DOD and VA
Systematic Data Sharing Would Help Expedite Servicemembers' Transition to VA Services Gao ID: GAO-05-722T May 19, 2005Since the onset of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), the Department of Defense (DOD) reported that more than 12,000 servicemembers have been injured in combat. While many return to active duty, others with more serious injuries are likely to be discharged from the military. To ensure the continuity of medical care and access to all other Department of Veterans Affairs' (VA) benefits, such as vocational rehabilitation, VA formed its Seamless Transition Task Force. In January 2005, GAO reported that VA had given high priority to OEF/OIF servicemembers, but faced challenges in identifying, locating, and following up with seriously injured servicemembers. GAO recommended that VA and DOD reach an agreement for VA to obtain systematic data from DOD, and the departments concurred. However, DOD raised privacy concerns. GAO was asked to review VA's efforts to expedite vocational rehabilitation services to seriously injured servicemembers and to determine the status of an agreement between DOD and VA to share health data. GAO relied on its prior work; interviewed VA and DOD officials; and reviewed the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA Privacy Rule, which govern the sharing of individually identifiable health data.
While VA has taken steps to expedite services to seriously injured servicemembers, VA does not have systematic data from DOD on seriously injured servicemembers who may need VA vocational rehabilitation and other benefits. As a result, VA has had to rely on its regional offices to develop informal data sharing arrangements with local military treatment facility (MTF) staff to identify servicemembers who may need vocational rehabilitation services. However, VA staff have no official data source from DOD from which to confirm the completeness and reliability of the data they obtain. Furthermore, they cannot provide reasonable assurance that some seriously injured servicemembers who may have benefited from vocational rehabilitation services have not been overlooked. Although several VA headquarters officials and regional office staff GAO interviewed said that systematic data from DOD would provide them with a way to reliably identify and follow up with seriously injured servicemembers, DOD and VA have not developed a data sharing agreement. Additionally, VA officials said these data would help VA plan for projected increases in the need for services for newly returning OEF/OIF servicemembers. VA has requested that DOD provide systematic data on seriously injured servicemembers who may need vocational rehabilitation. DOD and VA have been working on a data sharing agreement for over 2 years, but have not reached an agreement. DOD and VA differ in their understanding of HIPAA Privacy Rule provisions that govern the sharing of individually identifiable health data for servicemembers currently receiving treatment at MTFs, and the extent to which the Privacy Rule would permit that exchange. DOD's and VA's inability to resolve these differences has impeded coming to an agreement on exchanging seriously injured servicemembers' individually identifiable health data. Despite being unable to agree on an exchange of individually identifiable health data, DOD and VA are reviewing a draft memorandum of understanding, which the departments believe will move them closer to a data sharing agreement. However, GAO found that the draft memorandum restates many of the legal authorities contained in the Privacy Rule for the use and disclosure of individually identifiable health data. As a result, even if the memorandum of understanding is finalized, DOD and VA will still have to agree on what types of individually identifiable health data can be exchanged and when the data can be shared. DOD and VA generally agreed with GAO's findings.
GAO-05-722T, DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers' Transition to VA Services
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Testimony:
Before the Subcommittee on Oversight and Investigations, Committee on
Veterans' Affairs, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 10:00 a.m. EDT:
Thursday, May 19, 2005:
DOD and VA:
Systematic Data Sharing Would Help Expedite Servicemembers' Transition
to VA Services:
Statement of Cynthia A. Bascetta:
Director, Health Care--Veterans' Health and Benefits Issues:
GAO-05-722T:
GAO Highlights:
Highlights of GAO-05-722T, a testimony before the Subcommittee on
Oversight and Investigations, Committee on Veterans‘ Affairs, House of
Representatives:
Why GAO Did This Study:
Since the onset of Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF), the Department of Defense (DOD) reported that more than
12,000 servicemembers have been injured in combat. While many return to
active duty, others with more serious injuries are likely to be
discharged from the military. To ensure the continuity of medical care
and access to all other Department of Veterans Affairs‘ (VA) benefits,
such as vocational rehabilitation, VA formed its Seamless Transition
Task Force.
In January 2005, GAO reported that VA had given high priority to
OEF/OIF servicemembers, but faced challenges in identifying, locating,
and following up with seriously injured servicemembers. GAO recommended
that VA and DOD reach an agreement for VA to obtain systematic data
from DOD, and the departments concurred. However, DOD raised privacy
concerns.
