[House Report 115-671]
[From the U.S. Government Publishing Office]
115th Congress } { Rept. 115-671
HOUSE OF REPRESENTATIVES
2d Session } { Part 1
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VA MAINTAINING INTERNAL SYSTEMS AND STRENGTHENING INTEGRATED OUTSIDE
NETWORKS ACT OF 2018
_______
May 11, 2018.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Roe of Tennessee, from the Committee on Veterans' Affairs,
submitted the following
R E P O R T
together with
DISSENTING VIEWS
[To accompany H.R. 5674]
The Committee on Veterans' Affairs, to whom was referred
the bill (H.R. 5674) to establish a permanent community care
program for veterans, to establish a commission for the purpose
of making recommendations regarding the modernization or
realignment of facilities of the Veterans Health
Administration, to improve construction of the Department of
Veterans Affairs, to make certain improvements in the laws
administered by the Secretary of Veterans Affairs relating to
the home loan program of the Department of Veterans Affairs,
and for other purposes, having considered the same, report
favorably thereon without amendment and recommend that the bill
do pass.
CONTENTS
Page
Purpose and Summary.............................................. 2
Background and Need for Legislation.............................. 2
Hearings......................................................... 34
Subcommittee Consideration....................................... 34
Committee Consideration.......................................... 34
Committee Votes.................................................. 35
Committee Correspondence......................................... 43
Committee Oversight Findings..................................... 45
Statement of General Performance Goals and Objectives............ 45
New Budget Authority, Entitlement Authority, and Tax Expenditures 45
Earmarks and Tax and Tariff Benefits............................. 45
Committee Cost Estimate.......................................... 45
Congressional Budget Office Estimate............................. 45
Federal Mandates Statement....................................... 45
Advisory Committee Statement..................................... 46
Constitutional Authority Statement............................... 46
Applicability to Legislative Branch.............................. 46
Statement on Duplication of Federal Programs..................... 46
Disclosure of Directed Rulemaking................................ 46
Section-by-Section Analysis of the Legislation................... 46
Changes in Existing Law Made by the Bill as Reported............. 85
Dissenting Views................................................. 205
Purpose and Summary
H.R. 5674, the ``VA Maintaining Internal Systems and
Strengthening Integrated Outside Networks Act of 2018'' or the
``VA MISSION Act of 2018'' would strengthen and improve the
Department of Veterans Affairs (VA) healthcare system for the
benefit of the nation's veterans. The bill would consolidate
VA's multiple community care programs and authorities and
provide further funding for the Choice Program. It would
establish an Asset and Infrastructure Review (AIR) process to
recommend actions to modernize and realign VA's massive medical
infrastructure. It would also expand VA's Family Caregiver
Program to pre-9/11 veterans and increase VA's internal
capacity to care for veteran patients in VA medical facilities
through improvements to various recruitment and retention
programs. The bill represents a negotiated agreement between
the Committee on Veterans' Affairs of the U.S. House of
Representatives and the Committee on Veterans' Affairs of the
U.S. Senate and combines various elements of H.R. 4242, as
amended, H.R. 4243, as amended, and S. 2193, as amended.
Representative David P. Roe of Tennessee, the Chairman of the
full Committee, introduced H.R. 5674 on May 3, 2018.
Background and Need for Legislation
TITLE I--CARING FOR OUR VETERANS
Subtitle A--Developing an Integrated High-Performing Network
VA operates the nation's largest integrated healthcare
system and provides care to approximately nine million veteran
patients.\1\ The majority of the health care that veterans
receive through the VA health care system is provided through
medical professionals and support staff employed by VA and
working in VA facilities that are managed and overseen by the
Veterans Health Administration (VHA). However, since 1945, VA
has also collaborated with medical professionals and support
staff in the community--who are not VA employees and who do not
work in VA facilities--to provide veterans with timely,
accessible, high-quality care.\2\ This is generally referred to
as ``community care'' though has previously been referred to as
``non-VA care,'' ``fee basis care,'' or ``purchased care.''
Over time, Congress has authorized VA to use various community
care programs to care for veteran patients when a needed
clinical service cannot be provided by a given VA facility and
the veteran cannot be transferred to another VA facility, when
VA cannot recruit a needed clinician, when a veteran cannot
access a VA facility due to geographic inaccessibility, when
there is an emergent situation in which a delay in care in
order to travel to a VA facility could be considered life-
threatening, and in order to meet patient wait time standards.
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\1\About VHA. Veterans Health Administration. https://www.va.gov/
health/aboutVHA.asp. Accessed November 14, 2017.
\2\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown
University, Washington, D.C.
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The most recent VA community care program is the Choice
program (Choice). Choice was established by the Veterans
Access, Choice, and Accountability Act of 2014 (Public Law 113-
146; 128 STAT. 1754) (the Choice Act). Choice expanded the
availability of community care to veteran patients by setting
specific triggers upon which VA would be required to give
veterans the option of receiving care in the community rather
than in a VA medical facility. In general, veterans are
eligible to receive care through Choice if they are unable to
secure an appointment at a VA facility within 30 days or if
they reside more than 40 miles from the nearest VA facility.
Through Choice, veteran patients are referred to regional
networks of community providers who are managed by Third Party
Administrators (TPAs). However, under other community care
programs, VA refers veteran patients to community providers
through agreements with the Indian Health Service, the
Department of Defense, academic affiliates, or other entities;
through the Patient Centered Community Care program; or through
national or local contracts or sharing agreements.\3\
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\3\United States Cong. House Committee on Veterans' Affairs. ``The
State of VA's Fiscal Year 2015 Budget'' June 25, 2015. 114th Cong. 1st
sess. Washington: GPO, 2015 (statement of the Honorable Sloan Gibson,
Deputy Secretary of Veterans Affairs).
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Each of VA's current community care programs and
authorities contain different eligibility criteria, different
reimbursement rates, different payment structures, different
referral and authorization requirements, and different
contracting approaches.\4\ According to VA, ``this has resulted
in a complex and confusing landscape for veterans, community
providers, and [the] VA employees that serve and support
them.''\5\ As a result, ``veterans face excessive bureaucracy,
access based on administrative eligibility, and minimal care
coordination [which] inhibits the delivery of high-quality
personalized care.''\6\ This led VA and the Committee to
conclude that, ``it is imperative for VA to modernize how care
is provided through a high performing integrated network which
includes care provided both in VA and in the community.''\7\
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\4\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown
University, Washington, D.C.
\5\May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet.
``A Consolidated and Modernized VA Community Care Program.''
\6\Ibid.
\7\Ibid.
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That imperative has been exacerbated by a significant
increase in veteran demand for community care in recent years.
Since Choice was established in fiscal year 2014, community
care appointments increased by 61 percent overall and by 41
percent as a percentage of total VA appointments through fiscal
year 2016.\8\ That upward trend continued in fiscal year 2017,
with the number of completed appointments across the VA
healthcare system that occur in the community rising from 31
percent in fiscal year 2016 to 36 percent in fiscal year
2017.\9\
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\8\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown
University, Washington, D.C.
\9\United States Cong. House Committee on Veterans' Affairs. ``U.S.
Department of Veterans Affairs Budget Request for Fiscal Year 2019''
February 15, 2018. 115th Cong. 2nd sess. Washington: GPO, 2018
(Testimony of the the Honorable David Shulkin M.D., Secretary, U.S.
Department of Veterans Affairs).
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Despite the increased demand for and utilization of
community care, VA has struggled to effectively administer
community care programs and, consequently, veterans have not
always received timely care in the community. For many years,
the VA Inspector General (IG) has documented substantial
problems with VA's management of community care programs,
including issues authorizing and scheduling appointments,
managing consults, ensuring network adequacy, and promptly
paying community providers.\10\ This led the IG to conclude in
2017 that, ``our audits, reviews, and inspections have
highlighted that VA has had a history of challenges in
administering its purchased care programs [and] veteran's
access to care, proper expenditure of funds, timely payment of
providers, and continuity of care are at risk to the extent
that VA lack[s] adequate processes to manage funds and oversee
program execution.''\11\ The Government Accountability Office
(GAO) has found similar problems with VA's management of
community care programs. For example, in March 2017, GAO found
that veterans who were referred to Choice for routine care
because such care was not available through a VA facility in a
timely manner could potentially wait up to 81 calendar days to
obtain Choice care.\12\ GAO also found that VA had failed to
establish standardized processes and procedures for Choice, to
issue program guidance regarding Choice, and to track or
monitor how long it took VA medical centers to refer veterans
to Choice (a process which GAO found was duplicative and could
take up to 21 days).\13\
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\10\United States Cong. House Committee on Veterans' Affairs.
``Shaping the Future: Consolidating and Improving VA Community Care''
March 7, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement
of the Honorable Michael Missal, Inspector General, U.S. Department of
Veterans Affairs).
\11\Ibid.
\12\United States Cong. House Committee on Veterans' Affairs.
``Shaping the Future: Consolidating and Improving VA Community Care''
March 7, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement
of Randall B. Williamson, Director, Health Care, Government
Accountability Office).
\13\Ibid.
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The Committee is aware of the concerns expressed by VA, the
IG, and GAO regarding the challenging nature of many current VA
community care programs and the potential adverse consequences
veteran patients could face if those concerns are not
expeditiously addressed. The Committee believes that a robust,
consolidated VA community care program is vital to the long-
term stability and success of the VA healthcare system in at
least two significant ways. First, an effective VA community
care program augments the care provided in VA medical
facilities and, therefore, increases VA's capacity to serve the
nation's veterans. Second and most importantly, an effective VA
community care program helps to ensure that veterans have
access to timely, quality care and--as such--provides them with
improved health outcomes, patient satisfaction, care
coordination, and efficiency.\14\
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\14\May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet.
``A Consolidated and Modernized VA Community Care Program.''
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Accordingly, title I of the bill would establish a robust,
consolidated VA community care program, the Veterans Community
Care Program (the Program). Through the Program, veterans who
are enrolled in the VA healthcare system or otherwise entitled
to VA care would be granted access to care in the community
under certain circumstances, which are detailed below. VA would
be responsible for managing and overseeing the Program as well
as coordinating the care that veterans receive through the
Program, including ensuring that appointments are scheduled in
a timely manner and that continuity of care is preserved.
Access to community care would be required under the
Program if VA does not offer the care or services the veteran
requires, if VA does not operate a full-service medical
facility in the state in which a given veteran resides, if a
given veteran was eligible for care in the community under the
Choice 40-mile rule and meets certain other criteria, or if a
given veteran and the referring clinician agree that furnishing
care in the community is in the best medical interest of the
veteran after considering certain criteria. Access to community
care would also be required if VA is not able to furnish care
within designated access standards developed by VA after
consultation with certain other entities and published in the
Federal Register and on VA's website. Such designated access
standards would be reviewed at a minimum of every three years
and veterans would be able to request a determination at any
time regarding whether they are eligible to receive community
care as a result of such access standards.
Access to community care would be authorized under the
Program if a given medical service line within a VA facility
fails to meet certain VA quality standards developed by VA
after consultation with certain other entities and published on
the Center for Medicare and Medicaid's Hospital Compare
website. VA would be required to provide a plan to Congress
detailing how VA intends to remediate medical service lines
that fall below such quality standards and VA's authority to
refer veterans to the Program due to a failure to meet such
quality standards would be limited to no more than 36 service
lines nationally and three service lines per facility.
Access to community care would also be authorized under
this title to veterans in need of an organ or bone marrow
transplant if, in the opinion of the veteran's primary care
provider, the veteran has a medically compelling reason to
travel outside the region of the Organ Procurement and
Transplantation Network, established under section 372 of the
National Organ Transplantation Act (Public Law 98-507; 98 STAT.
2339). This provision is in accordance with the Committee's
belief that veterans in need of an organ or bone marrow
transplant have highly complex needs that may impede their
ability to travel for care more than other veterans and
necessitate care in the community using a lower eligibility
threshold than otherwise provided for through the Program. The
Committee's further thoughts regarding the provision of
transplant care through VA are explained in the descriptive
portion of section 153 below. However, the Committee believes
that veterans with amputations have similar needs to veterans
in need of transplants and are deserving of a similarly lower
threshold for community care. In particular, the Committee
remains supportive of VA's long-standing practice to allow
veterans with amputations to access prosthetic and orthotic
care through community providers and encourages VA to continue
that practice unabated.
Access to community care would also be authorized through
the Program for veterans in need of walk-in care. Veterans who
have used VA health care services in the 24-month period prior
would be eligible pursuant to this authority to seek walk-in
care through community providers and Federally-qualified health
centers who have entered into a contract or agreement with VA
to provide such care. Veterans who are not required to make a
copayment at a VA facility would be entitled to two walk-in
care visits without a copayment though VA would be authorized
to charge such veterans an adjustable copayment for subsequent
walk-in care visits. Veterans who are required to make a
copayment at a VA facility would pay such copayment for the
first two walk-in care visits though VA would be authorized to
charge an adjusted copayment for subsequent walk-in care
visits.
To resolve disputes regarding eligibility for care in the
community under the Program, title I of the bill would require
VA to provide veterans with a clinical appeal process to review
community care eligibility determinations but prohibit such
appeals from being appealed to the Board of Veterans Appeals.
Title 1 of the bill would also require VA to develop and
administer a number of training programs to ensure that
veterans, VA employees, and community providers are fully aware
of and educated on the Program, the VA healthcare system, and
mental and physical health conditions that are common among
veterans.
To carry out the Program, VA would be required to enter
into a contract or contracts to establish a network of
community care providers and authorized to establish tiered
networks pursuant to such contract or contracts but would be
prohibited from prioritizing providers in one tier over another
in a manner that limits a veteran's choice of providers. In
order to ensure quality of the community care provider
networks, VA would be authorized to deny, suspend, or revoke
the eligibility of a community provider to participate in the
community care program if the provider was previously removed
from VA employment or had their medical license revoked.
In recognition of the fact that veterans may sometimes
require services from community providers who have not entered
into a contract or agreement with VA, title I of the bill would
authorize VA to pay for services not subject to a contract or
agreement but deemed necessary by VA nevertheless. In such
cases, VA would be required to take reasonable efforts to enter
into a formal agreement, contract, or other legal arrangement
to ensure that future care and services provided by the
provider in question are covered.
Title I of the bill would also allow for the continuity of
existing memorandums of understanding and memorandums of
agreement that were in effect on the day before enactment of
the bill between VA and the American Indian and Alaska Native
healthcare systems as established under the terms of the VA and
Indian Health Service Memorandum of Understanding, signed
October 1, 2010, the National Reimbursement Agreement, signed
December 5, 2012, arrangements under section 405 of the Indian
Health Care Improvement Act, and agreements entered into under
sections 102 and 103 of the Choice Act to enhance the
collaboration between VA and the Native Hawaiian health care
system.
Title I of the bill would require VA, to the extent
practicable, to reimburse community care providers under the
Program at Medicare rates. However, the Committee recognizes
that such rates may not always be sufficient to yield an
adequate provider network that is available to treat veteran
patients, particularly in rural areas. As such, title I of the
bill would authorize VA to pay higher rates in highly rural
areas, to pay in accordance with the Alaska Fee Schedule for
providers in Alaska, and to pay in accordance with applicable
All-Payer Model Agreements in relevant states. What's more,
title 1 would also authorize VA to incorporate value-based
reimbursement models to the extent practicable to promote high-
quality care. The Committee encourages VA to utilize such
models to provide dialysis care in the community to veterans
pursuant to the national dialysis contracts that have been in
place for the last several years and of which the Committee
continues to strongly support.
The Committee strongly believes that VA's ability to timely
and accurately process payments to community providers is
critical to the Program's success and to ensuring access to
community care for the increasing number of veterans who rely
on it. The Committee also recognizes that VA's ability to
promptly reimburse community providers for the services they
provide to veteran patients has significantly fallen short of
expectations in recent years, which has hampered the viability
of VA's community care provider networks. In 2014, GAO issued a
report which found that community providers experienced
``lengthy delays'' in the processing of their claims that, in
some cases, took years to resolve.\15\ According to GAO, this
resulted in an environment where community providers are
hesitant to provide care to veterans due to fears they will not
be paid for services provided on VA's behalf.\16\ These
findings were echoed in GAO testimony in 2016, which stated
that ``the substantial increase in utilization of VA care in
the community programs poses challenges for VHA, which has had
ongoing difficulty processing claims from community providers
in a timely manner.''\17\ As such, title I of the bill would
establish a prompt payment process that would require VA to pay
for, or deny payment for, services within 30 calendar days of
receipt of a clean electronic claim or within 45 calendar days
of receipt of a clean paper claim. In the case of a denial, VA
would have to notify the provider of the reason for denying the
claim and what, if any, additional information would be
required to process the claim. Upon the receipt of the
additional information, VA would have to pay, deny, or
otherwise adjudicate the claim within 30 calendar days. Any
claim that has not been denied, made pending, or paid within
the specified time periods would be considered overdue and
subject to interest payment penalties. Community care entities
or providers would be required to submit a claim to VA within
180 days of providing care or services.
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\15\GAO-14-175, Actions Needed to Improve Administration and
Oversight of Veterans' Millennium Act Emergency Care Benefit. http://
www.gao.gov/assets/670/661404.pdf.
\16\Ibid.
\17\United States Cong. House Committee on Veterans' Affairs,
Subcommittee on Health. ``Choice Consolidation: Improving VA Community
Care Billing and Reimbursement'' February 11, 2016. 114th Cong. 2nd
sess. Washington: GPO, 2016 (statement of Randall B. Williamson,
Director, Health Care, U.S. Government Accountability Office).
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The Committee recognizes that VA may be best served by
delegating claims processing to a thirty party entity. As such,
title I would authorize VA to enter into an agreement with a
third party entity to electronically process claims from
community providers and would require an independent review of
VA's capacity to process claims in a timely manner and a cost
benefit analysis comparing VA's performance with a third party
claims processing entity. It would also require that VA conduct
a study on whether to establish a funding mechanism for a VA
contractor to act as a fiscal intermediary for the Federal
Government to pay claims.
The Committee recognizes that, in certain cases, veterans
may require community care outside of the Program. In general,
VA's community care authorities utilize traditional Federal
Acquisition Regulation (FAR)-based contracts to do business
with private providers. However, the Choice Act granted VA the
authority to purchase community care through non-FAR based
provider agreements. This was in recognition of the difficult
and sometimes burdensome processes and requirements that the
FAR imposes on some community providers. In particular, some
community providers have cited their classification as federal
contractors subject to the audit and reporting requirements of
the Department of Labor's Office of Federal Contract Compliance
Programs (OFCCP) as especially onerous. VA has claimed that
provider agreement authority would ``. . . ensure that veterans
receive the necessary care they earned through the fullest
complement of non-VA providers'' and, the absence of such
authority, ``has resulted in complications with extended care
providers and other [non-Choice providers as] some small, long-
term care facilities have already withdrawn their support of
veterans due to the overwhelming administrative requirements of
the FAR.''\18\ The American Health Care Association concurs and
has testified about the ``onerous reporting requirements and
regulations'' that have ``dissuaded nursing care centers from
admitting VA patients'' which ``limits the care available to
veterans needing long term care in their local
communities.''\19\ This has created an acute need in some
areas, particularly for those veterans who live in rural areas
where VA facilities are far away and community providers are
scarce. VA has requested legislative authority to enter into
non FAR-based provider agreements since 2015.\20\ Accordingly,
title I of the bill would authorize VA to enter into provider
agreements called Veterans Care Agreements (VCAs). VCAs would
not be subject to competition or other requirements associated
with federal contracts and the same affirmative action
moratorium that applies to TRICARE contractors and
subcontractors pursuant to OFCCP Directive 2014-01 would apply
to VCA contractors and subcontractors. Veteran eligibility for
care under VCAs would be subject to the same terms as VA care
itself and the rates paid under VCAs would, to the extent
practicable, be in accordance with rates specified for the
Program above.
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\18\January 2, 2017. U.S. Department of Veterans Affairs, The
Honorable Secretary Robert McDonald. ``Caring for Those Who Have Borne
the Battle: Cabinet Exit Memo.'' https://www.va.gov/opa/publications/
docs/VA-Exit-Memo.pdf
\19\United States Cong. House Committee on Veterans' Affairs.
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess.
Washington: GPO, 2017 (statement for the record from the American
Health Care Association).
\20\January 2, 2017. U.S. Department of Veterans Affairs, The
Honorable Secretary Robert McDonald. ``Caring for Those Who Have Borne
the Battle: Cabinet Exit Memo.'' https://www.va.gov/opa/publications/
docs/VA-Exit-Memo.pdf
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Title I of the bill would also authorize VA to enter into
VCAs with State Veterans Homes and eliminate competitive
contracting actions and other requirements associated with
federal contracts for State Veterans Homes. While not
considered federal contactors for the purposes of this section,
State Veterans Homes would still be required to follow federal
laws related to employment, fraud, waste, and abuse.
Finally, title I of the bill would require VA to perform
market area assessments on a number of key factors at least
once every four years. VA would be required to submit the
assessments to Congress and to use them to determine the
capacity of the Program's provider networks and access and
quality standards. VA would also be required to submit a
strategic plan to Congress, no later than one year after the
date of enactment and at least every four years thereafter. The
strategic plan would be required to specify the demand for care
and the capacity to meet such demand both at each VA medical
center and in the community. VA would be required to take a
number of elements into consideration when developing the
strategic plan and to identify emerging issues, challenges, and
opportunities and recommendations to address them. The
Committee believes the market area assessments and strategic
plan will assist VA in successfully implementing the Program
and in ensuring appropriate ongoing administration, management,
and oversight of the Program by VA.
Chapter 4--Other Matters Relating to Non-Department of Veterans Affairs
Providers
Section 131. Establishment of processes to ensure safe opioid
prescribing practices by non-Department of Veterans Affairs
health care providers
Between 1999 and 2016 more than 200,000 deaths were
attributed to overdoses from prescription drugs.\21\ Overdose
deaths remain elevated within the civilian population and
veterans have certainly not immune to that crisis or to the
opioid epidemic. Due to the prevalence of chronic pain in the
veteran population, many being treated with opioids, VA
instituted the Opioid Safety Initiative (OSI), a program using
evidence-based management guidelines, including dosing and
monitoring guidelines, to treat pain and to mitigate the risks
of prescription opioids.\22\ However, as demand for community
care among veterans continues to grow, the Committee is
concerned about the potential for inconsistencies in the
management of opioid prescriptions between VA and community
providers. The Committee believes that VA must take steps to
ensure safe opioid prescribing practices are adhered to when a
veteran is sent to the community for care. Accordingly, section
131 of the bill would require VA to provide OSI guidelines to
community providers participating in the Program, certify that
such providers have reviewed the guidelines, and implement a
process to ensure that such providers receive a veteran's
relevant history including all prescribed medications. It would
further require that prescriptions for opioids be filled at a
VA pharmacy (or at a community pharmacy only if prior
authorization has been received with exceptions for certain
urgent or emergent circumstances). It would also require opioid
prescriptions to be recorded in the electronic health record
and VA to remove from the Program provider networks any
community provider whose prescribing practices are inconsistent
with OSI or who violate licensing guidelines. The Committee
believes this would ensure an equitable provision of care in VA
and in the community and ensure safe and appropriate opioid
prescriptions are provided to veteran patients regardless of
where they receive VA care.
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\21\Prescription Opioid Overdose Data, Centers for Disease Control
and Prevention; https://www.cdc.gov/drugoverdose/data/overdose.html.
\22\Department of Veterans Affairs, Office of Inspector General
report no. 17-01846-316, Healthcare Inspection: Opioid Prescribing to
high-Risk Veterans Receiving VA Purchased Care, July 3, 2017.
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Section 132. Improving information sharing with community providers
The Committee believes that it is vital for VA and
community providers to be able to share pertinent medical
record information about the veteran patients they are jointly
treating in order to ensure that the care veterans receive in
the community is safe, effective, coordinated and of the
highest quality. This is particularly important given the
dramatic and growing increase in community care appointments in
the last several years, a trend the Committee expects to
continue under the Program. Section 132 of the bill would
clarify that VA could share medical record information with
community providers for the purpose of providing health care to
patients or performing other health care related activities and
remove certain restrictions on VA's ability to recover funds
from third parties for the cost of non-service-connected care.
The Committee believes this would improve the provision of care
to veteran patients from both VA providers and community
providers while also ensuring that personal patient information
is safeguarded from inappropriate disclosure.
Section 133. Competency standard for non-Department of Veterans Affairs
health care providers
While noting the growing importance of an effective
community care network on the overall strength and success of
the VA healthcare system, the Committee nevertheless
acknowledges that community providers are likely not as
familiar with or competent in military- and veteran-specific
conditions and concerns as VA providers are. To ensure that
veterans are able to access culturally competent care from care
through the Program, section 133 of the bill would require VA
to establish competency standards for community providers. Such
standards would include information regarding injuries and
illnesses that VA has a special expertise in, such as post-
traumatic stress disorder, traumatic brain injury, and military
sexual trauma. All community providers, to the extent
practicable as determined by VA, would be required to meet
these standards before furnishing care to veterans under the
Program.
Section 134. Department of Veterans Affairs participation in national
network of State-based prescription drug monitoring programs
The Centers for Disease Control and Prevention (CDC)
defines a PDMP as an electronic database that tracks controlled
substance prescriptions in a state and provides information
about prescribing and patient patterns and behaviors.\23\ PDMPs
have been shown to improve prescribing, inform clinical
practice, protect at-risk patients, and decrease substance
abuse treatment admissions.\24\ In 2011, the National
Association of Boards of Pharmacy (NABP) developed and launched
the Prescription Monitoring Program (PMP) InterConnect to
facilitate the secure exchange of information across state
lines by PDMPs.\25\ According to NABP, PDMPs are, ``. . . are
enhanced by PMP InterConnect because [it] provides the means
for physicians and pharmacists to more easily identify patients
with prescription drug abuse and misuse problems, especially if
those patients are crossing state lines to obtain drugs.''\26\
Currently 44 states and Washington, D.C. participate in PMP
InterConnect with several additional states intending to begin
sharing data using PMP InterConnect.\27\,\28\
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\23\What States Need to Know about PDMPs. Centers for Disease
Control and Prevention. https://www.cdc.gov/drugoverdose/pdmp/
states.html. Accessed April 30, 2018.
\24\Ibid
\25\NABP PMP InterConnect: The Only National Network of State-Based
PMPs. National Association of Boards of Pharmacy. https://
nabp.pharmacy/initiatives/pmp-interconnect/. Accessed April 30, 2018.
\26\Ibid.
\27\United States Cong. House Committee on Veterans' Affairs.
Legislative Hearing. April 17, 2018. 115th Cong. 2nd sess. Washington:
GPO, 2018 (statement from the Honorable Neal Dunn, U.S. House of
Representatives, 2nd District, Florida).
\28\NABP PMP InterConnect: The Only National Network of State-Based
PMPs. National Association of Boards of Pharmacy. https://
nabp.pharmacy/initiatives/pmp-interconnect/. Accessed April 30, 2018.
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Section 5701(l) of title 38 United States Code (U.S.C.)
requires VA to disclose information to PDMPs for either a
veteran or the dependent of a veteran who is prescribed a
controlled substance through VA ``to the extent necessary to
prevent misuse or diversion of prescription medications.''
Veterans Health Administration (VHA) Directive 1306 provides VA
national policy for querying PDMPs.\29\ It requires PDMPs to be
queried prior to initiating therapy with a controlled
substance, annually at a minimum, and more often when
clinically indicated unless the patient is enrolled in hospice
care or receives a controlled substance prescription for five
days or less without refills.\30\ The results of such query are
required to be documented in the patient's medical record and
are subject to limitations imposed by state law, in which case
providers and prescribers are required to conform to the
policies and recommendations of their state licensure.\31\
According to VA, this policy allows providers to identify
patients receiving controlled substances from multiple
providers which may assist in preventing accidental or
intentional misuse or diversion and in the detection,
prevention, and early treatment of substance use disorders.\32\
However, the policy does not allow VA to track controlled
substance prescriptions across multiple states since VA lacks
the authority to use a system like PMP InterConnect.
---------------------------------------------------------------------------
\29\VHA Directive 1306. Query State Prescription Drug Monitoring
Programs. October 19, 2016.
\30\Ibid.
\31\Ibid.
\32\Ibid.
---------------------------------------------------------------------------
Section 134 of the bill would require VA to enter into an
agreement with a national network of PDMPs to allow for the
monitoring of controlled substance prescriptions written in
participating states. It would also require VA health care
providers practicing in states that do not have a PDMP to join
the network of the closest state that does have a PDMP.
Chapter 5--Other Non-Department Health Care Matters
Section 141. Plans for use of supplemental appropriations required
Since the passage of the Choice Act in 2014, Congress has
acted numerous times to address unexpected shortfalls in the
Choice Fund and in VA's other medical care accounts as a result
of higher than expected demand for care in the community and
cost overruns as a result of the Denver replacement medical
center project in Aurora, Colorado. Some of those instances are
detailed in the descriptive portion of section 510 below. The
Committee is concerned about VA's seeming inability to
anticipate funding requirements and utilization timelines and
the impact such inability may have on the provision of care to
veteran patients and the appropriate use of taxpayer dollars.
Section 141 of the bill would require VA to submit a
justification to Congress for any new supplemental
appropriations request submitted outside of the standard budget
process. Such justification would be required no later than 45
days before the date on which a budgetary issue would start
affecting a program or service. It would be required to contain
a detailed strategic plan for how VA intends to use the
requested appropriation and for how long the requested funds
are expected to meet the need.
Section 142. Veterans Choice Fund flexibility
The Committee expects, based on numerous conversations with
VA senior leaders and rank-and-file employees alike, that it
will take one year from enactment for VA to implement the
Program. As described in the descriptive portion of section 510
below, the Committee intends to provide sufficient funding in
this bill to fund Choice and ensure access to timely, quality
care in the community to veteran patients until that time.
However, the Committee understands that, as the Program
approaches the implementation date, VA may require funding
flexibility to enable the Department of sufficiently balance
community care accounts. As such, section 142 of the bill would
authorize VA, beginning on March 1, 2019, to use funds
remaining in the Choice Fund to pay for community care provided
to veteran patients pursuant to Chapter 17 of title 38 U.S.C.
at community facilities or through community providers
furnishing care in VA facilities.
Section 143. Sunset of Veterans Choice Program
The Choice Act created and deposited $10 billion into the
Veterans Choice Fund to fund the Choice program. It also
stipulated that Choice would sunset either when the money in
the Choice Fund was fully expended or three years after
enactment of the Act. Since the law was enacted on August 7,
2014, three years after enactment of the Act would have been
August 7, 2017. However, the VA Choice and Quality Employment
Act of 2017 (Public Law 115-26; 131 STAT. 129) amended the
Choice Act to modify the termination date for Choice in April
2017 following testimony that VA expected to have money left in
the Choice Fund on August 7, 2017.\33\ Section 143 of the bill
would provide a sunset date for the Veterans Choice Program one
year after the date of enactment of this Act, upon which time
the Committee expects the Program to be fully implemented.
---------------------------------------------------------------------------
\33\United States Cong. House Committee on Veterans' Affairs
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset
Needs.'' March 7 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from the Honorable David Shulkin M.D, Secretary of Veterans
Affairs).
---------------------------------------------------------------------------
Subtitle B--Improving Department of Veterans Affairs Health Care
Delivery
Section 151. Licensure of health care professionals of the Department
of Veterans Affairs providing treatment via telemedicine
As a national, integrated health care system, VHA has a
responsibility to ensure that veteran patients receive the same
level of and access to care no matter where the veteran patient
is located.\34\ This is a particular challenge for veteran
patients residing in remote, rural, or medically underserved
areas far from VA medical facilities and for veteran patients
with mobility or other issues that impact their ability to
travel to VA medical facilities to receive care.\35\
---------------------------------------------------------------------------
\34\Authority of Health Care Providers to Practice Telehealth.
https://www.federalregister.gov/documents/2017/10/02/2017-20951/
authority-of-health-care-providers-to-practice-telehealth. Accessed
October 31, 2017.
\35\Ibid.
---------------------------------------------------------------------------
Telemedicine refers to ``the use of telehealth technologies
to provide clinical care in circumstances where distance
separates those receiving services and those providing
services.''\36\ By allowing VA clinicians to provide ``the
right care in the right place at the right time,'' telemedicine
is critical to VA's ability to deliver health care to veteran
patients who could not otherwise access such
care.\37\,\38\ According to VA, ``[telemedicine]
increases the accessibility of VA health care, bringing VA
medical services to locations convenient for beneficiaries,
including clinics in remote communities and beneficiaries'
homes.''\39\ In fiscal year 2016, VA health care providers
provided more than 2 million episodes of care via telemedicine
to more than 700,000 veteran patients, approximately 12 percent
of VA's total patient population.\40\ Veteran patients who have
had experience with VA telemedicine programs have demonstrated
improved health outcomes, including decreases in hospital
admissions.\41\
---------------------------------------------------------------------------
\36\VA Telehealth Services. https://www.telehealth.va.gov/ Accessed
October 30, 2017.
\37\Ibid.
\38\Authority of Health Care Providers to Practice Telehealth.
https://www.federalregister.gov/documents/2017/10/02/2017-20951/
authority-of-health-care-providers-to-practice-telehealth. Accessed
October 31, 2017.
\39\Ibid.
\40\Ibid.
\41\Ibid.
---------------------------------------------------------------------------
However, the continued expansion of telemedicine across the
VA health care system is constrained by restrictions on the
ability of VA providers to practice telemedicine across state
lines without jeopardizing their state licensure and facing
potential penalties for the unauthorized practice of
medicine.\42\ VA claims that this disparity--between VA health
care practice and state medical licensure laws--has severely
inhibited the provision of telemedicine in VA and, therefore,
reduced the availability and accessibility of care for veteran
patients.\43\
---------------------------------------------------------------------------
\42\Ibid.
\43\Ibid.
---------------------------------------------------------------------------
In response to this, VA announced on August 3, 2017, that
VA would be amending regulations to allow VA health care
providers who are licensed, registered, or certified in ``a
state'' to practice in any state when they are acting within
the scope of their VA employment--regardless of individual
state licensure, registration, or certification restrictions
except for applicable state restrictions on the authority to
prescribe and administer controlled substances.\44\ VA claims
that this action would serve to ``authorize VA health care
providers to furnish care, consistent with their employment
obligations, through [telemedicine], without fear of adverse
action by any state.''\45\ Despite this rulemaking, VA
testified during an October 24, 2017 Committee hearing that
legislation was needed to ``[provide] statutory protection and
[codify] VA's longstanding practice of allowing VA providers to
practice in any state as long as they are licensed in a
state.''\46\
---------------------------------------------------------------------------
\44\Ibid.
\45\Ibid.
\46\United States Cong. House Committee on Veterans' Affairs.
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess.
Washington: GPO, 2017 (statement from the Honorable David Shulkin M.D.,
Secretary of Veterans Affairs).
---------------------------------------------------------------------------
The Committee believes that the continued expansion of
telemedicine across the VA healthcare system will aid veterans
in receiving timely, quality care from VA and in achieving
improved health outcomes. Further, the Committee concurs with
the American Medical Association that providing VA healthcare
providers the authority to practice telemedicine across state
lines would, ``address the significant and unique need to
expand access to health care services for veterans being
treated within the VA system while also ensuring that important
patient protections remain in place, including the direct
oversight, accountability, training, and quality control
specific to VA-employed physicians and other health care
professionals.''\47\ As such, section 151 of the bill would
authorize a VA licensed health care provider to practice
telemedicine at any location in any state, regardless of where
the provider or patient is located and whether or not the
patient or provider is on federal government property, and
exercise preemption of state licensure, registration, and
certification laws, rules, and regulations or requirements to
the extent such state laws conflict with the ability of VA
providers to engage in the practice of telehealth while acting
within the state of their VA employment. Section 151 of the
bill would also require VA to submit a report to Congress on
the Department's telemedicine programs, which would allow the
effectiveness of VA telemedicine to be better understood.
---------------------------------------------------------------------------
\47\United States Cong. House Committee on Veterans' Affairs.
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess.
Washington: GPO, 2017 (statement for the record from the American
Medical Association).
---------------------------------------------------------------------------
Section 152. Authority for Department of Veterans Affairs Center for
Innovation for Care and Payment
As the nation's largest integrated healthcare system, the
Committee believes that VA has a unique ability to be a leader
in the healthcare industry. However, all too often, VA has
struggled to embrace innovation and private sector best
practices that would allow VA facilities to maximize
productivity, efficiency, and--most importantly--the provision
of modern, high quality care. Section 152 of the bill would aid
VA in this endeavor by authorizing a Center for Innovation for
Care and Payment (the Center). Through the Center, VA would
develop and test innovative approaches to testing payment and
service delivery models to reduce expenditures while preserving
or improving the quality of care. In doing so, VA would be
authorize to waive any current statutory requirements but would
first be required to submit a report to Congress explaining the
authorities to be waived and the reasons for such a waiver and
receive a bill or joint resolution approving such a waiver. VA
would also be required to conduct an evaluation of each model
tested and make such evaluation available to the public.
Section 153. Authorization to provide for operations on live donors for
purposes of conducting transplant procedures for veterans
VA has offered solid organ transplant services for eligible
veteran patients since 1962 and bone marrow transplant services
for eligible veteran patients since 1982.\48\ Through VA's
National Transplant Program, VA provides transplants primarily
through 13 VA transplant centers located in: Palo Alto,
California; Portland, Oregon; Seattle, Washington; Houston,
Texas; San Antonio, Texas; Salt Lake City, Utah; Iowa City,
Iowa; Madison, Wisconsin; Birmingham, Alabama; Nashville,
Tennessee; West Roxbury, Massachusetts; Bronx, New York;
Pittsburgh, Pennsylvania; and Richmond, Virginia.\49\
---------------------------------------------------------------------------
\48\VA National Transplant Program. https://www.va.gov/health/
services/transplant/.Accessed October 30, 2017.
\49\Ibid.
---------------------------------------------------------------------------
Since the implementation of the Choice program, the
Committee has heard an increasing number of complaints about
the VA transplant program from veterans who are concerned about
the lengthy travel required for many veterans to reach a VA
transplant center and barriers to receiving transplant care in
the community. For example, in 2016, Charles Nelson--a 100
percent service-connected veteran from Leander, Texas--
attempted to receive a kidney transplant through the VA health
care system.\50\ Mr. Nelson's non-veteran son, Austin, was
willing and able to serve as Mr. Nelson's live donor.\51\
Rather than travel to VA transplant centers in Nashville,
Tennessee, or Portland, Oregon, to receive his kidney
transplant, Mr. Nelson asked VA to authorize him to receive his
transplant at the University Hospital in San Antonio via the
Choice program.\52\ \53\ Though his request was approved by
local VA officials in Texas, VA Central Office in Washington,
D.C. denied Mr. Nelson's request to receive his transplant
through the Choice program, arguing that because Austin was not
a veteran VA would be unable to use Choice funds to cover the
costs of his care.\54\ Though Choice is just one of several
care in the community programs that VA could have used to cover
the costs of Mr. Nelson's transplant at the University Hospital
in San Antonio, Mr. Nelson eventually received his transplant
at that facility using his Medicare benefits, private
donations, and personal savings to cover the cost of his
care.\55\
---------------------------------------------------------------------------
\50\United States Cong. House Committee on Veterans' Affairs.
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess.
Washington: GPO, 2017 (statement for the record Representative John
Carter).
\51\Ibid.
\52\Ibid.
\53\Fox 7, ``Leander Veteran Fighting for VA to Pay for Kidney
Transplant,'' May 24, 2016, http://www.fox7austin.com/news/local-news/
disabled-leander-veteran-fighting-to-get-va-to-pay-for-kidney-
transplant
\54\United States Cong. House Committee on Veterans' Affairs.
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess.
Washington: GPO, 2017 (statement for the record Representative John
Carter).
\55\Ibid.
---------------------------------------------------------------------------
On June 29, 2016, the Journal of the American Medical
Association published an article which found that greater
distance from a VA Transplant Center was associated with a
lower likelihood of receiving a transplant and a greater
likelihood of death among certain veteran transplant
patients.\56\ Given the article's findings the Committee
believes that veterans residing far from VA transplant centers
should be given the option of receiving their transplant from
transplant centers in the community closer to the veteran's
place of residence. The Committee also believes that, wherever
possible, VA should remove barriers to transplant care in the
community for veteran patients and that, for veterans receiving
a transplant from a live donor, any associated care for the
live donor, should be covered by VA. Consistent with those
goals, section 153 of the bill would authorize VA to provide
for any care or services a live donor may require to carry out
a transplant procedure in either a VA transplant center or
medical facility or VA community care facility for an eligible
veteran notwithstanding that the live donor may not be eligible
for VA health care.
---------------------------------------------------------------------------
\56\Journal of the American Medical Association, ``Association of
Distance from a Transplant Center with Access to Waitlist Placement,
Receipt of Liver Transplantation, and Survival Among U.S. Veterans,
June 29, 2016, https://www.ncbi.nlm.nih.gov/pubmed/24668105.
---------------------------------------------------------------------------
Subtitle C--Family Caregivers
Improvements in battlefield medicine and follow-up
treatment have significantly improved survival rates for
severely wounded servicemembers. However, servicemembers
returning from battle with severe wounds that would have
previously proved fatal may require lifelong medical
intervention and supportive care and, as a result, family
members and friends are increasingly being called upon to act
as caregivers. The Committee acknowledges how integral
caregivers are to the rehabilitation and recovery process for
severely injured veterans as well as the significant physical,
mental, and financial toll that caregiving can take.
In recognition of that, Congress passed the Caregivers and
Veterans Omnibus Health Services Act (Public Law 111-163; 124
STAT. 1130), which established two programs to provide support
to veteran caregivers. The first program is the General
Caregiver Support Services Program. Under the General Caregiver
Support Services Program, caregivers of veterans from all eras
are eligible to receive peer support mentoring, caregiving
training, and support through VA's National Caregiver Support
line and website as well as through VA Caregiver Support
Coordinators located at every VA medical center. The second
program is the Program of Comprehensive Assistance for Family
Caregivers (Family Caregiver Program), which is available to
post-9/11 veterans only.
Under the Family Caregiver Program, approved family
caregivers of post-9/11 veterans are eligible to receive a
monthly, tax-free stipend paid directly to the caregiver;
enrollment in VA's Civilian Health and Medical Program
(CHAMPVA) if the caregiver is not already covered under an
existing insurance plan; up to 30 days of respite care; and
travel expenses when receiving initial caregiver training and
during the veterans' medical appointments. Veterans (or
servicemembers who are undergoing a medical discharge from the
Armed Forces) are eligible for the Family Caregiver Program if
they meet certain eligibility criteria, including: the presence
of a serious injury incurred or aggravated in the line of duty
on or after 9/11; a need for personal care services for at
least six continuous months as a result of such serious injury;
a clinical determination that participation in the Family
Caregiver Program is in the veteran's best interest; the lack
of simultaneous, regular provision of personal care services by
or through another entity or program; and an agreement to
receive ongoing care from a VA primary care team.
Veteran demand for the Family Caregiver Program has
outpaced expectations by 550 percent leading to delays,
workload concerns, and other issues.\57\ Many of those concerns
were detailed in a 2014 GAO report which found that staffing to
support the Family Caregiver Program was insufficient to meet
higher-than-expected demand at certain VA medical centers, with
some Caregiver Support Coordinators managing a workload of up
to 251 approved caregivers at a time.\58\ These staffing
shortages impeded the timeliness of key functions and
negatively affected services to caregivers.\59\ GAO also found
that oversight of the Family Caregiver Program is impeded by
information technology (IT) system limitations that prevented
access to key workload and other data.\60\ This led GAO to
conclude that, ``[a]fter 3 years of operation, it is clear that
VHA needs to formally reassess and restructure key aspects of
the Family Caregiver Program.''\61\ More than three years
later, many of the recommendations that GAO made to address
these findings remain open.
---------------------------------------------------------------------------
\57\United States Cong. House Committee on Veterans' Affairs. ``VA
Caregiver Support Program: Correcting Course for Veteran Caregivers.''
February 6, 2018. 115th Cong. 2nd sess. Washington: GPO, 2018
(Statement of the Honorable David P. Roe M.D., Chairman, Committee on
Veterans' Affairs, U.S. House of Representatives).
\58\GAO-14-675, Actions Needed to Address Higher-Than-Expected
Demand for the Family Caregiver Program. https://www.gao.gov/assets/
670/665928.pdf.
\59\Ibid.
\60\Ibid.
\61\Ibid.
---------------------------------------------------------------------------
Given that, the Committee has concerns about the management
and administration of the Family Caregiver Program. However,
the Committee also acknowledges the inequity that currently
exists between pre- and post-9/11 veterans and their caregivers
regarding the Family Caregiver Program. To address this
inequity and recognize the service and sacrifice of veteran
caregivers of all ages and eras, subtitle C of the bill would
expand eligibility for the Family Caregiver Program to pre-9/11
veterans. It would also require VA to implement an IT system
that fully supports the Family Caregiver Program and allows for
data assessment and comprehensive monitoring. Subtitle C would
further amend requirements for VA's annual report on the Family
Caregiver Program to include a description of any barriers to
accessing and receiving care and services through the Family
Caregiver Program and an evaluation of the sufficiency and
consistency of the training provided to family caregivers.
TITLE II--VA ASSET AND INFRASTRUCTURE REVIEW
Subtitle A--Asset and Infrastructure Review
VA is one of the federal government's largest property-
holding entities with a capital asset portfolio that includes
approximately 155 million square feet across more than 35,000
acres of land.\62\ Unlike many other federal agencies, the
majority--86 percent--of VA's capital asset portfolio is
owned.\63\ VA also controls approximately 24.6 million square
feet of leased space.\64\ In July 2017, VA testified before the
Committee that ``most of VA's infrastructure portfolio is
dated, in need of repair/replacement, and requires considerable
investment.''\65\ VA further testified that ``the majority of
VA facilities have out-lived their useful life-cycle,'' raising
serious questions about VA's continued ability to meet the
needs of veteran patients and beneficiaries.\66\
---------------------------------------------------------------------------
\62\United States Cong. House Committee on Veterans' Affairs
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from James M. Sullivan, Director of the Office of Asset
Enterprise Management, U.S. Department of Veterans Affairs).
\63\Ibid.
\64\Ibid.
\65\Ibid.
\66\Ibid.
---------------------------------------------------------------------------
Most VA facilities are medical facilities that are operated
by VHA. Nationally, VHA's portfolio includes 168 VA medical
centers, 135 community living centers, 48 domiciliary centers,
737 community-based outpatient clinics, 22 health care centers,
and 305 other outpatient facilities such as mobile treatment
spaces.\67\ The average VHA building is approaching 60 years
old, more than five times older than the average building age
of a not-for-profit hospital system in the United States.\68\
These buildings were designed to meet an older, primarily
inpatient, model of care.\69\ Thus, they are not well suited to
provide care in accordance with modern, primarily outpatient,
care models or to meet the contemporary ambulatory care needs
of veteran patients.\70\
---------------------------------------------------------------------------
\67\GAO-17-349, April 2017, ``VA Real Property: VA Should Improve
Its Efforts to Align Facilities with Veterans' Needs,'' https://
www.gao.gov/assets/690/683938.pdf.
\68\CMS Alliance to Modernize Healthcare Federally Funded Research
and Development Center, September 1, 2015, ``Independent Assessment of
the Health Care Delivery Systems and Management Processes of the
Department of Veterans Affairs,'' https://www.va.gov/opa/choiceact/
documents/assessments/Integrated--Report.pdf.
\69\Commission on Care, June 30, 2016, ``Commission on Care Final
Report,'' https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/
912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.pdf
\70\Ibid.
---------------------------------------------------------------------------
VHA's capital asset portfolio also includes a significant
number of vacant properties, which led the bipartisan
Commission on Care to note in 2016 that ``VHA's principal
mission is to provide health care to veterans, yet over time it
has acquired an ancillary mission: caretaker of an extensive
portfolio of vacant buildings.''\71\ The bipartisan Commission
on Care also found that ``maintaining outdated, vacant, and
unused buildings, which require millions of dollars in
maintenance even in mothball status, diminishes operating funds
needed for patient care and yields no benefit to veteran
patients.''\72\ VA announced in June 2017 that the Department
would initiate reuse or disposal of approximately 430 vacant
buildings totaling 5.9 million gross square feet over the next
two years.\73\ VA expects to save approximately $7 million
annually as a result of this effort.\74\ VA also intends to
review approximately 784 underutilized buildings to determine
if they can be reused or disposed of to yield additional
savings.\75\
---------------------------------------------------------------------------
\71\Ibid.
\72\Ibid.
\73\United States Cong. House Committee on Veterans' Affairs
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from James M. Sullivan, Director of the Office of Asset
Enterprise Management, U.S. Department of Veterans Affairs).
\74\Ibid.
\75\Ibid.
---------------------------------------------------------------------------
The amount of empty or underutilized spaces across the VA
health care system has been exacerbated by VHA's struggle to
align VA medical facilities with the veteran patient
population. In 2015, the Independent Assessment of the Health
Care Delivery Systems and Management Processes of VA
(Independent Assessment) found that VA struggles to
consistently allocate capital to projects that represent the
greatest areas of veteran need in the most cost effective and
timely manner.\76\ The Independent Assessment argued that the
misalignment of VA's properties with VA's patients was due, in
part, to lengthy approval and funding timelines that hinder
VA's ability to meet the identified space requirements to keep
up with veteran demand and invest in facility updates that
align with changing models for care.\77\ GAO made a similar
judgment in a 2017 report that found significant geographic
shifts in the veteran patient population coupled with changes
in the delivery of care, ``antiquated'' infrastructure, and
serious limitations with VA's capital planning processes
created, ``an imperative for VA to better align its medical
facilities and services.''\78\
---------------------------------------------------------------------------
\76\CMS Alliance to Modernize Healthcare Federally Funded Research
and Development Center, September 1, 2015, ``Independent Assessment of
the Health Care Delivery Systems and Management Processes of the
Department of Veterans Affairs,'' https://www.va.gov/opa/choiceact/
documents/assessments/Integrated_Report.pdf.
\77\Ibid.
\78\GAO-17-349, April 2017, ``VA Real Property: VA Should Improve
Its Efforts to Align Facilities with Veterans' Needs,'' https://
www.gao.gov/assets/690/683938.pdf.
---------------------------------------------------------------------------
Even absent a serious realignment effort, VA has identified
more than $50 billion in capital needs over the next decade to
modernize and maintain the Department's infrastructure.\79\
However, the capital requirement for VHA to maintain facilities
and meet projected growth needs over the next decade is two to
three times higher than anticipated funding levels, a gap which
is expected to could continue to widen.\80\ Furthermore, the
Independent Assessment also found that VA's construction costs
are double private industry best practice, that VA time-to-
complete construction projects exceeds both public and private
sector peers, and that VA's facility management costs are two
to three times higher than comparable private medical
facilities, on average.\81\
---------------------------------------------------------------------------
\79\United States Cong. House Committee on Veterans' Affairs
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from James M. Sullivan, Director of the Office of Asset
Enterprise Management, U.S. Department of Veterans Affairs).
\80\CMS Alliance to Modernize Healthcare Federally Funded Research
and Development Center, September 1, 2015, ``Independent Assessment of
the Health Care Delivery Systems and Management Processes of the
Department of Veterans Affairs,'' https://www.va.gov/opa/choiceact/
documents/assessments/Integrated_Report.pdf.
\81\Ibid.
---------------------------------------------------------------------------
VA has attempted to address the Department's capital asset
challenges previously. In 2003, Secretary Principi initiated
the VA Capital Asset Realignment for Enhanced Services (CARES)
process.\82\ As part of CARES, an independent commission was
formed to provide recommendations for the realignment and
allocation of capital assets to meet veteran health care demand
over the next 20 years.\83\ The CARES Commission conducted 38
public hearings and 10 public meetings around the country,
heard from 770 witnesses--including 135 members of Congress and
seven governors--and received written comments from more than
212,000 people.\84\ In February 2004, the CARES Commission
released a report recommending substantial changes to existing
VA facilities and a limited number of facility closures. Yet,
thirteen years after the CARES report was released, its
recommendations have yet to be fully implemented.\85\ Secretary
Prinicipi testified before the Committee in July 2017 that,
while CARES offered ``sound recommendations for realignment and
allocation of the Department's capital assets to meet demand
for VA's services over the next twenty years,'' it did not
require Congress to adopt or reject the final CARES
recommendations as a package and, thus, failed.\86\ The
bipartisan Commission on Care similarly noted that ``political
resistance doomed previous attempts to better align VHA's
capital assets and veterans' needs.''\87\ In light of this, the
Commission also recommended that Congress establish a VHA
facility and capital asset realignment process based on the
process established by the Department of Defense Base
Realignment and Closure Commission process to be implemented as
soon as practicable.\88\
---------------------------------------------------------------------------
\82\February 12, 2004, VA Office of Public and Intergovernmental
Affairs, ``CARES Commission Announces Recommendations,'' https://
www.va.gov/opa/pressrel/pressrelease.cfm?id=729.
\83\Ibid.
\84\Ibid.
\85\United States Cong. House Committee on Veterans' Affairs
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from the Honorable Anthony J.Principi).
\86\Ibid.
\87\Commission on Care, June 30, 2016, ``Commission on Care Final
Report,'' https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/
912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.pdf
\88\Ibid.
---------------------------------------------------------------------------
The Committee applauds VA's recent efforts to initiate
reuse or disposal of vacant and underutilized properties across
the country and encourages their continuation. However, the
Committee also believes that bold steps are needed to fully
address VHA's significant and increasing capital asset
challenges, to ensure VHA uses taxpayer dollars wisely in
caring for the nation's veterans, and--most importantly--to
ensure a strong VA health care system is available to meet the
needs veteran patients both today and for generations to come.
Accordingly, the Committee concurs with the bipartisan
Commission on Care's recommendation to establish a robust VHA
capital asset realignment process freed, to the greatest extent
possible, from political constraints.
As such, title II of the bill would require VA to establish
a nine member AIR Commission. The AIR Commissioners would be
appointed by the President, with the advice and consent of the
Senate and in consultation with Congressional leaders and
congressionally chartered, membership-based veterans service
organizations (VSOs). The Commission as a whole would be
required to reflect current demographics of veterans enrolled
in the VA health care system and to have expertise in health
care system and federal capital asset planning and management.
In addition, at least three Commissioners would be required to
represent the VSO community. The Commission would be tasked
with considering recommendations made by VA and submitting a
report to the President on VHA facility modernization and
realignment. The Commission would only be able to change a
recommendation made by VA for the modernization or realignment
of a VHA facility if: the Commission determines that VA
deviated substantially from VA's criteria in making a given
recommendation and a change would be consistent with the final
criteria; the Commission publishes a notice of the proposed
change in the Federal Register not less than 45 days before
transmitting the Commission's report including the change to
the President; and the Commission conducts public hearings on
the proposed change. Upon the President's approval of the
Commission's report, the report would be transmitted to
Congress. Congress would be required to act under expedited
legislative procedures to issue a resolution of disapproval of
the Commission's report and the full list of recommendations it
contains. Absent such a resolution, VA would be required to
take any such action as may be necessary to carry out the
actions recommended by the Commission.
The Committee recognizes that the implementation of the
Commission's recommended actions would be a substantial task
for VA as it is likely that VA will need to carry out a level
of construction, leasing, environmental compliance, and
property disposition activity that exceeds typical levels. As
VA's existing legal authority to initiate property actions may
be inadequate to accommodate the Commission's recommendations,
title II of the bill would include additional authorities to
allow VA to take such action as may be necessary to modernize
or realign any VHA facility and to transfer or lease properties
to historic preservation organizations. To ensure that VA's
maintenance needs continue to be met while the Commission's
work is ongoing, title II of the bill would prohibit VA from
pausing major or minor construction activities while the
Commission process is ongoing.
The Committee intends for the AIR Commission process to be
data-driven and to incorporate feedback from veterans,
employees, stakeholders, and communities who would be most
impacted by VHA modernization or realignment. As such, title II
of the bill would require VA to consult with VSOs to establish
criteria to use to assess and recommend the modernization or
realignment of VHA facilities and to take certain factors--
including local veteran and stakeholder input--into account to
ensure such recommendations are robust and fair. Title II of
the bill would also require VA to consult with local veterans
and VSOs to conduct periodic assessments of the capacity of
each Veterans Integrated Service Network (VISN) and VA medical
facility to furnish hospital care or medical services to
veterans. Each assessment would be required to: (1) identify
existing deficiencies in the furnishing of care and services to
veterans and how such deficiencies may be filled by entering
into contracts or agreements with community health care
providers or other entities under other provisions of law and
changing the way care and services are furnished at such VISNs
or VA medical facilities (including through extending hours of
operation, adding personnel, and expanding treatment space
through construction, leasing, or sharing of health care
facilities); (2) forecast both the short-term and long-term
demand in furnishing care and services at such VISN or VA
medical facility; (3) consider how demand affects the need to
enter into contracts or agreements; (4) consider the commercial
health care market of designated catchment areas conducted by a
non-governmental entity; and (5) consider the unique ability of
the Federal government to retain a presence in a rural area
otherwise devoid of commercial health care providers or from
which such providers are at risk of leaving.
