13236 Federal Register / Vol. 77, No. 44 / Tuesday, March 6, 2012 / Proposed Rules 

Lake Michigan, or his or her on-scene 

designated representative. 

Dated: February 3, 2012. 

M.W. Sibley, 

Captain, U.S. Coast Guard, Captain of the 

Port, Sector Lake Michigan. 

[FR Doc. 2012–5330 Filed 3–5–12; 8:45 am] 

BILLING CODE 9110–04–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Part 17 

RIN 2900–AO27 

Exempting In-Home Video Telehealth 

From Copayments 

AGENCY: Department of Veterans Affairs. 

ACTION: Proposed rule. 

SUMMARY: The Department of Veterans 

Affairs (VA) is proposing to amend its 

regulation that governs VA services that 

are not subject to copayment 

requirements for inpatient hospital care 

or outpatient medical care. Specifically, 

the regulation would be amended to 

exempt in-home video telehealth care 

from having any required copayment. 

This would remove a barrier that may 

have previously discouraged veterans 

from choosing to use in-home video 

telehealth as a viable medical care 

option. In turn, VA hopes to make the 

home a preferred place of care, 

whenever medically appropriate and 

possible. 

DATES: Written comments must be 

received on or before April 5, 2012. 

ADDRESSES: Written comments may be 

submitted through 

www.Regulations.gov; by mail or handdelivery to the Director, Regulations 

Management (02REG), Department of 

Veterans Affairs, 810 Vermont Ave. 

NW., Room 1068, Washington, DC 

20420; or by fax to (202) 273–9026. 

Comments should indicate that they are 

submitted in response to ‘‘RIN 2900– 

AO27]— Exempting In-home Video 

Telehealth from Copayments.’’ Copies of 

comments received will be available for 

public inspection in the Office of 

Regulation Policy and Management, 

Room 1063B, between the hours of 

8 a.m. and 4:30 p.m. Monday through 

Friday (except holidays). Please call 

(202) 461–4902 for an appointment (this 

is not a toll-free number). In addition, 

during the comment period, comments 

may be viewed online through the 

Federal Docket Management System 

(FDMS) at www.Regulations.gov. 

FOR FURTHER INFORMATION CONTACT: 

Kristin J. Cunningham, Director 

Business Policy, Chief Business Office, 

Department of Veterans Affairs, 810 

Vermont Ave. NW., Washington, DC 

20420; (202) 461–1599. (This is not a 

toll-free number.) 

SUPPLEMENTARY INFORMATION: Many of 

our nation’s veterans must travel great 

distances in order to obtain health care 

at a VA hospital or medical center. To 

improve veterans’ access to VA health 

care, VA established community-based 

outpatient clinics (CBOCs) located in 

local communities. VA has continued 

its efforts to improve veterans’ access to 

VA medical care by establishing 

‘‘telehealth’’ services. Telehealth allows 

VA to provide certain medical care 

without requiring the veteran to be 

physically present with the examining 

or treating medical professional. 

Telehealth helps ensure that veterans 

are able to get their care in a timely and 

convenient manner, by reducing 

burdens on the patient as well as 

appropriately reducing the utilization of 

VA resources without sacrificing the 

quality of care provided. The benefits of 

using this technology include increased 

access to specialist consultations, 

improved access to primary and 

ambulatory care, reduced waiting times, 

and decreased veteran travel. 

VA provides various telehealth 

services, including clinical video 

telehealth and in-home video telehealth 

care. Clinical video telehealth, as the 

name implies, occurs between two 

clinical settings, such as two VA 

Medical Centers (VAMCs), a VAMC and 

a CBOC, or two CBOCs. Clinical video 

telehealth may also connect patient and 

provider between VAMCs and VA 

Centers of Specialized Care, such as 

those established for Spinal Cord Injury 

(SCI), Traumatic Brain Injury (TBI) and 

Multiple Sclerosis (MS). Clinical video 

telehealth uses real-time interactive 

video conferencing, sometimes with 

supportive peripheral devices, such as a 

camera to closely examine skin. This 

allows a specialist located in another 

facility to assess and treat a veteran by 

providing care remotely. 