GAO was asked to review VA‘s efforts to expedite vocational
rehabilitation services to seriously injured servicemembers and to
determine the status of an agreement between DOD and VA to share health
data. GAO relied on its prior work; interviewed VA and DOD officials;
and reviewed the Health Insurance Portability and Accountability Act of
1996 (HIPAA) and the HIPAA Privacy Rule, which govern the sharing of
individually identifiable health data.
What GAO Found:
While VA has taken steps to expedite services to seriously injured
servicemembers, VA does not have systematic data from DOD on seriously
injured servicemembers who may need VA vocational rehabilitation and
other benefits. As a result, VA has had to rely on its regional offices
to develop informal data sharing arrangements with local military
treatment facility (MTF) staff to identify servicemembers who may need
vocational rehabilitation services. However, VA staff have no official
data source from DOD from which to confirm the completeness and
reliability of the data they obtain. Furthermore, they cannot provide
reasonable assurance that some seriously injured servicemembers who may
have benefited from vocational rehabilitation services have not been
overlooked. Although several VA headquarters officials and regional
office staff GAO interviewed said that systematic data from DOD would
provide them with a way to reliably identify and follow up with
seriously injured servicemembers, DOD and VA have not developed a data
sharing agreement. Additionally, VA officials said these data would
help VA plan for projected increases in the need for services for newly
returning OEF/OIF servicemembers. VA has requested that DOD provide
systematic data on seriously injured servicemembers who may need
vocational rehabilitation.
DOD and VA have been working on a data sharing agreement for over
2 years, but have not reached an agreement. DOD and VA differ in their
understanding of HIPAA Privacy Rule provisions that govern the sharing
of individually identifiable health data for servicemembers currently
receiving treatment at MTFs, and the extent to which the Privacy Rule
would permit that exchange. DOD‘s and VA‘s inability to resolve these
differences has impeded coming to an agreement on exchanging seriously
injured servicemembers‘ individually identifiable health data. Despite
being unable to agree on an exchange of individually identifiable
health data, DOD and VA are reviewing a draft memorandum of
understanding, which the departments believe will move them closer to a
data sharing agreement. However, GAO found that the draft memorandum
restates many of the legal authorities contained in the Privacy Rule
for the use and disclosure of individually identifiable health data. As
a result, even if the memorandum of understanding is finalized, DOD and
VA will still have to agree on what types of individually identifiable
health data can be exchanged and when the data can be shared. DOD and
VA generally agreed with GAO‘s findings.
www.gao.gov/cgi-bin/getrpt?GAO-05-722T.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia A. Bascetta at
(202) 512-7101.
[End of section]
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me to share our perspectives on seriously
injured servicemembers who could benefit from services offered by the
Department of Veterans Affairs (VA), such as vocational rehabilitation,
disability compensation, and health care, as they transition from
servicemember to veteran status. Since the onset of Operation Enduring
Freedom (OEF) in October 2001 and Operation Iraqi Freedom (OIF) in
March 2003, the Department of Defense (DOD) has reported that more than
12,000 servicemembers have been injured in combat. While many return to
active duty after they are treated, others who are more seriously
injured are likely to be discharged from their military obligations and
return to civilian life with disabilities. To ensure the continuity of
medical care as a first priority as well as to coordinate efforts to
ensure access to all other VA benefits, such as vocational
rehabilitation, VA formed its Seamless Transition Task Force in August
2003.
In January 2005, we reported that while VA has given high priority to
providing services to OEF/OIF servicemembers, it was challenged in its
efforts to identify, locate, and follow up with seriously injured
servicemembers.[Footnote 1] One key problem has been the lack of
systematic data from DOD about who is seriously injured, the nature of
their injuries, and where the servicemembers received treatment. As DOD
and VA have worked toward a seamless transition, DOD raised concerns
about privacy issues and the sharing of individually identifiable
health data. We recommended that VA and DOD collaborate to reach an
agreement for VA to have access to DOD data for seriously injured
servicemembers that both departments agree are needed to promote
recovery and return to work and both departments concurred.
