6456 Federal Register / Vol. 87, No. 24 / Friday, February 4, 2022 / Proposed Rules 

insufficient funds to cover the total of 

all fees due for any service, the service 

request(s) will not be processed. 

(v) Any balance remaining in a closed 

deposit account will be refunded to the 

account holder in accordance with 

Copyright Office policies. Unredeemed 

refunds will be handled in accordance 

with Library of Congress and U.S. 

Treasury rules and policies. 

(vi) The Copyright Office may refer 

any overdraft in a closed deposit 

account for collections. 

(6) Further information. For 

information on deposit accounts, see 

Circular 5 on the Copyright Office’s 

website, or request a copy at the address 

specified in § 201.1(b). 

* * * * * 

■ 5. Amend § 201.33 by revising 

paragraph (e) to read as follows: 

§ 201.33 Procedures for filing Notices of 

Intent to Enforce a restored copyright under 

the Uruguay Round Agreements Act. 

* * * * * 

(e) Fee. The filing fee for recording 

Notices of Intent to Enforce is 

prescribed in § 201.3(c). 

* * * * * 

§ 201.39 [Amended] 

■ 6. Remove § 201.39(g)(3). 

PART 202—PREREGISTRATION AND 

REGISTRATION OF CLAIMS TO 

COPYRIGHT 

■ 7. The authority citation for part 202 

continues to read as follows: 

Authority: 17 U.S.C. 408(f), 702. 

§ 202.3 [Amended] 

■ 8. Amend § 202.3 by removing 

(b)(2)(i)(C) and redesignating paragraph 

(b)(2)(i)(D) as (b)(2)(i)(C). 

■ 9. Amend § 202.12 by revising 

paragraph (c)(2) to read as follows: 

§ 202.12 Restored copyrights. 

* * * * * 

(c) * * * 

(2) Fee. The filing fee for registering 

a copyright claim in a restored work is 

prescribed in § 201.3(c) of this chapter. 

* * * * * 

■ 10. Amend § 202.16 by revising 

paragraph (c)(5) to read as follows: 

§ 202.16 Preregistration of copyrights. 

* * * * * 

(c) * * * 

(5) Fee. The filing fee for 

preregistration is prescribed in 

§ 201.3(c). 

* * * * * 

■ 11. Amend § 202.23 by revising 

paragraph (e)(2) to read as follows: 

§ 202.23 Full term retention of copyright 

deposits. 

* * * * * 

(e) * * * 

(2) Payment in the amount prescribed 

in § 201.3(d) of this chapter payable to 

the U.S. Copyright Office, must be 

received in the Copyright Office within 

60 calendar days from the date of 

mailing of the Copyright Office’s 

notification to the requestor that fullterm retention has been granted for a 

particular copyright deposit. 

* * * * * 

Dated: January 24, 2022. 

Kimberley Isbell, 

Acting General Counsel and Associate 

Register of Copyrights. 

[FR Doc. 2022–01776 Filed 2–3–22; 8:45 am] 

BILLING CODE 1410–30–P 

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: Proposed rule. 

SUMMARY: The Department of Veterans 

Affairs proposes to revise 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: Comments must be received on 

or before April 5, 2022. 

ADDRESSES: Comments may be 

submitted through www.Regulations.gov 

or mailed to, Paul B. Greenberg, Deputy 

Chief, Office of Academic Affiliations, 

(14AA), Department of Veterans Affairs, 

810 Vermont Ave. NW, Washington, DC 

20420. Comments should indicate that 

they are submitted in response to ‘‘RIN 

2900–AR01—VA Pilot Program on 

Graduate Medical Education and 

Residency.’’ Comments received will be 

available at regulations.gov for public 

viewing, inspection or copies. 

FOR FURTHER INFORMATION CONTACT: Paul 

B. Greenberg, Deputy Chief, Office of 

Academic Affiliations, (14AA), 

Department of Veterans Affairs, 810 

Vermont Ave. NW, Washington, DC 

20420, (202) 461–9490. (This is not a 

toll-free telephone number.) 

SUPPLEMENTARY INFORMATION: 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 (Pub. L. 115–182, 

hereafter referred to as the MISSION 

Act) mandated the Department of 

Veterans Affairs (VA) create a pilot 

program to establish additional medical 

residency positions authorized under 

section 7302 of title 38 United States 

Code (U.S.C.) (note to 38 U.S.C. 7302) at 

certain covered facilities. This proposed 

rule would establish substantive and 

procedural requirements to allow VA to 

administer this pilot program in a 

manner consistent with section 403 of 

the MISSION Act. 

Section 7302(e)(1) of title 38 United 

States Code (U.S.C.) permits VA to both 

establish medical residency programs in 

VA facilities and ensure that such 

established programs have a sufficient 

number of residents. Section 403 of the 

MISSION Act created a note to section 

7302 to expand VA’s authority to 

establish medical residency positions in 

covered facilities to include non-VA 

facilities such as health care facilities of 

the Department of Defense and Indian 

Health Service. Section 403 of the 

MISSION Act further provides 

parameters for VA to determine those 

covered facilities in which residents 

will be placed. For instance, section 403 

requires VA to consider certain factors 

to determine whether there is a clinical 

need for providers in areas where 

residents would be placed. Section 403 

also requires prioritized placement of 

residents under the pilot program in 

Indian Health Service facilities, Indian 

tribal or tribal organization facilities, 

certain underserved VA facilities, or 

other covered facilities. Section 403 

additionally authorizes VA to pay 

resident stipends and benefits regardless 

of whether such residents are assigned 

to a VA facility, and requires VA to pay 

certain startup costs of new residency 

programs (such as curriculum 

development and faculty salaries) if 

residents are placed in such programs 

under the pilot program. The authority 

for the pilot was initially scheduled to 

expire on August 7, 2024; however, it 

was subsequently extended to August 7, 

2031, under section 5107 of Public Law 

116–169. 

Before detailing the regulations we 

propose to implement this mandated 

pilot program, we provide a brief 

summary of VA’s administration of its 

Graduate Medical Education (GME) 

programming under 38 U.S.C. 7302(e), 

to establish a basic understanding of 

VA’s understand of the conduct of GME 

programming in general. Under section 

7302(e)(1), VA establishes new medical 

residency programs in VA facilities and 


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ensures that such programs have a 

sufficient number of residents; VA also 

ensures that existing medical residency 

programs have a sufficient number of 

residents. Criteria under sections 

7302(e)(1)(A)–(B) and (e)(2)(A)–(B) 

further guide VA’s selection of its 

facilities in which residency programs 

will be established or residents will be 

placed, where such criteria relate to VA 

staffing levels, location of VA facilities 

in certain areas deemed as health 

professional shortage areas, and priority 

for residents to be placed for the 

provision of specific types of health 

care. Through a request for proposal 

(RFP) mechanism, VA Central Office 

notifies VA facilities of these selection 

criteria as well as other parameters. This 

RFP details, among other things: 

