[Code of Federal Regulations] [Title 38, Volume 1] [Revised as of July 1, 2002] From the U.S. Government Printing Office via GPO Access [CITE: 38CFR17.36] [Page 585-590] TITLE 38--PENSIONS, BONUSES, AND VETERANS' RELIEF CHAPTER I--DEPARTMENT OF VETERANS AFFAIRS PART 17--MEDICAL--Table of Contents Sec. 17.36 Enrollment--provision of hospital and outpatient care to veterans. (a) Enrollment requirement for veterans. (1) Except as otherwise provided in Sec. 17.37, a veteran must be enrolled in the VA healthcare system as a condition for receiving the 'medical benefits package' set forth in Sec. 17.38. Note to paragraph (a)(1): A veteran may apply to be enrolled at any time. (See Sec. 17.36(d)(1).) (2) Except as provided in paragraph (a)(3) of this section, a veteran enrolled under this section is eligible for VA care as provided in the ``medical benefits package'' set forth in Sec. 17.38. Note to paragraph (a)(2): A veteran's enrollment status will be recognized throughout the United States. (3) A veteran enrolled based on having a disorder associated with exposure to a toxic substance or radiation, for a disorder associated with service in the Southwest Asia theater of operations during the Gulf War, or any illness associated with service in combat in a war after the Gulf War or during a period of hostility after November 11, 1998, as provided in 38 U.S.C. 1710(e), is eligible for VA care provided in the ``medical benefits package'' set forth in Sec. 17.38 for the disorder. (b) Categories of veterans eligible to be enrolled. The Secretary will determine which categories of veterans are eligible to be enrolled based on the following order of priority: (1) Veterans with a singular or combined rating of 50 percent or greater based on one or more service-connected disabilities or unemployability. (2) Veterans with a singular or combined rating of 30 percent or 40 percent based on one or more service-connected disabilities. (3) Veterans who are former prisoners of war; veterans with a singular or combined rating of 10 percent or 20 percent based on one or more service-connected disabilities; veterans who were discharged or released from active military service for a disability incurred or aggravated in the line of duty; veterans who receive disability [[Page 586]] compensation under 38 U.S.C. 1151; veterans whose entitlement to disability compensation is suspended pursuant to 38 U.S.C. 1151, but only to the extent that such veterans' continuing eligibility for that care is provided for in the judgment or settlement described in 38 U.S.C. 1151; veterans whose entitlement to disability compensation is suspended because of the receipt of military retired pay; and veterans receiving compensation at the 10 percent rating level based on multiple noncompensable service-connected disabilities that clearly interfere with normal employability. (4) Veterans who receive increased pension based on their need for regular aid and attendance or by reason of being permanently housebound and other veterans who are determined to be catastrophically disabled by the Chief of Staff (or equivalent clinical official) at the VA facility where they were examined; except that a veteran who is catastrophically disabled and who must agree under 38 U.S.C. 1710 to pay to the United States a co-payment as condition of receiving VA care, must agree to pay to the United States the applicable co-payment to be enrolled in priority category 4. (5) Veterans not covered by paragraphs (b)(1) through (b)(4) of this section who are determined to be unable to defray the expenses of necessary care under 38 U.S.C. 1722(a). (6) Veterans of the Mexican border period or of World War I; veterans solely seeking care for a disorder associated with exposure to a toxic substance or radiation, for a disorder associated with service in the Southwest Asia theater of operations during the Gulf War, or for any illness associated with service in combat in a war after the Gulf War or during a period of hostility after November 11, 1998, as provided and limited in 38 U.S.C. 1710(e); and veterans with 0 percent service- connected disabilities who are nevertheless compensated, including veterans receiving compensation for inactive tuberculosis. (7) Veterans who agree to pay to the United States the applicable copayment determined under 38 U.S.C. 1710(f) and 1710(g). This category is further prioritized into the following subcategories: (i) Noncompensable zero percent service-connected veterans; and (ii) All other priority category 7 veterans. (c) Federal Register notification of eligible enrollees. (1) It is anticipated that on or before August 1 of each year the Secretary will announce in paragraph (c)(2) of this section which categories of veterans are eligible to be enrolled. As necessary, the Secretary at any time may revise this determination by further amending paragraph (c)(2) of this section. The preamble to a Federal Register document announcing which priority categories are eligible to be enrolled must specify the