Like clinical video telehealth, inhome video telehealth care is used to 

connect a veteran to a VA health care 

professional using real-time 

videoconferencing, and other equipment 

as necessary, as a means to replicate 

aspects of face-to-face assessment and 

care delivery that do not require the 

health care professional to make an 

examination requiring physical contact. 

However, in-home video telehealth care 

is provided in a veteran’s home, 

eliminating the need for the veteran to 

travel to a clinical setting. Using 

telehealth capabilities, a VA clinician 

can assess elements of a patient’s care, 

such as wound management, psychiatric 

or psychotherapeutic care, exercise 

plans, and medication management. The 

clinician may also monitor patient selfcare by reviewing vital signs and 

evaluating the patient’s appearance on 

video. 

Prior to this proposed rulemaking, 

veterans have been required to pay a 

copayment for in-home video telehealth 

care. We believe that VA has authority 

by statute to discontinue charging 

copayments for these services. 

Section 1710(g)(1) of 38 U.S.C. states: 

The Secretary may not furnish medical 

services (except if such care constitutes 

hospice care) under subsection (a) of this 

section (including home health services 

under section 1717 of this title) to a veteran 

who is eligible for hospital care under this 

chapter by reason of subsection (a)(3) of this 

section unless the veteran agrees to pay to the 

United States in the case of each outpatient 

visit the applicable amount or amounts 

established by the Secretary by regulation. 

VA has interpreted section 1710(g)(1) to 

mean that VA has the discretion to 

establish the applicable copayment 

amount in regulation, even if such 

amount is zero. One such implementing 

regulation is 38 CFR 17.108. 

Generally, VA calculates the amount 

of a copayment based on the complexity 

of care provided and the resources 

needed to provide that care. In addition, 

VA may exempt certain care from the 

copayment requirement in an effort to 

make health care more accessible to 

veterans, or to encourage veterans to 

become more actively involved in their 

medical care, and thereby improve 

health care outcomes (which, in turn, 

lowers overall health care costs). VA 

proposes to make in-home video 

telehealth care exempt from copayments 

because it is not used to provide 

complex care and its use significantly 

reduces impact on VA resources 

compared to an in-person, outpatient 

visit. It also reduces any potential 

negative impact on the veteran’s health 

that might be incurred if the veteran 

were required to travel to a VA hospital 

or medical center to obtain the care that 

would be provided via in-home video 

telehealth. VA also wants to encourage 

veterans to use the in-home video 

telehealth care option when their 

provider finds it appropriate because we 

believe that it would help ensure that 

veterans comply with outpatient 

treatment plans by regularly following 

up with physicians and medical 

professionals, taking medication in 

appropriate doses on a regular basis, 

and generally being more engaged with 

their VA health care providers. 


srobinson on DSK4SPTVN1PROD with PROPOSALS
Federal Register / Vol. 77, No. 44 / Tuesday, March 6, 2012 / Proposed Rules 13237 

As previously stated in this 

rulemaking, in-home video telehealth 

allows a VA clinician to assess the 

elements of a veteran’s care, while the 

veteran remains at home. Conversely, 

clinical video telehealth assess the 

veteran’s medical condition in a clinical 

setting using resources and technology 

that allows a medical specialist, who 

may be hundreds of miles away, to 

interact with the veteran and provide 

the level of care needed to treat the 

medical condition. VA would not 

exempt clinical video telehealth 

services from the copayment 

requirement because the type of care a 

veteran receives in clinical video 

telehealth requires not just the use of 

CBOC’s technological resources, but 

also patient interaction between the 

attending physician that may be 

hundreds of miles away, and the 

medical staff in the CBOC. The 

attending medical staff in the CBOC 

follows the attending physician’s 

instructions in the placement of the 

adapted equipment that is used in 

clinical video telehealth in order to 

assess the veteran’s medical condition, 

to include the set up of the conference, 

use of the teleconference room, etc. All 

of these additional services provide a 

veteran a higher level of care than the 

level of care that the veteran receives 

through in-home video telehealth. 

Paragraph (e) of § 17.108 contains a 

list of services that are not subject to 

copayment requirements for inpatient 

hospital care or outpatient medical care. 

