- TXT
-
PDF
(PDF provides a complete and accurate display of this text.)
Tip
?
115th Congress } { Report
HOUSE OF REPRESENTATIVES
2d Session } { 115-585
======================================================================
VA CARE IN THE COMMUNITY ACT
_______
March 5, 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. 4242]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred
the bill (H.R. 4242) to amend title 38, United States Code, to
establish a permanent VA Care in the Community Program, and for
other purposes, having considered the same, report favorably
thereon with an amendment and recommend that the bill as
amended do pass.
CONTENTS
Page
Purpose and Summary.............................................. 28
Background and Need for Legislation.............................. 28
Hearings......................................................... 43
Subcommittee Consideration....................................... 44
Committee Consideration.......................................... 44
Committee Votes.................................................. 46
Committee Oversight Findings..................................... 54
Statement of General Performance Goals and Objectives............ 54
New Budget Authority, Entitlement Authority, and Tax Expenditures 54
Earmarks and Tax and Tariff Benefits............................. 54
Committee Cost Estimate.......................................... 54
Congressional Budget Office Estimate............................. 54
Federal Mandates Statement....................................... 61
Advisory Committee Statement..................................... 61
Constitutional Authority Statement............................... 61
Applicability to Legislative Branch.............................. 61
Statement on Duplication of Federal Programs..................... 62
Disclosure of Directed Rulemaking................................ 62
Section-by-Section Analysis of the Legislation................... 62
Changes in Existing Law Made by the Bill as Reported............. 71
Dissenting Views................................................. 161
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``VA Care in the
Community Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--IMPROVED ACCESS FOR VETERANS TO NON-DEPARTMENT OF VETERANS
AFFAIRS MEDICAL CARE
Sec. 101. Assignment of veterans to primary care providers.
Sec. 102. Establishment of VA Care in the Community Program.
Sec. 103. Veterans Care Agreements.
Sec. 104. Modification of authority to enter into agreements with State
homes to provide nursing home care.
Sec. 105. Department of Veterans Affairs electronic interface for
processing of medical claims.
Sec. 106. Funding for VA Care in the Community Program.
Sec. 107. Termination of certain provisions authorizing medical care to
veterans through non-Department of Veterans Affairs providers.
Sec. 108. Implementation and transition.
Sec. 109. Transplant procedures with live donors and related services.
TITLE II--OTHER ADMINISTRATIVE MATTERS
Sec. 201. Reimbursement for emergency ambulance services.
Sec. 202. Improvement of care coordination for veterans through
exchange of certain medical records.
Sec. 203. Elimination of copayment offset.
Sec. 204. Use of Department of Veterans Affairs Medical Care
Collections Fund for certain improvements in collections.
Sec. 205. Department of Veterans Affairs health care productivity
improvement.
Sec. 206. Licensure of health care professionals of the Department of
Veterans Affairs providing treatment via telemedicine.
Sec. 207. Establishment of processes to ensure safe opioid prescribing
practices by non-Department of Veterans Affairs health care providers.
Sec. 208. Assessment of health care furnished by the Department to
veterans who live in the territories.
Sec. 209. Oversight and accountability of financial processes of
Department of Veterans Affairs.
Sec. 210. Authority for Department of Veterans Affairs Center for
Innovation for Care and Payment.
TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS
Sec. 301. Designated scholarships for physicians and dentists under
Department of Veterans Affairs Health Professional Scholarship Program.
Sec. 302. Establishment of Department of Veterans Affairs Specialty
Education Loan Repayment Program.
Sec. 303. Veterans healing veterans medical access and scholarship
program.
TITLE I--IMPROVED ACCESS FOR VETERANS TO NON-DEPARTMENT OF VETERANS
AFFAIRS MEDICAL CARE
SEC. 101. ASSIGNMENT OF VETERANS TO PRIMARY CARE PROVIDERS.
Section 1706 of title 38, United States Code, is amended by adding at
the end the following new subsection:
``(d)(1) Except as provided in section 1703A of this title, in
furnishing primary care under this chapter, the Secretary shall assign
each eligible veteran to--
``(A) a patient-aligned care team of the Department; or
``(B) a dedicated primary care provider of the Department as
a part of any other model of providing consistent primary care
determined appropriate by the Secretary.
``(2) Each patient-aligned care team of the Department shall consist
of a team of health care professionals of the Department who--
``(A) provide to each eligible veteran comprehensive primary
care in partnership with the veteran; and
``(B) manage and coordinate comprehensive hospital care and
medical services consistent with the goals of care agreed upon
by the veteran and team.
``(3) The Secretary shall ensure that an eligible veteran is not
simultaneously assigned to more than one patient-aligned care team or
dedicated primary care provider under this subsection at a single
location, including by establishing procedures in the event a primary
care provider retires or is otherwise no longer able to treat the
veteran. In the case of an eligible veteran who resides in more than
one location, the Secretary may assign such veteran to a patient-
aligned care team or dedicated primary care provider at each such
location.
``(4) The term `eligible veteran' means a veteran who--
``(A) is enrolled in the patient enrollment system of the
Department established and operated under section 1705(a) of
this title; and
``(B) has--
``(i) been furnished hospital care or medical
services at or through a Department facility on at
least one occasion during the two-year period preceding
the date of the determination of eligibility; or
``(ii) requested a first-time appointment for
hospital care or medical services at a Department
facility.''.
SEC. 102. ESTABLISHMENT OF VA CARE IN THE COMMUNITY PROGRAM.
(a) Establishment of Program.--
(1) In general.--Chapter 17 of title 38, United States Code,
is amended by inserting after section 1703 the following new
section:
``Sec. 1703A. VA Care in the Community Program
``(a) Program.--(1) Subject to the availability of appropriations for
such purpose, hospital care, medical services, and extended care
services under this chapter shall be furnished to an eligible veteran
through contracts or agreements authorized under subsection (d), or
contracts or agreements, including national contracts or agreements,
authorized under section 8153 of this title or any other provision of
law administered by the Secretary, with network providers for the
furnishing of such care and services to veterans.
``(2) Subject to subsection (b), an eligible veteran may select a
provider of such care or services from among network providers.
``(3) The Secretary shall coordinate the furnishing of care and
services under this section to eligible veterans.
``(4)(A) In carrying out this section, the Secretary shall establish
regional networks of network providers. The Secretary shall determine,
and may modify, such regions based on the capacity and market
assessments of Veterans Integrated Service Networks conducted under
subsection (k) or upon recognized need.
``(B) The Secretary may enter into one or more contracts for the
purposes of managing the operations of the regional networks and for
the delivery of care pursuant to this section.
``(C) The Secretary shall--
``(i) verify upon enrollment, and annually thereafter, that
network providers have not been excluded from participation in
other federally funded health care programs; and
``(ii) submit to the Committees on Veterans' Affairs of the
House of Representatives and the Senate an annual report on the
results of such verifications.
``(b) Primary and Specialty Care.--(1)(A) If the Secretary is unable
to assign an eligible veteran to a patient-aligned care team or
dedicated primary care provider under section 1706(d) of this title
because the Secretary determines such a care team or provider at a
Department facility is not available--
``(i) the Secretary shall consult with the veteran regarding
available primary care providers from among network providers
that are located in the regional network in which the veteran
resides or a regional network that is adjacent to the regional
network in which the veteran resides; and
``(ii) the veteran may select one of the available primary
care providers to serve as the dedicated primary care provider
of the veteran.
``(B) In determining whether a patient-aligned care team or dedicated
provider under section 1706(d) of this title is available for
assignment to a veteran, the Secretary shall take into consideration
each of the following:
``(i) Whether the veteran faces an unusual or excessive
burden in accessing such patient-aligned care team or dedicated
provider at a medical facility of the Department including with
respect to--
``(I) geographical challenges;
``(II) environmental factors, including roads that
are not accessible to the general public, traffic, or
hazardous weather;
``(III) a medical condition of the veteran; or
``(IV) such other factors as determined by the
Secretary.
``(ii) Whether the veteran reasonably believes that the
assignment of a particular care team or provider to the veteran
would detrimentally affect the patient-provider relationship
and result in sub-optimal care to the veteran.
``(iii) Whether the panel size of the care team or provider
is at such a number that it would result in difficulty for the
veteran in accessing timely care or in sub-optimal care to the
veteran.
``(iv) Whether the veteran resides in a State where the
Department does not operated a full-service medical facility.
``(C) If the Secretary determines that a patient-aligned care team or
dedicated primary care provider at a Department facility has become
available for assignment to an eligible veteran who had been assigned
to a network provider under subparagraph (A), the Secretary shall
provide the veteran with the option of reassignment to the team or
provider at the Department facility.
``(D) In the case of an eligible veteran who is assigned to a network
provider under subparagraph (A), the Secretary shall reevaluate such
assignment not earlier than one year after a veteran makes a selection
under subparagraph (A)(ii), and on an annual basis thereafter, to--
``(i) determine whether the Secretary is able to assign to
the veteran a patient-aligned care team or dedicated primary
care provider under section 1706(d) of this title; and
``(ii) in consultation with and upon approval of the veteran,
make such assignment if able.
``(2)(A)(i) Except as provided in clause (ii), the Secretary may only
furnish specialty hospital care, medical services, or extended care
services to an eligible veteran under this section pursuant to a
referral for such specialty care or services made by the primary care
provider of the veteran.
``(ii) The Secretary may designate specialties which shall be exempt
from the requirement under clause (i).
``(B) The Secretary shall determine whether to furnish specialty
hospital care, medical services, or extended care services to an
eligible veteran pursuant to subparagraph (A)--
``(i) at a medical facility of the Department that is within
a reasonable distance of the residence of the veteran, as
determined by the Secretary;
``(ii) by a network provider that, to the greatest extent
practicable, is located in the regional network in which the
veteran resides or a regional network that is adjacent to the
regional network in which the veteran resides; or
``(iii) pursuant to an agreement described in subparagraph
(C).