The Committee also intends the AIR Commission process to be
transparent and veteran-centric. Accordingly, title II of the
bill would: require that each meeting of the Commission be open
to and all proceedings, information, and deliberations of the
Commission to be available for review by the public; to require
the online publication within 24 hours of any information
transmitted or received by VA, the Commission, or the President
regarding the Commission (or related activities) to be
published online within 24 hours; prohibit the restriction of
lawful communication from a VA employee to the Commission;
require VA to make the local capacity and commercial market
assessments publically available; and require the Commission to
conduct public hearings and include local veterans and VSOs as
witnesses in those hearings.
The Committee is aware that the ultimate success of the
Commission may be contingent upon ensuring VA has sufficient
time before the Commission begins its work to gather needed
data, establish appropriate criteria, and make initial
recommendations regarding facility actions. Accordingly, title
II of the bill would allow VA until January 31, 2022, before
transmitting recommendations to the Commission for review. The
Commission would then have a year to conduct their work before
transmitting the Commission's report to the President on
January 31, 2023. The Commission would terminate on December
31, 2023.
The Committee is aware of the sensitive political
considerations inherent in the AIR Commission process and, as
such, title II of the bill includes provisions stipulating
expedited legislative consideration of the Commission's report
by Congress. The Committee believes expedited consideration is
appropriate and necessary given the Committee's full
concurrence with Secretary Principi's testimony that:
[VA] will fail to honor our nation's commitment to
its veterans if VA's medical system does not evolve
with the times. . . While the practice of VA medicine
has evolved, VA's medical infrastructure has not kept
pace. VA facilities are out of step with changes in the
practice of medicine, with demographic changes in the
veteran population, and with statutory changes in VA's
health care benefits packages. If VA does not realign
itself, and close its unneeded facilities, the current
decline in the veteran population will make many VA
medical centers museums of the past--not the guideposts
for the future they should be.\89\
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\89\United States Cong. House Committee on Veterans' Affairs
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset
Needs.'' July 12, 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from the Honorable Anthony J.Principi).
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However, it is important to note that the Committee in no
way intends title II of the bill to supersede the prohibition
on the sale of the VA Greater Los Angeles Healthcare System
West LA (WLA) campus in Los Angeles, California, in current
law. The 387-acre property that the WLA campus resides on was
deeded to the United States in 1888 to be used as the Pacific
Branch of the National Home for Disabled Volunteer
Soldiers.\90\ The property was maintained in accordance with
this purpose until the 1970s when the WLA campus was placed
there. Today, the WLA campus is one of the busiest and largest
medical and research campuses in the entire VA healthcare
system. The Homeless Veterans Comprehensive Service Programs
Act of 1992 (Public Law 102-590, 106 STAT. 5136) authorized VA
to lease property on the WLA campus. However, in 2011, the
American Civil Liberties Union (ACLU) of Southern California
filed a class action lawsuit on behalf of homeless veterans
with disabilities alleging that VA was misusing the WLA campus
and discriminating against homeless veterans, ``because they
cannot access the medical, mental health and other services to
which they are entitled'' in part due to VA's use of the WLA
campus leasing authority.\91\ In January 2015, VA and attorneys
for the plaintiffs announced that they had reached an agreement
in that lawsuit in which VA agreed to develop a master plan for
the WLA campus to prioritize bridge and permanent supportive
housing for homeless veterans. The West Los Angeles Leasing Act
of 2016 (Public Law 114-226; 130 STAT. 926) authorized VA to
carry out certain leases on the WLA campus in accordance with
the master plan and prohibited the sale of any property located
on the WLA campus. Similar prohibitions can be found in both
the Veterans' Benefits and Services Act of 1988 (Public Law
100-322; 102 STAT. 487) and the Consolidated Appropriations
Act, 2008 (Public Law 110-161; 121 STAT. 1844). Given the
unique history and importance of the property the WLA campus is
located on, the Committee is strongly supportive of maintaining
and improving the WLA campus and increasing the services
provided to veterans on and through it.
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\90\VA Greater Los Angeles Campus Draft Master Plan, January 28,
2016, http://www.losangeles.va.gov/masterplan/.
\91\Valentini v. Shinseki. https://www.aclusocal.org/valentini/.
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Subtitle B--Other Infrastructure Matters
Section 211. Improvement to training of construction personnel
VA's construction management capability has come under
intense scrutiny for inadequacy in recent years. For example,
in 2013, GAO found that were substantially increased costs and
schedules were delayed for the largest VA major medical
facility construction projects in Denver, Colorado; Las Vegas,
Nevada; New Orleans, Louisiana; and Orlando, Florida.\92\ In
2015 GAO testified before the Committee that these projects
ranged from 66 percent to 427 percent over budget and 14 months
to 86 months behind schedule.\93\ Given these findings,
Congress enacted the Department of Veterans Affairs Expiring
Authorities Act of 2015 (Public Law 114-58; 129 STAT. 530),
which required that all VA medical facility construction
projects exceeding $100 million be managed by another federal
agency. Congress also enacted the Jeff Miller and Richard
Blumenthal Veterans Health Care and Benefits Improvement Act of
2016 (Public Law 114-315; 130 STAT. 1536), which required that
each VA employee with construction responsibilities undergoes a
program of ongoing professional training and development
including instruction on industry standards and acquisition
best practices. However, the Committee remains concerned about
the level of training that VA construction personnel receive
and about VA's interpretation of current law give that it
appears that VA has interpreted and implemented the law to
cover training courses that are not significantly more numerous
or wide ranging than the courses being offered before the law's
enactment. The Committee also believes that it is necessary to
broaden training in construction disciplines beyond architects,
engineers, real property specialists, and other such
professionals located in programmatic offices that are
specifically devoted to construction. There is a much wider
universe of personnel involved in construction acquisition,
notably including contracting officers, contract specialists,
and contracting officers' representatives. Relatedly, since the
passage of the Defense Workforce Improvement Act of 1991
(Public Law 101-510; 104 STAT. 1485), the accepted way to
deliver such interdisciplinary acquisition training is through
formal certification programs. All civilian agencies have
subsequently been mandated to adopt certification programs for
the fields of contracting and program management. The
Department of Defense continues to offer a wider range of
certification programs to its employees, notably including
certification in facilities engineering. The Committee asserts
that it would be advantageous for VA to adopt a similar, formal
certification program for construction and facilities
management.
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\92\GAO 13-302, GAO Report, ``VA Construction: Actions Needed to
Decrease Delays and Lower Costs of Major Medical Facility Projects,''
April 4, 2013.
\93\GAO-15-332T, GAO Testimony ``VA Construction: VA Actions to
Address Cost Increases and Schedule Delays at Major Medical-Facility
Projects,'' January 21, 2015; GAO-15-564T, GAO Testimony, ``VA
Construction: Actions to Address Cost Increases and Schedule Delays at
Denver and Other VA Major Medical-Facility Projects,'' April 24, 2015.
---------------------------------------------------------------------------
In accordance with this belief, section 211 of the bill
would require VA to implement a training and certification
program for construction and facilities management personnel.
All VA employees who are members of occupational series
relating to construction or facilities management or VA
employees who award or administer contracts for major
construction, minor construction, or non-recurring maintenance
(including contract specialists or contracting officers'
representatives) would be included in such a program. VA would
be required to create the training and certification program
within one year of enactment, to ensure a majority of covered
employees are certified within two years of enactment, and to
ensure that all covered employees are certified as quickly as
possible thereafter. VA would be required to model the training
and certification program on existing curricula and
certification programs in title 10 U.S.C. (namely, the existing
Defense Acquisition Workforce Improvement Act program).
Section 212. Review of enhanced use leases
Section 8162 of title 38 U.S.C. authorizes VA to enter into
enhanced use leases (EULs) with respect to VA property. Through
this authority, VA out-leases underutilized real estate to
private sector entities for the purpose of developing
supportive housing for homeless and at-risk veterans and their
families.\94\ VA asserts that EUL authority affords the
Department the ability to provide veterans with an expanded
range of services that would not otherwise be available on
medical center campuses and is both an important component of
VA's program to end homelessness among veterans and a critical
tool to assist VA in the effective management of physical
assets. The Committee concurs with that though also believes
that oversight of VA's use of its EUL authority is critical to
ensure the appropriate use of VA property. As such, section 212
would require the Office of Management and Budget to review
each EUL before it goes into effect to determine whether it is
in compliance with relevant statutes.
---------------------------------------------------------------------------
\94\Enhanced Use Lease (EUL). Department of Veterans Affairs.
https://www.va.gov/assetmanagement/. Accessed May 9, 2018.
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Section 213. Assessment of health care furnished by the Department to
veterans who live in the Pacific territories
Veterans in American Samoa, Guam, and the Northern Mariana
Islands face a number of barriers to timely, accessible VA care
and benefits. The principle barrier these veterans face is the
lack of VA care at home, which necessitates lengthy travel to
VA medical centers and clinics in other areas. In light of the
unique challenges that veterans residing in these territories
face accessing VA services, section 213 of the bill would
require VA to report on the care provided to veterans in these
areas. Such a report would be required to include whether VA
believes it would be feasible and appropriate to establish a VA
facility in any territory that does not already contain such a
facility.
TITLE III--IMPROVEMENTS TO RECRUITMENT OF HEALTH CARE PROFESSIONALS
Section 301. Designated scholarships for physicians and dentists under
Department of Veterans Affairs Health Professional Scholarship
Program
VA currently has several programs to address recruiting in
its professional ranks, including the Education Debt Repayment
Program and the Health Professions Scholarship Program (HPSP).
Despite these programs, VA maintains a significant number of
physician vacancies across the VA healthcare system. VA's
considerable recruitment and retention issues are worsened by
an aging workforce that is becoming increasingly retirement-
eligible.\95\
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\95\United States Cong. House Committee on Veterans' Affairs.
Legislative Hearing. March 16, 2016. 114th Cong. 2nd sess. Washington:
GPO, 2016. (Testimony from the Partnership for Public Service.)
---------------------------------------------------------------------------
To help alleviate the shortage of physicians, section 301
of the bill would provide scholarships to medical students in
exchange for service to VA. A minimum of two to four year
scholarships for medical and dental students would be required
so long as the shortage of those positions exceed 500. Once the
number falls below 500, the minimum number of scholarships
provided annually would be at least ten percent of the number
of positions deemed in shortage. The obligation requirement for
the scholarship is successful completion of residency training
leading to board eligibility in a specialty and 18 months of
clinical service at a VA facility for each year of scholarship
support. Section 301 would also authorize VA to provide
preference to veterans and require VA to conduct annual
advertising to educational institutions.
Section 302. Increase in maximum amount of debt that may be reduced
under Education Debt Reduction Program of Department of
Veterans Affairs
The Education Debt Repayment Program (EDRP) was authorized
by the Veterans Programs Enhancement Act of 1998 (Public Law
105-368; 112 STAT. 3315). EDRP is intended to provide veteran
patients with specialized care by increasing the supply of
qualified health care professionals in VA facilities and
assisting VA in meeting the need for qualified health care
professionals in occupations where recruitment or retention is
difficult.\96\ VA recently testified that EDRP is among VA's
most effective recruitment and retention programs.\97\ The
Committee strongly supports EDRP and recognizes the value it
has provided to VA facilities across the country. In an effort
to strengthen the effectiveness of EDRP, section 302 of the
bill would increase the amount of education debt reduction
available through EDRP from $120,000 to $200,000 over five
years and from $24,000 to $40,000 annually.
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\96\Education Debt Reduction Program (EDRP). https://
www.vacareers.va.gov/assets/common/print/EDRP_VA_Careers_Page.pdf.
Accessed May 8, 2018.
\97\United States Cong. House Committee on Veterans' Affairs. ``FY
2019 Department of Veterans Affairs Budget Request for the Veterans
Health Administration.'' March 15, 2018. 115th Cong. 2nd sess.
Washington: GPO, 2018. (Testimony from Carolyn M. Clancy M.D.,
Executive in Charge of the Veterans Health Administration for the U.S.
Department of Veterans Affairs.)
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Section 303. Establishing the Department of Veterans Affairs specialty
education loan repayment program
Given the recruitment and retention challenges that VA
faces and the need for VA to hire more high quality providers
to treat veteran patients, section 303 of the bill would
establish a new loan repayment program for medical or
osteopathic student loans for newly graduated medical students
or residents with at least 2 years of training remaining and
who are training in specialties deemed by VA to be experiencing
a shortage. The loan repayment would be $40,000 per year for a
maximum of $160,000. In exchange for the loan repayment, the
recipient would agree to obtain a license to practice medicine,
complete training leading to board eligibility in a specialty,
and to serve in clinical practice at a VA facility for a period
of 12 months for each $40,000 of loan repayment with a minimum
of 24 months of obligated service. Because resident salaries
are much lower than salaries for fully trained clinicians, the
Committee believes this would make the loan repayment more
economically meaningful and allow VA to fund specialty
positions in shortage areas, develop a predictable future
physician workforce, and ensure a cadre of physicians who are
incentivized to join VA's physician workforce and treat the
nation's veterans.
Section 304. Veterans healing veterans medical access and scholarship
program
In order to assist VA in recruiting veteran physicians,
section 304 would establish a pilot program for supporting four
years of medical school education costs for two veterans at
each of the five Teague-Cranston Schools and at four
historically black colleges and universities. The covered
medical schools would include Texas A&M College of Medicine,
Quillen College of Medicine at East Tennessee State University,
Boonshoft School of Medicine at Wright State University,
Edwards School Medicine at Marshall University, the University
of South Carolina School of Medicine, Drew University of
Medicine and Science, Howard University of Medicine, Meharry
Medical College, and Morehouse School of Medicine. The medical
schools that opt to participate in the program would be
required to reserve two seats each in the class of 2019.
Eligible veteran scholarship recipients would be those within
ten years of their last military discharge who are not eligible
for GI Bill benefits and who meet the minimum admission
requirement for medical school. The scholarship recipients
would agree to successfully complete medical school, obtain a
license to practice medicine, complete post-graduate training
leading to board eligibility in a specialty applicable to VA,
and after training, serve in clinical practice at a VA facility
for four years.
Section 305. Bonuses for recruitment, relocation, and retention
Chapter 45 and Chapter 53 of title 5 U.S.C. authorizes VA
to provide awards and bonuses to employees. The Choice Act
limited the amount of awards and bonuses payable to VA
employees to no more than $360 million from fiscal year 2014
through fiscal year 2024. The Comprehensive Addiction and
Recovery Act of 2016 (Public Law 114-198; 130 STAT 695) further
limited the amount of awards and bonuses payable to VA
employees to $230 million for fiscal year 2017 through fiscal
year 2018, $225 million for fiscal year 2019 through fiscal
year 2021, and $360 million for fiscal year 2022 through fiscal
year 2024. The limitations imposed on awards and bonuses to VA
employees included recruitment, relocation, and retention
incentive payments. This has raised concerns from VA, VSOs, and
other stakeholders that such limitations could have unintended
negative consequences on VA's ability to hire high-quality
clinicians and support staff to effectively serve veteran
patients. As such, section 305 of the bill roll back the
limitation on amounts available for award and would prioritize
recruitment, relocation, and retention incentives within the
total limitations on awards and bonuses.
Section 306. Inclusion of Vet Center employees in education debt
reduction program of Department of Veterans Affairs
As referenced in the analysis portion of section 302 of the
bill above, the Committee strongly supports EDRP and believes
it to be an effective tool to increase recruitment and
retention of highly-qualified clinicians. Through the
Readjustment Counseling Service, VA operates 300 Vet
Centers.\98\ Vet Centers provide readjustment counseling
services to eligible veterans, servicemembers, and their
families in an effort to assist them in making a successful
transition from the military to civilian life.\99\ Such
services include individual, group, and family counseling;
bereavement counseling; military sexual trauma counseling; peer
support; recreational opportunities; substance abuse
assessment; and employment assessment.\100\ The Committee
strongly supports the Vet Center program and commends the VA
clinicians working there for the services they provide to
veterans and their families. In an effort to aid those
clinicians in their work and to recruit more clinicians to join
their ranks, section 306 of the bill would require VA to ensure
that clinical staff working in Vet Centers are eligible to
compete for and participate in EDRP.
---------------------------------------------------------------------------
\98\Vet Center Program. https://www.vetcenter.va.gov/
Vet_Center_Services.asp. Accessed May 8, 2018.
\99\Ibid.
\100\Ibid.
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TITLE IV--HEALTH CARE IN UNDERSERVED AREAS
The Department of Health and Human Services' Health
Resources and Services Administration (HRSA) defines a
medically underserved area as an area designated by HRSA as
having too few primary care providers, a high infant mortality,
a high poverty or a high elderly population.\101\ The Committee
acknowledges that some VA facilities may meet this criterion or
may otherwise face unique challenges to providing timely,
quality care for veteran patients. As such, those facilities
may require a higher level of support and resources and should
be identified and supported by VA leaders. Accordingly, title
IV of the bill would require VA to: (1) develop criteria to
designate VA medical facilities as underserved facilities; (2)
consider a number of factors with respect to such facilities,
including the ratio of veterans to providers; the range of
specialties covered; whether the local community is medically
underserved; the type, number, and age of open consults; and
whether the facility is meeting VA's wait time goals; (3)
perform an analysis annually (if not more often) to determine
which facilities qualify as underserved; and (4) submit a plan
to Congress, within one year of enactment and not less
frequently than annually thereafter, to address underserved
facilities. Title IV of the bill would also require VA to carry
out a three-year pilot program to furnish mobile deployment
teams of medical personnel to underserved facilities and to
consider the medical positions of greatest need at such
facilities and the size and composition of teams to be
deployed. It would also require VA to establish a pilot program
to establish medical residency programs at covered facilities,
including VA facilities, a facility operated by an Indian tribe
or tribal organization, an Indian Health Service facility, a
Federally-qualified health center, or a DOD facility.
---------------------------------------------------------------------------
\101\AMUA Find. Health Resources and Services Administration.
https://datawarehouse.hrsa.gov/tools/analyzers/muafind.aspx. Accessed
May 9, 2018.
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TITLE V--OTHER MATTERS
Section 501. Annual report on performance awards and bonuses awarded to
certain high-level employees of the Department
As referenced in the analysis portion of section 305 of the
bill above, current law authorizes VA to provide performance
awards and bonuses to certain employees. The Committee
recognizes that this authority represents an important
recruitment and retention tool and can be a powerful incentive
to hard-working employees at all levels of the Department. The
Committee supports a judicious use of this authority to reward
top performers but desires transparency for Congress and the
American people regarding the performance awards and bonuses
that are paid to senior leaders across the country. As such,
section 501 of the bill would require VA to submit an annual
report to Congress on performance awards and bonuses paid to
the Veterans Integrated Service Network Directors, VA medical
center Directors, Regional Office Directors, and senior
executives. Each such report would be required to include the
amount of each award or bonus, the job title of each individual
who received an award or bonus, and the location where each
individual who received an award or bonus works.
Section 502. Role of Podiatrists in Department of Veterans Affairs
Approximately 61 percent of veterans newly separated from
service in the Armed Forces have used VA health care since
October 1, 2001.\102\ The most common diagnosis for these
veterans is for a musculoskeletal ailment.\103\ Some of these
musculoskeletal ailments are the result of lower extremity
injuries inflicted by improvised explosive devices on the
battlefield. Musculoskeletal ailments and lower extremity
injuries are also an increasingly prevalent concern among
previous generations of veterans who may be struggling with
issues exacerbated by aging, chronic conditions like diabetes,
and complications resulting from military service. A February
2017 VA white paper states that, in fiscal year 2016,
approximately 1.8 million veteran users of the VA healthcare
system were at risk for major foot wounds, infection, and
amputations.\104\ That number represents a 21 percent increase
from fiscal year 2015.\105\ This led VA to conclude that,
``[t]here is a growing health care demand for primary and
specialty podiatric services, especially among veterans
suffering from polytraumatic injuries, spinal cord injury, and
limb amputation.''\106\
---------------------------------------------------------------------------
\102\VA Health Care Utilization by Recent Veterans. Public Health,
Epidemiology. https://www.publichealth.va.gov/epidemiology/reports/
oefoifond/health-care-utilization/. Accessed July 20, 2017.
\103\Ibid.
\104\Department of Veterans Affairs White Paper on Podiatry Pay.
February 2017.
\105\Ibid.
\106\Ibid.
---------------------------------------------------------------------------
However, VA's ability to effectively and efficiently
recruit and retain podiatrists to treat foot and ankle issues
among veteran patients are hampered by outdated statutory
requirements governing the treatment of podiatrists within the
VA healthcare system. VA's qualifications for podiatrists were
developed in 1976 and have not kept pace with modern podiatric
education and training.\107\ The American Podiatric Medical
Association (APMA) testified in 2017 that ``unlike 41 years
ago, the current podiatric medical school curriculum is vastly
expanded in medicine, surgery and patient experiences and
encounters, including whole body history and physical
examinations.''\108\ Because VA's standards do not align with
current podiatry practice, VA podiatrists experience
disparities in recognition and pay when compared to their non-
VA peers, which results in serious podiatry recruitment and
retention issues within VA. The average compensation for a
podiatrist in the private sector is $30,000 higher than the
highest compensation available to a podiatrist practicing in
VA.\109\ As a result, VA struggles to recruit the most
experienced, qualified podiatrists and to retain the
podiatrists already practicing within the VA healthcare system.
For example, in fiscal years 2015 and 2016, almost 62 percent
of VA medical centers had to replace podiatrists, disrupting
patient care and continuity.\110\ What's more, 66 percent of
the new podiatrists hired in 2016 had less than 10 years of
experience and only 30 percent were board certified.\111\
Further, when there is a podiatry vacancy within a VA medical
facility, it takes an average of 14 months, for that vacancy to
be filled.\112\
---------------------------------------------------------------------------
\107\Ibid.
\108\United States Cong. House Committee on Veterans' Affairs
Subcommittee on Health. ``VA Specialized Services: Lower Extremity
Conditions'' May 2, 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from Seth Rubenstein DPM, Treasurer, Board of Trustees/
Immediate Past Chairman, Legislative Committee, American Podiatric
Medical Association).
\109\United States Cong. House Committee on Veterans' Affairs
Subcommittee on Health. ``VA Specialized Services: Lower Extremity
Conditions'' May 2, 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from Jeffrey Robbins, DPM, Chief of Podiatry, Veterans
Health Administration, U.S. Department of Veterans Affairs).
\110\Ibid.
\111\Ibid.
\112\VA White Paper on Podiatry Pay. February 2017.
---------------------------------------------------------------------------
To address the growing need for podiatry care within the VA
healthcare system, section 502 of the bill would stipulate that
a VA podiatrist is eligible to be appointed to a supervisory
position to the same degree that a VA physician is eligible to
be appointed to such a position. To ensure appropriate
supervision of specialty providers within the VA healthcare
system, section 502 of the bill would also require VA to work
with appropriate stakeholders to establish standards to ensure
that specialists appointed to supervisory positions do not
provide direct clinical oversight for purposes of peer review
or practice evaluation for providers of other clinical
specialties. Further, section 502 of the bill would make
Doctors of Podiatric Medicine (DPMs) equal to Doctors of
Osteopathy (DOs) and Medical Doctors (MDs) in terms of pay
within the VA healthcare system. The Committee believes that
this will correct long-standing inequities between the
treatment of podiatrists in VA medical facilities and in the
private sector, significantly improve VA's ability to recruit
and retain high-quality podiatrists to treat veteran patients
with foot and ankle issues and result in better care and higher
cost savings than would otherwise be expected.
Section 503. Definition of major medical facility project
Section 8104(a)(2) of title 38, U.S.C. requires
Congressional authorization for VA major medical facility
projects. A ``major medical facility project'' is defined as a
project for the construction, alteration, or acquisition of a
medical facility involving a total expenditure of more than $10
million. That $10 million threshold was set by the Veterans
Benefits, Health Care, and Information Technology Act of 2006
(Public Law 109-461, 120 STAT. 3403), which raised such
threshold from $7 million to $10 million. The bipartisan
Commission on Care noted that this $10 million threshold--which
has not been revisited since 2006--has made it difficult for VA
to modernize and renovate aging facilities in recent
years.\113\ The Committee concurs. Section 503 of the bill
would modify the definition of a VA major medical facility
project by raising the threshold for Congressional
authorization from $10 million to $20 million.
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\113\Commission on Care, June 30, 2016, ``Commission on Care Final
Report,'' https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/
912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.pdf
---------------------------------------------------------------------------
Section 504. Authorization of certain major medical facility projects
of Department of Veterans Affairs
As referenced in the analysis portion of section 503 of the
bill above, section 8104(a)(2) of title 38, U.S.C. requires
Congressional authorization for VA major medical facility
projects. Section 504 of the bill would authorize a VA major
medical facility project in Livermore, California, in an amount
not to exceed $117.3 million.
Section 505. Department of Veterans Affairs personnel transparency
Committee oversight as well as GAO and IG reports have
found inadequate staffing and gaps in hiring at VA facilities
nationwide for the last several years. This can adversely
impact care to veteran patients by creating or contributing to
access issues and scheduling delays. In December 2016, GAO
released a report, which found that VHA fell short of Federal
standards for effective internal controls to support Human
Resources (HR) functions, compromising VHA's ability to deliver
sufficient support to effectively recruit and retain the high-
quality employees VA needs to effectively serve veteran
patients.\114\ This finding is consistent with the Committee's
findings that VA HR employees in the field and in leadership
often lack information regarding key measures that could
indicate weaknesses in HR practices. This is particularly
concerning given that testimony before the Committee has found
that VA's considerable recruitment and retention issues are
worsened by an aging workforce that is becoming increasingly
retirement-eligible.\115\ In order to increase transparency
with respect to staffing for VA facilities and aid in
Congressional and stakeholder oversight of the generous hiring
authorities that VA has been granted, section 505 of the bill
would require VA to make information regarding vacancies,
accessions and separation actions, new hires, and personnel
encumbering positions publically
---------------------------------------------------------------------------
\114\GAO-17-30, December 2016, ``Management Attention is Needed to
Address Systemic, Long-standing Human Capital Challenges,'' http://
www.gao.gov/assets/690/681805.pdf
\115\United States Cong. House Committee on Veterans' Affairs
Subcommittee on Health. ``Legislative Hearing on draft legislation to
improve the authority of the Secretary of Veterans Affairs to hire and
retain physicians and other employees of the Department of Veterans
Affairs.'' March 16, 2016. 114th Cong. 2nd sess. Washington: GPO, 2016
(Testimony of Max Stier, President and Chief Executive Officer,
Partnership for Public Service.) available on a VA website. It would
also require the IG to conduct a review of the website on a semi-annual
basis and VA to report to Congress annually on the steps VA is taking
to achieve full staffing capacity, including the amount of additional
funds necessary to enable VA to reach full staffing capacity.
---------------------------------------------------------------------------
Section 506. Program on establishment of peer specialists in patient
aligned care team settings within medical centers of Department
of Veterans Affairs
VA operates a number of programs in which veteran patients
are assisted by fellow veterans who are employed by VA (or
serve as volunteers) and work alongside the veteran patient's
care team to promote a successful recovery and reintegration
and adherence to the veteran patient's plan of care. The
Committee strongly supports peer support programs, particularly
for those veteran patients who are struggling with mental
health or substance abuse issues. The Committee believes that
further integrating peer support into VA primary care settings
could help engage more veterans into these programs and assist
in reducing stigma and other barriers to care among at-risk
veterans. Accordingly, section 506 of the bill would require VA
to carry out a program to place at least two peer specialists
within patient aligned care teams to promote the use and
integration of mental health, substance use disorder, and
behavioral health services in a primary care setting.
Section 507. Department of Veterans Affairs medical scribe pilot
program
The use of electronic health records (EHRs) has become
standard practice for the vast majority of healthcare delivery
systems in United States. While evidence shows that EHRs do
improve patient safety and outcomes, many clinicians find using
EHRs to be burdensome and feel that taking time to enter data
into a computer detracts from the quality of their interaction
with patients and limits the amount of patients they are able
to see daily. To address this disconnect between providers,
patients, and productivity, private practices have begun
employing non-clinical staff whose sole purpose is entering
dictations from the physician into a patient's EHR and helping
the physician to navigate the patient's existing medical
record.
Medical scribes have proven to be particularly useful for
increasing physician productivity and satisfaction in fast-
paced clinical environments such as emergency departments (EDs)
and specialty care settings.\116\ Medical scribes are trained
on privacy considerations and on how to swiftly and accurately
navigate and enter data into a patient's medical record before
being assigned to a physician. Once appropriately trained, the
scribe then follows the physician during patient interactions
and documents each encounter as appropriate.
---------------------------------------------------------------------------
\116\Rajiv Arya MD, Danielle M. Salovich, Pamela Ohman-Strickland
PhD, Mark A. Merlin DO. ``Impact of Scribes on Performance Indicators
in the Emergency Department'' Academic Emergency Medicine: Official
Journal of the Society for Academic Emergency Medicine. April 23, 2010.
http://onlinelibrary.wiley.com/doi/10.1111/j.1553_2712.2010.00718.x/
full
---------------------------------------------------------------------------
Section 507 of the bill would create a two-year pilot
program under which VA will increase the use of medical scribes
in emergency department and specialty care settings at 10 VA
medical centers. To provide transparency on staffing
methodology for medical scribes in VA facilities, such pilot
would require half of the scribes in such pilot to be employed
by VA and half to be contract employees. VA would be required
to regularly report to Congress on the effects the pilot on
provider efficiency, patient satisfaction, average wait times,
the number of patients seen per day and the amount of time
required to train an employee to perform medical scribe
functions under the pilot program. GAO would also be required
to issue a report on the pilot after its conclusion.
Section 508. Loans guaranteed under home loan program of Department of
Veterans Affairs
Section 3729 of title 38, U.S.C., requires individuals who
utilize their VA home loan guaranty benefit to pay a funding
fee. The amount of the funding fee varies based on an
individual's status; the amount of down payment brought
forward; and the date of the loan origination. The rates of
funding fees (expressed as a percentage of the loan) have
remained the same since 2004. The funding fee can be rolled
into the life of the loan and is waived if the servicemember
has a service-connected disability. These fees reduce the
subsidy cost associated with VA's guaranty of mortgage loans,
and have typically been viewed as a reasonable cost to the
benefit gained by having VA guarantee a mortgage loan. Section
508 of the bill would extend the current funding fee rates for
mortgages closed on or after September 30, 2027, through
September 30, 2028. The Committee believes that this is a
reasonable extension of the current rates.
Section 509. Extension of reduction in amount of pension furnished by
Department of Veterans Affairs for certain veterans covered by
Medicaid plans for services furnished by nursing facilities
Section 5503 of title 38 U.S.C. sets forth the criteria
under which eligibility for income-based pension payments and
aid and attendance allowances are affected by domiciliary or
nursing home residence. In instances where a veteran, or
surviving spouse, has neither a spouse nor a child and is
receiving Medicaid-covered nursing home care, the veteran or
surviving spouse is eligible to receive no more than $90 per
month in VA pension or death pension payments for any period
after the end of the third full calendar month following the
month of admission. Under current law, this authority shall
expire on September 30, 2027. Section 509 of the bill would
extend such authority through September 30, 2028.
Section 510. Appropriation of amounts
To fund the Choice program, the Choice Act also created and
deposited $10 billion into the Veterans Choice Fund and
stipulated that Choice would sunset either when the money in
the Choice fund was fully expended or three years after
enactment of the Act. Since the law was enacted on August 7,
2014, three years after enactment of the Act would have been
August 7, 2017. However, Congress passed an Act to amend the
Veterans Access, Choice, and Accountability Act of 2014 to
modify the termination date for the Veterans Choice Program,
and for other purposes (Public Law 115-26; 131 STAT. 129) in
April 2017 following testimony that VA expected to have money
left in the Choice Fund on August 7, 2017.\117\ However, in
June 2017, VA testified that Choice funds would be fully
obligated sooner than previously expected and, as a result, VA
was requesting additional funds be deposited into the Choice
Fund.\118\ VA also testified that, without such action, waiting
times for veteran patients would increase and access to care in
the community would decrease.\119\ In response, Congress
enacted the VA Choice and Quality Employment Act of 2017
(Public Law 115-46; 131 STAT. 958) to appropriate $2.1 billion
into the Choice Fund to preserve the availability of Choice
care for veterans patients through the end of calendar year
2017 and the Third Continuing Appropriations for Fiscal Year
2018, Missile Defense, Health Provisions, Other Matters, and
Budgetary Effects Act (Public Law 115-96; 131 STAT. 2044) to
appropriate an additional $2.1 billion into the Choice Fund to
preserve the availability of Choice care for veterans patients
through May 2018.
---------------------------------------------------------------------------
\117\United States Cong. House Committee on Veterans' Affairs
Oversight Hearing--``Care Where it Count: Assessing VA's Capital Asset
Needs.'' March 7 2017. 115th Cong. 1st sess. Washington: GPO, 2017
(statement from the Honorable David Shulkin M.D, Secretary of Veterans
Affairs).
\118\United States Cong. House Committee on Veterans' Affairs
Oversight Hearing--``FY 2018 Department of Veterans Affairs Budget
Request for the Veterans Health Administration.'' June 22, 2017. 115th
Cong. 1st sess. Washington: GPO, 2017 (statement from Poonam Alaigh
M.D., Acting Under Secretary for Health, U.S. Department of Veterans
Affairs).
\119\Ibid.
---------------------------------------------------------------------------
Section 510 of the law would authorize and appropriate $5.2
billion to the Choice Fund. It is the Committee's intent that
this amount will be sufficient to ensure veteran access to care
until one year after enactment of the bill when the Program is
fully implemented.
Hearings
There were no full Committee or Subcommittee hearings held
on H.R. 5674. The bill represents a negotiated agreement
between the Committee on Veterans' Affairs of the U.S. House of
Representatives and the Committee on Veterans' Affairs of the
U.S. Senate and combines various elements of H.R. 4242, as
amended, H.R. 4243, as amended, and S. 2193, as amended.
Subcommittee Consideration
There was no Subcommittee consideration of H.R. 5674.
Committee Consideration
On May 8, 2018, the full Committee met in open markup
session, a quorum being present, and ordered H.R. 5674 to be
reported favorably to the House of Representatives by a
recorded vote of 20 yeas and 2 noes. During consideration of
the bill, the following amendments were considered:
An amendment offered by Representative Tim Walz of
Minnesota, the Ranking Member of the full Committee,
that would require discretionary budget caps to be
raised in accordance with the authorization of
appropriations and regulations made by or pursuant to
the bill. The amendment was not agreed to by a recorded
vote of 8 yeas to 13 noes.
An amendment offered by Representative Tim Walz of
Minnesota, the Ranking Member of the full Committee,
that would: (1) require VA to review a determination to
provide care to an eligible veteran in the community
six months after the date of such determination for
veterans referred to the community due to a VA medical
facility's failure to comply with quality standards and
one year after the date of such determination for
veterans referred to the community for other reasons;
and (2) cap at two the number of walk-in care visits a
veteran could make in a year. The amendment was not
agreed to by a recorded vote of 8 yeas to 13 noes.
An amendment offered by Representative Beto O'Rourke
of Texas that would allow a recipient of EDRP funds to
elect to receive payments on a monthly or annual basis.
The amendment was not agreed to by voice vote.
An amendment offered and then withdrawn by
Representative Julia Brownley of California that would
include roads that are not accessible to the general
public, traffic, or hazardous weather as
``environmental factors.''
An amendment offered and then withdrawn by
Representative Julia Brownley of California that would
require VA to provide child care assistance to eligible
veterans.
An amendment offered and then withdrawn by
Representative Julia Brownley of California that would
make the pilot program on counseling in retreat
settings for women veterans permanent.
An amendment in the nature of a substitute offered by
Representative Tim Walz of Minnesota, the Ranking
Member of full Committee, that would replace the bill
with a combination of elements from H.R. 4242, as
amended, and S. 2193, as amended. The amendment in the
nature of a substitute was not agreed to by a recorded
vote of 8 yeas to 14 noes.
Committee Votes
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives four recorded votes were taken on
amendments or in connection with ordering H.R. 5674 reported to
the House. Their disposition was as follows:
An amendment offered by Representative Tim Walz of
Minnesota, the Ranking Member of the full Committee,
that would require discretionary budget caps to be
raised in accordance with the authorization of
appropriations and regulations made by or pursuant to
the bill. The amendment was not agreed to by a recorded
vote of 8 yeas to 13 noes. The names of the Members who
voted for and against are as follows:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
An amendment offered by Representative Tim Walz of
Minnesota, the Ranking Member of the full Committee, that
would: (1) require VA to review a determination to provide care
to an eligible veteran in the community six months after the
date of such determination for veterans referred to the
community due to a VA medical facility's failure to comply with
quality standards and one year after the date of such
determination for veterans referred to the community for other
reasons; and (2) cap at two the number of walk-in care visits a
veteran could make in a year. The amendment was not agreed to
by a recorded vote of 8 yeas to 13 noes. The names of the
Members who voted for and against are as follows:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
An amendment in the nature of a substitute offered by
Representative Tim Walz of Minnesota, the Ranking Member of
full Committee, that would replace the bill with a combination
of elements from H.R. 4242, as amended, and S. 2193, as
amended. The amendment in the nature of a substitute was not
agreed to by a recorded vote of 8 yeas to 14 noes. The names of
the Members who voted for and against are as follows:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
A motion by Representative Gus Bilirakis of Florida, the
Vice Chairman of the full Committee, to report H.R. 5674
favorably to the House of Representatives was adopted by a
recorded vote of 20 yeas and 2 noes. The names of the Members
who voted for and against the motion are as follows:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Committee Oversight Findings
In compliance with clause 3(c)(1) of rule XIII and clause
(2)(b)(1) of rule X of the Rules of the House of
Representatives, the Committee's oversight findings and
recommendations are reflected in the descriptive portions of
this report.
Statement of General Performance Goals and Objectives
In accordance with clause 3(c)(4) of rule XIII of the Rules
of the House of Representatives, the Committee's performance
goals and objectives are to strengthen and improve the VA
healthcare system's ability to provide timely, quality care to
the nation's veterans and their caregivers.
New Budget Authority, Entitlement Authority, and Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee has requested
but not received from the Director of the Congressional Budget
Office an estimate of new budget authority, entitlement
authority, or tax expenditures or revenues.
Earmarks and Tax and Tariff Benefits
H.R. 5674 does not contain any Congressional earmarks,
limited tax benefits, or limited tariff benefits as defined in
clause 9 of rule XXI of the Rules of the House of
Representatives.
Committee Cost Estimate
The Committee has requested but not received from the
Director of the Congressional Budget Office an estimate of new
budget authority, entitlement authority, or tax expenditures or
revenues. The Committee believes, according to a preliminary
score from the Congressional Budget Office, that enactment of
H.R. 5674 would result in approximately $48 billion in
discretionary costs over 5 years and approximately $5.2 billion
in mandatory costs for the Choice fund.
Congressional Budget Office Cost Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the Committee has requested but not
received from the Director of the Congressional Budget Office
an estimate of the costs of the reported bill.
Federal Mandates Statement
The Committee has requested but not received from the
Director of the Congressional Budget Office an estimate of new
budget authority, entitlement authority, or tax expenditures or
revenues. The Committee intends to adopt as its own estimate of
Federal Mandates regarding H.R. 5674 prepared by the Director
of the Congressional Budget Office pursuant to Section 423 of
the Unfunded Mandates Reform Act.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act would be created by H.R.
5674.
Statement of Constitutional Authority
Pursuant to Article I, section 8 of the United States
Constitution, H.R. 5674 is authorized by Congress' power to
``provide for the common Defense and general Welfare of the
United States.''
Applicability to Legislative Branch
The Committee finds that H.R. 5674 does not relate to the
terms and conditions of employment or access to public services
or accommodations within the meaning of section 102(b)(3) of
the Congressional Accountability Act.
Statement on Duplication of Federal Programs
Pursuant to clause 3(c)(5) of rule XIII of the Rules of the
House of Representatives, the Committee finds that no provision
of H.R. 5674 establishes or reauthorizes a program of the
Federal Government known to be duplicative of another Federal
program, a program that was included in any report from the
Government Accountability Office to Congress pursuant to
section 21 of Public Law 111-139, or a program related to a
program identified in the most recent Catalog of Federal
Domestic Assistance.
Disclosure of Directed Rulemaking
Pursuant to section 3(i) of H. Res. 5, 115th Cong. (2017),
the Committee estimates that H.R. 5674 contains directed
rulemaking provisions that would require the Secretary to
prescribe regulations.
Section-by-Section Analysis of the Legislation
Section 1. Short title; Table of contents
Section 1(a) of the bill would provide a short title of
H.R. 5674, the ``VA Maintaining Internal Systems and
Strengthening Integrated Outside Networks Act of 2018'' or ``VA
MISSION Act of 2018.''
Section 1(b) of the bill would provide the table of
contents:
TITLE I--CARING FOR OUR VETERANS
Sec. 100. Short title; references to title 38, United
States Code.
Subtitle A--Developing an Integrated High-Performing Network
CHAPTER 1--ESTABLISHING COMMUNITY CARE PROGRAMS
Sec. 101. Establishment of Veterans Community Care Program.
Sec. 102. Authorization of agreements between Department of
Veterans Affairs and non-Department providers.
Sec. 103. Conforming amendments for State veterans homes.
Sec. 104. Access standards and standards for quality.
Sec. 105. Access to walk-in care.
Sec. 106. Strategy regarding the Department of Veterans
Affairs High-Performing Integrated Health Care Network.
Sec. 107. Applicability of Directive of Office of Federal
Contract Compliance Programs.
Sec. 108. Prevention of certain health care providers from
providing non-Department health care services to veterans.
Sec. 109. Remediation of medical service lines.
CHAPTER 2--PAYING PROVIDERS AND IMPROVING COLLECTIONS
Sec. 111. Prompt payment to providers.
Sec. 112. Authority to pay for authorized care not subject
to an agreement.
Sec. 113. Improvement of authority to recover the cost of
services furnished for non-service-connected disabilities.
Sec. 114. Processing of claims for reimbursement through
electronic interface.
CHAPTER 3--EDUCATION AND TRAINING PROGRAMS
Sec. 121. Education program on health care options.
Sec. 122. Training program for administration of non-
Department of Veterans Affairs health care.
Sec. 131. Establishment of processes to ensure safe opioid
prescribing practices by non-Department of Veterans Affairs
health care providers.
Sec. 132. Improving information sharing with community
providers.
Sec. 133. Competency standards for non-Department of
Veterans Affairs health care providers.
Sec. 134. Department of Veterans Affairs participation in
national network of State-based prescription drug monitoring
programs.
CHAPTER 5--OTHER NON-DEPARTMENT HEALTH CARE MATTERS
Sec. 141. Plans for Use of Supplemental Appropriations
Required.
Sec. 142. Veterans Choice Fund flexibility.
Sec. 143. Sunset of Veterans Choice Program.
Sec. 144. Conforming amendments.
Subtitle B--Improving Department of Veterans Affairs Health Care
Delivery
Sec. 151. Licensure of health care professionals of the
Department of Veterans Affairs providing treatment via
telemedicine.
Sec. 152. Authority for Department of Veterans Affairs
Center for Innovation for Care and Payment.
Sec. 153. Authorization to provide for operations on live
donors for purposes of conducting transplant procedures for
veterans.
Subtitle C--Family Caregivers
Sec. 161. Expansion of family caregiver program of
Department of Veterans Affairs.
Sec. 162. Implementation of information technology system
of Department of Veterans Affairs to assess and improve the
family caregiver program.
Sec. 163. Modifications to annual evaluation report on
caregiver program of Department of Veterans Affairs.
TITLE II--VA ASSET AND INFRASTRUCTURE REVIEW
Subtitle A--Asset and Infrastructure Review
Sec. 201. Short title.
Sec. 202. The Commission.
Sec. 203. Procedure for making recommendations.
Sec. 204. Actions regarding infrastructure and facilities
of the Veterans Health Administration.
Sec. 205. Implementation.
Sec. 206. Department of Veterans Affairs Asset and
Infrastructure Review Account.
Sec. 207. Congressional consideration of Commission report.
Sec. 208. Other matters.
Sec. 209. Definitions.
Subtitle B--Other Infrastructure Matters
Sec. 211. Improvement to training of construction
personnel.
Sec. 212. Review of enhanced use leases.
Sec. 213. Assessment of health care furnished by the
Department to veterans who live in the Pacific territories.
TITLE III--IMPROVEMENTS TO RECRUITMENT OF HEALTH CARE PROFESSIONALS
Sec. 301. Designated scholarships for physicians and
dentists under Department of Veterans Affairs Health
Professional Scholarship Program.
Sec. 302. Increase in maximum amount of debt that may be
reduced under Education Debt Reduction Program of Department of
Veterans Affairs.
Sec. 303. Establishing the Department of Veterans Affairs
Specialty Education Loan Repayment Program.
Sec. 304. Veterans healing veterans medical access and
scholarship program.
Sec. 305. Bonuses for recruitment, relocation, and
retention.
Sec. 306. Inclusion of Vet Center employees in education
debt reduction program of Department of Veterans Affairs.
TITLE IV--HEALTH CARE IN UNDERSERVED AREAS
Sec. 401. Development of criteria for designation of
certain medical facilities of the Department of Veterans
Affairs as underserved facilities and plan to address problem
of underserved facilities.
Sec. 402. Pilot program to furnish mobile deployment teams
to underserved facilities.
Sec. 403. Pilot program on graduate medical education and
residency.
TITLE V--OTHER MATTERS
Sec. 501. Annual report on performance awards and bonuses
awarded to certain high-level employees of the department.
Sec. 502. Role of podiatrists in Department of Veterans
Affairs.
Sec. 503. Definition of major medical Sec. 1. Short title;
table of contents.
Sec. 504. Authorization of certain major medical facility
projects of the Department of Veterans Affairs.
Sec. 505. Department of Veterans Affairs personnel
transparency.
Sec. 506. Program on establishment of peer specialists in
patient aligned care team settings within medical centers of
Department of Veterans Affairs.
Sec. 507. Department of Veterans Affairs medical scribe
pilot program.
Sec. 508. Loans guaranteed under home loan program of
Department of Veterans Affairs.
Sec. 509. Extension of reduction in amount of pension
furnished by Department of Veterans Affairs for certain
veterans covered by Medicaid plans for services furnished by
nursing facilities.
Sec. 510. Appropriation of amounts.
Sec. 511. Technical correction.
TITLE I--CARING FOR OUR VETERANS
Section 100. Short title; Reference to Title 38, United States Code
Section 100(a) of this bill would provide a short title to
be cited as the ``Caring for our Veterans Act of 2018.''
Section 100(b) of the bill would specify that any title
that is amended or repeal that is expressed in terms of an
amendment, is in reference to a section or provision in Title
38, U.S.C, unless otherwise expressed.
Subtitle A--Developing an Integrated High-Performing Network
Chapter 1--Establishing Community Care Programs
Section 101. Establishment of veterans community care program
Section 101(a) of this bill would amend section 1703 of
title 38 U.S.C. to read as follows: ``1703. Veterans Community
Care Program.''
The amended section 1703(a) would establish a program to
furnish hospital care, medical services, and extend care
services to covered veterans through health care providers
specified in subsection (c) of the amended section 1703. VA
would be required to coordinate the furnishing of hospital
care, medical services, and extended care services to covered
veterans, including coordination of, at a minimum, the
following: ensuring the scheduling of medical appointments in a
timely manner and the establishment of a mechanism to receive
medical records from non-Department providers; ensuring
continuity of care and services; ensuring coordination among
regional networks if the covered veteran accesses care and
services in a different network than the regional network in
which a covered veteran resides; and ensuring that covered
veterans do not experience a lapse in care resulting from
errors or delays by VA or its contractors or an unusual or
excessive burden in accessing hospital care, medical services,
or extended care services. The amended section 1703 would also
establish that a covered veteran is only authorized to receive
care or services under this section upon the authorization of
such care or services by VA.
The amended section 1703(b) would define the term ``covered
veteran'' as any veteran who is enrolled under section 1705 of
this title or, if not enrolled, is otherwise entitled to
hospital care, medical services, or extended care services.
The amended section 1703(c) would define ``health care
providers'' as providers participating in the Medicare program,
the Department of Defense, Indian Health Service, any
Federally-qualified health center, or any other provider that
meets criteria established by the Secretary.
The amended section 1703(d) would establish the conditions
under which care is required to be furnished through non-VA
providers. Subject to the availability of appropriations,
hospital care, medical services, and extended care services
shall be provided to a covered veteran through health care
providers specified in subsection (c) if: VA does not offer the
care or services the veteran requires; VA does not operate a
full service medical facility in the State in which the covered
veteran resides; the covered veteran was an eligible veteran
under the Veterans Access, Choice, and Accountability Act of
2014 as of the day before the date of enactment of this bill
who continues to reside in a location that would qualify the
veteran for eligibility under such section and either resides
in one of the five States with the lowest population density as
determined by data from the 2010 decennial census or does not
reside in such a State but received care or services under this
title in the year preceding the enactment of this bill and is
seeking care or services within two years of the date of the
enactment of this bill; the covered veteran has contacted VA to
request care or services and the Department is not able to
furnish such care and service in a manner that complies with
designated access standards developed by VA under section 1703B
of this title; or the covered veteran and the covered veteran's
referring clinician agree that furnishing care and services
through a non-Department entity or provider would be in the
best medical interest of the covered veteran based on criteria
created by VA. Such criteria shall include consideration of the
following: the distance between the covered veteran and the
facility that provides the care or services the veteran
requires; the nature of the care or services required; the
frequency that the care or services needs to be furnished; the
timeliness of available appointments for the care or services
the veteran needs; and whether the covered veteran faces an
unusual or excessive burden to access care or services, and
should include the following considerations: whether the
covered veteran faces an excessive driving distance,
geographical challenge, or environmental factor that impedes
the access of the covered veteran; whether the care or service
sought by the veteran is provided by a VA medical facility that
is reasonably accessible to a covered veteran; whether a
medical condition of the covered veteran affects the ability of
said veteran to travel; whether there is a compelling reason as
determined by VA that the veteran needs to receive care or
service from a medical facility other than a VA medical
facility; and such other consideration as VA considers
appropriate. The decision to receive hospital care, medical
services, or extended care services under such subparagraphs
from a non-department health care provider shall be at the
election of the veteran.
The amended section 1703(e) would establish conditions
under which care is authorized to be furnished through non-
Department providers. VA shall measure timeliness of a VA
medical service line in comparison with the same medical
service lines at different VA facilities and measure quality at
a VA medical service line of a facility by comparing it with
two or more distinct and appropriate non-Department service
lines. VA may not concurrently furnish care or services through
non-department providers with respect to more than three
medical service lines at any one VA facility and may not
concurrently furnish care or services through non-department
providers under this authority with respect to more than 36
medical service lines nationally. VA may limit the types of
care veterans receive in terms of the length of time such care
and services will be available, the location at which such care
and services will be available, and the clinical care and
services that will be available. Care authorized under this
subsection with respect to a medical service line shall cease
when the remediation described in section 1706A with respect to
such medical service line is complete. VA shall ensure
continuity and coordination of care for any veteran who elects
to receive care or services under this subsection from a non-
department health care provider through the completion of an
episode of care. VA would be required to publish in the Federal
Register, and shall take all reasonable steps to provide direct
notice to covered veterans affected, at least once a year
starting the time period during which such care and services
will be available, the location or locations where such care
and services will be available, and the clinical services
available at each location in accordance with regulations that
VA shall proscribe. The veteran shall elect whether to receive
the care or service.
The amended section 1703(f) would require the review of
decisions made under subsection (d) or (e) to be subject to
VA's clinical appeals process and may not be appealed to the
Board of Veterans' Appeals.
The amended section 1703(g) would authorize VA to develop a
tiered provider network based on criteria established by VA but
prohibit VA from prioritizing providers in a tier over
providers in any other tier in a manner that limits the choice
of a veteran in selecting a health care provider.
The amended section 1703(h) would require VA to enter into
consolidated, competitively bid contracts to establish networks
of health care providers to provide sufficient access to care.
VA must ensure that covered veterans are able to make their own
appointments using advanced technology, to the extent
practicable, and require VA, to the extent practicable, to
schedule appointments for care and service. VA may terminate a
contract with an entity at such time and upon such notice to
the entity as VA may specify for purposes of this section, if
VA notifies the appropriate committees of Congress that, at a
minimum the entity: failed to comply substantially with the
provisions of the contract or this section and the regulations
prescribed under this section; failed to comply with the access
standards or the standards for quality established by VA; is
excluded from participating in a Federal health care program;
is identified as an excluded source on the list maintained in
the System for Award Management, or any successor system; or
has been convicted of felony or other serious offense under
Federal or state law and the continued participation of the
entity would be detrimental to the best interests of veterans
or the Department. It is reasonable to terminate the contract
based on the health care needs of veterans or to terminate the
contract based on coverage provided by contract or sharing
agreements entered into under authorities other than this
section. Whenever an entity is failing to meet contractual
obligations, VA shall submit to the House and Senate Committees
on Veterans' Affairs a report on such failings. The report
shall include: an explanation of the reasons for providing such
notice; a description of the effect of such failure, including
with respect to cost, schedule, and requirements; a description
of the actions taken by VA to mitigate such failure; a
description of the actions taken by the contractor to address
such failure; and a description of any effect on the community
provider market for veterans in the affected area. VA would be
required to instruct each entity awarded a contract to
recognize and accept, on an interim basis, the credentials and
qualifications of health care providers who are authorized to
furnish care to veterans under a community care program of the
Department in effect as of the day before the date of enactment
of the Caring for our Veterans Act of 2018, including under the
Patient-Centered Community Care Program and the Veterans Choice
Program. The interim acceptance period shall be determined by
VA based on the following criteria: when the current
certification agreement for a health care provider expires and
whether the Department has enacted certification and
eligibility criteria and regulatory procedures by which non-
department providers will be authorized under this section. VA
would be required to create a system or systems for monitoring
and assessing the quality of care provided to veterans through
a network under this subsection.
The amended section 1703(i) would establish payment rates
for care and services. Except as provided in paragraph (2), and
to the extent practicable, the rate paid for care and services
under any provision in this title may not exceed the rate paid
by the United States to a provider of services or a supplier
under the Medicare program under title XI or title XVIII of the
Social Security Act, including but not limited to section 1834
of such Act, for the same care or services. A higher rate than
the rate established in paragraph (1) may be negotiated with
respect to furnishing care to a veteran who resides in a highly
rural area. A ``highly rural area'' is defined as an area
located in a county that has fewer than seven individuals
residing in that county per square mile. With respect to
furnishing care or services under this section in Alaska, the
Alaska Fee Schedule of the Department shall be followed, except
for when another payment agreement, including a contract or
provider agreement, is in effect. With respect to care or
services under this section in a state with an All-Payer Model
Agreement under section 1814(b)(3) of the Social Security Act,
the Medicare payment rates under paragraph (2)(A) shall be
calculated based on the payment rates under such agreement. VA
may incorporate, to the extent practicable, the use of value-
based reimbursement models to promote the provision of high-
quality care, and with respect to care for which there is not a
rate paid under Medicare, the rate paid for such care shall be
determined by VA.
The amended section 1703(j) would establish the standards
for the treatment of other health plan contracts. In any case
where a veteran is furnishing care under this section for a
non-service connected disability, as described in subsection
(a)(2) of section 1729 of this title, VA shall recover or
collect reasonable charges for such care from a health plan
contract described in section 1729.
The amended section 1703(k) would establish the standard
for payment made by the veteran. A covered veteran shall not
pay a greater amount for receiving care or services under this
section than the amount the veteran would pay for receiving the
same or comparable care at a medical facility of the Department
or health care provider of the Department.
The amended section 1703(l) would require the Secretary to
determine whether to authorize an organ or bone marrow
transplant for a covered veteran at a non-Department facility
when such transplant is required and, in the opinion of the
primary care provider, the covered veteran has a medically
compelling reason to travel outside the region of the Organ
Procurement and Transplantation Network.
The amended section 1703(m) would establish the system to
monitor the care provided. Not later than 540 days after the
date of enactment, and annually thereafter, VA shall submit to
the appropriate committees of Congress a review of the types
and frequency of care furnished trough non-Department
providers. The review submitted shall include an assessment of
the following: the top 25 percent of types of care and services
most frequently provided due to the Department not offering
such care and services; the frequency such care and services
were sought by covered veterans; an analysis of the reasons VA
was unable to provide such care; any steps the Department took
to provide such care and services at a medical facility of the
Department; and the cost of such care and services. In
monitoring the care furnished under this section, VA would be
required to do the following: with respect to the care
furnished through provider networks VA shall compile data on
the types of care furnished through such network and how many
patient used each type of care and service; identify gaps in
care furnished through such networks; identify how such gaps
may be fixed through new contracts with such networks or
changes in the manner in which care is provided through such
networks; assess the total amount spent by VA to furnish care
through such network; assess the timelines of the Department in
referring care and services to such networks; and assess the
timelines of such networks in accepting referrals and
scheduling and completing appointments. VA shall report the
number of medical service lines not to be providing care or
services that comply with the standards for quality that VA
established. Additionally, VA would assess the use of academic
affiliates and centers of excellence of the Department to
furnish care and services to veterans under this section.