Consideration factors to be assessed by 

VA Central Office (as well as the relative 

importance or weight of such factors); 

information required from VA facilities 

to be in any response to the RFP 

submitted back to VA Central Office; 

and the process to submit a response to 

the RFP, to include submission 

instructions and timelines for 

completion. Upon receipt of those RFP 

responses submitted by VA health care 

facilities, VA Central Office evaluates 

the responses submitted against the 

criteria in the RFP to determine those 

facilities in which residents will be 

placed or whether funding will be made 

available for certain costs of establishing 

new medical residency programs. In 

administering GME programming under 

section 7302(e), VA forms relationships 

with non-VA institutions that sponsor 

graduate medical educational programs 

(most often medical schools or teaching 

hospitals), and it is those sponsoring 

institutions that provide the residents 

that would be available for placement in 

VA facilities. VA, therefore, does not 

control the pool of participating 

educational programs or available 

residents, although VA does assess the 

requirements under section 7302(e) to 

determine the best placement for such 

residents in VA facilities. VA in effect 

then does not place residents but does 

provide for resident positions to be 

filled in VA facilities. Under section 

7302(d), VA forms academic affiliations 

with sponsoring institutions to delineate 

the responsibilities regarding the 

training of the residents, and VA enters 

into other separate agreements to 

control funding of both certain 

residency program educational costs 

(such as accreditation fees and National 

Resident Match Program fees) and the 

costs of paying resident stipends and 

benefits. VA envisions that the pilot 

program authorized under section 403 

would be conducted under the same 

basic tenets of GME programming as 

presented above, such that there would 

be agreements formed with academic 

affiliations with sponsoring institutions 

and the covered facilities recognized in 

section 403 and in which residents 

would be placed under the pilot. We 

will note throughout these proposed 

regulations where we expect there to be 

administrative and substantive 

similarities and differences between 

VA’s statutory GME programming under 

38 U.S.C. 7302 and the pilot program 

required by section 403. 

We propose to establish several new 

regulation sections in part 17 of title 38 

Code of Federal regulation (CFR) in 

§§ 17.243 through 17.248 to implement 

this mandated pilot program, as further 

discussed below. 

§ 17.243 Purpose and scope. 

Proposed § 17.243(a) would establish 

that proposed §§ 17.243 through 17.248 

would implement the VA Pilot Program 

on Graduate Medical Education and 

Residency (PPGMER) to place residents 

in existing or new residency programs 

in covered facilities and to reimburse 

certain costs associated with 

establishing new residency programs in 

covered facilities, as authorized by 

section 403 of Public Law 115–182. 

Proposed § 17.243(b) would establish 

the scope of the PPGMER by stating that 

§§ 17.243 through 17.248 would apply 

only to the PPGMER as authorized 

under section 403 of Public Law 115– 

182, and not to VA’s more general 

administration of GME programs in VA 

facilities as authorized under 38 U.S.C. 

7302(e). Establishing the scope of the 

PPGMER as separate from VA’s more 

general GME programming under 38 

U.S.C. 7302(e) would be necessary 

because the PPGMER is a time-limited 

pilot program that will sunset on August 

7, 2031 (unless statutorily reauthorized 

or made permanent), and because 

section 403 of the MISSION Act 

establishes PPGMER-specific criteria 

that do not otherwise apply to VA’s 

administration of GME programs under 

38 U.S.C. 7302(e). Additionally, 

although the PPGMER would be a 

separately administered program under 

these proposed regulations, the 

PPGMER would utilize some of the 

same administrative concepts or 

procedures as VA uses to administer 

programs under 38 U.S.C. 7302(e). For 

instance, some definitions as proposed 

in these regulations may be the same as 

established in certain VA policy used to 

administer GME programming under 

section 7302(e), as will be explained in 

discussion of proposed § 17.244. 

Proposed § 17.243 would not state the 

2031 sunset date of the PPGMER, as the 

authority for PPGMER may be extended 

or made permanent in the future. If the 

authority for PPGMER were not 

extended or made permanent, VA 

would cease to implement the PPGMER 

and would issue a publication in the 

Federal Register to remove and reserve 

the regulation. 

§ 17.244 Definitions. 

Proposed § 17.244 would establish 

definitions to apply to the PPGMER 

under proposed §§ 17.243 through 

17.249. 

The term benefit would be defined to 

mean 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 

(FICA) taxes, and retirement 

contributions. We believe this would be 

a commonly understood definition of 

this term as it is consistent with the 

characterization of benefits in VA policy 

that is used to administer programs 

under the authority of 38 U.S.C. 7302(e). 

This definition would be relevant as VA 

would pay benefits to residents as 

applicable, as explained later in the 

discussion of proposed § 17.248. 

The term covered facility would be 

defined to mean any facility identified 

in § 17.245, as that section is proposed 

and discussed later in this rulemaking. 

We would define covered facility in 

relation to proposed § 17.245, to avoid 

having to reference § 17.245 in every 

instance in which the term covered 

facility would be used in the proposed 

regulation text. 

The term educational activities would 

be defined to 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; attendance in didactic sessions; 

research; attendance at VA facility 

committee meetings; scholarly activities 

that are part of an accredited training 

program; and approved educational 

details. We believe this would be a 

commonly understood definition of this 

term as it is consistent with the 

characterization of existing educational 

activities in VA policy (see, e.g., 

Veterans Health Administration (VHA) 

Directive 1400.09, Education of 

Physicians and Dentists) that is used to 

administer programs under the 

authority of 38 U.S.C. 7302(e). This term 

would be relevant as it would be used 

to qualify those stipend and benefits 

payments VA may make for residents 


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under the PPGMER, as explained later 

in the discussion of proposed § 17.248. 

The term resident would be defined to 

mean physician trainees engaged in 

post-graduate specialty or subspecialty 

residency programs that are either 

accredited by the Accreditation Council 

for Graduate Medical Education or in 

the application process for 

accreditation. The term resident would 

further be defined to include 

individuals in their first post-graduate 

year (PGY–1) of training (often referred 

to as Interns), and individuals who have 

completed training in their primary 

specialty and continue training in a 

subspecialty graduate medical 

education program and (generally 

referred to as Fellows). These Fellows 

would often be PGY–4 and above, 

depending upon the specialty. This term 

is relevant as it would be used 

throughout these proposed regulations, 

and we believe this proposed definition 

would be commonly understood as it is 

consistent with the characterization of a 

resident in VA policy that is used to 

administer programs under the 

authority of 38 U.S.C. 7302(e). Because 

this definition would require the 

residency programs to be accredited or 

in the process for such accreditation by 

the Accreditation Council of Graduate 

Medical Education, VA would not 

consider individuals in non-accreditable 

programs, including VA Advanced 

Fellows or post-training chief residents, 

as residents under this pilot. While 

section 7302(e) uses the term residency 

position, for purposes of this proposed 

rule, we propose to use the term 

resident because that was the term used 

in sections 403(a)(4) through (6) and (b) 

of the MISSION Act. Additionally, the 

proposed definition of resident would 

permit VA to consider more than one 

resident as occupying a single resident 

position (such as a split assignment, 

which VA would track according to the 

percentage of VA assigned educational 

activities). 