``(C) An agreement described in this subparagraph is an agreement
entered into by the Secretary with a network provider under which--
``(i) specialty hospital care, medical services, or extended
care services are furnished to an eligible veteran pursuant to
subparagraph (A)--
``(I) at a medical facility of the Department by a
network provider possessing the appropriate
credentials, as determined by the Secretary; or
``(II) at a facility of a network provider by a
health care provider of the Department; and
``(ii) such specialty care or services are so furnished
either--
``(I) in accordance with this section with respect to
fees and payments for care and services furnished under
subsection (a); or
``(II) at no cost to the United States.
``(D) In making the determination under subparagraph (B), the
Secretary shall give priority to medical facilities and health care
providers of the Department but shall take into account--
``(i) whether the veteran faces an unusual or excessive
burden in accessing such specialty hospital care, medical
services, or extended care services at a medical facility of
the Department, including with respect to--
``(I) geographical challenges;
``(II) environmental factors, such as roads that are
not accessible to the general public, traffic, or
hazardous weather;
``(III) a medical condition of the veteran; or
``(IV) such other factors as determined by the
Secretary;
``(ii) whether the primary care provider of the veteran
recommends that such specialty hospital care, medical services,
or extended care services should be furnished by a network
provider;
``(iii) whether the veteran resides in a State where the
Department does not operate a full-service medical facility;
and
``(iv) in the case of a veteran who requires an organ or bone
marrow transplant, whether the veteran 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.
``(E) The Secretary shall ensure that each medical facility of the
Department processes referrals for specialty hospital care, medical
services, or extended care services in a standardized manner, including
with respect to the organization of the program office responsible for
such referrals.
``(F) In carrying out this section, the Secretary shall establish a
process to review any disagreement between an eligible veteran and the
Department, or between an eligible veteran and a health care provider
of the Department, regarding the eligibility of the veteran to receive
care or services from a network provider under this section or the
assignment of a primary care provider of the Department to the veteran.
In reviewing a disagreement under such process with respect to the
availability of and assignment to a patient aligned care team or
dedicated primary care provider, the Secretary may give deference to
the veteran with respect to any determination under subsection
(b)(1)(B)(ii).
``(G)(i) The Secretary shall develop procedures to ensure that
assigning a veteran to a patient-aligned care team or dedicated primary
care provider under subparagraph (A), (C), or (D) does not adversely
affect the continuity or quality of care for the veteran during the
transition.
``(ii) Procedures under clause (i) shall provide for--
``(I) the appointment of a contact in the Department for the
veteran who shall provide information to the veteran and
resolve issues regarding the transition;
``(II) the transfer of relevant medical records;
``(III) coordination of care between providers;
``(IV) the continued treatment of chronic or current episodes
of care (by means including medication, subspecialty care, and
ancillary services); and
``(V) any other action the Secretary determines is necessary.
``(c) Episodes of Care.--(1) The Secretary shall ensure that, at the
election of an eligible veteran who receives hospital care, medical
services, or extended care services from a network provider in an
episode of care under this section, the veteran receives such care or
services from that network provider, another network provider selected
by the veteran, or a health care provider of the Department, through
the completion of the episode of care, including all specialty and
ancillary services determined necessary by the provider as part of the
treatment recommended in the course of such care or services. In making
such determination with respect to necessary specialty and ancillary
services provided by a network provider, the network provider shall
consult with the Secretary, acting through the program office of the
appropriate medical facility.
``(2) In cases of episodes of care that the Secretary determines case
management to be appropriate, the Secretary shall provide case
management to an eligible veteran who receives hospital care, medical
services, or extended care services from a network provider for such
episodes of care. The Secretary may provide such case management
through the Veterans Health Administration or through an entity that
manages the operations of the regional networks pursuant to subsection
(a)(4)(B).
``(d) Care and Services Through Contracts and Agreements.--(1) The
Secretary shall enter into contracts or agreements, including national
contracts or agreements for, but not limited to, dialysis, for
furnishing care and services to eligible veterans under this section
with network providers.
``(2)(A) In entering into a contract or agreement under paragraph (1)
with a network provider, the Secretary shall--
``(i) negotiate rates for the furnishing of care and services
under this section; and
``(ii) reimburse the provider for such care and services at
the rates negotiated pursuant to clause (i) as provided in such
contract or agreement.
``(B)(i) Except as provided in paragraph (3), 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) In determining the rates under the Medicare Program under
title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for
purposes of clause (i), in the case of care or services furnished by a
provider of services with respect to which such rates are determined
under a fee schedule to which the area wage index under section
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395ww(d)(3)(E))
applies, such area wage index so applied to such provider of services
may not be less than 1.00.
``(C) In carrying out paragraph (2), the Secretary may incorporate
the use of value-based reimbursement models to promote the provision of
high-quality care.
``(3)(A) With respect to the furnishing of care or services under
this section to an eligible veteran who resides in a highly rural area
(as defined under the rural-urban commuting area codes developed by the
Secretary of Agriculture and the Secretary of Health and Human
Services), the Secretary of Veterans Affairs may negotiate a rate that
is more than the rate paid by the United States as described in
paragraph (2)(B).
``(B) 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.
``(C) With respect to furnishing care or services under this section
in a State with an All-Payer Model Agreement under the Social Security
Act that became effective on or after January 1, 2014, the Medicare
payment rates under paragraph (2)(B) shall be calculated based on the
payment rates under such agreement, or any such successor agreement.
``(D) With respect to furnishing care or services under this section
in a location in which the Secretary determines that adjusting the rate
paid by the United States as described in paragraph (2)(B) is
appropriate, the Secretary may negotiate such an adjusted rate.
``(E) With respect to furnishing care or services under this section
in a location or in a situation in which an exception to the rates paid
by the United States 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 applies, the Secretary may follow such exception.
``(F) With respect to furnishing care or services under this section
for care or services not covered under the Medicare Program under title
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), the
Secretary shall establish a schedule of fees for such care or services.
``(G) With respect to furnishing care or services under this section
pursuant to an agreement with a tribal or Federal entity, the Secretary
may negotiate a rate that is more than the rate paid by the United
States as described in paragraph (2)(B).
``(4) For the furnishing of care or services pursuant to a contract
or agreement under paragraph (1), a network provider may not collect
any amount that is greater than the rate negotiated pursuant to
paragraph (2)(A).
``(5)(A) If, in the course of an episode of care under this section,
any part of care or services is furnished by a medical provider who is
not a network provider, the Secretary may compensate such provider for
furnishing such care or services.
``(B) The Secretary shall make reasonable efforts to enter into a
contract or agreement under this section with any provider who is
compensated pursuant to subparagraph (A).
``(e) Prompt Payment Standard.--(1) The Secretary shall ensure that
claims for payments for hospital care, medical services, or extended
care services furnished under this section are processed in accordance
with this subsection, regardless of whether such claims are--
``(A) made by a network provider to the Secretary;
``(B) made by a network provider to a regional network
operated by a contractor pursuant to subsection (a)(4)(B); or
``(C) made by such a regional network to the Secretary.
``(2) A covered claimant that seeks payment for hospital care,
medical services, or extended care services furnished under this
section shall submit to the covered payer a claim for payment not later
than--
``(A) with respect to a claim by a network provider, 180 days
after the date on which the network provider furnishes such
care or services; or
``(B) with respect to a claim by a regional network operated
by a contractor, 180 days after the date on which the
contractor pays the network provider for furnishing such care
or services.
``(3) Notwithstanding chapter 39 of title 31 or any other provision
of law, the covered payer shall pay a covered claimant for hospital
care, medical services, or extended care services furnished under this
section--
``(A) in the case of a clean claim submitted to the covered
payer on paper, not later than 45 calendar days after receiving
the claim; or
``(B) in the case of a clean claim submitted to the covered
payer electronically, not later than 30 calendar days after
receiving the claim.
``(4)(A) If the covered payer denies a claim submitted by a covered
claimant under paragraph (1), the covered payer shall notify the
covered claimant of the reason for denying the claim and the additional
information, if any, that may be required to process the claim--
``(i) in the case of a clean claim submitted to the covered
payer on paper, not later than 45 calendar days after receiving
the claim; or
``(ii) in the case of a clean claim submitted to the covered
payer electronically, not later than 30 calendar days after
receiving the claim.
``(B) Upon receipt by the covered payer of additional information
specified under subparagraph (A) relating to a claim, the covered payer
shall pay, deny, or otherwise adjudicate the claim, as appropriate, not
later than 30 calendar days after receiving such information.
``(5)(A) If the covered payer has not paid a covered claimant or
denied a clean claim for payment by the covered claimant under this
subsection during the appropriate period specified in this subsection,
such clean claim shall be considered overdue.
``(B) If a clean claim for payment by a covered claimant is
considered overdue under subparagraph (A), in addition to the amount
the covered payer owes the covered claimant under the claim, the
covered payer shall owe the covered claimant an interest penalty amount
that shall--
``(i) be prorated daily;
``(ii) accrue from the date the payment was overdue;
``(iii) be payable at the time the claim is paid; and
``(iv) be computed at the rate of interest established by the
Secretary of the Treasury, and published in the Federal
Register, for interest payments under subsections (a)(1) and
(b) of section 7109 of title 41 that is in effect at the time
the covered payer accrues the obligation to pay the interest
penalty amount.
``(6)(A) If the covered payer overpays a covered claimant for
hospital care, medical services, or extended care services furnished
under this section--
``(i) the covered payer shall deduct the amount of any
overpayment from payments due to the covered claimant after the
date of such overpayment; or
``(ii) if the covered payer determines that there are no such
payments due after the date of the overpayment, the covered
claimant shall refund the amount of such overpayment not later
than 30 days after such determination.
