Document Headings

                    Document headings vary by document type but may contain                    the following:                  
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###### Department of Veterans Affairs

          - 38 CFR Part 17
          - RIN 2900-AS23

# AGENCY:

Department of Veterans Affairs

# ACTION:

Proposed rule

# SUMMARY:

The Department of Veterans Affairs (VA) proposes to revise its medical regulations to exempt Whole Health well-being services from the copayment requirements for inpatient hospital care and outpatient medical care. These Whole Health well-being services, which consist of Whole Health education and skill-building programs and complementary and integrative health well-being services, are provided to Veterans within the VA Whole Health System of Care to improve Veterans' overall health and well-being.

# DATES:

Comments must be received on or before March 4, 2025.

# ADDRESSES:

                        Comments may be submitted through                         *www.regulations.gov.*                         Except as provided herein, comments received before the close of the comment period will be available at                         *www.regulations.gov*                         for public viewing, inspection, or copying, including any personally identifiable or confidential business information that is included in a comment. We post the comments received before the close of the comment period on                               ( print page 280)    *www.regulations.gov*                         as soon as possible after they have been received. VA will not post public comments on                         *Regulations.gov*                         that make threats to individuals or institutions or suggest that the commenter will take actions to harm an individual. VA encourages individuals not to submit duplicative comments; however, we will post comments from multiple unique commenters even if the content is identical or nearly identical to other comments. Any public comment received after the comment period's closing date is considered late and will not be considered in the final rulemaking. In accordance with the Providing Accountability Through Transparency Act of 2023, a plain language summary (not more than 100 words in length) of this proposed rule is available at                         *www.regulations.gov,*                         under RIN 2900-AS23.                    

# FOR FURTHER INFORMATION CONTACT:

Kavitha Reddy, Associate Director, Employee Whole Health, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, 314-312-8126. (This is not a toll-free number.)

# SUPPLEMENTARY INFORMATION:

## Authority

Section 1710 of title 38 United States Code (U.S.C.) requires VA to furnish hospital care and medical services that VA determines to be needed for eligible Veterans. Section 1701(6) defines medical services as examination, treatment, and rehabilitative services, as well as other specifically listed services. VA implemented the statutory requirements through 38 Code of Federal Regulations (CFR) 17.38, frequently referred to as the Medical Benefits Package. Under section 1710(g)(1), VA may not furnish medical services to certain Veterans unless the Veteran agrees to pay “the applicable amount or amounts established by the Secretary [of VA] by regulation.” VA has interpreted section 1710(g)(1) to mean that VA may establish in regulation the amount of a copayment, even if that amount is zero, meaning that VA effectively has the authority to exempt certain care from copayment requirements. VA has set forth copayment requirements for inpatient hospital care, outpatient medical care, and urgent care in 38 CFR 17.108.

Generally, 38 CFR 17.108 sets forth requirements regarding copayments for inpatient hospital care and outpatient medical care provided to Veterans by VA. 38 CFR 17.108(b) and (c). Services not subject to copayments are listed in 38 CFR 17.108(e). VA has long acknowledged that copayments can deter Veterans from obtaining certain services and be a barrier to participation in a program promoted by VA. Therefore, to encourage Veterans to become more actively involved in their medical care, thereby improving health care outcomes and, in turn, lowering overall health care costs, VA has exempted certain services from the copayment requirements. There are currently multiple copayment exemptions listed in § 17.108(e) such as weight management counseling and publicly announced VA public health initiatives (for example, health fairs) or outpatient visits solely consisting of preventative screening and immunizations to encourage such behavior. In this rulemaking, VA proposes to add an additional copayment exemption for Whole Health well-being services to encourage Veterans to be more actively involved in their health care and further use these important services.