The term stipend would be defined to 

mean the annual salary paid by VA for 

a resident. We believe this proposed 

definition would be commonly 

understood as it is consistent with the 

characterization of a stipend in VA 

policy that is used to administer 

programs under the authority of 38 

U.S.C. 7302(e). This definition would be 

relevant as VA would pay stipends to 

residents as applicable, as explained 

later in the discussion of proposed 

§ 17.248. 

The term VA health care facility 

would be defined to mean 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. This definition would be 

relevant to characterize one type of 

covered facility under proposed 

§ 17.245, and relevant to characterize 

one assessment criterion under 

proposed § 17.246(a)(7). We believe this 

definition is reasonable because it 

would capture the VA settings in which 

a VA physician provides care to 

Veterans, as it would be physicians who 

are teaching residents to be placed 

under the PPGMER. 

§ 17.245 Covered facilities. 

Proposed § 17.245 would list the 

covered facilities in which residents 

may be placed under the PPGMER, 

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

MISSION Act. We would restate the list 

of covered facilities from section 

403(a)(2), versus merely crossreferencing section 403 or the statutory 

note to 38 U.S.C. 7302, for clarity and 

to provide regulatory citations that 

characterize or define certain terms 

related to covered facilities as 

applicable. Listing the facility types 

versus cross referencing section 403 

would also allow proposed § 17.245 to 

include applicable regulatory citations. 

For instance, section 403(a)(2)(B) 

establishes that one type of covered 

facility are those health care facilities 

operated by an Indian tribe or tribal 

organization as those terms are defined 

in 25 U.S.C. 5304; proposed § 17.245(b) 

would restate this language from section 

403 and would add the relevant 

regulatory citations for the definitions of 

Indian tribe and tribal organization. 

Proposed § 17.245 would establish the 

following types of facilities as covered 

facilities under the PPGMER, consistent 

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

Act: (1) A VA health care facility as 

defined in § 17.244; (2) 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; (3) a health care facility 

operated by the Indian Health Service; 

(4) a federally-qualified health center as 

defined in 42 U.S.C. 1396d(l)(2)(B); (5) 

a health care facility operated by the 

Department of Defense; or (6) other 

health care facilities deemed 

appropriate by VA. We note that 

although a VA health care facility is 

listed as a covered facility under section 

403(a)(2)(A) and would also be listed as 

a covered facility in proposed 

§ 17.245(a), we do not anticipate the 

PPGMER being a vehicle for the 

placement of residents in VA facilities, 

as VA intends to continue operating its 

GME programming to place residents in 

VA facilities as authorized under 38 

U.S.C. 7302 and 7406, separate from the 

PPGMER for the duration in which the 

PPGMER is implemented. We believe 

the authority under section 7302 is 

sufficient to place residents in VA 

facilities. However, we would not want 

to exclude from this proposed rule an 

express type of covered facility as listed 

in section 403(a)(2) of the MISSION Act. 

Similarly, proposed § 17.245(f) would 

provide, consistent with section 

403(a)(2)(F), that a covered facility 

could be any other health care facility 

as VA considers appropriate, giving VA 

the ability to place residents in a variety 

of facilities, such as those recognized by 

the Department of Health and Human 

Services as Rural Health Clinics, 

without curtailing the discretion 

provided to VA by section 403(a)(2)(F) 

in the administration of the PPGMER. 

§ 17.246 Consideration factors for 

placement of residents. 

Proposed § 17.246 would establish 

factors that VA would consider when 

determining in which covered facilities 

residents would be placed under the 

pilot. Consistent with section 

403(a)(4)(A)–(G) of the MISSION Act, 

proposed § 17.246(a)(1) through (7) 

would generally provide that VA would 

evaluate these factors in the context of 

whether there is a clinical need for 

providers in the area in which a covered 

facility is located. Proposed paragraphs 

(a)(1) through (7) would then restate 

from section 403(a)(4)(A)–(G) the 

specific factors VA must consider when 

determining whether there is a clinical 

need for providers in an area (those 

specific factors are discussed in detail 

further in this section of the preamble). 

We note that these proposed factors, 

consistent with section 403(a)(4), would 

not be weighted in any particular 

manner in the regulation text under 

proposed § 17.246(a), to allow flexibility 

for VA to consider the relative import of 

factors throughout the duration of the 

pilot. Although these factors would not 

be weighted in regulatory text, it may be 

the case that VA would assign levels of 

relative importance to these factors as 

part of its selection process, as 

discussed in the section of this 

preamble related to proposed § 17.247. 

Additionally, only one factor in 

proposed paragraphs (a)(1) through (7) 

would be required to be met for VA to 

determine that a covered facility would 

be in an area with a clinical need for 

providers. As discussed below, it may 

be the case that some covered facilities 

could be considered to meet the same 

factor under paragraphs (a)(1) through 

(7) of proposed § 17.246, and that 


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additional factors would need to be 

considered. 

Before discussing the specific factors 

that VA would consider in proposed 

§ 17.246(a)(1) through (7) to determine 

the clinical need for providers in an 

area, we clarify that VA would not be 

soliciting the interest of covered 

facilities to participate in the PPGMER 

through a public funding 

announcement, a public request for 

proposal, or by establishing an public 

application process, because section 403 

of the MISSION Act is not an express 

grant or cooperative agreement authority 

through which VA may offer a public 

funding opportunity. Further, section 

403 does not authorize any amount of 

money to be appropriated to implement 

the PPGMER, separate from VA’s 

administration of its existing GME 

programing authorized under 38 U.S.C. 

7302 and 7406. Because VA does not 

interpret that section 403 of the 

MISSION Act to authorize a public 

funding opportunity for which covered 

facilities may apply or submit a 

proposal to be considered, VA would 

not conduct a public solicitation. 

Rather, the parameters of VA’s selection 

process for covered facilities would be 

established in proposed § 17.247, as 

discussed later in this proposed rule. 

Consistent with section 403(a)(4)(A) 

of the MISSION Act, proposed 

§ 17.246(a)(1) would establish that VA 

would evaluate 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. 

Proposed § 17.246(a)(1)(i) would 

establish that VA considers a 

standardized geographic area to mean 

the county in which a covered facility 

is located. We believe this is a 

reasonable interpretation of a 

standardized geographic area by which 

to compare ratios of veterans to VA 

providers, as most covered facilities as 

well as VA should be able to access 

such data. We understand that 

proposing to use a county as the 

standardized geographic area would 

mean that covered facilities in the same 

county would have the same ratios of 

veterans to VA providers, making such 

facilities incomparable in terms of this 

consideration factor. We reiterate, 

therefore, that this is only one of 

multiple factors that VA would consider 

when determining the need for clinical 

providers in an area, and we do not 

anticipate that this factor would prevent 

covered facilities in the same county 

from being considered, provided other 

factors that indicate clinical need are 

met. Proposed § 17.246(a)(1)(ii) would 

clarify that when deciding the clinical 

need for providers in an area, VA may 

consider either or both of the ratio(s) for 

general practitioners and specialists, 

where a higher ratio of veterans to VA 

providers would indicate a higher need 

for health care providers in an area. We 

believe these clarifications would be 

consistent with section 403(a)(4)(A). 