``(B)(i) Before deducting any amount from a payment to a covered
claimant under subparagraph (A), the covered payer shall ensure that
the covered claimant is provided an opportunity--
``(I) to dispute the existence or amount of any overpayment
owed to the covered payer; and
``(II) to request a compromise with respect to any such
overpayment.
``(ii) The covered payer may not make any deduction from a payment to
a covered claimant under subparagraph (A) unless the covered payer has
made reasonable efforts to notify the covered claimant of the rights of
the covered claimant under subclauses (I) and (II) of clause (i).
``(iii) Upon receiving a dispute under subclause (I) of clause (i) or
a request under subclause (II) of such clause, the covered payer shall
make a determination with respect to such dispute or request before
making any deduction under subparagraph (A) unless the time required to
make such a determination would jeopardize the ability of the covered
payer to recover the full amount owed to the covered payer.
``(7) Notwithstanding any other provision of law, the Secretary may,
except in the case of a fraudulent claim, false claim, or
misrepresented claim, compromise any claim of an amount owed to the
United States under this section.
``(8) This subsection shall apply only to payments made on a claims
basis and not to capitation or other forms of periodic payments to
network providers.
``(9) A network provider that provides hospital care, medical
services, or extended care services to an eligible veteran under this
section may not seek any payment for such care or services from the
eligible veteran.
``(10) With respect to making a payment for hospital care or medical
services furnished to an eligible veteran by a network provider under
this section--
``(A) the Secretary may not require receipt by the veteran or
the Department of a medical record under subsection (g)
detailing such care or services before a covered payer makes a
payment for such care or services; and
``(B) the Secretary may require that the network provider
attests to such care or services so provided before a covered
payer makes a payment for such care or services.
``(f) Cost-Sharing.--(1) 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 under this chapter.
``(2) 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 under this chapter.
``(3) 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 this
title, the Secretary shall recover or collect reasonable charges for
such care or services from a health-plan contract described in section
1705A in accordance with such section 1729.
``(g) Medical Records.--(1) The Secretary shall ensure that any
network provider that furnishes care or services under this section to
an eligible veteran--
``(A) upon the request of the veteran, provides to the
veteran the medical records related to such care or services;
and
``(B) upon the completion of the provision of such care or
services to such veteran, provides to the Department the
medical records for the veteran furnished care or services
under this section in a timeframe and format specified by the
Secretary for purposes of this section, except the Secretary
may not require that any payment by the Secretary to the
eligible provider be contingent on such provision of medical
records.
``(2) To the extent practicable, the Secretary shall submit to a
network provider that furnishes care or services under this section to
an eligible veteran the medical records of such eligible veteran that
are maintained by the Department and are relevant to such care or
services.
``(3) To the extent practicable, the Secretary shall--
``(A) ensure that the medical records shared under paragraphs
(1) and (2) are shared in an electronic format accessible by
network providers and the Department through an Internet
website; and
``(B) provide to network providers access to the electronic
patient health record system of the Department, or successor
system, for the purpose of furnishing care or services under
this section.
``(h) Use of Card.--The Secretary shall ensure that the veteran
health identification card, or such successor identification card,
includes sufficient information to act as an identification card for an
eligible entity or other non-Department facility. The Secretary may not
use any amounts made available to the Secretary to issue separate
identification cards solely for the purpose of carrying out this
section.
``(i) Prescription Medications.--(1) With respect to requirements
relating to the licensing or credentialing of a network provider, the
Secretary shall ensure that the network provider is able to submit
prescriptions for pharmaceutical agents on the formulary of the
Department to pharmacies of the Department in a manner that is
substantially similar to the manner in which the network provider
submits prescriptions to retail pharmacies.
``(2) Nothing in this section shall be construed to affect the
process of the Department for filling and paying for prescription
medications.
``(j) Quality of Care.--In carrying out this section, the Secretary
shall use the quality of care standards set forth or used by the
Centers for Medicare & Medicaid Services or other quality of care
standards, as determined by the Secretary.
``(k) Capacity and Commercial Market Assessments.--(1) On a periodic
basis, but not less often than once every three years, the Secretary
shall conduct an assessment of the capacity of each Veterans Integrated
Service Network and medical facility of the Department to furnish care
or services under this chapter. Each such assessment shall--
``(A) identify gaps in furnishing such care or services at
such Veterans Integrated Service Network or medical facility;
``(B) identify how such gaps can be filled by--
``(i) entering into contracts or agreements with
network providers under this section or with entities
under other provisions of law;
``(ii) making changes in the way such care and
services are furnished at such Veterans Integrated
Service Network or medical facility, including but not
limited to--
``(I) extending hours of operation;
``(II) adding personnel; or
``(III) expanding space through construction,
leasing, or sharing of health care facilities;
and
``(iii) the building or realignment of Department
resources or personnel;
``(C) forecast, based on future projections and historical
trends, both the short- and long-term demand in furnishing care
or services at such Veterans Integrated Service Network or
medical facility and assess how such demand affects the needs
to use such network providers;
``(D) include a commercial health care market assessment of
designated catchment areas in the United States conducted by a
nongovernmental entity; and
``(E) consider the unique ability of the Federal Government
to retain a presence in an area otherwise devoid of commercial
health care providers or from which such providers are at a
risk of leaving.
``(2) The Secretary shall submit each assessment under paragraph (1)
to the Committees on Veterans' Affairs of the House of Representatives
and the Senate and shall make each such assessment publicly available.
``(l) Allocation of Funds.--The Secretary shall develop a plan for
the allocation of funds in the Medical Community Care account.
``(m) Reports on Rates.--Not later than December 31, 2019, and
annually thereafter during each of the subsequent three years, the
Secretary shall submit to the Committees on Veterans' Affairs of the
House of Representatives and the Senate a report detailing, for the
fiscal year preceding the fiscal year during which the report is
submitted, the rates paid by the Secretary for hospital care, medical
services, or extended care services under this section that, pursuant
to subsection (d)(3), are more than the rates described in subsection
(d)(2)(B) for the same care or services.
``(n) Definitions.--In this section:
``(1) The term `clean claim' means a claim submitted--
``(A) to the covered payer by a covered claimant for
purposes of payment by the covered payer of expenses
for hospital care or medical services furnished under
this section;
``(B) that contains substantially all of the required
elements necessary for accurate adjudication, without
requiring additional information from the network
provider; and
``(C) in such a nationally recognized format as may
be prescribed by the Secretary for purposes of paying
claims for hospital care or medical services furnished
under this section.
``(2) The term `covered claimant' means--
``(A) a network provider that submits a claim to the
Secretary for purposes of payment by the Secretary of
expenses for hospital care or medical services
furnished under this section; or
``(B) a regional network operated by a contractor
pursuant to subsection (a)(4)(B) that submits a claim
to the Secretary for purposes of reimbursement for a
payment made by the contractor to a network provider
for hospital care or medical services furnished under
this section.
``(3) The term `covered payer' means--
``(A) a regional network operated by a contractor
pursuant to subsection (a)(4)(B) with respect to a
claim made by a network provider to the contractor for
purposes of payment by the contractor of expenses for
hospital care or medical services furnished under this
section; or
``(B) the Secretary with respect to--
``(i) a claim made by a network provider to
the Secretary for purposes of payment by the
Secretary of expenses for hospital care or
medical services furnished under this section;
and
``(ii) a claim made by a regional network
operated by a contractor pursuant to subsection
(a)(4)(B) for purposes of reimbursement for a
payment described by subparagraph (A).
``(4) The term `eligible veteran' means a veteran who--
``(A) is enrolled in the patient enrollment system of
the Department established and operated under section
1705(a) of this title; and
``(B) has--
``(i) been furnished hospital care or medical
services at or through a Department facility on
at least one occasion during the two-year
period preceding the date of the determination
of eligibility; or
``(ii) requested a first-time appointment for
hospital care or medical services at a
Department facility.
``(5) The term `fraudulent claim' means a claim by a network
provider for reimbursement under this section that includes an
intentional and deliberate misrepresentation of a material fact
or facts that is intended to induce the Secretary to pay an
amount that was not legally owed to the provider.''.
(2) Clerical amendment.--The table of sections at the
beginning of chapter 17 of such title is amended by inserting
after the item relating to section 1703 the following new item:
``1703A. VA Care in the Community Program.''.
(b) Conforming Amendments.--The Veterans Access, Choice, and
Accountability Act of 2014 (Public Law 113-146) is amended--
(1) in section 101(p)(1) (38 U.S.C. 1701 note), by inserting
before the period at the end the following: ``or the date on
which the Secretary certifies to the Committees on Veterans'
Affairs of the House of Representatives and the Senate that the
Secretary is fully implementing section 1703A of title 38,
United States Code, whichever occurs first''; and
(2) in section 208(1), by striking ``section 101'' and
inserting ``section 1703A of title 38, United States Code''.
(c) Definitions.--Section 1701 of title 38, United States Code, is
amended by adding at the end the following new paragraphs:
``(11) The term `network provider' means any of the following
health care providers that have entered into a contract or
agreement under which the provider agrees to furnish care and
services to eligible veterans under section 1703A of this
title:
``(A) Any health care provider or supplier 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.
``(B) Any provider of items and services receiving
payment under a State plan under title XIX of such Act
(42 U.S.C. 1396 et seq.) or a waiver of such a plan.
``(C) 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))).
``(D) The Department of Defense.
``(E) The Indian Health Service.
``(F) Any health care provider that is an academic
affiliate of the Department.
``(G) Any health care provider not otherwise covered
under any of subparagraphs (A) through (F) that meets
criteria established by the Secretary for purposes of
such section.
``(12) The term `VA Care in the Community Program' means the
program under which the Secretary furnishes hospital care or
medical services to veterans through network providers pursuant
to section 1703A of this title.''.
(d) Transition of Provision of Care.--This Act, and the amendments
made by this Act, may not be construed to affect the obligations of the
Secretary of Veterans Affairs under contracts and agreements for the
provision of hospital care, medical services, and extended care
services entered into before the date of the enactment of this Act at
the terms and rates contained in such contracts and agreements.