Lastly, VA would assess the care and services furnished to
veterans under this section by medical facilities operated by
Federal agencies other than the Department.
The amended section 1703(n) would establish a prohibition
on certain limitations. VA shall not limit the types of care or
services veterans may receive under this section if it is in
the best medical interest of the veteran as determined by the
veteran and the veteran's health care provider. Additionally,
no provision in this section may be construed to alter or
modify any other provision of law establishing specific
eligibility criteria for certain care services.
The amended section 1703(o) would define the term
``appropriate committees of Congress'' to mean the Committee on
Veterans' Affairs and the Committee on Appropriations of the
Senate and the House of Representatives and the term ``medical
service line'' to mean a clinic within a VA medical center.
Section 101(b) of this bill would establish an effective
date. Section 1703 of title 38 U.S.C., as amended by subsection
(a), shall take effect on the later of the date that is 30 days
after the date on which VA submits the report required under
section 101(q)(2) of the Veterans Access, Choice, and
Accountability Act of 2014, or the date on which VA promulgates
regulations pursuant to subsection (c).
Section 101(c) of this bill would require VA to promulgate
regulations to carry out section 1703 of title 38 U.S.C. Before
promulgating the regulations required, VA shall provide to the
appropriate committees of Congress periodic updates to confirm
the progress of VA toward developing such regulations. The
first update shall occur no later than 120 days from the date
of the enactment of this Act.
Section 101(d) of this bill would require VA,
notwithstanding section 1703 of title 38 U.S.C., as amended by
subsection (a), to continue all contracts, memorandums of
understanding, memorandums of agreements, and other
arrangements that were in effect on the day before the date of
the enactment of this Act between VA and the Department of
American Indian and Alaska Native health care systems as
established under the terms of VA and the Department of
American Indian and Alaska Native Health Service Memorandum of
Understanding, signed October 1, 2010, the National
Reimbursement Agreement, signed December 5, 2012, arrangements
under section 405 of the Indian Health Care Improvement Act,
and agreements entered into under sections 102 and 103 of the
Veterans Access, Choice, and Accountability Act of 2014. In
addition, the above shall not be construed to prohibit VA and
the parties to the contracts, memorandums of understanding,
memorandums or agreements, and other arrangements described
from making lawful changes.
Sec. 102. Authorization of agreements between Department of Veterans
Affairs and non-Department providers
Section 102(a) of this bill would amend subchapter I of
chapter 17 by inserting after section 1703 the following new
section: Sec. 1703A. Agreements with eligible entities or
providers; certification processes''
The new section 1703A(a) would stipulate that when care or
service is required by a veteran who is entitled to such care
or service under this chapter is not feasibly available to the
veteran from a facility of the Department or through a contract
or sharing agreement entered into pursuant to another provision
of law, VA may furnish such care or services to such veteran
through an agreement under this section with an eligible entity
or provider to provide such care or services. An agreement
entered into under this section to provide care and service
shall be known as a ``Veterans Care Agreement.'' Care or
services provided to a veteran from a facility of VA or through
a contract or sharing agreement may be considered not feasibly
available when VA determines the veteran's medical condition,
the travel involved, the nature of the care or services
required, or a combination of these factors make the use of a
VA facility or sharing agreement impracticable or inadvisable.
The Secretary or any official authorized by the Secretary may
enter into a Veterans Care Agreement. Each agreement of
material size, as determined by VA, shall be reviewed by VA to
determine whether it is feasible and advisable to provide such
care or service within a VA facility or by sharing agreement,
and if so, act to do so. VA shall review each Veterans Care
Agreement of material size that has been in effect for at least
six months within the first two years of its taking effect, and
not less frequently than once every four years thereafter. If a
Veterans Care Agreement has not been in effect for at least six
months by the date of the required review, the agreement shall
be reviewed during the next cycle of required reviews. In
fiscal year 2019 and in each fiscal year thereafter, in
addition to the standards of material size established by VA,
any agreement for the purchase of extended care services that
exceeds $5,000,000 annually shall be considered of material
size. From time to time, VA may publish a notice in the Federal
Register to adjust the dollar amount specified above to account
for changes in the cost of health care based upon market
surveys and other available data.
The new section 1703A(b) would define eligible entities and
providers as: any provider of services that has enrolled and
enter into provider agreement under section 1866(a) of the
Social Security Act and any physician or supplier who has
enrolled and entered into a participation agreement under
section 1842(h) of such act; any provider participating under a
State plan under title XIX of such act; an Aging and Disability
Resource Center, an area agency on aging, or a State agency (as
defined in section 102 of the Older Americans Act); a center
for independent living (as defined in section 702 of the
Rehabilitation Act); or any entity or provider not described
above that VA determines to be eligible pursuant to the
certification process described above.
The new section 1703A(c) would require VA to establish a
process for certification of eligible providers or
recertification of current providers. The process shall, at a
minimum, establish deadlines for actions on applications for
certification; create standards for approval or denial of
certification, duration of certification, revocation of
certification, and recertification; require the denial of
certification if the provider is excluded from participating in
a Federal health care program under section 1128 or section
1128A of the Social Security Act; establish procedures for
screening eligible providers according to the risk of fraud,
waste, and abuse that are similar to the standards under
section 1866 of Social Security Act and title 48, Code of
Federal Regulations, or successor program; and apply the
restrictions and penalties set forth in chapter 21 of title 41
and treat this section as a procurement program only for the
purposes of applying such provisions.
The new section 1703A(d) would establish the rates paid by
VA to health care providers under a Veterans Care agreement at
the rates paid by the U.S. under section 1703(i) of this title.
The new section 1703A(e) would establish the terms of
Veterans Care Agreements. VA may define the requirements for
providers and entities entering into agreements under this
section based upon such factors as the number of patients
receiving care, the number of employees employed by said
entity, the amount paid by VA to the provider or entity, or
other factors as determined by VA. To furnish care under this
section, an eligible entity or provider shall agree: to accept
payment at the rates established in regulations prescribed
under this section; that payment by VA under this section on
behalf of a veteran to a provider of services or care shall,
unless rejected and refunded by the provider within 30 days of
receipt, constitute payment in full and extinguish any
liability on the part of the veteran for the treatment or care
provided, and no provision of a contract, agreement, or
assignment to the contrary shall operate to modify, limit, or
negate this requirement; to provide only the care and services
authorized by VA under this section and to obtain prior written
consent from VA for any care outside the scope of such
authorization; to bill VA in accordance with the regulations
under this section; to not seek to recover or collect from a
health plan contract or third party for any care or service
that is furnished or paid for by VA; to provide medical records
to VA in the time frame and format specified by VA; and to meet
such other terms and conditions, including quality of care
assurance standards as specified in regulation.
The new section 1703A(f) would establish the
discontinuation or nonrenewal of a Veterans Care Agreement. An
eligible entity or provider may discontinue a Veterans Care
Agreement upon notice to VA as may be provided in regulations
prescribed under this section. VA may discontinue a Veterans
Care Agreement upon such reasonable notice to the eligible
entity or provider as may be specified in regulations under
this section. VA may terminate the contract if an official
designated by VA: has determined that the provider failed to
comply substantially with the provisions of the agreement or
with provision of this section; has determined the provider is
excluded from participation in a Federal health care program
under the Social Security Act or is identified on the System
for Award Management Exclusions list as provided in part 9 of
title 48, Code of Federal Regulations, and part 180 of title 2
of such Code, or successor regulations; has ascertained that
the eligible entity or provider has been convicted of a felony
or other serious offense under Federal or State law and
determines the provider's continued participation would be
detrimental the best interest of veterans or VA; or has
determined that it is reasonable to terminate the agreement
based on health care needs of a veteran.
The new section 1703A(g) would require VA to establish a
system(s) for monitoring the quality of care provided to
veterans through Veterans Care Agreements and for assessing the
quality of care furnished by providers before the renewal of
their agreement.
The new section 1703A(h) would require VA to create
procedures for providers to present all disputes arising under
or related to Veterans Care Agreements. Such procedures
constitute the providers exhaustive and exclusive
administrative remedies. Providers must first exhaust such
administrative procedures before seeking any judicial review
under section 1346 of title 28. Any disputes under this section
must pertain to either the scope of authorization under the
agreement or claims for payment subject to the agreement and
are not claims that would otherwise require application of
sections 7101 through 7109 of title 41 U.S.C.
The new section 1703A(i) would establish the applicability
of other provisions of law under this section. A Veterans Care
Agreement may be authorized by VA and such action shall not be
treated as: an award for the purposes of such laws that would
otherwise require the use of competitive procedures for the
furnishing of care and services; or a Federal contract for the
acquisition of goods or services for purposes of any provision
of Federal law governing Federal contracts for the acquisition
of goods or services except section 4706(d) of title 41 U.S.C.
Unless otherwise specified in this section, any provider that
enters into an agreement is not subject to, in the carrying out
of the agreement, any law to which providers of services under
the Medicare program are not subject. An eligible provider is
subject to: all laws regarding integrity, ethics, or fraud, or
that subject a person to civil or criminal penalties; and all
laws that protect against employment discrimination or that
otherwise ensure equal employment opportunities. A provider
under this section shall not be treated as a Federal contractor
or subcontractor for purposes of chapter 67 of title 41, U.S.C.
The new section 1703A(j) would establish that care
furnished to a veteran under a Veterans Care Agreement shall be
subject to the same terms and provisions as they would be if
receiving care in VA.
The new section 1703A(k) would require VA to promulgate
regulations to carry out this section.
Section 102(b) of this bill provides for a clerical
amendment of the table of sections.
Sec. 103. Conforming amendments for State Veterans Homes
Section 103(a) of this bill would amend section 1745(a) of
title 38, U.S.C. to authorize VA to enter into Veteran Care
Agreements with State Veterans Homes and eliminate competitive
contracting actions and other requirements associated with
federal contracts. State Veterans Homes, while not considered
federal contactors for the purposes of this section, would
still be required to follow federal laws related to fraud,
waste, and abuse as well as employment law.
Section 103(b) of this bill would establish the effective
date as on or after the effective date of regulations issued by
VA.
Sec. 104. Access standards and standards for quality
Section 104(a) of this bill would further amend Subchapter
I of chapter 17 by inserting after section 1703A the following
new sections: ``Sec. 1703B. Access standards'' and
``Sec. 1703C. Standards for quality.''
The new section 1703B(a) would require VA to establish
access standards for furnishing care and services to covered
veterans and shall define such categories to cover all care and
services within the medical benefits package.
The new section 1703B(b) would ensure that the access
standards provide to covered veterans, VA employees, and health
care providers in the establish network, relevant comparative
information that is clear, useful, and timely so that covered
veterans can make informed decisions regarding their care.
The new section 1703B(c) would require VA to consult with
all pertinent Federal entities, private sector entities, and
other nongovernmental entities to create the access standards.
The new section 1703B(d) would require VA to submit to the
appropriate committees of Congress a report detailing the
access standards not later than 270 days after enactment.
Before submitting the report, VA shall provide periodic updates
to confirm progress toward developing the access standards. The
first update shall occur no later than 120 days after
enactment. Following the creation of access standards, VA shall
submit to the appropriate committees of Congress a report
detailing implementation of and compliance with the access
standards. This report shall be submitted no later than 540
days after implementation of the access standards.
The new section 1703B(e) would establish that every three
years after implementation, and no less frequently than once
every three years thereafter, VA must review the access
standards and submit a report to Congress on the findings and
any necessary modifications.
The new section 1703B(f) would require VA to ensure that
health care providers in the network are able to comply with
the access standards.
The new section 1703B(g) would have VA publish in the
Federal Register and on its website the access standards.
The new section 1703B(h) would allow for covered veterans
to contact VA at any time to request a determination of their
eligibility to receive care and services from a non-Department
entity or provider as it pertains to the access standards. VA
shall establish a process to review any requests from covered
veterans to determine clinical necessity for requested care and
if VA is able to provide such care in a manner that complies
with the designated access standards.
The new section 1703B(i) would define terms: ``appropriate
committees of Congress'' and ``covered veteran.''
The new section 1703C(a) would require VA to establish
standards for quality regarding care and services furnished by
VA and non-VA providers. In establishing standards for quality,
VA shall consider existing health quality measures in public
and private health care systems and shall consider data such
as: veteran satisfaction with care and service quality at VA
medical facilities within the past two years; the timeliness of
care; the effectiveness of care; the safety, including
complications, readmissions, and deaths; and efficiency of
care. VA shall consult with all pertinent Federal entities,
entities in the private sector, and other nongovernmental
entities in establishing standards of quality. VA shall submit
to the appropriate committees of Congress a report detailing
the standards for quality not later than 270 days after
enactment. Before submitting the report, VA shall provide
periodic updates to confirm progress toward developing the
standards for quality. The first update shall occur no later
than 120 days after enactment.
The new section 1703C(b) would require VA to publish data
on these quality measures on the Hospital Compare website
through the Centers for Medicare and Medicaid to give veterans
the information necessary to compare performance measures
between VA and community health care providers not later than
one year after implementation of the standards. VA shall
consider and solicit public comment on potential changes not
later than two years after implementation of the standards.
The new section 1703C(c) would define the terms:
``appropriate committees of Congress'' and ``covered veteran.''
Section 104(b) of this bill provides for a clerical
amendment of the table of sections.
Sec. 105. Access to Walk-In Care.
Section 105 of this bill would amend Subchapter I of
chapter 17 by inserting after section 1725 the following new
section: ``Sec. 1725A. Access to walk-in care.''
The new section 1725A(a) would require VA to develop
procedures to ensure eligible veterans can access walk-in care
from non-Department providers.
The new section 1725(b) defines an eligible veteran under
this section as one who is enrolled in the VA health system and
has received care within the last two years.
The new section 1725(c) defines qualifying non-department
entities or providers as a non-department provider or entity
with an agreement or contract with the VA to furnish services
provided under this section.
The new section 1725(d) authorizes VA to utilize Federally
Qualified Health Centers (FQHC), when practicable.
The new section 1725(e) requires VA to ensure continuity of
care for veterans who receive walk-in care, including the
sharing of medical records.
The new section 1725(f) requires VA to establish a
copayment structure for eligible veterans. For the first two
visits in a calendar year, a veteran who would not be required
to pay a copay if not otherwise required to pay such a copay
under this title. Similarly, for the first two visits in a
calendar year, a veteran who would be required to pay a copay
if otherwise required to pay such a copay under this title. The
Secretary shall prescribe by rule any adjusted copayment
requirements for visits furnished after the first two episodes
of care.
The new section 1725(g) requires VA to promulgate
regulations no later than one year after enactment to carry out
this section.
The new section 1725(h) defines ``walk-in care'' as non-
emergent care provided by a qualifying non-Department entity or
provider that furnishes episodic care and not longitudinal
management of conditions.
Section 105(b) of this bill establishes an effective date
upon the implementation of final regulations.
Section 105(c) of this bill provides for a clerical
amendment of the table of sections.
Sec. 106. Strategy regarding the Department of Veterans Affairs high-
performing integrated health care network
Section 106(a) of this bill would amend Subchapter II of
chapter 73 by inserting after section 7330B the following new
section: ``Sec. 7330C. Quadrennial Veterans Health
Administration Review.''
The new section 7330C(a) would require VA to conduct
quadrennial market area assessments, including: demand for VA
healthcare; an inventory of VA's capacity to provide
healthcare; an assessment of community contract capacity; an
assessment obtained from other Federal direct delivery systems
of their capacity to provide health care to veterans; an
assessment of the health care capacity of non-contracted
providers where there is insufficient network supply; an
assessment of the health care capacity of academic affiliates
and other VA collaborations as it relates to providing health
care to veterans; an assessment of the effects on VA health
care capacity by the access and quality standards established
under this bill; and the number of appointments for health care
services, disaggregated by VA medical facilities and non-
Department health care providers. VA shall submit to the
appropriate committees of Congress the market area assessments
and shall ensure that the Department budget for any fiscal year
reflects the findings of the most recent market assessments.
The new section 7330C(b) of the bill would require VA to
submit one year after the date of enactment and not less
frequently than once every four years thereafter to the
appropriate committees a strategic plan that specifies a four-
year forecast of demand for care from the Department, capacity
provided by each medical center of the Department, and capacity
provided through community care providers. In developing the
strategic plan, the Secretary shall assess access and quality
standards, assess market assessments, assess the needs of the
Department to provide for service connected conditions, consult
with key stakeholders, identify emerging issues, trends and
opportunities, develop recommendations, consider surveys,
examine existing programs and policies, assess remediation of
medical service lines, and consider other matters as
appropriate.
The new section 7330C(c) outlines responsibilities of VA
for overseeing transformation and organizational changes across
the Department, developing capital infrastructure planning and
procurement, and developing a multi-year budget process.
The new section 7330C(d) defines ``Appropriate Committees
of Jurisdiction.''
Section 106(b) of this bill provides for a clerical
amendment of the table of sections.
Sec. 107. Applicability of directive of Office of Federal Contract
Compliance programs
Section 107(a) of this bill would require the same
affirmative action moratorium on Veterans Care Agreement
contractors and subcontractors as is applied to TRICARE
contractors and subcontractors in Directive 2014-01 of the
Office of Federal Contract Compliance Programs of the
Department of Labor.
Section 107(b) of this bill would direct the above
moratorium to not be altered or rescinded until May 19, 2019.
Section 107(c) of this bill defines the term ``TRICARE
program.''
Sec. 108. Prevention of certain health care providers from providing
non-Department health care services to veterans
Section 108(a) of this bill would allow VA to deny or
revoke the eligibility of a provider to provide non-Department
care if VA deems that provider was removed from employment with
the Department due to conduct relating to the delivery of safe
and appropriate care or violated the requirements of a medical
license that resulted in the loss of such license.
Section 108(b) of this bill would allow VA permissive
action to deny, revoke, or suspend the eligibility of a health
care provider to provide non-Department care on and after the
date that is one year after enactment.
Section 108(c) of this bill would require VA to suspend the
eligibility of a non-VA provider if the provider is suspended
from serving as a VA provider.
Section 108(d) of this bill would require the Comptroller
General of the United States to submit to Congress a report on
the implementation of this section, including: the aggregate
number of health care providers denied or suspended; an
evaluation of any impact on access to care for patients or
staffing shortages; an explanation of the coordination of VA
with medical licensing boards of States and the efforts of VA
to address any concerns from these boards; and any
recommendations the Comptroller General finds appropriate.
Section 108(e) of this bill would define the term: ``non-
Department health care services.''
Sec. 109. Remediation of medical services lines
Section 109(a) of this bill would amend subchapter I of
chapter 17 by inserting after section 1706 the following new
section: ``Sec. 1706A. Remediation of medical service lines.''
The new section 1706A(a) would require VA to submit to
Congress a plan to remediate medical service lines not later
than 30 days after determining that the service line does not
comply with standards for quality. The specific actions shall
include, but are not limited to: increasing personnel or
temporary personnel assistance, including mobile deployment
teams; utilizing special hiring incentives, including the
Education Debt Reduction Program (EDRP) and recruitment,
relocation, and retention incentives; utilizing direct hiring
authority; providing improved training opportunities for staff;
acquiring improved equipment; making structural modifications
to the facility used by the medical service line; and such
other actions as VA considers appropriate.
The new section 1706A(b) would require each report to
include the individuals at the Central Office of the Veterans
Health Administration, the facility used by the medical service
line, and the central office of relevant Veterans Integrated
Service Network who are responsible for overseeing the progress
of the service line.
The new section 1706A(c) would require VA to submit interim
reports to Congress on the remediation actions and costs taken
for each medical service line submitted for assessment. This
analysis shall be published on the VA's website.
The new section 1706A(d) would require VA to submit annual
reports to Congress on the remediation actions and costs taken
for each medical service line submitted for assessment. This
analysis shall be published on the VA's website.
Section 109(b) of this bill provides for a clerical
amendment of the table of sections.
Chapter 2--Paying Providers and Improving Collections
Sec. 111. Prompt payment to providers
Section 111(a) of this bill would amend subchapter I of
chapter 17 by inserting after section 1703C, the following new
section: ``Sec. 1703D. Prompt payment standards.''
The new section 1703D(a) would establish a prompt payment
process that requires VA to pay for, or deny payment for,
services within 30 calendar days of receipt of a clean
electronic claim or within 45 calendar days of receipt of a
clean paper claim. In the case of a denial, VA would have to
notify the provider of the reason for denying the claim and
what, if any, additional information would be required to
process the claim. Upon the receipt of the additional
information, VA would have to pay, deny, or otherwise
adjudicate the claim within 30 calendar days. These
requirements would only apply to payments made on an invoice
basis and would not apply to capitation or other forms of
periodic payments to entities or providers.
The new section 1703D(b) would establish that Non-VA
entities or providers would be required to submit a claim to VA
within 180 days of providing care or services.
The new section 1703D(c) would establish the application of
title 31 to fraudulent claims. The Secretary shall prescribe
regulations barring a health care entity or provide from
furnishing care or services if it is determined that such
entity or provider submitted fraudulent claims.
The new section 1703D(d) would establish that any claim
that has not been denied, made pending, or paid within the
specified time periods would be considered overdue and subject
to interest payment penalties. VA to report annually on the
number of and the amount paid in overdue claims.
The new section 1703D(e) would authorize VA to deduct the
amount of any overpayment from payments due to an entity or
provider under certain conditions.
The new section 1703D(f) would require VA to provide to all
health care entities and providers in the program a list of
information and documentation that is required to establish a
clean claim under this section.
The new section 1703D(g) would allow VA to have claims
processing performed by either a contracted third-party
administrator or other entity to conduct these administrative
functions. This section would require an independent review of
claims that includes the capacity of VA to process such claims
in a timely manner and a cost benefit analysis comparing the
capacity of VA to a third-party entity capable of processing
such claims.
The new section 1703D(h) would require VA to submit to the
appropriate committees of Congress a report on the feasibility
and advisability of adopting a funding mechanism similar to
what is utilized by other Federal agencies.
The new section 1703D(i) would define the terms:
``appropriate committees of Congress'', ``clean electronic
claim'', ``clean paper claim'', ``fraudulent claims'', and
``health care entity or provider.''
Section 111(b) of this bill provides for a clerical
amendment of the table of sections
Sec. 112. Authority to pay for authorized care not subject to an
agreement.
Section 112(a) of this bill would amend subchapter IV of
chapter 81 by adding the following new section: ``Sec. 8159.
Authority to pay for services authorized but not subject to an
agreement.''
The new section 8159(a) would authorize VA to pay for
services not subject to a contract or agreement.
The new section 8159(b) would require VA to take reasonable
efforts to enter into a contract or agreement with a provider
to ensure that future care and services authorized by VA are
subject to the contract.
Section 112(b) of this bill provides for a clerical
amendment of the table of sections.
Sec. 113. Improvement of authority to recover the cost of services
furnished for non-service-connected disabilities
Section 113(a) of this bill would allow for VA to collect
from a third-party for care provided to non-veterans by
amending section 1729.
Section 113(b) of this bill would authorize VA to seek
collections when VA pays for care rather than furnishing it.
This section also removes duplicative language.
Section 113(c) of this bill would amend the statute on
eligible individuals.
Sec. 114. Processing of claims for reimbursement through electronic
interface
Section 114 of this bill would allow VA to enter into an
agreement with a third-party entity to electronically process
health care claims from community providers.
Chapter 3--Education and Training Programs
Sec. 121. Education program on health care options
Section 121(a) of this bill would require VA to develop and
administer an education program that teaches veterans about
their health care options.
Section 121(b) of this bill would establish the elements of
the program. It shall teach veterans about: eligibility
criteria for care from VA; priority groups for enrollment; the
copayments and other financial obligations, if any apply; how
to utilize the access standards and standards for quality;
teach veterans about the interaction between health insurance
and VA; and provide information on what to do when filing a
complaint about health care received.
Section 121(c) of this bill would require VA to ensure that
such programs are accessible to all veterans, regardless of
internet access or disabilities.
Section 121(d) of this bill would require VA to develop a
method to evaluate the effectiveness of the education program
and once a year, submit a report to Congress on the evaluations
of the education program.
Section 121(e) of this bill would define the terms:
``Medicaid'', ``Medicare'', and ``TRICARE program.''
Sec. 122. Training program for administration of non-Department of
Veterans Affairs health care
Section 122(a) of this bill would require VA to develop and
implement a training program to train employees and contractors
of VA on how to administer non-VA health care programs,
particularly the management of prescription opioids.
Section 122(b) of this bill would require VA to develop a
method to evaluate the effectiveness of the training program
and shall submit to Congress an annual report on the findings
of the evaluation.
Sec. 123. Continuing medical education for non-Department medical
professionals
Section 123(a) of this bill would establish a program to
provide continuing medical education material to non-VA medical
professionals at no cost to them.
Section 123(b) of this bill would establish that the
material provided to non-VA professionals be the same material
provided to VA professionals.
Section 123(c) of this bill would require VA to administer
the program, determine the curriculum of the program, ensure
the accreditation of the program in as many States as possible,
ensure the consistence of the program with rules and
regulations of medical licensing agency in each State, that the
program is no cost to the participant, and that VA monitor,
evaluate, and report to Congress on the utilization and
effectiveness once a year.
Section 123(d) of this bill would define ``non-Department
medical professional.''
Chapter 4--Other Matters Relating to Non-Department of Veterans Affairs
Providers
Sec. 131. Establishment of processes to ensure safe opioid prescribing
practices by non-Department of Veterans Affairs health care
providers
Section 131(a) of this bill would require VA to ensure that
all covered health care providers are provided a copy of and
certify that they have reviewed the evidence-based guidelines
for prescribing opioids set forth by the Opioid Safety
Initiative of VA.
Section 131(b) of this bill would require VA to implement a
process to ensure that, if a veteran is provided care by a
covered provider under the laws administered by VA, the
provider submit medical history of the veteran to VA.
Section 131(c) of this bill would require all covered
providers to submit medical record of any care furnished,
including prescriptions of opioids, to VA for each veteran
seen. Upon receiving these records, VA is responsible for
entering the prescriptions into the electronic health record of
the veteran, and VA is responsible for monitoring the
prescription as outlined in the Opioid Safety Initiative. VA
must submit an annual report to Congress evaluating the
compliance of cover providers with the requirements of this
section.
Section 131(d) of this bill would require VA to take
appropriate action with a covered provider determined to not be
adhering to or complying with the Opioid Safety Initiative. VA
may refuse authorization of care by such provider and direct
their removal from the network.
Section 131(e) of this bill would define ``covered health
care provider.''
Sec. 132. Improving information sharing with community providers
Section 132 of this bill would amend section 7332(b)(2) to
clarify that VA could share medical record information with
non-Department entities for the purpose of providing health
care to patients or performing other health care related
activities and remove certain restrictions on VA's ability to
recover funds from third parties for the cost of non-service-
connected care.
Sec. 133. Competency standards for non-Department of Veterans Affairs
health care providers
Section 133(a) of this bill would require VA to establish
standards and requirements for the provision of care by non-VA
health care providers in clinical areas for which VA has
special expertise, including post-traumatic stress disorder,
military sexual trauma-related conditions, and traumatic brain
injuries.
Section 133(b) of this bill would, to the extent possible,
require covered health care providers who are in a clinical
area of expertise for VA to fulfill training requirements
determined by VA, before furnishing care.
Section 133(c) of this bill would establish an effective
date at one year after the date of enactment.
Sec. 134. Department of Veterans Affairs participation in national
network of State-based prescription drug monitoring program
Section 134(a) of this bill would amend chapter 17 by
inserting after section 1730A the following new section:
``Sec. 1730B. Access to State prescription drug monitoring
programs.''
The new section 1730B(a) would allow any licensed health
care provider or delegate to be considered an authorized
recipient or user of data from the national network of State-
based prescription drug monitoring programs. Under this
authority, licensed health care providers or delegates would be
required to query the network in accordance with applicable VA
regulations and policies and no State would be authorized to
restrict the access of licensed health care providers or
delegates from accessing that State's prescription drug
monitoring programs.
The new section 1730B(b) would define ``covered patients.''
The new section 1730B(c) would define terms: ``controlled
substance'', ``delegate'', ``licensed health care provider'',
``national network of State-based prescription monitoring
programs'', and ``State''.
Section 134(b) of this bill provides for a clerical
amendment of the table of sections.
Chapter 5--Other Non-Department Health Care Matters
Sec. 141. Plans for use of supplemental appropriations required
Section 141 of this bill would require VA to submit to
Congress a justification for any new supplemental
appropriations request submitted outside of the standard budget
process no later than 45 days before the date on which a
budgetary issue would start affecting a program or service. It
would also require a detailed strategic plan on how VA intends
to use the requested appropriation and for how long the
requested funds are expected to meet the need.
Sec. 142. Veterans Choice fund flexibility
Section 142 of this bill would amend section 802 of the
Choice Act to authorize VA, beginning March 1, 2019, to use the
remaining Veterans Choice Fund to pay for any health care
services under Chapter 17 of Title 38 at non-Department
facilities or through non-Department providers furnishing care
in VA facilities.
Sec. 143. Sunset of Veterans Choice Program
Section 143 of this bill would provide a sunset date for
the Veterans Choice Program one year after the date of
enactment of this Act.
Sec. 144. Conforming amendments
Section 144 of this bill would repeal and replace existing
authorities to account for changes made by section 101 of the
bill to consolidate and create the Veterans Community Care
program.
Subtitle B--Improving Department of Veterans Affairs Health Care
Delivery
Sec. 151. Licensure of health care professionals of the Department of
Veterans Affairs providing treatment via telemedicine
Section 151(a) of this bill would amend Chapter 17 by
inserting after section 1730B, as added by section 134, the
following new section: ``Sec. 1730C. Licensure of health care
professionals providing treatment via telemedicine.''
The new section 1730C(a) would allow covered health care
professionals to practice at any location in any State if using
telemedicine under this chapter.
The new section 1730C(b) would define a ``covered health
care professional.''
The new section 1730C(c) would enforce that subsection (a)
of this section shall apply to a covered health care
professional regardless of whether they are located in a
Federally owned facility during the treatment.
The new section 1730C(d) would establish that this
provision shall supersede any provisions of State law if those
provisions are inconsistent with this section.
The new section 1730C(e) would establish that nothing may
be construed to remove, limit, or otherwise affect any
obligation of a covered health care professional under the
Controlled Substance Act.
The new section 1730C(f) would define ``State.''
Section 151(b) of this bill provides for a clerical
amendment of the table of sections.
Section 151(c) of this bill would require VA to submit a
report to Congress on the effectiveness of telemedicine within
one year of enactment, providing data on provider and patient
satisfaction, the effect of telemedicine on patient wait-times,
health care utilization, and other measures.
Sec. 152. Authority for Department of Veterans Affairs Center for
Innovation for Care and Payment
Section 152(a) of this bill would amend subchapter I of
chapter 17 by inserting after section 1703D, as added by
section 11, the following new section: ``Sec. 1703E. Center for
Innovation for Care and Payment.''
The new section 1703E(a) would authorize VA to carry out
pilot programs to develop innovative approaches to testing
payment and service delivery models to reduce expenditures
while preserving or improving the quality of care. VA would be
required to test models where VA determines that there is
evidence that the model addresses a defined population for
which there are deficits in care leading to poor clinical
outcomes or potentially avoidable expenditures. VA would be
required to focus on models expected to reduce program costs
while preserving or enhancing the quality of or access to care
VA provides. VA would be authorized to consider a number of
different factors in selecting models to test. The models
tested under this program could not be designed in such a way
as to allow the United States to recover or collect reasonable
charges from a Federal health care program (including Medicare,
Medicaid, and TRICARE) for care or services furnished by VA to
veterans.
The new section 1703E(b) would authorize the pilot programs
to last no longer than five years.
The new section 1703E(c) would require VA ensure that each
pilot program occurs in an area or areas appropriate for the
intended purpose of the program. To the extent possible, the
programs shall be located in geographically diverse areas.
The new section 1703E(d) would establish that the funding
for the pilot programs shall come from appropriations provided
in advance for VHA and information technology systems.
The new section 1703E(e) would require VA to publish
information and take all reasonable action to give notice to
veterans eligible to participate in the pilot programs.
The new section 1703E(f) would authorize VA to waive any
requirements under Title 38 only after submitting a report to
Congress explaining the authorities to be waived and the
reasons for such requirement. VA would only be allowed to act
upon any such waiver after Congress enacts a joint resolution
approving the action.
The new section 1703E(g) would limit VA to carrying out no
more than ten pilot programs concurrently and would prohibit VA
from spending more than $50 million per fiscal year on the
programs. This limit may be increased only if VA receives
written consent from the Chairmen of the Committees on
Veterans' Affairs in the House and the Senate, respectively.
The new section 1703E(h) would require VA to conduct an
evaluation of each model tested, which shall include an
analysis of the quality of care furnished under the model,
including the measurement of patient-level outcomes and
patient-centeredness criteria determined by VA and the changes
in spending by reason of that model. VA shall make the results
of each evaluation public in the Federal Registry.
The new section 1703E(i) would establish that VA shall
obtain advice from the Under Secretary for Health and the
Special Medical Advisory Group to develop and implement any of
the pilot programs, as well as consult relevant Federal
agencies and interested parties.
The new section 1703E(j) would authorize VA to expand,
through rulemaking, the duration and scope of successful pilot
programs to the extent VA determines that such expansion is
expected to reduce spending without reducing the quality of or
access to care or improve the quality of or access to care
without increasing spending; VA would also have to determine
that such expansion would not deny or limit the coverage or
provision of benefits for applicable individuals.
Section 152(b) of this bill provides for a conforming
amendment of the table of sections.
Sec. 153. Authorization to provide for operations on live donors for
purposes of conducting transplant procedures for veterans
Section 153(a) of this bill would amend subchapter VIII of
chapter 17 by adding the following new section: ``Sec. 1788.
Transplant procedures with live donors and related services.''
The new section 1788(a) would authorize VA to provide for
an operation on a live donor, regardless of the donor's
eligibility for VA health care, if the procedure is for an
eligible veteran.
The new section 1788(b) would require VA to provide any
care or services before and after conducting the transplant
procedure.
The new section 1788(c) would allow VA to, in carrying out
this section, provide the care and services from subsection (a)
and (b) of this section in a non-VA facility, provided VA has
an agreement with the facility.
Section 153(b) of this bill provides for a clerical
amendment of the table of sections.
Subtitle C--Family Caregivers
Sec. 161. Expansion of Family Caregiver Program of Department of
Veterans Affairs
Section 161(a) of this bill would amend Subparagraph (B) of
subsection (a)(2) of section 1720G to expand eligibility for
VA's Program of Comprehensive Assistance for Family Caregivers
to veterans with a serious injury incurred or aggravated in the
line of duty in the active military, naval, or air service on
or before May 7, 1975. After the date that is two years after
the date on which the certification is submitted, eligibility
would be expanded to also include veterans with a serious
injury incurred or aggravated in the line of duty in the active
military, naval, or air service after May 7, 1975, and before
September 11, 2001. Not later than 30 days after the date on
which VA submits to Congress the certification of this title,
VA shall publish the date specified in such subsection in the
Federal Register. The stipend calculation is also modified, and
VA shall take into account: the assessment by the family
caregiver of the needs of the veteran; the extent to which the
veteran can function safely and independently; and the amount
of time required for the family caregiver to provide assistance
to the veteran. VA shall provide instruction, preparation, and
training, as well as technical support, to each family
caregiver who is approved as a provider of personal care for an
eligible veteran. VA shall periodically evaluate the needs of
the eligible veteran to determine if additional instruction,
training, or technical support is needed. VA may enter into
agreements with Federal agencies, States, and private entities
to provide assistance to family caregivers, and VA may provider
fair compensation to these entities for assistance rendered.
Section 161(b) of this bill would modify the definition of
``personal care services'' under Subsection (d)(4).
Sec. 162. Implementation of information technology system of Department
of Veterans Affairs to assess and improve the Family Caregiver
Program
Section 162(a) of this bill would require VA to implement
an information technology system that fully supports the Family
Caregiver Program and allows for data assessment and
comprehensive monitoring by not later than October 1, 2018.
Section 162(b) of this bill would require VA to use data
from the system to conduct an assessment of key aspects of the
program and how they are carried out. The assessment shall
occur no later than 180 days after implementation of the
system.
Section 162(c) of this bill would establish that VA shall
use the system to monitor and assess the workload of the
Program and the use of support services by the caregivers.
Based on the monitoring and assessment, VA shall identify and
implement modifications to ensure the program is functioning as
intended.
Section 162(d) of this bill would require VA to submit a
report to Congress and the Comptroller General of the United
States not later than 90 days after the date of enactment of
this bill. The Comptroller General shall review the report and
notify Congress on the progress and assessment of the system.
Section 162(e) of this bill would define the terms:
``active military, naval, or air service'' and ``Program.''
Sec. 163. Modifications to annual evaluation report on Caregiver
Program of Department of Veterans Affairs
Section 163(a) of this bill would amend subparagraph
(A)(iv) of section 101(c)(2) of the Caregivers and Veterans
Omnibus Health Services Act by inserting ``including a
description of any barriers to accessing and receiving care and
services und such programs.''
Section 163(b) of this bill would amend Subparagraph (b) of
such section by inserting a requirement for an evaluation of
the sufficiency and consistency of caregiver training.
TITLE II--VA ASSET AND INFRASTRUCTURE REVIEW
Subtitle A--Asset and Infrastructure Review
Section 201. Short title
Section 201 of this bill would establish the short title of
the subtitle as the ``VA Asset and Infrastructure Review Act of
2018.''
Section 202. The Commission
Section 202(a) of this bill would establish an independent
``Asset and Infrastructure Review Commission.''
Section 202(b) of this bill would require the Commission to
carry out the duties described in this title.
Section 202(c) of this bill would require the President,
with the advice and consent of the Senate, to appoint nine AIR
Commissioners and to transmit nominations to the Senate by May
31, 2021. Additionally, it would require the President to
consult with the Speaker and minority leader of the House of
Representatives and the majority and minority leader of the
Senate in selecting individuals for Commission nomination and
congressionally chartered, membership-based veterans service
organizations (VSOs) specifically concerning the appointment of
three members. The President would be required to nominate one
person to serve as the Chair of the Commission and one person
to serve as the Vice Chair of the Commission, and in nominating
individuals for appointment to the Commission, to ensure: that
veterans (reflecting current demographics of veterans enrolled
in the VA health care system) are adequately represented in the
membership of the Commission; that at least one member of the
Commission has experience with a private integrated health care
system that has annual gross revenue of more than $50 million;
that at least one member has experience as a senior manager for
a Federally-qualified health center, the Department of Defense,
or the Indian Health Service; that at least one member has
experience with capital asset management for the Federal
government and is familiar with trades related to building and
real property (including construction, engineering,
architecture, leasing, and strategic partnerships); and, that
at least three members represent congressionally-chartered,
membership-based VSOs.
Section 202(d) of this bill would require the Commission to
meet only during calendar years 2022 and 2023, and requires
that each meeting of the Commission be open and all
proceedings, information, and deliberations of the Commission
to be available for review by the public.
Section 202(e) of this bill would require a vacancy in the
Commission to be filled in the same manner as the original
appointment, but the individual appointed to fill the vacancy
to serve only for the unexpired portion of the term for which
the individual's predecessor was appointed.
Section 202(f) of this bill would require Commissioners to
serve without pay, requires each member of the Commission who
is an officer/employee of the United States to only receive
compensation for their services as an officer/employee of the
U.S, and allows Commissioners to receive travel expenses,
including per diem.
Section 202(g) of this bill would require the Commission to
appoint a staff director who has not served as a VA employee
during the one-year period preceding the date of appointment
and who is not otherwise barred or prohibited from serving as a
Director under Federal ethics law and regulations by reason of
post-employment conflict of interest and requires the Director
to be paid at the rate of basic pay payable for level IV of the
Executive Schedule.
Section 202(h) of this bill would require the Director,
with the approval of the Commission, to appoint and fix the pay
of additional personnel, to make such appointments without
regard to the provisions of title 5 U.S.C. governing
appointments in the competitive service, and any personnel so
appointed to be paid without regard to provisions relating to
the classification and General Schedule pay rates except that
an individual so appointed may not receive pay in excess of the
annual rate of basic pay payable for GS-15. This bill would
allow not more than two-thirds of the personnel employed by or
detailed to the Commission to be on detail from VA and not more
half of the professional analysts to be detailed from VA. This
section also prohibits a person from being detailed to the
Commission from VA if, within six months before the detail is
set to begin, the person participated personally or
substantially in any matter concerning the preparation of
recommendations regarding Veterans Health Administration (VHA)
facilities. Additionally, it would allow any Federal department
or agency to detail personnel to the Commission upon request.
Lastly, this bill would allow the Commission to secure
necessary information from Federal agencies and Federal
agencies to furnish such information upon request.
Section 202(i) of this bill would allow the Commission to
procure, by contract to the extent funds are available, the
temporary or intermittent services or experts of consultants
and to lease real property and acquire personal property either
of its own accord or in consultation with the General Services
Administration (GSA).
Section 202(j) of this bill would terminate the Commission
on December 31, 2023.
Section 202(k) of this bill would prohibit the restriction
of lawful communication from a VA employee to the Commission.
Section 203. Procedure for making recommendations
Section 203(a) of this bill would require VA, not later
than February 1, 2021, and after consulting with VSOs, to
publish in the Federal Register and transmit to the Committees
on Veterans' Affairs of the House of Representatives and the
Senate the criteria proposed by VA to be used in assessment and
making recommendations regarding the modernization or
realignment of VHA facilities and require such criteria to
include the veteran's preference regarding access to VA health
care. VA would be required to hold a 90-day public comment
period for VA's proposed criteria, and, not later than May 31,
2021, to publish in the Federal Register and transmit to HVAC/
SVAC, the final criteria to be used in making recommendations
regarding the modernization or realignment of VHA facilities.
Section 203(b) of this bill would require VA, not later
than January 31, 2022, and after consulting with VSOs, to
publish in the Federal Register and transmit to Committees on
Veterans' Affairs of the House of Representatives and the
Senate a report detailing recommendations regarding the
modernization or realignment of VHA facilities. VA would be
required to consider the following factors in making
recommendations regarding the modernization or realignment of
VHA facilities: the degree to which health care delivery or
other site for providing services to veterans reflect VA's
metrics regarding market area health system planning; the
provision of effective and efficient access to high-quality
health care and services to veterans; the extent to which real
property that no longer meets the needs of the Federal
Government could be reconfigured, repurposed, consolidated,
realigned, exchanged, outleased, repurposed, replaced, sold, or
disposed; VHA's need to acquire infrastructure or facilities
that will be used for the provision of health care and service
to veterans; the extent to which operation and maintenance
costs are reduced through consolidating, collocating, and
reconfiguring space and through realizing other operational
efficiencies; the extent and timing of potential costs and
savings, including the number of years such costs and savings
will be incurred, beginning with the date of completion of the
proposed recommendation; the extent to which the real property
aligns with VA's mission; the extent to which any action would
impact other VA missions including education, research, or
emergency preparedness; local stakeholder inputs and any
factors identified through public field hearings; capacity and
commercial market assessments; and, any other factors VA
determines appropriate. VA would be required to assess the
capacity of each Veterans Integrated Service Network (VISN) and
VA medical facility to furnish hospital care or medical
services to veterans and require each assessment to: identify
existing deficiencies in the furnishing of care and services to
veterans and how such deficiencies may be filled by entering
into contracts or agreements with community health care
providers or other entities under other provisions of law and
changing the way care and services are furnished at such VISNs
or VA medical facilities (including through extending hours of
operation, adding personnel, and expanding treatment space
through construction, leasing, or sharing of health care
facilities); forecast, based on future projections and
historical trends, both the short-term and long-term demand in
furnishing care and services at such VISN or VA medical
facility; consider how demand affects the need to enter into
contracts or agreements; consider the commercial health care
market of designated catchment areas conducted by a non-
governmental entity; and, consider the unique ability of the
Federal government to retain a presence in a rural area
otherwise devoid of commercial health care providers or from
which such providers are at risk of leaving. VA would be
required to consult with VSOs and veterans served by each VISN
and medical facility affected by the assessments. VA would be
required to submit the local capacity and commercial market
assessments to Committees on Veterans' Affairs of the House of
Representatives and the Senate with the recommendations
regarding the modernization or realignment of VHA facilities
and to make the assessments publicly available. VA would be
required to include with the recommendations regarding the
modernization or realignment of VHA facilities a summary of the
selection process that resulted in the recommendation for each
VHA facility and a justification for each recommendation and to
transmit the summaries and justifications not later than 7 days
after the date of transmittal to HVAC/SVAC. VA shall consider
all facilities equally without regard to whether the facility
has been previously considered or proposed for reuse,
modernization, or realignment. VA shall make all information
used by VA to prepare a recommendation available to Congress,
the Commission and the Comptroller General. Each VA Under
Secretary, VISN director, VA medical center director, VA
program office director, and each person who is in a position
of duties which includes personal and substantial involvement
in the preparation and submission of information and
recommendations concerning the modernization or realignment of
VHA facilities would certify that information submitted to VA
or to the Commission concerning the modernization or
realignment of VHA facilities is accurate and complete to the
best of that person's knowledge and belief. The Commission is
required to conduct public hearings on VA's recommendations
regarding the modernization or realignment of VHA facilities,
to include required public hearings in regions affected by a VA
recommendation for the closure of a facility and, to the
greatest extent practicable, public hearings in regions
affected by a recommendation for other (non-closure) action by
VA. Each Commission public hearing shall include, at a minimum,
a local veteran who is enrolled in the VA healthcare system and
identified by a local VSO and a local elected official. The
Commission shall, not later than January 31, 2023, to transmit
to the President a report and analysis of the recommendations
made by VA together with the Commission's recommendations for
the modernization or realignment of VHA facilities. The
Commission is authorized to change a recommendation made by VA
for the modernization or realignment of a VHA facility only if
the Commission: determines that VA deviated substantially from
VA's final criteria in making such recommendation; determines
that the change is consistent with the final criteria;
publishes a notice of the proposed change in the Federal
Register not less than 45 days before transmitting the
Commission's recommendations to the President; and, conducts
public hearings on the proposed change. The Commission must
explain and justify any recommendation made by the Commission
that is different from the recommendations made by VA in the
Commission's report that is transmitted to the President and to
transmit the copy of such report to Committees on Veterans'
Affairs of the House of Representatives and the Senate on the
same day that it is transmitted to the President. The
Commission, after transmitting its report to the President,
shall promptly provide information used by the Commission in
making its recommendations to any Member of Congress upon
request.
Section 203(d) of this bill would require the President,
not later than February 15, 2023, to transmit to the Commission
and to Congress a report containing the President's approval or
disapproval of the Commission's recommendations. If the
President approves of the Commission's recommendations, the
President is required to transmit a copy of the Commission's
recommendations to the Congress together with a certification
of approval. If the President disapproves of the Commission's
recommendations in whole or in part, the President is required
to transmit to the Commission and the Congress the reasons for
that disapproval and require the Commission, not later than
March 15, 2023, to transmit a report containing the
Commission's findings and conclusions based on the review and
analysis of the reasons for disapproval and a list of
recommendations that the commission determines are appropriate
to the President. If the President approves of the Commission's
resubmitted recommendations, the President is required to
transmit a copy of the recommendations to Congress together
with a certification of such approval. This bill would require
the process for modernization or realignment of VHA facilities
to be terminated, if the President does not transmit a
certification of approval to Congress, by March 30, 2023.
Section 204. Actions regarding infrastructure and facilities of the
Veterans Health Administration
Section 204(a) of this bill would require VA, in the
absence of a resolution of Congressional disapproval having
been enacted within 45 days of Presidential transmission of the
report to Congress or the adjournment of the 117th Congress, to
begin implementing the recommendations made in the report under
Section 103(d) within 3 years the President having transmitted
the report to Congress.
Section 204(b) of this bill would allow VA not to carry out
any modernization or realignment recommendations by the
Commission in a report transmitted from the President if a
joint resolution is enacted disapproving such recommendations
of the Commission before the earlier of: the end of the 45-day
period beginning on the date on which the President transmits
such report; or the adjournment of Congress sine die for the
session during which a report is transmitted. Implementation
includes the planning of modernizations or realignments. Days
on which either House is not in session because of adjournment
of more than three days shall be excluded from the computation
of the period.
Section 205. Implementation
Section 205(a) of this bill would allow VA to take such
actions as necessary to implement the modernization or
realignment of any VHA facility, perform environmental
mitigation, abatement or restoration of facilities being closed
or realigned to include compliance with historical preservation
requirements, provide outplacement assistance to employees of
the Department, reimburse Federal agencies for services, and
enter into Enhanced Use Lease contracts.
Section 205(b) of this bill would outline how VA may
dispose or transfer surplus properties slated for disposal or
realignment under this Act, including consultation with state
and local governments for proper disposal of real property and
roads. VA may transfer title to a redevelopment authority for a
facility for the purposes of a federal lease for a term not to
exceed 50 years. Such lease may not require rental payments by
the government. If the lease involves a substantial portion of
the facility, the department or agency may obtain facility
services from the redevelopment authority as a provision of the
lease. Such services shall not include municipal services,
firefighting or security guard functions. Provisions of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980 apply. Nothing in this title shall limit
or otherwise affect application of McKinney-Vento Homeless
Assistance Act provisions.
Section 205(c) of this bill would exempt the actions of the
President, Commission, and the VA, except during the process of
disposal and relocation, from the National Environmental Policy
Act of 1969. The Secretary shall not have to consider the need
for closing, realigning, transferring function, or alternative
facilities in carrying out the this subtitle.
Section 205(d) of this bill would exempt VA from any legal
prohibition of closing or realigning VHA facilities included in
any appropriation or authorization Act.
Section 205(e) of this bill would provide the authority for
VA to transfer a deed of a VHA facility to a party who agrees
to perform the environmental compliance activities that are
required under Federal and State laws. Such transfer may occur
if VA certifies to Congress that all costs to be paid by the
Department are equal to or greater than market value or if such
cost are lower than the recipient of the transfer agrees to pay
the difference, and authorizes VA to pay the recipient an
amount equal to the lesser of the two such amounts. VA would be
required to disclose information regarding environmental
restoration, waste management, and environmental compliance
activities before entering into a deed transfer.
Section 206. Department of Veterans Affairs Asset and Infrastructure
Review Account
Section 206(a) of this bill would establish a single
account in the ledgers of the US Treasury with which VA shall
administer as a single account. The account shall be known as
``Department of Veterans Affairs Asset and Infrastructure
Review Account.''
Section 206(b) of this bill would allow for the credit to
the account any funds authorized and appropriated and any
proceeds from a lease, transfer, or disposal of property.
Section 206(c) of this bill would allow VA to use the
account for the purposes of carrying out this subtitle, to
cover property management and disposal costs, to cover costs of
supervision, inspection, overhead, engineering, and design, or
for any other purposes in support of the Department's mission
and operations.
Section 206(d) of this bill would require VA to establish a
consolidated budget display detailing the amount and nature of
the credits to and expenditures from, separately details
environmental remediation costs, specifies and details any
transfers, and details any intra-budget activity transfers with
the account that does or will exceed one million dollars during
a fiscal year. This information shall be submitted to Congress
as part of the Presidential budget submission.
Section 206(e) of this bill would require that upon closure
of the account any unobligated funds, upon submission of an
accounting report to the appropriate committees of Congress,
shall be transferred from the Treasury to VA. No later than 60
days after the closure of the Account, VA shall submit a report
to the appropriate committees of Congress detailing all the
funds credited to and expended from the Account and any
remaining funds.
Section 207. Congressional consideration of Commission report
Section 207(a) of this bill would describe the term ``joint
resolution'' as a resolution introduced within the 45-day
period beginning on the date on which the President transmits
the report to congress which does not include a preamble and
contains specific language as to the resolving clause and
title.
Section 207(b) of this bill would outline the means by
which the House of Representatives shall consider such
resolution to include reporting and discharge, proceeding to
consideration, and consideration.
Section 207(c) of this bill outlines the means by which the
Senate shall consider such resolution to include referral,
reporting and discharge, and floor consideration to include
consideration, vote on passage, and ruling of the chair on
procedure.
Section 207(d) of this bill would prohibit any amendment to
a joint resolution of disapproval.
Section 207(e) of the bill would define the coordination
between either House upon receipt of companion measures.
Section 207(f) of the bill would state that this section is
applicable only with respect to the procedure followed in that
House in the case of a joint resolution and supersedes other
rules only to the extent that it is inconsistent with such
rules, with the recognition of the constitutional right of
either House to change the rules.
Section 208. Other matters
Section 208(a) of the bill would require the online
publication of all communications, within 24 hours, between VA,
the Commission and the President with regards to this title.
Section 208(b) of this bill would prohibit the VA from
pausing or stopping any scheduled construction, leasing, long-
term planning project activities, or budgetary processes with
regards to the construction during the activities of the
Commission, President, or Congress in carrying out this title.
Section 208(c) of this bill authorizes the Secretary to
recommend, via budget submissions, any recommendations for
future commissions or other capital realignment and management
processes.
Section 209. Definitions
Section 209 of this bill would define the terms:
``Account'', ``Commission'', ``date of approval'', ``VHA
facility'', ``infrastructure'', ``modernization'',
``realignment'', ``Secretary'', ``redevelopment authority'',
and ``redevelopment plan.''
Subtitle B--Other Infrastructure Matters
Section 211. Improvement to training of construction personnel
Section 211 of this bill would amend subsection (g) of
section 8103 of title 38, U.S.C., requiring VA to implement a
training and certification program for construction and
facilities management personnel. VA would be required to create
the training and certification program within one year of
enactment, to ensure a majority of covered employees are
certified within two years of enactment, and to ensure that all
covered employees are certified as quickly as possible
thereafter. VA would be required to model the training and
certification program on existing curricula and certification
programs in title 10 U.S.C. (namely, the existing Defense
Acquisition Workforce Improvement Act program). VA would be
authorized to provide the training in-person, online, provided
by another Federal department or agency, or a combination of
the above. VA would be authorized to offer one or more than one
level of certification and to enter into a contract with an
appropriate entity to provide the training curriculum and
certification. All VA employees who are members of occupational
series relating to construction or facilities management or VA
employees who award or administer contracts for major
construction, minor construction, or non-recurring maintenance
(including contract specialists or contracting officers'
representatives) would be included.
Sec. 212. Review of enhanced use lease
Section 212 of this bill would amend section 8162(b)(6) to
require the Office of Management and Budget review each
enhanced use lease before the lease goes into effect.
Section 213. Assessment of health care furnished by the Department to
Veterans who live in the Pacific territories
Section 213(a) of this bill would require VA to submit to
the House and Senate Committees on Veterans' Affairs a report
regarding the health care furnished by VA to veterans who live
in the Pacific territories.
Section 213(b) of this bill would establish that the report
shall assess the ability of the Department to provide hospital
care, medical, mental health, and geriatric services, as well
as assess the feasibility of establishing a medical facility in
any territory that does not contain such a facility.
Section 213(c) of this bill would define the term:
``Pacific territories'' as American Samoa, Guam, and the
Northern Mariana Islands.
TITLE III--IMPROVEMENTS TO RECRUITMENT OF HEALTH CARE PROFESSIONALS
Sec. 301. Designated scholarships for physicians and dentists under
Department of Veterans Affairs Health Professional Scholarship
Program
Section 301(a) of this bill will amend section 7612(b) of
title 38, U.S.C., by requiring VA to award no fewer than 50
scholarships a year to individuals who are enrolled or have
accepted enrollment in a physician or dentist program. The
number of awarded scholarships must be at least 50 a year until
VA determines that staffing shortage of dentists and physicians
is lower than 500. VA would award scholarships in an amount
equal to not less than 10 percent of the staffing shortage.
VA's agreement to provide a scholarship will be provided for a
designated number of school years (two to four years). The
agreement will mandate the participant's service for 18 months
for every school year of scholarship funding. VA may give
preference to applicants who are veterans. On an annual basis,
VA will provide to appropriate educational institutions
information material about the availability of scholarships.
Section 301(b) of this bill amends Section 7617 of title
38, U.S.C., to authorize VA to recoup a debt owed from
scholarship recipients who fail to successfully complete post-
graduate training leading to eligibility for board
certification in a specialty.
Section 301(c) extends the effective date of Section 7619
of title 38, U.S.C. from December 21, 2019, to December 31,
2033.
Sec. 302. Increase in maximum amount of debt that may be reduced under
Education Debt Reduction Program of Department of Veterans
Affairs
Section 302(a) of this bill would amend Section 7683(d)(1)
of Title 38, U.S.C., to increase the amount of debt which may
be reimbursed under VA's Education Debt Reduction Program
(EDRP) to $200,000 total over five years for the Specialty
Education Loan Reduction Program, and $40,000 annually.
