83 FR 701 - Notice of Request for Information on the Department of Veterans Affairs Program of Comprehensive Assistance for Family Caregivers (PCAFC)

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 83, Issue 4 (January 5, 2018)

The Department of Veterans Affairs (VA) is requesting information regarding its Program of Comprehensive Assistance for Family Caregivers (PCAFC). Through PCAFC, VA provides certain medical, travel, training, and stipend benefits to designated family caregivers of eligible veterans and servicemembers who were seriously injured in the line of duty on or after September 11, 2001. This notice requests information and comments from interested parties to help inform PCAFC of any changes needed to increase consistency across the program, as well as ensure it supports those family caregivers of veterans servicemembers most in need.

[Federal Register Volume 83, Number 4 (Friday, January 5, 2018)]
[Notices]
[Pages 701-703]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2018-00004]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs Program of Comprehensive Assistance for Family Caregivers 
(PCAFC)

AGENCY: Department of Veterans Affairs.

ACTION: Request for information.

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SUMMARY: The Department of Veterans Affairs (VA) is requesting 
information regarding its Program of Comprehensive Assistance for 
Family Caregivers (PCAFC). Through PCAFC, VA provides certain medical, 
travel, training, and stipend benefits to designated family caregivers 
of eligible veterans and servicemembers who were seriously injured in 
the line of duty on or after September 11, 2001. This notice requests 
information and comments from interested parties to help inform PCAFC 
of any changes needed to increase consistency across the program, as 
well as ensure it supports those family caregivers of veterans 
servicemembers most in need.

DATES: Comments in response to this request for information must be 
received by VA on or before February 5, 2018.

ADDRESSES: Written comments may be submitted through http://www.Regulations.gov; by mail or hand delivery to the Director, Office 
of Regulation Policy and Management (00REG), Department of Veterans 
Affairs, 810 Vermont Avenue NW, Room 1068, Washington, DC 20420; or by 
fax to (202) 273-9026. Comments should indicate that they are submitted 
in response to ``Notice of Request for Information on the Department of 
Veterans Affairs Program of Comprehensive Assistance for Family 
Caregivers (PCAFC)''. Copies of comments received will be available for 
public inspection in the Office of Regulation Policy and Management 
(00REG), Department of Veterans Affairs, 810 Vermont Ave. NW, Room 
1063B, Washington, DC 20420, between the hours of 8:00 a.m. and 4:30 
p.m., Monday through Friday (except Federal holidays). Please call 
(202) 461-4902 (this is not a toll-free number) for an appointment. 
During the comment period, comments may also be viewed online through 
the Federal Docket Management System at www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Margaret Kabat, National Director, 
Caregiver Support Program, 10P4C, Veterans Health Administration, 
Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 
20420, 202-461-6780 (this is not a toll free number).

SUPPLEMENTARY INFORMATION: The Program of Comprehensive Assistance for 
Family Caregivers (PCAFC) was established by Title I of Public Law 111-
163, Caregivers and Veterans Omnibus Health Services Act of 2010, and 
is codified in section 1720G(a) of title 38, United States Code 
(U.S.C.). VA has been administering PCAFC continuously since May 5, 
2011 and has implemented this program through its regulations in part 
71 of title 38, Code of Federal Regulations (CFR). The purpose of PCAFC 
is to support family caregivers of eligible veterans (as defined in 38 
U.S.C. 1720G(a)(2) and 38 CFR 71.20 to include certain servicemembers) 
through the provision of caregiver benefits, including training, 
respite care, counseling, technical support, beneficiary travel (in 
certain circumstances), a monthly stipend payment, and access to health 
care (if qualified) through the Civilian Health and Medical Program of 
the Department of Veterans Affairs (CHAMPVA). 38 U.S.C. 1720G(a)(3), 38 
CFR 71.40.
    For purposes of this notice hereinafter, the term ``veteran'' 
refers to veterans and servicemembers who apply for or participate in 
the Program of Comprehensive Assistance for Family Caregivers.
    We are issuing this notice in order to solicit input on several 
components of the program, as further explained below. This notice and 
request for information serves as a means for VA to consult with key 
stakeholders on whether and how PCAFC should be modified to provide the 
highest quality care and support to veterans and their family 
caregivers in a consistent manner. We will use the information to 
inform any updates to this program and its implementing regulations. To 
the extent that there are any comments related to, or which would 
require changing, the relevant statutory authorities, those comments 
are outside the scope of this notice, as those would require 
Congressional action. The intent of this notice is for VA to garner 
input from the public on whether and how to change its regulations 
under the current statute.
    This notice and request for information has a comment period of 45 
days, during which individuals, groups, and entities may reply to the 
questions presented below. VA believes that 45 days is sufficient to 
provide comments, as the individuals, groups, and entities interested 
in this program likely have information and opinions readily available 
or can quickly compile and submit such information. Commenters are 
encouraged to provide complete but concise responses to the questions 
outlined below. Please note that VA will not respond to comments or 
questions regarding policy plans, decisions, or issues with regard to 
this notice. VA may choose to contact individual commenters, and such 
communications would serve to further clarify their written comments.
    In order to improve PCAFC, we are seeking information on the 
following topics and issues:

