41594 Federal Register / Vol. 87, No. 133 / Wednesday, July 13, 2022 / Rules and Regulations 

environment. This rule involves 

establishment of a temporary moving 

safety zone for navigable waters of the 

Corpus Christi Ship Channel within 500 

yards of the barge CBC MIAMI and 

barge JULIUS as they transport 

oversized equipment to the sea buoy. It 

is categorically excluded from further 

review under paragraph L60 (c) 

Appendix A, Table 1 of DHS Instruction 

Manual 023–01–001–01, Rev. 1. 

G. Protest Activities 

The Coast Guard respects the First 

Amendment rights of protesters. 

Protesters are asked to contact the 

person listed in the FOR FURTHER

INFORMATION CONTACT section to 

coordinate protest activities so that your 

message can be received without 

jeopardizing the safety or security of 

people, places or vessels. 

List of Subjects in 33 CFR Part 165 

Harbors, Marine safety, Navigation 

(water), Reporting and recordkeeping 

requirements, Security measures, 

Waterways. 

For the reasons discussed in the 

preamble, the Coast Guard amends 33 

CFR part 165 as follows: 

PART 165—REGULATED NAVIGATION 

AREAS AND LIMITED ACCESS AREAS 

■ 1. The authority citation for part 165 

continues to read as follows: 

Authority: 46 U.S.C. 70034, 70051; 33 CFR 

1.05–1, 6.04–1, 6.04–6, and 160.5; 

Department of Homeland Security Delegation 

No. 00170.1, Revision No. 01.2. 

■ 2. Add § 165.T08–0568 to read as 

follows: 

§ 165.T08–0568 Safety Zone; Gulf 

Intracoastal Waterway, Corpus Christi, TX 

(a) Location. The following area is a 

temporary moving safety zone: 

Navigable waters of the Gulf Intracoastal 

Waterway (GIWW) within 500 yards of 

the barge CBC MIAMI and barge JULIUS 

as they transports oversized equipment. 

Entry of vessels or persons into this 

zone is prohibited unless specifically 

authorized by the Captain of the Port 

Sector Corpus Christi (COTP) or a 

designated representative. 

(b) Effective period. This section is 

effective from July 10, 2022. through 

July 14, 2022. 

(c) Regulations. (1) According to the 

general regulations in § 165.23 of this 

part, entry into the temporary safety 

zone described in paragraph (a) of this 

section is prohibited unless authorized 

by the COTP or a designated 

representative. They may be contacted 

on Channel 16 VHF–FM (156.8 MHz) or 

by telephone at 361–939–0450. 

(2) If permission is granted, all 

persons and vessels shall comply with 

the instructions of the COTP or 

designated representative. 

(d) Information broadcasts. The COTP 

or a designated representative will 

inform the public of the enforcement 

times and date for this safety zone 

through Broadcast Notices to Mariners, 

Local Notices to Mariners, and/or Safety 

Marine Information Broadcasts as 

appropriate. 

Dated: July 6, 2022. 

H.C. Govertsen, 

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

Port Sector Corpus Christi. 

[FR Doc. 2022–14965 Filed 7–12–22; 8:45 am] 

BILLING CODE 9110–04–P 

DEPARTMENT OF HOMELAND 

SECURITY 

Coast Guard 

33 CFR Part 165 

[Docket No. USCG–2022–0583] 

Safety Zone; Fleet Week Maritime 

Festival, Pier 66, Elliott Bay, Seattle, 

WA 

AGENCY: Coast Guard, DHS. 

ACTION: Notification of enforcement of 

regulation. 

SUMMARY: The Coast Guard will enforce 

a safety zone for the Fleet Week 

Maritime Festival Pier 66 Safety Zone in 

Elliott Bay, Seattle, WA thirty minutes 

prior to the beginning, during, and 

thirty minutes following the conclusion 

of the parade of ships on August 1, 

2022. This action is necessary to 

provide for the safety of life on 

navigable waterways during this event. 

During the enforcement period, the 

operator of any vessel in the regulated 

area must comply with directions from 

the Patrol Commander or any Official 

Patrol displaying a Coast Guard ensign. 

DATES: The regulations in 33 CFR 

165.1330 will be enforced from 12 p.m. 

until 3:30 p.m. on August 1, 2022. 

FOR FURTHER INFORMATION CONTACT: If 

you have questions about this 

notification of enforcement, call or 

email Chief Warrant Officer William 

Martinez, Sector Puget Sound 

Waterways Management Division, U.S. 

Coast Guard; telephone 206–217–6051, 

email SectorPugetSoundWWM@

uscg.mil. 

SUPPLEMENTARY INFORMATION: The Coast 

Guard will enforce the safety zone for 

the Fleet Week Maritime Festival in 33 

CFR 165.1330, from 12 p.m. until 3:30 

p.m. on August 1, 2022. This action is 

being taken to provide for the safety of 

life on navigable waterways during this 

event. During the enforcement period, 

as reflected in § 165.1330, if you are the 

operator of a vessel in the regulated area 

you must comply with directions from 

the Patrol Commander or any Official 

Patrol displaying a Coast Guard ensign. 

The Captain of the Port may be assisted 

by other federal, state, or local agencies 

as needed. 

In accordance with the general 

regulations in 33 CFR part 165, subpart 

C, no vessel operator may enter, transit, 

moor, or anchor within this safety zone, 

except for vessels authorized by the 

Captain of the Port, Puget Sound or her 

designated representative. All vessel 

operators desiring entry into this safety 

zone shall gain prior authorization by 

contacting either the on-scene patrol 

craft on VHF Ch. 13 or Ch. 16, or Coast 

Guard Sector Puget Sound Joint Harbor 

Operations Center (JHOC) via telephone 

at (206) 217–6002. Vessel operators 

granted individual permission to enter 

this safety zone will be escorted by the 

on-scene patrol until no longer within 

the safety zone. 

In addition to this notice of 

enforcement in the Federal Register, the 

Coast Guard plans to provide 

notification of this enforcement period 

via the Local Notice to Mariners and 

marine information broadcasts. If the 

Captain of the Port determines that the 

regulated area need not be enforced for 

the full duration stated in this notice of 

enforcement, he may use a Broadcast 

Notice to Mariners to grant general 

permission to enter the regulated area. 

Dated: July 7, 2022. 

P.M. Hilbert, 

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

Port Sector Puget Sound. 

[FR Doc. 2022–14894 Filed 7–12–22; 8:45 am] 

BILLING CODE 9110–04–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Part 17 

RIN 2900–AP02 

Civilian Health and Medical Program of 

the Department of Veterans Affairs 

AGENCY: Department of Veterans Affairs 

ACTION: Final rule. 

SUMMARY: The Department of Veterans 

Affairs (VA) adopts as final, with 

changes, a proposed rule to amend its 

medical regulations concerning the 

Civilian Health and Medical Program of 

the Department of Veterans Affairs 

(CHAMPVA). The final rule clarifies 


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and updates these regulations to 

conform to changes in law and policy 

that control the administration of 

CHAMPVA and include details 

concerning the administration of 

CHAMPVA that were previously not 

reflected in regulation. The amendments 

improve our ability to effectively 

administer CHAMPVA and make 

technical revisions to make our 

regulations more understandable. In 

addition, this rulemaking expands 

covered services and supplies, to 

include certain preventive services, and 

eliminates cost-share amounts and 

deductibles for certain covered services. 

DATES: Effective date: This final rule is 

effective August 12, 2022. 

Applicability date: The provisions of 

this final rule shall apply to all 

applications for benefits that are 

received by VA on or after the effective 

date of this final rule or that are pending 

before VA, the United States Court of 

Appeals for Veterans Claims, or the 

United States Court of Appeals for the 

Federal Circuit on the effective date of 

this final rule. 

FOR FURTHER INFORMATION CONTACT: 

Joseph Duran, Director, Policy and 

Planning, Office of Integrated Veteran 

Care (OIVC), 3773 Cherry Creek North 

Drive, Denver, Colorado 80209, 

Joseph.Duran2@va.gov, (303) 370–1637. 

(This is not a toll-free number.) 

SUPPLEMENTARY INFORMATION: 

CHAMPVA is a health benefits program 

in which the Department of Veterans 

Affairs (VA) shares the cost of covered 

medical care services and supplies with 

spouses, children, survivors, and certain 

caregivers of veterans who meet 

eligibility criteria under 38 U.S.C. 1781. 