## Whole Health Well-Being Services and the Whole Health System of Care

Whole Health well-being services, which are services that focus on the overall well-being of the Veteran independent of treatment for a specific medical condition or diagnosis, are an important aspect of the Whole Health System of Care. The Whole Health System of Care is care that supports the Veteran's health and well-being in line with what matters most to the Veteran. The Whole Health System of Care engages and empowers Veterans to prioritize a healthy lifestyle—including mental, emotional, functional, spiritual, social, and community aspects—equipping them to take charge of their health and well-being by addressing lifestyle and environmental root causes of chronic disease. This approach has improved Veterans' perceptions of health care, increased their engagement in health care and self-care, and improved their life's meaning and purpose.

One component of the Whole Health System of Care focuses on the overall well-being of the Veteran that is independent of treatment of a specific medical condition or diagnosis to equip each Veteran to better manage their own health. The well-being component includes various services that are centered around what matters most to the Veteran and their health and well-being goals. Whole Health well-being services are provided to Veterans alongside conventional health care to promote, preserve, and restore health. All Whole Health well-being services provided by VA are in line with accepted standards of medical practice, serve to increase Veterans' access to care, and currently are authorized and provided to Veterans as part of the medical benefits package under 38 CFR 17.38. Whole Health well-being services include Whole Health education and skill-building programs and complementary and integrative health well-being services, both of which are discussed in further detail herein.

VA determined it is necessary to exempt these Whole Health well-being services from copayment to remove a barrier that may discourage Veterans from proactively engaging in the Whole Health System of Care and to further encourage Veterans to better manage their health and improve their overall well-being. Whole Health well-being services do not generally require the expertise of a licensed clinical provider or specialty care provider as these approaches are not used for treatment of a specific condition or diagnosis but rather to support health and overall well-being. A Veteran's participation in Whole Health well-being services can initiate a cascade of health benefits that result from a Veteran's conscious, committed participation in promoting, restoring, and preserving the Veteran's own health. Exempting Whole Health well-being services would encourage Veterans to proactively take advantage of well-being services to improve their overall well-being.

## Copayment Exemption for Whole Health Well-Being Services

In this rulemaking, we propose to amend 38 CFR 17.108 by adding new paragraph (e)(20) to exempt Whole Health well-being services from copayment requirements. New paragraph (e)(20) of section 17.108 would provide that “the following Whole Health well-being services” would be exempt from copayment requirements. As mentioned previously, Whole Health well-being services consist of Whole Health education and skill-building programs as well as complementary and integrative health well-being services. Proposed paragraphs (e)(20)(i) and (ii) would then describe these two categories of well-being services that would be exempt from copayment.

                    In addition, we would make two minor technical edits to maintain proper punctuation throughout the list of copayment exempt services in § 17.108(e). We would remove “and” at the end of current paragraph (17); we would remove the period at the end of paragraph (18) and in its place insert a semicolon; and we would remove the period at the end of paragraph (19) and                           ( print page 281)                        in its place insert a semicolon followed by “and.” These changes would ensure that new paragraph (20) would properly complete the list of currently exempt services in § 17.108(e).                

## Whole Health Education and Skill-Building Programs

Proposed § 17.108(e)(20)(i) would describe “Whole Health education and skill-building programs.” Whole Health education and skill-building programs would be defined as the services that educate, instruct, and empower Veterans to understand and implement the principles and practices of Whole Health. VA would use this definition for Whole Health education and skill-building programs because it would succinctly describe this category of Whole Health-focused programs and would be consistent with how Whole Health education and skill-building programs are provided to Veterans within VA. Whole Health education and skill-building programs have a Whole Health-focused curriculum, contribute to the overall well-being of the Veteran, and may be offered individually or in a group setting. Whole Health education and skill-building programs generally address Whole Health principles, promote well-being approaches, and focus on helping a Veteran meet their health and well-being goals. Such programs are developed in partnership with the Veterans Health Administration Office of Patient Centered Care and Cultural Transformation.