Section 302(b) of this bill requires VA to conduct and
submit to Congress a study on the demand for VA's EDRP, to
include: (1) the total number of vacancies within VHA whose
applicants are eligible for EDRP, (2) the types of medical
professionals in greatest demand in the US, and (3) projections
of the numbers and types of medical professions that meet the
needs of veterans.
Sec. 303. Establishing the Department of Veterans Affairs specialty
education loan repayment program
Section 303(a) of this bill would amend Chapter 76 of title
38, U.S.C., by inserting after subchapter VII the following new
subchapter: ``Subchapter VIII--Specialty Education Loan
Repayment Program.''
The new section, ``Sec. 7691. Establishment'' would
establish a loan repayment program to incentivize individuals
employed in the Veterans Health Administration to pursue
education and training in medical specialties for which VA
determines there is a shortage.
The new section, ``Sec. 7692. Purpose'' would outline the
purpose of the Specialty Education Loan Repayment Program.
The new section, ``Sec. 7693. Eligibility; preferences;
covered costs'' would outline eligibility for the participation
in the Specialty Education Loan Repayment Program, give
preference to veterans in this program, and outline which
expenses are allowed to be covered under this section.
The new section, ``Sec. 7694. Specialty education loan
repayment'' would outline the manner in which the Specialty
Education Loan Repayment Program are to be made.
The new section, ``Sec. 7695. Choice of location'' would
allow each participant who completes their residency to select
their location of employment from a list of medical facilities
of the VHA.
The new section, ``Sec. 7696. Term of Obligation'' would
outline the terms of the service obligation for the Specialty
Education Loan Repayment Program and would state that in the
case of a participant who receives an accredited fellowship in
a medical specialty other than a medical specialty described in
section 7692 of this title, VA, on written request of the
participant, may delay the terms of obligated service under
subsection (a) for the participant until after the participant
completes the fellowship, but in no case later than 60 days
after completion of such fellowship. A formula is established
by which VA may seek monetary collections from an employee who
violates the terms of obligated service under this section.
The new section, ``Sec. 7697. Relationship to Educational
Assistance Program'' would allow for participants of the
Specialty Education Loan Repayment Program to concurrently
participate in the Educational Assistance Program. This section
also includes conforming and technical amendments, as well as
requires VA to match participants with the projected needs of
the VA and to publicize the availability of the program.
Section 303(b) of this bill would provide conforming and
technical corrections.
Section 303(c) of this bill would require VA to consider
the needs of VHA and anticipate the needs during the next two
to six years.
Section 303(d) of this bill would require VA to determine
whether a facility of the Department is underserved.
Section 303(e) of this bill would require VA to offer
participation to the applicant not later than 28 days after the
applicant matches with a residency in a medical specialty and
such match is published.
Sec. 304. Veterans Healing Veterans Medical Access and Scholarship
Program
Section 304(a) of this bill would establish that VA shall
carry out a pilot program under which VA shall provide funding
for the medical education of a total of 18 eligible veterans.
Such funding shall be provided for two veterans enrolled in
each covered medical schools in accordance with this section.
Section 304(b) of this bill would establish the eligibility
requirements for the Veterans Healing Veterans Medical Access
and Scholarship Program.
Section 304(c) of this bill would require that each covered
medical school, if it opts to join the program, shall reserve
two seats in the entering class of 2019 for eligible veterans
with the highest admissions rankings for said class. Each
eligible veteran shall receive funding at an amount equal to
the cost of tuition for four years; books, fees, and technical
equipment; fees associated with the National Residency Match
Program; two away rotations performed during the fourth year at
a VA medical facility; and a monthly stipend for the four-year
period. Funds shall be distributed to eligible veterans at
other covered medical schools should one covered school not
have two eligible veteran applicants.
Section 304(d) of this bill would outline the terms of the
agreement for eligible veterans who accept funding for medical
education under this section. Additionally, this section states
that, if the eligible veteran breaches the above agreement, the
U.S. shall be entitled to recover an amount equal to the total
amount of funding received by the veteran.
Section 304(e) of this bill would allow covered schools to
accept more than two eligible veterans for the entering class
of 2019.
Section 304(f) of this bill would require that no later
than December 31, 2020, and annually thereafter for three
years, VA shall submit to Congress a full report on the pilot
program.
Section 304(g) of this bill would define ``covered medical
schools'' as Teague-Cranston medical schools and the medical
schools of Historically Black Colleges and Universities.
Sec. 305. Bonuses for recruitment, relocation, and retention
Section 302 of this bill amends Section 705(a) of PL113-146
to increase the amount authorized for the provision of bonuses
to improve recruitment, relocation, and retention of employees.
The section sets the limitations on bonus awards from
$230,000,000 to $250,000,000 for fiscal years 2019 through
2022, and from $225,000,000 to $290,000,000 for fiscal years
2022 through 2024, with a minimum of $20,000,000 for
recruitment, relocation, and retention bonuses for both time
periods
Sec. 306. Inclusion of Vet Center employees in Education Debt Reduction
Program of Department of Veterans Affairs
Section 306(a) of this bill extends eligibility for VA's
Education Debt Reduction Program (EDRP) to clinical staff
working at Vet Centers.
Section 306(b) of this bill directs VA to submit to
Congress a report on the number of participants in the EDRP who
work at Vet Centers.
Section 306(c) of this bill defines the term, ``Vet
Center.''
TITLE IV--HEALTH CARE IN UNDERSERVED AREAS
Sec. 401. Development of criteria for designation of certain medical
facilities of the Department of Veterans Affairs as underserved
facilities and plan to address problem of underserved
facilities
Section 401(a) of this bill would establish that VA shall,
not later than 180 days after enactment, develop criteria to
designate medical facilities as underserved.
Section 401(b) of this bill would require the developed
criteria to consider: the ratio of veterans to health care
providers of VA, including a separate ratio for general
practitioners and specialist; the range of clinical specialties
covered by such providers; whether the local community is
underserved; the type, number, and age of open consults;
whether the facility is meeting the wait-time goals of VA; and
such other criteria developed by VA.
Section 401(c) of this bill would require Veterans
Integrated Service Networks, not less than annually, perform an
analysis to determine which facilities qualify as underserved.
Section 401(d) of this bill would establish that not later
than one year after enactment and annually thereafter, VA shall
submit to congress a plan to address the problem of underserved
facilities.
Sec. 402. Pilot program to furnish mobile deployment teams to
underserved facilities
Section 402(a) of this bill would require VA to carry out a
pilot program to furnish mobile deployment teams to underserved
facilities.
Section 402(b) of this bill would establish that VA shall
consider the medical positions of greatest need at the
underserved facilities, the size and composition of the team
deployed, and other elements established by VA for oversight of
the program.
Section 402(c) of this bill would require that VA use the
results from the annual analysis from the above section 401(c)
of this bill to send mobile deployment teams to the underserved
areas with the most needed medical personnel.
Section 402(d) of this bill would require VA to report, not
later than one year after the date of enactment, to Congress on
the implementation of the program. Not later than the
termination date of the pilot program, VA shall also submit a
final report on the feasibility of extending and expanding the
pilot program and making the pilot program permanent.
Section 402(e) of this bill would establish the duration of
the pilot at three years after the date of enactment.
Section 402(f) of this bill would define the term
``underserved facility.''
Sec. 403. Pilot program on graduate medical education and residency
Section 403(a) of this bill would establish a pilot program
to create medical residency positions authorized under section
301(b)(2) of the Veterans Access, Choice, and Accountability
Act at covered facilities, including: VA facilities, a facility
operated by an Indian Tribe or tribal organization, an Indian
Health Service facility, a Federally-qualified health center, a
DOD facility, or any other health care facility considered
appropriate. To carry out the pilot program, VA may enter into
agreements with entities that operate covered facilities. When
establishing the parameters for location, affiliate sponsor,
and duration, VA shall consider: the ratio of veterans to
providers, including separate ratio for general practitioners
and specialists; the range of clinical specialties of providers
in the area; whether the specialty of a provider is included in
the most recent staffing shortage assessment; whether the local
community designated by VA as underserved; whether HHS has
designated the region as a health professional shortage area;
whether the facility is located in a rural or remote area; and
other criteria determined to be important to VA. VA may pay
stipends and provide benefits for residents regardless of
whether they have been assigned to a VA facility.
Section 403(b) of this bill would establish that VA shall
reimburse a covered facility for cost of: curriculum
development; recruitment and retention of faculty;
accreditation of the program by the Accreditation Council for
Graduate Medical Education; faculty salaries attributable to
duties under an agreement under this section; and expenses
relating to educating a resident under this program.
Section 403(c) of this bill would require VA to report not
less frequently than annually until the termination of the
project on the implementation of the pilot program.
Section 403(d) of this bill would establish the termination
date of the program of August 7, 2024.
TITLE V--OTHER MATTERS
Sec. 501. Annual report on performance awards and bonuses awarded to
certain high-level employees of the department
Section 501(a) of this bill would amend Chapter 7 of title
38, U.S.C. by adding the following new section ``Sec. 726.
Annual report on performance awards and bonuses awarded to
certain high-level employees.''
The new section 726(a) would require VA to submit a report
no later than 100 days after the end of each fiscal year to the
appropriate committees of Congress. The report shall contain a
description of all performance awards or bonuses awarded to
each of the following: Regional Office Director of the VA;
Director of a Medical Center of the VA; Director of a Veterans
Integrated Service Network; and Senior executive of VA.
The new section 726(b) would establish that each report
included the following: the amount rewarded; the job title of
the individual awarded the bonus; and the location where the
individual works.
The new section 726(c) would establish definitions.
Section 501(b) of this bill provides for a clerical
amendment of the table of sections.
Sec. 502. Role of podiatrists in Department of Veterans Affairs
Section 502(a) of this bill would amend Subchapter I of
chapter 74 by adding the following new section ``Sec. 7413.
Treatment of podiatrists; clinical oversight standards.''
The new section 7413(a) would establish that, except as
provided under subsection (b), a podiatric doctor appointed
under section 7401(1) of this title is eligible for any
supervisory position in the Veterans Health Administration to
the same decree as any other physician.
The new section 7413(b) would require VA to create
standards to ensure that specialists appointed to supervisory
positions do not provide direct clinical oversight for purposes
of peer review or practical evaluation for providers.
Section 502(a) of this bill provides for a clerical
amendment of the table of sections.
Section 502(b) of this bill would amend section 7404(b) of
such title to ensure that Doctors of Podiatric Medicine,
Doctors of Osteopathy, and VA Medical Doctors are equal in
terms of pay within the VA healthcare system. The effective
date of no later than 30 days after enactment of this bill.
Sec. 503. Definition of major medical facility project
Section 503(a) of this bill would amend section 8101(3) by
striking ``Secretary'' and all that follows through ``nursing
home'' and inserting ``Secretary, or as otherwise authorized by
law, for the provision of health-care services (including
hospital, outpatient clinic, nursing home).''
Section 503(b) of this bill would amend 8104(a) to modify
the definition of a VA major medical facility project from a
$10 million to $20 million project cost, excluding the
construction, alteration, or acquisition of shared medical
facility or acquisitions by exchange, non-recurring
maintenance, and shared facilities, which VA's estimated costs
do not exceed $20 million.
Sec. 504. Authorization of certain major medical facility projects of
the Department of Veterans Affairs
Section 504(a) of this bill would authorize VA to carry out
construction on the major medical facility projects in
Livermore, California. The project includes: the new East Bay
Community Based Outpatient Clinic and all associated site work;
construction of the central Valley Engineering and Logistics
support facility; and enhancing flood plain mitigation at the
Central Valley and East Bay Community Based Outpatient Clinics.
The construction shall not exceed $117.3 million.
Section 504(b) of this bill would authorize appropriations
for construction at $117.3 million.
Section 504(c) of this bill would require VA to submit a
report to the House and Senate Veterans Affairs Committees no
later than 90 days after enactment of this bill. The report
shall include the following: a line item accounting of
expenditures relating to construction management carried out by
VA for the project; the future amounts that are budgeted to be
obligated for construction management; a justification for the
expenditures above; and any agreement entered into by VA
regarding a non-VA Federal entity providing management services
relating to this project.
Sec. 505. Department of Veterans Affairs personnel transparency
Section 505(a) of this bill would require VA to make
publicly available on their website the following information
no later than 90 days after the enactment of this bill. VA will
post by medical facility: the number of personnel encumbering
positions; the number of accessions and separation actions
processed during the quarter preceding the date of the
publication of this information; the number of vacancies, by
occupation; and the percentage of new hires for VA who were
hired within the time-to-hire target of the Office of Personnel
Management. VA may withhold from publication information
relating to law enforcement, information security, or other
positions VA has determined to be sensitive. VA shall update
the information on a quarterly basis, and any VA position
filled by a contractor may not be published. The VA Office of
the Inspector General shall conduct a review of the website
semi-annually.
Section 505(b) of this bill would require VA to submit to
Congress an annual report on the steps VA is taking to achieve
full staffing capacity. The report shall include the amount of
additional funds necessary to enable VA to reach full staffing
capacity.
Section 506. Program on establishment of peer specialists in patient
aligned care team settings within medical centers of Department
of Veterans Affairs
Section 506(a) of this bill would require VA to carry out a
program to place at least two peer specialists in patient
aligned care teams at VA medical centers.
Section 506(b) of this bill would establish the timeframe
for creating the program as follows: not later than May 31,
2019, there shall be at least two peer specialists at 15
medical centers and not later than May 31, 2020, at 30 medical
centers.
Section 506(c) of this bill would require VA to select
medical centers for the program as follows: not fewer than five
shall be medical centers designated as polytrauma centers by
VA, and not fewer than ten shall be medical centers not
designated as polytrauma centers. Additionally, VA shall
consider the feasibility of selecting medical centers in the
following areas: rural areas and underserved areas; areas not
close to active military bases, and areas representing
different geographic locations.
Section 506(d) of this bill would require VA to ensure
that: the needs of female veterans are specifically considered
and addressed and female peer specialists are made available to
female veterans.
Section 506(e) of this bill would require VA to consider
ways in which peer specialists can conduct outreach to health
care providers serving veterans.
Section 506(f) of this bill would require VA to submit to
Congress a report not later than 180 days after enactment, and
every 180 days thereafter, on the effectiveness of the program.
Not later than 180 days after VA has determined the program has
been carried out at the last facility.
Sec. 507. Department of Veterans Affairs medical scribe pilot program
Section 507(a) of this bill would require VA to carry out a
pilot program to increase the use of medical scribes at VA
medical centers.
Section 507(b) of this bill would require the pilot program
be carried out at ten VA medical centers with at least four
being in rural areas, at least four being in urban areas, and
at least two being in areas with a need for increased access or
efficiency, as determined by VA.
Section 507(c) of this bill would require VA to hire 20
medical scribes as VA employees and seek to enter into
contracts with appropriate entities to employ 20 medical
scribes. It would also require VA to assign four medical
scribes to each of the identified medical centers with two
scribes assigned to each of two physicians, thirty percent of
the scribes assigned to an emergency care settings, and seventy
percent of the scribes assigned in specialty care settings in
specialties with the longest wait times or lowest efficiency
ratings, as determined by VA.
Section 507(d) of this bill would require VA to submit a
report to the Committees on Veterans' Affairs of the Senate and
the House of Representatives on the pilot program by not later
than 180 days after the date of the commencement of the pilot
and every 180 days thereafter for the duration of the pilot.
Each such report would be required to include a separate
analysis with respect to medical scribes employed by VA and
those performing VA functions under contract regarding provider
efficiency, patient satisfaction, average wait times, the
number of patients seen per day by each physician or
practitioner as well as metrics and data for analyzing the
effectiveness of the pilot including an evaluation of each of
the above elements at VA medical centers who employed scribes
for an appropriate period preceding the hiring of such scribes.
GAO is required to submit a report to Congress no more than 90
days after the termination of the pilot and such report is
required to include a comparison of the pilot program with
similar programs carried out in the private sector.
Section 507(e) of this bill would define the term:
``medical scribe'' as a licensed individual hired to enter
information into the electronic health record or chart at the
direction of a physician or licensed independent practitioner
whose responsibilities include assisting the physician or
practitioner in navigating the electronic health record,
responding to various messages as direct by the physician or
practitioner, and entering information into the electronic
health record as directed by the physician or practitioner; and
``urban'' and ``rural'' as having the meanings given such terms
under the rural-urban commuting codes developed by the
Secretary of Agriculture and the Secretary of Health and Human
Services.
Section 507(f) of this bill would stipulate that the pilot
program is to be carried out using amounts otherwise authorized
to be appropriated for VA and that no additional amounts are
authorized to be appropriated to carry out the requirements of
Section 507 of the bill.
Sec. 508. Extension of requirement to collect fees for housing loans
guaranteed by Secretary of Veterans Affairs
Section 508 of this bill would amend Section 3729(b)(2) of
title 38, U.S.C., by striking ``2027'' and inserting ``2028.''
Sec. 509. Extension of reduction in amount of pension furnished by
Department of Veteran Affairs for certain veterans covered by
Medicaid plans for services furnished by nursing facilities
Section 509 of this bill would amend Section 5503(d)(7) of
title 38, U.S.C., by striking ``September 30, 2027,'' and
inserting ``September 30, 2028.''
Sec. 510. Appropriations of amounts
Section 510 of this bill would authorize and appropriate
$5.2 billion to the Veterans Choice Fund.
Sec. 511. Technical correction
Section 511 of this bill would redesignate section 1712I of
title 38 U.S.C. as section 1720I of title 38 U.S.C.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, and existing law in which no
change is proposed is shown in roman):
TITLE 38, UNITED STATES CODE
* * * * * * *
PART I--GENERAL PROVISIONS
* * * * * * *
CHAPTER 7--EMPLOYEES
SUBCHAPTER I --GENERAL EMPLOYEE MATTERS
Sec.
701. Placement of employees in military installations.
* * * * * * *
726. Annual report on performance awards and bonuses awarded to certain
high-level employees.
* * * * * * *
SUBCHAPTER I--GENERAL EMPLOYEE MATTERS
* * * * * * *
Sec. 726. Annual report on performance awards and bonuses awarded to
certain high-level employees
(a) In General.--Not later than 100 days after the end of
each fiscal year, the Secretary shall submit to the appropriate
committees of Congress a report that contains, for the most
recent fiscal year ending before the submittal of the report, a
description of all performance awards or bonuses awarded to
each of the following:
(1) Regional Office Director of the Department.
(2) Director of a Medical Center of the Department.
(3) Director of a Veterans Integrated Service
Network.
(4) Senior executive of the Department.
(b) Elements.--Each report submitted under subsection (a)
shall include the following with respect to each performance
award or bonus awarded to an individual described in such
subsection:
(1) The amount of each award or bonus.
(2) The job title of the individual awarded the award
or bonus.
(3) The location where the individual awarded the
award or bonus works.
(c) Definitions.--In this section:
(1) The term ``appropriate committees of Congress''
means the Committees on Veterans' Affairs and
Appropriations of the Senate and House of
Representatives.
(2) The term ``senior executive'' means--
(A) a career appointee; or
(B) an individual--
(i) in an administrative or executive
position; and
(ii) appointed under section 7306(a)
or section 7401(1) of this title.
(3) The term ``career appointee'' has the meaning
given that term in section 3132(a) of title 5, United
States Code.
* * * * * * *
PART II--GENERAL BENEFITS
* * * * * * *
CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
SUBCHAPTER I--GENERAL
Sec.
1701. Definitions.
* * * * * * *
[1703. Contracts for hospital care and medical services in non-
Department facilities.]
1703. Veterans Community Care Program.
1703A. Agreements with eligible entities or providers; certification
processes.
1703B. Access standards.
1703C. Standards for quality.
1703D. Prompt payment standard.
1703E. Center for Innovation for Care and Payment.
* * * * * * *
1706A. Remediation of medical service lines.
* * * * * * *
SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS
* * * * * * *
Sec. 1725A. Access to walk-in care.
* * * * * * *
1730B. Access to State prescription drug monitoring programs.
1730C. Licensure of health care professionals providing treatment via
telemedicine.
* * * * * * *
SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS
* * * * * * *
1788. Transplant procedures with live donors and related services.
SUBCHAPTER I--GENERAL
* * * * * * *
[Sec. 1703. Contracts for hospital care and medical services in non-
Department facilities
[(a) When Department facilities are not capable of furnishing
economical hospital care or medical services because of
geographical inaccessibility or are not capable of furnishing
the care or services required, the Secretary, as authorized in
section 1710 of this title, may contract with non-Department
facilities in order to furnish any of the following:
[(1) Hospital care or medical services to a veteran
for the treatment of--
[(A) a service-connected disability;
[(B) a disability for which a veteran was
discharged or released from the active
military, naval, or air service; or
[(C) a disability of a veteran who has a
total disability permanent in nature from a
service-connected disability.
[(2) Medical services for the treatment of any
disability of--
[(A) a veteran described in section
1710(a)(1)(B) of this title;
[(B) a veteran who (i) has been furnished
hospital care, nursing home care, domiciliary
care, or medical services, and (ii) requires
medical services to complete treatment incident
to such care or services; or
[(C) a veteran described in section
1710(a)(2)(E) of this title, or a veteran who
is in receipt of increased pension, or
additional compensation or allowances based on
the need of regular aid and attendance or by
reason of being permanently housebound (or who,
but for the receipt of retired pay, would be in
receipt of such pension, compensation, or
allowance), if the Secretary has determined,
based on an examination by a physician employed
by the Department (or, in areas where no such
physician is available, by a physician carrying
out such function under a contract or fee
arrangement), that the medical condition of
such veteran precludes appropriate treatment in
Department facilities.
[(3) Hospital care or medical services for the
treatment of medical emergencies which pose a serious
threat to the life or health of a veteran receiving
medical services in a Department facility or nursing
home care under section 1720 of this title until such
time following the furnishing of care in the non-
Department facility as the veteran can be safely
transferred to a Department facility.
[(4) Hospital care for women veterans.
[(5) Hospital care, or medical services that will
obviate the need for hospital admission, for veterans
in a State (other than the Commonwealth of Puerto Rico)
not contiguous to the contiguous States, except that
the annually determined hospital patient load and
incidence of the furnishing of medical services to
veterans hospitalized or treated at the expense of the
Department in Government and non-Department facilities
in each such noncontiguous State shall be consistent
with the patient load or incidence of the furnishing of
medical services for veterans hospitalized or treated
by the Department within the 48 contiguous States and
the Commonwealth of Puerto Rico.
[(6) Diagnostic services necessary for determination
of eligibility for, or of the appropriate course of
treatment in connection with, furnishing medical
services at independent Department out-patient clinics
to obviate the need for hospital admission.
[(7) Outpatient dental services and treatment, and
related dental appliances, for a veteran described in
section 1712(a)(1)(F) of this title.
[(8) Diagnostic services (on an inpatient or
outpatient basis) for observation or examination of a
person to determine eligibility for a benefit or
service under laws administered by the Secretary.
[(b) In the case of any veteran for whom the Secretary
contracts to furnish care or services in a non-Department
facility pursuant to a provision of subsection (a) of this
section, the Secretary shall periodically review the necessity
for continuing such contractual arrangement pursuant to such
provision.
[(c) The Secretary shall include in the budget documents
which the Secretary submits to Congress for any fiscal year a
detailed report on the furnishing of contract care and services
during the most recently completed fiscal year under this
section, sections 1712A, 1720, 1720A, 1724, and 1732 of this
title, and section 115 of the Veterans' Benefits and Services
Act of 1988 (Public Law 100-322; 102 Stat. 501).
[(d)(1) The Secretary shall conduct a program of recovery
audits for fee basis contracts and other medical services
contracts for the care of veterans under this section, and for
beneficiaries under sections 1781, 1782, and 1783 of this
title, with respect to overpayments resulting from processing
or billing errors or fraudulent charges in payments for non-
Department care and services. The program shall be conducted by
contract.
[(2) Amounts collected, by setoff or otherwise, as the result
of an audit under the program conducted under this subsection
shall be available, without fiscal year limitation, for the
purposes for which funds are currently available to the
Secretary for medical care and for payment to a contractor of a
percentage of the amount collected as a result of an audit
carried out by the contractor.
[(3) The Secretary shall allocate all amounts collected under
this subsection with respect to a designated geographic service
area of the Veterans Health Administration, net of payments to
the contractor, to that region.
[(4) The authority of the Secretary under this subsection
terminates on September 30, 2020.]
Sec. 1703. Veterans Community Care Program
(a) In General.--(1) There is established a program to
furnish hospital care, medical services, and extended care
services to covered veterans through health care providers
specified in subsection (c).
(2) The Secretary shall coordinate the furnishing of hospital
care, medical services, and extended care services under this
section to covered veterans, including coordination of, at a
minimum, the following:
(A) Ensuring the scheduling of medical appointments
in a timely manner and the establishment of a mechanism
to receive medical records from non-Department
providers.
(B) Ensuring continuity of care and services.
(C) Ensuring coordination among regional networks if
the covered veteran accesses care and services in a
different network than the regional network in which
the covered veteran resides.
(D) Ensuring that covered veterans do not experience
a lapse in care resulting from errors or delays by the
Department or its contractors or an unusual or
excessive burden in accessing hospital care, medical
services, or extended care services.
(3) A covered veteran may only receive care or services under
this section upon the authorization of such care or services by
the Secretary.
(b) Covered Veterans.--For purposes of this section, a
covered veteran is any veteran who--
(1) is enrolled in the system of annual patient
enrollment established and operated under section 1705
of this title; or
(2) is not enrolled in such system but is otherwise
entitled to hospital care, medical services, or
extended care services under subsection (c)(2) of such
section.
(c) Health Care Providers Specified.--Health care providers
specified in this subsection are the following:
(1) Any health care provider that is participating in
the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.), including any
physician furnishing services under such a program.
(2) The Department of Defense.
(3) The Indian Health Service.
(4) Any Federally-qualified health center (as defined
in section 1905(l)(2)(B) of the Social Security Act (42
U.S.C. 1396d(l)(2)(B))).
(5) Any health care provider not otherwise covered
under any of paragraphs (1) through (4) that meets
criteria established by the Secretary for purposes of
this section.
(d) Conditions Under Which Care is Required to Be Furnished
Through Non-department Providers.--(1) The Secretary shall,
subject to the availability of appropriations, furnish hospital
care, medical services, and extended care services to a covered
veteran through health care providers specified in subsection
(c) if--
(A) the Department does not offer the care or
services the veteran requires;
(B) the Department does not operate a full-service
medical facility in the State in which the covered
veteran resides;
(C)(i) the covered veteran was an eligible veteran
under section 101(b)(2)(B) of the Veterans Access,
Choice, and Accountability Act of 2014 (Public Law 113-
146; 38 U.S.C. 1701 note) as of the day before the date
of the enactment of the Caring for Our Veterans Act of
2018;
(ii) continues to reside in a location that would
qualify the veteran for eligibility under such section;
and
(iii) either--
(I) resides in one of the five States with
the lowest population density as determined by
data from the 2010 decennial census; or
(II) resides in a State not described in
subclause (I) and--
(aa) received care or services under
this title in the year preceding the
enactment of the Caring for Our
Veterans Act of 2018; and
(bb) is seeking care or services
within two years of the date of the
enactment of the Caring for Our
Veterans Act of 2018;
(D) the covered veteran has contacted the Department
to request care or services and the Department is not
able to furnish such care or services in a manner that
complies with designated access standards developed by
the Secretary under section 1703B of this title; or
(E) the covered veteran and the covered veteran's
referring clinician agree that furnishing care and
services through a non-Department entity or provider
would be in the best medical interest of the covered
veteran based upon criteria developed by the Secretary.
(2) The Secretary shall ensure that the criteria developed
under paragraph (1)(E) include consideration of the following:
(A) The distance between the covered veteran and the
facility that provides the hospital care, medical
services, or extended care services the veteran needs.
(B) The nature of the hospital care, medical
services, or extended care services required.
(C) The frequency that the hospital care, medical
services, or extended care services needs to be
furnished.
(D) The timeliness of available appointments for the
hospital care, medical services, or extended care
services the veteran needs.
(E) Whether the covered veteran faces an unusual or
excessive burden to access hospital care, medical
services, or extended care services from the Department
medical facility where a covered veteran seeks hospital
care, medical services, or extended care services,
which shall include consideration of the following:
(i) Whether the covered veteran faces an
excessive driving distance, geographical
challenge, or environmental factor that impedes
the access of the covered veteran.
(ii) Whether the hospital care, medical
services, or extended care services sought by
the veteran is provided by a medical facility
of the Department that is reasonably accessible
to a covered veteran.
(iii) Whether a medical condition of the
covered veteran affects the ability of the
covered veteran to travel.
(iv) Whether there is compelling reason, as
determined by the Secretary, that the veteran
needs to receive hospital care, medical
services, or extended care services from a
medical facility other than a medical facility
of the Department.
(v) Such other considerations as the
Secretary considers appropriate.
(3) If the Secretary has determined that the Department does
not offer the care or services the covered veteran requires
under subparagraph (A) of paragraph (1), that the Department
does not operate a full-service medical facility in the State
in which the covered veteran resides under subparagraph (B) of
such paragraph, that the covered veteran is described under
subparagraph (C) of such paragraph, or that the Department is
not able to furnish care or services in a manner that complies
with designated access standards developed by the Secretary
under section 1703B of this title under subparagraph (D) of
such paragraph, the decision to receive hospital care, medical
services, or extended care services under such subparagraphs
from a health care provider specified in subsection (c) shall
be at the election of the veteran.
(e) Conditions Under Which Care is Authorized to Be Furnished
Through Non-department Providers.--(1)(A) The Secretary may
furnish hospital care, medical services, or extended care
services through a health care provider specified in subsection
(c) to a covered veteran served by a medical service line of
the Department that the Secretary has determined is not
providing care that complies with the standards for quality the
Secretary shall establish under section 1703C.
(B) In carrying out subparagraph (A), the Secretary shall--
(i) measure timeliness of the medical service line at
a facility of the Department when compared with the
same medical service line at different Department
facilities; and
(ii) measure quality at a medical service line of a
facility of the Department by comparing it with two or
more distinct and appropriate quality measures at non-
Department medical service lines.
(C)(i) The Secretary may not concurrently furnish hospital
care, medical services, or extended care services under
subparagraph (A) with respect to more than three medical
service lines described in such subparagraph at any one health
care facility of the Department.
(ii) The Secretary may not concurrently furnish hospital
care, medical services, or extended care services under
subparagraph (A) with respect to more than 36 medical service
lines nationally described in such subparagraph.
(2) The Secretary may limit the types of hospital care,
medical services, or extended care services covered veterans
may receive under paragraph (1) in terms of the length of time
such care and services will be available, the location at which
such care and services will be available, and the clinical care
and services that will be available.
(3)(A) Except as provided for in subparagraph (B), the
hospital care, medical services, and extended care services
authorized under paragraph (1) with respect to a medical
service line shall cease when the remediation described in
section 1706A with respect to such medical service line is
complete.
(B) The Secretary shall ensure continuity and coordination of
care for any veteran who elects to receive care or services
under paragraph (1) from a health care provider specified in
subsection (c) through the completion of an episode of care.
(4) The Secretary shall publish in the Federal Register, and
shall take all reasonable steps to provide direct notice to
covered veterans affected under this subsection, at least once
each year stating the time period during which such care and
services will be available, the location or locations where
such care and services will be available, and the clinical
services available at each location under this subsection in
accordance with regulations the Secretary shall prescribe.
(5) When the Secretary exercises the authority under
paragraph (1), the decision to receive care or services under
such paragraph from a health care provider specified in
subsection (c) shall be at the election of the covered veteran.
(f) Review of Decisions.--The review of any decision under
subsection (d) or (e) shall be subject to the Department's
clinical appeals process, and such decisions may not be
appealed to the Board of Veterans' Appeals.
(g) Tiered Network.--(1) To promote the provision of high-
quality and high-value hospital care, medical services, and
extended care services under this section, the Secretary may
develop a tiered provider network of eligible providers based
on criteria established by the Secretary for purposes of this
section.
(2) In developing a tiered provider network of eligible
providers under paragraph (1), the Secretary shall not
prioritize providers in a tier over providers in any other tier
in a manner that limits the choice of a covered veteran in
selecting a health care provider specified in subsection (c)
for receipt of hospital care, medical services, or extended
care services under this section.
(h) Contracts to Establish Networks of Health Care
Providers.--(1) The Secretary shall enter into consolidated,
competitively bid contracts to establish networks of health
care providers specified in paragraphs (1) and (5) of
subsection (c) for purposes of providing sufficient access to
hospital care, medical services, or extended care services
under this section.
(2)(A) The Secretary shall, to the extent practicable, ensure
that covered veterans are able to make their own appointments
using advanced technology.
(B) To the extent practicable, the Secretary shall be
responsible for the scheduling of appointments for hospital
care, medical services, and extended care services under this
section.
(3)(A) The Secretary may terminate a contract with an entity
entered into under paragraph (1) at such time and upon such
notice to the entity as the Secretary may specify for purposes
of this section, if the Secretary notifies the appropriate
committees of Congress that, at a minimum--
(i) the entity--
(I) failed to comply substantially with the
provisions of the contract or with the
provisions of this section and the regulations
prescribed under this section;
(II) failed to comply with the access
standards or the standards for quality
established by the Secretary;
(III) is excluded from participation in a
Federal health care program (as defined in
section 1128B(f) of the Social Security Act (42
U.S.C. 1320a-7b(f))) under section 1128 or
1128A of the Social Security Act (42 U.S.C.
1320a-7 and 1320a-7a);
(IV) is identified as an excluded source on
the list maintained in the System for Award
Management, or any successor system; or
(V) has been convicted of a felony or other
serious offense under Federal or State law and
the continued participation of the entity would
be detrimental to the best interests of
veterans or the Department;
(ii) it is reasonable to terminate the contract based
on the health care needs of veterans; or
(iii) it is reasonable to terminate the contract
based on coverage provided by contracts or sharing
agreements entered into under authorities other than
this section.
(B) Nothing in subparagraph (A) may be construed to restrict
the authority of the Secretary to terminate a contract entered
into under paragraph (1) under any other provision of law.
(4) Whenever the Secretary provides notice to an entity that
the entity is failing to meet contractual obligations entered
into under paragraph (1), the Secretary shall submit to the
Committee on Veterans' Affairs of the Senate and the Committee
on Veterans' Affairs of the House of Representatives a report
on such failure. Such report shall include the following:
(A) An explanation of the reasons for providing such
notice.
(B) A description of the effect of such failure,
including with respect to cost, schedule, and
requirements.
(C) A description of the actions taken by the
Secretary to mitigate such failure.
(D) A description of the actions taken by the
contractor to address such failure.
(E) A description of any effect on the community
provider market for veterans in the affected area.
(5)(A) The Secretary shall instruct each entity awarded a
contract under paragraph (1) to recognize and accept, on an
interim basis, the credentials and qualifications of health
care providers who are authorized to furnish hospital care and
medical services to veterans under a community care program of
the Department in effect as of the day before the date of the
enactment of the Caring for Our Veterans Act of 2018, including
under the Patient-Centered Community Care Program and the
Veterans Choice Program under section 101 of the Veterans
Access, Choice, and Accountability Act of 2014 (Public Law 113-
146; 38 U.S.C. 1701 note), as qualified providers under the
program established under this section.
(B) The interim acceptance period under subparagraph (A)
shall be determined by the Secretary based on the following
criteria:
(i) With respect to a health care provider, when the
current certification agreement for the health care
provider expires.
(ii) Whether the Department has enacted certification
and eligibility criteria and regulatory procedures by
which non-Department providers will be authorized under
this section.
(6) The Secretary shall establish a system or systems for
monitoring the quality of care provided to covered veterans
through a network under this subsection and for assessing the
quality of hospital care, medical services, and extended care
services furnished through such network before the renewal of
the contract for such network.
(i) Payment Rates for Care and Services.--(1) Except as
provided in paragraph (2), and to the extent practicable, the
rate paid for hospital care, medical services, or extended care
services under any provision in this title may not exceed the
rate paid by the United States to a provider of services (as
defined in section 1861(u) of the Social Security Act (42
U.S.C. 1395x(u))) or a supplier (as defined in section 1861(d)
of such Act (42 U.S.C. 1395x(d))) under the Medicare program
under title XI or title XVIII of the Social Security Act (42
U.S.C. 1301 et seq.), including section 1834 of such Act (42
U.S.C. 1395m), for the same care or services.
(2)(A) A higher rate than the rate paid by the United States
as described in paragraph (1) may be negotiated with respect to
the furnishing of care or services to a covered veteran who
resides in a highly rural area.
(B) In this paragraph, the term ``highly rural area'' means
an area located in a county that has fewer than seven
individuals residing in that county per square mile.
(3) With respect to furnishing care or services under this
section in Alaska, the Alaska Fee Schedule of the Department of
Veterans Affairs shall be followed, except for when another
payment agreement, including a contract or provider agreement,
is in effect.
(4) With respect to furnishing hospital care, medical
services, or extended care services under this section in a
State with an All-Payer Model Agreement under section
1814(b)(3) of the Social Security Act (42 U.S.C. 1395f(b)(3))
that became effective on or after January 1, 2014, the Medicare
payment rates under paragraph (2)(A) shall be calculated based
on the payment rates under such agreement.
(5) Notwithstanding paragraph (1), the Secretary may
incorporate, to the extent practicable, the use of value-based
reimbursement models to promote the provision of high-quality
care.
(6) With respect to hospital care, medical services, or
extended care services for which there is not a rate paid under
the Medicare program as described in paragraph (1), the rate
paid for such care or services shall be determined by the
Secretary.
(j) Treatment of Other Health Plan Contracts.--In any case in
which a covered veteran is furnished hospital care, medical
services, or extended care services under this section for a
non-service-connected disability described in subsection (a)(2)
of section 1729 of this title, the Secretary shall recover or
collect reasonable charges for such care or services from a
health plan contract described in section 1729 in accordance
with such section.
(k) Payment by Veteran.--A covered veteran shall not pay a
greater amount for receiving care or services under this
section than the amount the veteran would pay for receiving the
same or comparable care or services at a medical facility of
the Department or from a health care provider of the
Department.
(l) Transplant Authority for Improved Access.--(1) In the
case of a covered veteran described in paragraph (2), the
Secretary shall determine whether to authorize an organ or bone
marrow transplant for that covered veteran at a non-Department
facility.
(2) A covered veteran described in this paragraph--
(A) requires an organ or bone marrow transplant; and
(B) has, in the opinion of the primary care provider
of the veteran, a medically compelling reason to travel
outside the region of the Organ Procurement and
Transplantation Network, established under section 372
of the National Organ Transplantation Act (Public Law
98-507; 42 U.S.C. 274), in which the veteran resides,
to receive such transplant.
(m) Monitoring of Care Provided.--(1)(A) Not later than 540
days after the date of the enactment of the Caring for Our
Veterans Act of 2018, and not less frequently than annually
thereafter, the Secretary shall submit to appropriate
committees of Congress a review of the types and frequency of
care sought under subsection (d).
(B) The review submitted under subparagraph (A) shall include
an assessment of the following:
(i) The top 25 percent of types of care and services
most frequently provided under subsection (d) due to
the Department not offering such care and services.
(ii) The frequency such care and services were sought
by covered veterans under this section.
(iii) An analysis of the reasons the Department was
unable to provide such care and services.
(iv) Any steps the Department took to provide such
care and services at a medical facility of the
Department.
(v) The cost of such care and services.
(2) In monitoring the hospital care, medical services, and
extended care services furnished under this section, the
Secretary shall do the following:
(A) With respect to hospital care, medical services,
and extended care services furnished through provider
networks established under subsection (i)--
(i) compile data on the types of hospital
care, medical services, and extended care
services furnished through such networks and
how many patients used each type of care and
service;
(ii) identify gaps in hospital care, medical
services, or extended care services furnished
through such networks;
(iii) identify how such gaps may be fixed
through new contracts within such networks or
changes in the manner in which hospital care,
medical services, or extended care services are
furnished through such networks;
(iv) assess the total amounts spent by the
Department on hospital care, medical services,
and extended care services furnished through
such networks;
(v) assess the timeliness of the Department
in referring hospital care, medical services,
and extended care services to such networks;
and
(vi) assess the timeliness of such networks
in--
(I) accepting referrals; and
(II) scheduling and completing
appointments.
(B) Report the number of medical service lines the
Secretary has determined under subsection (e)(1) not to
be providing hospital care, medical services, or
extended care services that comply with the standards
for quality established by the Secretary.
(C) Assess the use of academic affiliates and centers
of excellence of the Department to furnish hospital
care, medical services, and extended care services to
covered veterans under this section.
(D) Assess the hospital care, medical services, and
extended care services furnished to covered veterans
under this section by medical facilities operated by
Federal agencies other than the Department.
(3) Not later than 540 days after the date of the enactment
of the Caring for Our Veterans Act of 2018 and not less
frequently than once each year thereafter, the Secretary shall
submit to the Committee on Veterans' Affairs of the Senate and
the Committee on Veterans' Affairs of the House of
Representatives a report on the information gathered under
paragraph (2).
(n) Prohibition on Certain Limitations.--(1) The Secretary
shall not limit the types of hospital care, medical services,
or extended care services covered veterans may receive under
this section if it is in the best medical interest of the
veteran to receive such hospital care, medical services, or
extended care services, as determined by the veteran and the
veteran's health care provider.
(2) No provision in this section may be construed to alter or
modify any other provision of law establishing specific
eligibility criteria for certain hospital care, medical
services, or extended care services.
(o) Definitions.--In this section:
(1) The term ``appropriate committees of Congress''
means--
(A) the Committee on Veterans' Affairs and
the Committee on Appropriations of the Senate;
and
(B) the Committee on Veterans' Affairs and
the Committee on Appropriations of the House of
Representatives.
(2) The term ``medical service line'' means a clinic
within a Department medical center.
Sec. 1703A. Agreements with eligible entities or providers;
certification processes
(a) Agreements Authorized.--(1)(A) When hospital care, a
medical service, or an extended care service required by a
veteran who is entitled to such care or service under this
chapter is not feasibly available to the veteran from a
facility of the Department or through a contract or sharing
agreement entered into pursuant to another provision of law,
the Secretary may furnish such care or service to such veteran
through an agreement under this section with an eligible entity
or provider to provide such hospital care, medical service, or
extended care service.
(B) An agreement entered into under this section to provide
hospital care, a medical service, or an extended care service
shall be known as a ``Veterans Care Agreement''.
(C) For purposes of subparagraph (A), hospital care, a
medical service, or an extended care service may be considered
not feasibly available to a veteran from a facility of the
Department or through a contract or sharing agreement described
in such subparagraph when the Secretary determines the
veteran's medical condition, the travel involved, the nature of
the care or services required, or a combination of these
factors make the use of a facility of the Department or a
contract or sharing agreement described in such subparagraph
impracticable or inadvisable.
(D) A Veterans Care Agreement may be entered into by the
Secretary or any Department official authorized by the
Secretary.
(2)(A) Subject to subparagraph (B), the Secretary shall
review each Veterans Care Agreement of material size, as
determined by the Secretary or set forth in paragraph (3), for
hospital care, a medical service, or an extended care service
to determine whether it is feasible and advisable to provide
such care or service within a facility of the Department or by
contract or sharing agreement entered into pursuant to another
provision of law and, if so, take action to do so.
(B)(i) The Secretary shall review each Veterans Care
Agreement of material size that has been in effect for at least
six months within the first two years of its taking effect, and
not less frequently than once every four years thereafter.
(ii) If a Veterans Care Agreement has not been in effect for
at least six months by the date of the review required by
subparagraph (A), the agreement shall be reviewed during the
next cycle required by subparagraph (A), and such review shall
serve as its review within the first two years of its taking
effect for purposes of clause (i).
(3)(A) In fiscal year 2019 and in each fiscal year
thereafter, in addition to such other Veterans Care Agreements
as the Secretary may determine are of material size, a Veterans
Care Agreement for the purchase of extended care services that
exceeds $5,000,000 annually shall be considered of material
size.
(B) From time to time, the Secretary may publish a notice in
the Federal Register to adjust the dollar amount specified in
subparagraph (A) to account for changes in the cost of health
care based upon recognized health care market surveys and other
available data.
(b) Eligible Entities and Providers.--For purposes of this
section, an eligible entity or provider is--
(1) any provider of services that has enrolled and
entered into a provider agreement under section 1866(a)
of the Social Security Act (42 U.S.C. 1395cc(a)) and
any physician or other supplier who has enrolled and
entered into a participation agreement under section
1842(h) of such Act (42 U.S.C. 1395u(h));
(2) any provider participating under a State plan
under title XIX of such Act (42 U.S.C. 1396 et seq.);
(3) an Aging and Disability Resource Center, an area
agency on aging, or a State agency (as defined in
section 102 of the Older Americans Act of 1965 (42
U.S.C. 3002));
(4) a center for independent living (as defined in
section 702 of the Rehabilitation Act of 1973 (29
U.S.C. 796a)); or
(5) any entity or provider not described in paragraph
(1) or (2) of this subsection that the Secretary
determines to be eligible pursuant to the certification
process described in subsection (c).
(c) Eligible Entity or Provider Certification Process.--The
Secretary shall establish by regulation a process for the
certification of eligible entities or providers or
recertification of eligible entities or providers under this
section. Such a process shall, at a minimum--
(1) establish deadlines for actions on applications
for certification;
(2) set forth standards for an approval or denial of
certification, duration of certification, revocation of
an eligible entity or provider's certification, and
recertification of eligible entities or providers;
(3) require the denial of certification if the
Secretary determines the eligible entity or provider is
excluded from participation in a Federal health care
program under section 1128 or section 1128A of the
Social Security Act (42 U.S.C. 1320a-7 or 1320a-7a) or
is currently identified as an excluded source on the
System for Award Management Exclusions list described
in part 9 of title 48, Code of Federal Regulations, and
part 180 of title 2 of such Code, or successor
regulations;
(4) establish procedures for screening eligible
entities or providers according to the risk of fraud,
waste, and abuse that are similar to the standards
under section 1866(j)(2)(B) of the Social Security Act
(42 U.S.C. 1395cc(j)(2)(B)) and section 9.104 of title
48, Code of Federal Regulations, or successor
regulations; and
(5) incorporate and apply the restrictions and
penalties set forth in chapter 21 of title 41 and treat
this section as a procurement program only for purposes
of applying such provisions.
(d) Rates.--To the extent practicable, the rates paid by the
Secretary for hospital care, medical services, and extended
care services provided under a Veterans Care Agreement shall be
in accordance with the rates paid by the United States under
section 1703(i) of this title.
(e) Terms of Veterans Care Agreements.--(1) Pursuant to
regulations promulgated under subsection (k), the Secretary may
define the requirements for providers and entities entering
into agreements under this section based upon such factors as
the number of patients receiving care or services, the number
of employees employed by the entity or provider furnishing such
care or services, the amount paid by the Secretary to the
provider or entity, or other factors as determined by the
Secretary.
(2) To furnish hospital care, medical services, or extended
care services under this section, an eligible entity or
provider shall agree--
(A) to accept payment at the rates established in
regulations prescribed under this section;
(B) that payment by the Secretary under this section
on behalf of a veteran to a provider of services or
care shall, unless rejected and refunded by the
provider within 30 days of receipt, constitute payment
in full and extinguish any liability on the part of the
veteran for the treatment or care provided, and no
provision of a contract, agreement, or assignment to
the contrary shall operate to modify, limit, or negate
this requirement;
(C) to provide only the care and services authorized
by the Department under this section and to obtain the
prior written consent of the Department to furnish care
or services outside the scope of such authorization;
(D) to bill the Department in accordance with the
methodology outlined in regulations prescribed under
this section;
(E) to not seek to recover or collect from a health
plan contract or third party, as those terms are
defined in section 1729 of this title, for any care or
service that is furnished or paid for by the
Department;
(F) to provide medical records to the Department in
the time frame and format specified by the Department;
and
(G) to meet such other terms and conditions,
including quality of care assurance standards, as the
Secretary may specify in regulation.
(f) Discontinuation or Nonrenewal of a Veterans Care
Agreement.--(1) An eligible entity or provider may discontinue
a Veterans Care Agreement at such time and upon such notice to
the Secretary as may be provided in regulations prescribed
under this section.
(2) The Secretary may discontinue a Veterans Care Agreement
with an eligible entity or provider at such time and upon such
reasonable notice to the eligible entity or provider as may be
specified in regulations prescribed under this section, if an
official designated by the Secretary--
(A) has determined that the eligible entity or
provider failed to comply substantially with the
provisions of the Veterans Care Agreement, or with the
provisions of this section or regulations prescribed
under this section;
(B) has determined the eligible entity or provider is
excluded from participation in a Federal health care
program under section 1128 or section 1128A of the
Social Security Act (42 U.S.C. 1320a-7 or 1320a-7a) or
is identified on the System for Award Management
Exclusions list as provided in part 9 of title 48, Code
of Federal Regulations, and part 180 of title 2 of such
Code, or successor regulations;
(C) has ascertained that the eligible entity or
provider has been convicted of a felony or other
serious offense under Federal or State law and
determines the eligible entity or provider's continued
participation would be detrimental to the best
interests of veterans or the Department; or
(D) has determined that it is reasonable to terminate
the agreement based on the health care needs of a
veteran.
(g) Quality of Care.--The Secretary shall establish a system
or systems for monitoring the quality of care provided to
veterans through Veterans Care Agreements and for assessing the
quality of hospital care, medical services, and extended care
services furnished by eligible entities and providers before
the renewal of Veterans Care Agreements.
(h) Disputes.--(1) The Secretary shall promulgate
administrative procedures for eligible entities and providers
to present all disputes arising under or related to Veterans
Care Agreements.
(2) Such procedures constitute the eligible entities' and
providers' exhaustive and exclusive administrative remedies.
(3) Eligible entities or providers must first exhaust such
administrative procedures before seeking any judicial review
under section 1346 of title 28 (known as the ``Tucker Act'').
(4) Disputes under this section must pertain to either the
scope of authorization under the Veterans Care Agreement or
claims for payment subject to the Veterans Care Agreement and
are not claims for the purposes of such laws that would
otherwise require application of sections 7101 through 7109 of
title 41, United States Code.
(i) Applicability of Other Provisions of Law.--(1) A Veterans
Care Agreement may be authorized by the Secretary or any
Department official authorized by the Secretary, and such
action shall not be treated as--
(A) an award for the purposes of such laws that would
otherwise require the use of competitive procedures for
the furnishing of care and services; or
(B) a Federal contract for the acquisition of goods
or services for purposes of any provision of Federal
law governing Federal contracts for the acquisition of
goods or services except section 4706(d) of title 41.
(2)(A) Except as provided in the agreement itself, in
subparagraph (B), and unless otherwise provided in this section
or regulations prescribed pursuant to this section, an eligible
entity or provider that enters into an agreement under this
section is not subject to, in the carrying out of the
agreement, any law to which providers of services and suppliers
under the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.) are not subject.
(B) An eligible entity or provider that enters into an
agreement under this section is subject to--
(i) all laws regarding integrity, ethics, or fraud,
or that subject a person to civil or criminal
penalties; and
(ii) all laws that protect against employment
discrimination or that otherwise ensure equal
employment opportunities.
(3) Notwithstanding paragraph (2)(B)(i), an eligible entity
or provider that enters into an agreement under this section
shall not be treated as a Federal contractor or subcontractor
for purposes of chapter 67 of title 41 (commonly known as the
``McNamara-O'Hara Service Contract Act of 1965'').
(j) Parity of Treatment.--Eligibility for hospital care,
medical services, and extended care services furnished to any
veteran pursuant to a Veterans Care Agreement shall be subject
to the same terms as though provided in a facility of the
Department, and provisions of this chapter applicable to
veterans receiving such care and services in a facility of the
Department shall apply to veterans treated under this section.
(k) Rulemaking.--The Secretary shall promulgate regulations
to carry out this section.
Sec. 1703B. Access standards
(a)(1) The Secretary shall establish access standards for
furnishing hospital care, medical services, or extended care
services to covered veterans for the purposes of section
1703(d).
(2) The Secretary shall ensure that the access standards
established under paragraph (1) define such categories of care
to cover all care and services within the medical benefits
package of the Department of Veterans Affairs.
(b) The Secretary shall ensure that the access standards
provide covered veterans, employees of the Department, and
health care providers in the network established under section
1703(h) with relevant comparative information that is clear,
useful, and timely, so that covered veterans can make informed
decisions regarding their health care.
(c) The Secretary shall consult with all pertinent Federal
entities (including the Department of Defense, the Department
of Health and Human Services, and the Centers for Medicare &
Medicaid Services), entities in the private sector, and other
nongovernmental entities in establishing access standards.
(d)(1) Not later than 270 days after the date of the
enactment of the Caring for Our Veterans Act of 2018, the
Secretary shall submit to the appropriate committees of
Congress a report detailing the access standards.
(2)(A) Before submitting the report required under paragraph
(1), the Secretary shall provide periodic updates to the
appropriate committees of Congress to confirm the Department's
progress towards developing the access standards required by
this section.
(B) The first update under subparagraph (A) shall occur no
later than 120 days from the date of the enactment of the
Caring for Our Veterans Act of 2018.
(3) Not later than 540 days after the date on which the
Secretary implements the access standards established under
subsection (a), the Secretary shall submit to the appropriate
committees of Congress a report detailing the implementation of
and compliance with such access standards by Department and
non-Department entities or providers.
(e) Not later than three years after the date on which the
Secretary establishes access standards under subsection (a) and
not less frequently than once every three years thereafter, the
Secretary shall--
(1) conduct a review of such standards; and
(2) submit to the appropriate committees of Congress
a report on the findings and any modification to the
access standards with respect to the review conducted
under paragraph (1).
(f) The Secretary shall ensure health care providers
specified under section 1703(c) are able to comply with the
applicable access standards established by the Secretary.
(g) The Secretary shall publish in the Federal Register and
on an internet website of the Department the designated access
standards established under this section for purposes of
section 1703(d)(1)(D).
(h)(1) Consistent with paragraphs (1)(D) and (3) of section
1703(d), covered veterans may contact the Department at any
time to request a determination regarding whether they are
eligible to receive care and services from a non-Department
entity or provider based on the Department being unable to
furnish such care and services in a manner that complies with
the designated access standards established under this section.
(2) The Secretary shall establish a process to review such
requests from covered veterans to determine whether--
(A) the requested care is clinically necessary; and
(B) the Department is able to provide such care in a
manner that complies with designated access standards
established under this section.
(3) The Secretary shall promptly respond to any such request
by a covered veteran.
(i)(1) The term ``appropriate committees of Congress''
means--
(A) the Committee on Veterans' Affairs and the
Committee on Appropriations of the Senate; and
(B) the Committee on Veterans' Affairs and the
Committee on Appropriations of the House of
Representatives.
(2) The term ``covered veterans'' refers to veterans
described in section 1703(b) of this title.
Sec. 1703C. Standards for quality
(a) In General.--(1) The Secretary shall establish standards
for quality regarding hospital care, medical services, and
extended care services furnished by the Department pursuant to
this title, including through non-Department health care
providers pursuant to section 1703 of this title.
(2) In establishing standards for quality under paragraph
(1), the Secretary shall consider existing health quality
measures that are applied to public and privately sponsored
health care systems with the purpose of providing covered
veterans relevant comparative information to make informed
decisions regarding their health care.
(3) The Secretary shall collect and consider data for
purposes of establishing the standards under paragraph (1).
Such data collection shall include--
(A) after consultation with veterans service
organizations and other key stakeholders on survey
development or modification of an existing survey, a
survey of veterans who have used hospital care, medical
services, or extended care services furnished by the
Veterans Health Administration during the most recent
two-year period to assess the satisfaction of the
veterans with service and quality of care; and
(B) datasets that include, at a minimum, elements
relating to the following:
(i) Timely care.
(ii) Effective care.
(iii) Safety, including, at a minimum,
complications, readmissions, and deaths.
(iv) Efficiency.
(4) The Secretary shall consult with all pertinent Federal
entities (including the Department of Defense, the Department
of Health and Human Services, and the Centers for Medicare &
Medicaid Services), entities in the private sector, and other
nongovernmental entities in establishing standards for quality.
(5)(A) Not later than 270 days after the date of the
enactment of the Caring for Our Veterans Act of 2018, the
Secretary shall submit to the appropriate committees of
Congress a report detailing the standards for quality.
(B)(i) Before submitting the report required under
subparagraph (A), the Secretary shall provide periodic updates
to the appropriate committees of Congress to confirm the
Department's progress towards developing the standards for
quality required by this section.
(ii) The first update under clause (i) shall occur no later
than 120 days from the date of the enactment of the Caring for
Our Veterans Act of 2018.
(b) Publication and Consideration of Public Comments.--(1)
Not later than one year after the date on which the Secretary
establishes standards for quality under subsection (a), the
Secretary shall publish the quality rating of medical
facilities of the Department in the publicly available Hospital
Compare website through the Centers for Medicare & Medicaid
Services for the purpose of providing veterans with information
that allows them to compare performance measure information
among Department and non-Department health care providers.