One criterion is that CHAMPVA 

beneficiaries cannot be eligible for 

TRICARE, a health care program 

administered by the Department of 

Defense (DoD) that is authorized to 

provide health care to certain family 

members of veterans. Another criterion 

is that primary family caregivers 

designated under 38 U.S.C. 

1720G(a)(7)(A) cannot be entitled to 

services under a health-plan contract as 

defined in 38 U.S.C. 1725(f). 

VA must operate the CHAMPVA 

program and provide for medical care in 

the same or similar manner and subject 

to the same or similar limitations as 

medical care is furnished to certain 

dependents and survivors of active duty 

and retired members of the Armed 

Forces under the CHAMPUS program. 

See 38 U.S.C. 1781(b). CHAMPUS was 

the original program administered by 

DoD to provide civilian health benefits 

for active duty military personnel, 

military retirees, and their dependents. 

See 32 CFR 199.1. Although the 

CHAMPUS program is still referenced 

in DoD regulations, DoD effectively 

replaced the CHAMPUS program with 

what is commonly known as the 

TRICARE Select plan (‘‘TRICARE’’). See 

32 CFR 199.1(r), 199.17(a)(6)(ii)(D) 

(identifying TRICARE Select as the basic 

CHAMPUS program). TRICARE’s 

current benefit structure offers varying 

degrees of medical benefits under 

multiple plan options beyond its Select 

plan. However, we administer 

CHAMPVA in the same or similar 

manner as TRICARE Select because the 

basic program is what is referenced by 

the CHAMPUS authority. Thus, all 

references in this rulemaking to 

TRICARE are to the TRICARE Select 

plan, which we refer to simply as 

TRICARE throughout most of this 

rulemaking for ease of reference. 

VA interprets the ‘‘same or similar 

manner’’ language in 38 U.S.C. 1781(b) 

to mean that we must generally 

administer CHAMPVA in a same or 

similar manner as the TRICARE Select 

plan. We do not interpret this statutory 

language as requiring VA to operate 

CHAMPVA in an identical manner to 

TRICARE. Rather, we interpret this 

language as affording VA needed 

flexibility to administer the program for 

CHAMPVA beneficiaries. For this 

reason, not every aspect of CHAMPVA 

will find a corollary in the TRICARE 

Select Plan. 

On January 17, 2018, VA proposed to 

amend its regulations governing 

CHAMPVA to expand covered services 

and supplies to include certain 

preventive services, improve our ability 

to effectively administer CHAMPVA, 

and waive cost-shares as well as 

deductibles for certain covered services. 

See 83 FR 2396. VA provided a 60-day 

period during which the public could 

submit comments to our proposal. The 

public comment period ended on March 

19, 2018, and we received six comments 

on the proposed rule. Public comments 

were generally supportive, however 

several comments suggested substantive 

changes to the proposed rule. We 

respond to these public comments here. 

§ 17.270 General Provisions and 

Definitions 

We proposed amending paragraph (b) 

by adding definitions for terms used in 

the CHAMPVA program. We proposed 

defining an ‘‘authorized non-VA 

provider’’ to mean an individual or 

institutional non-VA provider of 

CHAMPVA-covered medical services 

and supplies who is licensed or certified 

by a State to provide the covered 

medical services and supplies, or is 

otherwise certified by an appropriate 

national or professional association that 

sets standards for the specific medical 

provider. We stated that this 

requirement for State licensure or other 

certification would be similar to 

TRICARE, which requires that its 

providers be either licensed or certified 

by a State, or, where States do not offer 

licensure or certification, be otherwise 

certified by an appropriate national or 

professional association that sets 

standards for the specific medical 

provider. See TRICARE Policy Manual 

6010.60–M, Chapter 11 (‘‘Providers’’), 

section 3.2 (‘‘State Licensure And 

Certification’’). 

One commenter generally supported 

the proposed definition of authorized 

non-VA provider, and encouraged VA to 

continue to adopt this language 

throughout the CHAMPVA regulations 

to increase consistency and ensure that 

all healthcare providers, including 

nurse practitioners, are authorized to 

provide treatment and services to 

CHAMPVA members to the full extent 

of their licensure and certification. To 

clarify, this rulemaking does not address 

the scope of practice of health care 

professionals and does not authorize 

health care professionals to practice 

beyond the scope of their state license, 

certification, or registration. However, 

we note that CHAMPVA beneficiaries 

can seek care from qualified nurse 

practitioners practicing within the scope 

of their State license and privileges. We 

thank the commenter for their 

recommendations and make no changes 

to the rule based on the comment. 

One commenter opposed the 

inclusion of the language ‘‘otherwise 

certified by an appropriate national or 

professional association that sets 

standards for the specific medical 

provider.’’ The commenter was 

concerned that this language granted 

full practice authority to non-physician 

providers. To clarify, this rulemaking 

does not grant full practice authority to 

non-physician providers and does not 

supersede any State laws. The language 

was included to address the limited 

instance where members of a health care 

occupation or specialty practice area are 

not governed by a state through its 

licensure or certification procedures, 

but instead are governed by the 

requirements of a national or 

professional association such as the 

Joint Commission (previously known as 

the Joint Commission on Accreditation 

of Health Care Organizations) and the 

Commission on Accreditation of 

Rehabilitation Facilities (CARF). 

Changes to paragraph (c). In addition, 

VA makes technical edits to the rule for 

clarity. Proposed paragraph (c) 

addresses VA’s discretionary authority 


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to waive certain regulatory 

requirements. The second sentence of 

this proposed paragraph states that ‘‘it is 

VA’s intent that such discretionary 

authority would be used only under 

very unusual and limited circumstances 

and not to deny any individual any 

right, benefit, or privilege provided to 

him or her by statute or these 

regulations.’’ We are amending 

proposed paragraph (c) to remove the 

phrase ‘‘It is VA’s intent that’’ at the 

beginning of the second sentence in the 

definition as VA does not believe this 

predicate is necessary. VA is also 

amending the paragraph by replacing 

the word ‘‘shall’’ with ‘‘will’’ in the last 

sentence of the paragraph for clarity. 

§ 17.272 Benefits Limitations/ 

Exclusions 

As part of our reorganization of this 

section we proposed redesignating 

multiple subparagraphs in paragraph (a) 

which addresses exclusions from 

CHAMPVA coverage, including 

redesignating paragraph (a)(31) as 

paragraph (a)(30). This paragraph 

addresses excluded preventive services 

from CHAMPVA coverage, except for 

certain listed services. In addition, we 

proposed amending two listed 

exceptions, expanding one exception, 

and adding three exceptions. The 

proposed changes are intended to 

generally align CHAMPVA exceptions 

with those under TRICARE. 

One commenter recommended that 

VA health plans cover all preventive 

services with Grade ‘‘A’’ or ‘‘B’’ 

recommendations from the U.S. 

Preventive Services Task Force 

(USPSTF). The USPSTF is an 

independent, volunteer panel of 

national experts in prevention and 

evidence-based medicine. The Task 

Force makes evidence-based 

recommendations about clinical 

preventive services such as screenings, 

counseling services, and preventive 

medications. 

Consistent with our mandate to 

operate the CHAMPVA program in a 

same or similar manner as TRICARE, we 

follow TRICARE by adding to our list of 

covered preventive screenings the 

following preventive services: colorectal 

cancer screenings, breast cancer 

screenings, cervical cancer screenings, 

prostate cancer screenings, and 

immunizations. As explained in the 

proposed rule, TRICARE expanded its 

program to include certain preventive 

services, in response to specific 

statutory requirements. However, for the 

reasons also explained in the proposed 

rule, we add annual physical exams to 

this list, even though not included 

under TRICARE. 83 FR at 2401. A 

review of the USPSTF Grade ‘‘A’’ or ‘‘B’’ 

recommendations reveals that the task 

force recommends 52 specific 

preventive medical screenings or 

interventions, many of which would be 

part of a routine annual physical 

examination or otherwise addressed in 

CHAMPVA preventive services 

exceptions. Lastly, this rulemaking is 

limited to amending CHAMPVA 

regulations, and to the extent this public 

comment touches on other aspects of 

VA health care, the recommended 

changes exceed the scope of this 

rulemaking. 

We proposed redesignating paragraph 

(a)(51) as paragraph (a)(49). This 

paragraph excludes food, food 

substitutes, vitamins or other nutritional 

supplements, including those related to 

prenatal care for a home patient whose 

condition permits oral feeding, from 

CHAMPVA coverage. 

