5) of 

the Act, § 17.246(b), as proposed, 

established that there would be a 

prioritized placement of at least 100 

residents under the PPGMER. In the 

proposed rule, we clarified that VA 

would interpret the term ‘‘residents’’ to 

refer to the unique, individual 

physicians participating in the PPGMER 

and would not interpret the term 

‘‘residents’’ to refer to each individual 

residency position (or ‘‘slot’’) in which 

an individual physician participating in 

the PPGMER would be placed. We 

further explained that multiple 

PPGMER participants could occupy a 

single residency position while 

individually counting toward the 

priority placement mandate. Multiple 

commenters expressed disagreement 

with our proposed interpretation, 

stating VA should interpret ‘‘residents’’ 

to mean ‘‘residency positions’’ and 

should aim to place more than 100 

individual physicians into these priority 

placements. The commenters expressed 

concern that VA’s interpretation in the 

proposed rule was indicative of VA’s 

intention only to place 100 individual 

physicians and no more. 

We make no changes to the rule based 

on these comments. The term ‘‘resident’’ 

is commonly understood as a reference 

to a unique, individual person in the 

medical context, as Merriam-Webster 

defines ‘‘resident’’ (in the medical 

context) to mean a physician serving a 

residency. See Merriam-Webster 

Dictionary Online, ‘‘resident,’’ 

www.merriam-webster.com. This 

definition aligns with VA’s 

interpretation that in the medical 

context, ‘‘resident’’ refers to the 

individual physician participating in a 

residency program. As we noted in the 

proposed rule, interpreting ‘‘residents’’ 

to refer to the unique, individual 

physicians participating in the 

PPGMER, not the residency positions 

themselves, is also consistent with a 

plain reading of section 403(a)(5) of the 

Act. That plain reading, both on its own 

and when using the aforementioned 

medical definition of ‘‘resident’’, 

supports VA’s decision to consider 

priority placement of ‘‘no fewer than 

100 residents,’’ not 100 resident 

positions. Counting the unique, 

individual physicians who are placed in 

covered facilities given priority is the 

most logical way to ensure we meet 

Congressional intent. 

We emphasize that we do not 

interpret anything in section 403 of the 

Act nor this rulemaking to limit how 

many unique, individual physicians 

may serve in covered facilities given 

priority in placements. That is, VA may 

exceed the minimum requirement for 

priority in placements in the PPGMER. 

We received a related comment 

requesting that VA ‘‘reserve’’ a 

minimum of ten percent of resident 

positions created by the PPGMER for 

Indian Health Service and tribal health 

care facilities. We make no change to 

the rule based on this comment. As an 

initial matter, it is unclear from the 

comment whether the ten percent 

would be ten percent of the minimum 

100 residents placed in prioritized 

facilities under section 403(a)(5) of the 

Act, or ten percent of the total resident 

positions created by the PPGMER. 

Regardless, we do not read any 

authority in section 403 of the Act 

allowing VA to reserve a percentage of 

residents for a particular covered 

facility. Subsection (a)(5) is the sole 

provision in section 403 of the Act 

related to prioritization of resident 

placement in particular covered 

facilities. While it does not expressly 

require VA to reserve any percentage of 

resident placement to Indian Health 

Service and tribal care facilities, we note 

that three of the four enumerated 

categories of covered facilities in which 

no fewer than 100 residents must be 

placed are those operated by the Indian 

Health Service, an Indian tribe, or a 

tribal organization. 

We further believe that regulating 

additional criteria in § 17.246(b) to place 

no fewer than 100 residents under 

section 403(a)(5) the Act would be 

arbitrary and unnecessarily restrictive 

because the need for residents among 

the four types of prioritized facilities 

could shift over the life of the PPGMER, 

and VA’s selection of facilities for 

resident placement will be based on 

information VA receives pursuant to the 

request for proposal (where that 

information will vary each cycle that 

VA issues the request for proposal). 

§ 17.246—Weighting of Factors 

Section 17.246, as proposed, did not 

specify any particular weighting of 

consideration factors for placement of 

residents under the PPGMER. We 

received multiple comments stating VA 

should specify the weighting to be given 

to each consideration factor for 

placement of residents. Some 

commenters believed that VA should be 

transparent about how it will weigh 

factors and another commenter stated 

that VA’s decision directly contradicts 

Congressional intent to give priority to 

placements in covered facilities 

operated by the Indian Health Service, 

an Indian Tribe, a tribal organization, or 

located in communities designated as 

undeserved. We make no changes based 

on these comments. The consideration 

factors and priority in placements listed 

in § 17.246 are a restating of the factors 

listed in section 403(a)(4) and (5) of the 

Act, and section 403 of the Act does not 

otherwise establish any weighting of the 

factors. As stated in the proposed rule, 

weighting is not further included in the 

regulatory text itself so that VA 

maintains flexibility to adjust the 

relative importance of each 

consideration factor throughout the 

duration of the PPGMER. Consistent 

with 38 CFR 17.247(a)(1), each request 

for proposal will describe the specific 

consideration factors that will be used 

to evaluate responses, along with the 

relative importance of each factor. 

Because this is a pilot program, it is 

imperative that VA retain the ability to 

make crucial changes from year to year, 

addressing the outcome and lessons 

learned from prior resident placements 

and accounting for any changes in the 

medical and educational landscape. The 

decision not to include weighting in the 

regulation ensures VA can fully meet 

the intent of the PPGMER. 