Based on the rationale set forth in this 

preamble, VA proposes to amend 

§ 17.108(e) by adding a new paragraph 

(e)(16) to include in-home video 

telehealth care as exempt from 

copayment requirements. 

Administrative Procedure Act 

Concurrent with this proposed rule, 

we also are publishing a separate, 

substantively identical direct final rule 

in the ‘‘Rules and Regulations’’ section 

of this Federal Register. The 

simultaneous publication of these 

documents will speed notice and 

comment rulemaking under section 553 

of the Administrative Procedure Act 

should we have to withdraw the direct 

final rule due to receipt of significant 

adverse comments. 

For purposes of the direct final 

rulemaking, a significant adverse 

comment is one that explains why the 

rule would be inappropriate, including 

challenges to the rule’s underlying 

premise or approach, or why it would 

be ineffective or unacceptable without 

change. If significant adverse comments 

are received, VA will publish a notice 

of receipt of significant adverse 

comments in the Federal Register 

withdrawing the direct final rule. 

Under direct final rule procedures, 

unless significant adverse comments are 

received within the comment period, 

the regulation will become effective on 

the date specified above. After the close 

of the comment period, VA will publish 

a document in the Federal Register 

indicating that no adverse comments 

were received and confirming the date 

on which the final rule will become 

effective. VA will also publish a notice 

withdrawing this proposed rule. 

In the event the direct final rule is 

withdrawn because of significant 

adverse comments, VA can proceed 

with the rulemaking by addressing the 

comments received and publishing a 

final rule. The comment period for the 

proposed rule runs concurrently with 

that of the direct final rule. Any 

comments received under the direct 

final rule will be treated as comments 

regarding the proposed rule. VA will 

consider such comments in developing 

a subsequent final rule. Likewise, 

significant adverse comments submitted 

to the proposed rule will be considered 

as comments regarding the direct final 

rule. 

Effect of Rulemaking 

The Code of Federal Regulations, as 

proposed to be revised by this proposed 

rulemaking, would represent the 

exclusive legal authority on this subject. 

No contrary rules or procedures would 

be authorized. All VA guidance would 

be read to conform with this rulemaking 

if possible or, if not possible, such 

guidance would be superseded by this 

rulemaking. 

Paperwork Reduction Act 

This document contains no provisions 

constituting a collection of information 

under the Paperwork Reduction Act of 

1995 (44 U.S.C. 3501–3521). 

Regulatory Flexibility Act 

The Secretary hereby certifies that 

this proposed regulatory amendment 

would not have a significant economic 

impact on a substantial number of small 

entities as they are defined in the 

Regulatory Flexibility Act, 5 U.S.C. 601– 

612. This rulemaking would not directly 

affect any small entities. Only VA 

beneficiaries would be directly affected. 

Therefore, pursuant to 5 U.S.C. 605(b), 

this amendment would be exempt from 

the initial and final regulatory flexibility 

analysis requirements of sections 603 

and 604. 

Executive Orders 12866 and 13563 

Executive Orders 12866 and 13563 

direct agencies to assess the costs and 

benefits of available regulatory 

alternatives and, when regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, and other advantages; 

distributive impacts; and equity). 

Executive Order 13563 (Improving 

Regulation and Regulatory Review) 

emphasizes the importance of 

quantifying both costs and benefits, 

reducing costs, harmonizing rules, and 

promoting flexibility. Executive Order 

12866 (Regulatory Planning and 

Review) defines a ‘‘significant 

regulatory action,’’ which requires 

review by the Office of Management and 

Budget (OMB), as ‘‘any regulatory action 

that is likely to result in a rule that may: 

(1) Have an annual effect on the 

economy of $100 million or more or 

adversely affect in a material way the 

economy, a sector of the economy, 

productivity, competition, jobs, the 

environment, public health or safety, or 

State, local, or tribal governments or 

communities; (2) Create a serious 

inconsistency or otherwise interfere 

with an action taken or planned by 

another agency; (3) Materially alter the 

budgetary impact of entitlements, 

grants, user fees, or loan programs or the 

rights and obligations of recipients 

thereof; or (4) Raise novel legal or policy 

issues arising out of legal mandates, the 

President’s priorities, or the principles 

set forth in this Executive Order.’’ 