[[Page 702]]

Initial and Ongoing Eligibility of Veterans and Servicemembers

    In order to be eligible for PCAFC under the statute, the individual 
must be a veteran or a servicemember undergoing medical discharge from 
the Armed Forces and must have a serious injury (including traumatic 
brain injury, psychological trauma, or other mental disorder) incurred 
or aggravated in the line of duty in the active military, naval, or air 
service on or after September 11, 2001. 38 U.S.C. 1720G(a)(2)(A)-(B), 
38 CFR 71.20(a)-(b). We have defined ``serious injury'' as ``any 
injury, including traumatic brain injury, psychological trauma, or 
other mental disorder, incurred or aggravated in the line of duty in 
the active military, naval, or air service on or after September 11, 
2001, that renders the veteran or servicemember in need of personal 
care services.'' 38 CFR 71.15. We have interpreted 38 U.S.C. 1720G to 
require this causal relationship between the need for personal care 
services and the serious injury. 76 FR 26150.
    Additionally, 38 U.S.C. 1720G requires that eligibility be premised 
on an individual's need for personal care services because of (1) an 
inability to perform one or more activities of daily living, (2) a need 
for supervision or protection based on symptoms or residuals of 
neurological or other impairment or injury, or (3) such other matters 
as the Secretary considers appropriate. 38 U.S.C. 1720G(a)(2)(C)(i)-
(iii). This requirement is set forth in 38 CFR 71.20(c), in which we 
require that the serious injury renders the veteran in need of personal 
care services for a minimum period of six continuous months based on 
specified criteria. Otherwise, the criteria under Sec.  71.20(c) do not 
distinguish between, or require, any specific degree of need for 
assistance (e.g., in frequency, complexity, or scope).
    In order to be eligible for the program, we also require that a 
clinical determination be made that it is in the best interest of the 
individual to participate in the program. 38 CFR 71.20(d). This 
determination currently requires the clinician to consider whether 
participation in the program significantly enhances the individual's 
ability to live safely in a home setting, supports the individual's 
potential progress in rehabilitation, if such potential exists, and 
creates an environment that supports the health and well-being of the 
individual. 38 CFR 71.15. VA has found variability in how these three 
considerations are applied by clinicians assessing whether 
participation in PCAFC is in a veteran's best interest.
    Once a veteran has been determined to be eligible for the program 
and a family caregiver has been approved and designated, the veteran's 
well-being is monitored by VA no less often than every 90 days, unless 
otherwise clinically indicated. 38 CFR 71.40(b)(2). Currently, there is 
no regulatory requirement to reassess eligibility. If, however, the 
veteran's level of functioning improves, lessening the need for 
assistance of a family caregiver, VA may determine that the veteran no 
longer meets the eligibility criteria for PCAFC. Because approval and 
designation of a family caregiver is conditioned on the eligibility 
criteria being met, in the instance that a veteran is determined to be 
ineligible for the program, VA will revoke the family caregiver's 
designation, and the caregiver benefits will cease. 38 CFR 71.25(f), 
71.45(c).