§ 17.247—Request for Proposal 

Section 17.247, as proposed, stated 

that a request for proposal (RFP) would 

be issued by VA Central Office to VA 

health care facilities announcing 

opportunities for residents to be placed 

in covered facilities and to have costs 

paid or reimbursed in accordance with 

§ 17.248. The proposed rule further 

stated that VA health care facilities, in 

collaboration with covered facilities, 

would submit responses to the RFP 

directly to VA Central Office. Multiple 

commenters stated that establishing a 

process where the RFP is issued directly 

to VA health care facilities, and 

subsequently entrusting those facilities 

to announce the RFP and collect 

responses from potential covered 

facilities, could prevent consideration of 


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facilities that do not currently have an 

affiliate relationship with VA. The 

commenters recommended that VA 

publicly announce the RFP and allow 

proposals to be submitted directly by 

covered facilities. 

We agree that the RFP process 

contemplated in the proposed rule 

could limit VA’s ability to reach the 

facilities intended for participation the 

PPGMER. Therefore, we will change 

proposed § 17.247(a), which states that 

‘‘VA Central Office will issue a request 

for proposal (RFP) to VA health care 

facilities to announce opportunities for 

residents to be placed in covered 

facilities and to have costs paid or 

reimbursed under § 17.248’’ and remove 

the phrase ‘‘to VA health care facilities,’’ 

so the sentence states that ‘‘VA Central 

Office will issue a request for proposal 

(RFP) to announce opportunities for 

residents to be placed in covered 

facilities and to have costs paid or 

reimbursed under § 17.248.’’ This 

change will ensure there is no limitation 

on how VA Central Office may issue the 

RFP. 

We make two similar changes to 

clarify that covered facilities will submit 

responses to the RFP directly to VA 

Central Office. We will change proposed 

§ 17.247(b), which states that ‘‘VA 

health care facilities, in collaboration 

with covered facilities, will submit 

responses to the RFP to VA Central 

Office’’ and remove the phrase ‘‘VA 

health care facilities, in collaboration 

with’’ so the paragraph states that 

‘‘covered facilities will submit 

responses to the RFP to VA Central 

Office.’’ We also change proposed 

paragraph (c), which states that 

‘‘consistent with paragraph (a) of this 

section, VA Central Office will evaluate 

responses to the RFP from VA health 

care facilities and will determine those 

covered facilities where residents may 

be placed and costs under § 17.248 are 

paid or reimbursed’’ and remove the 

phrase ‘‘from VA health care facilities’’ 

so it states, ‘‘consistent with paragraph 

(a) of this section, VA Central Office 

will evaluate responses to the RFP and 

will determine those covered facilities 

where residents may be placed and 

costs under § 17.248 are paid or 

reimbursed.’’ 

These changes to § 17.247 ensure that 

all potential covered facilities may be 

considered for participation in the 

PPGMER and alleviate any burden on 

VA health care facilities to serve as an 

intermediary to announce, collect, and 

submit responses to the RFP to VA 

Central Office. VA believes these 

changes to the RFP process address the 

commenters’ concerns, meet the intent 

of the PPGMER to reach underserved 

areas, and clarify that the PPGMER is 

not a public funding opportunity or 

grant program. 

§ 17.248—Costs 

Section 403(a)(6) of the Act authorizes 

VA to pay the proportionate cost of 

stipends and benefits for residents 

participating in the PPGMER. In 

addition to stipends and benefits, if a 

covered facility establishes a new 

residency program and is selected for 

PPGMER participation, section 403(b) of 

the Act authorizes VA to reimburse 

certain initial costs associated with 

establishing that program. The statutory 

provisions related to these costs are 

codified and further clarified in 38 CFR 

17.248. 

Multiple commenters requested that 

VA amend the regulation to allow 

covered facilities with established 

residency programs to be eligible for 

reimbursement of costs associated with 

program operation. Specifically, these 

commenters requested VA cover 

expenses such as incremental costs for 

additional residents or slots, costs 

associated with expanding an existing 

GME program, costs for a ‘‘wide range 

of necessities’’ in operating residency 

programs, and costs that support tribes 

in attracting high quality providers (and 

setting aside a tribal allocation for this 

purpose). 

We make no change to the rule based 

on these comments. The statutory 

authority is clear—unlike section 

403(a)(2)(F) and (a)(4)(G), which provide 

VA the authority to consider ‘‘such 

other’’ covered facilities and 

consideration criteria when determining 

resident placements, the cost provisions 

in section 403(a)(6) and (b) of the Act 

are finite. Congress has not authorized 

VA to expand payment or 

reimbursement of costs beyond those 

expenses specifically enumerated in 

statute. 

Additionally, one commenter 

suggested that VA offer scholarships to 

residents participating in the PPGMER. 

We do not believe VA has authority 

under section 403 of the Act to offer any 

type of PPGMER-specific scholarship to 

residents placed under the PPGMER. 

PPGMER costs related to support of 

residents (as opposed to support of new 

residency programs) are provided in 

section 403(a)(6) of the Act, which 

limits payments to only stipends and 

benefits for residents placed under the 

PPGMER program. 

Additionally, one commenter 

provided recommendations for how VA 

should execute funding principles 

during administration of the PPGMER. 

