36C25618R0078-027.pdf

Department of Veterans Affairs § 17.107

(i) Express exclusions or limitations in third-party payer plans that are in-consistent with 38 U.S.C. 1729 are inop-erative. For example, a provision in a third-party payer’s plan that purports to disallow or limit payment for serv-ices provided by a government entity or paid for by a government program (or similar exclusion) is not a permis-sible ground for refusing or reducing third-party payment.

(ii) No objection, precondition or lim-itation may be asserted that defeats the statutory purpose of collecting from third-party payers. For example, a provision in a third-party payer’s plan that purports to disallow or limit payment for services for which the pa-tient has no obligation to pay (or simi-lar exclusion) is not a permissible ground for refusing or reducing third-party payment.

(iii) Third-party payers may not treat claims arising from services pro-vided in or through VA facilities less favorably than they treat claims aris-ing from services provided in other hos-pitals. For example, no provision of an employer sponsored program or plan that purports to make ineligible for coverage individuals who are eligible to receive VA medical care and serv-ices shall be permissible.

(iv) The lack of a participation agree-ment or the absence of privity of con-tract between a third-party payer and VA is not a permissible ground for re-fusing or reducing third-party pay-ment.

(v) A provision in a third-party payer plan, other than a Medicare supple-mental plan, that seeks to make Medi-care the primary payer and the plan the secondary payer or that would op-erate to carve out of the plan’s cov-erage an amount equivalent to the Medicare payment that would be made if the services were provided by a pro-vider to whom payment would be made under Part A or Part B of Medicare is not a permissible ground for refusing or reducing payment as the primary payer to VA by the third-party payer unless the provision expressly dis-allows payment as the primary payer to all providers to whom payment would not be made under Medicare (in-cluding payment under Part A, Part B, a Medicare HMO, or a Medicare Advan-tage plan).

(vi) A third-party payer may not refuse or reduce third-party payment to VA because VA’s claim form did not report hospital acquired conditions (HAC) or present on admission condi-tions (POA). VA is exempt from the Medicare Inpatient prospective pay-ment system and the Medicare rules for reporting POA or HAC information to third-party payers.

(vii) Health Maintenance Organiza-tions (HMOs) may not exclude claims or refuse to certify emergent and ur-gent services provided within the HMO’s service area or otherwise cov-ered non-emergency services provided out of the HMO’s service area. In addi-tion, opt-out or point-of-service op-tions available under an HMO plan may not exclude services otherwise payable under 38 U.S.C. 1729 or this part.

(g) Records. Pursuant to 38 U.S.C.

1729(h), VA shall make available for in-spection and review to representatives of third-party payers, from which the United States seeks payment, recov-ery, or collection under 38 U.S.C. 1729, appropriate health care records (or cop-ies of such records) of patients. How-ever, the appropriate records will be made available only for the purposes of verifying the care and services which are the subject of the claim(s) for pay-ment under 38 U.S.C. 1729, and for verifying that the care and services met the permissible criteria of the terms and conditions of the third-party payer’s plan. Patient care records will not be made available under any other circumstances to any other entity. VA will not make available to a third-party payer any other patient or VA records.

(Authority: 31 U.S.C. 3711, 38 U.S.C. 501, 1729, 42 U.S.C. 2651)

[76 FR 37204, June 24, 2011]

DISCIPLINARY CONTROL OF BENE-

FICIARIES RECEIVING HOSPITAL, DOMI-

CILIARY OR NURSING HOME CARE

§ 17.107 VA response to disruptive be-havior of patients.

(a) Definition. For the purposes of this section:

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38 CFR Ch. I (7–1–12 Edition) § 17.107

VA medical facility means VA medical centers, outpatient clinics, and domi-ciliaries.

(b) Response to disruptive patients. The time, place, and/or manner of the pro-vision of a patient’s medical care may be restricted by written order of the Chief of Staff of the VA Medical Center of jurisdiction or his or her designee if:

(1) The Chief of Staff or designee de-termines pursuant to paragraph (c) of this section that the patient’s behavior at a VA medical facility has jeopard-ized or could jeopardize the health or safety of other patients, VA staff, or guests at the facility, or otherwise interfere with the delivery of safe med-ical care to another patient at the fa-cility;

(2) The order is narrowly tailored to address the patient’s disruptive behav-ior and avoid undue interference with the patient’s care;

(3) The order is signed by the Chief of Staff or designee, and a copy is entered into the patient’s permanent medical record;

(4) The patient receives a copy of the order and written notice of the proce-dure for appealing the order to the Net-work Director of jurisdiction as soon as possible after issuance; and

(5) The order contains an effective date and any appropriate limits on the duration of or conditions for con-tinuing the restrictions. The Chief of Staff or designee may order restric-tions for a definite period or until the conditions for removing conditions specified in the order are satisfied. Un-less otherwise stated, the restrictions imposed by an order will take effect upon issuance by the Chief of Staff or designee. Any order issued by the Chief of Staff or designee shall include a summary of the pertinent facts and the bases for the Chief of Staff’s or des-ignee’s determination regarding the need for restrictions.

(c) Evaluation of disruptive behavior.