SEC. 103. VETERANS CARE AGREEMENTS.
(a) In General.--Subchapter I of chapter 17 of title 38, United
States Code, is further amended by inserting after section 1703A, as
added by section 102, the following new section:
``Sec. 1703B. Veterans Care Agreements with non-network providers
``(a) Veterans Care Agreements.--(1) In addition to furnishing
hospital care, medical services, or extended care services under this
chapter at facilities of the Department or under contracts or
agreements entered into pursuant to section 1703A of this title or any
other provision of law other than this section, the Secretary may
furnish such care and services to eligible veterans through the use of
agreements, to be known as `Veterans Care Agreements', entered into
under this section by the Secretary with eligible non-network
providers.
``(2) The Secretary may enter into a Veterans Care Agreement under
this section with an eligible non-network provider if the Secretary
determines that--
``(A) the provision of the hospital care, medical services,
or extended care services at a Department facility is
impracticable or inadvisable because of the medical condition
of the veteran, the travel involved, or the nature of the care
or services required, or a combination of such factors; and
``(B) such care or services are not available to be furnished
by a non-Department health care provider under a contract or
agreement entered into pursuant to a provision of law other
than this section.
``(3)(A) In accordance with subparagraphs (C) and (D), the Secretary
shall review each Veterans Care Agreement with a non-network provider
to determine whether it is practical or advisable to, instead of
carrying out such agreement--
``(i) provide at a Department facility the hospital care,
medical services, or extended care services covered by such
agreement; or
``(ii) enter into an agreement with the provider under
section 1703A of this title to provide such care or services.
``(B) If the Secretary determines pursuant to a review of a Veterans
Care Agreement under subparagraph (A) that it is practical or advisable
to provide hospital care, medical services, or extended care services
at a Department facility, or enter into an agreement under section
1703A of this title to provide such care or services, as the case may
be, the Secretary--
``(i) may not renew the Veterans Care Agreement; and
``(ii) shall take such actions as are necessary to implement
such determination.
``(C) This paragraph shall apply with respect to Veterans Care
Agreements entered into with a non-network provider whose gross annual
revenue, as determined under subsection (b)(1), exceeds--
``(i) $3,000,000, in the case of a provider that furnishes
homemaker or home health aide services; or
``(ii) $1,000,000, in the case of any other provider.
``(D) The Secretary shall conduct each review of a Veterans Care
Agreement under subparagraph (A) as follows:
``(i) Once during the 18-month period beginning on the date
that is six months after date on which the agreement is entered
into.
``(ii) Not less than once during each four-year period
beginning on the date on which the review under subparagraph
(A) is conducted.
``(b) Eligible Non-Network Providers.--A provider of hospital care,
medical services, or extended care services is eligible to enter into a
Veterans Care Agreement under this section if the Secretary determines
that the provider meets the following criteria:
``(1) The gross annual revenue of the provider under
contracts or agreements entered into with the Secretary in the
year preceding the year in which the provider enters into the
Veterans Care Agreement does not exceed--
``(A) $5,000,000 (as adjusted in a manner similar to
amounts adjusted pursuant to section 5312 of this
title), in the case of a provider that furnishes
homemaker or home health aide services; or
``(B) $2,000,000 (as so adjusted), in the case of any
other provider.
``(2) The provider is not a network provider and does not
otherwise provide hospital care, medical services, or extended
care services to patients pursuant to a contract entered into
with the Department.
``(3) The provider is--
``(A) a 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));
``(B) a physician or supplier that has enrolled and
entered into a participation agreement under section
1842(h) of such Act (42 U.S.C. 1395u(h));
``(C) a provider of items and services receiving
payment under a State plan under title XIX of such Act
(42 U.S.C. 1396 et seq.) or a waiver of such a plan;
``(D) 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)); or
``(E) a center for independent living (as defined in
section 702 of the Rehabilitation Act of 1973 (29
U.S.C. 796a)).
``(4) The provider is certified pursuant to the process
established under subsection (c)(1).
``(5) Any additional criteria determined appropriate by the
Secretary.
``(c) Provider Certification.--(1) The Secretary shall establish a
process for the certification of eligible providers to enter into
Veterans Care Agreements under this section that shall, at a minimum,
set forth the following:
``(A) Procedures for the submission of applications for
certification and deadlines for actions taken by the Secretary
with respect to such applications.
``(B) Standards and procedures for the approval and denial of
certifications and the revocation of certifications.
``(C) Procedures for assessing eligible providers based on
the risk of fraud, waste, and abuse of such providers similar
to the level of screening under section 1866(j)(2)(B) of the
Social Security Act (42 U.S.C. 1395(j)(2)(B)) and the standards
set forth under section 9.104 of title 48, Code of Federal
Regulations, or any successor regulation.
``(D) Requirement for denial or revocation of certification
if the Secretary determines that the otherwise eligible
provider is--
``(i) 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); or
``(ii) identified as an excluded source on the list
maintained in the System for Award Management, or any
successor system.
``(E) Procedures by which a provider whose certification is
denied or revoked under the procedures established under this
subsection will be identified as an excluded source on the list
maintained in the System for Award Management, or successor
system, if the Secretary determines that such exclusion is
appropriate.
``(2) To the extent practicable, the Secretary shall establish the
procedures under paragraph (1) in a manner that takes into account any
certification process administered by another department or agency of
the Federal Government that an eligible provider has completed by
reason of being a provider described in any of subparagraphs (A)
through (E) of subsection (b)(4).
``(3) The Secretary shall--
``(A) verify upon enrollment, and annually thereafter, that
eligible providers have not been excluded from participation in
other federally funded health care programs; and
``(B) submit to the Committees on Veterans' Affairs of the
House of Representatives and the Senate an annual report on the
results of such verifications.
``(d) Terms of Agreements.--Subsections (d), (e), (f), and (g) of
section 1703A of this title shall apply with respect to a Veterans Care
Agreement in the same manner such subsections apply to contracts and
agreements entered into under such section.
``(e) Exclusion of Certain Federal Contracting Provisions.--(1)
Notwithstanding any other provision of law, the Secretary may enter
into a Veterans Care Agreement using procedures other than competitive
procedures.
``(2)(A) Except as provided in subparagraph (B) and unless otherwise
provided in this section, an eligible non-network provider that enters
into a Veterans Care Agreement under this section is not subject to, in
the carrying out of the agreement, any provision of law that providers
of services and suppliers under the original Medicare fee-for-service
program under parts A and B of title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) or the Medicaid program under title XIX of
such Act (42 U.S.C. 1396 et seq.) are not subject to.
``(B) In addition to the provisions of laws covered by subparagraph
(A), an eligible non-network provider shall be subject to the following
provisions of law:
``(i) Any applicable law regarding integrity, ethics, or
fraud, or that subject a person to civil or criminal penalties.
``(ii) Section 1352 of title 31, except for the filing
requirements under subsection (b) of such section.
``(iii) Section 4705 or 4712 of title 41, and any other
applicable law regarding the protection of whistleblowers.
``(iv) Section 4706(d) of title 41.
``(v) Title VII of the Civil Rights Act of 1964 (42 U.S.C.
2000e et seq.) to the same extent as such title applies with
respect to the eligible non-network provider in providing care
or services through an agreement or arrangement other than
under a Veterans Care Agreement.
``(f) Termination of a Veterans Care Agreement.--(1) An eligible non-
network provider may terminate a Veterans Care Agreement with the
Secretary under this section at such time and upon such notice to the
Secretary as the Secretary may specify for purposes of this section.
``(2) The Secretary may terminate a Veterans Care Agreement with an
eligible non-network provider under this section at such time and upon
such notice to the provider as the Secretary may specify for the
purposes of this section, if the Secretary determines necessary.
``(g) Disputes.--(1) The Secretary shall establish administrative
procedures for providers with which the Secretary has entered into a
Veterans Care Agreement to present any dispute arising under or related
to the agreement.
``(2) Before using any dispute resolution mechanism under chapter 71
of title 41 with respect to a dispute arising under a Veterans Care
Agreement under this section, a provider must first exhaust the
administrative procedures established by the Secretary under paragraph
(1).
``(h) Authority To Pay for Other Authorized Services.--(1) If, in the
course of an episode of care for which hospital care, medical services,
or extended care services are furnished to an eligible veteran pursuant
to a Veterans Care Agreement, any part of such care or services is
furnished by a medical provider who is not an eligible non-network
provider or a network provider, the Secretary may compensate such
provider for furnishing such care or services.
``(2) The Secretary shall make reasonable efforts to enter into a
Veterans Care Agreement with any provider who is compensated pursuant
to paragraph (1).
``(i) Annual Reports.--(1) Not later than December 31 of the year
following the fiscal year in which the Secretary first enters into a
Veterans Care Agreement under this section, and each year thereafter,
the Secretary shall submit to the appropriate congressional committees
an annual report that includes a list of all Veterans Care Agreements
entered into as of the date of the report.
``(2) The requirement to submit a report under paragraph (1) shall
terminate on the date that is five years after the date of the
enactment of this section.
``(j) Quality of Care.--In carrying out this section, the Secretary
shall use the quality of care standards set forth or used by the
Centers for Medicare & Medicaid Services or other quality of care
standards, as determined by the Secretary.
``(k) Delegation.--The Secretary may delegate the authority to enter
into or terminate a Veterans Care Agreement to an official of the
Department at a level not below the Director of a Veterans Integrated
Service Network or the Director of a Network Contracting Office.
``(l) Definitions.--In this section:
``(1) The term `appropriate congressional committees' means--
``(A) the Committees on Veterans' Affairs of the
House of Representatives and the Senate; and
``(B) the Committees on Appropriations of the House
of Representatives and the Senate.