Although these suggestions are 

administrative in nature and do not 

directly impact the regulation, we 

address each to provide further 

information to stakeholders. The 

commenter suggested VA should fund 

actual costs, rather than a 

predetermined amount per resident; 

should make awards of no less than five 

years in duration; and should allow 

participation in any other Federal GME 

program if no costs were duplicated 

among the funding agencies. While not 

specifically stated, we believe these 

recommendations are related to the 

reimbursable expenses permitted for 

new residency programs in accordance 

with 17.248(b)(1) (since the commenter 

stated these expenses are ‘‘above and 

beyond’’ the stipends and benefits 

permitted under 17.248(a)). First, 

section 403(b) of the Act provides 

specific and limited authority for the 

types of expenses that can be 

reimbursed under the PPGMER. VA will 

treat the PPGMER equitably with its 

existing GME programming and will not 

exceed VA’s established maximum 

amounts for these types of payments 

under any existing GME agreements. 

Second, the authority for the PPGMER 

ends in 2031, which would provide a 

very limited window to make awards no 

less than five years in duration. Finally, 

participation in the PPGMER will not 

preclude participating in other Federal 

GME programs provided no costs are 

duplicated among the funding agencies. 

We make no changes based on these 

comments. 

Reporting and Evaluation 

Multiple commenters provided input 

related to the reporting requirement 

contained in section 403(c) of the Act 

requiring VA to provide yearly reports 

to Congress on the implementation of 

the PPGMER. While these reports will 

be submitted by VA directly to 

Congress, the data used to compile these 

reports must be collected by the covered 

facilities and residents participating in 

the PPGMER. 

One commenter requested that VA 

ensure that reporting requirements are 

not burdensome and only include data 

required by section 403(c) of the Act. 

Two commenters requested that VA 

explicitly include any reporting 

requirements in regulation, and one of 

those commenters also requested that 

VA outline how it will store the 

collected data. One commenter further 

requested that VA include three 

questions for evaluation of the pilot 

program in the final regulation, 

specifically: (1) was the PPGMER 

successful in accomplishing a 

predetermined goal; (2) does the 

PPGMER provide increased access for 

veterans to comprehensive primary care 


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and needed specialty care; and (3) are 

the physicians trained under the 

PPGMER continuing to provide access 

to veterans after training, and in areas of 

greatest need? We thank these 

commenters for their feedback, but we 

make no changes to the rule based on 

these comments. VA intends to collect 

only the data explicitly required by 

section 403(c) of the Act and will 

provide those statutory requirements in 

the RFP, which is in line with the 

commenter’s suggestion to only request 

data required by section 403(c) of the 

Act and would not be more burdensome 

than required. VA will not include 

additional questions evaluating the 

PPGMER in regulation, as it would be 

unnecessary. The aim of the Paperwork 

Reduction Act (PRA) is to reduce the 

total amount of paperwork burden the 

Federal government imposes on private 

businesses and citizens, and VA does 

not want to add any additional burden 

when we do not believe the 

commenter’s suggested questions would 

provide additional value in evaluating 

the PPGMER. VA will use only the 

reporting requirements stated in the Act. 

Additionally, VA will not provide 

information on data storage in 

regulation because requirements for the 

handling of Federal records are 

contained in 36 CFR chapter XII, 

subchapter B, parts 1220 through 1234, 

and further detailed in VA Directive 

6300, Records Information and 

Management (September 21, 2018). 

Further information on data collection 

and the estimated paperwork burden for 

the PPGMER is outlined in the PRA 

section of this rulemaking. 

Additionally, one commenter pointed 

out that VA did not outline a plan for 

data collection in the proposed 

rulemaking. After publication of the 

proposed rule, VA published a Federal 

Register notice detailing the information 

collection related to this rulemaking. 

See 87 FR 65852 (November 1, 2022). 

That Federal Register notice is available 

as part of this rulemaking docket on 

www.regulations.gov. 

Impact Analysis 

One commenter provided extensive 

feedback on the regulatory impact 

analysis (RIA) associated with the 

rulemaking. Much of the commenter’s 

input focused on the methodology and 

costing used to formulate the RIA, and 

did not relate to the regulatory 

framework proposed by VA. However, 

the commenter stated that the RIA 

provided information on the benefits of 

the PPGMER and how it will fulfill VA’s 

broader mission, which should be 

included in the purpose and scope in 38 

CFR 17.243. We thank the commenter 

for this feedback but make no changes 

to the rule. It would be unnecessary to 

describe the PPGMER’s potential 

benefits in regulation, and VA will keep 

the purpose and scope focused on the 

framework of the rulemaking. Regarding 

the commenter’s input on the RIA itself, 

the RIA details the anticipated need for 

rulemaking and sets out the 

assumptions and methodology used to 

determine the estimated financial 

impact of the PPGMER and the 

associated rulemaking. This estimate 

was created using regular VA business 

practices for its current GME 

programming. 

Clarifications 

We received multiple comments that 

we believe warrant clarification. Most 

importantly, multiple comments urged 

VA to conduct a tribal consultation 

prior to publishing a final rule. As 

mentioned at the beginning of this 

rulemaking, VA extended the public 

comment period by 90 days in order to 

conduct both an information session 

with tribal leaders and a full tribal 

consultation as required by VA policy 

and Executive Order 13175. We 

received comments from six tribes and 

tribal organizations, and all of the input 

we received was carefully considered as 

part of this final rulemaking. 

Many commenters seemed to have a 

general misunderstanding that the 

PPGMER was focused on increasing 

access to medical care for veterans 

specifically. We reiterate that the focus 

of this program is on the placement of 

residents who will provide medical 

care, not on the specific demographics 

of the individuals who will receive 

medical care from such residents. 

