[Code of Federal Regulations]
[Title 38, Volume 1]
[Revised as of January 1, 2007]
From the U.S. Government Printing Office via GPO Access
[CITE: 38CFR17.36]

[Page 636-643]
 
            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 and who, if required by law to do 
so, has agreed to make any applicable copayment is eligible for VA 
hospital and outpatient 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 awarded the 
Purple Heart; 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 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

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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.
    (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) if their income 
for the previous year constitutes ``low income'' under the geographical 
income limits established by the U.S. Department of Housing and Urban 
Development for the fiscal year that ended on September 30 of the 
previous calendar year. For purposes of this paragraph, VA will 
determine the income of veterans (to include the income of their spouses 
and dependents) using the rules in Sec. Sec. 3.271, 3.272, 3.273, and 
3.276. After determining the veterans' income and the number of persons 
in the veterans' family (including only the spouse and dependent 
children), VA will compare their income with the current applicable 
``low-income'' income limit for the public housing and section 8 
programs in their area that the U.S. Department of Housing and Urban 
Development publishes pursuant to 42 U.S.C. 1437a(b)(2). If the 
veteran's income is below the applicable ``low-income'' income limits 
for the area in which the veteran resides, the veteran will be 
considered to have ``low income'' for purposes of this paragraph. To 
avoid a hardship to a veteran, VA may use the projected income for the 
current year of the veteran, spouse, and dependent children if the 
projected income is below the ``low income'' income limit referenced 
above. This category is further prioritized into the following 
subcategories:
    (i) Noncompensable zero percent service-connected veterans who are 
in an enrolled status on a specified date announced in a Federal 
Register document promulgated under paragraph (c) of this section and 
who subsequently do not request disenrollment;
    (ii) Nonservice-connected veterans who are in an enrolled status on 
a specified date announced in a Federal Register document promulgated 
under paragraph (c) of this section and who subsequently do not request 
disenrollment;
    (iii) Noncompensable zero percent service-connected veterans not 
included in paragraph (b)(7)(i) of this section; and
    (iv) Nonservice-connected veterans not included in paragraph 
(b)(7)(ii) of this section.
    (8) Veterans not included in priority category 4 or 7, who are 
eligible for care only if they 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 who are 
in an enrolled status on a specified date announced in a Federal 
Register document promulgated under paragraph (c) of this section and 
who subsequently do not request disenrollment;
    (ii) Nonservice-connected veterans who are in an enrolled status on 
a specified date announced in a Federal Register document promulgated 
under paragraph (c) of this section and who subsequently do not request 
disenrollment;
    (iii) Noncompensable zero percent service-connected veterans not 
included in paragraph (b)(8)(i) of this section; and
    (iv) Nonservice-connected veterans not included in paragraph 
(b)(8)(ii) of this section.
    (c) Federal Register notification of eligible enrollees. (1) It is 
anticipated

[[Page 638]]

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) beginning January 17, 2003 
except that those veterans in priority category 8 who were not in an 
enrolled status on January 17, 2003 or who requested disenrollment after 
that date, are not eligible to be enrolled.
    (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 8 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 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. Veterans applying 
based on inclusion in priority category 7 must complete the entire form 
except for section IIE. VA form 10-10EZ is set forth in paragraph (f) of 
this section and is available from VA medical facilities.
    (2) Action on application. Upon receipt of a completed VA Form 10-
10EZ, a VA network or facility director, or the Deputy Under Secretary 
for Health for Operations and Management or Chief, Health Administration 
Service or equivalent official at a VA medical facility, or Director, 
Health Eligibility Center, 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 Deputy Under Secretary for Health 
for Operations and Management or Chief, Health Administration Service or 
equivalent official at a VA medical facility, or Director, Health 
Eligibility Center, will inform the applicant that the applicant is 
ineligible to be enrolled.

[[Page 639]]

    (3) Placement in enrollment categories. (i) Veterans will be placed 
in priority categories whether or not veterans in that category are 
eligible to be enrolled.
    (ii) A veteran will be placed in the highest priority category or 
categories for which the veteran qualifies.
    (iii) A veteran may be placed in only one priority category, except 
that a veteran placed in priority category 6 based on a specified 
disorder or illness will also be placed in priority category 7 or 
priority category 8, as applicable, if the veteran has previously agreed 
to pay the applicable copayment, for all matters not covered by priority 
category 6.
    (iv) A veteran who had been enrolled based on inclusion in priority 
category 5 and became no longer eligible for inclusion in priority 
category 5 due to failure to submit to VA a current VA Form 10-10EZ will 
be changed automatically to enrollment based on inclusion in priority 
category 6 or 8 (or more than one of these categories if the previous 
principle applies), as applicable, and be considered continuously 
enrolled. To meet the criteria for priority category 5, a veteran must 
be eligible for priority category 5 based on the information submitted 
to VA in a current VA Form 10-10EZ. To be current, after VA has sent a 
form 10-10EZ to the veteran at the veteran's last known address, the 
veteran must return the completed form (including signature) to the 
address on the return envelope within 60 days from the date VA sent the 
form to the veteran.
    (v) Veterans will be disenrolled, and reenrolled, in the order of 
the priority categories listed with veterans in priority category 1 
being the last to be disenrolled and the first to be reenrolled. 
Similarly, within priority categories 7 and 8, veterans will be 
disenrolled, and reenrolled, in the order of the priority subcategories 
listed with veterans in subcategory (i) being the last to be disenrolled 
and first to be reenrolled.
    (4) 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 Deputy Under Secretary for Health for Operations and 
Management or Chief, Health Administration Service or equivalent 
official at a VA medical facility, or Director, Health Eligibility 
Center, 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 Deputy Under Secretary for Health 
for Operations and Management or Chief, Health Administration Service or 
equivalent official at a VA medical facility, or Director, Health 
Eligibility Center, will inform the veteran that the veteran is 
ineligible to be enrolled.
    (5) Disenrollment. A veteran enrolled in the VA health care system 
under paragraph (d)(2) or (d)(4) of this section will be disenrolled 
only if:
    (i) The veteran submits to a VA medical center or the VA Health 
Eligibility Center, 1644 Tullie Circle, Atlanta, Georgia 30329, a signed 
document stating that the veteran no longer wishes to be enrolled; or
    (ii) A VA network or facility director, or the Deputy Under 
Secretary for Health for Operations and Management or Chief, Health 
Administration Service or equivalent official at a VA medical facility, 
or Director, Health Eligibility Center, 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 Deputy Under 
Secretary for Health for Operations and Management or Chief, Health 
Administration Service or equivalent official at a VA medical facility, 
or Director, Health Eligibility Center, determines that the veteran has 
been enrolled based on inclusion in priority category 5 or priority 
category 7; 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.

[[Page 640]]

    (6) Notification of enrollment status. Notice of a decision by a VA 
network or facility director, or the Deputy Under Secretary for Health 
for Operations and Management or Chief, Health Administration Service or 
equivalent official at a VA medical facility, or Director, Health 
Eligibility Center, 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 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

[[Page 641]]

    (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.

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[GRAPHIC] [TIFF OMITTED] TR06OC99.000


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[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, 1521, 1701, 1705, 1710, 1721, 1722)

[64 FR 54212, Oct. 6, 1999, as amended at 67 FR 35039, May 17, 2002; 67 
FR 62887, Oct. 9, 2002; 68 FR 2672, Jan. 17, 2003]

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