One commenter asked why 

CHAMPVA does not cover prescription 

prenatal vitamins for pregnant 

beneficiaries when TRICARE provides 

prenatal vitamins. As stated earlier, 

CHAMPVA must operate in the same or 

similar manner to TRICARE. See 38 

U.S.C. 1781(b). TRICARE covers 

medically necessary vitamins used for 

the management of a covered disease or 

condition pursuant to a prescription, 

order, or recommendation of a TRICARE 

authorized provider acting within the 

provider’s scope of license/certificate of 

practice. The term ‘‘covered disease or 

condition’’ includes pregnancy in 

relation to prenatal vitamins, with the 

limitation that the prenatal vitamins 

that require a prescription in the United 

States may be covered for prenatal care 

only. 32 CFR 199.4(d)(3)(vi)(D)(5). We 

agree that prenatal vitamins should be 

provided when deemed medically 

necessary as part of a treatment plan for 

a pregnant beneficiary. Accordingly, we 

are amending redesignated paragraph 

(a)(49), removing the explicit restriction 

on prenatal care, and amending the 

paragraph to include clarifying 

language. As amended, newly 

redesignated paragraph (a)(49) excludes 

food, food substitutes, vitamins or other 

nutritional supplements, including 

those related to care for a home patient 

whose condition permits oral feeding, 

except for prenatal vitamins which are 

medically necessary as a component of 

prenatal care and prescribed by a VA 

provider or an authorized non-VA 

provider as defined in § 17.270. 

Previously, smoking cessation 

services and supplies were specifically 

excluded from CHAMPVA coverage. In 

paragraph (a)(76) we proposed that overthe-counter pharmaceutical smoking 

cessation supplies approved by the U.S. 

Food and Drug Administration, 

prescribed, and provided through 

Medications by Mail (MbM), would not 

be excluded from CHAMPVA coverage. 

In a related provision, in 38 CFR 

17.270(a)(3)(ii), we proposed that 

smoking cessation pharmaceutical 

supplies would be available only 

through MbM. Smoking cessation 

supplies would be available to 

CHAMPVA beneficiaries who are not 

eligible for Medicare and do not have 

any other prescription health insurance. 

One commenter supported the 

proposed change but recommended that 

VA increase opportunities for family 

physicians and other healthcare 

clinicians to counsel patients about 

tobacco cessation. We agree with the 

commenter and believe that the changes 

we proposed to CHAMPVA exclusions 

support efforts to promote smoking 

cessation. By removing the regulatory 

restrictions and allowing for smoking 

cessation services and supplies VA 

believes it is increasing the 

opportunities for physicians to care for 

beneficiaries who use tobacco products 

and improving payment for primary 

care cessation counseling. Under this 

final rule, smoking cessation 

counseling, including coverage of 

pharmaceuticals, is a covered benefit 

when CHAMPVA is the primary payer 

and any prescribed, FDA-approved 

smoking cessation pharmaceutical 

products are delivered through MbM. 

This mirrors TRICARE, which covers 

smoking cessation pharmaceutical 

products only when delivered through 

its mail order pharmacy program. Thus, 

we are covering these services in a 

similar manner to TRICARE. 

Additionally, by providing smoking 

cessation products through MbM, the 

beneficiary avoids any CHAMPVA costsharing amounts which might otherwise 

apply if purchased through a retail 

pharmacy. We make no changes based 

on this comment. 

§ 17.273 Preauthorization 

We proposed revising 

preauthorization requirements by 

adding language to indicate when a 

beneficiary has ‘‘other health insurance’’ 

that provides primary coverage for the 

benefit, preauthorization requirements 

will not apply. To provide benefits in a 

similar fashion as TRICARE we 

proposed waiving any requirement for 

preauthorization where other health 

insurance covers the benefit. In 

addition, we proposed removing the 

requirement for preauthorization for 

durable medical equipment (DME) as a 

covered service or supply. 

One commenter encouraged VA to 

apply prior authorization principles in 


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CHAMPVA and other health plans 

under VA’s purview such as: activities 

requiring prior authorization must be 

justified in terms of financial recovery, 

cost of administration, workflow 

burden, and lack of another feasible 

method of utilization control; prior 

authorization should be eliminated for 

physicians with aligned financial 

incentives (e.g., shared savings) and 

proven successful stewardship; and 

eliminate prior authorization for DME, 

imaging, supplies, and generic drugs. To 

the extent this comment addresses 

health care provided by VA other than 

CHAMPVA, it focuses on issues beyond 

the scope of this rulemaking. VA 

follows guidelines in its CHAMPVA 

regulations specifying the need for prior 

authorization under specific sets of 

circumstances. Also, with the removal 

of prior authorization for DME in this 

final rule, CHAMPVA no longer requires 

preauthorization for DME, imaging, 

supplies, or generic drugs. Whenever 

prior authorization is required, 

however, we note that VA always 

determines need based on the best 

interest of the beneficiaries we serve. 

In addition, the commenter 

recommended the VA apply transitional 

steps for changing preauthorization 

requirements, and offered suggestions 

primarily related to VA’s relationship to 

VA contractors. Generally, CHAMPVA 

does not engage VA contractors to 

provide health care to CHAMPVA 

beneficiaries. The only instance where a 

CHAMPVA beneficiary could possibly 

receive care from a VA contractor 

working in that capacity is where a 

beneficiary who is not eligible for 

Medicare receives care in a VA medical 

facility on a space available basis 

through the CHAMPVA In-house 

Treatment Initiative (CITI). In that 

instance, if the VA provider is operating 

in the VA medical facility on a 

contractual basis the provider works 

under the same rules as a health care 

provider who is a VA employee. The 

transitional steps listed by the 

commenter are beyond the scope of this 

rulemaking, and we make no changes 

based on this comment. 

§ 17.274 Cost Sharing 

This section addresses cost sharing 

and deductibles. Proposed paragraph (b) 

focuses on annual deductibles ($50 per 

beneficiary or $100 per family) as well 

as instances where the deductible is 

waived. One commenter expressed 

concern with the patients’ inability to 

afford medically necessary care. The 

commenter stated that the escalation in 

deductibles is limiting access to care, 

and higher deductibles create a financial 

disconnect between individuals, their 

primary care physician, and the broader 

health care system. CHAMPVA does not 

have a high deductible plan but an 

annual deductible of $50 per beneficiary 

or $100 per family. CHAMPVA 

deductible amounts have not escalated 

and have remained unchanged since at 

least 1999. The commenter’s general 

concern regarding escalating 

deductibles limiting access to care does 

not apply to the CHAMPVA program. 

We make no changes based on this 

comment. 

However, we are making one minor 

edit to paragraph (a)(1)(v) to clarify that 

CHAMPVA beneficiary cost-share 

requirements do not apply to various 

other preventive services as determined 

by the Secretary of Veterans Affairs. VA 

determined that this subparagraph was 

not specific enough in that it did not 

specify that ‘‘preventive’’ services as 

determined by the Secretary is not 

subject to CHAMPVA beneficiary costshare requirements. 

§ 17.275 CHAMPVA Determined 

Allowable Amount Calculation 

We proposed adding a new § 17.275 

to describe the various payment 

methodologies used by CHAMPVA to 

calculate the CHAMPVA determined 

allowable amount for covered services 

and supplies. We stated that CHAMPVA 

uses the same or similar payment 

methodologies to establish allowable 

reimbursement amounts for providers as 

TRICARE, and that proposed payment 

methodologies would be consistent with 

current VA practice. 

One commenter expressed concerns 

regarding CHAMPVA’s non-VA 

provider reimbursement amounts not 

being equal to Medicare reimbursement 

amounts in response to CHAMPVA’s 

clarification of a provider accepting 

assignment. When feasible, CHAMPVA 

determines its allowable charges using 

TRICARE’s reimbursement 

methodologies. In this instance, 

CHAMPVA uses TRICARE’s physician 

fee schedule, which is equivalent to 

Medicare’s physician fee schedule, to 

determine the CHAMPVA Maximum 

Allowable Charge. Additionally, this 

commenter stated that VA should offer 

contracts at least at the Medicare rate, so 

family physicians and other non-VA 

entities can afford to treat veterans. 