projected number of fiscal year applicants for enrollment in each priority category, projected healthcare utilization and expenditures for veterans in each priority category, appropriated funds and other revenue projected to be available for fiscal year enrollees, and results-- projected total expenditures for enrollees by priority category. The determination should include consideration of relevant internal and external factors, e.g., economic changes, changes in medical practices, and waiting times to obtain an appointment for care. Consistent with these criteria, the Secretary will determine which categories of veterans are eligible to be enrolled based on the order of priority specified in paragraph (b) of this section. (2) Unless changed by a rulemaking document in accordance with paragraph (c)(1) of this section, VA will enroll all priority categories of veterans set forth in Sec. 17.36(b) for the period from October 1, 1999 through September 30, 2000. (d) Enrollment and disenrollment process--(1) Application for enrollment. A veteran may apply to be enrolled in the VA healthcare system at any time. A veteran who wishes to be enrolled must apply by submitting a VA Form 10-10EZ to a VA medical facility. Veterans applying based on inclusion in priority categories 1, 2, 3, 6, and 7 do not need to complete section II, but must complete the rest of the form. Veterans applying based on inclusion in priority category 4 because of their [[Page 587]] need for regular aid and attendance or by being permanently housebound need not complete section II, but must complete the rest of the form. Veterans applying based on inclusion in priority category 4 because they are catastrophically disabled need not complete section II, but must complete the rest of the form, if: they agree to pay to the United States the applicable copayment determined under 38 U.S.C. 1710(f) and 1710(g); they are a veteran of the Mexican border period or of World War I or a veteran with a 0 percent service-connected disability who is nevertheless compensated; their catastrophic disability is a disorder associated with exposure to a toxic substance or radiation, or with service in the Southwest Asia theater of operations during the Gulf War as provided in 38 U.S.C. 1710(e); or their catastrophic disability is an illness associated with service in combat in a war after the Gulf War or during a period of hostility after November 11, 1998, as provided in 38 U.S.C. 1710(e). All other veterans applying based on inclusion in priority category 4 because they are catastrophically disabled must complete the entire form. Veterans applying based on inclusion in priority category 5 must complete the entire form. VA Form 10-10EZ is set forth in paragraph (f) of this section and is available from VA medical facilities. Note to paragraph (d)(1): To remain enrolled based on inclusion in priority category 5, a veteran annually must return information to VA on a VA Form 10-10EZ as provided in paragraph (d)(4)(iii) of this section and otherwise meet the requirements for enrollment. (2) Action on application. Upon receipt of a completed VA Form 10- 10EZ, a VA network or facility director, or the Chief Network Officer, will accept a veteran as an enrollee upon determining that the veteran is in a priority category eligible to be enrolled as set forth in Sec. 17.36(c)(2). Upon determining that a veteran is not in a priority category eligible to be enrolled, the VA network or facility director, or the Chief Network Officer, will inform the applicant that the applicant is ineligible to be enrolled. (3) Automatic enrollment. Notwithstanding other provisions of this section, veterans who were notified by VA letter that they were enrolled in the VA healthcare system under the trial VA enrollment program prior to October 1, 1998, automatically will be enrolled in the VA healthcare system under this section if determined by a VA network or facility director, or the Chief Network Officer, that the veteran is in a priority category eligible to be enrolled as set forth in Sec. 17.36(c)(2). Upon determining that a veteran is not in a priority category eligible to be enrolled, the VA network or facility director, or the Chief Network Officer, will inform the veteran that the veteran is ineligible to be enrolled. (4) Disenrollment. A veteran enrolled under paragraph (d)(2) or (d)(3) of this section will be disenrolled only if: (i) The veteran submits to a VA medical center a signed document stating that the veteran no longer wishes to be enrolled; (ii) A VA network or facility director, or the Chief Network Officer, determines that the veteran is no longer in a priority category eligible to be enrolled, as set forth in Sec. 17.36(c)(2); or (iii) A VA network or facility director, or the Chief Network Officer, determines that the veteran has been enrolled based on inclusion in priority category 5; determines that the veteran was sent by mail a VA Form 10-10EZ; and determines that the veteran failed to return the completed form