Neither the regulation nor section 403 of 

the Act contain any criteria or 

curtailments regarding the individuals 

eligible to receive medical care from 

residents participating in the PPGMER. 

While 38 CFR 17.245(a) allows for 

resident placements at a VA health care 

facility consistent with section 

403(a)(2)(A) of the Act, we do not 

anticipate using the PPGMER to 

supplement the resident positions 

permanently authorized under VA’s 

existing GME authority. Instead, we 

intend to prioritize placements at nonVA facilities outlined in 38 CFR 

17.245(b) through (f). While we believe 

it is possible that a veteran could end up 

receiving medical care from a resident 

participating in the PPGMER, we 

imagine this situation would occur at a 

non-VA facility and involve a veteran 

eligible for health care through another 

(non-VA) source. 

Additionally, some comments 

indicated a misunderstanding that VA is 

involved in the actual selection and 

placement process of individual 

residents for participation in the 

PPGMER. One commenter stated that 

VA should clarify how residents are 

selected for participation, one 

commenter requested VA fill positions 

with rural and American Indian/Alaska 

Native residents, and one commenter 

provided recommendations for how to 

better incentivize participation in the 

program. 

As stated in the proposed rule, 

residents apply to and are hired directly 

by GME institutions, which are most 

often medical schools or teaching 

hospitals. VA forms relationships with 

non-VA institutions sponsoring GME 

programs, and it is those sponsoring 

institutions that will provide residents 

to participate in the PPGMER. VA does 

not select residents for its GME 

programming authorized under 38 

U.S.C. 7302, and VA will not deviate 

from that process in the administration 

of the PPGMER. While VA maintains an 

affiliate relationship with certain GME 

institutions, placement of residents at 

VA and non-VA facilities lies solely 

within the discretion of the affiliate 

institution, not VA. Once VA has 

selected the covered entities where 

residents will be placed, those affiliate 

institutions will select individual 

residents to fill those PPGMER resident 

positions. 

One commenter provided multiple 

recommendations related to the actual 

substance of the training residents 

participating in the PPGMER will 

receive. Consistent with section 403 of 

the Act, the regulation mentions 

training only in reference to the 

standard medical educational process 

and in referencing certain reimbursable 

costs for new residency programs. 

Because the substantive training of 

residents is beyond the scope of this 

rulemaking, we do not specifically 

address these comments. 

One commenter asked for clarification 

as to what VA considers ‘‘medically 

underserved.’’ VA must consider five or 

more factors under section 401 of the 

Act, one of which is ‘‘whether the local 

community is medically underserved.’’ 

Under 38 CFR 17.246(a)(4), VA will 

consider whether the local community 

of a covered entity is designated as 

‘‘underserved,’’ and both the statute and 

the regulation state that VA will make 

the ‘‘underserved’’ determination using 

criteria developed under section 401 of 

the Act. The determination of whether 

a VA facility is underserved is led by 

VA’s Partnered Evidence-Based Policy 

Resource Center (PEPReC). Each year 

PEPReC, in coordination with VA’s 

Office of Veterans Access to Care and 


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various program offices, uses intricate 

statistical modeling to generate a list of 

potentially underserved VA facilities to 

help local and national leaders provide 

better access to care for veterans. 

Further detailed information on the 

methodology and model variables used 

to make this determination is available 

on PEPReC’s website at 

www.peprec.research.va.gov under ‘‘Our 

Projects.’’ 

Other Comments 

We received multiple comments 

requesting VA take certain actions in 

conjunction with the PPGMER. While 

these comments are not within the 

scope of the rulemaking itself, we want 

to acknowledge and briefly address the 

thoughtful input provided by the 

commenters. We note that while these 

comments are administrative in nature, 

they could be appropriate for inclusion 

in a covered facility’s proposal. 

We received multiple comments 

urging VA to support residency 

programs at covered facilities already in 

existence, to include tribal-affiliated 

residency programs. We make no 

changes based on these comments. 

While there is no preference for existing 

programs over new programs in the 

regulation or in section 403 of the Act, 

we believe existing residency programs 

at covered facilities will be strong 

candidates for PPGMER resident 

placements, and tribal-affiliated covered 

facilities will receive priority in 

placements under 38 CFR 17.246(b). 

One commenter urged VA to consider 

how we can provide long-term support 

for small and new residency programs 

after completion of the pilot program. 

We make no changes based on this 

comment. Once the pilot concludes, VA 

may only rely on its existing GME 

authority to fund resident salary and 

benefits for residents placed in VA 

facilities. Certain additional costs, such 

as VA’s share of accreditation fees, may 

be reimbursed using an Educational 

Cost Contract between VA and the 

sponsoring institution. However, the 

authority in section 403 of the Act is not 

intended to provide ‘‘long-term 

support’’ as suggested by the 

commenter. 

One commenter suggested VA 

collaborate with IHS and tribal health 

facilities directly to ‘‘determine 

specialty specific needs for medical 

residents’’ to better serve tribes, and 

another commenter suggested VA 

engage the VA Advisory Committee on 

Tribal and Indian Affairs to develop and 

implement the PPGMER, especially the 

reimbursement mechanism. We make 

no changes based on these comments. 

VA plans to work through its Office of 

Tribal and Government Relations 

(OTGR) and the VA Advisory 

Committee on Tribal and Indian Affairs 

to ensure widest dissemination of the 

RFP to tribal stakeholders, including 

IHS and tribal health facilities. 