CHAMPVA does not contract with 

providers to treat veterans. CHAMPVA 

is a family member health benefits 

program for dependents of permanently 

and totally disabled and certain other 

veterans and certain caregivers. Under 

it, VA uses the TRICARE physician fee 

schedule amount, which is equivalent to 

the Medicare physician fee schedule 

amount, to determine the CHAMPVA 

Maximum Allowable Charge. We make 

no changes based on this comment. 

Proposed paragraph (h) provided that 

reimbursement for durable medical 

equipment, prosthetics, orthotics, and 

supplies (DMEPOS) would be based on 

the same amounts established under the 

Centers for Medicare & Medicaid 

Services (CMS) DMEPOS fee schedule 

under 42 CFR part 414, subpart D, 

which is the same methodology used in 

TRICARE regulations to calculate 

DMEPOS payments. See 32 CFR 

199.14(k). The allowed amount would 

be that which is in effect in the specific 

geographic location at the time 

CHAMPVA-covered services and 

supplies are provided to a CHAMPVA 

beneficiary. 

One commenter urged VA to review 

Medicare’s current policies related to 

the Medicare benefit for DMEPOS to 

evaluate potential access to care for our 

beneficiaries. The commenter stated that 

Medicare’s fee schedules in noncompetitive bidding areas, which are 

based on single payment amounts, 

results in reduced access to DMEPOS 

and inadequate payment to suppliers. 

Although we understand the 

commenter’s concern, we chose to 

revise our regulations to be consistent 

with the Medicare fee schedule because 

TRICARE uses the Medicare fee 

schedule. Also, we believe that 

matching TRICARE payment 

methodologies as closely as possible is 

the best way to provide for medical care 

in the same or similar manner as 

TRICARE pursuant to 38 U.S.C. 1781(b). 

The rates at which VA pays for care are 

an integral part of the ‘‘provision’’ of 

care, and therefore, we think this is an 

area where VA should remain in line 

with TRICARE. We thank the 

commenter for their suggestion, but 

make no changes to the rule based on 

this comment. 

In paragraph (j) we proposed 

establishing in regulation the current 

CHAMPVA reimbursement 

methodology for hospice care. This 

methodology uses rates in the CMS 

hospice per diem rate payment system, 

which is the same methodology used in 

TRICARE regulations to calculate 

hospice payments. See 32 CFR 

199.14(g)(9). 

One commenter inquired whether 

CHAMPVA will use Medicare rates for 

each year by hospice level of care, 

including two tiers of payment for 

routine home care. Although TRICARE 

regulations do not reflect the two-tiered 

payment system, it is reflected in its 

reimbursement manual. See TRICARE 

Reimbursement Manual 6010.61–M, 

April 1, 2015, Chapter 11, Section 4, 

Subsection 3.1.1.3. TRICARE 


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implemented the two-tiered payment 

rates for routine home care (RHC) levels 

of care effective January 1, 2016. 

CHAMPVA cannot, however, 

implement the two-tiered payment 

system due to current IT system 

limitations. We will consider adopting 

this methodology in the future, 

dependent on increased system 

capabilities. CHAMPVA already uses 

Medicare’s annual hospice rates and 

utilizes Medicare’s rates for each level 

of hospice service, with the exception of 

the ‘‘61-day and over’’ routine home 

care (RHC) rates. For RHC, CHAMPVA 

currently only reimburses Medicare’s 1– 

60 day RHC rate for all routine home 

care days, regardless of the number of 

days RHC is provided. For RHC 

provided for 61 days or more, 

CHAMPVA reimburses at a higher rate 

than allowable under Medicare rules. 

The final rule codifies these practices. 

In addition, the commenter asked 

how CHAMPVA will track any updates 

that Medicare makes in the structure of 

its hospice payment system. CHAMPVA 

annually reviews Medicare’s hospice 

proposed rules and final rules in the 

Federal Register to maintain awareness 

of any potential change in TRICARE 

reimbursement methodologies. If 

TRICARE implements any Medicare 

reimbursement updates in the future, 

CHAMPVA will assess the feasibility of 

implementing such changes. 

The commenter inquired as to 

whether changes in the hospice 

payment structure by CMS are mirrored 

by CHAMPVA in the same time frame 

as Medicare. CHAMPVA is not based on 

the Medicare program, but instead must 

operate in the same or similar manner 

as TRICARE. 

Finally, the commenter asked about 

communication regarding hospice 

updates to Veterans Integrated Service 

Networks (VISNs) and local VA 

facilities and offered suggestions for 

improving communications. Internal VA 

processes, including avenues of 

communication between a VA medical 

facility and the VISN, are not typically 

addressed via regulation. Rather, 

internal processes and procedures are 

more properly delineated in agency 

policy. We make no changes to this 

rulemaking based on these comments. 

Changes to paragraph (g). In addition, 

we are making a technical edit to 

paragraph (g). In the proposed rule, we 

proposed revising this paragraph to state 

that the CHAMPVA Skilled Nursing 

Facility (SNF) care reimbursement 

methodology is based on the CMS 

Prospective Payment System for SNFs 

under 42 CFR part 413, subpart J 

(Medicare Resource Utilization Group 

(RUG) rates). See 83 FR 2411. Medicare 

replaced the RUG rates in fiscal year 

2020 with Patient Driven Payment 

Model (PDPM) rates. Therefore, in this 

rulemaking, we are removing the phrase 

‘‘Medicare Resource Utilization Group 

(RUG) rates’’ in the parenthetical. We 

note that the PDPM reporting 

mechanism decreases the administrative 

burden on providers but does not 

impact reimbursement rates. VA makes 

no other changes in this paragraph. 

Changes to paragraph (k). We are also 

making a technical edit to paragraph (k) 

to conform with minor changes to 

Medicare payment methodologies that 

went into effect after the public 

comment period closed. In the proposed 

rule, we proposed revising paragraph (k) 

to state that the CHAMPVA home health 

care reimbursement methodology, based 

on Medicare’s home health prospective 

payment system, uses a fixed case-mix 

and wage-adjusted national 60-day 

episode payment amount to act as 

payment in full for costs associated with 

furnishing home health services with 

exceptions allowing for additional 

payment to be established. See 83 FR 

2396. Additionally, we explained that 

we would make the change of adopting 

TRICARE’s reimbursement methodology 

for intermittent or part-time home 

health services, which itself is based on 

Medicare’s reimbursement 

methodology. In other words, the 

proposed substantive rule for this 

paragraph is that CHAMPVA will 

reimburse these services in a manner 

similar to TRICARE, which adopts 

Medicare’s methodology. We received 

no comments on proposed 17.275(k). 

Since the proposed rule was 

published (January 17, 2018), Medicare 

has finalized changes that change 

aspects of its methodology for paying for 

home health services. More specifically, 

on November 13, 2018, CMS published 

a final rule with comment period (RIN 

0938–AT29) that amended 42 CFR part 

484 to, inter alia, update the Home 

Health Prospective Payment System 

(HH PPS) payment methodology, 

effective January 1, 2020. See 83 FR 

56406. Of relevance here, that CMS final 

rule changed its regulations from 

requiring a 60-day episode payment to 

a 30-day episode payment. 

The ‘‘60-day episode of care’’ 

language in the proposed rule at 38 CFR 

17.275(k) referred to the substantive 

content in that paragraph, which was 

the proposed use of Medicare’s HH PPS 

payment methodology when 

determining payment for intermittent or 

part-time home health care consistent 

with that used by TRICARE. The 

inclusion of the reference to the length 

of the episode of care was intended to 

be informative in nature and aligned 

with Medicare rules as of the date the 

proposed rule published. In this final 

rulemaking we are not changing the 

payment methodology that CHAMPVA 

utilizes when determining payment for 

intermittent or part-time home health 

care. However, we are removing the 

reference to a specific episode of care 

length in reference to Medicare’s HH 

PPS payment methodology, which no 

longer uses a 60-day episode of care. As 

discussed above, Medicare has adopted 

a 30-day episode of care in its final rule, 

effective January 1, 2020 (see RIN 0938– 

AT39 (83 FR 56406) published 

November 13, 2018). Removing 

reference to a specific length for an 

episode of care as it relates to payment 

for intermittent or part time home 

health care will preserve needed 

flexibility to adequately implement and 

update our HH PPS in a manner 

consistent with any changes made by 

TRICARE. The public was fairly 

apprised of the potential scope and 

substance of the proposed rule—that we 

would be using Medicare’s HH PPS 

payment methodology for payment for 

intermittent or part time home health 

care, and that remains the same in the 

final rule. This rulemaking revises 

paragraph (k) to state that the 

CHAMPVA home health care 

reimbursement methodology, based on 

TRICARE’s home health prospective 

payment system, uses a fixed case-mix 

and wage-adjusted episode payment 

amount to act as payment in full for 

costs associated with furnishing home 

health services with exceptions 

allowing for additional payment to be 

established. Because the proposed 

substantive rule for paragraph (k) is 

unchanged here, removing the detail 

describing how it is currently calculated 

under Medicare is a technical fix to 

avoid the need for future updates of 

such details. 