``(2) The term `eligible veteran' has the meaning given such
term in section 1703A(m) of this title.''.
(b) Clerical Amendment.--The table of sections at the beginning of
such chapter is amended by inserting after the item relating to section
1703A, as added by section 102, the following new item:
``1703B. Veterans Care Agreements with non-network providers.''.
SEC. 104. MODIFICATION OF AUTHORITY TO ENTER INTO AGREEMENTS WITH STATE
HOMES TO PROVIDE NURSING HOME CARE.
(a) Use of Agreements.--
(1) In general.--Paragraph (1) of section 1745(a) of title
38, United States Code, is amended, in the matter preceding
subparagraph (A), by striking ``a contract (or agreement under
section 1720(c)(1) of this title)'' and inserting ``an
agreement''.
(2) Payment.--Paragraph (2) of such section is amended by
striking ``contract (or agreement)'' each place it appears and
inserting ``agreement''.
(b) Treatment of Certain Laws.--Such section is amended by adding at
the end the following new paragraph:
``(4)(A) An agreement under this section may be entered into without
regard to any law that would require the Secretary to use competitive
procedures in selecting the party with which to enter into the
agreement.
``(B)(i) Except as provided in clause (ii) and unless otherwise
provided in this section or in 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 law to
which providers of services and suppliers are not subject under the
original Medicare fee-for-service program under parts A and B of title
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) or the
Medicaid program under title XIX of such Act (42 U.S.C. 1396 et seq.).
``(ii) The exclusion under clause (i) does not apply to laws
regarding integrity, ethics, fraud, or that subject a person to civil
or criminal penalties.
``(C) Title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et
seq.) shall apply with respect to a State home that enters into an
agreement under this section to the same extent as such title applies
with respect to the State home in providing care or services through an
agreement or arrangement other than under this section.''.
(c) Effective Date.--
(1) In general.--The amendments made by this section shall
apply to agreements entered into under section 1745 of such
title on and after the date on which the regulations prescribed
by the Secretary of Veterans Affairs to implement such
amendments take effect.
(2) Publication.--The Secretary shall publish the date
described in paragraph (1) in the Federal Register not later
than 30 days before such date.
SEC. 105. DEPARTMENT OF VETERANS AFFAIRS ELECTRONIC INTERFACE FOR
PROCESSING OF MEDICAL CLAIMS.
(a) Electronic Interface.--Not later than the implementation date
specified in section 108(a), the Chief Information Officer of the
Department of Veterans Affairs shall ensure that the information
technology system used by the Department to receive, process, and pay
claims under the VA Care in the Community Program established in
section 1703A of title 38, United States Code, as added by section 102,
and under Veterans Care Agreements established in section 1703B of such
title, as added by section 103, includes the following:
(1) A function through which a covered non-Department health
care provider may submit all required data and supporting
information required for claims reimbursement through
electronic data interchanges.
(2) An ability to automatically adjudicate claims.
(3) A centralized claims database that is accessible
nationwide.
(4) Integration with the relevant eligibility and
authorization information technology systems of the Department.
(5) Ability for a covered non-Department health care provider
to ascertain the status of a pending claim submitted by the
provider, receive information regarding missing documentation
or discrepancies that may impede claim processing timelines or
result in rejection, and receive notification when such claim
is accepted for reimbursement or rejected.
(6) A claim review system similar to that used by the Centers
for Medicare & Medicaid Services, as of the date of the
enactment of this Act, including the use of contractors to
perform audits through data analytics, to determine the
appropriateness and accuracy of claims of providers and to
ensure program integrity and oversight.
(b) Security and Privacy.--The Chief Information Officer shall also
ensure that the information technology system covered under subsection
(a) meets the following criteria:
(1) Such system shall be developed and implemented in
compliance with all applicable laws, regulations and Federal
Government standards regarding information security, privacy,
and accessibility.
(2) Such system shall provide for the elicitation, analysis,
and prioritization of functional and nonfunctional information
security and privacy requirements for such system, including
security and privacy services and architectural requirements
relating to security and privacy based on a thorough risk
assessment of all reasonably anticipated cyber and noncyber
threats to the security and privacy of electronic protected
health information made available through such interface.
(3) Such system shall provide for the elicitation, analysis,
and prioritization of secure development requirements relating
to such system.
(4) Such system shall provide assurance that the prioritized
information security and privacy requirements of such system--
(A) are correctly implemented in the design and
implementation of such system through the systems
development lifecycle; and
(B) satisfy the information objectives of such system
relating to security and privacy throughout the systems
development lifecycle.
(c) Contract Authority.--The Chief Information Officer may enter into
a contract for purposes of carrying out this section.
(d) Definitions.--In this section:
(1) The term ``electronic protected health information'' has
the meaning given that term in section 160.103 of title 45,
Code of Federal Regulations, as in effect on the date of the
enactment of this Act.
(2) The term ``covered non-Department health care provider''
means--
(A) a network provider (as defined by section
1701(11) of title 38, United States Code, as added by
section 102);
(B) a non-network provider with which the Secretary
has entered into a Veterans Care Agreement under
section 1703B of such title, as added by section 103;
or
(C) any other non-Department eligible provider or
non-Department health care provider that furnishes
hospital care or medical services pursuant to chapter
17 of such title.
(3) The term ``secure development requirements'' means, with
respect to the information technology system established under
subsection (a), activities that are required to be completed
during the system development lifecycle of such interface, such
as secure coding principles and test methodologies.
(4) The term ``VA Care in the Community Program'' has the
meaning given that term in section 1701(12) of title 38, United
States Code, as added by section 102.
SEC. 106. FUNDING FOR VA CARE IN THE COMMUNITY PROGRAM.
(a) In General.--All amounts required to carry out the VA Care in the
Community Program and Veterans Care Agreements under section 1703B of
title 38, United States Code, shall be derived from the Veterans Health
Administration, Medical Community Care account.
(b) Transfer of Amounts.--
(1) In general.--Any unobligated amounts in the Veterans
Choice Fund under section 802 of the Veterans Access, Choice,
and Accountability Act of 2014 (Public Law 113-146; 38 U.S.C.
1701 note) shall be transferred to the Veterans Health
Administration, Medical Community Care account on the later of
the following dates:
(A) The date that is one year after the date of the
enactment of this Act.
(B) The date on which the Secretary of Veterans
Affairs submits to the Committees on Veterans' Affairs
of the Senate and the House of Representatives the
certification required by section 107(c).
(2) Conforming repeal.--
(A) In general.--Effective immediately following the
transfer of amounts under paragraph (1), section 802 of
the Veterans Access, Choice, and Accountability Act of
2014 (Public Law 113-146; 38 U.S.C. 1701 note) is
repealed.
(B) Conforming amendment.--Section 4003 of the
Surface Transportation and Veterans Health Care Choice
Improvement Act of 2015 (Public Law 114-41; 38 U.S.C.
1701 note) is amended by striking ``for non-Department
provider programs (as defined in section 2(d))'' and
all that follows through ``1802)'' and inserting the
following: ``for the VA Care in the Community Program
(as defined in section 1701(12) of title 38, United
States Code) and Veterans Care Agreements under section
1703B of title 38, United States Code''.
(c) VA Care in the Community Program Defined.--In this section, the
term ``VA Care in the Community Program'' has the meaning given that
term in section 1701(12) of title 38, United States Code, as added by
section 102.
SEC. 107. TERMINATION OF CERTAIN PROVISIONS AUTHORIZING MEDICAL CARE TO
VETERANS THROUGH NON-DEPARTMENT OF VETERANS AFFAIRS
PROVIDERS.
(a) Termination of Authority To Contract for Care in Non-Department
Facilities.--
(1) In general.--Section 603of title 38, United States Code,
is amended by adding at the end the following new subsection:
``(e) The authority of the Secretary to carry out this section
terminates on the date on which the Secretary certifies to the
Committees on Veterans' Affairs of the House of Representatives and the
Senate that the Secretary is fully implementing section 1703A of this
title.''.
(2) Conforming amendments.--
(A) Dental care.--Section 1712(a) of such title is
amended--
(i) in paragraph (3), by striking ``under
clause (1), (2), or (5) of section 1703(a) of
this title'' and inserting ``under the VA Care
in the Community Program''; and
(ii) in paragraph (4)(A), in the first
sentence--
(I) by striking ``and section 1703 of
this title'' and inserting ``and the VA
Care in the Community Program (with
respect to such a year beginning on or
after the date on which the Secretary
commences implementation of the VA Care
in the Community Program)''; and
(II) by striking ``in section 1703 of
this title'' and inserting ``under the
VA Care in the Community Program''.
(B) Readjustment counseling.--Section 1712A(e)(1) of
such title is amended by striking ``(under sections
1703(a)(2) and 1710(a)(1)(B) of this title)'' and
inserting ``(under the VA Care in the Community
Program)''.
(C) Death in department facility.--Section
2303(a)(2)(B)(i) of such title is amended by striking
``in accordance with section 1703 of this title'' and
inserting ``under the VA Care in the Community
Program''.
(D) Medicare provider agreements.--Section
1866(a)(1)(L) of the Social Security Act (42 U.S.C.
1395cc(a)(1)(L)) is amended--
(i) by striking ``under section 1703 of title
38'' and inserting ``under the VA Care in the
Community Program (as defined in section
1701(12) of title 38, United States Code)'';
and
(ii) by striking ``such section'' and
inserting ``such program''.
(b) Repeal of Authority To Contract for Scarce Medical Specialists.--
(1) In general.--Section 7409 of title 38, United States
Code, is repealed.
(2) Clerical amendment.--The table of sections at the
beginning of chapter 74 of such title is amended by striking
the item relating to section 7409.
(c) Effective Date.--The amendments made by subsections (a) and (b)
shall take effect on the date on which the Secretary certifies to the
Committees on Veterans' Affairs of the House of Representatives and the
Senate that the Secretary is fully implementing section 1703A of title
38, United States Code, as added by section 102.