The economic, interagency, 

budgetary, legal, and policy 

implications of this regulatory action 

have been examined and it has been 

determined not to be a significant 

regulatory action under Executive Order 

12866. 

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 

expenditure by State, local, or tribal 

governments, in the aggregate, or by the 

private sector, of $100 million or more 

(adjusted annually for inflation) in any 

given year. This proposed rule would 

have no such effect on State, local, or 

tribal governments, or on the private 

sector. 

Catalog of Federal Domestic Assistance 

The Catalog of Federal Domestic 

Assistance program number and title for 

this proposed rule are as follows: 64.007 

Blind Rehabilitation Centers; 64.008, 

Veterans Domiciliary Care; 64.009, 

Veterans Medical Care Benefits; 64.010, 

Veterans Nursing Home Care; 64.014, 


srobinson on DSK4SPTVN1PROD with PROPOSALS
13238 Federal Register / Vol. 77, No. 44 / Tuesday, March 6, 2012 / Proposed Rules 

Veterans State Domiciliary Care; 64.015, 

Veterans State Nursing Home Care; 

64.018, Sharing Specialized Medical 

Resources; 64.019, Veterans 

Rehabilitation Alcohol and Drug 

Dependence; and 64.022, Veterans 

Home Based Primary Care. 

Signing Authority 

The Secretary of Veterans Affairs, or 

designee, approved this document and 

authorized the undersigned to sign and 

submit the document to the Office of the 

Federal Register for publication 

electronically as an official document of 

the Department of Veterans Affairs. John 

R. Gingrich, Chief of Staff, Department 

of Veterans Affairs, approved this 

document on February 28, 2012, for 

publication. 

List of Subjects in 38 CFR Part 17 

Administrative practice and 

procedure, Health care, Health facilities, 

Mental health programs, Nursing 

homes, Veterans. 

Dated: March 1, 2012. 

Robert C. McFetridge, 

Director, Office of Regulation Policy and 

Management, Office of the General Counsel, 

Department of Veterans Affairs. 

For the reasons set forth in the 

preamble, we propose to amend 38 CFR 

part 17 as follows: 

PART 17—MEDICAL 

1. The authority citation for part 17 

continues to read as follows: 

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

specific sections. 

2. Amend § 17.108 by adding 

paragraph (e)(16) to read as follows: 

§ 17.108 Copayments for inpatient hospital 

care and outpatient medical care. 

* * * * * 

(e) * * * 

(16) In-home video telehealth care. 

* * * * * 

[FR Doc. 2012–5355 Filed 3–5–12; 8:45 am] 

BILLING CODE 8320–01–P 

ENVIRONMENTAL PROTECTION 

AGENCY 

40 CFR Part 52 

[EPA–R10–OAR–2012–0112, FRL–9643–5] 

Partial Approval and Promulgation of 

Implementation Plans; Washington: 

Infrastructure Requirements for the 

1997 8-Hour Ozone National Ambient 

Air Quality Standards 

AGENCY: Environmental Protection 

Agency (EPA). 

ACTION: Proposed rule. 

SUMMARY: EPA is proposing to partially 

approve the State Implementation Plan 

(SIP) submittal from the Washington 

State Department of Ecology (Ecology) 

to demonstrate that the SIP meets the 

requirements of section 110(a)(1) and (2) 

of the Clean Air Act (CAA) for the 

National Ambient Air Quality Standards 

(NAAQS) promulgated for ozone on July 

18, 1997. EPA is proposing to find that 

the current Washington SIP meets the 

following 110(a)(2) infrastructure 

elements for the 1997 8-hour ozone 

NAAQS: (A), (B), (C), (D)(ii), (E), (F), (G), 

(H), (J), (K), (L), and (M), except for 

portions related to the major source 

Prevention of Significant Deterioration 

(PSD) permitting program which is 

implemented under a Federal 

Implementation Plan. 

DATES: Comments must be received on 

or before April 5, 2012. 