§ 17.277 Appeals 

This section addresses appeals. If a 

CHAMPVA beneficiary or provider 

disagrees with a determination 

concerning CHAMPVA-covered services 

and supplies or calculation of benefits, 

a request for reconsideration may be 

made. If the beneficiary or provider 

disagrees with the reconsideration 

determination, the denial of CHAMPVA 

benefits based on legal eligibility 

requirements may be appealed to the 

Board of Veterans’ Appeals (BVA). 

Although we received no public 

comments on this section, changes are 

necessary to address issues raised by the 

Veterans Appeals Improvement and 

Modernization Act of 2017 (Pub. L. 115– 

55) (‘‘the AMA’’). The AMA revised 

processes for resolving VA benefits 


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claims and appeals of VA benefits 

decisions. In February 2019, VA 

promulgated rules to implement the 

AMA under 38 CFR parts 3 and 8, 14, 

19, 20, and 21. 84 FR 138 (January 18, 

2019). 

On February 21, 2020, VA published 

a proposed rule to revise several 

sections of 38 CFR part 17 including 

17.276. See 85 FR 10118. In that 

proposed rule, we updated 38 CFR 

17.276 to reflect that reconsideration 

within the VHA appeals process is only 

available in legacy claims. Id. The 

comment period ended on April 21, 

2020. VA received no comments on the 

proposed changes to 17.276. Given the 

effect these changes have on the 

CHAMPVA program, VA adopts the 

proposed changes to 17.276 from 85 FR 

10118 in this rulemaking and 

redesignates the section as 17.277. 

Paperwork Reduction Act 

This final rule contains no provisions 

constituting a collection of information 

under the Paperwork Reduction Act of 

1995 (44 U.S.C. 3501–3521). 

Regulatory Flexibility Act 

The Secretary hereby certifies that 

this final rule will not have a significant 

economic impact on a substantial 

number of small entities as they are 

defined in the Regulatory Flexibility 

Act, 5 U.S.C. 601–612. The final 

payment methods in this rulemaking 

will include new reimbursement rates 

for the Outpatient Prospective Payment 

System (OPPS), Home Health 

Prospective Payment System (HH PPS), 

and Sole Community Hospitals (SCHs) 

reimbursement methodologies. These 

revised methodologies will not 

significantly affect small businesses due 

to the following reasons: (1) The health 

care industry, to include Medicare and 

TRICARE, is currently using these 

payment methods and most providers 

are used to these reimbursement rates, 

if not expecting to receive them; (2) 

CHAMPVA’s beneficiary population is 

relatively small compared to these other 

health care payers. On this basis, the 

Secretary certifies that the adoption of 

this final rule will not have a significant 

economic impact on a substantial 

number of small entities as they are 

defined in the Regulatory Flexibility 

Act. 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. 

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 this rule to be 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. 

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, or tribal 

governments, in the aggregate, or by the 

private sector, of $100 million or more 

(adjusted annually for inflation) in any 

one year. This final rule will have no 

such effect on state, local, or tribal 

governments, or on the private sector. 

Assistance Listing 

The Assistance Listing numbers and 

titles for the programs affected by this 

document are 64.009, Veterans Medical 

Care Benefits; 64.010, Veterans Nursing 

Home Care; and 64.011, Veterans Dental 

Care; 64.012, Veterans Prescription 

Service; 64.013, Veterans Prosthetic 

Appliances; and 64.019, Veterans 

Rehabilitation Alcohol and Drug 

Dependence. 

Congressional Review Act 

This regulatory action is a major rule 

under the Congressional Review Act, 5 

U.S.C. 801–808, because it may result in 

an annual effect on the economy of $100 

million or more. In accordance with 5 

U.S.C. 801(a)(1), VA will submit to the 

Comptroller General and to Congress a 

copy of this Regulation and the 

Regulatory Impact Analysis (RIA) 

associated with the Regulation. 

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 (VA) amends 38 CFR part 17 as 

follows: 

PART 17—MEDICAL 

■ 1. The general authority citation for 

part 17 continues and authority 

citations for §§ 17.270, 17,271, 17.278 

and 17.279 are added in numerical 

order to read as follows to read as 

follows 

38 U.S.C. 501, and as noted in specific 

sections. 

* * * * * 

Sections 17.270, and 17.272 through 

17.277 are also issued under 38 U.S.C. 1781. 

Section 17.271 is also issued under 38 

U.S.C. 1720G(a)(7)(A) and 1781. 

Section 17.278 is also issued under 38 

U.S.C. 1781 and 42 U.S.C. 2651. 

Section 17.279 is also issued under 5 

U.S.C. 552 and 552a; 38 U.S.C. 1781, 5701, 

and 7332. 

* * * * * 

■ 2. Revise § 17.270 to read as follows: 

§ 17.270 General provisions and 

definitions. 

(a) Overview of CHAMPVA. 

CHAMPVA is the Civilian Health and 

Medical Program of the Department of 

Veterans Affairs (VA). Generally, 

CHAMPVA furnishes medical care in 

the same or similar manner, and subject 

to the same or similar limitations, as 

medical care furnished to certain 

dependents and survivors of active duty 

and retired members of the Armed 

Forces under chapter 55 of title 10, 

United States Code (CHAMPUS), 

commonly referred to as the TRICARE 

Select plan. Under CHAMPVA, VA 

shares the cost of medically necessary 

services and supplies with eligible 

beneficiaries within the 50 United 

States, the District of Columbia, the U.S. 

territories, and abroad. Under 


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CHAMPVA, medical services and 

supplies may be provided as follows: 

(1) By an authorized non-VA 

provider. 

(2) By a VA provider at a VA facility, 

on a resource-available basis through 

the CHAMPVA In-house Treatment 

Initiative (CITI) to CHAMPVA 

beneficiaries who are not also eligible 

for Medicare. 

(3) Through VA Medications by Mail 

(MbM). 

(i) Only CHAMPVA beneficiaries who 

do not have any other type of health 

insurance that pays for prescriptions, 

including Medicare Part D, may use 

MbM. 

(ii) Smoking cessation pharmaceutical 

supplies will only be provided through 

MbM and only to CHAMPVA 

beneficiaries that are not also eligible for 

Medicare. 

(b) Definitions. The following 

definitions apply to CHAMPVA 

(§§ 17.270 through 17.278): 

Accepted assignment refers to the 

action of an authorized non-VA 

provider who accepts responsibility for 

the care of a CHAMPVA beneficiary and 

thereby agrees to accept the CHAMPVA 

determined allowable amount as full 

payment for services and supplies 

rendered to the beneficiary. (The 

provider’s acceptance of the CHAMPVA 

determined allowable amount 

extinguishes the beneficiary’s payment 

liability to the provider with the 

exception of applicable cost-shares and 

deductibles.) 

Authorized non-VA provider means 

an individual or institutional non-VA 

provider of CHAMPVA-covered medical 

services and supplies that meets any of 

the following criteria: 

(i) Is licensed or certified by a state to 

provide the medical services and 

supplies; or 

(ii) Where a state does not offer 

licensure or certification, is otherwise 

certified by an appropriate national or 

professional association that sets 

standards for the specific medical 

provider. 

Calendar year means January 1 

through December 31. 

CHAMPVA beneficiary means a 

person enrolled under § 17.271. 

CHAMPVA-covered services and 

supplies mean those medical services 

and supplies that are medically 

necessary and appropriate for the 

treatment of a condition and that are not 

specifically excluded under 

§ 17.272(a)(1) through (84). 

CHAMPVA determined allowable 

amount has the meaning set forth in 

§ 17.272(b)(1). 

CHAMPVA In-house Treatment 

Initiative (CITI) means the initiative 

under 38 U.S.C. 1781(b) under which 

participating VA medical facilities 

provide medical services and supplies 

to CHAMPVA beneficiaries who are not 

also eligible for Medicare, subject to 

availability of space and resources. 