(2) Not later than two years after the date on which the
Secretary establishes standards for quality under subsection
(a), the Secretary shall consider and solicit public comment on
potential changes to the measures used in such standards to
ensure that they include the most up-to-date and applicable
industry measures for veterans.
(c)(1) The term ``appropriate committees of Congress''
means--
(A) the Committee on Veterans' Affairs and the
Committee on Appropriations of the Senate; and
(B) the Committee on Veterans' Affairs and the
Committee on Appropriations of the House of
Representatives.
(2) The term ``covered veterans'' refers to veterans
described in section 1703(b) of this title.
Sec. 1703D. Prompt payment standard
(a) In General.--(1) Notwithstanding any other provision of
this title or of any other provision of law, the Secretary
shall pay for hospital care, medical services, or extended care
services furnished by health care entities or providers under
this chapter within 45 calendar days upon receipt of a clean
paper claim or 30 calendar days upon receipt of a clean
electronic claim.
(2) If a claim is denied, the Secretary shall, within 45
calendar days of denial for a paper claim and 30 calendar days
of denial for an electronic claim, notify the health care
entity or provider of the reason for denying the claim and
what, if any, additional information is required to process the
claim.
(3) Upon the receipt of the additional information, the
Secretary shall ensure that the claim is paid, denied, or
otherwise adjudicated within 30 calendar days from the receipt
of the requested information.
(4) This section shall only apply to payments made on an
invoice basis and shall not apply to capitation or other forms
of periodic payment to entities or providers.
(b) Submittal of Claims by Health Care Entities and
Providers.--A health care entity or provider that furnishes
hospital care, a medical service, or an extended care service
under this chapter shall submit to the Secretary a claim for
payment for furnishing the hospital care, medical service, or
extended care service not later than 180 days after the date on
which the entity or provider furnished the hospital care,
medical service, or extended care service.
(c) Fraudulent Claims.--(1) Sections 3729 through 3733 of
title 31 shall apply to fraudulent claims for payment submitted
to the Secretary by a health care entity or provider under this
chapter.
(2) Pursuant to regulations prescribed by the Secretary, the
Secretary shall bar a health care entity or provider from
furnishing hospital care, medical services, and extended care
services under this chapter when the Secretary determines the
entity or provider has submitted to the Secretary fraudulent
health care claims for payment by the Secretary.
(d) Overdue Claims.--(1) Any claim that has not been denied
with notice, made pending with notice, or paid to the health
care entity or provider by the Secretary shall be overdue if
the notice or payment is not received by the entity provider
within the time periods specified in subsection (a).
(2)(A) If a claim is overdue under this subsection, the
Secretary may, under the requirements established by subsection
(a) and consistent with the provisions of chapter 39 of title
31 (commonly referred to as the ``Prompt Payment Act''),
require that interest be paid on clean claims.
(B) Interest paid under subparagraph (A) shall be computed at
the rate of interest established by the Secretary of the
Treasury under section 3902 of title 31 and published in the
Federal Register.
(3) Not less frequently than annually, the Secretary shall
submit to Congress a report on payment of overdue claims under
this subsection, disaggregated by paper and electronic claims,
that includes the following:
(A) The amount paid in overdue claims described in
this subsection, disaggregated by the amount of the
overdue claim and the amount of interest paid on such
overdue claim.
(B) The number of such overdue claims and the average
number of days late each claim was paid, disaggregated
by facility of the Department and Veterans Integrated
Service Network region.
(e) Overpayment.--(1) The Secretary shall deduct the amount
of any overpayment from payments due a health care entity or
provider under this chapter.
(2) Deductions may not be made under this subsection unless
the Secretary has made reasonable efforts to notify a health
care entity or provider of the right to dispute the existence
or amount of such indebtedness and the right to request a
compromise of such indebtedness.
(3) The Secretary shall make a determination with respect to
any such dispute or request prior to deducting any overpayment
unless the time required to make such a determination before
making any deductions would jeopardize the Secretary's ability
to recover the full amount of such indebtedness.
(f) Information and Documentation Required.--(1) The
Secretary shall provide to all health care entities and
providers participating in a program to furnish hospital care,
medical services, or extended care services under this chapter
a list of information and documentation that is required to
establish a clean claim under this section.
(2) The Secretary shall consult with entities in the health
care industry, in the public and private sector, to determine
the information and documentation to include in the list under
paragraph (1).
(3) If the Secretary modifies the information and
documentation included in the list under paragraph (1), the
Secretary shall notify all health care entities and providers
described in paragraph (1) not later than 30 days before such
modifications take effect.
(g) Processing of Claims.--(1) In processing a claim for
compensation for hospital care, medical services, or extended
care services furnished by a non-Department health care entity
or provider under this chapter, the Secretary may act through--
(A) a non-Department entity that is under contract or
agreement for the program established under section
1703(a) of this title; or
(B) a non-Department entity that specializes in such
processing for other Federal agency health care
systems.
(2) The Secretary shall seek to contract with a third party
to conduct a review of claims described in paragraph (3) that
includes--
(A) a feasibility assessment to determine the
capacity of the Department to process such claims in a
timely manner; and
(B) a cost benefit analysis comparing the capacity of
the Department to a third party entity capable of
processing such claims.
(3) The review required under paragraph (2) shall apply to
claims for hospital care, medical services, or extended care
services furnished under section 1703 of this Act, as amended
by the Caring for Our Veterans Act of 2018, that are processed
by the Department.
(h) Report on Encounter Data System.--(1) Not later than 90
days after the date of the enactment of the Caring for Our
Veterans Act of 2018, the Secretary shall submit to the
appropriate committees of Congress a report on the feasibility
and advisability of adopting a funding mechanism similar to
what is utilized by other Federal agencies to allow a
contracted entity to act as a fiscal intermediary for the
Federal Government to distribute, or pass through, Federal
Government funds for certain non-underwritten hospital care,
medical services, or extended care services.
(2) The Secretary may coordinate with the Department of
Defense, the Department of Health and Human Services, and the
Department of the Treasury in developing the report required by
paragraph (1).
(i) Definitions.--In this section:
(1) The term ``appropriate committees of Congress''
means--
(A) the Committee on Veterans' Affairs and
the Committee on Appropriations of the Senate;
and
(B) the Committee on Veterans' Affairs and
the Committee on Appropriations of the House of
Representatives.
(2) The term ``clean electronic claim'' means the
transmission of data for purposes of payment of covered
health care expenses that is submitted to the Secretary
which contains substantially all of the required data
elements necessary for accurate adjudication, without
obtaining additional information from the entity or
provider that furnished the care or service, submitted
in such format as prescribed by the Secretary in
regulations for the purpose of paying claims for care
or services.
(3) The term ``clean paper claim'' means a paper
claim for payment of covered health care expenses that
is submitted to the Secretary which contains
substantially all of the required data elements
necessary for accurate adjudication, without obtaining
additional information from the entity or provider that
furnished the care or service, submitted in such format
as prescribed by the Secretary in regulations for the
purpose of paying claims for care or services.
(4) The term ``fraudulent claims'' means the knowing
misrepresentation of a material fact or facts by a
health care entity or provider made to induce the
Secretary to pay a claim that was not legally payable
to that provider.
(5) The term ``health care entity or provider''
includes any non-Department health care entity or
provider, but does not include any Federal health care
entity or provider.
Sec. 1703E. Center for Innovation for Care and Payment
(a) In General.--(1) There is established within the
Department a Center for Innovation for Care and Payment (in
this section referred to as the ``Center'').
(2) The Secretary, acting through the Center, may carry out
such pilot programs the Secretary determines to be appropriate
to develop innovative approaches to testing payment and service
delivery models in order to reduce expenditures while
preserving or enhancing the quality of care furnished by the
Department.
(3) The Secretary, acting through the Center, shall test
payment and service delivery models to determine whether such
models--
(A) improve access to, and quality, timeliness, and
patient satisfaction of care and services; and
(B) create cost savings for the Department.
(4)(A) The Secretary shall test a model in a location where
the Secretary determines that the model will addresses deficits
in care (including poor clinical outcomes or potentially
avoidable expenditures) for a defined population.
(B) The Secretary shall focus on models the Secretary expects
to reduce program costs while preserving or enhancing the
quality of care received by individuals receiving benefits
under this chapter.
(C) The models selected may include those described in
section 1115A(b)(2)(B) of the Social Security Act (42 U.S.C.
1315a(b)(2)(B)).
(5) In selecting a model for testing, the Secretary may
consider, in addition to other factors identified in this
subsection, the following factors:
(A) Whether the model includes a regular process for
monitoring and updating patient care plans in a manner
that is consistent with the needs and preferences of
individuals receiving benefits under this chapter.
(B) Whether the model places the individual receiving
benefits under this chapter (including family members
and other caregivers of such individual) at the center
of the care team of such individual.
(C) Whether the model uses technology or new systems
to coordinate care over time and across settings.
(D) Whether the model demonstrates effective linkage
with other public sector payers, private sector payers,
or statewide payment models.
(6)(A) Models tested under this section may not be designed
in such a way that would allow the United States to recover or
collect reasonable charges from a Federal health care program
for care or services furnished by the Secretary to a veteran
under pilot programs carried out under this section.
(B) In this paragraph, the term ``Federal health care
program'' means--
(i) an insurance program described in section 1811 of
the Social Security Act (42 U.S.C. 1395c) or
established by section 1831 of such Act (42 U.S.C.
1395j); or
(ii) a State plan for medical assistance approved
under title XIX of such Act (42 U.S.C. 1396 et seq.);
or
(iii) a TRICARE program operated under sections 1075,
1075a, 1076, 1076a, 1076c, 1076d, 1076e, or 1076f of
title 10.
(b) Duration.--Each pilot program carried out by the
Secretary under this section shall terminate no later than five
years after the date of the commencement of the pilot program.
(c) Location.--The Secretary shall ensure that each pilot
program carried out under this section occurs in an area or
areas appropriate for the intended purposes of the pilot
program. To the extent practicable, the Secretary shall ensure
that the pilot programs are located in geographically diverse
areas of the United States.
(d) Budget.--Funding for each pilot program carried out by
the Secretary under this section shall come from
appropriations--
(1) provided in advance in appropriations acts for
the Veterans Health Administration; and
(2) provided for information technology systems.
(e) Notice.--The Secretary shall--
(1) publish information about each pilot program
under this section in the Federal Register; and
(2) take reasonable actions to provide direct notice
to veterans eligible to participate in such pilot
programs.
(f) Waiver of Authorities.--(1) Subject to reporting under
paragraph (2) and approval under paragraph (3), in implementing
a pilot program under this section, the Secretary may waive
such requirements in subchapters I, II, and III of this chapter
as the Secretary determines necessary solely for the purposes
of carrying out this section with respect to testing models
described in subsection (a).
(2) Before waiving any authority under paragraph (1), the
Secretary shall submit to the Speaker of the House of
Representatives, the minority leader of the House of
Representatives, the majority leader of the Senate, the
minority leader of the Senate, and each standing committee with
jurisdiction under the rules of the Senate and of the House of
Representatives to report a bill to amend the provision or
provisions of law that would be waived by the Department, a
report describing in detail the following:
(A) The specific authorities to be waived under the
pilot program.
(B) The standard or standards to be used in the pilot
program in lieu of the waived authorities.
(C) The reasons for such waiver or waivers.
(D) A description of the metric or metrics the
Secretary will use to determine the effect of the
waiver or waivers upon the access to and quality,
timeliness, or patient satisfaction of care and
services furnished through the pilot program.
(E) The anticipated cost savings, if any, of the
pilot program.
(F) The schedule for interim reports on the pilot
program describing the results of the pilot program so
far and the feasibility and advisability of continuing
the pilot program.
(G) The schedule for the termination of the pilot
program and the submission of a final report on the
pilot program describing the result of the pilot
program and the feasibility and advisability of making
the pilot program permanent.
(H) The estimated budget of the pilot program.
(3)(A) Upon receipt of a report submitted under paragraph
(2), each House of Congress shall provide copies of the report
to the chairman and ranking member of each standing committee
with jurisdiction under the rules of the House of
Representatives or the Senate to report a bill to amend the
provision or provisions of law that would be waived by the
Department under this subsection.
(B)(i) The waiver requested by the Secretary under paragraph
(2) shall be considered approved under this paragraph if there
is enacted into law a bill or joint resolution approving such
request in its entirety. Such bill or joint resolution shall be
passed by recorded vote to reflect the vote of each member of
Congress thereon.
(ii) The provisions of this paragraph are enacted by
Congress--
(I) as an exercise of the rulemaking power of the
Senate and the House of Representatives and as such
shall be considered as part of the rules of each House
of Congress, and shall supersede other rules only to
the extent that they are inconsistent therewith; and
(II) with full recognition of the constitutional
right of either House of Congress to change the rules
(so far as they relate to the procedures of that House)
at any time, in the same manner, and to the same extent
as in the case of any other rule of that House.
(C) During the 60-calendar-day period beginning on the date
on which the Secretary submits the report described in
paragraph (2) to Congress, it shall be in order as a matter of
highest privilege in each House of Congress to consider a bill
or joint resolution, if offered by the majority leader of such
House (or a designee), approving such request in its entirety.
(g) Limitations.--(1) The Secretary may not carry out more
than 10 pilot programs concurrently.
(2)(A) Subject to subparagraph (B), the Secretary may
not expend more than $50,000,000 in any fiscal year
from amounts under subsection (d).
(B) The Secretary may expend more than the amount in
subparagraph (A) if--
(i) the Secretary determines that the
additional expenditure is necessary to carry
out pilot programs under this section;
(ii) the Secretary submits to the Committees
on Veterans' Affairs of the Senate and the
House of Representatives a report setting forth
the amount of the additional expenditure and a
justification for the additional expenditure;
and
(iii) the Chairmen of the Committees on
Veterans' Affairs of the Senate and the House
of Representatives transmit to the Secretary a
letter approving of the additional expenditure.
(3) The waiver provisions in subsection (f) shall not
apply unless the Secretary, in accordance with the
requirements in subsection (f), submits the first
proposal for a pilot program not later than 18 months
after the date of the enactment of the Caring for Our
Veterans Act of 2018.
(4) Notwithstanding section 502 of this title, decisions by
the Secretary under this section shall, consistent with section
511 of this title, be final and conclusive and may not be
reviewed by any other official or by any court, whether by an
action in the nature of mandamus or otherwise.
(5)(A) If the Secretary determines that a pilot program is
not improving the quality of care or producing cost savings,
the Secretary shall--
(i) propose a modification to the pilot program in
the interim report that shall also be considered a
report under subsection (f)(2) and shall be subject to
the terms and conditions of subsection (f)(2); or
(ii) terminate such pilot program not later than 30
days after submitting the interim report to Congress.
(B) If the Secretary terminates a pilot program under
subparagraph (A)(ii), for purposes of subparagraphs (F) and (G)
of subsection (f)(2), such interim report will also serve as
the final report for that pilot program.
(h) Evaluation and Reporting Requirements.--(1) The Secretary
shall conduct an evaluation of each model tested, which shall
include, at a minimum, an analysis of--
(A) the quality of care furnished under the model,
including the measurement of patient-level outcomes and
patient-centeredness criteria determined appropriate by
the Secretary; and
(B) the changes in spending by reason of that model.
(2) The Secretary shall make the results of each evaluation
under this subsection available to the public in a timely
fashion and may establish requirements for other entities
participating in the testing of models under this section to
collect and report information that the Secretary determines is
necessary to monitor and evaluate such models.
(i) Coordination and Advice.--(1) The Secretary shall obtain
advice from the Under Secretary for Health and the Special
Medical Advisory Group established pursuant to section 7312 of
this title in the development and implementation of any pilot
program operated under this section.
(2) In carrying out the duties under this section, the
Secretary shall consult representatives of relevant Federal
agencies, and clinical and analytical experts with expertise in
medicine and health care management. The Secretary shall use
appropriate mechanisms to seek input from interested parties.
(j) Expansion of Successful Pilot Programs.--Taking into
account the evaluation under subsection (f), the Secretary may,
through rulemaking, expand (including implementation on a
nationwide basis) the duration and the scope of a model that is
being tested under subsection (a) to the extent determined
appropriate by the Secretary, if--
(1) the Secretary determines that such expansion is
expected to--
(A) reduce spending without reducing the
quality of care; or
(B) improve the quality of patient care
without increasing spending; and
(2) the Secretary determines that such expansion
would not deny or limit the coverage or provision of
benefits for individuals receiving benefits under this
chapter.
* * * * * * *
Sec. 1706A. Remediation of medical service lines
(a) In General.--Not later than 30 days after determining
under section 1703(e)(1) that a medical service line of the
Department is providing hospital care, medical services, or
extended care services that does not comply with the standards
for quality established by the Secretary, the Secretary shall
submit to Congress an assessment of the factors that led the
Secretary to make such determination and a plan with specific
actions, and the time to complete them, to be taken to comply
with such standards for quality, including the following:
(1) Increasing personnel or temporary personnel
assistance, including mobile deployment teams.
(2) Special hiring incentives, including the
Education Debt Reduction Program under subchapter VII
of chapter 76 of this title and recruitment,
relocation, and retention incentives.
(3) Utilizing direct hiring authority.
(4) Providing improved training opportunities for
staff.
(5) Acquiring improved equipment.
(6) Making structural modifications to the facility
used by the medical service line.
(7) Such other actions as the Secretary considers
appropriate.
(b) Responsible Parties.--In each assessment submitted under
subsection (a) with respect to a medical service line, the
Secretary shall identify the individuals at the Central Office
of the Veterans Health Administration, the facility used by the
medical service line, and the central office of the relevant
Veterans Integrated Service Network who are responsible for
overseeing the progress of that medical service line in
complying with the standards for quality established by the
Secretary.
(c) Interim Reports.--Not later than 180 days after
submitting an assessment under subsection (a) with respect to a
medical service line, the Secretary shall submit to Congress a
report on the progress of that medical service line in
complying with the standards for quality established by the
Secretary and any other measures the Secretary will take to
assist the medical service line in complying with such
standards for quality.
(d) Annual Reports.--Not less frequently than once each year,
the Secretary shall--
(1) submit to Congress an analysis of the remediation
actions and costs of such actions taken with respect to
each medical service line with respect to which the
Secretary submitted an assessment and plan under
paragraph (1) in the preceding year, including an
update on the progress of each such medical service
line in complying with the standards for quality and
timeliness established by the Secretary and any other
actions the Secretary is undertaking to assist the
medical service line in complying with standards for
quality as established by the Secretary; and
(2) publish such analysis on the internet website of
the Department.
* * * * * * *
SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL
TREATMENT
* * * * * * *
Sec. 1712. Dental care; drugs and medicines for certain disabled
veterans; vaccines
(a)(1) Outpatient dental services and treatment, and related
dental appliances, shall be furnished under this section only
for a dental condition or disability--
(A) which is service-connected and compensable in
degree;
(B) which is service-connected, but not compensable
in degree, but only if--
(i) the dental condition or disability is
shown to have been in existence at the time of
the veteran's discharge or release from active
military, naval, or air service;
(ii) the veteran had served on active duty
for a period of not less than 180 days or, in
the case of a veteran who served on active duty
during the Persian Gulf War, 90 days
immediately before such discharge or release;
(iii) application for treatment is made
within 180 days after such discharge or
release, except that (I) in the case of a
veteran who reentered active military, naval,
or air service within 90 days after the date of
such veteran's prior discharge or release from
such service, application may be made within
180 days from the date of such veteran's
subsequent discharge or release from such
service, and (II) if a disqualifying discharge
or release has been corrected by competent
authority, application may be made within 180
days after the date of correction; and
(iv) the veteran's certificate of discharge
or release from active duty does not bear a
certification that the veteran was provided,
within the 90-day period immediately before the
date of such discharge or release, a complete
dental examination (including dental X-rays)
and all appropriate dental services and
treatment indicated by the examination to be
needed;
(C) which is a service-connected dental condition or
disability due to combat wounds or other service
trauma, or of a former prisoner of war;
(D) which is associated with and is aggravating a
disability resulting from some other disease or injury
which was incurred in or aggravated by active military,
naval, or air service;
(E) which is a non-service-connected condition or
disability of a veteran for which treatment was begun
while such veteran was receiving hospital care under
this chapter and such services and treatment are
reasonably necessary to complete such treatment;
(F) from which a veteran who is a former prisoner of
war is suffering;
(G) from which a veteran who has a service-connected
disability rated as total is suffering; or
(H) the treatment of which is medically necessary (i)
in preparation for hospital admission, or (ii) for a
veteran otherwise receiving care or services under this
chapter.
(2) The Secretary concerned shall at the time a member of the
Armed Forces is discharged or released from a period of active
military, naval, or air service of not less than 180 days or,
in the case of a veteran who served on active duty during the
Persian Gulf War, 90 days provide to such member a written
explanation of the provisions of clause (B) of paragraph (1) of
this subsection and enter in the service records of the member
a statement signed by the member acknowledging receipt of such
explanation (or, if the member refuses to sign such statement,
a certification from an officer designated for such purpose by
the Secretary concerned that the member was provided such
explanation).
(3) The total amount which the Secretary may expend for
furnishing, during any twelve-month period, outpatient dental
services, treatment, or related dental appliances to a veteran
under this section through private facilities for which the
Secretary has contracted [under clause (1), (2), or (5) of
section 1703(a) of this title] or entered an agreement may not
exceed $1,000 unless the Secretary determines, prior to the
furnishing of such services, treatment, or appliances and based
on an examination of the veteran by a dentist employed by the
Department (or, in an area where no such dentist is available,
by a dentist conducting such examination under a contract or
fee arrangement), that the furnishing of such services,
treatment, or appliances at such cost is reasonably necessary.
(4)(A) Except as provided in subparagraph (B) of this
paragraph, in any year in which the President's Budget for the
fiscal year beginning October 1 of such year includes an amount
for expenditures for contract dental care [under the provisions
of this subsection and section 1703 of this title] during such
fiscal year in excess of the level of expenditures made for
such purpose during fiscal year 1978, the Secretary shall, not
later than February 15 of such year, submit a report to the
appropriate committees of the Congress justifying the requested
level of expenditures for contract dental care and explaining
why the application of the criteria prescribed in section 1703
of this title for contracting with private facilities and in
the second sentence of section 1710(c) of this title for
furnishing incidental dental care to hospitalized veterans will
not preclude the need for expenditures for contract dental care
in excess of the fiscal year 1978 level of expenditures for
such purpose. In any case in which the amount included in the
President's Budget for any fiscal year for expenditures for
contract dental care under such provisions is not in excess of
the level of expenditures made for such purpose during fiscal
year 1978 and the Secretary determines after the date of
submission of such budget and before the end of such fiscal
year that the level of expenditures for such contract dental
care during such fiscal year will exceed the fiscal year 1978
level of expenditures, the Secretary shall submit a report to
the appropriate committees of the Congress containing both a
justification (with respect to the projected level of
expenditures for such fiscal year) and an explanation as
required in the preceding sentence in the case of a report
submitted pursuant to such sentence. Any report submitted
pursuant to this paragraph shall include a comment by the
Secretary on the effect of the application of the criteria
prescribed in the second sentence of section 1710(c) of this
title for furnishing incidental dental care to hospitalized
veterans.
(B) A report under subparagraph (A) of this paragraph with
respect to a fiscal year is not required if, in the documents
submitted by the Secretary to the Congress in justification for
the amounts included for Department programs in the President's
Budget, the Secretary specifies with respect to contract dental
care described in such subparagraph--
(i) the actual level of expenditures for such care in
the fiscal year preceding the fiscal year in which such
Budget is submitted;
(ii) a current estimate of the level of expenditures
for such care in the fiscal year in which such Budget
is submitted; and
(iii) the amount included in such Budget for such
care.
(b) Dental services and related appliances for a dental
condition or disability described in paragraph (1)(B) of
subsection (a) shall be furnished on a one-time completion
basis, unless the services rendered on a one-time completion
basis are found unacceptable within the limitations of good
professional standards, in which event such additional services
may be afforded as are required to complete professionally
acceptable treatment.
(c) Dental appliances, wheelchairs, artificial limbs,
trusses, special clothing, and similar appliances to be
furnished by the Secretary under this section may be procured
by the Secretary either by purchase or by manufacture,
whichever the Secretary determines may be advantageous and
reasonably necessary.
(d) The Secretary shall furnish to each veteran who is
receiving additional compensation or allowance under chapter 11
of this title, or increased pension as a veteran of a period of
war, by reason of being permanently housebound or in need of
regular aid and attendance, such drugs and medicines as may be
ordered on prescription of a duly licensed physician as
specific therapy in the treatment of any illness or injury
suffered by such veteran. The Secretary shall continue to
furnish such drugs and medicines so ordered to any such veteran
in need of regular aid and attendance whose pension payments
have been discontinued solely because such veteran's annual
income is greater than the applicable maximum annual income
limitation, but only so long as such veteran's annual income
does not exceed such maximum annual income limitation by more
than $1,000.
(e) In order to assist the Secretary of Health and Human
Services in carrying out national immunization programs under
other provisions of law, the Secretary may authorize the
administration of immunizations to eligible veterans who
voluntarily request such immunizations in connection with the
provision of care for a disability under this chapter in any
Department health care facility. Any such immunization shall be
made using vaccine furnished by the Secretary of Health and
Human Services at no cost to the Department. For such purpose,
notwithstanding any other provision of law, the Secretary of
Health and Human Services may provide such vaccine to the
Department at no cost. Section 7316 of this title shall apply
to claims alleging negligence or malpractice on the part of
Department personnel granted immunity under such section.
Sec. 1712A. Eligibility for readjustment counseling and related mental
health services
(a)(1)(A) Upon the request of any individual referred to in
subparagraph (C), the Secretary shall furnish counseling,
including by furnishing counseling through a Vet Center, to the
individual--
(i) in the case of an individual referred to in
clauses (i) through (iv) of subparagraph (C), to assist
the individual in readjusting to civilian life; and
(ii) in the case of an individual referred to in
clause (v) of such subparagraph who is a family member
of a veteran or member described in such clause--
(I) in the case of a member who is deployed
in a theater of combat operations or an area at
a time during which hostilities are occurring
in that area, during such deployment to assist
such individual in coping with such deployment;
and
(II) in the case of a veteran or member who
is readjusting to civilian life, to the degree
that counseling furnished to such individual is
found to aid in the readjustment of such
veteran or member to civilian life.
(B) Counseling furnished to an individual under subparagraph
(A) may include a comprehensive individual assessment of the
individual's psychological, social, and other characteristics
to ascertain whether--
(i) in the case of an individual referred to in
clauses (i) through (iv) of subparagraph (C), such
individual has difficulties associated with readjusting
to civilian life; and
(ii) in the case of an individual referred to in
clause (v) of such subparagraph, such individual has
difficulties associated with--
(I) coping with the deployment of a member
described in subclause (I) of such clause; or
(II) readjustment to civilian life of a
veteran or member described in subclause (II)
of such clause.
(C) Subparagraph (A) applies to the following individuals:
(i) Any individual who is a veteran or member of the
Armed Forces, including a member of a reserve component
of the Armed Forces, who served on active duty in a
theater of combat operations or an area at a time
during which hostilities occurred in that area.
(ii) Any individual who is a veteran or member of the
Armed Forces, including a member of a reserve component
of the Armed Forces, who provided direct emergency
medical or mental health care, or mortuary services to
the causalities of combat operations or hostilities,
but who at the time was located outside the theater of
combat operations or area of hostilities.
(iii) Any individual who is a veteran or member of
the Armed Forces, including a member of a reserve
component of the Armed Forces, who engaged in combat
with an enemy of the United States or against an
opposing military force in a theater of combat
operations or an area at a time during which
hostilities occurred in that area by remotely
controlling an unmanned aerial vehicle, notwithstanding
whether the physical location of such veteran or member
during such combat was within such theater of combat
operations or area.
(iv) Any individual who received counseling under
this section before the date of the enactment of the
National Defense Authorization Act for Fiscal Year
2013.
(v) Any individual who is a family member of any--
(I) member of the Armed Forces, including a
member of a reserve component of the Armed
Forces, who is serving on active duty in a
theater of combat operations or in an area at a
time during which hostilities are occurring in
that area; or
(II) veteran or member of the Armed Forces
described in this subparagraph.
(2) Upon request of an individual described in paragraph
(1)(C), the Secretary shall provide the individual a
comprehensive individual assessment as described in paragraph
(1)(B) as soon as practicable after receiving the request, but
not later than 30 days after receiving the request.
(b)(1) If, on the basis of the assessment furnished under
subsection (a) of this section, a licensed or certified mental
health care provider employed by the Department (or, in areas
where no such licensed or certified mental health care provider
is available, a licensed or certified mental health care
provider carrying out such function under a contract or fee
arrangement with the Secretary) determines that the provision
of mental health services to such veteran is necessary to
facilitate the successful readjustment of the veteran to
civilian life, such veteran shall, within the limits of
Department facilities, be furnished such services on an
outpatient basis. For the purposes of furnishing such mental
health services, the counseling furnished under subsection (a)
of this section shall be considered to have been furnished by
the Department as a part of hospital care. Any hospital care
and other medical services considered necessary on the basis of
the assessment furnished under subsection (a) of this section
shall be furnished only in accordance with the eligibility
criteria otherwise set forth in this chapter (including the
eligibility criteria set forth in section 1784 of this title).
(2) Mental health services furnished under paragraph (1) of
this subsection may, if determined to be essential to the
effective treatment and readjustment of the veteran, include
such consultation, counseling, training, services, and expenses
as are described in sections 1782 and 1783 of this title.
(c) Upon receipt of a request for counseling under this
section from any individual who has been discharged or released
from active military, naval, or air service but who is not
otherwise eligible for such counseling, the Secretary shall--
(1) provide referral services to assist such
individual, to the maximum extent practicable, in
obtaining mental health care and services from sources
outside the Department; and
(2) if pertinent, advise such individual of such
individual's rights to apply to the appropriate
military, naval, or air service, and to the Department,
for review of such individual's discharge or release
from such service.
(d) The Under Secretary for Health may provide for such
training of professional, paraprofessional, and lay personnel
as is necessary to carry out this section effectively, and, in
carrying out this section, may utilize the services of
paraprofessionals, individuals who are volunteers working
without compensation, and individuals who are veteran-students
(as described in section 3485 of this title) in initial intake
and screening activities.
(e)(1) In furnishing counseling and related mental health
services under subsections (a) and (b) of this section, the
Secretary shall have available the same authority to enter into
contracts or agreements with private facilities that is
available to the Secretary [(under sections 1703(a)(2) and
1710(a)(1)(B) of this title)] in furnishing medical services to
veterans suffering from total service-connected disabilities.
(2) Before furnishing counseling or related mental health
services described in subsections (a) and (b) of this section
through a contract facility, as authorized by this subsection,
the Secretary shall approve (in accordance with criteria which
the Secretary shall prescribe by regulation) the quality and
effectiveness of the program operated by such facility for the
purpose for which the counseling or services are to be
furnished.
(3) The authority of the Secretary to enter into contracts
under this subsection shall be effective for any fiscal year
only to such extent or in such amounts as are provided in
appropriation Acts.
(f) The Secretary, in cooperation with the Secretary of
Defense, shall take such action as the Secretary considers
appropriate to notify veterans who may be eligible for
assistance under this section of such potential eligibility.
(g) In carrying out this section and in furtherance of the
Secretary's responsibility to carry out outreach activities
under chapter 63 of this title, the Secretary may provide for
and facilitate the participation of personnel employed by the
Secretary to provide services under this section in
recreational programs that are--
(1) designed to encourage the readjustment of
veterans described in subsection (a)(1)(C); and
(2) operated by any organization named in or approved
under section 5902 of this title.
(h) For the purposes of this section:
(1) The term ``Vet Center'' means a facility which is
operated by the Department for the provision of
services under this section and which is situated apart
from Department general health care facilities.
(2) The term ``Department general health-care
facility'' means a health-care facility which is
operated by the Department for the furnishing of
health-care services under this chapter, not limited to
services provided through the program established under
this section.
(3) The term ``family member'', with respect to a
veteran or member of the Armed Forces, means an
individual who--
(A) is a member of the family of the veteran
or member, including--
(i) a parent;
(ii) a spouse;
(iii) a child;
(iv) a step-family member; and
(v) an extended family member; or
(B) lives with the veteran or member but is
not a member of the family of the veteran or
member.
* * * * * * *
Sec. 1720G. Assistance and support services for caregivers
(a) Program of Comprehensive Assistance for Family
Caregivers.--(1)(A) The Secretary shall establish a program of
comprehensive assistance for family caregivers of eligible
veterans.
(B) The Secretary shall only provide support under the
program required by subparagraph (A) to a family caregiver of
an eligible veteran if the Secretary determines it is in the
best interest of the eligible veteran to do so.
(2) For purposes of this subsection, an eligible veteran is
any individual who--
(A) is a veteran or member of the Armed Forces
undergoing medical discharge from the Armed Forces;
[(B) has 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; and]
(B) for assistance provided under this subsection--
(i) before the date on which the Secretary
submits to Congress a certification that the
Department has fully implemented the
information technology system required by
section 162(a) of the Caring for Our Veterans
Act of 2018, has 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;
(ii) during the two-year period beginning on
the date on which the Secretary submitted to
Congress the certification described in clause
(i), has 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--
(I) on or before May 7, 1975; or
(II) on or after September 11, 2001;
or
(iii) after the date that is two years after
the date on which the Secretary submits to
Congress the certification described in clause
(i), has 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; and
(C) is in need of personal care services because of--
(i) an inability to perform one or more
activities of daily living;
(ii) a need for supervision or protection
based on symptoms or residuals of neurological
or other impairment or injury[; or];
(iii) a need for regular or extensive
instruction or supervision without which the
ability of the veteran to function in daily
life would be seriously impaired; or
[(iii)] (iv) such other matters as the
Secretary considers appropriate.
(3)(A) As part of the program required by paragraph (1), the
Secretary shall provide to family caregivers of eligible
veterans the following assistance:
(i) To each family caregiver who is approved as a
provider of personal care services for an eligible
veteran under paragraph (6)--
(I) such instruction, preparation, and
training as the Secretary considers appropriate
for the family caregiver to provide personal
care services to the eligible veteran;
(II) ongoing technical support consisting of
information and assistance to address, in a
timely manner, the routine, emergency, and
specialized caregiving needs of the family
caregiver in providing personal care services
to the eligible veteran;
(III) counseling; and
(IV) lodging and subsistence under section
111(e) of this title.
(ii) To each family caregiver who is designated as
the primary provider of personal care services for an
eligible veteran under paragraph (7)--
(I) the assistance described in clause (i);
(II) such mental health services as the
Secretary determines appropriate;
(III) respite care of not less than 30 days
annually, including 24-hour per day care of the
veteran commensurate with the care provided by
the family caregiver to permit extended
respite;
(IV) medical care under section 1781 of this
title[; and];
(V) a monthly personal caregiver stipend[.];
and
(VI) through the use of contracts with, or
the provision of grants to, public or private
entities--
(aa) financial planning services
relating to the needs of injured
veterans and their caregivers; and
(bb) legal services, including legal
advice and consultation, relating to
the needs of injured veterans and their
caregivers.
(B) Respite care provided under subparagraph (A)(ii)(III)
shall be medically and age-appropriate and include in-home
care.
(C)(i) The amount of the monthly personal caregiver stipend
provided under subparagraph (A)(ii)(V) shall be determined in
accordance with a schedule established by the Secretary that
specifies stipends based upon the amount and degree of personal
care services provided.
(ii) The Secretary shall ensure, to the extent practicable,
that the schedule required by clause (i) specifies that the
amount of the monthly personal caregiver stipend provided to a
primary provider of personal care services for the provision of
personal care services to an eligible veteran is not less than
the monthly amount a commercial home health care entity would
pay an individual in the geographic area of the eligible
veteran to provide equivalent personal care services to the
eligible veteran.
(iii) In determining the amount and degree of personal care
services provided under clause (i) with respect to an eligible
veteran whose need for personal care services is based in whole
or in part on a need for supervision or protection under
paragraph (2)(C)(ii) or regular instruction or supervision
under paragraph (2)(C)(iii), the Secretary shall take into
account the following:
(I) The assessment by the family caregiver of the
needs and limitations of the veteran.
(II) The extent to which the veteran can function
safely and independently in the absence of such
supervision, protection, or instruction.
(III) The amount of time required for the family
caregiver to provide such supervision, protection, or
instruction to the veteran.
[(iii)] (iv) If personal care services are not available from
a commercial home health entity in the geographic area of an
eligible veteran, the amount of the monthly personal caregiver
stipend payable under the schedule required by clause (i) with
respect to the eligible veteran shall be determined by taking
into consideration the costs of commercial providers of
personal care services in providing personal care services in
geographic areas other than the geographic area of the eligible
veteran with similar costs of living.
(D) In providing instruction, preparation, and training under
subparagraph (A)(i)(I) and technical support under subparagraph
(A)(i)(II) to each family caregiver who is approved as a
provider of personal care services for an eligible veteran
under paragraph (6), the Secretary shall periodically evaluate
the needs of the eligible veteran and the skills of the family
caregiver of such veteran to determine if additional
instruction, preparation, training, or technical support under
those subparagraphs is necessary.
(4) An eligible veteran and a family member of the eligible
veteran seeking to participate in the program required by
paragraph (1) shall jointly submit to the Secretary an
application therefor in such form and in such manner as the
Secretary considers appropriate.
(5) For each application submitted jointly by an eligible
veteran and family member, the Secretary shall evaluate (in
collaboration with the primary care team for the eligible
veteran to the maximum extent practicable)--
(A) the eligible veteran--
(i) to identify the personal care services
required by the eligible veteran; and
(ii) to determine whether such requirements
could be significantly or substantially
satisfied through the provision of personal
care services from a family member; and
(B) the family member to determine the amount of
instruction, preparation, and training, if any, the
family member requires to provide the personal care
services required by the eligible veteran--
(i) as a provider of personal care services
for the eligible veteran; and
(ii) as the primary provider of personal care
services for the eligible veteran.
(6)(A) The Secretary shall provide each family member of an
eligible veteran who makes a joint application under paragraph
(4) the instruction, preparation, and training determined to be
required by such family member under paragraph (5)(B).
(B) Upon the successful completion by a family member of an
eligible veteran of instruction, preparation, and training
under subparagraph (A), the Secretary shall approve the family
member as a provider of personal care services for the eligible
veteran.
(C) The Secretary shall, subject to regulations the Secretary
shall prescribe, provide for necessary travel, lodging, and per
diem expenses incurred by a family member of an eligible
veteran in undergoing instruction, preparation, and training
under subparagraph (A).
(D) If the participation of a family member of an eligible
veteran in instruction, preparation, and training under
subparagraph (A) would interfere with the provision of personal
care services to the eligible veteran, the Secretary shall,
subject to regulations as the Secretary shall prescribe and in
consultation with the veteran, provide respite care to the
eligible veteran during the provision of such instruction,
preparation, and training to the family member so that the
family member can participate in such instruction, preparation,
and training without interfering with the provision of such
services to the eligible veteran.
(7)(A) For each eligible veteran with at least one family
member who is described by subparagraph (B), the Secretary
shall designate one family member of such eligible veteran as
the primary provider of personal care services for such
eligible veteran.
(B) A primary provider of personal care services designated
for an eligible veteran under subparagraph (A) shall be
selected from among family members of the eligible veteran
who--
(i) are approved under paragraph (6) as a provider of
personal care services for the eligible veteran;
(ii) elect to provide the personal care services to
the eligible veteran that the Secretary determines the
eligible veteran requires under paragraph (5)(A)(i);
(iii) have the consent of the eligible veteran to be
the primary provider of personal care services for the
eligible veteran; and
(iv) are considered by the Secretary as competent to
be the primary provider of personal care services for
the eligible veteran.
(C) An eligible veteran receiving personal care services from
a family member designated as the primary provider of personal
care services for the eligible veteran under subparagraph (A)
may, in accordance with procedures the Secretary shall
establish for such purposes, revoke consent with respect to
such family member under subparagraph (B)(iii).
(D) If a family member designated as the primary provider of
personal care services for an eligible veteran under
subparagraph (A) subsequently fails to meet any requirement set
forth in subparagraph (B), the Secretary--
(i) shall immediately revoke the family member's
designation under subparagraph (A); and
(ii) may designate, in consultation with the eligible
veteran, a new primary provider of personal care
services for the eligible veteran under such
subparagraph.
(E) The Secretary shall take such actions as may be necessary
to ensure that the revocation of a designation under
subparagraph (A) with respect to an eligible veteran does not
interfere with the provision of personal care services required
by the eligible veteran.
(8) If an eligible veteran lacks the capacity to make a
decision under this subsection, the Secretary may, in
accordance with regulations and policies of the Department
regarding appointment of guardians or the use of powers of
attorney, appoint a surrogate for the eligible veteran who may
make decisions and take action under this subsection on behalf
of the eligible veteran.
(9)(A) The Secretary shall monitor the well-being of each
eligible veteran receiving personal care services under the
program required by paragraph (1).
(B) The Secretary shall document each finding the Secretary
considers pertinent to the appropriate delivery of personal
care services to an eligible veteran under the program.
(C) The Secretary shall establish procedures to ensure
appropriate follow-up regarding findings described in
subparagraph (B). Such procedures may include the following:
(i) Visiting an eligible veteran in the eligible
veteran's home to review directly the quality of
personal care services provided to the eligible
veteran.
(ii) Taking such corrective action with respect to
the findings of any review of the quality of personal
care services provided an eligible veteran as the
Secretary considers appropriate, which may include--
(I) providing additional training to a family
caregiver; and
(II) suspending or revoking the approval of a
family caregiver under paragraph (6) or the
designation of a family caregiver under
paragraph (7).
(10) The Secretary shall carry out outreach to inform
eligible veterans and family members of eligible veterans of
the program required by paragraph (1) and the benefits of
participating in the program.
(11)(A) In providing assistance under this subsection to
family caregivers of eligible veterans, the Secretary may enter
into contracts, provider agreements, and memoranda of
understanding with Federal agencies, States, and private,
nonprofit, and other entities to provide such assistance to
such family caregivers.
(B) The Secretary may provide assistance under this paragraph
only if such assistance is reasonably accessible to the family
caregiver and is substantially equivalent or better in quality
to similar services provided by the Department.
(C) The Secretary may provide fair compensation to Federal
agencies, States, and other entities that provide assistance
under this paragraph.
(b) Program of General Caregiver Support Services.--(1) The
Secretary shall establish a program of support services for
caregivers of covered veterans who are enrolled in the health
care system established under section 1705(a) of this title
(including caregivers who do not reside with such veterans).
(2) For purposes of this subsection, a covered veteran is any
individual who needs personal care services because of--
(A) an inability to perform one or more activities of
daily living;
(B) a need for supervision or protection based on
symptoms or residuals of neurological or other
impairment or injury; or
(C) such other matters as the Secretary shall
specify.
(3)(A) The support services furnished to caregivers of
covered veterans under the program required by paragraph (1)
shall include the following:
(i) Services regarding the administering of personal
care services, which, subject to subparagraph (B),
shall include--
(I) educational sessions made available both
in person and on an Internet website;
(II) use of telehealth and other available
technologies; and
(III) teaching techniques, strategies, and
skills for caring for a disabled veteran;
(ii) Counseling and other services under section 1782
of this title.
(iii) Respite care under section 1720B of this title
that is medically and age appropriate for the veteran
(including 24-hour per day in-home care).
(iv) Information concerning the supportive services
available to caregivers under this subsection and other
public, private, and nonprofit agencies that offer
support to caregivers.
(B) If the Secretary certifies to the Committees on Veterans'
Affairs of the Senate and the House of Representatives that
funding available for a fiscal year is insufficient to fund the
provision of services specified in one or more subclauses of
subparagraph (A)(i), the Secretary shall not be required under
subparagraph (A) to provide the services so specified in the
certification during the period beginning on the date that is
180 days after the date the certification is received by the
Committees and ending on the last day of the fiscal year.
(4) In providing information under paragraph (3)(A)(iv), the
Secretary shall collaborate with the Assistant Secretary for
Aging of the Department of Health and Human Services in order
to provide caregivers access to aging and disability resource
centers under the Administration on Aging of the Department of
Health and Human Services.
(5) In carrying out the program required by paragraph (1),
the Secretary shall conduct outreach to inform covered veterans
and caregivers of covered veterans about the program. The
outreach shall include an emphasis on covered veterans and
caregivers of covered veterans living in rural areas.
(c) Construction.--(1) A decision by the Secretary under this
section affecting the furnishing of assistance or support shall
be considered a medical determination.
(2) Nothing in this section shall be construed to create--
(A) an employment relationship between the Secretary
and an individual in receipt of assistance or support
under this section; or
(B) any entitlement to any assistance or support
provided under this section.
(d) Definitions.--In this section:
(1) The term ``caregiver'', with respect to an
eligible veteran under subsection (a) or a covered
veteran under subsection (b), means an individual who
provides personal care services to the veteran.
(2) The term ``family caregiver'', with respect to an
eligible veteran under subsection (a), means a family
member who is a caregiver of the veteran.
(3) The term ``family member'', with respect to an
eligible veteran under subsection (a), means an
individual who--
(A) is a member of the family of the veteran,
including--
(i) a parent;
(ii) a spouse;
(iii) a child;
(iv) a step-family member; and
(v) an extended family member; or
(B) lives with the veteran but is not a
member of the family of the veteran.
(4) The term ``personal care services'', with respect
to an eligible veteran under subsection (a) or a
covered veteran under subsection (b), means services
that provide the veteran the following:
(A) Assistance with one or more [independent]
activities of daily living.
(B) Supervision or protection based on
symptoms or residuals of neurological or other
impairment or injury.
(C) Regular or extensive instruction or
supervision without which the ability of the
veteran to function in daily life would be
seriously impaired.
[(B)] (D) Any other non-institutional
extended care (as such term is used in section
1701(6)(E) of this title).
(e) Authorization of Appropriations.--There are authorized to
be appropriated to carry out the programs required by
subsections (a) and (b)--
(1) $60,000,000 for fiscal year 2010;
(2) $1,542,000,000 for the period of fiscal years
2011 through 2015;
(3) $625,000,000 for fiscal year 2016;
(4) $734,628,000 for fiscal year 2017; and
(5) $839,828,000 for each of fiscal years 2018 and
2019.
* * * * * * *
Sec. [1712I] 1720I. Mental and behavioral health care for certain
former members of the Armed Forces
(a) In General The Secretary shall furnish to former members
of the Armed Forces described in subsection (b)--
(1) an initial mental health assessment; and
(2) the mental healthcare or behavioral healthcare
services authorized under this chapter that are
required to treat the mental or behavioral health care
needs of the former service members, including risk of
suicide or harming others.
(b) Eligible Individuals A former member of the Armed Forces
described in this subsection is an individual who--
(1) is a former member of the Armed Forces, including
the reserve components;
(2) while serving in the active military, naval, or
air service, was discharged or released therefrom under
a condition that is not honorable but not--
(A) a dishonorable discharge; or
(B) a discharge by court-martial;
(3) is not otherwise eligible to enroll in the health
care system established by section 1705 of this title;
and
(4)(A)(i) served in the Armed Forces for a period of
more than 100 cumulative days; and
(ii) was deployed in a theater of combat operations,
in support of a contingency operation, or in an area at
a time during which hostilities are occurring in that
area during such service, including by controlling an
unmanned aerial vehicle from a location other than such
theater or area; or
(B) while serving in the Armed Forces, was the victim
of a physical assault of a sexual nature, a battery of
a sexual nature, or sexual harassment (as defined in
section 1720D(f) of this title).
(c) Non-Department Care(1) In furnishing mental or behavioral
health care services to an individual under this section, the
Secretary may provide such mental or behavioral health care
services at a non- Department facility if--
(A) in the judgment of a mental health professional
employed by the Department, the receipt of mental or
behavioral health care services by that individual in
facilities of the Department would be clinically
inadvisable; or
(B) facilities of the Department are not capable of
furnishing such mental or behavioral health care
services to that individual economically because of
geographical inaccessibility.
(2) The Secretary shall carry out paragraph (1) pursuant to
section 1703 of this title or any other provision of law
authorizing the Secretary to enter into contracts or agreements
to furnish hospital care and medical services to veterans at
non-Department facilities.
(d) Setting and Referrals In furnishing mental and behavioral
health care services to individuals under this section, the
Secretary shall--
(1) seek to ensure that such services are furnished
in settings that are therapeutically appropriate,
taking into account the circumstances that resulted in
the need for such services; and
(2) provide referral services to assist former
members who are not eligible for services under this
chapter to obtain services from sources outside the
Department.
(e) Information The Secretary shall provide information on
the mental and behavioral health care services available under
this section. Efforts by the Secretary to provide such
information--
(1) shall include notification of each eligible
individual described in subsection (b) about the
eligibility of the individual for covered mental and
behavioral health care under this section not later
than the later of--
(A) 180 days after the date of the enactment
of the Military Construction, Veterans Affairs,
and Related Agencies Appropriations Act, 2018;
or
(B) 180 days after the date on which the
individual was discharged or released from the
active military, naval, or air service;
(2) shall include availability of a toll-free
telephone number (commonly referred to as an 800
number);
(3) shall ensure that information about the mental
health care services available under this section--
(A) is revised and updated as appropriate;
(B) is made available and visibly posted at
appropriate facilities of the Department; and
(C) is made available to State veteran
agencies and through appropriate public
information services; and
(4) shall include coordination with the Secretary of
Defense seeking to ensure that members of the Armed
Forces and individuals who are being separated from
active military, naval, or air service are provided
appropriate information about programs, requirements,
and procedures for applying for mental health care
services under this section.
(f) Annual Reports(1) Not less frequently than once each
year, the Secretary shall submit to the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans' Affairs of
the House of Representatives a report on the mental and
behavioral health care services provided under this section.
(2) Each report submitted under paragraph (1) shall include,
with respect to the year preceding the submittal of the report,
the following:
(A) The number of eligible individuals who were
furnished mental or behavioral health care services
under this section, disaggregated by the number of men
who received such services and the number of women who
received such services.
(B) The number of individuals who requested an
initial mental health assessment under subsection
(a)(1).
(C) Such other information as the Secretary considers
appropriate.
* * * * * * *
SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS
* * * * * * *
Sec. 1725A. Access to walk-in care
(a) Procedures to Ensure Access to Walk-in Care.--The
Secretary shall develop procedures to ensure that eligible
veterans are able to access walk-in care from qualifying non-
Department entities or providers.
(b) Eligible Veterans.--For purposes of this section, an
eligible veteran is any individual who--
(1) is enrolled in the health care system established
under section 1705(a) of this title; and
(2) has received care under this chapter within the
24-month period preceding the furnishing of walk-in
care under this section.
(c) Qualifying Non-Department Entities or Providers.--For
purposes of this section, a qualifying non-Department entity or
provider is a non-Department entity or provider that has
entered into a contract or other agreement with the Secretary
to furnish services under this section.
(d) Federally-qualified Health Centers.--Whenever
practicable, the Secretary may use a Federally-qualified health
center (as defined in section 1905(l)(2)(B) of the Social
Security Act (42 U.S.C. 1396d(l)(2)(B))) to carry out this
section.
(e) Continuity of Care.--The Secretary shall ensure
continuity of care for those eligible veterans who receive
walk-in care services under this section, including through the
establishment of a mechanism to receive medical records from
walk-in care providers and provide pertinent patient medical
records to providers of walk-in care.
(f) Copayments.--(1)(A) The Secretary may require an eligible
veteran to pay the United States a copayment for each episode
of hospital care or medical services provided under this
section if the eligible veteran would be required to pay a
copayment under this title.
(B) An eligible veteran not required to pay a copayment under
this title may access walk-in care without a copayment for the
first two visits in a calendar year. For any additional visits,
a copayment at an amount determined by the Secretary may be
required.
(C) An eligible veteran required to pay a copayment under
this title may be required to pay a regular copayment for the
first two walk-in care visits in a calendar year. For any
additional visits, a higher copayment at an amount determined
by the Secretary may be required.
(2) After the first two episodes of care furnished to an
eligible veteran under this section, the Secretary may adjust
the copayment required of the veteran under this subsection
based upon the priority group of enrollment of the eligible
veteran, the number of episodes of care furnished to the
eligible veteran during a year, and other factors the Secretary
considers appropriate under this section.
(3) The amount or amounts of the copayments required under
this subsection shall be prescribed by the Secretary by rule.
(4) Section 8153(c) of this title shall not apply to this
subsection.
(g) Regulations.--Not later than one year after the date of
the enactment of the Caring for Our Veterans Act of 2018, the
Secretary shall promulgate regulations to carry out this
section.
(h) Walk-in Care Defined.--In this section, the term ``walk-
in care'' means non-emergent care provided by a qualifying non-
Department entity or provider that furnishes episodic care and
not longitudinal management of conditions and is otherwise
defined through regulations the Secretary shall promulgate.
* * * * * * *
Sec. 1729. Recovery by the United States of the cost of certain care
and services
(a)[(1) Subject to the provisions of this section, in any
case in which a veteran is furnished care or services under
this chapter for a non-service-connected disability described
in paragraph (2) of this subsection, the United States has the
right to recover or collect reasonable charges for such care or
services (as determined by the Secretary) from a third party to
the extent that the veteran (or the provider of the care or
services) would be eligible to receive payment for such care or
services from such third party if the care or services had not
been furnished by a department or agency of the United States.]
(1) Subject to the provisions of this section, in any case in
which the United States is required by law to furnish or pay
for care or services under this chapter for a non-service-
connected disability described in paragraph (2) of this
subsection, the United States has the right to recover or
collect from a third party the reasonable charges of care or
services so furnished or paid for to the extent that the
recipient or provider of the care or services would be eligible
to receive payment for such care or services from such third
party if the care or services had not been furnished or paid
for by a department or agency of the United States.
(2) Paragraph (1) of this subsection applies to a non-
service-connected disability--
(A) that is incurred incident to [the veteran's] the
individual's employment and that is covered under a
workers' compensation law or plan that provides for
payment for the cost of health care and services
provided to [the veteran] the individual by reason of
the disability;
(B) that is incurred as the result of a motor vehicle
accident to which applies a State law that requires the
owners or operators of motor vehicles registered in
that State to have in force automobile accident
reparations insurance;
(C) that is incurred as the result of a crime of
personal violence that occurred in a State, or a
political subdivision of a State, in which a person
injured as the result of such a crime is entitled to
receive health care and services at such State's or
subdivision's expense for personal injuries suffered as
the result of such crime;
[(D) that is incurred by a veteran--
[(i) who does not have a service-connected
disability; and
[(ii) who is entitled to care (or payment of
the expenses of care) under a health-plan
contract; or]
(D) that is incurred by an individual who is entitled
to care (or payment of the expenses of care) under a
health-plan contract.
(E) for which care and services are furnished before
September 30, 2019, under this chapter to a veteran
who--
(i) has a service-connected disability; and
(ii) is entitled to care (or payment of the
expenses of care) under a health-plan contract.
(3) In the case of a health-plan contract that contains a
requirement for payment of a deductible or copayment by [the
veteran] the individual--
(A) [the veteran's] the individual's not having paid
such deductible or copayment with respect to care or
services furnished under this chapter shall not
preclude recovery or collection under this section; and
(B) the amount that the United States may collect or
recover under this section shall be reduced by the
appropriate deductible or copayment amount, or both.
(b)(1) As to the right provided in subsection (a) of this
section, the United States shall be subrogated to any right or
claim that [the veteran] the individual (or [the veteran's] the
individual's personal representative, successor, dependents, or
survivors) may have against a third party.
(2)(A) In order to enforce any right or claim to which the
United States is subrogated under paragraph (1) of this
subsection, the United States may intervene or join in any
action or proceeding brought by [the veteran] the individual
(or [the veteran's] the individual's personal representative,
successor, dependents, or survivors) against a third party.
(B) The United States may institute and prosecute legal
proceedings against the third party if--
(i) an action or proceeding described in subparagraph
(A) of this paragraph is not begun within 180 days
after the first day on which care or services for which
recovery is sought are furnished to [the veteran] the
individual by the Secretary under this chapter;
(ii) the United States has sent written notice by
certified mail to [the veteran] the individual at [the
veteran's] the individual's last-known address (or to
[the veteran's] the individual's personal
representative or successor) of the intention of the
United States to institute such legal proceedings; and
(iii) a period of 60 days has passed following the
mailing of such notice.
(C) A proceeding under subparagraph (B) of this paragraph may
not be brought after the end of the six-year period beginning
on the last day on which the care or services for which
recovery is sought are furnished.
(c)(1) The Secretary may compromise, settle, or waive any
claim which the United States has under this section.
(2)(A) The Secretary, after consultation with the Comptroller
General of the United States, shall prescribe regulations for
the purpose of determining reasonable charges for care or
services under subsection (a)(1) of this section. Any
determination of such charges shall be made in accordance with
such regulations.