Consistent with section 403(a)(4)(B) of 

the MISSION Act, proposed 

§ 17.246(a)(2) would establish that VA 

would evaluate 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, which we believe 

is a reasonable interpretation of section 

403(a)(4)(B) to reflect a commonplace 

understanding that fewer types of 

providers in an area can indicate a 

greater clinical need. Proposed 

§ 17.246(a)(2) would consider the range 

of specialties of both VA and non-VA 

providers in an area because section 

403(a)(4)(B) is not specific to only VA 

providers. We note that the term 

standardized geographic area as used in 

proposed § 17.246(a)(2) would mean the 

county in which a covered facility is 

located, consistent with how that term 

is defined in proposed § 17.246(a)(1)(i). 

Consistent with section 403(a)(4)(C) of 

the MISSION Act, proposed 

§ 17.246(a)(3) would establish that VA 

would evaluate whether the specialty of 

a provider is included in the most 

recent staffing shortage determination 

by VA under 38 U.S.C. 7412. Under 

section 7412(a), not later than 

September 30 of each year, the Inspector 

General of VA shall determine, certain 

clinical and nonclinical occupations for 

which there are the largest staffing 

shortages with respect to each VA 

medical center of the Department. The 

type of providers considered under 

proposed § 17.246(a)(3) would be based 

on the list developed pursuant to 38 

U.S.C. 7412(a). We note that the list 

developed pursuant to 38 U.S.C. 7412(a) 

is a national list (based on data from all 

VA medical centers in the country 

related to shortages of providers), and 

that this factor would not be evaluated 

in relation to provider types or numbers 

at any one VA facility. We also note that 

a covered facility would not similarly 

have to have a shortage of the type of 

provider on the list developed pursuant 

to 38 U.S.C. 7412, as it may be that a 

sufficient number of such providers at a 

covered facility could indicate the best 

conditions in which VA should place 

residents (as these would be the very 

types of providers VA needs more of). 

We would not regulate this factor more 

specifically, however, to provide VA the 

flexibility in assessing the list 

developed pursuant to 38 U.S.C. 7412. 

Consistent with section 403(a)(4)(D) of 

the MISSION Act, proposed 

§ 17.246(a)(4) would establish that VA 

would evaluate whether a covered 

facility is located 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. We note that section 

403(a)(4)(D) of the MISSION Act would 

require VA to consider whether the 

local community is designated as 

underserved pursuant to criteria 

developed under section 401 of Public 

Law 115–182. Section 401 of Public Law 

115–182 relates to VA’s criteria to 

designate its facilities as underserved, 

rather than communities at large. To 

clarify any potential inconsistency 

between the reference to underserved 

VA facilities in section 401 and 

underserved communities in section 

403, we believe a reasonable reading of 

section 403(a)(4)(D) provides for VA to 

consider whether covered facilities are 

located in a local community in which 

a VA facility has been designated as 

underserved under section 401. In 

developing the criteria to identify 

underserved VA facilities under section 

401, VA must consider various factors, 

including the ratio of veterans to VA 

health care providers in an area, the 

range of clinical specialties offered, 

whether the local community is 

medically underserved, data on open 

consults, whether the facility is meeting 

the wait-time goals of the Department, 

and such other factors that VA considers 

important in determining which 

facilities are not adequately serving area 

veterans. For purposes of this factor, if 

a covered facility is located in the same 

Veterans Integrated Service Network 

(VISN) as a VA facility designated as 

underserved pursuant to section 401, 

then VA would consider that covered 

facility to be located in the same local 

community as the VA facility. We 

believe the service area of a VISN would 

allow VA to consider a broad range of 

covered facilities, but we would not 

regulate that requirement more 

specifically in the event that VA facility 

service area names change in the future. 

Using the phrase local community in 

proposed § 17.246(a)(4) would also be 

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

the MISSION Act, and would allow VA 

the flexibility to consider a service area 

that is different from a VISN in the 

future, in which case VA would clearly 

indicate a different standard in the 

request for proposal that is sent to VA 

health care facilities for consideration. 


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Lastly, we note that under section 401, 

a VA facility is characterized as a 

medical center, ambulatory care facility, 

and a community-based outpatient 

clinic. Proposed § 17.246(a)(4) would 

reference VA facility to be consistent 

with section 401. 

Consistent with section 403(a)(4)(E) of 

the MISSION Act, proposed 

§ 17.246(a)(5) would establish that VA 

would evaluate whether the covered 

facility is located in a community 

designated by the Secretary of Health 

and Human Services (HHS) as a health 

professional shortage area under 42 

U.S.C. 254e. Under 42 U.S.C. 254e(a)(1), 

a health professional shortage is an area 

in an urban or rural area that has been 

determined to have a provider shortage 

and which is not reasonably accessible 

to an adequately served area, a 

population group that has been 

determined to have such a shortage, or 

a public or nonprofit private medical 

facility or other public facility that has 

been determined to have such a 

shortage. 

Consistent with section 403(a)(4)(F) of 

the MISSION Act, proposed 

§ 17.246(a)(6) would establish that VA 

would evaluate whether the covered 

facility is in a rural or remote area. 

Proposed paragraph (a)(6)(i) would 

further interpret a rural area to mean 

those areas identified by the U.S. 

Census Bureau as rural. Section 403 

does not specifically define or 

characterize the meaning of the term 

rural, and therefore, we believe it is 

rational to use the definition provided 

by the U.S. Census Bureau. The Census 

Bureau’s classification of rural consists 

of all territory, population, and housing 

units located outside of urbanized areas 

and urban clusters. Interested parties are 

referred to the Census Bureau’s website 

(https://www.census.gov/programssurveys/geography/guidance/geo-areas/ 

urban-rural.html) for additional 

information. Proposed paragraph 

(a)(6)(ii) would further interpret a 

remote area to mean 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. VA would 

adopt this characterization of a remote 

area because it does not have a similarly 

comprehensive characterization of 

remote areas in statute or regulation. As 

we are unsure of the level of familiarity 

with this standard related to a frontier 

or remote area, as opposed to the 

characterization of a rural area as 

proposed above, we provide the 

following background. The Economic 

Research Service within the United 

States Department of Agriculture has 

developed ZIP-code-level FAR 

designations, where the phrase frontier 

and remote is used to describe territory 

characterized by some combination of 

low population size and high 

geographic remoteness. The most 

updated set of FAR codes is based on 

urban-rural data from the 2010 

decennial census and provides four FAR 

definition levels, ranging from one that 

is relatively inclusive (12.2 million FAR 

level one residents) to one that is more 

restrictive (2.3 million FAR level four 

residents). FAR areas are defined in 

relation to the time it takes to travel by 

car to the edges of nearby urban areas, 

and four FAR levels are necessary 

because rural areas experience degrees 

of remoteness at higher or lower 

population levels that affect access to 

different types of goods and services. 

For instance, a larger number of people 

live significant distances from cities 

providing high order goods and 

services, such as advanced medical 

procedures, stores selling major 

household appliances, regional airport 

hubs, or professional sports franchises, 

and level one FAR codes are meant to 

approximate this degree of remoteness. 