Child has the definition established in 

38 U.S.C. 101. 

Claim means a request by an 

authorized non-VA provider or by a 

CHAMPVA beneficiary for payment or 

reimbursement for medical services and 

supplies provided to a CHAMPVA 

beneficiary. 

Fiscal year means October 1 through 

September 30. 

Medications by Mail (MbM) means the 

initiative under which VA provides 

outpatient prescription medications 

through the mail to CHAMPVA 

beneficiaries. 

Other health insurance (OHI) means 

health insurance plans or programs 

(including Medicare) or third-party 

coverage that provide coverage to a 

CHAMPVA beneficiary for expenses 

incurred for medical services and 

supplies. 

Payer refers to OHI, as defined in this 

section, that is obligated to pay for 

CHAMPVA-covered medical services 

and supplies. In a situation in which, in 

addition to CHAMPVA, one or more 

payers is/are responsible to pay for such 

services and supplies (i.e., a ‘‘double 

coverage’’ situation), there would be a 

primary payer (i.e., the payer obligated 

to pay first), secondary payer (i.e., the 

payer obligated to pay after the primary 

payer), etc. In double coverage 

situations, CHAMPVA would be the last 

payer. 

Service-connected has the definition 

established in 38 U.S.C. 101. 

Spouse refers to a person who is 

married to a veteran and whose 

marriage is valid as determined under 

38 U.S.C. 103(c). 

Surviving spouse refers to a person 

who was married to and is the 

widow(er) of a veteran as determined 

under 38 U.S.C. 103(c). 

(c) Discretionary authority. When it is 

determined to be in the best interest of 

VA, VA may waive any requirement in 

§§ 17.270 through 17.278, except any 

requirement specifically set forth in 38 

U.S.C. 1781, or otherwise imposed by 

statute. Such discretionary authority 

would be used only under very unusual 

and limited circumstances and not to 

deny any individual any right, benefit, 

or privilege provided to him or her by 

statute or these regulations. Any such 

waiver will apply only to the individual 

circumstance or case involved and will 

in no way be construed to be precedentsetting. 

■ 3. Amend § 17.271 by: 

■ a. Removing the word ‘‘and’’ at the 

end of paragraph (a)(3); 

■ b. Redesignating paragraph (a)(4) as 

paragraph (a)(5); 

■ c. Adding a new paragraph (a)(4); 

■ d. Removing the authority citation 

following paragraph (a); and 

■ e. Removing the authority citation 

following paragraph (b)(5). 

The addition and revision read as 

follows: 

§ 17.271 Eligibility. 

(a) * * * 

(4) An individual designated as a 

Primary Family Caregiver, under 38 CFR 

71.25(f), who is not entitled to care or 

services under a health-plan contract (as 

defined in 38 U.S.C. 1725(f)(2)); and 

* * * * * 

■ 4. Amend § 17.272 by: 

■ a. Revising paragraph (a)(2); 

■ b. In paragraph (a)(3) introductory 

text, removing the phrase ‘‘(Medicaid 

excluded)’’; 

■ c. Adding paragraphs (a)(3)(iii) and 

(iv); 

■ d. Revising paragraph (a)(21)(ix); 

■ e. Removing paragraph (a)(26); 

■ f. Redesignating paragraphs (a)(27) 

through (38) as paragraphs (a)(26) 

through (37), respectively; 

■ g. In newly redesignated paragraph 

(a)(30), revising the introductory text 

and paragraphs (a)(30)(v) and (vi) and 

adding paragraphs (a)(30)(xi) through 

(xiv); 

■ h. Removing paragraph (a)(39); 

■ i. Redesignating paragraphs (a)(40) 

through (56) as paragraphs (a)(38) 

through (54), respectively; 

■ j. In newly redesignated paragraph 

(a)(40)(iv), removing ‘‘(a)(42)(iii)(A)’’ 

and adding in its place ‘‘(a)(40)(iii)(A)’’; 

■ k. Revising redesignated paragraph 

(a)(49); 

■ l. Removing paragraph (a)(57); 

■ m. Redesignating paragraphs (a)(58) 

through (71) as paragraphs (a)(55) 

through (68), respectively; 

■ n. Revising newly redesignated 

paragraphs (a)(57) through (59); 

■ o. Removing paragraph (a)(72); 

■ p. Redesignating paragraphs (a)(73) 

through (86) as paragraphs (a)(69) 

through (82), respectively; 

■ q. Revising newly redesignated 

paragraph (a)(76); 

■ r. Adding paragraphs (a)(83) and (84); 

■ s. Revising paragraph (b); and 

■ t. Removing the authority citation at 

the end of the section. 

The revisions and additions read as 

follows: 

§ 17.272 Benefits limitations/exclusions. 

(a) * * * 

(2) Services and supplies required as 

a result of an occupational disease or 


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injury for which benefits are payable 

under workers’ compensation or similar 

protection plan (whether or not such 

benefits have been applied for or paid) 

except when such benefits are 

exhausted and the services and supplies 

are otherwise not excluded from 

CHAMPVA coverage. 

(3) * * * 

(iii) Indian Health Service. 

(iv) CHAMPVA supplemental 

policies. 

* * * * * 

(21) * * * 

(ix) Treatment for stabilization of 

myofascial pain dysfunction syndrome, 

also referred to as temporomandibular 

joint disorder (TMD). Authorization is 

limited to initial imaging such as 

radiographs, Computed Tomography, or 

Magnetic Resonance Imaging; up to four 

office visits; and the construction of an 

occlusal splint. 

* * * * * 

(30) Preventive care (such as 

employment-requested physical 

examinations and routine screening 

procedures). The following exceptions 

apply, including but not limited to: 

* * * * * 

(v) Cervical cancer screening. 

(vi) Breast cancer screening. 

* * * * * 

(xi) Colorectal cancer screening. 

(xii) Prostate cancer screening. 

(xiii) Annual physical examination. 

(xiv) Vaccinations/immunizations. 

* * * * * 

(49) Food, food substitutes, vitamins 

or other nutritional supplements, 

including those related to care for a 

home patient whose condition permits 

oral feeding, except for prenatal 

vitamins which are medically necessary 

as a component of prenatal care and 

prescribed by a VA provider or an 

authorized non-VA provider as defined 

in § 17.270 of this part. 

* * * * * 

(57) Unless a waiver for extended 

coverage is granted in advance: 

Inpatient mental health services in 

excess of 30 days in any calendar year 

(or in an admission), in the case of a 

patient 19 years of age or older; 45 days 

in any calendar year (or in an 

admission), in the case of a patient 

under 19 years of age; or 150 days of 

residential treatment care in any 

calendar year (or in an admission). 

(58) Outpatient mental health services 

in excess of 23 visits in a calendar year 

unless a waiver for extended coverage is 

granted in advance. 

(59) Institutional services for partial 

hospitalization in excess of 60 treatment 

days in any calendar year (or in an 

admission) unless a waiver for extended 

coverage is granted in advance. 

* * * * * 

(76) Over-the-counter products except 

for pharmaceutical smoking cessation 

supplies that are approved by the U.S. 

Food and Drug Administration, 

prescribed, and provided through MbM, 

and insulin and related diabetic testing 

supplies and syringes. 

* * * * * 

(83) Medications not approved by the 

U.S. Food and Drug Administration 

(FDA), excluding FDA exceptions to the 

approval requirement. 

(84) Services and supplies related to 

the treatment of dyslexia. 

(b) Costs of services and supplies to 

the extent such amounts are billed over 

the CHAMPVA determined allowable 

amount are specifically excluded from 

coverage. 

(1) The CHAMPVA determined 

allowable amount is the maximum level 

of payment by CHAMPVA to an 

authorized non-VA provider for the 

provision of CHAMPVA-covered 

services and supplies to a CHAMPVA 

beneficiary. The CHAMPVA determined 

allowable amount is determined before 

consideration of cost sharing and the 

application of deductibles or OHI. 

(2) A Medicare-participating hospital 

must accept the CHAMPVA determined 

allowable amount for inpatient services 

provided to a CHAMPVA beneficiary as 

payment in full. See 42 CFR 489.25. 

(3) An authorized non-VA provider 

who accepts responsibility for the care 

of a CHAMPVA beneficiary thereby 

agrees to accept the CHAMPVA 

determined allowable amount as full 

payment for services and supplies 

rendered to the beneficiary (i.e., 

accepted assignment). The provider’s 

acceptance of the CHAMPVA 

determined allowable amount 

extinguishes the beneficiary’s payment 

liability to the provider. Any attempts to 

collect any additional amount from the 

CHAMPVA beneficiary may result in 

the provider being excluded from 

Federal benefits programs. See 42 CFR 

1003.105. 