(B) Such regulations shall provide that the reasonable
charges for care or services sought to be recovered or
collected from a third-party liable under a health-plan
contract may not exceed the amount that such third party
demonstrates to the satisfaction of the Secretary it would pay
for the care or services if provided by facilities (other than
facilities of departments or agencies of the United States) in
the same geographic area.
(C) Not later than 45 days after the date on which the
Secretary prescribes such regulations (or any amendment to such
regulations), the Comptroller General shall submit to the
Committees on Veterans' Affairs of the Senate and the House of
Representatives the Comptroller General's comments on and
recommendations regarding such regulations (or amendment).
(d) Any contract or agreement into which the Secretary enters
with a person under section 3718 of title 31 for collection
services to recover indebtedness owed the United States under
this section shall provide, with respect to such services, that
such person is subject to sections 5701 and 7332 of this title.
(e) [A veteran] An individual eligible for care or services
under this chapter--
(1) may not be denied such care or services by reason
of this section; and
(2) may not be required by reason of this section to
make any copayment or deductible payment in order to
receive such care.
(f) No law of any State or of any political subdivision of a
State, and no provision of any contract or other agreement,
shall operate to prevent recovery or collection by the United
States under this section or with respect to care or services
furnished under section 1784 of this title.
(h)(1) Subject to paragraph (3) of this subsection, the
Secretary shall make available medical records of [a veteran]
an individual described in paragraph (2) of this subsection for
inspection and review by representatives of the third party
concerned for the sole purposes of permitting the third party
to verify--
(A) that the care or services for which recovery or
collection is sought were furnished to [the veteran]
the individual; and
(B) that the provision of such care or services to
[the veteran] the individual meets criteria generally
applicable under the health-plan contract involved.
(2) [A veteran] An individual described in this paragraph is
[a veteran] an individual who is a beneficiary of a health-plan
contract under which recovery or collection is sought under
this section from the third party concerned for the cost of the
care or services furnished to [the veteran] the individual.
(3) Records shall be made available under this subsection
under such conditions to protect the confidentiality of such
records as the Secretary shall prescribe in regulations.
(i) For purposes of this section--
(1)(A) The term ``health-plan contract'' means an
insurance policy or contract, medical or hospital
service agreement, membership or subscription contract,
or similar arrangement, under which health services for
individuals are provided or the expenses of such
services are paid.
(B) Such term does not include--
(i) an insurance program described in section
1811 of the Social Security Act (42 U.S.C.
1395c) or established by section 1831 of such
Act (42 U.S.C. 1395j);
(ii) a State plan for medical assistance
approved under title XIX of such Act (42 U.S.C.
1396 et seq.);
(iii) a workers' compensation law or plan
described in subparagraph (A) of subsection
(a)(2) of this section; or
(iv) a program, plan, or policy under a law
described in subparagraph (B) or (C) of such
subsection.
(2) The term ``payment'' includes reimbursement and
indemnification.
(3) The term ``third party'' means--
(A) a State or political subdivision of a
State;
(B) an employer or an employer's insurance
carrier;
(C) an automobile accident reparations
insurance carrier; or
(D) a person obligated to provide, or to pay
the expenses of, health services under a
health-plan contract.
* * * * * * *
Sec. 1730B. Access to State prescription drug monitoring programs
(a) Access to Programs.--(1) Any licensed health care
provider or delegate of such a provider shall be considered an
authorized recipient or user for the purpose of querying and
receiving data from the national network of State-based
prescription drug monitoring programs to support the safe and
effective prescribing of controlled substances to covered
patients.
(2) Under the authority granted by paragraph (1)--
(A) licensed health care providers or delegates of
such providers shall query such network in accordance
with applicable regulations and policies of the
Veterans Health Administration; and
(B) notwithstanding any general or specific provision
of law, rule, or regulation of a State, no State may
restrict the access of licensed health care providers
or delegates of such providers from accessing that
State's prescription drug monitoring programs.
(3) No State shall deny or revoke the license, registration,
or certification of a licensed health care provider or delegate
who otherwise meets that State's qualifications for holding the
license, registration, or certification on the basis that the
licensed health care provider or delegate queried or received
data, or attempted to query or receive data, from the national
network of State-based prescription drug monitoring programs
under this section.
(b) Covered Patients.--For purposes of this section, a
covered patient is a patient who--
(1) receives a prescription for a controlled
substance; and
(2) is not receiving palliative care or enrolled in
hospice care.
(c) Definitions.--In this section:
(1) The term ``controlled substance'' has the meaning
given such term in section 102(6) of the Controlled
Substances Act (21 U.S.C. 802(6)).
(2) The term ``delegate'' means a person or automated
system accessing the national network of State-based
prescription monitoring programs at the direction or
under the supervision of a licensed health care
provider.
(3) The term ``licensed health care provider'' means
a health care provider employed by the Department who
is licensed, certified, or registered within any State
to fill or prescribe medications within the scope of
his or her practice as a Department employee.
(4) The term ``national network of State-based
prescription monitoring programs'' means an
interconnected nation-wide system that facilitates the
transfer to State prescription drug monitoring program
data across State lines.
(5) The term ``State'' means a State, as defined in
section 101(20) of this title, or a political
subdivision of a State.
Sec. 1730C. Licensure of health care professionals providing treatment
via telemedicine
(a) In General.--Notwithstanding any provision of law
regarding the licensure of health care professionals, a covered
health care professional may practice the health care
profession of the health care professional at any location in
any State, regardless of where the covered health care
professional or the patient is located, if the covered health
care professional is using telemedicine to provide treatment to
an individual under this chapter.
(b) Covered Health Care Professionals.--For purposes of this
section, a covered health care professional is any health care
professional who--
(1) is an employee of the Department appointed under
the authority under section 7306, 7401, 7405, 7406, or
7408 of this title or title 5;
(2) is authorized by the Secretary to provide health
care under this chapter;
(3) is required to adhere to all standards for
quality relating to the provision of medicine in
accordance with applicable policies of the Department;
and
(4) has an active, current, full, and unrestricted
license, registration, or certification in a State to
practice the health care profession of the health care
professional.
(c) Property of Federal Government.--Subsection (a) shall
apply to a covered health care professional providing treatment
to a patient regardless of whether the covered health care
professional or patient is located in a facility owned by the
Federal Government during such treatment.
(d) Relation to State Law.--(1) The provisions of this
section shall supersede any provisions of the law of any State
to the extent that such provision of State law are inconsistent
with this section.
(2) No State shall deny or revoke the license, registration,
or certification of a covered health care professional who
otherwise meets the qualifications of the State for holding the
license, registration, or certification on the basis that the
covered health care professional has engaged or intends to
engage in activity covered by subsection (a).
(e) Rule of Construction.--Nothing in this section may be
construed to remove, limit, or otherwise affect any obligation
of a covered health care professional under the Controlled
Substances Act (21 U.S.C. 801 et seq.).
(f) State Defined.--In this section, the term ``State'' means
a State, as defined in section 101(20) of this title, or a
political subdivision of a State.
* * * * * * *
SUBCHAPTER V--PAYMENTS TO STATE HOMES
* * * * * * *
Sec. 1745. Nursing home care, adult day health care, and medications
for veterans with service-connected disabilities
(a)(1) The Secretary shall enter into a contract [(or
agreement under section 1720(c)(1) of this title)] (or an
agreement) with each State home for payment by the Secretary
for nursing home care provided in the home, in any case in
which such care is provided to any veteran as follows:
(A) Any veteran in need of such care for a service-
connected disability.
(B) Any veteran who--
(i) has a service-connected disability rated
at 70 percent or more; and
(ii) is in need of such care.
(2) Payment under each contract (or agreement) between the
Secretary and a State home under paragraph (1) shall be based
on a methodology, developed by the Secretary in consultation
with the State home, to adequately reimburse the State home for
the care provided by the State home under the contract (or
agreement).
(3) Payment by the Secretary under paragraph (1) to a State
home for nursing home care provided to a veteran described in
that paragraph constitutes payment in full to the State home
for such care furnished to that veteran.
(4)(A) An agreement under this section may be authorized by
the Secretary or any Department official authorized by the
Secretary, and any such action is not an award for purposes of
such laws that would otherwise require the use of competitive
procedures for the furnishing of hospital care, medical
services, and extended care services.
(B)(i) Except as provided in the agreement itself, in clause
(ii), and unless otherwise provided in this section or
regulations prescribed pursuant to this section, a State home
that enters into an agreement under this section is not subject
to, in the carrying out of the agreement, any provision of law
to which providers of services and suppliers under the Medicare
program under title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.) are not subject.
(ii) A State home that enters into an agreement under this
section is subject to--
(I) all provisions of law regarding integrity,
ethics, or fraud, or that subject a person to civil or
criminal penalties;
(II) all provisions of law that protect against
employment discrimination or that otherwise ensure
equal employment opportunities; and
(III) all provisions in subchapter V of chapter 17 of
this title.
(iii) Notwithstanding subparagraph (B)(ii)(I), a State home
that enters into an agreement under this section may not be
treated as a Federal contractor or subcontractor for purposes
of chapter 67 of title 41 (known as the ``McNamara-O'Hara
Service Contract Act of 1965'').
(b) The Secretary shall furnish such drugs and medicines as
may be ordered on prescription of a duly licensed physician as
specific therapy in the treatment of illness or injury to any
veteran as follows:
(1) Any veteran who--
(A) is not being provided nursing home care
for which payment is payable under subsection
(a); and
(B) is in need of such drugs and medicines
for a service-connected disability.
(2) Any veteran who--
(A) has a service-connected disability rated
at 50 percent or more;
(B) is not being provided nursing home care
for which payment is payable under subsection
(a); and
(C) is in need of such drugs and medicines.
(c) Any State home that requests payment or reimbursement for
services provided to a veteran under this section shall provide
to the Secretary such information as the Secretary considers
necessary to identify each individual veteran eligible for
payment under such section.
(d)(1) The Secretary shall enter into an agreement with each
State home for payment by the Secretary for medical supervision
model adult day health care provided to a veteran described in
subsection (a)(1) on whose behalf the State home is not in
receipt of payment for nursing home care from the Secretary.
(2)(A) Payment under each agreement between the Secretary and
a State home under paragraph (1) for each veteran who receives
medical supervision model adult day health care under such
agreement shall be made at a rate established through
regulations prescribed by the Secretary to adequately reimburse
the State home for the care provided by the State home,
including necessary transportation expenses.
(B) The Secretary shall consult with the State homes in
prescribing regulations under subparagraph (A).
(C) The rate established through regulations under
subparagraph (A) shall not take effect until the date that is
30 days after the date on which those regulations are published
in the Federal Register.
(3) Payment by the Secretary under paragraph (1) to a State
home for medical supervision model adult day health care
provided to a veteran described in that paragraph constitutes
payment in full to the State home for such care furnished to
that veteran.
(4) In this subsection, the term ``medical supervision model
adult day health care'' means adult day health care that
includes the coordination of physician services, dental
services, nursing services, the administration of drugs, and
such other requirements as determined appropriate by the
Secretary.
* * * * * * *
SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS
* * * * * * *
Sec. 1788. Transplant procedures with live donors and related services
(a) In General.--Subject to subsections (b) and (c), in a
case in which a veteran is eligible for a transplant procedure
from the Department, the Secretary may provide for an operation
on a live donor to carry out such procedure for such veteran,
notwithstanding that the live donor may not be eligible for
health care from the Department.
(b) Other Services.--Subject to the availability of
appropriations for such purpose, the Secretary shall furnish to
a live donor any care or services before and after conducting
the transplant procedure under subsection (a) that may be
required in connection with such procedure.
(c) Use of Non-department Facilities.--In carrying out this
section, the Secretary may provide for the operation described
in subsection (a) on a live donor and furnish to the live donor
the care and services described in subsection (b) at a non-
Department facility pursuant to an agreement entered into by
the Secretary under this chapter. The live donor shall be
deemed to be an individual eligible for hospital care and
medical services at a non-Department facility pursuant to such
an agreement solely for the purposes of receiving such
operation, care, and services at the non-Department facility.
* * * * * * *
CHAPTER 23--BURIAL BENEFITS
* * * * * * *
Sec. 2303. Death in Department facility; plot allowance
(a)(1) When a veteran dies in a facility described in
paragraph (2), the Secretary shall--
(A) pay the actual cost (not to exceed $700 (as
increased from time to time under subsection (c))) of
the burial and funeral or, within such limits, may make
contracts for such services without regard to the laws
requiring advertisement for proposals for supplies and
services for the Department; and
(B) when such a death occurs in a State, transport
the body to the place of burial in the same or any
other State.
(2) A facility described in this paragraph is--
(A) a facility of the Department (as defined in
section 1 701(3) of this title) to which the deceased
was properly admitted for hospital, nursing home, or
domiciliary care under section 1710 or 1711(a) of this
title; or
(B) an institution at which the deceased veteran was,
at the time of death, receiving--
(i) hospital care in accordance [with section
1703] with sections 1703A, 8111, and 8153 of
this title;
(ii) nursing home care under section 1720 of
this title; or
(iii) nursing home care for which payments
are made under section 1741 of this title.
(b) In addition to the benefits provided for under section
2302 of this title and subsection (a) of this section, in the
case of a veteran who is eligible for burial in a national
cemetery under section 2402 of this title and who is not buried
in a national cemetery or other cemetery under the jurisdiction
of the United States--
(1) if such veteran is buried (without charge for the
cost of a plot or interment) in a cemetery, or a
section of a cemetery, that (A) is used solely for the
interment of persons who are (i) eligible for burial in
a national cemetery, and (ii) members of a reserve
component of the Armed Forces not otherwise eligible
for such burial or former members of such a reserve
component not otherwise eligible for such burial who
are discharged or released from service under
conditions other than dishonorable, and(B) is owned by
a State or by an agency or political subdivision of a
State, the Secretary shall pay to such State, agency,
or political subdivision the sum of $700 (as increased
from time to time under subsection (c)) as a plot or
interment allowance for such veteran; and
(2) if such veteran is eligible for a burial
allowance under section 2302 of this title or under
subsection (a) of this section, or was discharged from
the active military, naval, or air service for a
disability incurred or aggravated in line of duty, and
such veteran is buried in a cemetery, or a section of a
cemetery, other than as described in clause (1) of this
subsection, the Secretary shall pay a sum not exceeding
$700 (as increased from time to time under subsection
(c)) as a plot or interment allowance to such person as
the Secretary prescribes, except that if any part of
the plot or interment costs of a burial to which this
clause applies has been paid or assumed by a State, an
agency or political subdivision of a State, or a former
employer of the deceased veteran, no claim for such
allowance shall be allowed for more than the difference
between the entire amount of the expenses incurred and
the amount paid or assumed by any or all of the
foregoing entities.
(c) With respect to any fiscal year, the Secretary shall
provide a percentage increase (rounded to the nearest dollar)
in the maximum amount of burial and funeral expenses payable
under subsection (a) and in the maximum amount of the plot or
interment allowance payable under subsection (b), equal to the
percentage by which--
(1) the Consumer Price Index (all items, United
States city average) for the 12-month period ending on
the June 30 preceding the beginning of the fiscal year
for which the increase is made, exceeds
(2) the Consumer Price Index for the 12-month period
preceding the 12-month period described in paragraph
(1).
* * * * * * *
PART III--READJUSTMENT AND RELATED BENEFITS
* * * * * * *
CHAPTER 37--HOUSING AND SMALL BUSINESS LOANS
* * * * * * *
SUBCHAPTER III--ADMINISTRATIVE PROVISIONS
* * * * * * *
Sec. 3729. Loan fee
(a) Requirement of Fee.--(1) Except as provided in subsection
(c), a fee shall be collected from each person obtaining a
housing loan guaranteed, insured, or made under this chapter,
and each person assuming a loan to which section 3714 of this
title applies. No such loan may be guaranteed, insured, made,
or assumed until the fee payable under this section has been
remitted to the Secretary.
(2) The fee may be included in the loan and paid from the
proceeds thereof.
(b) Determination of Fee.--(1) The amount of the fee shall be
determined from the loan fee table in paragraph (2). The fee is
expressed as a percentage of the total amount of the loan
guaranteed, insured, or made, or, in the case of a loan
assumption, the unpaid principal balance of the loan on the
date of the transfer of the property.
(2) The loan fee table referred to in paragraph (1) is as
follows:
LOAN FEE TABLE
------------------------------------------------------------------------
Active duty
Type of loan veteran Reservist Other obligor
------------------------------------------------------------------------
(A)(i) Initial 2.00 2.75 NA
loan
described in
section 3710
(a) to
purchase or
construct a
dwelling with
0-down, or
any other
initial loan
described in
section 3710
(a) other
than with 5-
down or 10-
down (closed
before
January 1,
2004)
(A)(ii) 2.20 2.40 NA
Initial loan
described in
section 3710
(a) to
purchase or
construct a
dwelling with
0-down, or
any other
initial loan
described in
section 3710
(a) other
than with 5-
down or 10-
down (closed
on or after
January 1,
2004, and
before
October 1,
2004)
(A)(iii) 2.15 2.40 NA
Initial loan
described in
section 3710
(a) to
purchase or
construct a
dwelling with
0-down, or
any other
initial loan
described in
section 3710
(a) other
than with 5-
down or 10-
down (closed
on or after
October 1,
2004, and
before
September 30,
[2027] 2028)
(A)(iv) 1.40 1.65 NA
Initial loan
described in
section 3710
(a) to
purchase or
construct a
dwelling with
0-down, or
any other
initial loan
described in
section 3710
(a) other
than with 5-
down or 10-
down (closed
on or after
September 30,
[2027] 2028)
(B)(i) 3.30 3.30 NA
Subsequent
loan
described in
section 3710
(a) to
purchase or
construct a
dwelling with
0-down, or
any other
subsequent
loan
described in
section 3710
(a) (closed
before
September 30,
[2027] 2028)
(B)(ii) 1.25 1.25 NA
Subsequent
loan
described in
section 3710
(a) to
purchase or
construct a
dwelling with
0-down, or
any other
subsequent
loan
described in
section 3710
(a) (closed
on or after
September 30,
[2027] 2028)
(C)(i) Loan 1.50 1.75 NA
described in
section 3710
(a) to
purchase or
construct a
dwelling with
5-down
(closed
before
September 30,
[2027] 2028)
(C)(ii) Loan 0.75 1.00 NA
described in
section 3710
(a) to
purchase or
construct a
dwelling with
5-down
(closed on or
after
September 30,
[2027] 2028)
(D)(i) Initial 1.25 1.50 NA
loan
described in
section 3710
(a) to
purchase or
construct a
dwelling with
10-down
(closed
before
September 30,
[2027] 2028)
(D)(ii) 0.50 0.75 NA
Initial loan
described in
section 3710
(a) to
purchase or
construct a
dwelling with
10-down
(closed on or
after
September 30,
[2027] 2028)
(E) Interest 0.50 0.50 NA
rate
reduction
refinancing
loan
(F) Direct 1.00 1.00 NA
loan under
section 3711
(G) 1.00 1.00 NA
Manufactured
home loan
under section
3712 (other
than an
interest rate
reduction
refinancing
loan)
(H) Loan to 1.25 1.25 NA
Native
American
veteran under
section 3762
(other than
an interest
rate
reduction
refinancing
loan)
(I) Loan 0.50 0.50 0.50
assumption
under section
3714
(J) Loan under 2.25 2.25 2.25
section 3733
(a)
------------------------------------------------------------------------
(3) Any reference to a section in the ``Type of loan'' column
in the loan fee table in paragraph (2) refers to a section of
this title.
(4) For the purposes of paragraph (2):
(A) The term ``active duty veteran'' means any
veteran eligible for the benefits of this chapter other
than a Reservist.
(B) The term ``Reservist'' means a veteran described
in section 3701 (b)(5)(A) of this title who is eligible
under section 3702(a)(2)(E) of this title.
(C) The term ``other obligor'' means a person who is
not a veteran, as defined in section 101 of this title
or other provision of this chapter.
(D) The term ``initial loan'' means a loan to a
veteran guaranteed under section 3710 or made under
section 3711 of this title if the veteran has never
obtained a loan guaranteed under section 3710 or made
under section 3711 of this title.
(E) The term ``subsequent loan'' means a loan to a
veteran, other than an interest rate reduction
refinancing loan, guaranteed under section 3710 or made
under section 3711 of this title if the veteran has
previously obtained a loan guaranteed under section
3710 or made under section 3711 of this title.
(F) The term ``interest rate reduction refinancing
loan'' means a loan described in section 3710(a)(8),
3710(a)(9)(B)(i), 3710(a)(11), 3712(a)(1)(F), or
3762(h) of this title.
(G) The term ``0-down'' means a downpayment, if any,
of less than 5 percent of the total purchase price or
construction cost of the dwelling.
(H) The term ``5-down'' means a downpayment of at
least 5 percent or more, but less than 10 percent, of
the total purchase price or construction cost of the
dwelling.
(I) The term ``10-down'' means a downpayment of 10
percent or more of the total purchase price or
construction cost of the dwelling.
(c) Waiver of Fee.--(1) A fee may not be collected under this
section from a veteran who is receiving compensation (or who,
but for the receipt of retirement pay or active service pay,
would be entitled to receive compensation) or from a surviving
spouse of any veteran (including a person who died in the
active military, naval, or air service) who died from a
service-connected disability.
(2)(A) A veteran described in subparagraph (B) shall be
treated as receiving compensation for purposes of this
subsection as of the date of the rating described in such
subparagraph without regard to whether an effective date of the
award of compensation is established as of that date.
(B) A veteran described in this subparagraph is a veteran who
is rated eligible to receive compensation--
(i) as the result of a pre-discharge disability
examination and rating; or
(ii) based on a pre-discharge review of existing
medical evidence (including service medical and
treatment records) that results in the issuance of a
memorandum rating.
* * * * * * *
PART IV--GENERAL ADMINISTRATIVE PROVISIONS
* * * * * * *
CHAPTER 55--MINORS, INCOMPETENTS, AND OTHER WARDS
* * * * * * *
Sec. 5503. Hospitalized veterans and estates of incompetent
institutionalized veterans
(a)(1)(A) Where any veteran having neither spouse nor child
is being furnished domiciliary care by the Department, no
pension in excess of $90 per month shall be paid to or for the
veteran for any period after the end of the third full calendar
month following the month of admission for such care.
(B) Except as provided in subparagraph (D) of this paragraph,
where any veteran having neither spouse nor child is being
furnished nursing home care by the Department, no pension in
excess of $90 per month shall be paid to or for the veteran for
any period after the end of the third full calendar month
following the month of admission for such care. Any amount in
excess of $90 per month to which the veteran would be entitled
but for the application of the preceding sentence shall be
deposited in a revolving fund at the Department medical
facility which furnished the veteran nursing care, and such
amount shall be available for obligation without fiscal year
limitation to help defray operating expenses of that facility.
(C) No pension in excess of $90 per month shall be paid to or
for a veteran having neither spouse nor child for any period
after the month in which such veteran is readmitted for care
described in subparagraph (A) or (B) of this paragraph and
furnished by the Department if such veteran is readmitted
within six months of a period of care in connection with which
pension was reduced pursuant to subparagraph (A) or (B) of this
paragraph.
(D) In the case of a veteran being furnished nursing home
care by the Department and with respect to whom subparagraph
(B) of this paragraph requires a reduction in pension, such
reduction shall not be made for a period of up to three
additional calendar months after the last day of the third
month referred to in such subparagraph if the Secretary
determines that the primary purpose for the furnishing of such
care during such additional period is for the Department to
provide such veteran with a prescribed program of
rehabilitation services, under chapter 17 of this title,
designed to restore such veteran's ability to function within
such veteran's family and community. If the Secretary
determines that it is necessary, after such period, for the
veteran to continue such program of rehabilitation services in
order to achieve the purposes of such program and that the
primary purpose of furnishing nursing home care to the veteran
continues to be the provision of such program to the veteran,
the reduction in pension required by subparagraph (B) of this
paragraph shall not be made for the number of calendar months
that the Secretary determines is necessary for the veteran to
achieve the purposes of such program.
(2) The provisions of paragraph (1) shall also apply to a
veteran being furnished such care who has a spouse but whose
pension is payable under section 1521(b) of this title. In such
a case, the Secretary may apportion and pay to the spouse, upon
an affirmative showing of hardship, all or any part of the
amounts in excess of the amount payable to the veteran while
being furnished such care which would be payable to the veteran
if pension were payable under section 1521(c) of this title.
(b) Notwithstanding any other provision of this section or
any other provision of law, no reduction shall be made in the
pension of any veteran for any part of the period during which
the veteran is furnished hospital treatment, or institutional
or domiciliary care, for Hansen's disease, by the United States
or any political subdivision thereof.
(c) Where any veteran in receipt of an aid and attendance
allowance described in subsection (r) or (t) of section 1114 of
this title is hospitalized at Government expense, such
allowance shall be discontinued from the first day of the
second calendar month which begins after the date of the
veteran's admission for such hospitalization for so long as
such hospitalization continues. Any discontinuance required by
administrative regulation, during hospitalization of a veteran
by the Department, of increased pension based on need of
regular aid and attendance or additional compensation based on
need of regular aid and attendance as described in subsection
(l) or (m) of section 1114 of this title, shall not be
effective earlier than the first day of the second calendar
month which begins after the date of the veteran's admission
for hospitalization. In case a veteran affected by this
subsection leaves a hospital against medical advice and is
thereafter admitted to hospitalization within six months from
the date of such departure, such allowance, increased pension,
or additional compensation, as the case may be, shall be
discontinued from the date of such readmission for so long as
such hospitalization continues.
(d)(1) For the purposes of this subsection--
(A) the term ``Medicaid plan'' means a State plan for
medical assistance referred to in section 1902(a) of
the Social Security Act (42 U.S.C. 1396a(a)); and
(B) the term ``nursing facility'' means a nursing
facility described in section 1919 of such Act (42
U.S.C. 1396r), other than a facility that is a State
home with respect to which the Secretary makes per diem
payments for nursing home care pursuant to section
1741(a) of this title.
(2) If a veteran having neither spouse nor child is covered
by a Medicaid plan for services furnished such veteran by a
nursing facility, no pension in excess of $90 per month shall
be paid to or for the veteran for any period after the month of
admission to such nursing facility.
(3) Notwithstanding any provision of title XIX of the Social
Security Act, the amount of the payment paid a nursing facility
pursuant to a Medicaid plan for services furnished a veteran
may not be reduced by any amount of pension permitted to be
paid such veteran under paragraph (2) of this subsection.
(4) A veteran is not liable to the United States for any
payment of pension in excess of the amount permitted under this
subsection that is paid to or for the veteran by reason of the
inability or failure of the Secretary to reduce the veteran's
pension under this subsection unless such inability or failure
is the result of a willful concealment by the veteran of
information necessary to make a reduction in pension under this
subsection.
(5)(A) The provisions of this subsection shall apply with
respect to a surviving spouse having no child in the same
manner as they apply to a veteran having neither spouse nor
child.
(B) The provisions of this subsection shall apply with
respect to a child entitled to pension under section 1542 of
this title in the same manner as they apply to a veteran having
neither spouse nor child.
(6) The costs of administering this subsection shall be paid
for from amounts available to the Department of Veterans
Affairs for the payment of compensation and pension.
(7) This subsection expires on [September 30, 2027] September
30, 2028.
* * * * * * *
PART V--BOARDS, ADMINISTRATIONS, AND SERVICES
* * * * * * *
CHAPTER 73--VETERANS HEALTH ADMINISTRATION - ORGANIZATION AND FUNCTIONS
SUBCHAPTER I--ORGANIZATION
Sec.
7301. Functions of Veterans Health Administration: in general.
* * * * * * *
SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION
* * * * * * *
7330C. Quadrennial Veterans Health Administration review.
* * * * * * *
SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION
* * * * * * *
Sec. 7330C. Quadrennial Veterans Health Administration review
(a) Market Area Assessments.--(1) Not less frequently than
every four years, the Secretary of Veterans Affairs shall
perform market area assessments regarding the health care
services furnished under the laws administered by the
Secretary.
(2) Each market area assessment established under paragraph
(1) shall include the following:
(A) An assessment of the demand for health care from
the Department, disaggregated by geographic market
areas as determined by the Secretary, including the
number of requests for health care services under the
laws administered by the Secretary.
(B) An inventory of the health care capacity of the
Department of Veterans Affairs across the Department's
system of facilities.
(C) An assessment of the health care capacity to be
provided through contracted community care providers
and providers who entered into a provider agreement
with the Department under section 1703A of title 38, as
added by section 102, including the number of
providers, the geographic location of the providers,
and categories or types of health care services
provided by the providers.
(D) An assessment obtained from other Federal direct
delivery systems of their capacity to provide health
care to veterans.
(E) An assessment of the health care capacity of non-
contracted providers where there is insufficient
network supply.
(F) An assessment of the health care capacity of
academic affiliates and other collaborations of the
Department as it relates to providing health care to
veterans.
(G) An assessment of the effects on health care
capacity of the access standards and standards for
quality established under sections 1703B and 1703C of
this title.
(H) The number of appointments for health care
services under the laws administered by the Secretary,
disaggregated by--
(i) appointments at facilities of the
Department of Veterans Affairs; and
(ii) appointments with non-Department health
care providers.
(3)(A) The Secretary shall submit to the appropriate
committees of Congress the market area assessments established
in paragraph (1).
(B) The Secretary also shall submit to the appropriate
committees of Congress the market area assessments completed by
or being performed on the day before the date of the enactment
of the Caring for Our Veterans Act of 2018.
(4)(A) The Secretary shall use the market area assessments
established under paragraph (1) to--
(i) determine the capacity of the health care
provider networks established under section 1703(h) of
this title;
(ii) inform the Department budget, in accordance with
subparagraph (B); and
(iii) inform and assess the appropriateness of the
access standards established under section 1703B of
this title and standards for quality under section
1703C and to make recommendations for any changes to
such standards.
(B) The Secretary shall ensure that the Department budget for
any fiscal year (as submitted with the budget of the President
under section 1105(a) of title 31) reflects the findings of the
Secretary with respect to the most recent market area
assessments under paragraph (1) and health care utilization
data from the Department and non-Department entities or
providers furnishing care and services to covered veterans as
described in section 1703(b).
(b) Strategic Plan to Meet Health Care Demand.--(1) Not later
than one year after the date of the enactment of the Caring for
Our Veterans Act of 2018 and not less frequently than once
every four years thereafter, the Secretary shall submit to the
appropriate committees of Congress a strategic plan that
specifies a four-year forecast of--
(A) the demand for health care from the Department,
disaggregated by geographic area as determined by the
Secretary;
(B) the health care capacity to be provided at each
medical center of the Department; and
(C) the health care capacity to be provided through
community care providers.
(2) In preparing the strategic plan under paragraph (1), the
Secretary shall--
(A) assess the access standards and standards for
quality established under sections 1703B and 1703C of
this title;
(B) assess the market area assessments established
under subsection (a);
(C) assess the needs of the Department based on
identified services that provide management of
conditions or disorders related to military service for
which there is limited experience or access in the
national market, the overall health of veterans
throughout their lifespan, or other services as the
Secretary determines appropriate;
(D) consult with key stakeholders within the
Department, the heads of other Federal agencies, and
other relevant governmental and nongovernmental
entities, including State, local, and tribal government
officials, members of Congress, veterans service
organizations, private sector representatives,
academics, and other policy experts;
(E) identify emerging issues, trends, problems, and
opportunities that could affect health care services
furnished under the laws administered by the Secretary;
(F) develop recommendations regarding both short- and
long-term priorities for health care services furnished
under the laws administered by the Secretary;
(G) after consultation with veterans service
organizations and other key stakeholders on survey
development or modification of an existing survey,
consider a survey of veterans who have used hospital
care, medical services, or extended care services
furnished by the Veterans Health Administration during
the most recent two-year period to assess the
satisfaction of the veterans with service and quality
of care;
(H) conduct a comprehensive examination of programs
and policies of the Department regarding the delivery
of health care services and the demand of health care
services for veterans in future years;
(I) assess the remediation of medical service lines
of the Department as described in section 1706A in
conjunction with the utilization of non-Department
entities or providers to offset remediation; and
(J) consider such other matters as the Secretary
considers appropriate.
(c) Responsibilities.--The Secretary shall be responsible
for--
(1) overseeing the transformation and organizational
change across the Department to achieve such high
performing integrated health care network;
(2) developing the capital infrastructure planning
and procurement processes, whether minor or major
construction projects or leases; and
(3) developing a multi-year budget process that is
capable of forecasting future year budget requirements
and projecting the cost of delivering health care
services under a high-performing integrated health care
network.
(d) Appropriate Committees of Congress Defined.--In this
section, the term ``appropriate committees of Congress''
means--
(1) the Committee on Veterans' Affairs and the
Committee on Appropriations of the Senate; and
(2) the Committee on Veterans' Affairs and the
Committee on Appropriations of the House of
Representatives.
SUBCHAPTER III--PROTECTION OF PATIENT RIGHTS
* * * * * * *
Sec. 7332. Confidentiality of certain medical records
(a)(1) Records of the identity, diagnosis, prognosis, or
treatment of any patient or subject which are maintained in
connection with the performance of any program or activity
(including education, training, treatment, rehabilitation, or
research) relating to drug abuse, alcoholism or alcohol abuse,
infection with the human immunodeficiency virus, or sickle cell
anemia which is carried out by or for the Department under this
title shall, except as provided in subsections (e) and (f), be
confidential, and (section 5701 of this title to the contrary
notwithstanding) such records may be disclosed only for the
purposes and under the circumstances expressly authorized under
subsection (b).
(2) Paragraph (1) prohibits the disclosure to any person or
entity other than the patient or subject concerned of the fact
that a special written consent is required in order for such
records to be disclosed.
(b)(1) The content of any record referred to in subsection
(a) may be disclosed by the Secretary in accordance with the
prior written consent of the patient or subject with respect to
whom such record is maintained, but only to such extent, under
such circumstances, and for such purposes as may be allowed in
regulations prescribed by the Secretary.
(2) Whether or not any patient or subject, with respect to
whom any given record referred to in subsection (a) is
maintained, gives written consent, the content of such record
may be disclosed by the Secretary as follows:
(A) To medical personnel to the extent necessary to
meet a bona fide medical emergency.
(B) To qualified personnel for the purpose of
conducting scientific research, management audits,
financial audits, or program evaluation, but such
personnel may not identify, directly or indirectly, any
individual patient or subject in any report of such
research, audit, or evaluation, or otherwise disclose
patient or subject identities in any manner.
(C)(i) In the case of any record which is maintained
in connection with the performance of any program or
activity relating to infection with the human
immunodeficiency virus, to a Federal, State, or local
public-health authority charged under Federal or State
law with the protection of the public health, and to
which Federal or State law requires disclosure of such
record, if a qualified representative of such authority
has made a written request that such record be provided
as required pursuant to such law for a purpose
authorized by such law.
(ii) A person to whom a record is disclosed under
this paragraph may not redisclose or use such record
for a purpose other than that for which the disclosure
was made.
(D) If authorized by an appropriate order of a court
of competent jurisdiction granted after application
showing good cause therefor. In assessing good cause
the court shall weigh the public interest and the need
for disclosure against the injury to the patient or
subject, to the physician-patient relationship, and to
the treatment services. Upon the granting of such
order, the court, in determining the extent to which
any disclosure of all or any part of any record is
necessary, shall impose appropriate safeguards against
unauthorized disclosure.
(E) To an entity described in paragraph (1)(B) of
section 5701(k) of this title, but only to the extent
authorized by such section.
(F)(i) To a representative of a patient who lacks
decision-making capacity, when a practitioner deems the
content of the given record necessary for that
representative to make an informed decision regarding
the patient's treatment.
(ii) In this subparagraph, the term
``representative'' means an individual, organization,
or other body authorized under section 7331 of this
title and its implementing regulations to give informed
consent on behalf of a patient who lacks decision-
making capacity.
(G) To a State controlled substance monitoring
program, including a program approved by the Secretary
of Health and Human Services under section 399O of the
Public Health Service Act (42 U.S.C. 280g-3), to the
extent necessary to prevent misuse and diversion of
prescription medicines.
[(H)(i) To a non-Department entity (including private
entities and other Federal agencies) that provides
hospital care or medical services to veterans as
authorized by the Secretary.
[(ii) An entity to which a record is disclosed under
this subparagraph may not redisclose or use such record
for a purpose other than that for which the disclosure
was made.]
(H)(i) To a non-Department entity (including private
entities and other Federal agencies) for purposes of
providing health care, including hospital care, medical
services, and extended care services, to patients or
performing other health care-related activities or
functions.
(ii) An entity to which a record is disclosed under
this subparagraph may not disclose or use such record
for a purpose other than that for which the disclosure
was made or as permitted by law.
(I) To a third party in order to recover or collect
reasonable charges for care furnished to, or paid on
behalf of, a patient in connection with a non-service
connected disability as permitted by section 1729 of
this title or for a condition for which recovery is
authorized or with respect to which the United States
is deemed to be a third party beneficiary under the Act
entitled ``An Act to provide for the recovery from
tortiously liable third persons of the cost of hospital
and medical care and treatment furnished by the United
States'' (Public Law 87-693; 42 U.S.C. 2651 et seq.;
commonly known as the ``Federal Medical Care Recovery
Act'').
(3) In the event that the patient or subject who is the
subject of any record referred to in subsection (a) is
deceased, the content of any such record may be disclosed by
the Secretary only upon the prior written request of the next
of kin, executor, administrator, or other personal
representative of such patient or subject and only if the
Secretary determines that such disclosure is necessary for such
survivor to obtain benefits to which such survivor may be
entitled, including the pursuit of legal action, but then only
to the extent, under such circumstances, and for such purposes
as may be allowed in regulations prescribed pursuant to section
7334 of this title.
(c) Except as authorized by a court order granted under
subsection (b)(2)(D), no record referred to in subsection (a)
may be used to initiate or substantiate any criminal charges
against, or to conduct any investigation of, a patient or
subject.
(d) The prohibitions of this section shall continue to apply
to records concerning any person who has been a patient or
subject, irrespective of whether or when such person ceases to
be a patient.
(e) The prohibitions of this section shall not prevent any
interchange of records--
(1) within and among those components of the
Department furnishing health care to veterans, or
determining eligibility for benefits under this title;
or
(2) between such components furnishing health care to
veterans and the Armed Forces.
(f)(1) Notwithstanding subsection (a) but subject to
paragraph (2), a physician or a professional counselor may
disclose information or records indicating that a patient or
subject is infected with the human immunodeficiency virus if
the disclosure is made to (A) the spouse of the patient or
subject, or (B) to an individual whom the patient or subject
has, during the process of professional counseling or of
testing to determine whether the patient or subject is infected
with such virus, identified as being a sexual partner of such
patient or subject.
(2)(A) A disclosure under paragraph (1) may be made only if
the physician or counselor, after making reasonable efforts to
counsel and encourage the patient or subject to provide the
information to the spouse or sexual partner, reasonably
believes that the patient or subject will not provide the
information to the spouse or sexual partner and that the
disclosure is necessary to protect the health of the spouse or
sexual partner.
(B) A disclosure under such paragraph may be made by a
physician or counselor other than the physician or counselor
referred to in subparagraph (A) if such physician or counselor
is unavailable by reason of absence or termination of
employment to make the disclosure.
(g) Any person who violates any provision of this section or
any regulation issued pursuant to this section shall be fined,
in the case of a first offense, up to the maximum amount
provided under section 5701(f) of this title for a first
offense under that section and, in the case of a subsequent
offense, up to the maximum amount provided under section
5701(f) of this title for a subsequent offense under that
section.
* * * * * * *
CHAPTER 74--VETERANS HEALTH ADMINISTRATION - PERSONNEL
SUBCHAPTER I--APPOINTMENTS
Sec.
7401. Appointments in Veterans Health Administration.
* * * * * * *
7413. Treatment of podiatrists; clinical oversight standards.
* * * * * * *
SUBCHAPTER I--APPOINTMENTS
* * * * * * *
Sec. 7404. Grades and pay scales
(a)(1)(A) The annual rates or ranges of rates of basic pay
for positions provided in section 7306 and 7401(4) of this
title shall be prescribed from time to time by Executive order
as authorized by chapter 53 of title 5 or as otherwise
authorized by law.
(B) Section 5377 of title 5 shall apply to a position under
section 7401(4) of this title as if such position were included
in the definition of ``position'' in section 5377(a) of title
5.
(2) The pay of physicians and dentists serving in positions
to which an Executive order applies under paragraph (1) shall
be determined under subchapter III of this chapter instead of
such Executive order.
(3)(A) The rate of basic pay for a position to which an
Executive order applies under paragraph (1) and is not
described by paragraph (2) shall be set in accordance with
section 5382 of title 5 as if such position were a Senior
Executive Service position (as such term is defined in section
3132(a) of title 5).
(B) A rate of basic pay for a position may not be set under
subparagraph (A) in excess of--
(i) in the case the position is not described in
clause (ii), the rate of basic pay payable for level
III of the Executive Schedule; or
(ii) in the case that the position is covered by a
performance appraisal system that meets the
certification criteria established by regulation under
section 5307(d) of title 5, the rate of basic pay
payable for level II of the Executive Schedule.
(C) Notwithstanding the provisions of subsection (d) of
section 5307 of title 5, the Secretary may make any
certification under that subsection instead of the Office of
Personnel Management and without concurrence of the Office of
Management and Budget.
(b) The grades for positions provided for in paragraph (1) of
section 7401 of this title shall be as follows. The annual
ranges of rates of basic pay for those grades shall be
prescribed from time to time by Executive order as authorized
by chapter 53 of title 5 or as otherwise authorized by law:
[PHYSICIAN AND DENTIST SCHEDULE] PHYSICIAN AND
SURGEON (MD/DO), PODIATRIC SURGEON (DPM), AND DENTIST
AND ORAL SURGEON (DDS, DMD) SCHEDULE
[Physician grade] Physician and surgeon grade.
Dentist grade.
NURSE SCHEDULE
Nurse V.
Nurse IV.
Nurse III.
Nurse II.
Nurse I.
CLINICAL [PODIATRIST, CHIROPRACTOR, AND] CHIROPRACTOR
AND OPTOMETRIST SCHEDULE
Chief grade.
Senior grade.
Intermediate grade.
Full grade.
Associate grade.
(c) Notwithstanding the provisions of section 7425(a) of this
title, a person appointed under section 7306 of this title who
is not eligible for pay under subchapter III shall be deemed to
be a career appointee for the purposes of sections 4507 and
5384 of title 5.
(d) Except as provided under subsection (e), subchapter III,
and section 7457 of this title, pay for positions for which
basic pay is paid under this section may not be paid at a rate
in excess of the rate of basic pay authorized by section 5316
of title 5 for positions in Level V of the Executive Schedule.
(e) The position of Chief Nursing Officer, Office of Nursing
Services, shall be exempt from the provisions of section 7451
of this title and shall be paid at a rate determined by the
Secretary, not to exceed the maximum rate established for the
Senior Executive Service under section 5382 of title 5.
* * * * * * *
Sec. 7413. Treatment of podiatrists; clinical oversight standards
(a) Podiatrists.--Except as provided by subsection (b), a
doctor of podiatric medicine who is appointed as a podiatrist
under section 7401(1) of this title is eligible for any
supervisory position in the Veterans Health Administration to
the same degree that a physician appointed under such section
is eligible for the position.
(b) Establishment of Clinical Oversight Standards.--The
Secretary, in consultation with appropriate stakeholders, shall
establish standards to ensure that specialists appointed in the
Veterans Health Administration to supervisory positions do not
provide direct clinical oversight for purposes of peer review
or practice evaluation for providers of other clinical
specialties.
* * * * * * *
CHAPTER 76--HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM
SUBCHAPTER I--GENERAL
Sec.
7601. Establishment of program; purpose.
* * * * * * *
Subchapter VIII--Specialty Education Loan Repayment Program
Sec.
7691. Establishment.
7692. Purpose.
7693. Eligibility; preferences; covered costs.
7694. Specialty education loan repayment.
7695. Choice of location.
7696. Term of obligated service.
7697. Relationship to Educational Assistance Program.
SUBCHAPTER I--GENERAL
Sec. 7601. Establishment of program; purpose
(a) There is hereby established a program to be known as the
Department of Veterans Affairs Health Professionals Educational
Assistance Program (hereinafter in this chapter referred to as
the ``Educational Assistance Program''). The program consists
of--
(1) the scholarship program provided for in
subchapter II of this chapter;
(2) the tuition reimbursement program provided for in
subchapter III of this chapter;
(3) the Selected Reserve member stipend program
provided for under subchapter V of this chapter;
(4) the employee incentive scholarship program
provided for in subchapter VI of this chapter; [and]
(5) the education debt reduction program provided for
in subchapter VII of this chapter[.]; and
(6) the specialty education loan repayment program
provided for in subchapter VIII of this chapter.
(b) The purpose of the Educational Assistance Program is to
assist in providing an adequate supply of trained health-care
personnel for the Department and the Nation.
* * * * * * *
Sec. 7603. Application and acceptance
(a)(1) To apply to participate in the Educational Assistance
Program under subchapter II, III, V, [or VI] VI, or VIII of
this chapter, an individual shall submit to the Secretary an
application for such participation together with an agreement
described in section 7604 of this title under which the
participant agrees to serve a period of obligated service in
the Veterans Health Administration as provided in the agreement
in return for payment of educational assistance as provided in
the agreement.
(2) To apply to participate in the Educational Assistance
Program under subchapter VII of this chapter, an individual
shall submit to the Secretary an application for such
participation.
(b)(1) An individual becomes a participant in the Educational
Assistance Program upon the Secretary's approval of the
individual's application and the Secretary's acceptance of the
agreement (if required).
(2) Upon the Secretary's approval of an individual's
participation in the program, the Secretary shall promptly
notify the individual of that approval. Such notice shall be in
writing.
(c)(1) In distributing application forms and agreement forms
to individuals desiring to participate in the Educational
Assistance Program, the Secretary shall include with such forms
the following:
(A) A fair summary of the rights and liabilities of
an individual whose application is approved (and whose
agreement is accepted) by the Secretary, including a
clear explanation of the damages to which the United
States is entitled if the individual breaches the
agreement.
(B) A full description of the terms and conditions
that apply to participation in the Educational
Assistance Program and service in the Veterans Health
Administration.
(2) The Secretary shall make such application forms and other
information available to individuals desiring to participate in
the Educational Assistance Program on a date sufficiently early
to allow such individuals adequate time to prepare and submit
such forms.
(d) In selecting applicants for acceptance in the Educational
Assistance Program, the Secretary shall give priority to the
applications of individuals who have previously received
educational assistance under the program and have not completed
the course of education or training undertaken under such
program.
Sec. 7604. Terms of agreement
An agreement between the Secretary and a participant in the
Educational Assistance Program shall be in writing, shall be
signed by the participant, and shall include the following
provisions:
(1) The Secretary's agreement--
(A) to provide the participant with
educational assistance as authorized in
subchapter II, III, V, [or VI] VI, or VIII of
this chapter and specified in the agreement;
and
(B) to afford the participant the opportunity
for employment in the Veterans Health
Administration (subject to the availability of
appropriated funds for such purpose and other
qualifications established in accordance with
section 7402 of this title).
(2) The participant's agreement--
(A) to accept such educational assistance;
(B) to maintain enrollment and attendance in
the course of training until completed;
(C) while enrolled in such course, to
maintain an acceptable level of academic
standing (as determined by the educational
institution offering such course of training
under regulations prescribed by the Secretary);
and
(D) after completion of the course of
training, to serve as a full-time employee in
the Veterans Health Administration as specified
in the agreement in accordance with subchapter
II, III, V, [or VI] VI, or VIII of this
chapter.
(3) A provision that any financial obligation of the
United States arising out of an agreement entered into
under this chapter, and any obligation of the
participant which is conditioned on such agreement, is
contingent upon funds being appropriated for
educational assistance under this chapter.
(4) A statement of the damages to which the United
States is entitled under this chapter for the
participant's breach of the agreement.
(5) Such other terms as are required to be included
in the agreement under subchapter II, III, V, [or VI]
VI, or VIII of this chapter or as the Secretary may
require consistent with the provisions of this chapter.
SUBCHAPTER II--SCHOLARSHIP PROGRAM
* * * * * * *
Sec. 7612. Eligibility; application; agreement
(a)(1) Except as provided in paragraph (2) of this
subsection, an individual must be accepted for enrollment or be
enrolled (as described in section 7602 of this title) as a
full-time student to be eligible to participate in the
Scholarship Program.
(2) An individual who is an eligible Department employee may
be accepted as a participant if accepted for enrollment or
enrolled (as described in section 7602 of this title) for study
on less than a full-time but not less than a half-time basis.
(Such a participant is hereinafter in this subchapter referred
to as a ``part-time student''.)
(3) For the purposes of paragraph (2) of this subsection, an
eligible Department employee is a full-time Department employee
who is permanently assigned to a Department health-care
facility on the date on which the individual submits the
application referred to in section 7603 of this title and on
the date on which the individual becomes a participant in the
Scholarship Program.
(b)(1) A scholarship may be awarded under this subchapter
only in a qualifying field of education or training.
(2) A qualifying field of education or training for purposes
of this subchapter is education or training leading to
employment as an appointee under paragraph (1) or (3) of
section 7401 of this title.
(3) The Secretary may designate additional fields of
education or training as qualifying fields of education or
training if the education or training leads to employment in a
position which would qualify the individual for increased basic
pay under subsection (a)(1) of section 7455 of this title for
personnel described in subsection (a)(2)(B) of such section.
(4) Before awarding the initial scholarship in a course of
education or training other than medicine or nursing, the
Secretary shall notify the Committees on Veterans' Affairs of
the Senate and House of Representatives of the Secretary's
intent to award a scholarship in such course of education or
training. The notice shall include a statement of the reasons
why the award of scholarships in that course of education or
training is necessary to assist in providing the Department
with an adequate supply of personnel in the health profession
concerned. Any such notice shall be given not less than 60 days
before the first such scholarship is awarded.
(5) In selecting applicants for the Scholarship Program, the
Secretary--
(A) shall give priority to applicants who will be
entering their final year in a course of training;
(B) shall give priority to applicants pursuing a
course of education or training toward a career in an
occupation for which the Inspector General of the
Department has, in the most current determination
published in the Federal Register pursuant to section
7412(a) of this title, determined that there is one of
the largest staffing shortages throughout the
Department with respect to such occupation; and
(C) shall ensure an equitable allocation of
scholarships to persons enrolled in the second year of
a program leading to an associate degree in nursing.
(6)(A) Of the scholarships awarded under this subchapter, the
Secretary shall ensure that not less than 50 scholarships are
awarded each year to individuals who are accepted for
enrollment or enrolled (as described in section 7602 of this
title) in a program of education or training leading to
employment as a physician or dentist until such date as the
Secretary determines that the staffing shortage of physicians
and dentists in the Department is less than 500.
(B) After such date, the Secretary shall ensure that of the
scholarships awarded under this subchapter, a number of
scholarships is awarded each year to individuals referred to in
subparagraph (A) in an amount equal to not less than ten
percent of the staffing shortage of physicians and dentists in
the Department, as determined by the Secretary.
(C) Notwithstanding subsection (c)(1), the agreement between
the Secretary and a participant in the Scholarship Program who
receives a scholarship pursuant to this paragraph shall provide
the following:
(i) The Secretary's agreement to provide the
participant with a scholarship under this subchapter
for a specified number (from two to four) of school
years during which the participant is pursuing a course
of education or training leading to employment as a
physician or dentist.
(ii) The participant's agreement to serve as a full-
time employee in the Veterans Health Administration for
a period of time (hereinafter in this subchapter
referred to as the ``period of obligated service'') of
18 months for each school year or part thereof for
which the participant was provided a scholarship under
the Scholarship Program.
(D) In providing scholarships pursuant to this paragraph, the
Secretary may provide a preference for applicants who are
veterans.
(E) On an annual basis, the Secretary shall provide to
appropriate educational institutions informational material
about the availability of scholarships under this paragraph.
(c)(1) An agreement between the Secretary and a participant
in the Scholarship Program shall (in addition to the
requirements set forth in section 7604 of this title) include
the following:
(A) The Secretary's agreement to provide the
participant with a scholarship under this subchapter
for a specified number (from one to four) of school
years during which the participant is pursuing a course
of education or training described in section 7602 of
this title.
(B) The participant's agreement to serve as a full-
time employee in the Veterans Health Administration for
a period of time (hereinafter in this subchapter
referred to as the ``period of obligated service'') of
one calendar year for each school year or part thereof
for which the participant was provided a scholarship
under the Scholarship Program, but for not less than
two years.
(2) In a case in which an extension is granted under section
7614(3) of this title, the number of years for which a
scholarship may be provided under this subchapter shall be the
number of school years provided for as a result of the
extension.
(3) In the case of a participant who is a part-time student--
(A) the period of obligated service shall be reduced
in accordance with the proportion that the number of
credit hours carried by such participant in any such
school year bears to the number of credit hours
required to be carried by a full-time student in the
course of training being pursued by the participant,
but in no event to less than one year; and
(B) the agreement shall include the participant's
agreement to maintain employment, while enrolled in
such course of education or training, as a Department
employee permanently assigned to a Department health-
care facility.
(4) If a participant's period of obligated service is
deferred under section 7616(b)(3)(A)(i) of this title, the
agreement terms under paragraph (1) of this subsection shall
provide for the participant to serve any additional period of
obligated service that is prescribed by the Secretary under
section 7616(b)(4)(B) of this title.
* * * * * * *
Sec. 7617. Breach of agreement: liability
(a) A participant in the Scholarship Program (other than a
participant described in subsection (b) of this section) who
fails to accept payment, or instructs the educational
institution in which the participant is enrolled not to accept
payment, in whole or in part, of a scholarship under the
agreement entered into under section 7603 of this title shall
be liable to the United States for liquidated damages in the
amount of $1,500. Such liability is in addition to any period
of obligated service or other obligation or liability under the
agreement.
(b) A participant in the Scholarship Program shall be liable
to the United States for the amount which has been paid to or
on behalf of the participant under the agreement if any of the
following occurs:
(1) The participant fails to maintain an acceptable
level of academic standing in the educational
institution in which the participant is enrolled (as
determined by the educational institution under
regulations prescribed by the Secretary).
(2) The participant is dismissed from such
educational institution for disciplinary reasons.
(3) The participant voluntarily terminates the course
of training in such educational institution before the
completion of such course of training.
(4) In the case of a participant who is enrolled in a
program or education or training leading to employment
as a physician, the participant fails to successfully
complete post-graduate training leading to eligibility
for board certification in a specialty.
[(4)] (5) The participant fails to become licensed to
practice medicine, osteopathy, dentistry, podiatry, or
optometry in a State, fails to become licensed as a
registered nurse in a State, or fails to meet any
applicable licensure requirement in the case of any
other health-care personnel who provide either direct
patient-care services or services incident to direct
patient-care services, during a period of time
determined under regulations prescribed by the
Secretary.
[(5)] (6) In the case of a participant who is a part-
time student, the participant fails to maintain
employment, while enrolled in the course of training
being pursued by such participant, as a Department
employee permanently assigned to a Department health-
care facility.
Liability under this subsection is in lieu of any service
obligation arising under the participant's agreement.
(c)(1) If a participant in the Scholarship Program breaches
the agreement by failing (for any reason) to complete such
participant's period of obligated service, the United States
shall be entitled to recover from the participant an amount
determined in accordance with the following formula:
A=3(t-s/t)
In such formula:
(A) ``A'' is the amount the United States is entitled
to recover.
(B) ``'' is the sum of (i) the amounts paid
under this subchapter to or on behalf of the
participant, and (ii) the interest on such amounts
which would be payable if at the time the amounts were
paid they were loans bearing interest at the maximum
legal prevailing rate, as determined by the Treasurer
of the United States.
(C) ``t'' is the total number of months in the
participant's period of obligated service, including
any additional period of obligated service in
accordance with section 7616(b)(4) of this title.
(D) ``s'' is the number of months of such period
served by the participant in accordance with section
7613 of this title.
(2) Any amount of damages which the United States is entitled
to recover under this section shall be paid to the United
States within the one-year period beginning on the date of the
breach of the agreement.
* * * * * * *
Sec. 7619. Expiration of program
The Secretary may not furnish scholarships to new
participants in the Scholarship Program after [December 31,
2019] December 31, 2033.
* * * * * * *
SUBCHAPTER IV--ADMINISTRATIVE MATTERS
Sec. 7631. Periodic adjustments in amount of assistance
(a)(1) Whenever there is a general Federal pay increase, the
Secretary shall increase the maximum monthly stipend amount,
the maximum tuition reimbursement amount, the maximum Selected
Reserve member stipend amount, the maximum employee incentive
scholarship amount, and the maximum education debt reduction
payments amount, and the maximum specialty education loan
repayment amount. Any such increase shall take effect with
respect to any school year that ends in the fiscal year in
which the pay increase takes effect.
(2) The amount of any increase under paragraph (1) of this
subsection is the previous maximum amount under that paragraph
multiplied by the overall percentage of the adjustment in the
rates of pay under the General Schedule made under the general
Federal pay increase. Such amount shall be rounded to the next
lower multiple of $1.