One commenter urged VA to 

‘‘consider recent successes in residency 

programs at urban facilities as an 

indicator of the need and impact 

residency programs have in urban AI/ 

AN [American Indian/Alaska Native] 

communities.’’ Another commenter 

requested VA collaborate directly with 

and increase funding to GME programs 

with high rates of AI/AN graduates. We 

make no changes based on these 

comments. VA will use the statutory 

criteria to prioritize locations for 

resident placements under 38 CFR 

17.246(b), which would include urban 

AI/AN facilities operated by IHS, an 

Indian tribe, or a tribal organization. 

One commenter wanted VA to 

provide specific guidance on how rural 

communities will be targeted, and 

another commenter similarly urged VA 

to expand the pilot in ways that will 

support the training of more physicians 

in rural communities. We make no 

changes based on these comments. VA 

will use the statutory criteria to 

prioritize locations for resident 

placements under 38 CFR 17.246(b), 

which would include facilities located 

in the same areas as VA facilities 

designated as underserved under 38 

CFR 17.246(b). 

Finally, one commenter requested 

that VA provide a public report to 

inform future policymaking. The 

commenter suggested that the report 

contain information about the PPGMER 

such as the VA health care facilities that 

submitted proposals, the covered 

facilities chosen for resident 

placements, the participating GME 

affiliates, and the specialties of residents 

participating in the PPGMER. We make 

no changes based on this comment. VA 

intends to make certain PPGMER 

information available on the Office of 

Academic Affiliations website 

(www.va.gov/oaa). 

Change Not Based on Comments 

VA makes one minor technical change 

to the definition of ‘‘VA health care 

facility’’ in 38 CFR 17.244 to remove the 

capitalization of ‘‘Veteran,’’ changing 

the term to ‘‘veteran.’’ This change 

maintains consistency of the term’s 

usage throughout these and other VA 

regulations. 

Executive Orders 12866, 13563, and 

14094 

Executive Order 12866 (Regulatory 

Planning and Review) directs 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 

14094 (Executive Order on Modernizing 

Regulatory Review) supplements and 

reaffirms the principles, structures, and 

definitions governing contemporary 

regulatory review established in 

Executive Order 12866 of September 30, 

1993 (Regulatory Planning and Review), 

and Executive Order 13563 of January 

18, 2011 (Improving Regulation and 

Regulatory Review). The Office of 

Information and Regulatory Affairs has 

determined that this rulemaking is a 

significant regulatory action under 

Executive Order 12866, as amended by 

Executive Order 14094. The Regulatory 

Impact Analysis associated with this 

rulemaking can be found as a 

supporting document at 

www.regulations.gov. 

Regulatory Flexibility Act 

The Secretary hereby certifies that 

this final 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 through 612). The 

residents who will be placed in covered 

facilities and have certain stipends and 

benefits paid for by VA are individuals 

and not small entities. To the extent that 

any covered facilities are small entities, 

there is no significant economic impact 

because the rulemaking only permits 

VA’s reimbursement of certain start-up 

costs associated with new residency 

programs. Additionally, there is no 

funding opportunity for which covered 

facilities may apply to be considered 

and otherwise no economic gain or loss 

for covered facilities associated with 

this rule. 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. 

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 


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77520 Federal Register / Vol. 88, No. 217 / Monday, November 13, 2023 / Rules and Regulations 

(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. 

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. According to the 

implementing regulations for the 

Paperwork Reduction Act (5 CFR 

1320.8(b)(2)(vi)), an agency may not 

collect or sponsor the collection of 

information, nor may it impose an 

information collection requirement, 

unless it displays a currently valid 

Office of Management and Budget 

(OMB) control number. 

This rule includes provisions 

constituting collections of information 

under the Paperwork Reduction Act of 

1995 that require approval by OMB. 

Accordingly, pursuant to 44 U.S.C. 

3507(d), VA is submitting a copy of this 

rulemaking action to OMB for review. 

The proposed rule did not include a 

PRA notice, and the 60-day notice was 

published separately in the Federal 

Register on November 1, 2022 (Vol. 87, 

No. 210, pages 65852–65853). VA did 

not receive any public comments on the 

proposed information collection in 

response to this notice. OMB assigns 

control numbers to collections 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. If 

OMB does not approve the collection of 

information as requested, VA will 

immediately remove the provisions 

containing a collection of information or 

take such other action as is directed by 

OMB. 

Participants in the PPGMER must 

collect and provide VA with certain 

programmatic data to enable VA to 

report to Congress on the pilot program, 

as required by statute, until the program 

terminates on August 7, 2031. This 

information would be collected by the 

residents placed in covered facilities 

under the PPGMER and their GME 

sponsoring institutions. The sponsors 

themselves will determine the best 

method for collection of the necessary 

data depending on their own resources 

and staffing. The information to be 

collected will include required 

elements, such as number of patients 

seen per day by each resident placed in 

a covered facility under the PPGMER, 

for the annual report on the pilot 

program submitted to Congress by VA. 

Title: Physician Resident Data 

Collection. 

• Summary of collection of 

information: This collection of 

information is used to determine the 

number of patients seen by physician 

residents each day/month under the 

PPGMER, pursuant to § 17.243. The 

information would be collected by 

residents placed in covered facilities 

under the PPGMER. 

• Description of the need for 

information and proposed use of 

information: This information is needed 

to calculate the total number patients 

seen by residents placed in covered 

facilities under the PPGMER. 