You asked us to testify on VA's and DOD's efforts to provide a seamless
transition for seriously injured OEF/OIF servicemembers. Specifically,
we (1) reviewed VA's efforts to expedite vocational rehabilitation
services to seriously injured servicemembers and (2) determined the
status of an agreement between DOD and VA to share health data. My
comments today highlight the findings of our earlier work on VA's
vocational rehabilitation services for seriously injured servicemembers
returning from OEF/OIF and our ongoing work on DOD's and VA's data
sharing agreement.[Footnote 2]
Our January 2005 report on VA's efforts to expedite vocational
rehabilitation services to OEF/OIF servicemembers was based on
interviews with officials at VA headquarters and at 12 of VA's 57
regional offices. Five of the 12 regional offices are located near the
five major Army military treatment facilities (MTF) treating the
majority of seriously injured OEF/OIF servicemembers during our review.
We visited Walter Reed Army Medical Center where most seriously injured
Army servicemembers are initially treated. To do our work on the status
of DOD's and VA's data sharing agreement, we reviewed a draft
memorandum of understanding for the sharing of data between DOD and VA,
pertinent provisions of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and the HIPAA Privacy Rule, which
govern the sharing of individually identifiable health data.[Footnote
3] We also spoke with officials responsible for the implementation of
the Privacy Rule at DOD and VA. We discussed the information contained
in this statement with DOD and VA officials who agreed with our
findings. We did our work from March through May 2005 in accordance
with generally accepted government auditing standards.
In summary, while VA has taken steps to expedite services to seriously
injured OEF/OIF servicemembers, VA does not have systematic data from
DOD on those servicemembers who may need vocational rehabilitation and
other benefits from VA. As a result, VA has had to rely on its regional
offices to develop informal data sharing arrangements with local MTF
staff to identify servicemembers who may need vocational rehabilitation
services. However, VA staff have no official data source from DOD from
which to confirm the completeness and reliability of the data obtained
through these informal, local arrangements. Furthermore, VA staff
cannot provide reasonable assurance that some seriously injured
servicemembers who may have benefited from early intervention by a
vocational rehabilitation counselor have not been overlooked.
Unresolved issues between DOD and VA continue to delay the systematic
sharing of data. To obtain systematic data from DOD on seriously
injured OEF/OIF servicemembers who may need VA services, DOD and VA
have been working on an agreement to exchange servicemembers' health
data for over 2 years. DOD and VA differ in their understanding of
HIPAA Privacy Rule provisions that govern the sharing of individually
identifiable health data for seriously injured servicemembers receiving
treatment in MTFs, and the extent to which the Privacy Rule would
permit that exchange. DOD's and VA's inability to resolve these
differences has impeded coming to an agreement on exchanging seriously
injured servicemembers' individually identifiable health data. We
continue to believe that an agreement between DOD and VA to share
health data would expedite the delivery of VA services to OEF/OIF
servicemembers, as well as help ensure a seamless transition.
Background:
Servicemembers deployed to Afghanistan and Iraq are surviving injuries
that would have been fatal in past conflicts due, in part, to advances
in battlefield medicine and protective equipment. However, the severity
of their injuries can result in a lengthy transition from injured
servicemember to veteran. Initially, most seriously injured
servicemembers are brought to Landstuhl Regional Medical Center in
Germany for treatment. From there, they are usually transported to
major MTFs in the United States. According to DOD officials, once
stabilized and discharged from MTFs, servicemembers usually relocate
closer to their homes or military bases and are treated as outpatients.
At this point, the military generally begins to assess whether the
servicemember will be able to remain in the military, a process that
could take months to complete.
Faced with the need to provide benefits and services to a new
generation of veterans with disabilities, VA formed an internal task
force--the Seamless Transition Task Force--in August 2003 to develop
and implement policies to improve the transition of injured
servicemembers back to civilian life. Although the task force's initial
priority was to ensure the continuity of medical care for injured
servicemembers as they transitioned from military to VA health care, it
also coordinated efforts to ensure access to all other VA benefits,
including vocational rehabilitation.
DOD has also supported transition assistance in various ways. For
example, the VA/DOD Joint Executive Committee was established in
February 2002 to promote collaboration between the two departments,
including resolving obstacles to information sharing. The committee is
chaired by the Deputy Secretary of Veterans Affairs and the Under
Secretary of Defense for Personnel and Readiness. In addition, the
Army--in cooperation with VA--established the Disabled Soldier Support
System in April 2004 as an advocacy group and information clearinghouse
to clarify the services available to disabled soldiers as they
transition to civilian life. In addition, DOD participated at times on
VA's Seamless Transition Task Force.