The following sentence would then provide a non-exhaustive list of the categories of programs that would be included as Whole Health education and skill-building programs. The list would include Whole Health coaching, Whole Health partner sessions, and Whole Health education and skill-building courses. The list of these categories of programs would be consistent with how Whole Health education and skill-building programs currently are provided to Veterans within VA. VA believes that a non-exhaustive list would be most beneficial because these categories would adequately capture any approved Whole Health education and skill-building programs available within the Whole Health System of Care. However, as the VA Whole Health System of Care becomes more firmly established as the model for how VA provides health care, VA is developing, improving, and expanding Whole Health education and skill-building programs continuously with an openness to innovation and iterative improvement based on Veteran feedback and evidence. Therefore, a non-exhaustive list would provide VA with the flexibility it needs to continue to provide Whole Health education and skill-building programs that meet the needs of Veterans and improve Veterans' overall well-being.

Whole Health coaching is a Veteran-centered process that facilitates and empowers Veterans to develop and achieve their self-determined health and well-being goals. In Whole Health coaching, the coach supports Veterans in mobilizing their internal strengths and external resources to develop strategies for making sustainable, healthy lifestyle behavior changes that support improved health and well-being. Whole Health coaching includes connecting health and well-being goals to what matters most to the Veteran and following up on actions needed to achieve these values-based goals. Whole Health coaches work in close collaboration with interdisciplinary staff and teams throughout VA medical facilities to enhance well-being and assist with management of chronic disease. This type of interprofessional, team-based care is important for high quality, Veteran-centered Whole Health care.

In Whole Health partnering, a Whole Health partner facilitates individual and group sessions where Veterans learn about the Whole Health approach and identify their meaning and purpose. They work in collaboration with staff and teams, further supporting interprofessional, team-based delivery of health care. Veterans then can reflect on their personal well-being and create health and well-being goals centered around what matters most to them for their quality of life. Whole Health partners welcome Veterans into the Whole Health System of Care, have knowledge of internal and external Whole Health System of Care resources, help Veterans navigate the Whole Health System of Care, and connect Veterans to the best options to support their overall health and well-being. Whole Health partners` often conduct introductory sessions to orient Veterans to Whole Health and assist them in filling out elements of their personal health plan.

Whole Health education and skill-building courses are courses that generally address Whole Health principles, promote well-being approaches, and focus on helping the Veteran meet health and well-being goals. Current offerings within VA provide education on the concept of Whole Health, Whole Health coaching, Whole Health partnering, and how Veterans can take charge of their life and health.

## Complementary and Integrative Health Well-Being Services

Proposed § 17.108(e)(20)(ii) would describe the complementary and integrative health well-being services that would be exempt from copayment requirements. Like proposed paragraph (i), proposed paragraph (ii) would first define complementary and integrative health well-being services. Complementary and integrative health well-being services would be defined as the services that promote health, well-being, and self-care independent of treatment of a specific medical condition or diagnosis. In general, complementary and integrative health services are a group of diverse services and practices not broadly considered to be part of conventional health care, but often used in conjunction with conventional health care. Complementary and integrative health services are used in the Whole Health System of Care as they place importance on the relationship between the practitioner and patient and focus on the whole person.

The following sentence then would provide a non-exhaustive list of the types of services that would be included as complementary and integrative health well-being services. The services would be guided imagery, meditation, Tai Chi/Qigong, and yoga for well-being, which would be consistent with how complementary and integrative health well-being services currently are provided within VA. We believe listing these types of services in regulation would adequately capture the current complementary and integrative health well-being services available within the Whole Health System of Care. Like Whole Health education and skill-building programs in proposed paragraph (i), we would use a non-exhaustive list to provide flexibility to VA to continue to evaluate the efficacy of additional complementary and integrative health well-being approaches that would meet the needs of Veterans and improve Veterans' overall well-being.

Guided imagery is the practice of using a series of multi-sensory images designed to trigger specific changes in an individual's physiology, emotions, or mental state for the purpose of increasing an individual's healing response or causing unconscious change. Guided imagery may be performed by a complementary and integrative health provider in an individual or group clinical setting.