• Description of likely respondents: 

Participating residents. 

• Estimated number of respondents 

per year: 100. 

• Estimated frequency of responses 

per year: 1 time per year. 

• Estimated average burden per 

response: 6 hours. 

• Estimated total annual reporting 

and recordkeeping burden: 600 hours. 

• Total estimated cost to respondents 

per year: VA estimates the total annual 

cost to respondents will be $23,006. The 

mean hourly wage for a resident is 

$38.34 (for data collection). The 

estimated wage information was taken 

from VA’s internal data systems, using 

average salary data for physician 

residents in post-graduate years 1 to 3. 

Title: GME Sponsor Annual Data 

Consolidation. 

• Summary of collection of 

information: This collection of 

information is used to consolidate 

physician resident data and compile an 

annual report to Congress, pursuant to 

§ 17.243. The GME sponsoring 

institutions will collect the data and 

provide it to VA for inclusion in the 

report to Congress. 

• Description of the need for 

information and proposed use of 

information: This information is needed 

to provide data for the annual report to 

Congress. 

• Description of likely respondents: 

GME sponsoring institutions. 

• Estimated number of respondents 

per year: 10. 

• Estimated frequency of responses 

per year: 1 time per year. 

• Estimated average burden per 

response: 120 hours. 

• Estimated total annual reporting 

and recordkeeping burden: 1,200 hours. 

• Total estimated cost to respondents 

per year: VA estimates the total annual 

cost to respondents will be $30,708. The 

mean hourly wage for a health 

information technologist is $25.59 (for 

data consolidation and reporting). The 

estimated wage information was taken 

from the Bureau of Labor Statistics from 

the following website: https://

www.bls.gov/oes/current/oes_nat.htm. 

Congressional Review Act 

Pursuant to the Congressional Review 

Act (5 U.S.C. 801 et seq.), the Office of 

Information and Regulatory Affairs 

designated this rule as not a major rule, 

as defined by 5 U.S.C. 804(2). 

List of Subjects in 38 CFR Part 17 

Administrative practice and 

procedure, Colleges and universities, 

Education, Government contracts, 

Health care, Health facilities, Health 

professions, Indians, Medical and dental 

schools, Reporting and recordkeeping 

requirements, Scholarships and 

fellowships, Schools, Veterans. 

Signing Authority 

Denis McDonough, Secretary of 

Veterans Affairs, signed and approved 

this document on September 14, 2023, 

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. 

For the reasons stated in the 

preamble, the Department of Veterans 

Affairs amends 38 CFR part 17 as 

follows: 

PART 17—MEDICAL 

■ 1. Amend the authority citation for 

part 17 by adding an entry for §§ 17.243 

through 17.248 in numerical order to 

read in part as follows: 

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

specific sections. 

* * * * * 

Sections 17.243 through 17.248 are also 

issued under 38 U.S.C. 7302 note. 

* * * * * 

■ 2. Add an undesignated center 

heading and §§ 17.243 through 17.248 to 

read as follows: 

VA Pilot Program on Graduate Medical 

Education and Residency 

§ 17.243 Purpose and scope. 

(a) Purpose. This section and 

§§ 17.244 through 17.248 implement the 

VA Pilot Program on Graduate Medical 

Education and Residency (PPGMER), 

which permits placement of residents in 

existing or new residency programs in 

covered facilities and permits VA to 

reimburse certain costs associated with 

establishing new residency programs in 

covered facilities, as authorized by 

section 403 of Public Law 115–182. 

(b) Scope. This section and §§ 17.244 

through 17.248 apply only to the 


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PPGMER as authorized under section 

403 of Public Law 115–182, and not to 

VA’s more general administration of 

graduate medical residency programs in 

VA facilities as authorized under 38 

U.S.C. 7302(e). 

§ 17.244 Definitions. 

For purposes of §§ 17.243 through 

17.248: 

Benefit means a benefit provided by 

VA to a resident that has monetary 

value in addition to a resident’s stipend, 

which may include but not be limited 

to health insurance, life insurance, 

worker’s compensation, disability 

insurance, Federal Insurance 

Contributions Act taxes, and retirement 

contributions. 

Covered facility means any facility 

identified in § 17.245. 

Educational activities mean all 

activities in which residents participate 

to meet educational goals or curriculum 

requirements of a residency program, to 

include but not be limited to: clinical 

duties; research; attendance in didactic 

sessions; attendance at facility 

committee meetings; scholarly activities 

that are part of an accredited training 

program; and approved educational 

details. 

Resident means physician trainees 

engaged in post-graduate specialty or 

subspecialty training programs that are 

either accredited by the Accreditation 

Council for Graduate Medical Education 

or in the application process for such 

accreditation. A resident may include 

an individual in their first post-graduate 

year (PGY–1) of training (often referred 

to as an intern), and an individual who 

has completed training in their primary 

specialty and continues training in a 

subspecialty graduate medical 

education program (generally referred to 

a fellow). 

Stipend means the annual salary paid 

by VA for a resident. 

VA health care facility means any VAowned or VA-operated location where 

VA physicians provide care to veterans, 

to include but not be limited to a VA 

medical center, independent outpatient 

clinic, domiciliary, nursing home 

(community living center), residential 

treatment program, and communitybased clinic. 

§ 17.245 Covered facilities. 

A covered facility is any of the 

following: 

(a) A VA health care facility; 

(b) A health care facility operated by 

an Indian tribe or tribal organization, as 

those terms are defined in 25 U.S.C. 