Separation from the military and return to civilian life often entail
the exchange of individually identifiable health data between DOD and
VA. The exchange of these data must comply with the HIPAA Privacy Rule,
which became effective April 14, 2001.[Footnote 4] The Privacy Rule
permits VA and DOD to share servicemembers' health data under certain
circumstances.
VA Has Taken Steps to Expedite Vocational Rehabilitation Services, but
Lack of Systematic Data from DOD Poses a Challenge:
VA has given priority consideration and assistance to seriously injured
servicemembers returning from Afghanistan and Iraq. In a September 2003
letter, VA asked its regional offices to coordinate with staff at MTFs
in their areas to ascertain the identities, medical conditions, and
military status of the seriously injured OEF/OIF servicemembers. VA
specifically instructed regional offices to focus on servicemembers
whose disabilities were definitely or likely to result in military
separation. Minimally, this included servicemembers with injuries that
had been classified as "very serious," "serious," or in a "special
category."[Footnote 5] In this letter, VA instructed its regional
offices to assign a case manager to each seriously injured
servicemember who applied for disability compensation. In addition, VA
noted the particular importance of early intervention for those who
were seriously injured and emphasized that seriously injured
servicemembers applying for vocational rehabilitation should receive
the fastest possible service. Moreover, VA reminded vocational
rehabilitation staff that they can initiate evaluation and counseling
and, in some cases, authorize training before a servicemember was
discharged.[Footnote 6]
Since most seriously injured servicemembers are initially treated at
major MTFs, VA has detailed staff to these facilities to identify and
educate these servicemembers about VA services.[Footnote 7] These staff
include VA social workers and disability compensation benefits
counselors. At Walter Reed Army Medical Center, where the largest
number of seriously injured servicemembers has been treated, VA's
Washington, D.C. regional office has since 2001 also provided a
vocational rehabilitation counselor to work with hospitalized patients,
specifically to offer and provide vocational counseling and evaluation.
The counselor reported attempting to contact all patients within 48
hours of their arrival and visited them routinely thereafter to
establish rapport. Her primary mission is to work with servicemembers
who will need to prepare for civilian employment, although she told us
that her early intervention efforts could also help servicemembers who
are able to remain in the military.
Staff at another regional office noted that they also advocate early
intervention. These staff said that they try to contact servicemembers
as soon as possible to establish rapport and provide vocational
rehabilitation program information even before the servicemembers are
physically ready to begin vocational rehabilitation. We previously
reported on the importance of early intervention to maximize the work
potential of individuals with disabilities. We reported, for example,
that rehabilitation offered as close as possible to the onset of
disabling impairments has the greatest likelihood of success.[Footnote
8]
Despite efforts by VA's regional offices to identify and obtain medical
information on seriously injured OEF/OIF servicemembers, lack of
systematic data from DOD poses a challenge. Although VA requested in
the spring of 2004 that DOD provide on a systematic basis personal
identifying data, medical data, and DOD's injury classification for
seriously injured servicemembers, DOD and VA have not developed a data
sharing agreement. In the absence of a data sharing agreement with DOD,
VA cannot reliably identify all seriously injured servicemembers or
know with certainty when they are medically stabilized, when they may
be undergoing evaluation for a medical discharge, or when they are
discharged from the military. As a result, VA cannot provide reasonable
assurance that some seriously injured servicemembers who may benefit
from vocational rehabilitation services have not been overlooked.
In our review of 12 VA regional offices, we found that the nature of
the local relationship between VA staff and MTF staff was a key factor
in the completeness and reliability of the information that the MTF
provided on seriously injured servicemembers. For example, at one
location, the MTF staff provided VA regional office staff with the
names of new patients but no indication of the severity of their
conditions or the combat theater from which they were returning.
Another regional office reported receiving lists of servicemembers for
whom the Army had initiated a medical separation in addition to lists
of patients with information on the severity of their injuries. Some
regional offices were able to capitalize on long-standing informal
relationships. For example, the VA coordinator responsible for
identifying and monitoring the seriously injured servicemembers at one
regional office had served as an Army nurse at the local MTF and was
provided all pertinent information.