ADDRESSES: Submit your comments, 

identified by Docket ID No. EPA–R10– 

OAR–2012–0112, by any of the 

following methods: 

• www.regulations.gov: Follow the 

on-line instructions for submitting 

comments. 

• Email: R10- 

Public_Comments@epa.gov. 

• Mail: Jeff Hunt, EPA Region 10, 

Office of Air, Waste and Toxics (AWT– 

107), 1200 Sixth Avenue, Suite 900, 

Seattle, WA 98101. 

• Hand Delivery/Courier: EPA Region 

10, 1200 Sixth Avenue, Suite 900, 

Seattle, WA 98101. Attention: Jeff Hunt, 

Office of Air, Waste and Toxics, AWT– 

107. Such deliveries are only accepted 

during normal hours of operation, and 

special arrangements should be made 

for deliveries of boxed information. 

Instructions: Direct your comments to 

Docket ID No. EPA–R10–OAR–2012– 

0112 EPA’s policy is that all comments 

received will be included in the public 

docket without change and may be 

made available online at 

www.regulations.gov, including any 

personal information provided, unless 

the comment includes information 

claimed to be Confidential Business 

Information (CBI) or other information 

whose disclosure is restricted by statute. 

Do not submit information that you 

consider to be CBI or otherwise 

protected through www.regulations.gov 

or email. The www.regulations.gov Web 

site is an ‘‘anonymous access’’ system, 

which means EPA will not know your 

identity or contact information unless 

you provide it in the body of your 

comment. If you send an email 

comment directly to EPA without going 

through www.regulations.gov your email 

address will be automatically captured 

and included as part of the comment 

that is placed in the public docket and 

made available on the Internet. If you 

submit an electronic comment, EPA 

recommends that you include your 

name and other contact information in 

the body of your comment and with any 

disk or CD–ROM you submit. If EPA 

cannot read your comment due to 

technical difficulties and cannot contact 

you for clarification, EPA may not be 

able to consider your comment. 

Electronic files should avoid the use of 

special characters, any form of 

encryption, and be free of any defects or 

viruses. 

Docket: All documents in the docket 

are listed in the www.regulations.gov 

index. Although listed in the index, 

some information is not publicly 

available, e.g., CBI or other information 

whose disclosure is restricted by statute. 

Certain other material, such as 

copyrighted material, is not placed on 

the Internet and will be publicly 

available only in hard copy. Publicly 

available docket materials are available 

either electronically in 

www.regulations.gov or in hard copy 

during normal business hours at the 

Office of Air, Waste and Toxics, EPA 

Region 10, 1200 Sixth Avenue, Seattle, 

WA 98101. 

FOR FURTHER INFORMATION CONTACT: Jeff 

Hunt at telephone number: (206) 553– 

0256, email address: hunt.jeff@epa.gov, 

or the above EPA, Region 10 address. 

SUPPLEMENTARY INFORMATION: 

Throughout this document wherever 

‘‘we’’, ‘‘us’’ or ‘‘our’’ are used, we mean 

EPA. Information is organized as 

follows: 

Table of Contents 

I. What action is EPA proposing? 

II. What is the background for the action that 

EPA is proposing? 

III. What infrastructure elements are required 

under sections 110(a)(1) and (2)? 

IV. What is the scope of action on 

infrastructure submittals? 

V. What is EPA’s analysis of Washington’s 

submittal? 

VI. Scope of Proposed Action 

VII. Proposed Action 

VIII. Washington Notice Provision 

IX. Statutory and Executive Order Reviews 

I. What action is EPA proposing? 

EPA is proposing to partially approve 

the State Implementation Plan (SIP) 

submittal from the State of Washington 

to demonstrate that the SIP meets the 

requirements of section 110(a)(1) and (2) 

of the Clean Air Act (CAA) for the 

National Ambient Air Quality Standards 

(NAAQS) promulgated for ozone on July 

18, 1997. EPA is proposing to find that 

the current Washington SIP, as codified 

at 40 CFR Part 52 Subpart WW meets 


srobinson on DSK4SPTVN1PROD with PROPOSALS