■ 5. Amend § 17.273 by: 

■ a. Revising the introductory text and 

paragraph (d); 

■ b. Removing paragraph (e); 

■ c. Redesignating paragraph (f) as 

paragraph (e); 

■ d. Adding new paragraph (f); and 

■ e. Removing the authority citation at 

the end of the section. 

The revisions and addition read as 

follows: 

§ 17.273 Preauthorization. 

Preauthorization or advance approval 

is required for any of the following, 

except when the benefit is covered by 

the CHAMPVA beneficiary’s other 

health insurance (OHI): 

* * * * * 

(d) Dental care. For limitations on 

dental care, see § 17.272(a)(21)(i) 

through (xii). 

* * * * * 

(f) CHAMPVA will perform a 

retrospective medical necessity review 

during the coordination of benefits 

process if: 

(1) It is determined that CHAMPVA is 

the responsible payer for services and 

supplies but CHAMPVA 

preauthorization was not obtained prior 

to delivery of the services or supplies; 

and, 

(2) The claim for payment is filed 

within the appropriate one-year period. 

■ 6. Amend § 17.274 by: 

■ a. Revising paragraphs (a), (b), and (c); 

■ b. Adding a heading to paragraph (d); 

■ c. Adding paragraph (e); and 

■ d. Removing the authority citation at 

the end of the section. 

The revisions and additions read as 

follows: 

§ 17.274 Cost sharing. 

(a) Cost sharing generally. CHAMPVA 

is a cost sharing program in which the 

cost of covered services is shared with 

the CHAMPVA beneficiary. CHAMPVA 

pays the CHAMPVA determined 

allowable amount less the CHAMPVA 

deductible, if applicable, and less the 

CHAMPVA beneficiary cost-share. 

(1) CHAMPVA beneficiary cost-share 

requirements do not apply to the 

following: 

(i) Supplies provided through VA 

MbM. 

(ii) Any medical services and supplies 

provided to a CHAMPVA beneficiary 

through CITI. 

(iii) The following services, even if 

not provided through CITI: 

(A) Colorectal cancer screening. 

(B) Breast cancer screening. 

(C) Cervical cancer screening. 

(D) Prostate cancer screening. 

(E) Annual physical exams. 

(F) Vaccinations/immunizations. 

(G) Well child care from birth to age 

six, as described in § 17.272(a)(30)(i). 

(iv) Hospice services. 

(v) Or other preventive services as 

determined by the Secretary of Veterans 

Affairs. 

(2) [Reserved] 

(b) Deductibles. In addition to the 

CHAMPVA beneficiary cost-share, an 

annual (calendar year) outpatient 

deductible requirement ($50 per 

beneficiary or $100 per family) must be 

satisfied prior to VA payment of 

outpatient benefits. The deductible 

requirement is waived for: 


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(1) CHAMPVA-covered services and 

supplies provided through VA MbM or 

through CITI. 

(2) Inpatient services. 

(3) Preventive services listed in 

paragraph (a)(1)(iii) of this section. 

(4) Hospice services. 

(5) Or other services as determined by 

the Secretary of Veterans Affairs. 

(c) Cost sharing limitations. To 

provide financial protection against the 

impact of a long-term illness or injury, 

there is a $3,000 calendar year limit or 

‘‘catastrophic cap’’ per CHAMPVA 

eligible family on the CHAMPVA 

beneficiary’s out-of-pocket costs for 

allowable services and supplies. After a 

family has paid $3,000 in out-of-pocket 

costs, to include both cost-share and 

deductible amounts, in a calendar year, 

CHAMPVA will pay the full allowable 

amounts for the remaining CHAMPVAcovered services and supplies through 

the end of that calendar year. Credits to 

the annual catastrophic cap are limited 

to the applied annual deductible(s) and 

the CHAMPVA beneficiary cost-share 

amount. Costs above the CHAMPVA 

determined allowable amount, as well 

as costs associated with non-covered 

medical services and supplies, are not 

credited toward the catastrophic cap 

calculation. 

(d) Non-payment. * * * 

(e) Cost-share calculation. The 

CHAMPVA beneficiary’s cost-share 

amount, if not waived under paragraph 

(a)(1) of this section, is 25 percent of the 

CHAMPVA determined allowable 

amount in excess of the annual calendar 

year deductible (see § 17.275 for 

procedures related to the calculation of 

the allowable amount for CHAMPVAcovered services and supplies), except 

for the following: 

(1) For inpatient services subject to 

the CHAMPVA Diagnosis Related Group 

(DRG) payment system, the cost-share is 

the lesser of: 

(i) The per diem rate multiplied by 

the number of inpatient days; 

(ii) 25 percent of the hospital’s billed 

amount; or 

(iii) The base CHAMPVA DRG rate. 

(2) For inpatient mental health low 

volume hospitals and units (less than 25 

mental health discharges per federal 

fiscal year), the cost-share is the lesser 

of: 

(i) The fixed per diem rate multiplied 

by the number of inpatient days; or 

(ii) 25 percent of the hospital’s billed 

charges. 

■ 7. Redesignate §§ 17.275 through 

17.278 as §§ 17.276 through 17.279. 

■ 8. Add new § 17.275 to read as 

follows: 

§ 17.275 CHAMPVA determined allowable 

amount calculation. 

CHAMPVA calculates the allowable 

amount in the following ways, for the 

following covered services and supplies: 

(a) Inpatient hospital services (nonmental health). Unless exempt or 

subject to a methodology under 

paragraph (b) or (c) of this section, 

inpatient hospital services provided in 

the 50 states, the District of Columbia, 

and Puerto Rico are subject to the 

CHAMPVA Diagnosis Related Group 

(DRG)-based reimbursement 

methodology. Under the CHAMPVA 

DRG-based payment system, hospitals 

are paid a predetermined amount per 

discharge for inpatient hospital services, 

which will not exceed the billed 

amount. Certain inpatient services will 

be reimbursed under the CHAMPVA 

Cost-to-Charge (CTC) reimbursement 

methodology. 

(b) Inpatient hospital services (mental 

health). The CHAMPVA inpatient 

mental health per diem reimbursement 

methodology is used to calculate 

reimbursement for inpatient mental 

health hospital care in specialty 

psychiatric hospitals and psychiatric 

units of general acute hospitals that are 

exempt from the CHAMPVA DRG-based 

payment system. The per diem rate is 

calculated by multiplying the daily rate 

by the number of days (length of stay). 

The daily rate is updated each fiscal 

year for both high volume hospitals (25 

or more discharges per fiscal year) and 

low volume hospitals (fewer than 25 

discharges per fiscal year). 

(c) Other inpatient hospital services. 

(1) The CHAMPVA CTC reimbursement 

methodology is used to calculate 

reimbursement for inpatient care 

furnished by hospitals or facilities that 

are exempt from either of the 

methodologies in paragraph (a) or (b) of 

this section. Such hospitals or facilities 

will be paid at the CHAMPVA CTC ratio 

times the billed charges that are 

customary and not in excess of rates or 

fees the hospital or facility charges the 

general public for similar services in a 

community. 

(2) The following hospitals and 

services are subject to the CHAMPVA 

CTC payment methodology: 

(i) Any hospital that qualifies as a 

cancer hospital under Medicare 

standards and has elected to be exempt 

from the Centers for Medicare & 

Medicaid Services (CMS) prospective 

payment system. 

(ii) Christian Science sanatoriums. 

(iii) Critical Access Hospitals. 

(iv) Any hospital outside the 50 states, 

the District of Columbia, or Puerto Rico. 

(v) Hospitals within hospitals. 

(vi) Long-term care hospitals. 

(vii) Non-Medicare participating 

hospitals. 

(viii) Non-VA Federal Health Care 

Facilities (e.g., military treatment 

facilities, Indian Health Service). 

(ix) Rehabilitation hospitals. 

(x) Hospital or hospital-based services 

subject to state waiver in any state that 

has implemented a separate DRG-based 

payment system or similar payment 

system in order to control costs. 

(xi) Hospitals and services as 

determined by the Secretary of Veterans 

Affairs. 

(d) Outpatient hospital services. The 

CHAMPVA outpatient prospective 

payment system (OPPS) is used to 

calculate the allowable amount for 

outpatient services provided in 

hospitals subject to Medicare OPPS. 