5304 and at 25 CFR 273.106; 

(c) A health care facility operated by 

the Indian Health Service; 

(d) A federally-qualified health center 

as defined in 42 U.S.C. 1396d(l)(2)(B); 

(e) A health care facility operated by 

the Department of Defense; or 

(f) Other health care facilities deemed 

appropriate by VA. 

§ 17.246 Consideration factors for 

placement of residents. 

(a) General. When determining in 

which covered facilities residents will 

be placed, VA shall consider the clinical 

need for health care providers in an 

area, as determined by VA’s evaluation 

of the following factors: 

(1) The ratio of veterans to VA 

providers for a standardized geographic 

area surrounding a covered facility, 

including a separate ratio for general 

practitioners and specialists. 

(i) For purposes of paragraphs (a)(1) 

and (2) of this section, standardized 

geographic area means the county in 

which the covered facility is located. 

(ii) VA may consider either or both of 

the ratio(s) for general practitioners and 

specialists, where a higher ratio of 

veterans to VA providers indicates a 

higher need for health care providers in 

an area. 

(2) The range of clinical specialties of 

VA and non-VA providers for a 

standardized geographic area 

surrounding a covered facility, where 

the presence of fewer clinical specialties 

indicates a higher need for health care 

providers in an area. 

(3) Whether the specialty of a 

provider is included in the most recent 

staffing shortage determination by VA 

under 38 U.S.C. 7412. 

(4) Whether the covered facility is in 

the local community of a VA facility 

that has been designated by VA as an 

underserved facility pursuant to criteria 

developed under section 401 of Public 

Law 115–182. 

(5) Whether the covered facility is 

located in a community that is 

designated by the Secretary of Health 

and Human Services as a health 

professional shortage area under 42 

U.S.C. 254e. 

(6) Whether the covered facility is in 

a rural or remote area, where: 

(i) A rural area means an area 

identified by the U.S. Census Bureau as 

rural; and 

(ii) A remote area means an area 

within a zip-code designated as a 

frontier and remote area (FAR) code by 

the Economic Research Service within 

the United States Department of 

Agriculture, based on the most recent 

decennial census and to include all 

identified FAR code levels. 

(7) Such other criteria as VA 

considers important in determining 

those covered facilities that are not 

adequately serving area veterans. These 

factors may include but are not limited 

to: 

(i) Proximity of a non-VA covered 

facility to a VA health care facility, such 

that residents placed in non-VA covered 

facilities may also receive training in 

VA health care facilities. 

(ii) Programmatic considerations 

related to establishing or maintaining a 

sustainable residency program, such as: 

whether the stated objectives of a 

residency program align with VA’s 

workforce needs; the likely or known 

available educational infrastructure of a 

new residency program or existing 

residency program (including the ability 

to attract and retain qualified teaching 

faculty); and the ability of the residency 

program to remain financially 

sustainable after the cessation of 

funding that VA may furnish under 

§ 17.248. 

(b) Priority in placements. For the 

duration in which the PPGMER is 

administered, no fewer than 100 

residents will be placed in covered 

facilities operated by either the Indian 

Health Service, an Indian tribe, a tribal 

organization, or covered facilities 

located in the same areas as VA 

facilities designated by VA as 

underserved pursuant to criteria 

developed under section 401 of Public 

Law 115–182. 

§ 17.247 Determination process for 

placement of residents. 

Section 403 of Public Law 115–182 

does not authorize a grant program or 

cooperative agreement program through 

which covered facilities or any other 

entity may apply for residents to be 

placed in covered facilities or to apply 

for VA to pay or reimburse costs under 

§ 17.248. VA therefore will not conduct 

a public solicitation to determine those 

covered facilities in which residents 

may be placed or to determine costs that 

may be paid or reimbursed under 

§ 17.248. VA will instead determine 

those covered facilities in which 

residents may be placed and determine 

any costs to be paid or reimbursed 

under § 17.248 in accordance with the 

following parameters: 

(a) VA Central Office will issue a 

request for proposal (RFP) to announce 

opportunities for residents to be placed 

in covered facilities and to have costs 

paid or reimbursed under § 17.248. This 

RFP will describe, at a minimum: 

(1) Consideration factors to include 

the criteria in § 17.246, that will be used 

to evaluate any responses to the RFP, as 

well as the relative importance of such 

consideration factors; 

(2) Information required to be in any 

responses to the RFP; and 


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(3) The process to submit a response 

to the RFP. 

(b) Covered facilities will submit 

responses to the RFP to VA Central 

Office. 

(c) Consistent with paragraph (a) of 

this section, VA Central Office will 

evaluate responses to the RFP and will 

determine those covered facilities where 

residents may be placed and costs under 

§ 17.248 are paid or reimbursed. 

§ 17.248 Costs of placing residents and 

new residency programs. 

Once VA determines in which 

covered facilities residents will be 

placed in accordance with §§ 17.246 

through 17.247, payment or 

reimbursement is authorized for the 

following costs: 

(a) Resident stipends and benefits. For 

residents placed in covered facilities, 

VA may pay only the proportionate cost 

of resident stipends and benefits that are 

associated with residents participating 

in educational activities directly related 

to the PPGMER, in accordance with any 

contract, agreement, or other 

arrangement VA has legal authority to 

form. 

(b) Costs associated with new 

residency programs. (1) If a covered 

facility establishes a new residency 

program in which a resident is placed, 

VA will reimburse the following costs in 

accordance with any contract, 

agreement, or other arrangement VA has 

legal authority to form. 

