2020-28441. Reasonable Charges for Medical Care or Services; v4.215 Calendar Year (CY) 2021 Update

AGENCY:

Department of Veterans Affairs (VA).

ACTION:

Notice.

SUMMARY:

This VA notice updates the data for calculating what VA refers to as the Reasonable Charges collected or recovered by VA for medical care or services provided or furnished by VA to a Veteran.

DATES:

This change is effective January 1, 2021.

FOR FURTHER INFORMATION CONTACT:

Romona Greene, Office of Community Care, Revenue Operations, Payer Relations and Services, Rates and Charges (13RO1), Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420; telephone: [phone] (This is not a toll-free number).

SUPPLEMENTARY INFORMATION:

Section 17.101(a)(1) of title 38 CFR sets forth the Reasonable Charges, relating to collection or recovery by VA, under § 1729 of title 38 U.S.C., for medical care or services provided or furnished by VA to a Veteran for: a nonservice-connected disability for which the Veteran is entitled to care (or the payment of expenses for care) under a health plan contract; a nonservice-connected disability incurred incident to the Veteran's employment and covered under a worker's compensation law or plan that provides reimbursement or indemnification for such care and services; or, for a nonservice-connected disability incurred as a result of a motor vehicle accident in a state that requires automobile accident reparations insurance. Section 17.101 provides the methodologies for establishing billed amounts for several types of charges; however, this notice will only address partial hospitalization facility charges; outpatient facility charges; physician and other professional charges, including professional charges for anesthesia services and dental services; pathology and laboratory charges; observation care facility charges; ambulance and other emergency transportation charges; and charges for durable medical equipment, drugs, injectables, and other medical services, items, and supplies identified by Healthcare Common Procedure Coding System (HCPCS) Level II codes.

Section 17.101(a)(2) provides that the actual charge amounts at individual VA medical facilities are based on these methodologies and the data sources used for calculating those actual charge amounts will either be published in a notice in the Federal Register or will be posted on VA's Office of Community Care (OCC) website at: https://www.va.gov/​communitycare/​revenue_​ops/​payer_​rates.asp.

Certain charges are updated as stated in this notice and will be effective on January 1, 2021.

In cases where VA has not established charges for medical care or services provided or furnished at VA expense (by either VA or non-VA providers) under other provisions or regulations, the method for determining VA's charges is set forth at 38 CFR 17.101(a)(8).

Based on the methodologies set forth in § 17.101, this notice provides an update to charges for CY 2021 HCPCS Level II and Current Procedural Terminology codes. Charges are also being updated based on more recent versions of data sources for the following charge types: partial hospitalization facility charges; outpatient facility charges; physician and other professional charges, including professional charges for anesthesia services and dental services; pathology and laboratory charges; observation care facility charges; ambulance and other emergency transportation charges; and charges for durable medical equipment, drugs, injectables and other medical services, items, and supplies identified by HCPCS Level II codes. As of the date of this notice, the actual charge amounts at individual VA medical facilities are based on the methodologies and data sources described in § 17.101. The nationwide charges will be posted on VA's OCC website at: https://www.va.gov/​communitycare/​revenue_​ops/​payer_​rates.asp under the heading “Reasonable Charges Data Tables and identified as v4.215 Data Tables (Outpatient and Professional)”.

The list of data sources used for calculating the actual charge amounts listed above also will be posted on VA's OCC website under the heading “Reasonable Charges Data Sources and identified as Reasonable Charges v4.215 Data Sources (Outpatient and Professional) (PDF)”.

Acute inpatient facility charges and skilled nursing facility/sub-acute inpatient facility charges remain the same as set forth in the notice published in the Federal Register on September 22, 2020 (85 FR 59606).

We are also updating the list of VA medical facility locations. The list of VA medical facility locations, including the first three digits of their zip codes as well as their provider-based designation, will be posted on VA's OCC website under the heading “VA Medical Facility Locations and identified as v4.215 (Jan21)”.

Consistent with § 17.101(a)(2), the updated data and supplementary tables containing the changes described in this notice will be posted on VA's OCC website at: https://www.va.gov/​communitycare/​revenue_​ops/​payer_​rates.asp under the heading “Reasonable Charges Rules, Notices, and Federal Register and identified as v4.215 Federal Register Notice 01/01/21 (Outpatient and Professional)”. The updated data and supplementary tables containing the changes described will be effective until changed by a subsequent Federal Register notice.

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 the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Brooks D. Tucker, Assistant Secretary for Congressional and Legislative Affairs, Performing the Delegable Duties of the Chief of Staff, Department of Veterans Affairs, approved this document on December 18, 2020, for publication.

Luvenia Potts,

Regulation Development Coordinator, Office of Regulation Policy & Management, Office of the Secretary, Department of Veterans Affairs.