A smaller number of people have 

difficulty accessing low order goods and 

services, such as grocery stores, gas 

stations, and basic health-care services, 

and level-four FAR codes more closely 

coincide with this higher degree of 

remoteness. Other types of goods and 

services—clothing stores, car 

dealerships, movie theaters—fall 

somewhere in between. We would use 

all four levels of FAR codes to 

characterize remote areas for purposes 

of these proposed rules. 

Consistent with 403(a)(4)(G) of the 

MISSION Act, proposed § 17.246(a)(7) 

would implement VA’s permissive 

authority, for purposes of resident 

placements under PPGMER, to evaluate 

other criteria that VA considers 

important in determining those covered 

facilities that are not adequately serving 

area veterans. Proposed paragraph (a)(7) 

would include a non-exhaustive list of 

criteria VA would consider. Proposed 

§ 17.246(a)(7)(i) would establish that VA 

may evaluate the 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. This criterion would be useful 

in assessing to what extent residents 

placed in non-VA covered facilities 

could reasonably be expected to travel 

to also receive resident training in VA 

health care facilities, consistent with the 

requirement that the discretionary 

criteria in section 403(a)(4)(G) of the 

MISSION Act relate to identifying those 

covered facilities that may not be 

adequately serving area veterans. For 

purposes of assessing the criterion in 

proposed § 17.246(a)(7)(i), VA would 

define a VA health care facility to mean 

any VA location where VA physicians 

provide care to Veterans, such as a VA 

medical center, independent outpatient 

clinic, domiciliary, nursing home 

(community living center), residential 

treatment program, and any of a variety 

of community-based clinics. We note 

that this definition is broader than the 

term ‘‘VA facility’’ under proposed 

§ 17.246(a)(4), as proposed § 17.246 

would relate to an independent 

characterization of the term VA facility 

under section 401 of Public Law 115– 

182. We also note that proposed 

§ 17.246(a)(7)(i) does not create any 

requirement for residents placed under 

the PPGMER to necessarily rotate to VA 

facilities to receive training, it is merely 

one additional criterion that VA may 

assess in accordance with section 

403(a)(4)(G) of the MISSION Act. Any 

requirement for rotation to VA facilities 

for residents placed under the PPGMER, 

like other training requirements for such 

residents, would be controlled by the 

agreements formed as will be discussed 

in the section of this rule that addresses 

proposed § 17.248. Proposed 

§ 17.246(a)(7)(ii) would establish that 

VA may evaluate programmatic 

considerations related to establishing or 

maintaining a sustainable residency 

program when determining facilities are 

not adequately serving area veterans, for 

purposes of placing residents in covered 

facilities. These programmatic 

considerations would include but not be 

limited to 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 any 

financial support from VA that may be 

furnished under proposed § 17.248. 

These considerations would allow VA 

to assess the likelihood of a residency 

program to be successful and 

sustainable, thus ensuring VA’s 

resources in funding residents would be 

well placed to support the PPGMER. 

Proposed § 17.246(b) would establish 

that there would be a prioritized 

placement of residents under the 

PPGMER to no fewer than 100 residents 

for the duration in which the PPGMER 


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is administered 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. This minimum number of 

residents to be placed in these specific 

covered facilities is consistent with the 

requirement in section 403(a)(5) of the 

MISSION Act. Proposed § 17.246(b) 

would further clarify that the placement 

of these 100 residents would be for the 

duration in which the PPGMER is 

administered, because we do not read 

anything in section 403(a)(5) to require 

these 100 residents to be the first 

residents placed under this pilot 

program. We also interpret section 

403(a)(5) of the MISSION Act to require 

VA to consider priority placement of at 

least 100 residents and not 100 resident 

positions, which is consistent with a 

plain reading of section 403(a)(5). We 

clarify this point because we would 

define the term resident to permit 

multiple residents to occupy a single 

resident position as appropriate. We 

note that, generally, residents placed 

through the PPGMER could be at any 

point in their residency, and that any 

such placement at any point in a 

residency would qualify amongst the 

100 priority placements in proposed 

§ 17.246. 

§ 17.247 Determination process for 

placement of residents. 

We reiterate from earlier in this 

proposed rule that VA does not interpret 

that section 403 authorizes a public 

funding opportunity through which 

covered facilities or any other entity 

may apply or submit a proposal to VA, 

for VA to then consider having residents 

placed in covered facilities and paying 

their stipends or benefits, or to 

reimburse certain costs of new 

residency programs. The introductory 

text to proposed § 17.247 would 

therefore state that 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 (where 

proposed § 17.248, as discussed later in 

this rulemaking, would establish VA’s 

payment of resident stipends and 

benefits, and VA’s reimbursement of 

certain costs of new residency 

programs). The introductory text to 

proposed § 17.247 would further 

establish that VA will therefore not 

conduct a public solicitation to 

determine those covered facilities in 

which residents may be places or to 

determine costs that may be paid or 

reimbursed under § 17.248, but that VA 

would instead make such 

determinations based on the parameters 

further established in proposed 

§ 17.247(a) through (c). 

Proposed § 17.247(a) would state 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 (as explained 

later in this rulemaking, proposed 

§ 17.248 will outline the types of costs 

available to be paid or reimbursed by 

VA under the PPGMER.) Proposed 

§ 17.247(a) would further state that the 

RFP issued by VA Central Office would 

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 (3) the process to submit a 

response to the RFP. Under proposed 

§ 17.247(a), the RFP issued by VA 

Central Office would provide education 

to VA health care facilities in the 

evaluation of the factors in proposed 

§ 17.246(a)(1) through (7) to determine 

clinical need for providers in an area, 

and the VA health care facilities would 

then assess covered facilities that may 

be located in such areas to weigh the 

factors and determine those covered 

facilities that meet the criteria under the 

RFP. We reiterate from earlier in this 

rulemaking that VA Central Office 

conducts an RFP process to administer 

its more general GME programming 

under section 7302(e), and VA envisions 

a similar process to be followed under 

the PPGMER, where VA Central Office 

notifies VA facilities (directly, or 

through channels via Veterans 

Integrated Service Networks) of a 

forthcoming RFP cycle for the funding 

of residents or certain resident program 

costs. The RFP in turn would provide 

VA health care facilities with all 

required information to complete a 

response, including a clear statement of 

the consideration factors and 

submission instructions to include any 

submission dates as applicable and 

points of contact for questions. The RFP 

will additionally provide a general 

timeline in which VA health care 

facilities will conduct the process of 

assessing the consideration factors and 

reaching out to covered facilities 

regarding the RFP. The consideration 

factors in the RFP for the PPGMER 

would include those consideration 

factors expressly stated in section 

403(a)(4) and in proposed § 17.246, and 

the relative importance of such factors 

(e.g., whether they may be weighted 

differently). We reiterate from earlier in 

the preamble that the consideration 

factors in proposed § 17.246 would not 

be weighted in the regulatory text itself 

to allow VA the flexibility to consider 

the relative importance of factors over 

the duration of the pilot, as the relative 

importance of those factors may change. 

For instance, an RFP issued by VA 

Central Office for the PPGMER could 

indicate that there would be more 

weight assigned to areas that issued 

responses with covered facilities 

operated by 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, as these are deemed 

priority placement factors for the 

PPGMER in section 403(a)(5). 

