Rule2023-08298
Medical Benefits Package; Chiropractic Services
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
April 21, 2023
Effective
May 22, 2023
Issuing agencies
Veterans Affairs Department
Abstract
The Department of Veterans Affairs (VA) is amending its medical regulations to add chiropractic services to the definitions of medical services and preventive care. VA will further revise the definition of medical services to include rehabilitative services consistent with its statutory definition and to reflect changes made in other VA medical regulations and in prior legislation not previously codified. The amendments will make the amended regulations consistent with current practices, prior changes in law and other VA medical regulations, and changes in law made by the Consolidated Appropriations Act, 2018. These amendments will not substantively change the current administration of medical benefits to veterans.
Full Text
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<title>Federal Register, Volume 88 Issue 77 (Friday, April 21, 2023)</title>
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[Federal Register Volume 88, Number 77 (Friday, April 21, 2023)]
[Rules and Regulations]
[Pages 24481-24483]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-08298]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 17
RIN 2900-AQ70
Medical Benefits Package; Chiropractic Services
AGENCY: Department of Veterans Affairs.
ACTION: Final rule.
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SUMMARY: The Department of Veterans Affairs (VA) is amending its
medical regulations to add chiropractic services to the definitions of
medical services and preventive care. VA will further revise the
definition of medical services to include rehabilitative services
consistent with its statutory definition and to reflect changes made in
other VA medical regulations and in prior legislation not previously
codified. The amendments will make the amended regulations consistent
with current practices, prior changes in law and other VA medical
regulations, and changes in law made by the Consolidated Appropriations
Act, 2018. These amendments will not substantively change the current
administration of medical benefits to veterans.
DATES: This rule is effective May 22, 2023.
FOR FURTHER INFORMATION CONTACT: Anthony Lisi, D.C., Director, Veterans
Health Administration Chiropractic Service, Rehabilitation and
Prosthetic Services (12RPS3), 810 Vermont Ave. NW, Washington, DC
20420, (203) 932-5711, ext. 5341. (This is not a toll-free number.)
SUPPLEMENTARY INFORMATION: On October 21, 2021, VA published a proposed
rule in the Federal Register (86 FR 58237) that would revise its
medical regulations to explicitly include chiropractic and
rehabilitative care. VA provided a 60-day comment period, which ended
on December 20, 2021. VA received six comments on the proposed rule.
Section 1710 of title 38 of the United States Code (U.S.C.)
requires VA to furnish hospital care and medical services which the
Secretary determines to be needed for eligible veterans. The term
medical services is defined in 38 U.S.C. 1701(6) to include medical
examination, treatment, and rehabilitation, and further lists
particular types of medical services in section 1701(6)(A)-(H). Section
245 of Public Law 115-141, the Consolidated Appropriations Act, 2018
(March 23, 2018), amended 38 U.S.C. 1701(6) to add chiropractic
services to the definition of medical services, amended section 1701(8)
to include chiropractic services to the definition of rehabilitative
services, and amended section 1701(9) to add chiropractic examinations
and services to the definition of preventive services. VA regulates
definitions for certain terms, to include medical services, in title 38
Code of Federal Regulations (CFR) 17.30, and regulates the provision of
hospital care and medical services in 38 CFR 17.38. This final rule
amends 38 CFR 17.30 and 17.38, consistent with the proposed rule, to
conform to these statutory changes and expressly recognize chiropractic
services as medical services.
All six comments--including one submitted by the American
Chiropractic Association, the largest professional organization
representing chiropractors in the U.S.--expressed support for the rule,
and we thank the commenters for their support. While all comments were
supportive, four warrant clarification.
One commenter is a chiropractor working with veterans who expressed
a personal desire, as well as a desire held by the commenter's
patients, to see chiropractic care covered as part of veteran medical
benefits. We believe this commenter supported the addition of
chiropractic services as part of the medical benefits package in
proposed Sec. 17.38(a)(2)(x) but may not have understood that
chiropractic services have been provided by VA to veterans since 2000.
We clarify for the commenter, and reiterate from the proposed rule,
that the proposed changes are intended to expressly recognize
chiropractic services as medical services available to veterans, making
VA regulations consistent with changes in law made by the Consolidated
Appropriations Act of 2018 as well as with current VA practice. The
proposed changes will not affect the administration of medical
benefits, which currently include chiropractic services. We do not make
any changes based on this comment.
While voicing support for the proposed rule, one commenter stated
the change does not go far enough, because it does not include other
``whole-person'' medical treatments and
[[Page 24482]]
methodologies such as osteopathic manipulation, physical therapy, and
massage therapy. The commenter recommended listing these three
modalities alongside chiropractic care as covered preventive care
services under 38 CFR 17.38(a)(2)(x). VA embraces whole health by
offering various complimentary and integrative health approaches and
promoting veteran self-care and well-being. However, the primary
purpose of this rulemaking is to conform Sec. 17.38 with the statutory
changes made to 38 U.S.C. 1701 in the Consolidated Appropriations Act,
2018, and not to conform VA regulations to reflect an exhaustive list
of all treatment modalities that may be available as either basic or
preventive care in the medical benefits package in Sec. 17.38(a). We
clarify for the commenter, however, that the additional modalities
mentioned by the commenter are currently authorized forms of outpatient
care for veterans under Sec. 17.38(a)(1)(i), dependent upon factors
like provider availability and medical necessity. We do not make any
changes from the proposed rule based on this comment.