VA staff at the 12 regional offices generally expressed confidence that
the data sources they developed enabled them to identify most seriously
injured servicemembers. However, we noted that informal data sharing
relationships could break down with changes in personnel at either the
MTF or the VA regional office. Several VA headquarters' officials and
regional office staff we interviewed said that systematic data from DOD
would provide them with a way to reliably identify and follow up with
seriously injured servicemembers. Additionally, VA officials said these
data would help them plan for projected increases in services for newly
returning OEF/OIF servicemembers.
Unresolved Issues Continue to Delay a Data Sharing Agreement:
After more than 2 years of discussion, DOD and VA have not developed a
data sharing agreement. Although DOD and VA officials agree that the
HIPAA Privacy Rule permits the exchange of individually identifiable
health data if the individual signs a proper authorization, the
departments have not pursued this as an alternative to a data sharing
agreement. DOD and VA officials said the departments want to pursue
options under other provisions of the Privacy Rule that may permit them
to exchange data without individual authorizations. However, DOD and VA
differ in their understanding of HIPAA Privacy Rule provisions that
govern the sharing of individually identifiable health data for
servicemembers currently receiving treatment in MTFs without an
authorization, and the extent to which the Privacy Rule would permit
that exchange. DOD's and VA's inability to resolve these differences
has impeded coming to an agreement on exchanging servicemembers'
individually identifiable health data.
Two examples help illustrate the different views of DOD and VA
regarding the HIPAA Privacy Rule. First, the Privacy Rule permits
covered entities that are also government agencies providing public
benefits to disclose individually identifiable health data to each
other when the programs serve the same or similar populations, and the
disclosure is necessary to coordinate the covered functions of such
programs or to improve administration and management related to the
covered functions of the programs.[Footnote 9],[Footnote 10] VA
officials have said they believe that this provision allows DOD to
share servicemembers' health data with VA because the departments serve
the same or similar populations--active duty servicemembers who
transition to veteran status. VA officials also said they believe that
DOD and VA provide public benefits. In contrast, a DOD official who is
responsible for implementation of the Privacy Rule does not agree that
DOD and VA serve the same or similar populations or that DOD provides
public benefits. This official said he believes that serving the same
or similar populations means that servicemembers have a dual
eligibility for both DOD and VA services. Although the official said
that while some former servicemembers are dually eligible for DOD and
VA services, not all qualify for both services simultaneously. This
official also said that the services that DOD provides are not public
benefits because they are unlike the examples of public benefits
programs provided in the preamble to the Privacy Rule.[Footnote 11] The
Privacy Rule does not define public benefits.
In the second example, the Privacy Rule explicitly permits the
disclosure of individually identifiable health data by DOD to VA upon
the separation or discharge of a servicemember in order to determine
eligibility for VA benefits.[Footnote 12] DOD views "upon the
separation or discharge" as referring to the separation process that
varies by servicemember, but which begins with the decision by DOD that
the servicemember will separate. According to VA officials, the HIPAA
Privacy Rule would allow DOD to share data sooner than the decision by
DOD that the servicemember will separate. However, DOD is reluctant to
provide individually identifiable health data to VA until DOD is
certain that a servicemember will separate from the military. DOD is
concerned that VA's outreach to servicemembers who are still on active
duty could work at cross-purposes to the military's retention goals.
According to DOD officials, it would be premature for VA to begin
working with servicemembers who may eventually return to active duty.
VA contends that DOD could define the specific point of separation or
discharge earlier in the process. In commenting on our January 2005
report, VA said that a memorandum of understanding was then being
negotiated that would allow VA to obtain from DOD the servicemember's
medical information prior to discharge from military service. VA added
that its Office of General Counsel was confident that there are
exceptions in the Privacy Rule that would permit military service
medical information to be disclosed for VA benefits purposes and that
it had pressed the case with DOD's General Counsel. As of May 17, 2005,
the memorandum of understanding between DOD and VA has not been
finalized.