Alternatively, an RFP issued by VA 

Central Office for the PPGMER could 

indicate that there would be more 

weight assigned depending on the 

specialty of a provider included in the 

most recent staffing shortage 

determination by VA under 38 U.S.C. 

7412. 

Proposed § 17.247(b) would then 

establish that VA health care facilities, 

in collaboration with covered facilities, 

will submit responses to the RFP to VA 

Central Office. This language would 

permit only VA health care facilities to 

submit responses to the RFP issued by 

VA Central Office, to further reinforce 

VA’s interpretation that section 403 

does not authorize a public funding 

opportunity for which covered facilities 

may apply directly or submit a proposal 

to be considered. VA health care 

facilities would assess covered facilities 

in their areas that participate with 

institutions that sponsor medical 

educational programs (most often a 

medical school or teaching hospital), 

where typically VA already has 

academic partnerships with such 

sponsoring institutions and the RFP 

details the involvement of any 

particular sponsoring institution. 

However, VA would not be prevented in 

these proposed regulations from 

assessing covered facilities that did not 

have educational relationships with 

sponsoring institutions, and covered 

facilities would not be prevented from 

initiating contact with a VA facility to 

determine if such covered facilities may 

meet the requirements to participate in 

the PPGMER as detailed in the RFP. We 

reiterate that the RFP will provide a 

general timeline in which VA health 


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care facilities will conduct the process 

of assessing the consideration factors 

and reaching out to covered facilities 

regarding the RFP. 

Proposed § 17.247(c) would then state 

that 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. In its evaluation, 

VA Central Office will assess the 

consideration factors established in the 

RFP to include the criteria in § 17.246, 

and will weigh those factors as their 

relative importance would be 

established in the RFP. 

§ 17.248 Costs of funding residents 

and new residency programs. 

Proposed § 17.248 would establish the 

types of costs that VA may fund under 

the PPGMER to place residents in 

covered facilities or to reimburse certain 

costs incurred by new residency 

programs in accordance with sections 

403(a)(6) and (b)(1)–(b)(5) of the 

MISSION Act. Section 403(a)(6) 

authorizes VA to pay stipends and 

provide benefits for residents in 

positions created under section 

403(a)(1), and section 403(b) authorizes 

VA to reimburse certain new residency 

program costs if VA places a resident in 

such a program. 

To address a few preliminary matters, 

we note that section 403(a)(6) is a 

discretionary authority to pay stipends 

and benefits of residents, regardless of 

whether they have been assigned to a 

VA facility, and that VA would retain 

this discretion in proposed § 17.248 to 

include establishing any general 

restrictions or conditions for such 

payments. We further interpret the 

discretionary nature of section 403(a)(6) 

to authorize VA’s funding of resident 

stipends and benefits either through a 

direct payment or reimbursement 

mechanism, in accordance with any 

contract, agreement, or other 

arrangement VA has legal authority to 

form (possibly, to include payment 

mechanisms as applicable that VA 

currently uses to administer its more 

general GME programming under 38 

U.S.C. 7302(e)). Conversely, we 

interpret section 403(b) as a mandatory 

authority to reimburse certain new 

resident program costs if VA places a 

resident in such programs, and further 

that subsections (b)(1)–(b)(5) establish 

the mandatory costs that must be 

reimbursed. However, we do not 

interpret that section 403(b) limits VA’s 

authority to determine restrictions or 

criteria for such reimbursement. Lastly, 

consistent with section 403(a)(3), and 

other authorities under which VA may 

legally enter into contracts, agreements, 

or other arrangements, VA would enter 

into such contracts, agreements, or other 

arrangements to administer the 

PPGMER. It would be those contracts, 

agreements, or other arrangements that 

would establish the terms to control 

costs that could be funded. 

The introductory text of proposed 

§ 17.248 would establish that once VA 

determines in which covered facilities 

residents will be placed, in accordance 

with §§ 17.246 through 17.247, payment 

or reimbursement of certain costs would 

be authorized. Proposed § 17.248(a) 

would establish the first category of 

funding available under the PPGMER, 

related to resident stipends and benefits, 

consistent with section 403(a)(6). 

Proposed § 17.248(a) would establish 

that, for residents placed in covered 

facilities by VA, 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. This language is intended to 

limit payments of stipend and benefits 

to only those educational activities that 

support the PPGMER, to prevent VA’s 

payment for educational activities a 

resident may complete when they may 

engage in duties or responsibilities 

associated with portions of their 

training not associated with the 

PPGMER (such as when a resident may 

have portions of their training paid for 

by other entities not engaged with the 

PPGMER). We clarify that educational 

activities directly related to the 

PPGMER could be associated with the 

treatment of non-veteran patients, as 

section 403(a)(6) of the MISSION Act 

clearly permits VA to pay stipends and 

benefits for residents outside of VA 

facilities, and section 403(b) permits VA 

to reimburse certain costs associated 

with new residency programs 

established in covered facilities, which 

includes non-VA facilities. More 

generally, a primary purpose of VA’s 

administration of GME programming 

under 38 U.S.C. 7302(e), and under 

section 403 of the MISSION Act by 

extension, is to fulfill one of VA’s 

missions under 38 U.S.C. 7302 to assist 

in providing an adequate supply of 

health personnel to the United States. 

We reiterate from the discussion of 

proposed § 17.246(a)(7)(i) that this rule 

would not create any requirement for 

residents placed under the PPGMER to 

necessarily rotate to VA health care 

facilities to receive training, and any 

such requirement (as with other training 

requirements for PPGMER residents) 

would be controlled by the agreements 

formed as discussed further in this 

section of the rule related to proposed 

§ 17.248. Proposed § 17.248(a) would 

further state that VA’s payment of 

stipends and benefits would be in 

accordance with any contract, 

agreement, or other arrangement VA has 

legal authority to form. In addition, such 

stipends and benefits will not exceed 

VA’s established maximum amounts for 

payments under any existing GME 

agreements. This language intends to 

establish that any criteria or restrictions 

related to VA’s payment of stipends and 

benefits would be clearly indicated in 

contracts, agreements, or other 

arrangements outside of the proposed 

rule. This language would allow VA the 

flexibility to establish payment 

parameters as would be relevant to a 

covered facility, within the appropriate 

purchasing or other mechanisms that 

VA may legally use, to include an 

agreement permitted under section 

403(a)(3) of Public Law 115–182. We 

note that VA would be bound by any 

legal requirements as they exist outside 

of this proposed rule with regards to 

these other authorities to enter into 

contracts, agreements, or other 

arrangements. Proposed § 17.248(a) 

would not state or reference these other 

authorities, or the resulting payment 

instruments, however, to provide VA 

and covered facilities the flexibility that 

would be needed to properly implement 

the payment of resident stipends and 

benefits. 

Proposed § 17.248(b) would establish 

that VA may reimburse certain costs 

associated with new residency 

programs, consistent with section 

403(b)(1)–(5) of the MISSION Act. 