A supportive comment submitted by a group of graduate students
stated a belief that VA currently provides only limited chiropractic
services and that the proposed rule would authorize additional
chiropractic resources for veterans through the hiring of additional
chiropractors. To clarify, the proposed rule did not pose regulatory
revisions to increase chiropractic resources or services, but only to
conform current regulatory language to the authorizing statutory
language and current VA practice. Chiropractic resources are already
available at VA medical centers and through the Community Care Program.
In the group comment referenced above, one individual commenter
also stated that while they supported the rule and did not find any
issue with VA providing chiropractic care prior to the regulations
being published and effective, the commenter suggested that, in the
future, VA should not authorize new types of treatment or care without
first, or simultaneously, publishing a regulation. We thank the
commenter for that suggestion. However, in some situations VA is able
to administer medically necessary benefits to veterans as soon as they
are authorized without having to wait for regulations to be published.
The commenter detailed their own experience serving on active duty
and as a veteran receiving health care through VA, and we thank the
commenter for their service. We do not make any changes from the
proposed rule based on this comment.
One commenter expressed support for making chiropractic services
available in nursing homes, a term which could apply to various VA-run
and VA-affiliated programs, such as: Community Living Centers, which
are VA-run nursing homes; Community Nursing Homes, which are nursing
homes owned and operated by commercial providers where VA contracts for
beneficiary care; and State Veterans Homes, which are recognized by VA,
but owned and operated by the state where they are located. While
chiropractic care is available to veterans eligible for the medical
benefits package, we note that these services may not be available on-
site at each type of nursing home to which the commenter may have been
referring.
Based on the rationale set forth in the Supplementary Information
to the proposed rule and in this final rule, VA is adopting the
proposed rule as a final rule without changes.
Paperwork Reduction Act
This action does not contain any provisions constituting
collections 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 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. There would be no material changes to the medical benefits
available to 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.
Executive Order 12866 and 13563
Executive Orders 12866 and 13563 direct agencies to assess the
costs and benefits of available regulatory alternatives and, when
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, and other advantages; distributive impacts;
and equity). Executive Order 13563 (Improving Regulation and Regulatory
Review) emphasizes the importance of quantifying both costs and
benefits, reducing costs, harmonizing rules, and promoting flexibility.
The Office of Information and Regulatory Affairs has determined that
this rule is not a significant regulatory action under Executive Order
12866. The Regulatory Impact Analysis associated with this rulemaking
can be found as a supporting document at <a href="http://www.regulations.gov">www.regulations.gov</a>.
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 final rule will have no such effect on
State, local, and tribal governments, or on the private sector.
Assistance Listings
The Assistance Listings numbers and titles for the programs
affected by this document are 64.014, Veterans State Domiciliary Care;
64.015, Veterans State Nursing Home Care; 64.029, Purchase Care
Program; 64.049, VHA Community Living Center.
List of Subjects in 38 CFR Part 17
Administrative practice and procedure, Claims, Day care, Dental
health, Health care, Health facilities, Health professions, Health
records, Homeless, Medical and Dental schools, Medical devices, Medical
research, Mental health programs, Nursing homes, Reporting and
recordkeeping requirements, Veterans.
Signing Authority
Denis McDonough, Secretary of Veterans Affairs, approved this
document on April 14, 2023, 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.
Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of
General Counsel, Department of Veterans Affairs.
For the reasons set forth in the preamble, we amend 38 CFR part 17
as follows:
PART 17--MEDICAL
0
1. The authority citation for part 17 is amended by adding an entry for
Sec. 17.30 and revising the entry for Sec. 17.38 to read in part as
follows:
Authority: 38 U.S.C. 501, and as noted in specific sections.
Section 17.30 is also issued under 38 U.S.C. 1701.
* * * * *
[[Page 24483]]
Section 17.38 is also issued under 38 U.S.C. 1701 and 1703.
* * * * *
0
2. Amend Sec. 17.30 by:
0
a. Revising paragraphs (a) introductory text and (a)(1);
0
b. Redesignating paragraphs (a)(2) and (3) as paragraphs (a)(3) and
(4), respectively; and
0
c. Adding new (a)(2) to read as follows:
Sec. 17.30 Definitions.
* * * * *
(a) Medical services. The term medical services includes the
following:
(1) Medical examination, treatment, and rehabilitative services (as
defined in 38 U.S.C. 1701(8)).
(2) Surgical services, dental services and appliances as authorized
in Sec. Sec. 17.160 through 17.166, optometric and podiatric services,
chiropractic services, preventive health care services set forth in 38
U.S.C. 1701(9), noninstitutional extended care, and items and services
as authorized in Sec. Sec. 17.3200 through 17.3250.
* * * * *
0
3. Amend Sec. 17.38 by adding paragraph (a)(2)(x) to read as follows:
Sec. 17.38 Medical benefits package.
(a) * * *
(2) * * *
(x) Chiropractic services.
* * * * *
[FR Doc. 2023-08298 Filed 4-20-23; 8:45 am]
BILLING CODE 8320-01-P
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</html>Indexed from Federal Register on April 21, 2023.
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