(b) For purposes of this section:
(1) The term ``maximum monthly stipend amount'' means
the maximum monthly stipend that may be paid to a
participant in the Scholarship Program specified in
section 7613(b) of this title and as previously
adjusted (if at all) in accordance with this section.
(2) The term ``maximum tuition reimbursement amount''
means the maximum amount of tuition reimbursement
provided to a participant in the Tuition Reimbursement
Program specified in section 7622(e) of this title and
as previously adjusted (if at all) in accordance with
this section.
(3) The term ``maximum Selected Reserve member
stipend amount'' means the maximum amount of assistance
provided to a person receiving assistance under
subchapter V of this chapter, as specified in section
7653 of this title and as previously adjusted (if at
all) in accordance with this section.
(4) The term ``maximum employee incentive scholarship
amount'' means the maximum amount of the scholarship
payable to a participant in the Department of Veterans
Affairs Employee Incentive Scholarship Program under
subchapter VI of this chapter, as specified in section
7673(b)(1) of this title and as previously adjusted (if
at all) in accordance with this section.
(5) The term ``maximum education debt reduction
payments amount'' means the maximum amount of education
debt reduction payments payable to a participant in the
Department of Veterans Affairs Education Debt Reduction
Program under subchapter VII of this chapter, as
specified in section 7683(d)(1) of this title and as
previously adjusted (if at all) in accordance with this
section.
(6) The term ``general Federal pay increase'' means
an adjustment (if an increase) in the rates of pay
under the General Schedule under subchapter III of
chapter 53 of title 5.
(7) The term ``specialty education loan repayment amount''
means the maximum amount of specialty education loan repayment
payments payable to or for a participant in the Department of
Veterans Affairs Specialty Education Loan Repayment Program
under subchapter VIII of this chapter, as specified in section
7694(c)(1) of this title and as previously adjusted (if at all)
in accordance with this section.
Sec. 7632. Annual report
Not later than March 1 of each year, the Secretary shall
submit to Congress a report on the Educational Assistance
Program. Each such report shall include the following
information:
(1) The number of students receiving educational
assistance under the Educational Assistance Program,
showing the numbers of students receiving assistance
under the Scholarship Program, the Tuition
Reimbursement Program, the Employee Incentive
Scholarship Program, [and the Education Debt Reduction
Program] the Education Debt Reduction Program, and the
Specialty Education Loan Repayment Program separately,
and the number of students (if any) enrolled in each
type of health profession training under each program.
(2) The education institutions (if any) providing
such training to students in each program.
(3) The number of applications filed under each
program, by health profession category, during the
school year beginning in such year and the total number
of such applications so filed for all years in which
the Educational Assistance Program (or predecessor
program) has been in existence.
(4) The average amounts of educational assistance
provided per participant in the Scholarship Program,
per participant in the Tuition Reimbursement Program,
per participant in the Employee Incentive Scholarship
Program, [and per participant in the Education Debt
Reduction Program] per participant in the Education
Debt Reduction Program, and per participant in the
Specialty Education Loan Repayment Program.
(5) The amount of tuition and other expenses paid, by
health profession category, in the aggregate and at
each educational institution for the school year
beginning in such year and for prior school years.
(6) The number of scholarships accepted, by health
profession category, during the school year beginning
in such year and the number, by health profession
category, which were offered and not accepted.
(7) The number of participants who complete a course
or course of training in each program each year and for
all years that such program (or predecessor program)
has been in existence.
* * * * * * *
SUBCHAPTER VII--EDUCATION DEBT REDUCTION PROGRAM
* * * * * * *
Sec. 7683. Education debt reduction
(a) In General.--Education debt reduction payments under the
Education Debt Reduction Program shall consist of--
(1) payments to individuals selected to participate
in the program of principal and interest on loans
described in section 7682(a)(2) of this title; or
(2) payments for the principal and interest on such
loans of such individuals to the holders of such loans.
(b) Frequency of Payment.--(1) The Secretary may make
education debt reduction payments to or for any given
participant in the Education Debt Reduction Program on a
monthly or annual basis, as determined by the Secretary.
(2) The Secretary shall make such payments at the end of the
period determined by the Secretary under paragraph (1).
(c) Performance Requirement.--The Secretary may make
education debt reduction payments to or for a participant in
the Education Debt Reduction Program for a period only if the
Secretary determines that the individual maintained an
acceptable level of performance in the position or positions
served by the participant during the period.
(d) Maximum Annual Amount.--(1) The amount of education debt
reduction payments made to or for a participant under the
Education Debt Reduction Program may not exceed [$120,000]
$200,000 over a total of five years of participation in the
Program, of which not more than [$24,000] $40,000 of such
payments may be made in each year of participation in the
Program.
(2)(A) The Secretary may waive the limitations under
paragraph (1) in the case of a participant described in
subparagraph (B). In the case of such a waiver, the total
amount of education debt repayments payable to or for that
participant is the total amount of the principal and the
interest on the participant's loans referred to in subsection
(a).
(B) A participant described in this subparagraph is a
participant in the Program who the Secretary determines serves
in a position for which there is a shortage of qualified
employees by reason of either the location or the requirements
of the position.
* * * * * * *
SUBCHAPTER VIII--SPECIALTY EDUCATION LOAN REPAYMENT PROGRAM
Sec. 7691. Establishment
As part of the Educational Assistance Program, the Secretary
may carry out a student loan repayment program under section
5379 of title 5. The program shall be known as the Department
of Veterans Affairs Specialty Education Loan Repayment Program
(in this chapter referred to as the ``Specialty Education Loan
Repayment Program'').
Sec. 7692. Purpose
The purpose of the Specialty Education Loan Repayment Program
is to assist, through the establishment of an incentive program
for certain individuals employed in the Veterans Health
Administration, in meeting the staffing needs of the Veterans
Health Administration for physicians in medical specialties for
which the Secretary determines recruitment or retention of
qualified personnel is difficult.
Sec. 7693. Eligibility; preferences; covered costs
(a) Eligibility.--An individual is eligible to participate in
the Specialty Education Loan Repayment Program if the
individual--
(1) is hired under section 7401 of this title to work
in an occupation described in section 7692 of this
title;
(2) owes any amount of principal or interest under a
loan, the proceeds of which were used by or on behalf
of that individual to pay costs relating to a course of
education or training which led to a degree that
qualified the individual for the position referred to
in paragraph (1); and
(3) is--
(A) recently graduated from an accredited
medical or osteopathic school and matched to an
accredited residency program in a medical
specialty described in section 7692 of this
title; or
(B) a physician in training in a medical
specialty described in section 7692 of this
title with more than two years remaining in
such training.
(b) Preferences.--In selecting individuals for participation
in the Specialty Education Loan Repayment Program under this
subchapter, the Secretary may give preference to the following:
(1) Individuals who are, or will be, participating in
residency programs in health care facilities--
(A) located in rural areas;
(B) operated by Indian tribes, tribal
organizations, or the Indian Health Service; or
(C) affiliated with underserved health care
facilities of the Department.
(2) Veterans.
(c) Covered Costs.--For purposes of subsection (a)(2), costs
relating to a course of education or training include--
(1) tuition expenses;
(2) all other reasonable educational expenses,
including expenses for fees, books, equipment, and
laboratory expenses; and
(3) reasonable living expenses.
Sec. 7694. Specialty education loan repayment
(a) In General.--Payments under the Specialty Education Loan
Repayment Program shall consist of payments for the principal
and interest on loans described in section 7682(a)(2) of this
title for individuals selected to participate in the Program to
the holders of such loans.
(b) Frequency of Payment.--The Secretary shall make payments
for any given participant in the Specialty Education Loan
Repayment Program on a schedule determined appropriate by the
Secretary.
(c) Maximum Amount; Waiver.--(1) The amount of payments made
for a participant under the Specialty Education Loan Repayment
Program may not exceed $160,000 over a total of four years of
participation in the Program, of which not more than $40,000 of
such payments may be made in each year of participation in the
Program.
(2)(A) The Secretary may waive the limitations under
paragraph (1) in the case of a participant described in
subparagraph (B). In the case of such a waiver, the total
amount of payments payable to or for that participant is the
total amount of the principal and the interest on the
participant's loans referred to in subsection (a).
(B) A participant described in this subparagraph is a
participant in the Program who the Secretary determines serves
in a position for which there is a shortage of qualified
employees by reason of either the location or the requirements
of the position.
Sec. 7695. Choice of location
Each participant in the Specialty Education Loan Repayment
Program who completes residency may select, from a list of
medical facilities of the Veterans Health Administration
provided by the Secretary, at which such facility the
participant will work in a medical specialty described in
section 7692 of this title.
Sec. 7696. Term of obligated service
(a) In General.--In addition to any requirements under
section 5379(c) of title 5, a participant in the Specialty
Education Loan Repayment Program must agree, in writing and
before the Secretary may make any payment to or for the
participant, to--
(1) obtain a license to practice medicine in a State;
(2) successfully complete post-graduate training
leading to eligibility for board certification in a
specialty;
(3) serve as a full-time clinical practice employee
of the Veterans Health Administration for 12 months for
every $40,000 in such benefits that the employee
receives, but in no case for fewer than 24 months; and
(4) except as provided in subsection (b), to begin
such service as a full-time practice employee by not
later than 60 days after completing a residency.
(b) Fellowship.--In the case of a participant who receives an
accredited fellowship in a medical specialty other than a
medical specialty described in section 7692 of this title, the
Secretary, on written request of the participant, may delay the
term of obligated service under subsection (a) for the
participant until after the participant completes the
fellowship, but in no case later than 60 days after completion
of such fellowship.
(c) Penalty.--(1) An employee who does not complete a period
of obligated service under this section shall owe the Federal
Government an amount determined in accordance with the
following formula: A=B((T-S)T)).
(2) In the formula in paragraph (1):
(A) `` A'' is the amount the employee owes the
Federal Government.
(B) `` B'' is the sum of all payments to or for the
participant under the Specialty Education Loan
Repayment Program.
(C) `` T'' is the number of months in the period of
obligated service of the employee.
(D) `` S'' is the number of whole months of such
period of obligated service served by the employee.
Sec. 7697. Relationship to Educational Assistance Program
Assistance under the Specialty Education Loan Repayment
Program may be in addition to other assistance available to
individuals under the Educational Assistance Program.
* * * * * * *
PART VI--ACQUISITION AND DISPOSITION OF PROPERTY
* * * * * * *
CHAPTER 81--ACQUISITION AND OPERATION OF HOSPITAL AND DOMICILIARY
FACILITIES; PROCUREMENT AND SUPPLY; ENHANCED-USE LEASES OF REAL
PROPERTY
SUBCHAPTER I--ACQUISITION AND OPERATION OF MEDICAL FACILITIES
Sec.
8101. Definitions.
* * * * * * *
SUBCHAPTER IV--SHARING OF MEDICAL FACILITIES, EQUIPMENT, AND INFORMATION
* * * * * * *
8159. Authority to pay for services authorized but not subject to an
agreement.
* * * * * * *
SUBCHAPTER I--ACQUISITION AND OPERATION OF MEDICAL FACILITIES
Sec. 8101. Definitions
For the purposes of this subchapter:
(1) The term ``alter'', with respect to a medical facility,
means to repair, remodel, improve, or extend such medical
facility.
(2) The terms ``construct'' and ``alter'', with respect to a
medical facility, include such engineering, architectural,
legal, fiscal, and economic investigations and studies and such
surveys, designs, plans, construction documents,
specifications, procedures, and other similar actions as are
necessary for the construction or alteration, as the case may
be, of such medical facility and as are carried out after the
completion of the advanced planning (including the development
of project requirements and design development) for such
facility.
(3) The term ``medical facility'' means any facility or part
thereof which is, or will be, under the jurisdiction of the
[Secretary for the provision of health-care services (including
hospital, nursing home,] Secretary, or as otherwise authorized
by law, for the provision of health-care services (including
hospital, outpatient clinic, nursing home, or domiciliary care
or medical services), including any necessary building and
auxiliary structure, garage, parking facility, mechanical
equipment, trackage facilities leading thereto, abutting
sidewalks, accommodations for attending personnel, and
recreation facilities associated therewith.
(4) The term ``committee'' means the Committee on Veterans'
Affairs of the House of Representatives or the Committee on
Veterans' Affairs of the Senate, and the term ``committees''
means both such committees.
* * * * * * *
Sec. 8103. Authority to construct and alter, and to acquire sites for,
medical facilities
(a) Subject to section 8104 of this title, the Secretary--
(1) may construct or alter any medical facility and
may acquire, by purchase, lease, condemnation,
donation, exchange, or otherwise, such land or
interests in land as the Secretary considers necessary
for use as the site for such construction or
alteration;
(2) may acquire, by purchase, lease, condemnation,
donation, exchange, or otherwise, any facility
(including the site of such facility) that the
Secretary considers necessary for use as a medical
facility; and
(3) in order to assure compliance with section
8110(a)(2) of this title, in the case of any outpatient
medical facility for which it is proposed to lease
space and for which a qualified lessor and an
appropriate leasing arrangement are available, shall
execute a lease for such facility within 12 months
after funds are made available for such purpose.
(b) Whenever the Secretary considers it to be in the interest
of the United States to construct a new medical facility to
replace an existing medical facility, the Secretary (1) may
demolish the existing facility and use the site on which it is
located for the site of the new medical facility, or (2) if in
the judgment of the Secretary it is more advantageous to
construct such medical facility on a different site in the same
locality, may exchange such existing facility and the site of
such existing facility for the different site.
(c) Whenever the Secretary determines that any site acquired
for the construction of a medical facility is not suitable for
that purpose, the Secretary may exchange such site for another
site to be used for that purpose or may sell such site.
(d)(1) The Secretary may provide for the acquisition of not
more than three facilities for the provision of outpatient
services or nursing home care through lease-purchase
arrangements on real property under the jurisdiction of the
Department of Veterans Affairs.
(2)(A) In carrying out this subsection and notwithstanding
any other provision of law, the Secretary may lease, with or
without compensation and for a period of not to exceed 35
years, to another party any of the real property described in
paragraph (1) of this subsection.
(B) Such real property shall be used as the site of a
facility referred to in paragraph (1) of this subsection--
(i) constructed and owned by the lessee of such real
property; and
(ii) leased under paragraph (3)(A) of this subsection
to the Department for such use and for such other
activities as the Secretary determines are appropriate.
(3)(A) The Secretary may enter into a lease for the use of
any facility described in paragraph (2)(B) of this subsection
for not more than 35 years under such terms and conditions as
may be in the best interests of the Department.
(B) Each agreement to lease a facility under subparagraph (A)
of this paragraph shall include a provision that--
(i) the obligation of the United States to make
payments under the agreement is subject to the
availability of appropriations for that purpose; and
(ii) the ownership of such facility shall vest in the
United States at the end of such lease.
(4)(A) The Secretary may sublease any space in such a
facility to another party at a rate not less than--
(i) the rental rate paid by the Secretary for such
space under paragraph (3) of this subsection; plus
(ii) the amount the Secretary pays for the costs of
administering such facility (including operation,
maintenance, utility, and rehabilitation costs) which
are attributable to such space.
(B) In any such sublease, the Secretary shall include such
terms relating to default and nonperformance as the Secretary
considers appropriate to protect the interests of the United
States.
(5) The Secretary shall use the receipts of any payment for
the lease of real property under paragraph (2) for the payment
of the lease of a facility under paragraph (3).
(6) The authority to enter into an agreement under this
subsection--
(A) shall not take effect until the Secretary has
entered into agreements under section 316 of this title
to carry out at least three collocations; and
(B) shall expire on October 1, 1993.
(e)(1) In the case of any super construction project, the
Secretary shall enter into an agreement with an appropriate
non-Department Federal entity to provide full project
management services for the super construction project,
including management over the project design, acquisition,
construction, and contract changes.
(2) An agreement entered into under paragraph (1) with a
Federal entity shall provide that the Secretary shall reimburse
the Federal entity for all costs associated with the provision
of project management services under the agreement.
(3) In this subsection, the term ``super construction
project'' means a project for the construction, alteration, or
acquisition of a medical facility involving a total expenditure
of more than $100,000,000.
(f) To the maximum extent practicable, the Secretary shall
use industry standards, standard designs, and best practices in
carrying out the construction of medical facilities.
[(g) The Secretary shall ensure that each employee of the
Department with responsibilities, as determined by the
Secretary, relating to the infrastructure construction or
alteration of medical facilities, including such construction
or alteration carried out pursuant to contracts or agreements,
undergoes a program of ongoing professional training and
development. Such program shall be designed to ensure that
employees maintain adequate expertise relating to industry
standards and best practices for the acquisition of design and
construction services. The Secretary may provide the program
under this subsection directly or through a contract or
agreement with a non-Federal entity or with a non-Department
Federal entity.]
(g)(1)(A) Not later than September 30 of the fiscal year
following the fiscal year during which the VA Asset and
Infrastructure Review Act of 2018 is enacted, the Secretary
shall implement the covered training curriculum and the covered
certification program.
(B) In designing and implementing the covered training
curriculum and the covered certification program under
paragraph (1), the Secretary shall use as models existing
training curricula and certification programs that have been
established under chapter 87 of title 10, United States Code,
as determined relevant by the Secretary.
(2) The Secretary may develop the training curriculum under
paragraph (1)(A) in a manner that provides such training in any
combination of--
(A) training provided in person;
(B) training provided over an internet website; or
(C) training provided by another department or agency
of the Federal Government.
(3) The Secretary may develop the certification program under
paragraph (1)(A) in a manner that uses--
(A) one level of certification; or
(B) more than one level of certification, as
determined appropriate by the Secretary with respect to
the level of certification for different grades of the
General Schedule.
(4) The Secretary may enter into a contract with an
appropriate entity to provide the covered training curriculum
and the covered certification program under paragraph (1)(A).
(5)(A) Not later than September 30 of the second fiscal year
following the fiscal year during which the VA Asset and
Infrastructure Review Act of 2018 is enacted, the Secretary
shall ensure that the majority of employees subject to the
covered certification program achieve the certification or the
appropriate level of certification pursuant to paragraph (3),
as the case may be.
(B) After carrying out subparagraph (A), the Secretary shall
ensure that each employee subject to the covered certification
program achieves the certification or the appropriate level of
certification pursuant to paragraph (3), as the case may be, as
quickly as practicable.
(6) In this subsection:
(A) The term ``covered certification program'' means,
with respect to employees of the Department of Veterans
Affairs who are members of occupational series relating
to construction or facilities management, or employees
of the Department who award or administer contracts for
major construction, minor construction, or nonrecurring
maintenance, including as contract specialists or
contracting officers' representatives, a program to
certify knowledge and skills relating to construction
or facilities management and to ensure that such
employees maintain adequate expertise relating to
industry standards and best practices for the
acquisition of design and construction services.
(B) The term ``covered training curriculum'' means,
with respect to employees specified in subparagraph
(A), a training curriculum relating to construction or
facilities management.
Sec. 8104. Congressional approval of certain medical facility
acquisitions
(a)(1) The purpose of this subsection is to enable Congress
to ensure the equitable distribution of medical facilities
throughout the United States, taking into consideration the
comparative urgency of the need for the services to be provided
in the case of each particular facility.
(2) No funds may be appropriated for any fiscal year, and the
Secretary may not obligate or expend funds (other than for
advance planning and design), for any major medical facility
project or any major medical facility lease unless funds for
that project or lease have been specifically authorized by law.
[(3) For the purpose of this subsection:
[(A) The term ``major medical facility project''
means a project for the construction, alteration, or
acquisition of a medical facility involving a total
expenditure of more than $10,000,000, but such term
does not include an acquisition by exchange.
[(B) The term ``major medical facility lease'' means
a lease for space for use as a new medical facility at
an average annual rental of more than $1,000,000.]
(3) For purposes of this subsection, the term ``major medical
facility project'' means a project for the construction,
alteration, or acquisition of a medical facility involving a
total expenditure of more than $20,000,000, but such term does
not include an acquisition by exchange, non-recurring
maintenance projects of the Department, or the construction,
alteration, or acquisition of a shared Federal medical facility
for which the Department's estimated share of the project costs
does not exceed $20,000,000.
(b) Whenever the President or the Secretary submit to the
Congress a request for the funding of a major medical facility
project (as defined in subsection (a)(3)(A)) or a major medical
facility lease (as defined in subsection (a)(3)(B)), the
Secretary shall submit to each committee, on the same day, a
prospectus of the proposed medical facility. Any such
prospectus shall include the following:
(1) A detailed estimate of the total costs of the
medical facility to be constructed, altered, leased, or
otherwise acquired under this subchapter, including a
description of the location of such facility and, in
the case of a prospectus proposing the construction of
a new or replacement medical facility, a detailed
report of the consideration that was given to acquiring
an existing facility by lease or purchase and to the
sharing of health-care resources with the Department of
Defense under section 8111 of this title. Such detailed
estimate shall include an identification of each of the
following:
(A) Total construction costs.
(B) Activation costs.
(C) Special purpose alterations (lump-sum
payment) costs.
(D) Number of personnel.
(E) Total costs of ancillary services,
equipment, and all other items.
(2) Demographic data applicable to such facility,
including information on projected changes in the
population of veterans to be served by the facility
over a five-year period, a ten-year period, and a
twenty-year period.
(3) Current and projected workload and utilization
data regarding the facility, including information on
projected changes in workload and utilization over a
five-year period, a ten-year period, and a twenty-year
period.
(4) Projected operating costs of the facility,
including both recurring and non-recurring costs
(including and identifying both recurring and non-
recurring costs (including activation costs and total
costs of ancillary services, equipment and all other
items)) over a five-year period, a ten-year period, and
a twenty-year period.
(5) The priority score assigned to the project or
lease under the Department's prioritization methodology
and, if the project or lease is being proposed for
funding before a project or lease with a higher score,
a specific explanation of the factors other than the
priority score that were considered and the basis on
which the project or lease is proposed for funding
ahead of projects or leases with higher priority
scores.
(6) In the case of a prospectus proposing the
construction of a new or replacement medical facility,
each of the following:
(A) A detailed estimate of the total costs
(including total construction costs, activation
costs, special purpose alterations (lump-sum
payment) costs, number of personnel and total
costs of ancillary services, equipment and all
other items) for each alternative to
construction of the facility that was
considered.
(B) A comparison of total costs to total
benefits for each such alternative.
(C) An explanation of why the preferred
alternative is the most effective means to
achieve the stated project goals and the most
cost-effective alternative.
(7) In the case of a prospectus proposing funding for
a major medical facility lease, a detailed analysis of
how the lease is expected to comply with Office of
Management and Budget Circular A-11 and section 1341 of
title 31 (commonly referred to as the ``Anti-Deficiency
Act''). Any such analysis shall include--
(A) an analysis of the classification of the
lease as a ``lease-purchase'', ``capital
lease'', or ``operating lease'' as those terms
are defined in Office of Management and Budget
Circular A-11;
(B) an analysis of the obligation of
budgetary resources associated with the lease;
and
(C) an analysis of the methodology used in
determining the asset cost, fair market value,
and cancellation costs of the lease.
(c)(1) Not less than 30 days before obligating funds for a
major medical facility project approved by a law described in
subsection (a)(2) of this section in an amount that would cause
the total amount obligated for that project to exceed the
amount specified in the law for that project (or would add to
total obligations exceeding such specified amount) by more than
10 percent, the Secretary shall provide the committees with
notice of the Secretary's intention to do so and the reasons
for the specified amount being exceeded.
(2) The Secretary shall--
(A) enter into a contract or agreement with an
appropriate non-department Federal entity with the
ability to conduct forensic audits on medical facility
projects for the conduct of an external forensic audit
of the expenditures relating to any major medical
facility or super construction project for which the
total expenditures exceed the amount requested in the
initial budget request for the project submitted to
Congress under section 1105 of title 31 by more than 25
percent; and
(B) enter into a contract or agreement with an
appropriate non-department Federal entity with the
ability to conduct forensic audits on medical facility
projects for the conduct of an external audit of the
medical center construction project in Aurora,
Colorado.
(d)(1) Except as provided in paragraph (2), in any case in
which the Secretary proposes that funds be used for a purpose
other than the purpose for which such funds were appropriated,
the Secretary shall promptly notify each committee, in writing,
of the particulars involved and the reasons why such funds were
not used for the purpose for which appropriated.
(2)(A) In any fiscal year, unobligated amounts in the
Construction, Major Projects account that are a direct result
of bid savings from a major construction project may only be
obligated for major construction projects authorized for that
fiscal year or a previous fiscal year.
(B) Whenever the Secretary obligates amounts for a major
construction project under subparagraph (A), the Secretary
shall submit to the Committee on Veterans' Affairs and the
Committee on Appropriations of the Senate and the Committee on
Veterans' Affairs and the Committee on Appropriations of the
House of Representatives notice of the following:
(i) The major construction project that is the source
of the bid savings.
(ii) If the major construction project that is the
source of the bid savings is not complete--
(I) the amount already obligated by the
Department or available in the project reserve
for such project;
(II) the percentage of such project that has
been completed; and
(III) the amount available to the Department
to complete such project.
(iii) The other major construction project for which
the bid savings amounts are being obligated.
(iv) The bid savings amounts being obligated for such
other major construction project.
(C) The Secretary may not obligate an amount under
subparagraph (A) to expand the purpose of a major construction
project except pursuant to a provision of law enacted after the
date on which the Secretary submits to the committees described
in subparagraph (B) notice of the following:
(i) The major construction project that is the source
of the bid savings.
(ii) The major construction project for which the
Secretary intends to expand the purpose.
(iii) A description of such expansion of purpose.
(iv) The amounts the Secretary intends to obligate to
expand the purpose.
(e) The Secretary may accept gifts or donations for any of
the purposes of this subchapter.
(f) The Secretary may not obligate funds in an amount in
excess of $500,000 from the Advance Planning Fund of the
Department toward design or development of a major medical
facility project (as defined in subsection (a)(3)(A)) until--
(1) the Secretary submits to the committees a report
on the proposed obligation; and
(2) a period of 30 days has passed after the date on
which the report is received by the committees.
(g) The limitation in subsection (f) does not apply to a
project for which funds have been authorized by law in
accordance with subsection (a)(2).
(h)(1) Not less than 30 days before entering into a major
medical facility lease, the Secretary shall submit to the
Committees on Veterans' Affairs of the Senate and the House of
Representatives--
(A) notice of the Secretary's intention to enter into
the lease;
(B) a detailed summary of the proposed lease;
(C) a description and analysis of any differences
between the prospectus submitted pursuant to subsection
(b) and the proposed lease; and
(D) a scoring analysis demonstrating that the
proposed lease fully complies with Office of Management
and Budget Circular A-11.
(2) Each committee described in paragraph (1) shall ensure
that any information submitted to the committee under such
paragraph is treated by the committee with the same level of
confidentiality as is required by law of the Secretary and
subject to the same statutory penalties for unauthorized
disclosure or use as the Secretary.
(3) Not more than 30 days after entering into a major medical
facility lease, the Secretary shall submit to each committee
described in paragraph (1) a report on any material differences
between the lease that was entered into and the proposed lease
described under such paragraph, including how the lease that
was entered into changes the previously submitted scoring
analysis described in subparagraph (D) of such paragraph.
* * * * * * *
SUBCHAPTER IV--SHARING OF MEDICAL FACILITIES, EQUIPMENT, AND
INFORMATION
* * * * * * *
Sec. 8159. Authority to pay for services authorized but not subject to
an agreement
(a) In General.--If, in the course of furnishing hospital
care, a medical service, or an extended care service authorized
by the Secretary and pursuant to a contract, agreement, or
other arrangement with the Secretary, a provider who is not a
party to the contract, agreement, or other arrangement
furnishes hospital care, a medical service, or an extended care
service that the Secretary considers necessary, the Secretary
may compensate the provider for the cost of such care or
service.
(b) New Contracts and Agreements.--The Secretary shall take
reasonable efforts to enter into a contract, agreement, or
other arrangement with a provider described in subsection (a)
to ensure that future care and services authorized by the
Secretary and furnished by the provider are subject to such a
contract, agreement, or other arrangement.
SUBCHAPTER V--ENHANCED-USE LEASES OF REAL PROPERTY
* * * * * * *
Sec. 8162. Enhanced-use leases
(a)(1) The Secretary may in accordance with this subchapter
enter into leases with respect to real property that is under
the jurisdiction or control of the Secretary. Any such lease
under this subchapter may be referred to as an ``enhanced-use
lease''. The Secretary may dispose of any such property that is
leased to another party under this subchapter in accordance
with section 8164 of this title. The Secretary may exercise the
authority provided by this subchapter notwithstanding section
8122 of this title, subchapter II of chapter 5 of title 40,
sections 541-555 and 1302 of title 40, or any other provision
of law (other than Federal laws relating to environmental and
historic preservation) inconsistent with this section. The
applicability of this subchapter to section 421(b) of the
Veterans' Benefits and Services Act of 1988 (Public Law 100-
322; 102 Stat. 553) is covered by subsection (c).
(2) The Secretary may enter into an enhanced-use lease only
for the provision of supportive housing and if the lease is not
inconsistent with and will not adversely affect the mission of
the Department.
(3) The provisions of sections 3141-3144, 3146, and 3147 of
title 40 shall not, by reason of this section, become
inapplicable to property that is leased to another party under
an enhanced-use lease.
(4) A property that is leased to another party under an
enhanced-use lease may not be considered to be unutilized or
underutilized for purposes of section 501 of the McKinney-Vento
Homeless Assistance Act (42 U.S.C. 11411).
(b)(1) If the Secretary has determined that a property should
be leased to another party through an enhanced-use lease, the
Secretary shall, at the Secretary's discretion, select the
party with whom the lease will be entered into using such
selection procedures as the Secretary considers appropriate.
(2) The term of an enhanced-use lease may not exceed 75
years.
(3)(A) For any enhanced-use lease entered into by the
Secretary, the lease consideration provided to the Secretary
shall consist solely of cash at fair value as determined by the
Secretary.
(B) The Secretary shall receive no other type of
consideration for an enhanced-use lease besides cash.
(C) The Secretary may enter into an enhanced-use lease
without receiving consideration.
(D) The Secretary may not waive or postpone the obligation of
a lessee to pay any consideration under an enhanced-use lease,
including monthly rent.
(4) The terms of an enhanced-use lease may provide for the
Secretary to use minor construction funds for capital
contribution payments.
(5) The terms of an enhanced-use lease may not provide for
any acquisition, contract, demonstration, exchange, grant,
incentive, procurement, sale, other transaction authority,
service agreement, use agreement, lease, or lease-back by the
Secretary or Federal Government.
[(6) The Secretary may not enter into an enhanced-use lease
without certification in advance in writing by the Director of
the Office of Management and Budget that such lease complies
with the requirements of this subchapter.]
(6) The Office of Management and Budget shall review each
enhanced-use lease before the lease goes into effect to
determine whether the lease is in compliance with paragraph
(5).
(c) The entering into an enhanced-use lease covering any land
or improvement described in section 421(b)(2) of the Veterans'
Benefits and Services Act of 1988 (Public Law 100-322; 102
Stat. 553) or section 224(a) of the Military Construction and
Veterans Affairs and Related Agencies Appropriations Act, 2008,
other than an enhanced-use lease under the Los Angeles Homeless
Veterans Leasing Act of 2016, shall be considered to be
prohibited by such sections unless specifically authorized by
law.
(d)(1) Nothing in this subchapter authorizes the Secretary to
enter into an enhanced-use lease that provides for, is
contingent upon, or otherwise authorizes the Federal Government
to guarantee a loan made by a third party to a lessee for
purposes of the enhanced-use lease.
(2) Nothing in this subchapter shall be construed to abrogate
or constitute a waiver of the sovereign immunity of the United
States with respect to any loan, financing, or other financial
agreement entered into by the lessee and a third party relating
to an enhanced-use lease.
* * * * * * *
----------
VETERANS ACCESS, CHOICE, AND ACCOUNTABILITY ACT OF 2014
* * * * * * *
TITLE I--IMPROVEMENT OF ACCESS TO CARE FROM NON-DEPARTMENT OF VETERANS
AFFAIRS PROVIDERS
SEC. 101. EXPANDED AVAILABILITY OF HOSPITAL CARE AND MEDICAL SERVICES
FOR VETERANS THROUGH THE USE OF AGREEMENTS WITH
NON-DEPARTMENT OF VETERANS AFFAIRS ENTITIES.
(a) Expansion of Available Care and Services.--
(1) Furnishing of care.--
(A) In General.--Hospital care and medical
services under chapter 17 of title 38, United
States Code, shall be furnished to an eligible
veteran described in subsection (b), at the
election of such veteran, through agreements
authorized under subsection (d), or any other
law administered by the Secretary of Veterans
Affairs, with entities specified in
subparagraph (B) for the furnishing of such
care and services to veterans.
(B) Entities specified.--The entities
specified in this subparagraph are the
following:
(i) Any health care provider that is
participating in the Medicare program
under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.),
including any physician furnishing
services under such program.
(ii) Any Federally-qualified health
center (as defined in section
1905(l)(2)(B) of the Social Security
Act (42 U.S.C. 1396d(l)(2)(B))).
(iii) The Department of Defense.
(iv) The Indian Health Service.
(v) Subject to subsection (d)(5), a
health care provider not otherwise
covered under any of clauses (i)
through (iv).
(2) Choice of provider.--An eligible veteran who
makes an election under subsection (c) to receive
hospital care or medical services under this section
may select a provider of such care or services from
among the entities specified in paragraph (1)(B) that
are accessible to the veteran.
(3) Coordination of care and services.--The Secretary
shall coordinate, through the Non-VA Care Coordination
Program of the Department of Veterans Affairs, the
furnishing of care and services under this section to
eligible veterans, including by ensuring that an
eligible veteran receives an appointment for such care
and services within the wait-time goals of the Veterans
Health Administration for the furnishing of hospital
care and medical services.
(b) Eligible Veterans.--A veteran is an eligible veteran for
purposes of this section if--
(1) the veteran is enrolled in the patient enrollment
system of the Department of Veterans Affairs
established and operated under section 1705 of title
38, United States Code, including any such veteran who
has not received hospital care or medical services from
the Department and has contacted the Department seeking
an initial appointment from the Department for the
receipt of such care or services; and
(2) the veteran--
(A) attempts, or has attempted, to schedule
an appointment for the receipt of hospital care
or medical services under chapter 17 of title
38, United States Code, but is unable to
schedule an appointment within--
(i) the wait-time goals of the
Veterans Health Administration for the
furnishing of such care or services; or
(ii) with respect to such care or
services that are clinically necessary,
the period determined necessary for
such care or services if such period is
shorter than such wait-time goals;
(B) resides more than 40 miles (as calculated
based on distance traveled) from--
(i) with respect to a veteran who is
seeking primary care, a medical
facility of the Department, including a
community-based outpatient clinic, that
is able to provide such primary care by
a full-time primary care physician; or
(ii) with respect to a veteran not
covered under clause (i), the medical
facility of the Department, including a
community-based outpatient clinic, that
is closest to the residence of the
veteran;
(C) resides--
(i) in a State without a medical
facility of the Department that
provides--
(I) hospital care;
(II) emergency medical
services; and
(III) surgical care rated by
the Secretary as having a
surgical complexity of
standard; and
(ii) more than 20 miles from a
medical facility of the Department
described in clause (i); or
(D)(i) resides in a location, other than a
location in Guam, American Samoa, or the
Republic of the Philippines, that is 40 miles
or less from a medical facility of the
Department, including a community-based
outpatient clinic; and
(ii)(I) is required to travel by air,
boat, or ferry to reach each medical
facility described in clause (i) that
is 40 miles or less from the residence
of the veteran; or
(II) faces an unusual or
excessive burden in traveling
to such a medical facility of
the Department based on--
(aa) geographical
challenges;
(bb) environmental
factors, such as roads
that are not accessible
to the general public,
traffic, or hazardous
weather;
(cc) a medical
condition that impacts
the ability to travel;
or
(dd) other factors,
as determined by the
Secretary.
(c) Election and Authorization.--
(1) In general.--In the case of an eligible veteran
described in subsection (b)(2)(A), the Secretary shall,
at the election of the eligible veteran--
(A) provide the veteran an appointment that
exceeds the wait-time goals described in such
subsection or place such eligible veteran on an
electronic waiting list described in paragraph
(2) for an appointment for hospital care or
medical services the veteran has elected to
receive under this section; or
(B)(i) authorize that such care or services
be furnished to the eligible veteran under this
section for a period of time specified by the
Secretary; and
(ii) notify the eligible veteran by
the most effective means available,
including electronic communication or
notification in writing, describing the
care or services the eligible veteran
is eligible to receive under this
section.
(2) Electronic waiting list.--The electronic waiting
list described in this paragraph shall be maintained by
the Department and allow access by each eligible
veteran via www.myhealth.va.gov or any successor
website (or other digital channel) for the following
purposes:
(A) To determine the place of such eligible
veteran on the waiting list.
(B) To determine the average length of time
an individual spends on the waiting list,
disaggregated by medical facility of the
Department and type of care or service needed,
for purposes of allowing such eligible veteran
to make an informed election under paragraph
(1).
(d) Care and Services Through Agreements.--
(1) Agreements.--
(A) In general.--The Secretary shall enter
into agreements for furnishing care and
services to eligible veterans under this
section with entities specified in subsection
(a)(1)(B). An agreement entered into pursuant
to this subparagraph may not be treated as a
Federal contract for the acquisition of goods
or services and is not subject to any provision
of law governing Federal contracts for the
acquisition of goods or services. Before
entering into an agreement pursuant to this
subparagraph, the Secretary shall, to the
maximum extent practicable and consistent with
the requirements of this section, furnish such
care and services to such veterans under this
section with such entities pursuant to sharing
agreements, existing contracts entered into by
the Secretary, or other processes available at
medical facilities of the Department.
(B) Agreement defined.--In this paragraph,
the term ``agreement'' includes contracts,
intergovernmental agreements, and provider
agreements, as appropriate.
(2) Rates and reimbursement.--
(A) In general.--In entering into an
agreement under paragraph (1) with an entity
specified in subsection (a)(1)(B), the
Secretary shall--
(i) negotiate rates for the
furnishing of care and services under
this section; and
(ii) reimburse the entity for such
care and services at the rates
negotiated pursuant to clause (i) as
provided in such agreement.
(B) Limit on rates.--
(i) In general.--Except as provided
in clause (ii), rates negotiated under
subparagraph (A)(i) shall not be more
than the rates paid by the United
States to a provider of services (as
defined in section 1861(u) of the
Social Security Act (42 U.S.C.
1395x(u))) or a supplier (as defined in
section 1861(d) of such Act (42 U.S.C.
1395x(d))) under the Medicare program
under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.)
for the same care or services.
(ii) Exception.--
(I) In general.--The
Secretary may negotiate a rate
that is more than the rate paid
by the United States as
described in clause (i) with
respect to the furnishing of
care or services under this
section to an eligible veteran
who resides in a highly rural
area.
(II) Highly rural area
defined.--In this clause, the
term ``highly rural area''
means an area located in a
county that has fewer than
seven individuals residing in
that county per square mile.
(III) Other exceptions.--With
respect to furnishing care or
services under this section in
Alaska, the Alaska Fee Schedule
of the Department of Veterans
Affairs will be followed,
except for when another payment
agreement, including a contract
or provider agreement, is in
place. With respect to care or
services furnished under this
section in a State with an All-
Payer Model Agreement under the
Social Security Act that became
effective on January 1, 2014,
the Medicare payment rates
under clause (i) shall be
calculated based on the payment
rates under such agreement.
(C) Limit on collection.--For the furnishing
of care or services pursuant to an agreement
under paragraph (1), an entity specified in
subsection (a)(1)(B) may not collect any amount
that is greater than the rate negotiated
pursuant to subparagraph (A)(i).
(3) Certain procedures.--
(A) In general.--In entering into an
agreement under paragraph (1) with an entity
described in subparagraph (B), the Secretary
may use the procedures, including those
procedures relating to reimbursement, available
for entering into provider agreements under
section 1866(a) of the Social Security Act (42
U.S.C. 1395cc(a)) and participation agreements
under section 1842(h) of such Act (42 U.S.C.
1395u(h)). During the period in which such
entity furnishes care or services pursuant to
this section, such entity may not be treated as
a Federal contractor or subcontractor by the
Office of Federal Contract Compliance Programs
of the Department of Labor by virtue of
furnishing such care or services.
(B) Entities described.--The entities
described in this subparagraph are the
following:
(i) In the case of the Medicare
program, any provider of services that
has entered into a provider agreement
under section 1866(a) of the Social
Security Act (42 U.S.C. 1395cc(a)) and
any physician or other supplier who has
entered into a participation agreement
under section 1842(h) of such Act (42
U.S.C. 1395u(h)); and
(ii) In the case of the Medicaid
program, any provider participating
under a State plan under title XIX of
such Act (42 U.S.C. 1396 et seq.).
(4) Information on policies and procedures.--The
Secretary shall provide to any entity with which the
Secretary has entered into an agreement under paragraph
(1) the following:
(A) Information on applicable policies and
procedures for submitting bills or claims for
authorized care or services furnished to
eligible veterans under this section.
(B) Access to a telephone hotline maintained
by the Department that such entity may call for
information on the following:
(i) Procedures for furnishing care
and services under this section.
(ii) Procedures for submitting bills
or claims for authorized care and
services furnished to eligible veterans
under this section and being reimbursed
for furnishing such care and services.
(iii) Whether particular care or
services under this section are
authorized, and the procedures for
authorization of such care or services.
(5) Agreements with other providers.--In accordance
with the rates determined pursuant to paragraph (2),
the Secretary may enter into agreements under paragraph
(1) for furnishing care and services to eligible
veterans under this section with an entity specified in
subsection (a)(1)(B)(v) if the entity meets criteria
established by the Secretary for purposes of this
section.
(e) Responsibility for Costs of Certain Care.--
(1) Submittal of information on health-care plans.--
Before receiving hospital care or medical services
under this section, an eligible veteran shall provide
to the Secretary information on any health-care plan
described in paragraph (2) under which the eligible
veteran is covered.
(2) Health-care plan.--A health-care plan described
in this paragraph--
(A) is an insurance policy or contract,
medical or hospital service agreement,
membership or subscription contract, or similar
arrangement not administered by the Secretary
of Veterans Affairs, under which health
services for individuals are provided or the
expenses of such services are paid; and
(B) does not include any such policy,
contract, agreement, or similar arrangement
pursuant to title XVIII or XIX of the Social
Security Act (42 U.S.C. 1395 et seq.) or
chapter 55 of title 10, United States Code.
(3) Recovery of costs for certain care.--
(A) In general.--In any case in which an
eligible veteran is furnished hospital care or
medical services under this section for a non-
service-connected disability described in
subsection (a)(2) of section 1729 of title 38,
United States Code, or for a condition for
which recovery is authorized or with respect to
which the United States is deemed to be a third
party beneficiary under Public Law 87-693,
commonly known as the ``Federal Medical Care
Recovery Act'' (42 U.S.C. 2651 et seq.), the
Secretary shall recover or collect from a third
party (as defined in subsection (i) of such
section 1729) reasonable charges for such care
or services to the extent that the veteran (or
the provider of the care or services) would be
eligible to receive payment for such care or
services from such third party if the care or
services had not been furnished by a department
or agency of the United States.
(B) Use of amounts.--Amounts collected by the
Secretary under subparagraph (A) shall be
deposited in the Medical Community Care account
of the Department. Amounts so deposited shall
remain available until expended.
(f) Veterans Choice Card.--
(1) In general.--For purposes of receiving care and
services under this section, the Secretary shall, not
later than 90 days after the date of the enactment of
this Act, issue to each veteran described in subsection
(b)(1) a card that may be presented to a health care
provider to facilitate the receipt of care or services
under this section.
(2) Name of card.--Each card issued under paragraph
(1) shall be known as a ``Veterans Choice Card''.
(3) Details of card.--Each Veterans Choice Card
issued to a veteran under paragraph (1) shall include
the following:
(A) The name of the veteran.
(B) An identification number for the veteran
that is not the social security number of the
veteran.
(C) The contact information of an appropriate
office of the Department for health care
providers to confirm that care or services
under this section are authorized for the
veteran.
(D) Contact information and other relevant
information for the submittal of claims or
bills for the furnishing of care or services
under this section.
(E) The following statement: ``This card is
for qualifying medical care outside the
Department of Veterans Affairs. Please call the
Department of Veterans Affairs phone number
specified on this card to ensure that treatment
has been authorized.''.
(4) Information on use of card.--Upon issuing a
Veterans Choice Card to a veteran, the Secretary shall
provide the veteran with information clearly stating
the circumstances under which the veteran may be
eligible for care or services under this section.
(g) Information on Availability of Care.--The Secretary shall
provide information to a veteran about the availability of care
and services under this section in the following circumstances:
(1) When the veteran enrolls in the patient
enrollment system of the Department under section 1705
of title 38, United States Code.
(2) When the veteran attempts to schedule an
appointment for the receipt of hospital care or medical
services from the Department but is unable to schedule
an appointment within the wait-time goals of the
Veterans Health Administration for the furnishing of
such care or services.
(3) When the veteran becomes eligible for hospital
care or medical services under this section under
subparagraph (B), (C), or (D) of subsection (b)(2).
(h) Follow-Up Care.--In carrying out this section, the
Secretary shall ensure that, at the election of an eligible
veteran who receives hospital care or medical services from a
health care provider in an episode of care under this section,
the veteran receives such hospital care and medical services
from such health care provider through the completion of the
episode of care, including all specialty and ancillary services
deemed necessary as part of the treatment recommended in the
course of such hospital care or medical services.
(i) Providers.--To be eligible to furnish care or services
under this section, a health care provider must--
(1) maintain at least the same or similar credentials
and licenses as those credentials and licenses that are
required of health care providers of the Department, as
determined by the Secretary for purposes of this
section; and
(2) submit, not less frequently than once each year
during the period in which the Secretary is authorized
to carry out this section pursuant to subsection (p),
verification of such licenses and credentials
maintained by such health care provider.
(j) Cost-Sharing.--
(1) In general.--The Secretary shall require an
eligible veteran to pay a copayment for the receipt of
care or services under this section only if such
eligible veteran would be required to pay a copayment
for the receipt of such care or services at a medical
facility of the Department or from a health care
provider of the Department pursuant to chapter 17 of
title 38, United States Code.
(2) Limitation.--The amount of a copayment charged
under paragraph (1) may not exceed the amount of the
copayment that would be payable by such eligible
veteran for the receipt of such care or services at a
medical facility of the Department or from a health
care provider of the Department pursuant to chapter 17
of title 38, United States Code.
(3) Collection of copayment.--A health care provider
that furnishes care or services to an eligible veteran
under this section shall collect the copayment required
under paragraph (1) from such eligible veteran at the
time of furnishing such care or services.
(k) Claims processing system.--
(1) In general.--The Secretary shall provide for an
efficient nationwide system for processing and paying
bills or claims for authorized care and services
furnished to eligible veterans under this section.
(2) Regulations.--Not later than 90 days after the
date of the enactment of this Act, the Secretary of
Veterans Affairs shall prescribe regulations for the
implementation of such system.
(3) Oversight.--The Chief Business Office of the
Veterans Health Administration shall oversee the
implementation and maintenance of such system.
(4) Accuracy of payment.--
(A) In general.--The Secretary shall ensure
that such system meets such goals for accuracy
of payment as the Secretary shall specify for
purposes of this section.
(B) Quarterly report.--
(i) In general.--The Secretary shall
submit to the Committee on Veterans'
Affairs of the Senate and the Committee
on Veterans' Affairs of the House of
Representatives a quarterly report on
the accuracy of such system.
(ii) Elements.--Each report required
by clause (i) shall include the
following:
(I) A description of the
goals for accuracy for such
system specified by the
Secretary under subparagraph
(A).
(II) An assessment of the
success of the Department in
meeting such goals during the
quarter covered by the report.
(iii) Deadline.--The Secretary shall
submit each report required by clause
(i) not later than 20 days after the
end of the quarter covered by the
report.
(l) Medical Records.--
(1) In general.--The Secretary shall ensure that any
health care provider that furnishes care or services
under this section to an eligible veteran submits to
the Department a copy of any medical record related to
the care or services provided to such eligible veteran
by such health care provider for inclusion in the
electronic medical record of such eligible veteran
maintained by the Department upon the completion of the
provision of such care or services to such eligible
veteran.
(2) Electronic format.--Any medical record submitted
to the Department under paragraph (1) shall, to the
extent possible, be in an electronic format.
(m) Tracking of Missed Appointments.--The Secretary shall
implement a mechanism to track any missed appointments for care
or services under this section by eligible veterans to ensure
that the Department does not pay for such care or services that
were not furnished to an eligible veteran.
(n) Implementation.--Not later than 90 days after the date of
the enactment of this Act, the Secretary shall prescribe
interim final regulations on the implementation of this section
and publish such regulations in the Federal Register.
(o) Inspector General Report.--Not later than 30 days after
the date on which the Secretary determines that 75 percent of
the amounts deposited in the Veterans Choice Fund established
by section 802 have been exhausted, the Inspector General of
the Department shall submit to the Secretary a report on the
results of an audit of the care and services furnished under
this section to ensure the accuracy and timeliness of payments
by the Department for the cost of such care and services,
including any findings and recommendations of the Inspector
General.
[(p) Authority To Furnish Care and Services.--
[(1) In general.--The Secretary may not use the
authority under this section to furnish care and
services after the date specified in paragraph (2).
[(2) Date specified.--The date specified in this
paragraph is the date on which the Secretary has
exhausted all amounts deposited in the Veterans Choice
Fund established by section 802.
[(3) Publication.--The Secretary shall publish such
date in the Federal Register and on an Internet website
of the Department available to the public not later
than 30 days before such date.]
(p) Authority To Furnish Care and Services.--The Secretary
may not use the authority under this section to furnish care
and services after the date that is one year after the date of
the enactment of the Caring for Our Veterans Act of 2018.
(q) Reports.--
(1) Initial report.--Not later than 90 days after the
publication of the interim final regulations under
subsection (n), the Secretary shall submit to the
Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of
Representatives a report on the furnishing of care and
services under this section that includes the
following:
(A) The number of eligible veterans who have
received care or services under this section.
(B) A description of the types of care and
services furnished to eligible veterans under
this section.
(2) Final report.--Not later than 30 days after the
date on which the Secretary determines that 75 percent
of the amounts deposited in the Veterans Choice Fund
established by section 802 have been exhausted, the
Secretary shall submit to the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans'
Affairs of the House of Representatives a report on the
furnishing of care and services under this section that
includes the following:
(A) The total number of eligible veterans who
have received care or services under this
section, disaggregated by--
(i) eligible veterans described in
subsection (b)(2)(A);
(ii) eligible veterans described in
subsection (b)(2)(B);
(iii) eligible veterans described in
subsection (b)(2)(C); and
(iv) eligible veterans described in
subsection (b)(2)(D).
(B) A description of the types of care and
services furnished to eligible veterans under
this section.
(C) An accounting of the total cost of
furnishing care and services to eligible
veterans under this section.
(D) The results of a survey of eligible
veterans who have received care or services
under this section on the satisfaction of such
eligible veterans with the care or services
received by such eligible veterans under this
section.
(E) An assessment of the effect of furnishing
care and services under this section on wait
times for appointments for the receipt of
hospital care and medical services from the
Department.
(F) An assessment of the feasibility and
advisability of continuing furnishing care and
services under this section after the
termination date specified in subsection (p).
(r) Rule of Construction.--Nothing in this section shall be
construed to alter the process of the Department for filling
and paying for prescription medications.
(s) Wait-Time Goals of the Veterans Health Administration.--
(1) In general.--Except as provided in paragraph (2),
in this section, the term ``wait-time goals of the
Veterans Health Administration'' means not more than 30
days from the date on which a veteran requests an
appointment for hospital care or medical services from
the Department.
(2) Alternate goals.--If the Secretary submits to
Congress, not later than 60 days after the date of the
enactment of this Act, a report stating that the actual
wait-time goals of the Veterans Health Administration
are different from the wait-time goals specified in
paragraph (1)--
(A) for purposes of this section, the wait-
time goals of the Veterans Health
Administration shall be the wait-time goals
submitted by the Secretary under this
paragraph; and
(B) the Secretary shall publish such wait-
time goals in the Federal Register and on an
Internet website of the Department available to
the public.
(t) Waiver of Certain Printing Requirements.--Section 501 of
title 44, United States Code, shall not apply in carrying out
this section.
* * * * * * *
TITLE VII--OTHER VETERANS MATTERS
* * * * * * *
SEC. 705. LIMITATION ON AWARDS AND BONUSES PAID TO EMPLOYEES OF
DEPARTMENT OF VETERANS AFFAIRS.
(a) Limitation.--The Secretary of Veterans Affairs shall
ensure that the aggregate amount of awards and bonuses paid by
the Secretary in a fiscal year under chapter 45 or 53 of title
5, United States Code, or any other awards or bonuses
authorized under such title or title 38, United States Code,
does not exceed the following amounts:
(1) With respect to each of fiscal years 2017 through
2018, [$230,000,000] $250,000,000, of which not less
than $20,000,000 shall be for recruitment, relocation,
and retention bonuses.
(2) With respect to each of fiscal years 2019 through
2021, [$225,000,000] $290,000,000, of which not less
than $20,000,000 shall be for recruitment, relocation,
and retention bonuses.
(3) With respect to each of fiscal years 2022 through
2024, $360,000,000.
(b) Sense of Congress.--It is the sense of Congress that the
limitation under subsection (a) should not disproportionately
impact lower-wage employees and that the Department of Veterans
Affairs is encouraged to use bonuses to incentivize high-
performing employees in areas in which retention is
challenging.
* * * * * * *
TITLE VIII--OTHER MATTERS
* * * * * * *
SEC. 802. VETERANS CHOICE FUND.
(a) In general.--There is established in the Treasury of the
United States a fund to be known as the Veterans Choice Fund.
(b) Administration of Fund.--The Secretary of Veterans
Affairs shall administer the Veterans Choice Fund established
by subsection (a).
(c) Use of Amounts.--
(1) In general.--Except as provided [by paragraph
(3)] in paragraphs (3) and (4), any amounts deposited
in the Veteran Choice Fund shall be used by the
Secretary of Veterans Affairs to carry out section 101,
including, subject to paragraph (2), any administrative
requirements of such section.
(2) Amount for administrative requirements.--
(A) Limitation.--Except as provided by
subparagraph (B), of the amounts deposited in
the Veterans Choice Fund, not more than
$300,000,000 may be used for administrative
requirements to carry out section 101.
(B) Increase.--The Secretary may increase the
amount set forth in subparagraph (A) with
respect to the amounts used for administrative
requirements if--
(i) the Secretary determines that the
amount of such increase is necessary to
carry out section 101;
(ii) the Secretary submits to the
Committees on Veterans' Affairs and
Appropriations of the House of
Representatives and the Committees on
Veterans' Affairs and Appropriations of
the Senate a report described in
subparagraph (C); and
(iii) a period of 60 days has elapsed
following the date on which the
Secretary submits the report under
clause (ii).
(C) Report.--A report described in this
subparagraph is a report that contains the
following:
(i) A notification of the amount of
the increase that the Secretary
determines necessary under subparagraph
(B)(i).
(ii) The justifications for such
increased amount.
(iii) The administrative requirements
that the Secretary will carry out using
such increased amount.
(3) Temporary authority for other uses.--
(A) Other non-department care.--In addition
to the use of amounts described in paragraph
(1), of the amounts deposited in the Veterans
Choice Fund, not more than $3,348,500,000 may
be used by the Secretary during the period
described in subparagraph (C) for amounts
obligated by the Secretary on or after May 1,
2015, to furnish health care to individuals
pursuant to chapter 17 of title 38, United
States Code, at non-Department facilities,
including pursuant to non-Department provider
programs other than the program established by
section 101.
(B) Hepatitis c.--Of the amount specified in
subparagraph (A), not more than $500,000,000
may be used by the Secretary during the period
described in subparagraph (C) for
pharmaceutical expenses relating to the
treatment of Hepatitis C.
(C) Period described.--The period described
in this subparagraph is the period beginning on
the date of the enactment of the VA Budget and
Choice Improvement Act and ending on October 1,
2015.
(D) Reports.--Not later than 14 days after
the date of the enactment of the VA Budget and
Choice Improvement Act, and not less frequently
than once every 14-day period thereafter during
the period described in subparagraph (C), the
Secretary shall submit to the appropriate
congressional committees a report detailing--
(i) the amounts used by the Secretary
pursuant to subparagraphs (A) and (B);
and
(ii) an identification of such
amounts listed by the non-Department
provider program for which the amounts
were used.
(E) Definitions.--In this paragraph:
(i) The term ``appropriate
congressional committees'' means--
(I) the Committee on
Veterans' Affairs and the
Committee on Appropriations of
the House of Representatives;
and
(II) the Committee on
Veterans' Affairs and the
Committee on Appropriations of
the Senate.
(ii) The term ``non-Department
facilities'' has the meaning given that
term in section 1701 of title 38,
United States Code.