                    Meditation is the defined practice or technique (often arising from a contemplative tradition) that primarily                           ( print page 282)                        focuses on training an individual's attention regulation processes with the intent of cultivating general mental well-being and/or specific capacities such as concentration, compassion, or insight. The focus of meditation is on training attentional processes rather than specifically targeting a change in mental content.                

Tai Chi is the mind-body exercise rooted in the Asian traditions of martial arts, Chinese medicine, and philosophy that combines slow-flowing intentional movements with breathing, awareness, and visualization. Tai Chi enhances relaxation, vitality, focus, posture, balance, strength, flexibility, and mood.

Qigong is the ancient Chinese healing art (like Tai Chi) with a focus on cultivating the body's vital energy or “qi.” Qigong involves the coordination of breath, posture, awareness, visualization, and focused movements and may be practiced as a stationary or moving meditation.

Yoga is the mind-body practice rooted in ancient Indian philosophy that typically combines physical postures, breathing techniques, meditation or relaxation, and discussion on applications to daily life. There are many different yoga styles ranging from gentle to physically demanding practices. Yoga for well-being is the practice of yoga to advance an individual's general sense of well-being. Yoga for well-being is often practiced in a group setting and focuses on general health, stress reduction, fitness, and/or community.

## Executive Orders 12866, 13563, and 14094

Executive Order 12866 (Regulatory Planning and Review; September 30, 1993) directs agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages; distributive impacts; and equity). Executive Order 13563 (Improving Regulation and Regulatory Review; January 18, 2011) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 14094 (Modernizing Regulatory Review; April 6, 2023) supplements and reaffirms the principles, structures, and definitions governing contemporary regulatory review established in Executive Order 12866 and Executive Order 13563. The Office of Information and Regulatory Affairs has determined that this rulemaking is not a significant regulatory action under Executive Order 12866, as amended by Executive Order 14094. The Regulatory Impact Analysis associated with this rulemaking can be found as a supporting document at                     *www.regulations.gov.*

## Regulatory Flexibility Act

The Secretary hereby certifies that this proposed rule 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 proposed rule would exempt certain health care services from copayment. This proposed rule would not cause a significant economic impact on small entities because it is limited to copayments that would be received by VA directly from Veterans. 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

This proposed rule contains no provisions constituting a collection of information under the provisions of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521).

# List of Subjects in 38 CFR Part 17

      - Administrative practice and procedure
      - Alcohol abuse
      - Alcoholism
      - Claims
      - Day care
      - Drug abuse
      - Government contracts
      - Health care
      - Health facilities
      - Health professions
      - Mental health programs
      - Nursing homes
      - Reporting and recordkeeping requirements
      - Veterans

## Signing Authority

Denis McDonough, Secretary of Veterans Affairs, signed and approved this document on December 18, 2024, 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 set forth below:

# 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 revising paragraphs (e)(17) through (19) and adding paragraph (e)(20) to read as follows: 

§ 17.108 

* * * * *

(e) * * *

(17) Mental health peer support services;

(18) An outpatient care visit solely for education on the use of opioid antagonists to reverse the effects of overdoses of specific medications or substances;

(19) Emergent suicide care as authorized under 38 CFR 17.1200-17.1230; and

(20) The following Whole Health well-being services:

                        (i)                         *Whole Health education and skill-building programs.*                         The programs that educate, instruct, and empower Veterans to understand and implement the principles and practices of Whole Health. Whole Health education and skill-building programs may include, but are not limited to, Whole Health coaching, Whole Health partner sessions, and Whole Health education and skill-building courses.                    

                        (ii)                         *Complementary and integrative health well-being services.*                         The services that promote health, well-being, and self-care independent of treatment of a specific medical condition or diagnosis. Complementary and integrative health well-being services may include, but are not limited to, guided imagery, meditation, Tai Chi/Qigong, and yoga for well-being.                    

* * * * *

[FR Doc. 2024-31494 Filed 1-2-25; 8:45 am]

BILLING CODE 8320-01-P