SEC. 108. IMPLEMENTATION AND TRANSITION.
(a) Implementation.--The Secretary of Veterans Affairs shall commence
the implementation of section 1703A of title 38, United States Code, as
added by section 102, and section 1703B of such title, as added by
section 103, and shall make the transfer under section 106(b), by not
later than one year after the date of the enactment of this Act. The
Secretary shall prescribe interim final regulations to implement such
sections and publish such regulations in the Federal Register.
(b) Training.--Before commencing the implementation of sections 1703A
and 1703B of title 38, United States Code, as added by sections 102 and
103, respectively, the Secretary of Veterans Affairs shall--
(1) certify to the Committees on Veterans' Affairs of the
House of Representatives and the Senate that--
(A) each network provider (as defined by section
1701(11) of title 38, United States Code) and eligible
non-network provider that furnishes care or services
under such section 1703A or section 1703B is trained to
furnish such care or services under such sections; and
(B) each employee of the Department that refers,
authorizes, or coordinates such care or services is
trained to carry out such sections; and
(2) establish standard, written guidance for network
providers, non-Department health care providers, and any non-
Department administrative entities acting on behalf of such
providers, with respect to the policies and procedures for
furnishing care or services under such sections.
SEC. 109. TRANSPLANT PROCEDURES WITH LIVE DONORS AND RELATED SERVICES.
(a) In General.--Subchapter I of chapter 17 of title 38, United
States Code, is further amended by inserting after section 1703B, as
added by section 103, the following new section:
``Sec. 1703C. 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.--(1) In carrying out this
subsection, 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
section. 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.
``(2) The Secretary may only provide for an operation at a non-
Department of Veterans Affairs transplant center pursuant to paragraph
(1) if the center is in compliance with regulations prescribed by the
Centers for Medicare & Medicaid Services applicable to transplant
centers.''.
(b) Clerical Amendment.--The table of section at the beginning of
such chapter is further amended by inserting after the item relating to
section 1703B, as added by section 103, the following new item:
``1703C. Transplant procedures with live donors and related
services.''.
TITLE II--OTHER ADMINISTRATIVE MATTERS
SEC. 201. REIMBURSEMENT FOR EMERGENCY AMBULANCE SERVICES.
(a) In General.--Section 1725(c) of title 38, United States Code, is
amended by adding at the end the following new paragraph:
``(5) In delineating the circumstances under which reimbursement may
be made under this section for ambulance services for an individual,
the Secretary shall treat such services as emergency services for which
reimbursement may be made under this section if the Secretary
determines that--
``(A) the request for ambulance services was made as a result
of the sudden onset of a medical condition of such a nature
that a prudent layperson who possesses an average knowledge of
health and medicine--
``(i) would have reasonably expected that a delay in
seeking immediate medical attention would have been
hazardous to the life or health of the individual; or
``(ii) could reasonably expect the absence of
immediate medical attention to result in placing the
health of the individual in serious jeopardy, the
serious impairment of bodily functions, or the serious
dysfunction of any bodily organ or part; and
``(B) the individual is transported to the most appropriate
medical facility capable of treating such medical condition.''.
(b) Effective Date.--The amendment made by subsection (a) shall take
effect on the date of the enactment of this Act and shall apply with
respect to ambulance services provided on or after January 1, 2019.
SEC. 202. IMPROVEMENT OF CARE COORDINATION FOR VETERANS THROUGH
EXCHANGE OF CERTAIN MEDICAL RECORDS.
Section 7332(b) of title 38, United States Code, is amended--
(1) in paragraph (2), by adding at the end the following new
subparagraphs:
``(I) To a public or private health care provider in
order to provide treatment or health care to a shared
patient.
``(J) To a third party in order to recover or collect
reasonable charges for care furnished to a veteran for
a non-service-connected disability pursuant to section
1729 of this title or section 1 of Public Law 87-693
(42 U.S.C. 2651).''; and
(2) by adding at the end the following new paragraph:
``(4) Nothing in this section shall be construed to authorize any
provision of records in violation of relevant health record privacy
laws, including the Health Insurance Portability and Accountability Act
of 1996 (Public Law 104-191).''.
SEC. 203. ELIMINATION OF COPAYMENT OFFSET.
(a) In General.--Section 1729(a) of title 38, United States Code, is
amended by adding at the end the following new paragraph:
``(4) Notwithstanding any other provision of law, any amount
that the United States may collect or recover under this
section shall not affect any copayment amount a veteran is
otherwise obligated to pay under this chapter.''.
(b) Effective Date.--The amendment made by subsection (a) shall take
effect on the date of the enactment of this Act and apply with respect
to a copayment obligation that arises on or after the date of the
enactment of this Act.
SEC. 204. USE OF DEPARTMENT OF VETERANS AFFAIRS MEDICAL CARE
COLLECTIONS FUND FOR CERTAIN IMPROVEMENTS IN
COLLECTIONS.
Section 1729A(c)(1)(B) of title 38, United States Code, is amended by
inserting ``(including with respect to automatic data processing or
information technology improvements)'' after ``collection''.
SEC. 205. DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE PRODUCTIVITY
IMPROVEMENT.
(a) In General.--Subchapter I of chapter 17 of title 38, United
States Code, is further amended by inserting after section 1705A the
following new section:
``Sec. 1705B. Management of health care: productivity
``(a) Relative Value Unit Tracking.--The Secretary shall track
relative value units for all Department providers.
``(b) Clinical Procedure Coding Training.--The Secretary shall
require all Department providers to attend training on clinical
procedure coding.
``(c) Performance Standards.--(1) The Secretary shall establish for
each Department facility--
``(A) in accordance with paragraph (2), standardized
performance standards based on nationally recognized relative
value unit production standards applicable to each specific
profession in order to evaluate clinical productivity at the
provider and facility level;
``(B) remediation plans to address low clinical productivity
and clinical inefficiency; and
``(C) an ongoing process to systematically review the
content, implementation, and outcome of the plans developed
under subparagraph (B).
``(2) In establishing the performance standards under paragraph
(1)(A), the Secretary may--
``(A) incorporate values-based productivity models; and
``(B) take into account non-clinical duties, including with
respect to training and research.
``(d) Definitions.--In this section:
``(1) The term `Department provider' means an employee of the
Department whose primary responsibilities include furnishing
hospital care or medical services, including a physician, a
dentist, an optometrist, a podiatrist, a chiropractor, an
advanced practice registered nurse, and a physician's assistant
acting as an independent provider.
``(2) The term `relative value unit' means a unit for
measuring workload by determining the time, mental effort and
judgment, technical skill, physical effort, and stress involved
in delivering a procedure.''.
(b) Clerical Amendment.--The table of sections at the beginning of
such chapter is further amended by inserting after the item relating to
section 1705A the following new item:
``1705B. Management of health care: productivity.''.
(c) Report.--Not later than one year after the date of the enactment
of this Act, the Secretary shall submit to Congress a report on the
implementation of section 1705B of title 38, United States Code, as
added by subsection (a). Such report shall include, for each
professional category of Department providers, the relative value unit
of such category of providers at the national, Veterans Integrated
Service Network, and facility levels.
SEC. 206. LICENSURE OF HEALTH CARE PROFESSIONALS OF THE DEPARTMENT OF
VETERANS AFFAIRS PROVIDING TREATMENT VIA
TELEMEDICINE.
(a) In General.--Chapter 17 of title 38, United States Code, is
further amended by inserting after section 1730A the following new
section:
``Sec. 1730B. 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) 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.
``(c) 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.).
``(d) Covered Health Care Professional Defined.--In this section, the
term `covered health care professional' means a 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 quality standards relating
to the provision of telemedicine 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.''.
(b) Clerical Amendment.--The table of sections at the beginning of
chapter 17 of such title is further amended by inserting after the item
relating to section 1730A the following new item:
``1730B. Licensure of health care professionals providing treatment via
telemedicine.''.
(c) Report on Telemedicine.--
(1) In general.--Not later than one year after the date of
the enactment of this Act, the Secretary of Veterans Affairs
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 effectiveness of the use of
telemedicine by the Department of Veterans Affairs.
(2) Elements.--The report required by paragraph (1) shall
include an assessment of the following:
(A) The satisfaction of veterans with telemedicine
furnished by the Department.
(B) The satisfaction of health care providers in
providing telemedicine furnished by the Department.
(C) The effect of telemedicine furnished by the
Department on the following:
(i) The ability of veterans to access health
care, whether from the Department or from non-
Department health care providers.
(ii) The frequency of use by veterans of
telemedicine.
(iii) The productivity of health care
providers.
(iv) Wait times for an appointment for the
receipt of health care from the Department.
(v) The reduction, if any, in the use by
veterans of in-person services at Department
facilities and non-Department facilities.
(D) The types of appointments for the receipt of
telemedicine furnished by the Department that were
provided during the one-year period preceding the
submittal of the report.
(E) The number of appointments for the receipt of
telemedicine furnished by the Department that were
requested during such period, disaggregated by Veterans
Integrated Service Network.
(F) Savings by the Department, if any, including
travel costs, of furnishing health care through the use
of telemedicine during such period.
SEC. 207. ESTABLISHMENT OF PROCESSES TO ENSURE SAFE OPIOID PRESCRIBING
PRACTICES BY NON-DEPARTMENT OF VETERANS AFFAIRS
HEALTH CARE PROVIDERS.
(a) Receipt and Review of Guidelines.--The Secretary of Veterans
Affairs shall 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 the Department of Veterans Affairs under sections
911(a)(2) and 912(c) of the Jason Simcakoski Memorial and Promise Act
(Public Law 114-198; 38 U.S.C. 1701 note) before first providing care
under the laws administered by the Secretary and at any time when those
guidelines are modified thereafter.