Despite being unable to agree on an exchange of individually
identifiable health data, DOD and VA are currently reviewing a draft
memorandum of understanding. DOD and VA officials told us they believe
that the memorandum of understanding will move the two departments
closer to a data sharing agreement. However, we found that the draft
memorandum of understanding restates many of the legal authorities
contained in the Privacy Rule for the use and disclosure of
individually identifiable health data. For example, the draft
memorandum of understanding does not specify that individually
identifiable health data of OEF/OIF servicemembers shall be disclosed
and restates that data will be shared upon separation or discharge
without further defining the specific point during the separation or
discharge process when data can be shared. As a result, even if the
memorandum of understanding is finalized, DOD and VA will still not
have a data sharing agreement that specifies what types of individually
identifiable health data can be exchanged and when the data can be
shared.
Mr. Chairman, this completes my prepared remarks. I will be pleased to
answer any questions you or other Members of the Subcommittee may have
at this time.
Contact and Acknowledgments:
For further information, please contact Cynthia A. Bascetta at (202)
512-7101. Also contributing to this statement were Mary Ann Curran,
Marcia Mann, Kevin Milne, and Janet Overton.
[End of section]
Related GAO Products:
Vocational Rehabilitation: VA Has Opportunities to Improve Services,
but Faces Significant Challenges. GAO-05-572T. Washington, D.C.: April
20, 2005.
VA Disability Benefits and Health Care: Providing Certain Services to
the Seriously Injured Poses Challenges. GAO-05-444T. Washington, D.C.:
March 17, 2005.
Vocational Rehabilitation: More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers. GAO-05-167.
Washington, D.C.: January 14, 2005.
Health Information: First-Year Experiences under the Federal Privacy
Rule. GAO-04-965. Washington, D.C.: September 3, 2004.
FOOTNOTES
[1] GAO, Vocational Rehabilitation: More VA and DOD Collaboration
Needed to Expedite Services for Seriously Injured Servicemembers, GAO-
05-167 (Washington, D.C.: Jan. 14, 2005).
[2] See related GAO products listed at the end of this testimony.
[3] Pub. L. No. 104-191, § 264, 110 Stat. 1936, 2033-34; 45 C.F.R. §
164.500, et seq. (2004).
[4] The Privacy Rule applies to covered entities and specifies how
individually identifiable health data may be used and disclosed by
covered entities. See 45 C.F.R. §§ 164.500(a), 164.502 (2004). Covered
entities are defined in the Privacy Rule as health plans,
clearinghouses, and certain health care providers. Both the DOD health
care system and the VA health care system are covered entities. See 45
C.F.R. § 160.103 (2004). All covered entities had to comply with the
Privacy Rule by April 14, 2003, with the exception of small health
plans.
[5] Army regulations classify illnesses and injuries as "very serious"
when life is imminently endangered; as "serious" when there is a cause
for immediate concern but there is no imminent danger to life; and as
"special category" when the patient has a particular condition, such as
loss of limb or sight, a psychiatric condition, paralysis, or a
permanent disfigurement.
[6] Servicemembers can receive vocational rehabilitation services prior
to separation from the military under certain circumstances. For
example, hospitalized servicemembers pending discharge may receive all
VA vocational rehabilitation benefits--such as counseling, evaluation,
and training--except for the monthly subsistence allowance. 38 U.S.C.
§§ 3102, 3104, and 3113.
[7] In our January 2005 report, we focused on five MTFs, which treated
the majority of seriously injured OEF/OIF servicemembers: Brooke Army
Medical Center in Texas; Walter Reed Army Medical Center in Washington,
D.C.; Madigan Army Medical Center in Washington; Eisenhower Army
Medical Center in Georgia; and Darnall Army Community Hospital in
Texas. VA also has placed staff at Evans Army Community Hospital in
Colorado and Bethesda Naval Medical Center in Maryland.
[8] GAO, Vocational Rehabilitation: VA Has Opportunities to Improve
Services, but Faces Significant Challenges, GAO-05-572T (Washington,
D.C.: Apr. 20, 2005), and SSA Disability: Program Redesign Necessary to
Encourage Return to Work, GAO/HEHS-96-62 (Washington, D.C.: Apr. 24,
1996).
[9] See 45 C.F.R § 164.512(k)(6) (2004).
[10] Covered functions in general are a health plan's or health care
provider's activities of providing or arranging for health care
services. See 45 C.F.R. § 164.103 (2004).
[11] See 65 Fed. Reg. 82462, 82541-42 (2000).
[12] See 45 C.F.R. § 164.512(k)(1)(ii) (2004).