Continuation of Benefits After Revocation

    Under PCAFC, caregiver benefits may continue for a period of time 
after revocation of the family caregiver's designation in limited 
situations. For example, under Sec.  71.45(b)(4), caregiver benefits 
continue for 30 days after the date of revocation initiated by the 
veteran or his or her surrogate, subject to certain exceptions. 
Additionally, under Sec.  71.45(c), caregiver benefits continue for 90 
days after revocation initiated by VA, subject to certain exceptions. 
We provide these extended periods of benefits to allow a family 
caregiver, who did not request the revocation, a transition period 
before benefits are discontinued (particularly, for certain benefits 
like health care). We believe these extended benefits periods are 
consistent with the purpose of 38 U.S.C. 1720G and represent an 
appropriate and compassionate way to interpret and enforce the law. 76 
FR 26155-26156. The 30- and 90-day periods set forth in Sec.  
71.45(b)(4) and (c), respectively, are the only instances in which the 
regulations provide for extended caregiver benefits beyond the date of 
revocation.
    While a family caregiver can voluntarily leave the program at any 
time, when a family caregiver initiates revocation, his or her 
caregiver benefits terminate at the present or future date of 
revocation as specified by the family caregiver. 38 CFR 71.45(a). While 
a family caregiver is not required to provide a basis for revocation, a 
family caregiver's voluntary revocation may involve instances when the 
family caregiver leaves because of a situation involving actions of the 
veteran. VA is seeking input on whether there are any circumstances in 
which a family caregiver's benefits should be extended beyond the 
revocation date when the family caregiver makes the decision to be 
removed as the family caregiver as well as the length of such an 
extension.

Determination of Stipend Payment Methodology for Primary Family 
Caregivers

    Section 1720G(a)(3)(A)(ii)(V) of title 38, U.S.C., requires VA to 
provide a monthly stipend to primary family caregivers of eligible 
veterans. Under the statute, VA is required to base the stipend amount 
on the amount and degree of personal care services provided; to the 
extent practicable, ensure that the amount is not less than the monthly 
amount a commercial home health care entity would pay an individual in 
the geographic area of the veteran to provide equivalent personal care 
services; and in the instance that the geographic area does not have a 
commercial home health entity, VA must take into consideration the 
costs of commercial providers of personal care services in those 
geographic areas with similar costs of living. See 38 U.S.C. 
1720G(a)(3)(C).
    Under the implementing regulations, VA relies on the U.S. 
Department of Labor's Bureau of Labor Statistics (BLS) hourly wage rate 
for home health aides at the 75th percentile in the veteran's 
geographic area of residence, which is multiplied by the Consumer Price 
Index for All Urban Consumers. 38 CFR 71.15, 71.40(c)(4). We have used 
the BLS wage rate to meet the intent of the statute to ensure that 
primary family caregivers are not paid less than home health aides in 
the applicable geographic area. 76 FR 26154. These rates, however, 
fluctuate annually in conjunction with changing geographical area 
designations, which can result in alterations to stipend amounts.
    VA also calculates the stipend amount based on a veteran's assigned 
tier level which is determined by a clinical assessment of functional 
needs, as further detailed in 38 CFR 71.40(c)(4). Specifically, VA 
determines the veteran's level of dependency based on the degree to 
which he or she is unable to perform one or more activities of daily 
living or the degree to which he or she is in need of supervision or 
protection based on symptoms or residuals of neurological or other 
impairment or injury. VA conducts a clinical assessment, which is 
scored and summed. Based on the sum of all ratings, the veteran is 
assigned a tier level. Each tier level is assigned a

[[Page 703]]

number of hours, up to forty hours per week. The primary family 
caregiver receives a stipend based on the assigned tier level. 
Currently, this is a determination based upon the needs of the veteran, 
not the family caregiver, and it distinguishes among three different 
tiers.