(b) Inclusion of Medical History and Current Medications.--The
Secretary shall implement a process to ensure that, if care of a
veteran by a covered health care provider is authorized under the laws
administered by the Secretary, the document authorizing such care
includes the relevant medical history of the veteran and a list of all
medications prescribed to the veteran.
(c) Submittal of Prescriptions.--
(1) In general.--Except as provided in paragraph (3), the
Secretary shall require, to the maximum extent practicable,
each covered health care provider to submit prescriptions for
opioids--
(A) to the Department for prior authorization for the
prescribing of a limited amount of opioids under
contracts the Department has with retail pharmacies; or
(B) directly to a pharmacy of the Department for the
dispensing of such prescription.
(2) Department responsibility.--In carrying out paragraph
(1), upon receipt by the Department of a prescription for
opioids for a veteran under the laws administered by the
Secretary, the Secretary shall--
(A) record such prescription in the electronic health
record of the veteran; and
(B) monitor such prescription as outlined in the
Opioid Safety Initiative of the Department.
(3) Exception.--
(A) In general.--A covered health care provider is
not required under paragraph (1)(B) to submit an opioid
prescription directly to a pharmacy of the Department
if--
(i) the health care provider determines that
there is an immediate medical need for the
prescription, including an urgent or emergent
prescription or a prescription dispensed as
part of an opioid treatment program that
provides office-based medications; and
(ii)(I) following an inquiry into the matter,
a pharmacy of the Department notifies the
health care provider that it cannot fill the
prescription in a timely manner; or
(II) the health care provider determines that
the requirement under paragraph (1)(B) would
impose an undue hardship on the veteran,
including with respect to travel distances, as
determined by the Secretary.
(B) Notification to department.--If a covered health
care provider uses an exception under subparagraph (A)
with respect to an opioid prescription for a veteran,
the health care provider shall, on the same day the
prescription is written, submit to the Secretary for
inclusion in the electronic health record of the
veteran a notice, in such form as the Secretary may
establish, providing information about the prescription
and describing the reason for the exception.
(C) Report.--
(i) In general.--Not less frequently than
quarterly, 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 evaluating
the compliance of covered health care providers
with the requirements under this paragraph and
setting forth data on the use by health care
providers of exceptions under subparagraph (A)
and notices under subparagraph (B).
(ii) Elements.--Each report required by
clause (i) shall include the following with
respect to the quarter covered by the report:
(I) The number of exceptions used
under subparagraph (A) and notices
received under subparagraph (B).
(II) The rate of compliance by the
Department with the requirement under
subparagraph (B) to include such
notices in the health records of
veterans.
(III) The identification of any
covered health care providers that,
based on criteria prescribed the
Secretary, are determined by the
Secretary to be statistical outliers
regarding the use of exceptions under
subparagraph (A).
(d) Use of Opioid Safety Initiative Guidelines.--
(1) In general.--If a director of a medical center of the
Department or a Veterans Integrated Service Network determines
that the opioid prescribing practices of a covered health care
provider conflicts with or is otherwise inconsistent with the
standards of appropriate and safe care, as that term is used in
section 913(d) of the Jason Simcakoski Memorial and Promise Act
(Public Law 114-198; 38 U.S.C. 1701 note), the director shall
take such action as the director considers appropriate to
ensure the safety of all veterans receiving care from that
health care provider, including removing or directing the
removal of any such health care provider from provider networks
or otherwise refusing to authorize care of veterans by such
health care provider in any program authorized under the laws
administered by the Secretary.
(2) Inclusion in contracts.--The Secretary shall ensure that
any contracts entered into by the Secretary with third parties
involved in administering programs that provide care in the
community to veterans under the laws administered by the
Secretary specifically grant the authority set forth in
paragraph (1) to such third parties and to the directors
described in that paragraph, as the case may be.
(e) Denial or Revocation of Eligibility of Non-Department
Providers.--The Secretary shall deny or revoke the eligibility of a
non-Department health care provider to provide health care to veterans
under the laws administered by the Secretary if the Secretary
determines that the opioid prescribing practices of the provider--
(1) violate the requirements of a medical license of the
health care provider; or
(2) detract from the ability of the health care provider to
deliver safe and appropriate health care.
(f) Covered Health Care Provider Defined.--In this section, the term
``covered health care provider'' means a non-Department of Veterans
Affairs health care provider who provides health care to veterans under
the laws administered by the Secretary of Veterans Affairs.
SEC. 208. ASSESSMENT OF HEALTH CARE FURNISHED BY THE DEPARTMENT TO
VETERANS WHO LIVE IN THE TERRITORIES.
(a) In General.--Not later than 180 days after the date of the
enactment of this Act, the Secretary of Veterans Affairs shall submit
to the Committees on Veterans' Affairs of the Senate and the House of
Representatives a report regarding health care furnished by the
Department of Veterans Affairs to veterans who live in the territories.
(b) Elements.--The report under subsection (a) shall include
assessments of the following:
(1) The ability of the Department to furnish to veterans who
live in the territories the following:
(A) Hospital care.
(B) Medical services.
(C) Mental health services.
(D) Geriatric services.
(2) The feasibility of establishing a medical facility of the
Department in any territory that does not contain such a
facility.
(c) Definition.--In this section, the term ``territories'' means the
Northern Mariana Islands, Puerto Rico, American Samoa, Guam, and the
Virgin Islands.
SEC. 209. OVERSIGHT AND ACCOUNTABILITY OF FINANCIAL PROCESSES OF
DEPARTMENT OF VETERANS AFFAIRS.
(a) Sense of Congress.--It is the sense of Congress that--
(1) the normal budget process for the Department of Veterans
Affairs should be grounded in sound actuarial analysis based on
accurate demand forecasting;
(2) the regular budget process for the Department should be
the norm;
(3) supplemental requests for appropriations should be used
sparingly and for unforeseen demand or natural occurrences; and
(4) upon receipt of the financial audit of the Office of
Inspector General of the Department, the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans' Affairs of
the House of Representatives shall give due consideration to
the report, including by holding hearings as appropriate
(b) Plans for Use of Supplemental Appropriations Required.--Whenever
the Secretary submits to address a budgetary issue affecting the
Department of Veterans Affairs to Congress a request for supplemental
appropriations or any other appropriation when the request is submitted
outside the standard budget process, the Secretary shall, not later
than 45 days before the date on which such budgetary issue would start
affecting a program or service, submit to Congress a justification for
the request, including a plan that details how the Secretary intends to
use the requested appropriation and how long the requested
appropriation is expected to meet the needs of the Department and
certification that the request was made using an updated and sound
actuarial analysis.
(c) Annual Attestation Regarding Financial Projections.--Concurrent
with the President's annual budget request submitted to Congress under
section 1105 of title 31, United States Code, for fiscal year 2019 and
each fiscal year thereafter, the Chief Financial Officer of the
Department of Veterans Affairs shall submit to the Committee on
Veterans' Affairs of the Senate and the Committee on Veterans' Affairs
of the House of Representatives the following:
(1) A statement of assurance that financial projections
included in such budget or the supporting materials submitted
along with such budget for the Department of Veterans Affairs
are sufficient to provide benefits and services under laws
administered by the Secretary of Veterans Affairs.
(2) A certification of the Chief Financial Officer's
responsibility for internal financial controls of the
Department.
(3) An attestation that the Chief Financial Officer has
collaborated sufficiently with the financial officers of the
facilities and components of the Department to be confident in
such financial projections.
SEC. 210. AUTHORITY FOR DEPARTMENT OF VETERANS AFFAIRS CENTER FOR
INNOVATION FOR CARE AND PAYMENT.
(a) In General.--Subchapter I of chapter 17, as amended by section
103, is further amended by inserting after section 1703C, as added by
section 109, the following new section:
``Sec. 1703D. 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 at the center of the care team
(including family members and other caregivers) 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.
``(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 a report 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 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 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 VA Care in
the Community Act.
``(2) 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.
``(3)(A) If the Secretary determines that the 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)(A) 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 the pilot program under
subparagraph (A)(ii), for purposes of clauses (vi) and (vii) of
subsection (f)(2)(A), 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 Consultation.--(1) The Secretary shall consult
with 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.''.
(b) Conforming Amendment.--The table of sections at the beginning of
such chapter, as amended by section 109, is further amended by
inserting after the item relating to section 1703C the following new
item:
``1703D. Center for Innovation for Care and Payment.''.
TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS
SEC. 301. DESIGNATED SCHOLARSHIPS FOR PHYSICIANS AND DENTISTS UNDER
DEPARTMENT OF VETERANS AFFAIRS HEALTH PROFESSIONAL
SCHOLARSHIP PROGRAM.
(a) Scholarships for Physicians and Dentists.--Section 7612(b) of
title 38, United States Code, is amended by adding at the end the
following new paragraph:
``(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.''.
(b) Breach of Agreement.--Section 7617(b) of such title is amended--
(1) by redesignating paragraphs (4) and (5) as paragraphs (5)
and (6), respectively; and
(2) by inserting after paragraph (3) the following new
paragraph (4):
``(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.''.
(c) Extension of Program.--Section 7619 of such title is amended by
striking ``December 31, 2019'' and inserting ``December 31, 2033''.
SEC. 302. ESTABLISHMENT OF DEPARTMENT OF VETERANS AFFAIRS SPECIALTY
EDUCATION LOAN REPAYMENT PROGRAM.
(a) In General.--Chapter 76 of title 38, United States Code, is
amended by inserting after subchapter VII the following new subchapter:
``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; preference; 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) Preference for Veterans.--In selecting individuals for
participation in the Specialty Education Loan Repayment Program under
this subchapter, the Secretary may give preference to 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.''.
(b) Conforming and Technical Amendments.--
(1) Conforming amendments.--
(A) Section 7601(a) of title 38, United States Code,
is amended--
(i) in paragraph (4), by striking ``and'';
(ii) in paragraph (5), by striking the period
and inserting ``; and''; and
(iii) by adding at the end the following new
paragraph:
``(6) the specialty education loan repayment program provided
for in subchapter VIII of this chapter.''.