This will include the utilization of 

TRICARE’s reimbursement methodology 

to include specific coding requirements, 

ambulatory payment classifications 

(APCs), nationally established APC 

amounts, and associated adjustments. 

(e) Outpatient and inpatient nonhospital services. Payments to 

individual authorized non-VA providers 

(not hospitals) for CHAMPVA-covered 

medical services and supplies provided 

on an outpatient or inpatient basis, 

including but not limited to, anesthesia 

services, laboratory services, and other 

professional fees associated with 

individual authorized non-VA 

providers, are reimbursed based on the 

lesser of: 

(1) The CHAMPVA Maximum 

Allowable Charge; 

(2) The prevailing amount, which is 

the amount equal to the maximum 

reasonable amount allowed providers 

for a specific procedure in a specific 

locality; or, 

(3) The billed amount. 

(f) Pharmacy services and supplies. 

The CHAMPVA pharmacy services and 

supplies payment methodology is based 

on specific CHAMPVA pharmacy points 

of service, which dictate the amounts 

paid by VA. VA pays: 

(1) For services and supplies obtained 

from a retail in-network pharmacy, the 

lesser of the billed amount or the 

contracted rate; or 

(2) For supplies obtained from a retail 

out-of-network pharmacy, the lesser of 

the billed amount plus a dispensing fee 

or the average wholesale price plus a 

dispensing fee. 

(g) Skilled Nursing Facility (SNF) 

care. The CHAMPVA SNF 

reimbursement methodology is based on 

the CMS prospective payment system 

for SNFs under 42 CFR part 413, subpart 

J. 

(h) Durable medical equipment, 

prosthetics, orthotics, and supplies 


jspears on DSK121TN23PROD with RULES1
Federal Register / Vol. 87, No. 133 / Wednesday, July 13, 2022 / Rules and Regulations 41603 

(DMEPOS). The CHAMPVA DMEPOS 

reimbursement methodology is based on 

the same amounts established under the 

CMS DMEPOS fee schedule under 42 

CFR part 414, subpart D. The 

CHAMPVA determined allowable 

amount for DMEPOS is the amount in 

effect in the specific geographic location 

at the time CHAMPVA-covered medical 

services and supplies are provided to a 

CHAMPVA beneficiary. 

(i) Ambulance services. CHAMPVA 

adopts Medicare’s Ambulance Fee 

Schedule (AFS) for ambulance services, 

with the exception of services furnished 

by a Critical Access Hospital (CAH). 

Ambulance services are paid based on 

the lesser of the Medicare AFS or the 

billed amount. Ambulance services 

provided by a CAH are paid on the same 

bases as the CTC method under 

paragraph (c) of this section. 

(j) Hospice care. CHAMPVA hospice 

reimbursement methodology uses 

Medicare per diem hospice rates. 

(k) Home health care (intermittent or 

part-time). CHAMPVA home health care 

reimbursement methodology, based on 

Medicare’s home health prospective 

payment system, uses a fixed case-mix 

and wage-adjusted episode payment 

amount to act as payment in full for 

costs associated with furnishing home 

health services with exceptions 

allowing for additional payment to be 

established. 

(l) Ambulatory surgery. The 

CHAMPVA reimbursement 

methodology for facility charges 

associated with procedures performed 

in a freestanding ambulatory surgery 

center is based on a prospectively 

determined amount, similar to that used 

by TRICARE. These facility charges do 

not include physician fees, 

anesthesiologist fees, or fees of other 

authorized non-VA providers; such 

independent professional fees must be 

submitted separately from facility fees 

and are calculated under the 

methodology in paragraph (e) of this 

section. 

(m) CHAMPVA-covered medical 

services and supplies provided outside 

the United States. VA shall determine 

the appropriate reimbursement 

method(s) for CHAMPVA-covered 

medical services and supplies provided 

by authorized non-VA providers outside 

the United States. 

(n) Sole Community Hospitals. The 

CHAMPVA reimbursement 

methodology for inpatient services 

provided in a Sole Community Hospital 

(SCH) will be the greater of: the 

allowable amount determined by 

multiplying the billed charges by the 

SCH’s most recently available cost-tocharge ratio from the CMS Inpatient 

Provider Specific File or the DRG 

reimbursement rate. 

■ 9. Amend newly redesignated 

§ 17.276 by: 

■ a. Revising paragraphs (a) 

introductory text and (b); 

■ b. Adding paragraphs (c) and (d); and 

■ c. Removing the authority citation at 

the end of the section. 

The revisions and additions read as 

follows: 

§ 17.276 Claim-filing deadlines. 

(a) Unless an exception is granted 

under paragraph (b) of this section, 

claims for medical services and supplies 

must be filed no later than: 

* * * * * 

(b) Requests for an exception to the 

claim filing deadline must be submitted 

in writing and include a complete 

explanation of the circumstances 

resulting in late filing along with all 

available supporting documentation. 

Each request for an exception to the 

claim filing deadline will be reviewed 

individually and considered on its own 

merit. VA may grant exceptions to the 

requirements in paragraph (a) of this 

section if it determines that there was 

good cause for missing the filing 

deadline. For example, when dual 

coverage exists, CHAMPVA payment, if 

any, cannot be determined until after 

the primary insurance carrier has 

adjudicated the claim. In such 

circumstances an exception may be 

granted provided that the delay on the 

part of the primary insurance carrier is 

not attributable to the beneficiary. 

Delays due to provider billing 

procedures do not constitute a valid 

basis for an exception. 

(c) Claims for CHAMPVA-covered 

services and supplies provided before 

the date of the event that qualifies an 

individual under § 17.271 are not 

reimbursable. 

(d) CHAMPVA is the last payer to 

OHI, as that term is defined in 

§ 17.270(b). CHAMPVA benefits will 

generally not be paid until the claim has 

been filed with the OHI and the OHI has 

issued a final payment determination or 

explanation of benefits. CHAMPVA is 

secondary payer to Medicare per the 

terms of § 17.271(b). 

■ 10. Revise newly redesignated 

§ 17.277 to read as follows: 

§ 17.277 Appeals. 

(a) This section applies only to legacy 

claims. 

(b) Notice of the initial determination 

regarding payment of CHAMPVA 

benefits will be provided to the 

CHAMPVA beneficiary on a CHAMPVA 

Explanation of Benefits (EOB) form. The 

EOB form is generated by the 

CHAMPVA automated payment 

processing system. If a CHAMPVA 

beneficiary or provider disagrees with 

the determination concerning 

CHAMPVA-covered services and 

supplies or calculation of benefits, he or 

she may request reconsideration. Such 

requests must be submitted to VA in 

writing within one year of the date of 

the initial determination. The request 

must state why the CHAMPVA claimant 

believes the decision is in error and 

must include any new and relevant 

information not previously considered. 

Any request for reconsideration that 

does not identify the reason for dispute 

will be returned to the claimant without 

further consideration. After reviewing 

the claim and any relevant supporting 

documentation, VA will issue a written 

determination to the claimant that 

affirms, reverses, or modifies the 

previous decision. If the claimant is still 

dissatisfied, within 90 days of the date 

of the decision he or she may make a 

written request for review by VA. After 

reviewing the claim and any relevant 

supporting documentation, VA will 

issue a written determination to the 

claimant that affirms, reverses, or 

modifies the previous decision. The 

decision of VA with respect to benefit 

coverage and computation of benefits is 

final. When a CHAMPVA beneficiary 

has other health insurance (OHI), an 

appeal must first be filed with the OHI, 

and a determination made, before 

submitting the appeal to CHAMPVA 

with limited exceptions such as if the 

OHI deems the issue non-appealable. 

Denial of CHAMPVA benefits based on 

legal eligibility requirements may be 

appealed to the Board of Veterans’ 

Appeals in accordance with 38 CFR part 

20. Medical determinations are not 

appealable to the Board. 38 CFR 20.101. 

■ 11. Revise newly redesignated 

§ 17.278 to read as follows: 

§ 17.278 Medical care cost recovery. 

VA will actively pursue medical care 

cost recovery in accordance with 

applicable law. 

§ 17.279 [Amended] 

■ 12. In newly redesignated § 17.279, 

remove the authority citation at the end 

of the section. 

[FR Doc. 2022–14285 Filed 7–12–22; 8:45 am] 

BILLING CODE 8320–01–P 


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