(iii) The term ``non-Department
provider program'' has the meaning
given that term in section 4002(d) of
the VA Budget and Choice Improvement
Act.
(4) Permanent authority for other uses.--Beginning on
March 1, 2019, amounts remaining in the Veterans Choice
Fund may be used to furnish hospital care, medical
services, and extended care services to individuals
pursuant to chapter 17 of title 38, United States Code,
at non-Department facilities, including pursuant to
non-Department provider programs other than the program
established by section 101. Such amounts shall be
available in addition to amounts available in other
appropriations accounts for such purposes.
(d) Appropriation and Deposit of Amounts.--
(1) In general.--There is authorized to be
appropriated, and is appropriated, to the Secretary of
Veterans Affairs, out of any funds in the Treasury not
otherwise appropriated $10,000,000,000 to be deposited
in the Veterans Choice Fund established by subsection
(a). Such funds shall be available for obligation or
expenditure without fiscal year limitation, and only
for the program created under section 101(or for
hospital care and medical services pursuant [to
subsection (c)(3)] to paragraphs (3) and (4) of
subsection (c) of this section).
(2) Availability.--The amount appropriated under
paragraph (1) shall remain available until expended.
(e) Sense of Congress.--It is the sense of Congress that the
Veterans Choice Fund is a supplement to but distinct from the
Department of Veterans Affairs' current and expected level of
non-Department care currently part of Department's medical care
budget. Congress expects that the Department will maintain at
least its existing obligations of non-Department care programs
in addition to but distinct from the Veterans Choice Fund for
each of fiscal years 2015 through 2017.
* * * * * * *
----------
SOCIAL SECURITY ACT
* * * * * * *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED
* * * * * * *
Part E--Miscellaneous Provisions
* * * * * * *
agreements with providers of services; enrollment processes
Sec. 1866. (a)(1) Any provider of services (except a fund
designated for purposes of section 1814(g) and section 1835(e))
shall be qualified to participate under this title and shall be
eligible for payments under this title if it files with the
Secretary an agreement--
(A)(i) not to charge, except as provided in paragraph
(2), any individual or any other person for items or
services for which such individual is entitled to have
payment made under this title (or for which he would be
so entitled if such provider of services had complied
with the procedural and other requirements under or
pursuant to this title or for which such provider is
paid pursuant to the provisions of section 1814(e)),
and (ii) not to impose any charge that is prohibited
under section 1902(n)(3),
(B) not to charge any individual or any other person
for items or services for which such individual is not
entitled to have payment made under this title because
payment for expenses incurred for such items or
services may not be made by reason of the provisions of
paragraph (1) or (9) of section 1862(a), but only if
(i) such individual was without fault in incurring such
expenses and (ii) the Secretary's determination that
such payment may not be made for such items and
services was made after the third year following the
year in which notice of such payment was sent to such
individual; except that the Secretary may reduce such
three-year period to not less than one year if he finds
such reduction is consistent with the objectives of
this title,
(C) to make adequate provision for return (or other
disposition, in accordance with regulations) of any
moneys incorrectly collected from such individual or
other person,
(D) to promptly notify the Secretary of its
employment of an individual who, at any time during the
year preceding such employment, was employed in a
managerial, accounting, auditing, or similar capacity
(as determined by the Secretary by regulation) by an
agency or organization which serves as a fiscal
intermediary or carrier (for purposes of part A or part
B, or both, of this title) with respect to the
provider,
(E) to release data with respect to patients of such
provider upon request to an organization having a
contract with the Secretary under part B of title XI as
may be necessary (i) to allow such organization to
carry out its functions under such contract, or (ii) to
allow such organization to carry out similar review
functions under any contract the organization may have
with a private or public agency paying for health care
in the same area with respect to patients who authorize
release of such data for such purposes,
(F)(i) in the case of hospitals which provide
inpatient hospital services for which payment may be
made under subsection (b), (c), or (d) of section 1886,
to maintain an agreement with a professional standards
review organization (if there is such an organization
in existence in the area in which the hospital is
located) or with a quality improvement organization
which has a contract with the Secretary under part B of
title XI for the area in which the hospital is located,
under which the organization will perform functions
under that part with respect to the review of the
validity of diagnostic information provided by such
hospital, the completeness, adequacy, and quality of
care provided, the appropriateness of admissions and
discharges, and the appropriateness of care provided
for which additional payments are sought under section
1886(d)(5), with respect to inpatient hospital services
for which payment may be made under part A of this
title (and for purposes of payment under this title,
the cost of such agreement to the hospital shall be
considered a cost incurred by such hospital in
providing inpatient services under part A, and (I)
shall be paid directly by the Secretary to such
organization on behalf of such hospital in accordance
with a rate per review established by the Secretary,
(II) shall be transferred from the Federal Hospital
Insurance Trust Fund, without regard to amounts
appropriated in advance in appropriation Acts, in the
same manner as transfers are made for payment for
services provided directly to beneficiaries, and (III)
shall not be less in the aggregate for a fiscal year
than the aggregate amount expended in fiscal year 1988
for direct and administrative costs (adjusted for
inflation and for any direct or administrative costs
incurred as a result of review functions added with
respect to a subsequent fiscal year) of such reviews),
(ii) in the case of hospitals, critical access
hospitals, skilled nursing facilities, and home health
agencies, to maintain an agreement with a quality
improvement organization (which has a contract with the
Secretary under part B of title XI for the area in
which the hospital, facility, or agency is located) to
perform the functions described in paragraph (3)(A),
(G) in the case of hospitals which provide inpatient
hospital services for which payment may be made under
subsection (b) or (d) of section 1886, not to charge
any individual or any other person for inpatient
hospital services for which such individual would be
entitled to have payment made under part A but for a
denial or reduction of payments under section
1886(f)(2),
(H)(i) in the case of hospitals which provide
services for which payment may be made under this title
and in the case of critical access hospitals which
provide critical access hospital services, to have all
items and services (other than physicians' services as
defined in regulations for purposes of section
1862(a)(14), and other than services described by
section 1861(s)(2)(K), certified nurse-midwife
services, qualified psychologist services, and services
of a certified registered nurse anesthetist) (I) that
are furnished to an individual who is a patient of the
hospital, and (II) for which the individual is entitled
to have payment made under this title, furnished by the
hospital or otherwise under arrangements (as defined in
section 1861(w)(1)) made by the hospital,
(ii) in the case of skilled nursing facilities which
provide covered skilled nursing facility services--
(I) that are furnished to an individual who
is a resident of the skilled nursing facility
during a period in which the resident is
provided covered post-hospital extended care
services (or, for services described in section
1861(s)(2)(D), that are furnished to such an
individual without regard to such period), and
(II) for which the individual is entitled to
have payment made under this title,
to have items and services (other than services
described in section 1888(e)(2)(A)(ii)) furnished by
the skilled nursing facility or otherwise under
arrangements (as defined in section 1861(w)(1)) made by
the skilled nursing facility,
(I) in the case of a hospital or critical access
hospital--
(i) to adopt and enforce a policy to ensure
compliance with the requirements of section
1867 and to meet the requirements of such
section,
(ii) to maintain medical and other records
related to individuals transferred to or from
the hospital for a period of five years from
the date of the transfer, and
(iii) to maintain a list of physicians who
are on call for duty after the initial
examination to provide treatment necessary to
stabilize an individual with an emergency
medical condition,
(J) in the case of hospitals which provide inpatient
hospital services for which payment may be made under
this title, to be a participating provider of medical
care under any health plan contracted for under section
1079 or 1086 of title 10, or under section 613 of title
38, United States Code, in accordance with admission
practices, payment methodology, and amounts as
prescribed under joint regulations issued by the
Secretary and by the Secretaries of Defense and
Transportation, in implementation of sections 1079 and
1086 of title 10, United States Code,
(K) not to charge any individual or any other person
for items or services for which payment under this
title is denied under section 1154(a)(2) by reason of a
determination under section 1154(a)(1)(B),
(L) in the case of hospitals which provide inpatient
hospital services for which payment may be made under
this title, to be a participating provider of medical
care under section 603 of title 38, United States Code,
in accordance with such admission practices, and such
payment methodology and amounts, as are prescribed
under joint regulations issued by the Secretary and by
the Secretary of Veterans Affairs in implementation of
such section,
(M) in the case of hospitals, to provide to each
individual who is entitled to benefits under part A (or
to a person acting on the individual's behalf), at or
about the time of the individual's admission as an
inpatient to the hospital, a written statement
(containing such language as the Secretary prescribes
consistent with this paragraph) which explains--
(i) the individual's rights to benefits for
inpatient hospital services and for post-
hospital services under this title,
(ii) the circumstances under which such an
individual will and will not be liable for
charges for continued stay in the hospital,
(iii) the individual's right to appeal
denials of benefits for continued inpatient
hospital services, including the practical
steps to initiate such an appeal, and
(iv) the individual's liability for payment
for services if such a denial of benefits is
upheld on appeal,--and which provides such
additional information as the Secretary may
specify,
(N) in the case of hospitals and critical access
hospitals--
(i) to make available to its patients the
directory or directories of participating
physicians (published under section 1842(h)(4))
for the area served by the hospital or critical
access hospital,
(ii) if hospital personnel (including staff
of any emergency or outpatient department)
refer a patient to a nonparticipating physician
for further medical care on an outpatient
basis, the personnel must inform the patient
that the physician is a nonparticipating
physician and, whenever practicable, must
identify at least one qualified participating
physician who is listed in such a directory and
from whom the patient may receive the necessary
services,
(iii) to post conspicuously in any emergency
department a sign (in a form specified by the
Secretary) specifying rights of individuals
under section 1867 with respect to examination
and treatment for emergency medical conditions
and women in labor, and
(iv) to post conspicuously (in a form
specified by the Secretary) information
indicating whether or not the hospital
participates in the medicaid program under a
State plan approved under title XIX,
(O) to accept as payment in full for services that
are covered under this title and are furnished to any
individual enrolled with a Medicare+Choice organization
under part C, with a PACE provider under section 1894
or 1934, or with an eligible organization with a risk-
sharing contract under section 1876, under section
1876(i)(2)(A) (as in effect before February 1, 1985),
under section 402(a) of the Social Security Amendments
of 1967, or under section 222(a) of the Social Security
Amendments of 1972, which does not have a contract (or,
in the case of a PACE provider, contract or other
agreement) establishing payment amounts for services
furnished to members of the organization or PACE
program eligible individuals enrolled with the PACE
provider, the amounts that would be made as a payment
in full under this title (less any payments under
sections 1886(d)(11) and 1886(h)(3)(D)) if the
individuals were not so enrolled,
(P) in the case of home health agencies which provide
home health services to individuals entitled to
benefits under this title who require catheters,
catheter supplies, ostomy bags, and supplies related to
ostomy car (described in section 1861(m)(5)), to offer
to furnish such supplies to such an individual as part
of their furnishing of home health services,
(Q) in the case of hospitals, skilled nursing
facilities, home health agencies, and hospice programs,
to comply with the requirement of subsection (f)
(relating to maintaining written policies and
procedures respecting advance directives),
(R) to contract only with a health care clearinghouse
(as defined in section 1171) that meets each standard
and implementation specification adopted or established
under part C of title XI on or after the date on which
the health care clearinghouse is required to comply
with the standard or specification,
(S) in the case of a hospital that has a financial
interest (as specified by the Secretary in regulations)
in an entity to which individuals are referred as
described in section 1861(ee)(2)(H)(ii), or in which
such an entity has such a financial interest, or in
which another entity has such a financial interest
(directly or indirectly) with such hospital and such an
entity, to maintain and disclose to the Secretary (in a
form and manner specified by the Secretary) information
on--
(i) the nature of such financial interest,
(ii) the number of individuals who were
discharged from the hospital and who were
identified as requiring home health services,
and
(iii) the percentage of such individuals who
received such services from such provider (or
another such provider),
(T) in the case of hospitals and critical access
hospitals, to furnish to the Secretary such data as the
Secretary determines appropriate pursuant to
subparagraph (E) of section 1886(d)(12) to carry out
such section,
(U) in the case of hospitals which furnish inpatient
hospital services for which payment may be made under
this title, to be a participating provider of medical
care both--
(i) under the contract health services
program funded by the Indian Health Service and
operated by the Indian Health Service, an
Indian tribe, or tribal organization (as those
terms are defined in section 4 of the Indian
Health Care Improvement Act), with respect to
items and services that are covered under such
program and furnished to an individual eligible
for such items and services under such program;
and
(ii) under any program funded by the Indian
Health Service and operated by an urban Indian
organization with respect to the purchase of
items and services for an eligible urban Indian
(as those terms are defined in such section 4),
in accordance with regulations promulgated by the
Secretary regarding admission practices, payment
methodology, and rates of payment (including the
acceptance of no more than such payment rate as payment
in full for such items and services,
(V) in the case of hospitals that are not otherwise
subject to the Occupational Safety and Health Act of
1970 (or a State occupational safety and health plan
that is approved under 18(b) of such Act), to comply
with the Bloodborne Pathogens standard under section
1910.1030 of title 29 of the Code of Federal
Regulations (or as subsequently redesignated),
(W) in the case of a hospital described in
section 1886(d)(1)(B)(v), to report quality
data to the Secretary in accordance with
subsection (k),
(X) maintain and, upon request of the
Secretary, provide access to documentation
relating to written orders or requests for
payment for durable medical equipment,
certifications for home health services, or
referrals for other items or services written
or ordered by the provider under this title, as
specified by the Secretary, and
(Y) beginning 12 months after the date of the
enactment of this subparagraph, in the case of a
hospital or critical access hospital, with respect to
each individual who receives observation services as an
outpatient at such hospital or critical access hospital
for more than 24 hours, to provide to such individual
not later than 36 hours after the time such individual
begins receiving such services (or, if sooner, upon
release)--
(i) such oral explanation of the written
notification described in clause (ii), and such
documentation of the provision of such
explanation, as the Secretary determines to be
appropriate;
(ii) a written notification (as specified by
the Secretary pursuant to rulemaking and
containing such language as the Secretary
prescribes consistent with this paragraph)
which--
(I) explains the status of the
individual as an outpatient receiving
observation services and not as an
inpatient of the hospital or critical
access hospital and the reasons for
such status of such individual;
(II) explains the implications of
such status on services furnished by
the hospital or critical access
hospital (including services furnished
on an inpatient basis), such as
implications for cost-sharing
requirements under this title and for
subsequent eligibility for coverage
under this title for services furnished
by a skilled nursing facility;
(III) includes such additional
information as the Secretary determines
appropriate;
(IV) either--
(aa) is signed by such
individual or a person acting
on such individual's behalf to
acknowledge receipt of such
notification; or
(bb) if such individual or
person refuses to provide the
signature described in item
(aa), is signed by the staff
member of the hospital or
critical access hospital who
presented the written
notification and includes the
name and title of such staff
member, a certification that
the notification was presented,
and the date and time the
notification was presented; and
(V) is written and formatted using
plain language and is made available in
appropriate languages as determined by
the Secretary.
In the case of a hospital which has an agreement in effect with
an organization described in subparagraph (F), which
organization's contract with the Secretary under part B of
title XI is terminated on or after October 1, 1984, the
hospital shall not be determined to be out of compliance with
the requirement of such subparagraph during the six month
period beginning on the date of the termination of that
contract.
(2)(A) A provider of services may charge such individual or
other person (i) the amount of any deduction or coinsurance
amount imposed pursuant to section 1813(a)(1), (a)(3), or
(a)(4), section 1833(b), or section 1861(y)(3) with respect to
such items and services (not in excess of the amount
customarily charged for such items and services by such
provider), and (ii) an amount equal to 20 per centum of the
reasonable charges for such items and services (not in excess
of 20 per centum of the amount customarily charged for such
items and services by such provider) for which payment is made
under part B or which are durable medical equipment furnished
as home health services (but in the case of items and services
furnished to individuals with end-stage renal disease, an
amount equal to 20 percent of the estimated amounts for such
items and services calculated on the basis established by the
Secretary). In the case of items and services described in
section 1833(c), clause (ii) of the preceding sentence shall be
applied by substituting for 20 percent the proportion which is
appropriate under such section. A provider of services may not
impose a charge under clause (ii) of the first sentence of this
subparagraph with respect to items and services described in
section 1861(s)(10)(A) and with respect to clinical diagnostic
laboratory tests for which payment is made under part B.
Notwithstanding the first sentence of this subparagraph, a home
health agency may charge such an individual or person, with
respect to covered items subject to payment under section
1834(a), the amount of any deduction imposed under section
1833(b) and 20 percent of the payment basis described in
section 1834(a)(1)(B). In the case of items and services for
which payment is made under part B under the prospective
payment system established under section 1833(t), clause (ii)
of the first sentence shall be applied by substituting for 20
percent of the reasonable charge, the applicable copayment
amount established under section 1833(t)(5). In the case of
services described in section 1833(a)(8) or section 1833(a)(9)
for which payment is made under part B under section 1834(k),
clause (ii) of the first sentence shall be applied by
substituting for 20 percent of the reasonable charge for such
services 20 percent of the lesser of the actual charge or the
applicable fee schedule amount (as defined in such section) for
such services.
(B) Where a provider of services has furnished, at the
request of such individual, items or services which are in
excess of or more expensive than the items or services with
respect to which payment may be made under this title, such
provider of services may also charge such individual or other
person for such more expensive items or services to the extent
that the amount customarily charged by it for the items or
services furnished at such request exceeds the amount
customarily charged by it for the items or services with
respect to which payment may be made under this title.
(C) A provider of services may in accordance with its
customary practice also appropriately charge any such
individual for any whole blood (or equivalent quantities of
packed red blood cells, as defined under regulations) furnished
him with respect to which a deductible is imposed under section
1813(a)(2), except that (i) any excess of such charge over the
cost to such provider for the blood (or equivalent quantities
of packed red blood cells, as so defined) shall be deducted
from any payment to such provider under this title, (ii) no
such charge may be imposed for the cost of administration of
such blood (or equivalent quantities of packed red blood cells,
as so defined), and (iii) such charge may not be made to the
extent such blood (or equivalent quantities of packed red blood
cells, as so defined) has been replaced on behalf of such
individual or arrangements have been made for its replacement
on his behalf. For purposes of subparagraph (C), whole blood
(or equivalent quantities of packed red blood cells, as so
defined) furnished an individual shall be deemed replaced when
the provider of services is given one pint of blood for each
pint of blood (or equivalent quantities of packed red blood
cells, as so defined) furnished such individual with respect to
which a deduction is imposed under section 1813(a)(2).
(D) Where a provider of services customarily furnishes items
or services which are in excess of or more expensive than the
items or services with respect to which payment may be made
under this title, such provider, notwithstanding the preceding
provisions of this paragraph, may not, under the authority of
section 1866(a)(2)(B)(ii), charge any individual or other
person any amount for such items or services in excess of the
amount of the payment which may otherwise be made for such
items or services under this title if the admitting physician
has a direct or indirect financial interest in such provider.
(3)(A) Under the agreement required under paragraph
(1)(F)(ii), the quality improvement organization must perform
functions (other than those covered under an agreement under
paragraph (1)(F)(i)) under the third sentence of section
1154(a)(4)(A) and under section 1154(a)(14) with respect to
services, furnished by the hospital, critical access hospital,
facility, or agency involved, for which payment may be made
under this title.
(B) For purposes of payment under this title, the cost of
such an agreement to the hospital, critical access hospital,
facility, or agency shall be considered a cost incurred by such
hospital, critical access hospital, facility, or agency in
providing covered services under this title and shall be paid
directly by the Secretary to the quality improvement
organization on behalf of such hospital, critical access
hospital, facility, or agency in accordance with a schedule
established by the Secretary.
(C) Such payments--
(i) shall be transferred in appropriate proportions
from the Federal Hospital Insurance Trust Fund and from
the Federal Supplementary Medical Insurance Trust Fund,
without regard to amounts appropriated in advance in
appropriation Acts, in the same manner as transfers are
made for payment for services provided directly to
beneficiaries, and
(ii) shall not be less in the aggregate for a fiscal
year--
(I) in the case of hospitals, than the amount
specified in paragraph (1)(F)(i)(III), and
(II) in the case of facilities, critical
access hospitals, and agencies, than the
amounts the Secretary determines to be
sufficient to cover the costs of such
organizations' conducting the activities
described in subparagraph (A) with respect to
such facilities, critical access hospitals, or
agencies under part B of title XI.
(b)(1) A provider of services may terminate an agreement with
the Secretary under this section at such time and upon such
notice to the Secretary and the public as may be provided in
regulations, except that notice of more than six months shall
not be required.
(2) The Secretary may refuse to enter into an agreement under
this section or, upon such reasonable notice to the provider
and the public as may be specified in regulations, may refuse
to renew or may terminate such an agreement after the
Secretary--
(A) has determined that the provider fails to comply
substantially with the provisions of the agreement,
with the provisions of this title and regulations
thereunder, or with a corrective action required under
section 1886(f)(2)(B),
(B) has determined that the provider fails
substantially to meet the applicable provisions of
section 1861,
(C) has excluded the provider from participation in a
program under this title pursuant to section 1128 or
section 1128A, or
(D) has ascertained that the provider has been
convicted of a felony under Federal or State law for an
offense which the Secretary determines is detrimental
to the best interests of the program or program
beneficiaries.
(3) A termination of an agreement or a refusal to renew an
agreement under this subsection shall become effective on the
same date and in the same manner as an exclusion from
participation under the programs under this title becomes
effective under section 1128(c).
(4)(A) A hospital that fails to comply with the requirement
of subsection (a)(1)(V) (relating to the Bloodborne Pathogens
standard) is subject to a civil money penalty in an amount
described in subparagraph (B), but is not subject to
termination of an agreement under this section.
(B) The amount referred to in subparagraph (A) is an amount
that is similar to the amount of civil penalties that may be
imposed under section 17 of the Occupational Safety and Health
Act of 1970 for a violation of the Bloodborne Pathogens
standard referred to in subsection (a)(1)(U) by a hospital that
is subject to the provisions of such Act.
(C) A civil money penalty under this paragraph shall be
imposed and collected in the same manner as civil money
penalties under subsection (a) of section 1128A are imposed and
collected under that section.
(c)(1) Where the Secretary has terminated or has refused to
renew an agreement under this title with a provider of
services, such provider may not file another agreement under
this title unless the Secretary finds that the reason for the
termination or nonrenewal has been removed and that there is
reasonable assurance that it will not recur.
(2) Where the Secretary has terminated or has refused to
renew an agreement under this title with a provider of
services, the Secretary shall promptly notify each State agency
which administers or supervises the administration of a State
plan approved under title XIX of such termination or
nonrenewal.
(d) If the Secretary finds that there is a substantial
failure to make timely review in accordance with section
1861(k) of long-stay cases in a hospital, he may, in lieu of
terminating his agreement with such hospital, decide that, with
respect to any individual admitted to such hospital after a
subsequent date specified by him, no payment shall be made
under this title for inpatient hospital services (including
inpatient psychiatric hospital services) after the 20th day of
a continuous period of such services. Such decision may be made
effective only after such notice to the hospital and to the
public, as may be prescribed by regulations, and its
effectiveness shall terminate when the Secretary finds that the
reason therefor has been removed and that there is reasonable
assurance that it will not recur. The Secretary shall not make
any such decision except after reasonable notice and
opportunity for hearing to the institution or agency affected
thereby.
(e) For purposes of this section, the term ``provider of
services'' shall include--
(1) a clinic, rehabilitation agency, or public health
agency if, in the case of a clinic or rehabilitation
agency, such clinic or agency meets the requirements of
section 1861(p)(4)(A) (or meets the requirements of
such section through the operation of subsection (g) or
(ll)(2) of section 1861), or if, in the case of a
public health agency, such agency meets the
requirements of section 1861(p)(4)(B) (or meets the
requirements of such section through the operation of
subsection (g) or (ll)(2) of section 1861), but only
with respect to the furnishing of outpatient physical
therapy services (as therein defined), (through the
operation of section 1861(g)) with respect to the
furnishing of outpatient occupational therapy services,
or (through the operation of section 1861(ll)(2)) with
respect to the furnishing of outpatient speech-language
pathology; and
(2) a community mental health center (as defined in
section 1861(ff)(3)(B)), but only with respect to the
furnishing of partial hospitalization services (as
described in section 1861(ff)(1)).
(f)(1) For purposes of subsection (a)(1)(Q) and sections
1819(c)(2)(E), 1833(s), 1855(i), 1876(c)(8), and 1891(a)(6),
the requirement of this subsection is that a provider of
services, Medicare+Choice organization, or prepaid or eligible
organization (as the case may be) maintain written policies and
procedures with respect to all adult individuals receiving
medical care by or through the provider or organization--
(A) to provide written information to each such
individual concerning--
(i) an individual's rights under State law
(whether statutory or as recognized by the
courts of the State) to make decisions
concerning such medical care, including the
right to accept or refuse medical or surgical
treatment and the right to formulate advance
directives (as defined in paragraph (3)), and
(ii) the written policies of the provider or
organization respecting the implementation of
such rights;
(B) to document in a prominent part of the
individual's current medical record whether or not the
individual has executed an advance directive;
(C) not to condition the provision of care or
otherwise discriminate against an individual based on
whether or not the individual has executed an advance
directive;
(D) to ensure compliance with requirements of State
law (whether statutory or as recognized by the courts
of the State) respecting advance directives at
facilities of the provider or organization; and
(E) to provide (individually or with others) for
education for staff and the community on issues
concerning advance directives.
Subparagraph (C) shall not be construed as requiring the
provision of care which conflicts with an advance directive.
(2) The written information described in paragraph (1)(A)
shall be provided to an adult individual--
(A) in the case of a hospital, at the time of the
individual's admission as an inpatient,
(B) in the case of a skilled nursing facility, at the
time of the individual's admission as a resident,
(C) in the case of a home health agency, in advance
of the individual coming under the care of the agency,
(D) in the case of a hospice program, at the time of
initial receipt of hospice care by the individual from
the program, and
(E) in the case of an eligible organization (as
defined in section 1876(b)) or an organization provided
payments under section 1833(a)(1)(A) or a
Medicare+Choice organization, at the time of enrollment
of the individual with the organization.
(3) In this subsection, the term ``advance directive'' means
a written instruction, such as a living will or durable power
of attorney for health care, recognized under State law
(whether statutory or as recognized by the courts of the State)
and relating to the provision of such care when the individual
is incapacitated.
(4) For construction relating to this subsection, see section
7 of the Assisted Suicide Funding Restriction Act of 1997
(relating to clarification respecting assisted suicide,
euthanasia, and mercy killing).
(g) Except as permitted under subsection (a)(2), any person
who knowingly and willfully presents, or causes to be
presented, a bill or request for payment inconsistent with an
arrangement under subsection (a)(1)(H) or in violation of the
requirement for such an arrangement, is subject to a civil
money penalty of not to exceed $2,000. The provisions of
section 1128A (other than subsections (a) and (b)) shall apply
to a civil money penalty under the previous sentence in the
same manner as such provisions apply to a penalty or proceeding
under section 1128A(a).
(h)(1)(A) Except as provided in paragraph (2), an institution
or agency dissatisfied with a determination by the Secretary
that it is not a provider of services or with a determination
described in subsection (b)(2) shall be entitled to a hearing
thereon by the Secretary (after reasonable notice) to the same
extent as is provided in section 205(b), and to judicial review
of the Secretary's final decision after such hearing as is
provided in section 205(g), except that, in so applying such
sections and in applying section 205(l) thereto, any reference
therein to the Commissioner of Social Security or the Social
Security Administration shall be considered a reference to the
Secretary or the Department of Health and Human Services,
respectively.
(B) An institution or agency described in subparagraph (A)
that has filed for a hearing under subparagraph (A) shall have
expedited access to judicial review under this subparagraph in
the same manner as providers of services, suppliers, and
individuals entitled to benefits under part A or enrolled under
part B, or both, may obtain expedited access to judicial review
under the process established under section 1869(b)(2). Nothing
in this subparagraph shall be construed to affect the
application of any remedy imposed under section 1819 during the
pendency of an appeal under this subparagraph.
(C)(i) The Secretary shall develop and implement a process to
expedite proceedings under this subsection in which--
(I) the remedy of termination of participation has
been imposed;
(II) a remedy described in clause (i) or (iii) of
section 1819(h)(2)(B) has been imposed, but only if
such remedy has been imposed on an immediate basis; or
(III) a determination has been made as to a finding
of substandard quality of care that results in the loss
of approval of a skilled nursing facility's nurse aide
training program.
(ii) Under such process under clause (i), priority shall be
provided in cases of termination described in clause (i)(I).
(iii) Nothing in this subparagraph shall be construed to
affect the application of any remedy imposed under section 1819
during the pendency of an appeal under this subparagraph.
(2) An institution or agency is not entitled to separate
notice and opportunity for a hearing under both section 1128
and this section with respect to a determination or
determinations based on the same underlying facts and issues.
(i)(1) If the Secretary determines that a psychiatric
hospital which has an agreement in effect under this section no
longer meets the requirements for a psychiatric hospital under
this title and further finds that the hospital's deficiencies--
(A) immediately jeopardize the health and safety of
its patients, the Secretary shall terminate such
agreement; or
(B) do not immediately jeopardize the health and
safety of its patients, the Secretary may terminate
such agreement, or provide that no payment will be made
under this title with respect to any individual
admitted to such hospital after the effective date of
the finding, or both.
(2) If a psychiatric hospital, found to have deficiencies
described in paragraph (1)(B), has not complied with the
requirements of this title--
(A) within 3 months after the date the hospital is
found to be out of compliance with such requirements,
the Secretary shall provide that no payment will be
made under this title with respect to any individual
admitted to such hospital after the end of such 3-month
period, or
(B) within 6 months after the date the hospital is
found to be out of compliance with such requirements,
no payment may be made under this title with respect to
any individual in the hospital until the Secretary
finds that the hospital is in compliance with the
requirements of this title.
(j) Enrollment Process for Providers of Services and
Suppliers.--
(1) Enrollment process.--
(A) In general.--The Secretary shall
establish by regulation a process for the
enrollment of providers of services and
suppliers under this title. Such process shall
include screening of providers and suppliers in
accordance with paragraph (2), a provisional
period of enhanced oversight in accordance with
paragraph (3), disclosure requirements in
accordance with paragraph (5), the imposition
of temporary enrollment moratoria in accordance
with paragraph (7), and the establishment of
compliance programs in accordance with
paragraph (9).
(B) Deadlines.--The Secretary shall establish
by regulation procedures under which there are
deadlines for actions on applications for
enrollment (and, if applicable, renewal of
enrollment). The Secretary shall monitor the
performance of medicare administrative
contractors in meeting the deadlines
established under this subparagraph.
(C) Consultation before changing provider
enrollment forms.--The Secretary shall consult
with providers of services and suppliers before
making changes in the provider enrollment forms
required of such providers and suppliers to be
eligible to submit claims for which payment may
be made under this title.
(2) Provider screening.--
(A) Procedures.--Not later than 180 days
after the date of enactment of this paragraph,
the Secretary, in consultation with the
Inspector General of the Department of Health
and Human Services, shall establish procedures
under which screening is conducted with respect
to providers of medical or other items or
services and suppliers under the program under
this title, the Medicaid program under title
XIX, and the CHIP program under title XXI.
(B) Level of screening.--The Secretary shall
determine the level of screening conducted
under this paragraph according to the risk of
fraud, waste, and abuse, as determined by the
Secretary, with respect to the category of
provider of medical or other items or services
or supplier. Such screening--
(i) shall include a licensure check,
which may include such checks across
States; and
(ii) may, as the Secretary determines
appropriate based on the risk of fraud,
waste, and abuse described in the
preceding sentence, include--
(I) a criminal background
check;
(II) fingerprinting;
(III) unscheduled and
unannounced site visits,
including preenrollment site
visits;
(IV) database checks
(including such checks across
States); and
(V) such other screening as
the Secretary determines
appropriate.
(C) Application fees.--
(i) Institutional providers.--Except
as provided in clause (ii), the
Secretary shall impose a fee on each
institutional provider of medical or
other items or services or supplier
(such as a hospital or skilled nursing
facility) with respect to which
screening is conducted under this
paragraph in an amount equal to--
(I) for 2010, $500; and
(II) for 2011 and each
subsequent year, the amount
determined under this clause
for the preceding year,
adjusted by the percentage
change in the consumer price
index for all urban consumers
(all items; United States city
average) for the 12-month
period ending with June of the
previous year.
(ii) Hardship exception; waiver for
certain medicaid providers.--The
Secretary may, on a case-by-case basis,
exempt a provider of medical or other
items or services or supplier from the
imposition of an application fee under
this subparagraph if the Secretary
determines that the imposition of the
application fee would result in a
hardship. The Secretary may waive the
application fee under this subparagraph
for providers enrolled in a State
Medicaid program for whom the State
demonstrates that imposition of the fee
would impede beneficiary access to
care.
(iii) Use of funds.--Amounts
collected as a result of the imposition
of a fee under this subparagraph shall
be used by the Secretary for program
integrity efforts, including to cover
the costs of conducting screening under
this paragraph and to carry out this
subsection and section 1128J.
(D) Application and enforcement.--
(i) New providers of services and
suppliers.--The screening under this
paragraph shall apply, in the case of a
provider of medical or other items or
services or supplier who is not
enrolled in the program under this
title, title XIX, or title XXI as of
the date of enactment of this
paragraph, on or after the date that is
1 year after such date of enactment.
(ii) Current providers of services
and suppliers.--The screening under
this paragraph shall apply, in the case
of a provider of medical or other items
or services or supplier who is enrolled
in the program under this title, title
XIX, or title XXI as of such date of
enactment, on or after the date that is
2 years after such date of enactment.
(iii) Revalidation of enrollment.--
Effective beginning on the date that is
180 days after such date of enactment,
the screening under this paragraph
shall apply with respect to the
revalidation of enrollment of a
provider of medical or other items or
services or supplier in the program
under this title, title XIX, or title
XXI.
(iv) Limitation on enrollment and
revalidation of enrollment.--In no case
may a provider of medical or other
items or services or supplier who has
not been screened under this paragraph
be initially enrolled or reenrolled in
the program under this title, title
XIX, or title XXI on or after the date
that is 3 years after such date of
enactment.
(E) Use of information from the department of
treasury concerning tax debts.--In reviewing
the application of a provider of services or
supplier to enroll or reenroll under the
program under this title, the Secretary shall
take into account the information supplied by
the Secretary of the Treasury pursuant to
section 6103(l)(22) of the Internal Revenue
Code of 1986, in determining whether to deny
such application or to apply enhanced oversight
to such provider of services or supplier
pursuant to paragraph (3) if the Secretary
determines such provider of services or
supplier owes such a debt.
(F) Expedited rulemaking.--The Secretary may
promulgate an interim final rule to carry out
this paragraph.
(3) Provisional period of enhanced oversight for new
providers of services and suppliers.--
(A) In general.--The Secretary shall
establish procedures to provide for a
provisional period of not less than 30 days and
not more than 1 year during which new providers
of medical or other items or services and
suppliers, as the Secretary determines
appropriate, including categories of providers
or suppliers, would be subject to enhanced
oversight, such as prepayment review and
payment caps, under the program under this
title, the Medicaid program under title XIX.
and the CHIP program under title XXI.
(B) Implementation.--The Secretary may
establish by program instruction or otherwise
the procedures under this paragraph.
(4) 90-day period of enhanced oversight for initial
claims of dme suppliers.--For periods beginning after
January 1, 2011, if the Secretary determines that there
is a significant risk of fraudulent activity among
suppliers of durable medical equipment, in the case of
a supplier of durable medical equipment who is within a
category or geographic area under title XVIII
identified pursuant to such determination and who is
initially enrolling under such title, the Secretary
shall, notwithstanding sections 1816(c), 1842(c), and
1869(a)(2), withhold payment under such title with
respect to durable medical equipment furnished by such
supplier during the 90-day period beginning on the date
of the first submission of a claim under such title for
durable medical equipment furnished by such supplier.
(5) Increased disclosure requirements.--
(A) Disclosure.--A provider of medical or
other items or services or supplier who submits
an application for enrollment or revalidation
of enrollment in the program under this title,
title XIX, or title XXI on or after the date
that is 1 year after the date of enactment of
this paragraph shall disclose (in a form and
manner and at such time as determined by the
Secretary) any current or previous affiliation
(directly or indirectly) with a provider of
medical or other items or services or supplier
that has uncollected debt, has been or is
subject to a payment suspension under a Federal
health care program (as defined in section
1128B(f)), has been excluded from participation
under the program under this title, the
Medicaid program under title XIX, or the CHIP
program under title XXI, or has had its billing
privileges denied or revoked.
(B) Authority to deny enrollment.--If the
Secretary determines that such previous
affiliation poses an undue risk of fraud,
waste, or abuse, the Secretary may deny such
application. Such a denial shall be subject to
appeal in accordance with paragraph (7).
(6) Authority to adjust payments of providers of
services and suppliers with the same tax identification
number for medicare obligations.--
(A) In general.--Notwithstanding any other
provision of this title, in the case of an
applicable provider of services or supplier,
the Secretary may make any necessary
adjustments to payments to the applicable
provider of services or supplier under the
program under this title in order to satisfy
any amount described in subparagraph (B)(ii)
due from such obligated provider of services or
supplier.
(B) Definitions.--In this paragraph:
(i) In general.--The term
``applicable provider of services or
supplier'' means a provider of services
or supplier that has the same taxpayer
identification number assigned under
section 6109 of the Internal Revenue
Code of 1986 as is assigned to the
obligated provider of services or
supplier under such section, regardless
of whether the applicable provider of
services or supplier is assigned a
different billing number or national
provider identification number under
the program under this title than is
assigned to the obligated provider of
services or supplier.
(ii) Obligated provider of services
or supplier.--The term ``obligated
provider of services or supplier''
means a provider of services or
supplier that owes an amount that is
more than the amount required to be
paid under the program under this title
(as determined by the Secretary).
(7) Temporary moratorium on enrollment of new
providers; nonpayment.--
(A) In general.--The Secretary may impose a
temporary moratorium on the enrollment of new
providers of services and suppliers, including
categories of providers of services and
suppliers, in the program under this title,
under the Medicaid program under title XIX, or
under the CHIP program under title XXI if the
Secretary determines such moratorium is
necessary to prevent or combat fraud, waste, or
abuse under either such program.
(B) Limitation on review.--There shall be no
judicial review under section 1869, section
1878, or otherwise, of a temporary moratorium
imposed under subparagraph (A).
(C) Nonpayment.--
(i) In general.--No payment may be
made under this title or under a
program described in subparagraph (A)
with respect to an item or service
described in clause (ii) furnished on
or after October 1, 2017.
(ii) Item or service described.--An
item or service described in this
clause is an item or service
furnished--
(I) within a geographic area
with respect to which a
temporary moratorium imposed
under subparagraph (A) is in
effect; and
(II) by a provider of
services or supplier that meets
the requirements of clause
(iii).
(iii) Requirements.--For purposes of
clause (ii), the requirements of this
clause are that a provider of services
or supplier--
(I) enrolls under this title
on or after the effective date
of such temporary moratorium;
and
(II) is within a category of
providers of services and
suppliers (as described in
subparagraph (A)) subject to
such temporary moratorium.
(iv) Prohibition on charges for
specified items or services.--In no
case shall a provider of services or
supplier described in clause (ii)(II)
charge an individual or other person
for an item or service described in
clause (ii) furnished on or after
October 1, 2017, to an individual
entitled to benefits under part A or
enrolled under part B or an individual
under a program specified in
subparagraph (A).
(8) Compliance programs.--
(A) In general.--On or after the date of
implementation determined by the Secretary
under subparagraph (C), a provider of medical
or other items or services or supplier within a
particular industry sector or category shall,
as a condition of enrollment in the program
under this title, title XIX, or title XXI,
establish a compliance program that contains
the core elements established under
subparagraph (B) with respect to that provider
or supplier and industry or category.
(B) Establishment of core elements.--The
Secretary, in consultation with the Inspector
General of the Department of Health and Human
Services, shall establish core elements for a
compliance program under subparagraph (A) for
providers or suppliers within a particular
industry or category.
(C) Timeline for implementation.--The
Secretary shall determine the timeline for the
establishment of the core elements under
subparagraph (B) and the date of the
implementation of subparagraph (A) for
providers or suppliers within a particular
industry or category. The Secretary shall, in
determining such date of implementation,
consider the extent to which the adoption of
compliance programs by a provider of medical or
other items or services or supplier is
widespread in a particular industry sector or
with respect to a particular provider or
supplier category.
(9) Hearing rights in cases of denial or non-
renewal.--A provider of services or supplier whose
application to enroll (or, if applicable, to renew
enrollment) under this title is denied may have a
hearing and judicial review of such denial under the
procedures that apply under subsection (h)(1)(A) to a
provider of services that is dissatisfied with a
determination by the Secretary.
(k) Quality Reporting by Cancer Hospitals.--
(1) In general.--For purposes of fiscal year 2014 and
each subsequent fiscal year, a hospital described in
section 1886(d)(1)(B)(v) shall submit data to the
Secretary in accordance with paragraph (2) with respect
to such a fiscal year.
(2) Submission of quality data.--For fiscal year 2014
and each subsequent fiscal year, each hospital
described in such section shall submit to the Secretary
data on quality measures specified under paragraph (3).
Such data shall be submitted in a form and manner, and
at a time, specified by the Secretary for purposes of
this subparagraph.
(3) Quality measures.--
(A) In general.--Subject to subparagraph (B),
any measure specified by the Secretary under
this paragraph must have been endorsed by the
entity with a contract under section 1890(a).
(B) Exception.--In the case of a specified
area or medical topic determined appropriate by
the Secretary for which a feasible and
practical measure has not been endorsed by the
entity with a contract under section 1890(a),
the Secretary may specify a measure that is not
so endorsed as long as due consideration is
given to measures that have been endorsed or
adopted by a consensus organization identified
by the Secretary.
(C) Time frame.--Not later than October 1,
2012, the Secretary shall publish the measures
selected under this paragraph that will be
applicable with respect to fiscal year 2014.
(4) Public availability of data submitted.--The
Secretary shall establish procedures for making data
submitted under paragraph (4) available to the public.
Such procedures shall ensure that a hospital described
in section 1886(d)(1)(B)(v) has the opportunity to
review the data that is to be made public with respect
to the hospital prior to such data being made public.
The Secretary shall report quality measures of process,
structure, outcome, patients' perspective on care,
efficiency, and costs of care that relate to services
furnished in such hospitals on the Internet website of
the Centers for Medicare & Medicaid Services.
* * * * * * *
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SECTION 104 OF THE VETERANS' BENEFITS IMPROVEMENTS ACT OF 1994
SEC. 104. DEVELOPMENT OF MEDICAL EVALUATION PROTOCOL.
(a) Uniform Medical Evaluation Protocol.--(1) The Secretary
of Veterans Affairs shall develop and implement a uniform and
comprehensive medical evaluation protocol that will ensure
appropriate medical assessment, diagnosis, and treatment of
Persian Gulf War veterans who are suffering from illnesses the
origins of which are (as of the date of the enactment of this
Act) unknown and that may be attributable to service in the
Southwest Asia theater of operations during the Persian Gulf
War. The protocol shall include an evaluation of complaints
relating to illnesses involving the reproductive system.
(2) If such a protocol is not implemented before the end of
the 120-day period beginning on the date of the enactment of
this Act, the Secretary shall, before the end of such period,
submit to the Committees on Veterans' Affairs of the Senate and
House of Representatives a report as to why such a protocol has
not yet been developed.
(3)(A) The Secretary shall ensure that the evaluation under
the protocol developed under this section is available at all
Department medical centers that have the capability of
providing the medical assessment, diagnosis, and treatment
required under the protocol.
(B) The Secretary may enter into contracts with non-
Department medical facilities for the provision of the
evaluation under the protocol.
(C) In the case of a veteran whose residence is distant from
a medical center described in subparagraph (A), the Secretary
may provide the evaluation through a Department medical center
described in that subparagraph and, in such a case, may provide
the veteran the travel and incidental expenses therefor
pursuant to the provisions of section 111 of title 38, United
States Code.
(4)(A) If the Secretary is unable to diagnose the symptoms or
illness of a veteran provided an evaluation, or if the symptoms
or illness of a veteran do not respond to treatment provided by
the Secretary, the Secretary may use the authority [in section
1703] in sections 1703A, 8111, and 8153 of title 38, United
States Code, in order to provide for the veteran to receive
diagnostic tests or treatment at a non-Department medical
facility that may have the capability of diagnosing or treating
the symptoms or illness of the veteran. The Secretary may
provide the veteran the travel and incidental expenses therefor
pursuant to the provisions of section 111 of title 38, United
States Code.
(B) The Secretary shall request from each non-Department
medical facility that examines or treats a veteran under this
paragraph such information relating to the diagnosis or
treatment as the Secretary considers appropriate.
(5) In each year after the implementation of the protocol,
the Secretary shall enter into an agreement with the National
Academy of Sciences under which agreement appropriate experts
shall review the adequacy of the protocol and its
implementation by the Department of Veterans Affairs.
(b) Relationship to Other Comprehensive Clinical Evaluation
Protocols.--The Secretary, in consultation with the Secretary
of Defense, shall ensure that the information collected through
the protocol described in this section is collected and
maintained in a manner that permits the effective and efficient
cross-reference of that information with information collected
and maintained through the comprehensive clinical protocols of
the Department of Defense for Persian Gulf War veterans.
(c) Case Definitions and Diagnoses.--The Secretary shall
develop case definitions or diagnoses for illnesses associated
with the service described in subsection (a)(1). The Secretary
shall develop such definitions or diagnoses at the earliest
possible date.
----------
CAREGIVERS AND VETERANS OMNIBUS HEALTH SERVICES ACT OF 2010
* * * * * * *
TITLE I--CAREGIVER SUPPORT
SEC. 101. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS.
(a) Assistance and Support Services.--
(1) (Amendatory-Omitted)
(2) (Amendatory-Omitted)
(3) Effective date.--
(A) In General.--The amendments made by this
subsection shall take effect on the date that
is 270 days after the date of the enactment of
this Act.
(B) Implementation.--The Secretary of
Veterans Affairs shall commence the programs
required by subsections (a) and (b) of section
1720G of title 38, United States Code, as added
by paragraph (1) of this subsection, on the
date on which the amendments made by this
subsection take effect.
(b) Implementation Plan and Report.--
(1) In General.--Not later than 180 days after the
date of the enactment of this Act, the Secretary of
Veterans Affairs shall--
(A) develop a plan for the implementation of
the program of comprehensive assistance for
family caregivers required by section
1720G(a)(1) of title 38, United States Code, as
added by subsection (a)(1) of this section; and
(B) submit to the Committee on Veterans'
Affairs of the Senate and the Committee on
Veterans' Affairs of the House of
Representatives a report on such plan.
(2) Consultation.--In developing the plan required by
paragraph (1)(A), the Secretary shall consult with the
following:
(A) Individuals described in section
1720G(a)(2) of title 38, United States Code, as
added by subsection (a)(1) of this section.
(B) Family members of such individuals who
provide personal care services to such
individuals.
(C) The Secretary of Defense with respect to
matters concerning personal care services for
members of the Armed Forces undergoing medical
discharge from the Armed Forces who are
eligible to benefit from personal care services
furnished under the program of comprehensive
assistance required by section 1720G(a)(1) of
such title, as so added.
(D) Veterans service organizations, as
recognized by the Secretary for the
representation of veterans under section 5902
of such title.
(E) National organizations that specialize in
the provision of assistance to individuals with
the types of disabilities that family
caregivers will encounter while providing
personal care services under the program of
comprehensive assistance required by section
1720G(a)(1) of such title, as so added.
(F) National organizations that specialize in
provision of assistance to family members of
veterans who provide personal care services to
such veterans.
(G) Such other organizations with an interest
in the provision of care to veterans and
assistance to family caregivers as the
Secretary considers appropriate.
(3) Report contents.--The report required by
paragraph (1)(B) shall contain the following:
(A) The plan required by paragraph (1)(A).
(B) A description of the individuals,
caregivers, and organizations consulted by the
Secretary of Veterans Affairs under paragraph
(2).
(C) A description of such consultations.
(D) The recommendations of such individuals,
caregivers, and organizations, if any, that
were not adopted and incorporated into the plan
required by paragraph (1)(A), and the reasons
the Secretary did not adopt such
recommendations.
(c) Annual Evaluation Report.--
(1) In General.--Not later than 2 years after the
date described in subsection (a)(3)(A) and annually
thereafter, the Secretary shall submit to the Committee
on Veterans' Affairs of the Senate and the Committee on
Veterans' Affairs of the House of Representatives a
comprehensive report on the implementation of section
1720G of title 38, United States Code, as added by
subsection (a)(1).
(2) Contents.--The report required by paragraph (1)
shall include the following:
(A) With respect to the program of
comprehensive assistance for family caregivers
required by subsection (a)(1) of such section
1720G and the program of general caregiver
support services required by subsection (b)(1)
of such section--
(i) the number of caregivers that
received assistance under such
programs;
(ii) the cost to the Department of
providing assistance under such
programs;
(iii) a description of the outcomes
achieved by, and any measurable
benefits of, carrying out such
programs;
(iv) an assessment of the
effectiveness and the efficiency of the
implementation of such programs,
including a description of any barriers
to accessing and receiving care and
services under such programs; and
(v) such recommendations, including
recommendations for legislative or
administrative action, as the Secretary
considers appropriate in light of
carrying out such programs.
(B) With respect to the program of
comprehensive assistance for family caregivers
required by such subsection (a)(1)--
(i) a description of the outreach
activities carried out by the Secretary
under such program[; and];
(ii) an assessment of the manner in
which resources are expended by the
Secretary under such program,
particularly with respect to the
provision of monthly personal caregiver
stipends under paragraph (3)(A)(ii)(v)
of such subsection (a)[.]; and
(iii) an evaluation of the
sufficiency and consistency of the
training provided to family caregivers
under such program in preparing family
caregivers to provide care to veterans
under such program.
(C) With respect to the provision of general
caregiver support services required by such
subsection (b)(1)--
(i) a summary of the support services
made available under the program;
(ii) the number of caregivers who
received support services under the
program;
(iii) the cost to the Department of
providing each support service provided
under the program; and
(iv) such other information as the
Secretary considers appropriate.
(d) Report on Expansion of Family Caregiver Assistance.--
(1) In general.--Not later than 2 years after the
date described in subsection (a)(3)(A), the Secretary
shall submit to the Committee on Veterans' Affairs of
the Senate and the Committee on Veterans' Affairs of
the House of Representatives a report on the
feasibility and advisability of expanding the provision
of assistance under section 1720G(a) of title 38,
United States Code, as added by subsection (a)(1), to
family caregivers of veterans who have a serious injury
incurred or aggravated in the line of duty in the
active military, naval, or air service before September
11, 2001.
(2) Recommendations.--The report required by
paragraph (1) shall include such recommendations as the
Secretary considers appropriate with respect to the
expansion described in such paragraph.
* * * * * * *
DISSENTING VIEWS
The Minority offers the following dissenting views for H.R.
5674, VA Maintaining Internal Systems and Strengthening Outside
Networks (MISSION) Act of 2018:
This Committee, along with our Senate counterparts, have
spent the better part of this Congress outlining how to
consolidate the Department of Veterans Affairs' (VA) seven
community care programs, all with different eligibility
criteria and payment rates, into a single, consolidated, easy
to use and administer program. The policy outlined in H.R. 5674
is the result of that hard work. While the Minority largely
agrees with said policy, we do have concerns.
Overall, the Minority is pleased that moving forward all
community care will be funded using discretionary dollars.
However, we are concerned the coming fiscal cliff could
catastrophically jeopardize VA's ability to continue providing
care and services to our nation's veterans.
Ranking Member Walz offered an amendment that would
consider the authorization of appropriations in H.R. 5674 as a
change in the concepts and definitions in section 251(b)(1) of
the Balanced Budget and Emergency Deficit Control Act of 1985
(2 U.S.C. Sec. 901(b)(1)). This Change in Concepts and
Definitions, opposed by the Majority, is vital to ensuring the
mandatory costs in H.R. 5674 that are shifted to discretionary
costs will be covered with an adjustment to discretionary
appropriations levels that are specified for those
authorizations of appropriations. Without this language
covering the costs within the current caps established by the
Bipartisan Budget Act (P.L. 115-123) will be difficult if not
impossible. Without the inclusion of this language this bill is
setting up a situation where the cost of the Community Care
program will exhaust its funds in the middle of FY 2019 and
force VA to cannibalize itself to meet the needs of this
program.
President Trump's VA budget already proposed spending half
of the $4 billion increase in VA's budget caps under the
Bipartisan Budget Act deal on community care instead of VA's
infrastructure--a violation of the deal. The $4 billion cap
increase for VA under the Bipartisan Budget Act deal was for
addressing VA's significant infrastructure needs. Without a
change in concepts and definitions, this bill will renege on
that deal as VA would be forced to find the funds under the
caps (to prevent triggering across the board cuts under
sequestration) to pay for community care.
Passing this bill without the change in the concepts and
definitions would amount to an unfunded mandate that would
force cuts to VA programs, including medical services provided
by VA providers, VA research, and maintenance and construction
for VA medical facilities. The significant costs associated
with sending veterans to the private sector for care under this
program could also require significant cuts to other non-
defense discretionary programs such as veterans homelessness
programs like HUD-VASH, veteran treatment courts, and veteran
job training and employment assistance programs administered by
other federal agencies. Without the change in concepts and
definitions language, veterans and their families would be
affected by these cuts, while more and more health care is
administered by private providers.
Furthermore, given the budgetary concerns outlined above
and the substantial preliminary score that accompanied HR 5674,
nearly $51 billion over five years, the minority is concerned
that certain provisions in this bill will become unfunded
mandates giving veterans a false promise. In some instances,
these veterans have been waiting for nearly a decade to receive
parity in services. It would be unconscionable to not deliver
on those pledges following implementation of this legislation.
Restricting eligibility should not be used as a pay for in the
future. Time and again the Minority has opposed robbing Peter
to pay Paul and in this instance the Administration would seek
to rob Paul to pay Paul. That is simply unacceptable.
At the time of writing these views, VA does not have a
permanent Secretary, Undersecretary for Health or a Deputy
Undersecretary for Health for Community Care. The Minority is
troubled the lack of permanent leadership at VA will have a
detrimental effect on the Department's ability to implement
such a large piece of complex legislation. Without permanent
leadership in place, Congress will not have anyone to hold
accountable as VA undertakes the monumental task of
consolidating multiple community care programs into a single
multi-billion dollar a year program funded with taxpayer money.
If history at this agency has taught us anything, interim and
acting officials generally do not own the issue or problem.
Instead they simply seek to maintain the status quo until a
successor can be named. Given the task at hand, that would be a
disaster. The Minority implores the administration to name
permanent leadership in these roles as quickly as possible. The
task ahead is too important.
In addition, the eligibility criteria laid out in HR 5674
for the new Veterans Community Care Program are complex,
arguably more so then the current Veterans Choice Program, and
in some instances nuanced, which will require careful oversight
by this Committee to ensure accurate interpretation as
regulations are written and policies and procedures are
implemented. For example, while the Committee failed to adopt
an amendment by Representative Brownley at the May 8, 2018
markup that sought to explicitly indicate traffic should be
considered an ``environmental factor'' providers and veterans
should consider as they determine whether a veteran would be
best placed to receive care at a VA facility or in the
community, the Minority expects as VA writes regulations
related to this topic that they would allow traffic to be a
consideration under ``environmental factor''. During the
markup, Chairman Roe indicated he agreed with the premise but
had been limited in his ability to support the amendment due to
a preexisting deal he had with Ranking Member Walz regarding
the broader legislation.
Finally, while the Commission on Care recommended a Base
Realignment and Closure (BRAC)-like review was needed for VA,
declaring it would, ``offer a level of rigor far beyond what
currently exists for repurposing and selling capital
assets''\1\, we are not convinced such a model is entirely
appropriate in the case of VA. That being said, the Minority is
not opposed to the concept of realigning VA's capital assets to
right-size the agency. To the contrary. We believe that process
is long overdue.
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\1\Commission on Care, page 60, June 30, 2016, ``Commission on Care
Final Report,'' https://s3.amazonlaws.com/sitesusa/wp-content/uploads/
sites/912/2016/07/Commission-on-Care_Final-Report_0630_16_FOR-WEB.pdf.
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The Minority would like to express their appreciation to
the Majority for working with us to remedy some of the specific
concerns we had related to the Commission and its process.
However, we remain concerned that Title II does not provide the
Secretary enough tools and authorities on the front end of the
process as he or she makes their recommendations to the
Commission. For example, Minority staff had advocated for
inclusion of provisions that would have provided the Secretary
the authority to enter into more public-private partnerships
and the ability to enter into agreements or contracts with the
Secretary of Health and Human Services for mutually beneficial
coordination, use or exchange of health care resources between
VA and the Public Health Service which would give the Secretary
additional options to consider as they drafted recommendations
to the Commission.
Timothy J. Walz.
[all]