Consistent with section 403(b), 

proposed § 17.248(b)(1) would establish 

that if a covered facility establishes a 

new residency program in which VA 

places a resident, VA will reimburse 

certain costs as further detailed in 

proposed § 17.248(b)(1)(i) through (v), 

where the following costs in proposed 

paragraphs (b)(1)(i) through (v) mirror 

the types of costs established in sections 

403(b)(1)–(5), which are: Curriculum 

development costs; recruitment and 

retention of faculty costs; accreditation 

costs; faculty salary costs; and resident 

education expense costs. Each of the 

types of costs established in proposed 

§ 17.248(b)(1)(i) through (v) would be 

further characterized by the following 

non-exhaustive examples: (1) 

Curriculum development costs would 

include but not be limited to costs 

associated with needs analysis, didactic 

activities, materials, equipment, 

consultant fees, and instructional 

design; (2) recruitment and retention of 

faculty costs would include but not be 


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limited to costs associated with 

advertising available faculty positions, 

and monetary incentives to fill such 

positions such as relocation costs and 

educational loan repayment; (3) 

accreditation costs would 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; (4) faculty salary 

costs would include only the 

proportionate cost of faculty performing 

duties directly related to the PPGMER; 

and (5) 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. We further note that 

faculty salary costs in proposed 

§ 17.248(b)(1)(iv) would have a similar 

qualifying restriction as with resident 

stipends and benefits in proposed 

§ 17.248(a), where faculty salary costs 

would be limited to only the 

proportionate cost of faculty performing 

duties directly related to the PPGMER. 

This restriction would provide an 

express notice that VA would not, for 

instance, reimburse costs for any 

portion of salary of an attending 

physician that correlates with 

supervising residents that were not 

participating in the PPGMER, as it may 

be the case that a group of residents 

being supervised by an attending 

physician is not fully comprised of 

PPGMER participants. Similar to 

proposed § 17.248(a), proposed 

§ 17.248(b) would further state that VA’s 

reimbursement of certain costs 

associated with a new residency 

program would be in accordance with 

any contract, agreement, or other 

arrangement VA has legal authority to 

form, and that reimbursements for 

authorized costs may not exceed VA’s 

established maximum amounts for 

payment under any existing GME 

agreements. This language intends to 

establish that any criteria or restrictions 

related to VA’s reimbursement of these 

costs would be clearly indicated in 

contracts, agreements, or other 

arrangements outside of the proposed 

rule, again to allow the flexibility to 

establish parameters as would be 

relevant and within the appropriate 

purchasing or reimbursement 

mechanisms that VA may legally use. 

We note that VA would be bound by 

any legal requirements as exist outside 

of this proposed rule with regards to 

these other authorities to enter into 

contracts, agreements, or other 

arrangements, but that proposed 

§ 17.248(b) would not state or reference 

these other authorities, again to provide 

VA and covered facilities the flexibility 

that would be needed to properly 

implement the reimbursement of these 

costs. 

Although proposed § 17.248(a) and (b) 

would not state any express criteria or 

restrictions that might exist in contracts, 

agreements, or other arrangements that 

would control the payment of resident 

stipends or benefits or reimbursement of 

certain new residency program costs, 

some examples of such criteria or 

restrictions could include: Establishing 

a discontinuation date for payments or 

reimbursements; establishing 

limitations on payments proportionate 

to the number of residents placed by 

VA; establishing any fixed dollar 

amount limits as found relevant or 

appropriate; or establishing a restricted 

look-back period, whereby VA would 

not reimburse the costs of, for instance, 

certain curriculum development costs 

that might occur prior to a specified 

timeframe before VA places a resident. 

Similarly, proposed § 17.248(a) and (b) 

would not expressly list the legal 

authorities or types of contracts, 

agreements, or other arrangements 

under which VA may pay resident 

stipends or benefits, or reimburse 

certain costs of new residency programs, 

or more generally to administer other 

typical aspects of GME programming 

through the PPGMER. Again, this lack of 

specificity with regards to identifying 

specific legal instruments in regulation 

would allow VA maximum flexibility to 

administer the PPGMER. However, we 

reiterate from earlier in this rulemaking 

that VA would otherwise be bound by 

any legal requirements as exist outside 

of this proposed rule with regards to 

these other authorities to enter into 

contracts, agreements, or other 

arrangements. We also reiterate from 

earlier in this rulemaking that VA 

would seek to administer the PPGMER 

in much the same manner as VA’s more 

general GME programming is 

administered under 38 U.S.C. 7302(e), 

as would be applicable and permissible, 

which would likely include the forming 

of certain agreements between VA and 

sponsoring institutions to establish 

responsibilities for educating residents 

and to control VA’s funding of residents 

and certain costs of new residency 

programs, or the evidence that such 

agreements were formed between 

sponsoring institutions and non-VA 

covered facilities. We therefore provide 

the following examples of types of 

agreements VA uses to administer its 

more general GME programming under 

section 7302(e), to provide some idea of 

whether the same or similar instruments 

might also be used to administer the 

PPGMER. Under VA’s more general 

GME programming pursuant to 38 

U.S.C. 7302(e), VA uses an affiliation 

agreement to delineate the duties and 

responsibilities regarding the training of 

residents, where an affiliation 

agreement is a central part of the 

relationship between VA and the 

affiliated institution and may involve 

specific provisions related to patient 

care, education, or research. Affiliated 

institutions can include academic 

institutions and other sponsoring 

institutions such as community 

hospitals, clinics, state agencies military 

treatment facilities, or Federal Health 

Education Consortia. VA would look to 

an affiliation agreement or similar 

instrument to form similar relationships 

with entities to administer the PPGMER. 

We note that VA policy currently 

recognizes sponsoring institutions and 

other entities as able to enter into an 

affiliation agreement prior to a subject 

residency program receiving 

comprehensive or full accreditation, 

such as an institution whose residency 

program may have some stage of 

Accreditation Council for Graduate 

Medical Education (ACGME) initial or 

provisional accreditation. See VHA 

Handbook 1400.03, Veterans Health 

Administration Educational 

Relationships. Under the PPGMER, we 

would retain VA’s ability to enter into 

affiliation agreements or similar 

instruments or look to the formation of 

such instruments between sponsoring 

institutions and non-VA covered 

facilities, where the subject residency 

programs may have some form of initial 

or provisional ACGME accreditation. 

Under VA’s more general GME 

programming pursuant to 38 U.S.C. 

7302(e), a disbursement agreement is 

used to administer stipend and benefits 

payments to residents in VA facilities. A 

disbursement agreement is an agreement 

through which VA allows a disbursing 

agent to administer salary payments and 

fringe benefits for medical residents 

assigned to a VA facility, where the 

disbursing agent may be the sponsoring 

institution for the residency training 

program itself or an entity delegated by 

the sponsoring institution(s) to handle 

stipend and benefit disbursements (e.g., 

a graduate medical education 

consortium). VA may look to a similar 

instrument to administer stipend and 

benefits payments for residents it places 

in non-VA facilities under the PPGMER, 

or any other contract, agreement, or 


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other arrangement VA may enter into as 

permissible and applicable. 

Under VA’s more general GME 

programming pursuant to 38 U.S.C. 