In making determinations under para-graph (b) of this section, the Chief of Staff or designee must consider all per-tinent facts, including any prior coun-seling of the patient regarding his or her disruptive behavior or any pattern of such behavior, and whether the dis-ruptive behavior is a result of the pa-tient’s individual fears, preferences, or perceived needs. A patient’s disruptive behavior must be assessed in connec-tion with VA’s duty to provide good quality care, including care designed to reduce or otherwise clinically address the patient’s behavior.

(d) Restrictions. The restrictions on care imposed under this section may include but are not limited to:

(1) Specifying the hours in which nonemergent outpatient care will be provided;

(2) Arranging for medical and any other services to be provided in a par-ticular patient care area (e.g., private exam room near an exit);

(3) Arranging for medical and any other services to be provided at a spe-cific site of care;

(4) Specifying the health care pro-vider, and related personnel, who will be involved with the patient’s care;

(5) Requiring police escort; or

(6) Authorizing VA providers to ter-minate an encounter immediately if certain behaviors occur.

(e) Review of restrictions. The patient may request the Network Director’s re-view of any order issued under this sec-tion within 30 days of the effective date of the order by submitting a written request to the Chief of Staff. The Chief of Staff shall forward the order and the patient’s request to the Network Direc-tor for a final decision. The Network Director shall issue a final decision on this matter within 30 days. VA will en-force the order while it is under review by the Network Director. The Chief of Staff will provide the patient who made the request written notice of the Network Director’s final decision.

NOTE TO § 17.106: Although VA may restrict the time, place, and/or manner of care under this section, VA will continue to offer the full range of needed medical care to which a patient is eligible under title 38 of the United States Code or Code of Federal Regulations.

Patients have the right to accept or refuse treatments or procedures, and such refusal by a patient is not a basis for restricting the provision of care under this section.

(Authority: 38 U.S.C. 501, 901, 1721)

[75 FR 69883, Nov. 16, 2010. Redesignated at 76 FR 37204, June 24, 2011]

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Department of Veterans Affairs § 17.108

COPAYMENTS

§ 17.108 Copayments for inpatient hos-pital care and outpatient medical care.

(a) General. This section sets forth re-quirements regarding copayments for inpatient hospital care and outpatient medical care provided to veterans by

VA.

(b) Copayments for inpatient hospital care. (1) Except as provided in para-graphs (d) or (e) of this section, a vet-eran, as a condition of receiving inpa-tient hospital care provided by VA (provided either directly by VA or ob-tained by VA by contract), must agree to pay VA (and is obligated to pay VA) the applicable copayment, as set forth in paragraph (b)(2) or (b)(3) of this sec-tion.

(2) The copayment for inpatient hos-pital care shall be, during any 365-day period, a copayment equaling the sum of:

(i) $10 for every day the veteran re-ceives inpatient hospital care, and

(ii) The lesser of:

(A) The sum of the inpatient Medi-care deductible for the first 90 days of care and one-half of the inpatient Medicare deductible for each subse-quent 90 days of care (or fraction there-

of) after the first 90 days of such care during such 365-day period, or

(B) VA’s cost of providing the care.

(3) The copayment for inpatient hos-pital care for veterans enrolled in pri-ority category 7 shall be 20 percent of the amount computed under paragraph (b)(2) of this section.

NOTE TO § 17.108(b): The requirement that a veteran agree to pay the copayment would be met by submitting to VA a signed VA Form 10–10EZ. This is the application form for enrollment in the VA healthcare system and also is the document used for providing means-test information annually.

(c) Copayments for outpatient medical care. (1) Except as provided in para-graphs (d), (e) or (f) of this section, a veteran, as a condition of receiving outpatient medical care provided by VA, must agree to pay VA (and is obli-gated to pay VA) a copayment as set forth in paragraph (c)(2) of this section.

(2) The copayment for outpatient medical care is $15 for a primary care outpatient visit and $50 for a specialty care outpatient visit. If a veteran has more than one primary care encounter on the same day and no specialty care encounter on that day, the copayment amount is the copayment for one pri-mary care outpatient visit. If a veteran has one or more primary care encoun-ters and one or more specialty care en-counters on the same day, the copay-ment amount is the copayment for one specialty care outpatient visit.

(3) For purposes of this section, a pri-mary care visit is an episode of care furnished in a clinic that provides inte-grated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sus-tained partnership with patients, and practicing in the context of family and community. Primary care includes, but is not limited to, diagnosis and man-agement of acute and chronic bio-psychosocial conditions, health pro-motion, disease prevention, overall care management, and patient and caregiver education. Each patient’s identified primary care clinician deliv-ers services in the context of a larger interdisciplinary primary care team.

Patients have access to the primary care clinician and much of the primary care team without need of a referral. In contrast, specialty care is generally provided through referral. A specialty care outpatient visit is an episode of care furnished in a clinic that does not provide primary care, and is only pro-vided through a referral. Some exam-ples of specialty care provided at a spe-cialty care clinic are radiology services requiring the immediate presence of a physician, audiology, optometry, mag-netic resonance imagery (MRI), com-puterized axial tomography (CAT) scan, nuclear medicine studies, sur-gical consultative services, and ambu-latory surgery.

NOTE TO § 17.108(c): The requirement that a veteran agree to pay the copayment would be met by submitting to VA a signed VA Form 10–10EZ. This is the application form for enrollment in the VA healthcare system and also is the document used for providing means-test information annually.

(d) Veterans not subject to copayment requirements for inpatient hospital care or outpatient medical care. The following

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