(i) Curriculum development costs, to 

include but not be limited to costs 

associated with needs analysis, didactic 

activities, materials, equipment, 

consultant fees, and instructional 

design. 

(ii) Recruitment and retention of 

faculty costs, to include but not be 

limited to costs associated with 

advertising available faculty positions, 

and monetary incentives to fill such 

positions such as relocation costs and 

educational loan repayment. 

(iii) Accreditation costs, to include 

but not be limited to the administrative 

fees incurred by a covered facility in 

association with applying for only 

initial accreditation of the program by 

the Accreditation Council for Graduate 

Medical Education (ACGME). 

(iv) Faculty salary costs, to include 

only the proportionate cost of faculty 

performing duties directly related to the 

PPGMER. 

(v) Resident education expense costs, 

to include but not be limited to costs 

associated with the required purchase of 

medical equipment and required 

training, national resident match 

program participation fees, and 

residency program management 

software fees. 

(2) VA considers new residency 

programs as only those residency 

programs that have initial ACGME 

accreditation or have continued ACGME 

accreditation without outcomes, and 

have not graduated an inaugural class, 

at the time VA has determined those 

covered facilities where residents will 

be placed under § 17.247(c). 

[FR Doc. 2023–24709 Filed 11–9–23; 8:45 am] 

BILLING CODE 8320–01–P 

FEDERAL COMMUNICATIONS 

COMMISSION 

47 CFR Part 54 

[CC Docket Nos. 02–6, 96–45 and 97–21; 

FCC 23–56; FR ID 184270] 

Schools and Libraries Universal 

Service Support Mechanism, FederalState Joint Board on Universal Service, 

and Changes to the Board of Directors 

of the National Exchange Carrier 

Association, Inc 

AGENCY: Federal Communications 

Commission. 

ACTION: Final rule; announcement of 

effective date. 

SUMMARY: In this document, the Federal 

Communications Commission 

(Commission) announces that the Office 

of Management and Budget (OMB) has 

approved, until November 30, 2024, the 

information collection associated with 

the Commission’s Schools and Libraries 

Universal Service Support Mechanism, 

Federal-State Joint Board on Universal 

Service, and Changes to the Board of 

Directors of the National Exchange 

Carrier Association, Inc. Report and 

Order’s (Order) E-Rate rules. This 

document is consistent with the Order, 

which stated the Commission would 

publish a document in the Federal 

Register announcing the effective date 

of the amendments to the Commission’s 

regulations. 

DATES: The amendments to 47 CFR 

54.503(c)(2)(i)(B) and 54.504(a)(1)(ii) 

published at 88 FR 55410, August 15, 

2023 are effective November 13, 2023. 

FOR FURTHER INFORMATION CONTACT: 

Contact Nicole Ongele at (202) 418– 

2991 or via email: Nicole.Ongele@

fcc.gov. 

SUPPLEMENTARY INFORMATION: This 

document announces that, on 

September 25, 2023, OMB approved the 

information collection requirements 

relating to the E-Rate rules contained in 

the Commission’s Order, FCC 23–56, 

published at 88 FR 55410, August 15, 

2023. The OMB Control Number is 

3060–0806. The Commission publishes 

this document as an announcement of 

the effective date of the rules. If you 

have any comments on the burden 

estimates listed below, or how the 

Commission can improve the 

collections and reduce any burdens 

caused thereby, please contact Nicole 

Ongele, Federal Communications 

Commission, 45 L Street NE, 

Washington, DC 20554. Please include 

the OMB Control Number, 3060–0806, 

in your correspondence. The 

Commission will also accept your 

comments via email at PRA@fcc.gov. 

To request materials in accessible 

formats for people with disabilities 

(Braille, large print, electronic files, 

audio format), send an email to fcc504@

fcc.gov or call the Consumer and 

Governmental Affairs Bureau at (202) 

418–0530 (voice), (202) 418–0432 

(TTY). 

Synopsis 

As required by the Paperwork 

Reduction Act of 1995 (44 U.S.C. 3507), 

the Commission is notifying the public 

that it received OMB approval on 

September 25, 2023, for the information 

collection requirements contained in 47 

CFR 54.503(c)(2)(i)(B) and 

54.504(a)(1)(ii) published at 88 FR 

55410, August 15, 2023. Under 5 CFR 

part 1320, an agency may not conduct 

or sponsor a collection of information 

unless it displays a current, valid OMB 

Control Number. 

No person shall be subject to any 

penalty for failing to comply with a 

collection of information subject to the 

Paperwork Reduction Act that does not 

display a current, valid OMB Control 

Number. The OMB Control Number is 

3060–0806. 

The foregoing notice is required by 

the Paperwork Reduction Act of 1995, 

Public Law 104–13, October 1, 1995, 

and 44 U.S.C. 3507. 

The total annual reporting burdens 

and costs for the respondents are as 

follows: 

OMB Control Number: 3060–0806. 

OMB Approval Date: September 25, 

2023. 

OMB Expiration Date: November 30, 

2024. 

Title: Universal Service—Schools and 

Libraries Universal Service Program, 

FCC Forms 470 and 471. 

Form Number: FCC Form 470 and 

FCC Form 471. 

Respondents: State, local or tribal 

government institutions, and other notfor-profit institutions. 

Number of Respondents and 

Responses: 43,000 respondents; 67,100 

responses. 


khammond on DSKJM1Z7X2PROD with RULES