7302(e), VA uses educational cost 

contracts to pay pro-rated educational 

costs of the affiliated institutions 

sponsoring residency programs. These 

educational cost contracts are entered 

into pursuant to 38 U.S.C. 8153, where 

the relevant health care resource being 

purchased includes health care support 

resources and administrative resources 

to include the operation of a residency 

program. The pro-rated educational 

costs to be covered are set forth in an 

educational cost contract in proportion 

to the number of residents that actually 

rotate to a VA facility. VA may look to 

a similar instrument to administer 

payments of costs associated with the 

PPGMER, or any other contract, 

agreement, or other arrangement VA 

may enter into as permissible and 

applicable. 

VA also generally uses memoranda of 

agreement or understanding (MOA or 

MOU) as legally permissible to enter 

into agreements with entities and may 

look to such instruments to administer 

payments of costs associated with the 

PPGMER or to administer other aspects 

of the PPGMER. For instance, a MOA or 

MOU might be used to clearly indicate 

to a covered facility the extent of 

reimbursable costs allowable under 

proposed § 17.248(b), and could also 

include instructions for submitting to 

VA invoices of such costs and 

timeframes and modes of 

reimbursement. 

Proposed § 17.248(b)(2) would lastly 

establish that 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). We believe the ACGME 

status of initial accreditation or 

continued ACGME accreditation 

without outcomes captures those 

residency programs still in development 

and that would benefit from VA’s 

reimbursement of certain start-up costs 

in establishing a residency program. The 

additional criterion that such programs 

must not have graduated an inaugural 

class further supports that VA funding 

will not go to residency programs that 

otherwise have fully functioning 

curriculums and infrastructure to 

produce graduates. The ACGME status 

of initial accreditation is considered a 

developmental stage where residency 

programs can accept residents, and this 

status allows for site visits to determine 

compliance with relevant ACGME 

standards. As background, when a 

status of initial accreditation is 

conferred on a sponsoring institution or 

program, that institution or program 

will have a full site visit within two 

years of the effective date of initial 

accreditation, where the effective date is 

the date of the decision by the ACGME 

review committee (or, any effective date 

such committee may apply retroactively 

to the beginning of the academic year). 

If a residency program does not 

matriculate residents in the first 

academic year after receiving a status of 

initial accreditation, a site visit is 

conducted within three years from the 

effective date of such accreditation. If a 

sponsoring institution or program 

demonstrates substantial compliance at 

the subsequent review, the ACGME 

review committee may confer a status of 

continued accreditation or continued 

accreditation without outcomes. 

Proposed § 17.248(b)(2) would only 

include the ACGME status of continued 

accreditation without outcomes, beyond 

the initial accreditation stage, because 

continued accreditation without 

outcomes indicates that no residents 

have graduated, which in turn may 

indicate that the residency program still 

requires VA funding of certain costs to 

fully develop its curriculum and 

infrastructure. 

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. The Office of 

Information and Regulatory Affairs has 

determined that this rule is a significant 

regulatory action under Executive Order 

12866. The Regulatory Impact Analysis 

associated with this rulemaking can be 

found as a supporting document at 

www.regulations.gov. 

Consultation and Coordination With 

Indian Tribal Governments 

We have analyzed this proposed rule 

in accordance with the principles set 

forth in Executive Order 13175. We 

have tentatively determined that the 

rule does not contain policies that 

would have a substantial direct effect on 

one or more Indian Tribes, on the 

relationship between the Federal 

Government and Indian Tribes, or on 

the distribution of power and 

responsibilities between the Federal 

Government and Indian Tribes. The 

Agency solicits comments from tribal 

officials on any potential impact on 

Indian Tribes from this proposed action. 

Regulatory Flexibility Act 

The Secretary hereby certifies that 

this rulemaking 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. The 

residents to be placed for training in 

covered facilities and to have certain 

stipend and benefits costs 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 would only permit VA’s 

reimbursement and not payment of 

certain costs associated with certain 

start up costs associated with new 

residency programs, 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 

(adjusted annually for inflation) in any 

one year. This proposed rule would 

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. Except for 

emergency approvals under 44 U.S.C. 

3507(j), VA may not conduct or sponsor, 

and a person is not required to respond 

to, a collection of information unless it 

displays a currently valid Office of 

Management and Budget (OMB) control 

number. This proposed rule contains no 

provisions constituting a collection of 

information under the Paperwork 


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Federal Register / Vol. 87, No. 24 / Friday, February 4, 2022 / Proposed Rules 6465 

Reduction Act of 1995 (44 U.S.C. 3501– 

3521). 

Assistance Listing 

The Assistance Listing program 

numbers and titles for the programs 

affected by this document are 64.011— 

Veterans Dental Care; 64.026—Veterans 

State Adult Day Health Care; 64.040— 

VHA Inpatient Medicine; 64.041—VHA 

Outpatient Specialty Care; 64.042— 

VHA Inpatient Surgery; 64.043—VHA 

Mental Health Residential; 64.045— 

VHA Outpatient Ancillary Services; 

64.046—VHA Inpatient Psychiatry; 

64.047—VHA Primary Care; 64.048— 

VHA Mental Health clinics; 64.050— 

VHA Diagnostic Care; 64.054—Research 

and Development. 

List of Subjects in 38 CFR Part 17 

Administrative practice and 

procedure, Alcohol abuse, Alcoholism, 

Claims, Day care, Dental health, Drug 

abuse, Foreign relations, Government 

contracts, Grant programs—health, 

Grant programs—veterans, Health care, 

Health facilities, Health professions, 

Health records, Homeless, Medical and 

dental schools, Medical devices, 

Medical research, Mental health 

programs, Nursing homes, Philippines, 

Reporting and recordkeeping 

requirements, Scholarships and 

fellowships, Travel and transportation 

expenses, Veterans. 

Signing Authority 

Denis McDonough, Secretary of 

Veterans Affairs, approved this 

document on October 8, 2021, and 

authorized the undersigned to sign and 

submit the document to the Office of the 

Federal Register for publication 

electronically as an official document of 

the Department of Veterans Affairs. 

Consuela Benjamin, 

Regulations 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 proposes to amend 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 

Sec. 

17.243 Purpose and scope. 

17.244 Definitions. 

17.245 Covered facilities. 

17.246 Consideration factors for placement 

of residents. 

17.247 Determination process for placement 

of residents. 

17.248 Costs of placing residents and new 

residency programs. 

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 

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. 


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6466 Federal Register / Vol. 87, No. 24 / Friday, February 4, 2022 / Proposed Rules 

(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 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. 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 

(3) The process to submit a response 

to the RFP. 

(b) VA health care facilities, in 

collaboration with 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 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. 

§ 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. 2022–02292 Filed 2–3–22; 8:45 am] 

BILLING CODE 8320–01–P 

ENVIRONMENTAL PROTECTION 

AGENCY 

40 CFR Part 63 

[EPA–HQ–OAR–2018–0746; FRL–6494.1– 

01–OAR] 

RIN 2060–AV54 

Reconsideration of the 2020 National 

Emission Standards for Hazardous Air 

Pollutants: Miscellaneous Organic 

Chemical Manufacturing Residual Risk 

and Technology Review 

AGENCY: Environmental Protection 

Agency (EPA). 

ACTION: Proposed rule; reconsideration 

of final rule. 


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