Request for Information

    Through this notice, we are soliciting information on PCAFC. We ask 
respondents to address the following questions, where possible, in the 
context of the discussion in this document. Commenters do not need to 
address every question and should focus on those that relate to their 
expertise or perspectives. To the extent possible, please clearly 
indicate which question(s) you address in your response. As previously 
mentioned, responses to this request will inform our updates to PCAFC. 
Accordingly, we request comments on the following:
    1. Should VA change how ``serious injury'' is defined for the 
purposes of eligibility?
    a. Should the severity of injury be considered in determining 
eligibility to ensure VA is supporting family caregivers of Veterans 
most in need? If so, how should the level of severity be determined?
    b. How should VA define veterans who are most in need?
    c. Should eligibility be limited to only those veterans who without 
a family caregiver providing personal care services would otherwise 
require institutionalization? If so, how should this be determined?
    2. One of the bases upon which a veteran can be determined to need 
personal care services is his or her need for supervision or protection 
based on symptoms or residuals of neurological or other impairment or 
injury.
    a. What should be the criteria to assess a veteran's need for 
supervision or protection?
    b. What standardized tools should be used to assess a veteran's 
need for supervision or protection because of a mental health 
condition?
    3. To be eligible for the program, participation must be determined 
to be in the ``best interest'' of the veteran. How should ``best 
interest'' be defined?
    a. How can VA improve consistency in ``best interest'' 
determinations for participation in the program?
    b. Are there any conditions under which participation would not be 
in a veteran's best interest?
    4. Once approved for PCAFC, should the veteran's eligibility be 
reassessed at specific time intervals or based on certain clinical 
indicators?
    a. If so, what intervals and/or what clinical indicators should be 
used?
    b. Should reassessments be standard for every participant? Are 
there conditions under which continued eligibility should be presumed 
and a reassessment not needed? If so, what would these conditions be?
    5. When VA determines that a veteran or family caregiver is no 
longer eligible for PCAFC or the family caregiver or veteran no longer 
wishes to participate in PCAFC, the family caregiver's designation is 
``revoked''. The term ``revok[ed]'' is used in the statute (38 U.S.C. 
1720G(a)(9)(C)(ii)(II)); however, stakeholders have expressed concerns 
that this term is not supportive of participants. What terminology 
should VA use in reference to those participants who are determined to 
be no longer eligible for the program?
    a. Should VA use such language as removal, discharge, or graduate 
in reference to participants who become ineligible for the program?
    6. Should the timeframes for continuation of benefits for family 
caregivers who are revoked from the Program be modified?
    a. If so, how?
    b. Under what circumstances should family caregiver benefits be 
continued after revocation? For example, should VA continue providing 
benefits to a family caregiver who requests revocation due to an unsafe 
environment created by a veteran, such as an instance involving 
intimate partner violence committed by a veteran? How long should the 
benefits be continued under such circumstances?
    7. VA's methodology of stipend calculations using the U.S. 
Department of Labor's Bureau of Labor Statistics (BLS) wage rates is 
complex and creates variability in stipend amounts annually across 
localities. How should VA calculate stipend rates?
    a. What other standards or rates should VA consider using to 
calculate stipends?
    b. Should VA use one BLS rate per state, i.e., one rate that is 
applicable to all veterans residing in a particular state?
    c. Should VA have one stipend amount for all primary family 
caregivers?
    8. A veteran is assigned a stipend tier based on the amount and 
degree of personal care services provided. How should VA assess and 
determine the amount and degree of personal care services provided to 
the veteran by the family caregiver?
    a. How should ``degree of'' need be determined, for both physical 
needs and those related to the need for supervision and protection?
    b. Should ``degree of'' need be based on either physical needs or 
needs related to psychological disorder? Or should all factors be 
considered together?
    c. Should the three tier system be changed? If so, how should it be 
changed?

Paperwork Reduction Act

    This request for information constitutes a general solicitation of 
public comments as stated in the implementing regulations of the 
Paperwork Reduction Act of 1995 at 5 CFR 1320.3(h)(4). Therefore, this 
request for information does not impose information collection 
requirements (i.e., reporting, recordkeeping or third-party disclosure 
requirements). Consequently, there is no need for review by the Office 
of Management and Budget under the authority of the Paperwork Reduction 
Act of 1995 (44 U.S.C. 3501 et seq.).

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of Federal Register for publication electronically as an 
official document of the Department of Veterans Affairs. Gina S. 
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs, 
approved this document on December 6, 2017, for publication.

    Dated: December 6, 2017.
Jeffrey Martin,
Impact Analyst, Office of Regulation Policy & Management, Office of the 
Secretary, Department of Veterans Affairs.
[FR Doc. 2018-00004 Filed 1-4-18; 8:45 am]
 BILLING CODE 8320-01-P