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[Federal Register Volume 90, Number 2 (Friday, January 3, 2025)]
[Proposed Rules]
[Pages 279-282]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-31494]

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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AS23

Exempting Whole Health Well-Being Services From Copayment

AGENCY: Department of Veterans Affairs

ACTION: Proposed rule

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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

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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 Sec.  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 
Sec.  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

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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 Sec.  17.108(e).

Whole Health Education and Skill-Building Programs

    Proposed Sec.  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 Sec.  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

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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

0
1. The authority citation for part 17 continues to read as follows:

    Authority: 38 U.S.C. 501, and as noted in specific sections.
* * * * *
0
2. Amend Sec.  17.108 by revising paragraphs (e)(17) through (19) and 
adding paragraph (e)(20) to read as follows:

Sec.  17.108  Copayments for inpatient hospital care and outpatient 
medical care.

* * * * *
    (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.
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[FR Doc. 2024-31494 Filed 1-2-25; 8:45 am]
BILLING CODE 8320-01-P
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