to the address on the return envelope within 60 days from receipt of the form. VA Form 10-10EZ is set forth in paragraph (f) of this section. (5) Notification of enrollment status. Notice of a decision by a VA network or facility director, or the Chief Network Officer, regarding enrollment status will be provided to the affected veteran by letter and will contain the reasons for the decision. The letter will include an effective date for any changes and a statement regarding appeal rights. The decision will be based on all information available to the decisionmaker, including the information contained in VA Form 10-10EZ. (e) Catastrophically disabled. For purposes of this section, catastrophically disabled means to have a permanent severely disabling injury, disorder, or disease that compromises the ability to [[Page 588]] carry out the activities of daily living to such a degree that the individual requires personal or mechanical assistance to leave home or bed or requires constant supervision to avoid physical harm to self or others. This definition is met if an individual has been found by the Chief of Staff (or equivalent clinical official) at the VA facility where the individual was examined to have a permanent condition specified in paragraph (e)(1) of this section; to meet permanently one of the conditions specified in paragraph (e)(2) of this section by a clinical evaluation of the patient's medical records that documents that the patient previously met the permanent criteria and continues to meet such criteria (permanently) or would continue to meet such criteria (permanently) without the continuation of on-going treatment; or to meet permanently one of the conditions specified in paragraph (e)(2) of this section by a current medical examination that documents that the patient meets the permanent criteria and will continue to meet such criteria (permanently) or would continue to meet such criteria (permanently) without the continuation of on-going treatment. (1) Quadriplegia and quadriparesis (ICD-9-CM Code 344.0x: 344.00, 344.01, 344.02, 344.03, 344.04, 3.44.09), paraplegia (ICD-9-CM Code 344.1), blindness (ICD-9-CM Code 369.4), persistent vegetative state (ICD-9-CM Code 780.03), or a condition resulting from two of the following procedures (ICD-9-CM Code 84.x or associated V Codes when available or Current Procedural Terminology (CPT) Codes) provided the two procedures were not on the same limb: (i) Amputation through hand (ICD-9-CM Code 84.03 or V Code V49.63 or CPT Code 25927); (ii) Disarticulation of wrist (ICD-9-CM Code 84.04 or V Code V49.64 or CPT Code 25920); (iii) Amputation through forearm (ICD-9-CM Code 84.05 or V Code V49.65 or CPT Codes 25900, 25905); (iv) Disarticulation of forearm (ICD-9-CM Code 84.05 or V Code V49.66 or CPT Codes 25900, 25905); (v) Amputation or disarticulation through elbow. (ICD-9-CM Code 84.06 or V Code V49.66 or CPT 24999); (vi) Amputation through humerus (ICD-9-CM Code 84.07 or V Code V49.66 or CPT Codes 24900, 24920); (vii) Shoulder disarticulation (ICD-9-CM Code 84.08 or V Code V49.67 or CPT Code 23920); (viii) Forequarter amputation (ICD-9-CM Code 84.09 or CPT Code 23900); (ix) Lower limb amputation not otherwise specified (ICD-9-CM Code 84.10 or V Code V49.70 or CPT Codes 27880, 27882); (x) Amputation of great toe (ICD-9-CM Code 84.11 or V Code V49.71 or CPT Codes 28810, 28820); (xi) Amputation through foot (ICD-9-CM Code 84.12 or V Code V49.73 or CPT Codes 28800, 28805); (xii) Disarticulation of ankle (ICD-9-CM Code 84.13 or V Code V49.74 or CPT 27889); (xiii) Amputation through malleoli (ICD-9-CM Code 84.14 or V Code V49.75 or CPT Code 27888); (xiv) Other amputation below knee (ICD-9-CM Code 84.15 or V Code V49.75 or CPT Codes 27880, 27882); (xv) Disarticulation of knee (ICD-9-CM Code 84.16 or V Code V49.76 or CPT Code 27598); (xvi) Above knee amputation (ICD-9-CM Code 84.17 or V Code V49.76 or CPT Code 27598); (xvii) Disarticulation of hip (ICD-9-CM Code 84.18 or V Code V49.77 or CPT Code 27295); and (xviii) Hindquarter amputation (ICD-9-CM Code 84.19 or CPT Code 27290). (2)(i) Dependent in 3 or more Activities of Daily Living (eating, dressing, bathing, toileting, transferring, incontinence of bowel and/or bladder), with at least 3 of the dependencies being permanent with a rating of 1, using the Katz scale. (ii) A score of 10 or lower using the Folstein Mini-Mental State Examination. (iii) A score of 2 or lower on at least 4 of the 13 motor items using the Functional Independence Measure. (iv) A score of 30 or lower using the Global Assessment of Functioning. (f) VA Form 10-10EZ. [insert actual photocopy of VA Form 10-10EZ] [[Page 589]] [GRAPHIC] [TIFF OMITTED] TR06OC99.000 [[Page 590]] [GRAPHIC] [TIFF OMITTED] TR06OC99.001 (The Office of Management and Budget has approved the information collection requirements in this section under control number 2900-0091.) Authority: 38 U.S.C. 101, 501, 1701, 1705, 1710, 1721, 1722 [64 FR 54212, Oct. 6, 1999, as amended at 67 FR 35039, May 17, 2002] [[Page 591]]