(B) Section 7603(a)(1) of title 38, United States
Code, is amended by striking ``or VI'' and inserting
``VI, or VIII''.
(C) Section 7604 of title 38, United States Code, is
amended by striking ``or VI'' each place it appears and
inserting ``VI, or VIII''.
(D) Section 7631 of title 38, United States Code, is
amended--
(i) in subsection (a)(1)--
(I) by striking ``and'' after
``scholarship amount,''; and
(II) by inserting ``, and the maximum
specialty education loan repayment
amount'' after ``reduction payments
amount''; and
(ii) in subsection (b) by adding at the end
the following new paragraph:
``(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.''.
(E) Section 7632 of title 38, United States Code, is
amended--
(i) in paragraph (1), by striking ``and the
Education Debt Reduction Program'' and
inserting ``the Education Debt Reduction
Program, and the Specialty Education Loan
Repayment Program''; and
(ii) in paragraph (4), by striking ``and per
participant in the Education Debt Reduction
Program'' and inserting ``per participant in
the Education Debt Reduction Program, and per
participant in the Specialty Education Loan
Repayment Program''.
(2) Table of sections.--The table of sections at the
beginning of chapter 76 of such title is amended by inserting
after the items relating to subchapter VII the following:
``subchapter viii--specialty education loan repayment program
``7691. Establishment.
``7692. Purpose.
``7693. Eligibility; preference; covered costs.
``7694. Specialty education loan repayment.
``7695. Choice of location.
``7696. Term of obligated service.
``7697. Relationship to Educational Assistance Program.''.
(c) Needs of the VHA.--In making determinations each year under
section 7692 of title 38, United States Code, as enacted by subsection
(a), the Secretary of Veterans Affairs shall consider the anticipated
needs of the Veterans Health Administration during the period two to
six years in the future.
(d) Offer Deadline.--In the case of an applicant who applies before
receiving a residency match and whom the Secretary of Veterans Affairs
selects for participation in the Specialty Education Loan Repayment
Program established by subsection (a), the Secretary shall offer
participation to the applicant not later than 28 days after--
(1) the applicant matches with a residency in a medical
specialty described in section 7692 of title 38, United States
Code, as enacted by subsection (a); and
(2) such match is published.
(e) Publicity.--The Secretary of Veterans Affairs shall take such
steps as the Secretary determines are appropriate to publicize the
Specialty Education Loan Repayment Program established under subchapter
VIII of chapter 76 of title 38, United States Code, as enacted by
subsection (a).
SEC. 303. VETERANS HEALING VETERANS MEDICAL ACCESS AND SCHOLARSHIP
PROGRAM.
(a) Establishment.--The Secretary of Veterans Affairs, acting through
the Office of Academic Affiliations of the Department of Veterans
Affairs, shall carry out a pilot program under which the Secretary
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.
(b) Eligible Veterans.--To be eligible to receive funding for medical
education under this section, a veteran shall--
(1) have been discharged from the Armed Forces not more than
ten years before the date of application for admission to a
covered medical school;
(2) not be entitled to educational assistance under chapter
30, 31, 32, 33, 34, or 35 of title 38, United States Code, or
chapter 1606 or 1607 of title 10, United States Code;
(3) apply for admission to a covered medical school for the
entering class of 2019;
(4) indicate on such application for admission that the
veteran would like to be considered for an award of funding
under this section;
(5) meet the minimum admissions criteria for the covered
medical school to which the veteran applies; and
(6) enter into an agreement described in subsection (e).
(c) Award of Funding.--
(1) In general.--Each covered medical school that opts to
participate in the program under this section shall reserve two
seats in the entering class of 2019 for eligible veterans who
receive funding under such program. Such funding shall be
awarded to the two eligible veterans with the highest
admissions rankings for such class at such school.
(2) Amount of funding.--Each eligible veteran who receives
funding under this section shall receive an amount equal to the
actual cost of--
(A) tuition at the covered medical school at which
the veteran enrolls for four years;
(B) books, fees, and technical equipment;
(C) fees associated with the National Residency Match
Program;
(D) two away rotations performed during the fourth
year at a Department of Veterans Affairs medical
facility; and
(E) a monthly stipend for the four-year period during
which the veteran is enrolled in medical school in an
amount to be determined by the Secretary.
(3) Distribution of funding.--In the event that two or more
eligible veterans do not apply for admission at one of the
covered medical schools for the entering class of 2019, the
Secretary shall distribute the available funding to eligible
veterans who applied for admission at other covered medical
schools.
(d) Agreement.--
(1) Terms of agreement.--Each eligible veteran who accepts
funding for medical education under this section shall enter
into an agreement with the Secretary that provides that the
veteran agrees--
(A) to maintain enrollment and attendance in the
medical school;
(B) while enrolled in such medical school, to
maintain an acceptable level of academic standing (as
determined by the medical school under regulations
prescribed by the Secretary);
(C) to complete post-graduate training leading to
eligibility for board certification in a speciality
applicable to the Department of Veterans Affairs, as
determined by the Secretary;
(D) after completion of medical school, to obtain a
license to practice medicine in a State; and
(E) after completion of medical school and post-
graduate training, to serve as a full-time clinical
practice employee in the Veterans Health Administration
for a period of four years.
(2) Breach of agreement.--If an eligible veteran who accepts
funding under this section breaches the terms of the agreement
described in paragraph (1), the United States shall be entitled
to recover damages in an amount equal to the total amount of
such funding received by the veteran.
(e) Rule of Construction.--Nothing in this section shall be construed
to prevent any covered medical school from accepting more than two
eligible veterans for the entering class of 2019.
(f) Report to Congress.--Not later than December 31, 2020, and
annually thereafter for the subsequent three years, the Secretary shall
submit to Congress a report on the pilot program under this section.
Such report shall include the evaluation of the Secretary of the
success of the pilot program, including the number of veterans who
received funding under the program who matriculated and an evaluation
of the academic progress of such veterans.
(g) Covered Medical Schools.--In this section, the term ``covered
medical school'' means any of the following.
(1) The Teague-Cranston medical schools, consisting of--
(A) Texas A&M; College of Medicine;
(B) Quillen College of Medicine at East Tennessee
State University;
(C) Boonshoft School of Medicine at Wright State
University;
(D) Joan C. Edwards School of Medicine at Marshall
University; and
(E) University of South Carolina School of Medicine.
(2) Charles R Drew University of Medicine and Science.
(3) Howard University College of Medicine.
(4) Meharry Medical College.
(5) Morehouse School of Medicine.
Purpose and Summary
H.R. 4242, as amended, the ``VA Care in the Community
Act,'' would improve the provision of care and services to
veterans through Department of Veterans Affairs (VA) medical
facilities and through VA providers in the community.
Representative David P. Roe of Tennessee, the Chairman of the
Committee on Veterans' Affairs, introduced H.R. 4242 on
November 3, 2017.
Background and Need for Legislation
TITLE I--IMPROVED ACCESS FOR VETERANS TO NON-DEPARTMENT OF VETERANS
AFFAIRS MEDICAL CARE
VA operates the largest integrated health care system in
the country and provides care to approximately nine million
veteran patients.\1\ The majority of the health care that
veterans receive through VA is provided by VA-employed medical
professionals and support staff at VA medical facilities, which
are managed by the Veterans Health Administration (VHA).\2\
However, since 1945, VA has also collaborated with medical
professionals and support staff in the community who are not VA
employees to provide veterans with timely, accessible, high-
quality care.\3\ 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 community care when a needed
clinical service cannot be provided by a 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.
---------------------------------------------------------------------------
\1\About VHA. Veterans Health Administration. https://www.va.gov/
health/aboutVHA.asp. Accessed November 14, 2017.
\2\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).
\3\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown
University, Washington, D.C.
---------------------------------------------------------------------------
The most recent VA community care authority 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). Choice expanded the availability of
community care to veteran patients by setting specific triggers
that would require VA 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 medical
facility within 30 days or if they reside more than 40 miles
from the nearest VA medical facility. Through Choice, veteran
patients are referred to regional networks of community
providers who are managed by Third Party Administrators.
However, under other community care programs, VA refers veteran
patients to community providers through agreements with the
Indian Health Service, the Department of Defense, or academic
affiliates; through the Patient Centered Community Care
program; or through national or local contracts or sharing
agreements.\4\
---------------------------------------------------------------------------
\4\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).
---------------------------------------------------------------------------
Each of VA's current community care programs and
authorities contain different eligibility criteria,
reimbursement rates, payment structures, referral and
authorization requirements, and contracting approaches.\5\
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.''\6\ 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.''\7\ 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.''\8\
---------------------------------------------------------------------------
\5\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown
University, Washington, D.C.
\6\May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet.
``A Consolidated and Modernized VA Community Care Program.''
\7\Ibid.
\8\Ibid.
---------------------------------------------------------------------------
That imperative has been exacerbated by a significant
increase in veteran demand for community care in recent years.
Since the establishment of Choice in fiscal year 2014,
community care appointments have increased by 61 percent
overall and by 41 percent as a percentage of total VA
appointments.\9\ In fiscal year 2016, 31 percent of all
completed appointments across the VA health care system were
held in the community.\10\ However, Choice represents a
relatively small portion of the overall community care
landscape, accounting for just 23 percent of all community care
appointments in fiscal year 2016.\11\
---------------------------------------------------------------------------
\9\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown
University, Washington, D.C.
\10\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).
\11\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown
University, Washington, D.C.
---------------------------------------------------------------------------
Despite the increased demand for and utilization of
community care, VA has struggled to effectively administer
community care programs and veterans do not always receive
timely care when utilizing community care. For many years, the
VA Inspector General 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.\12\ The IG concluded that, ``our audits, reviews,
and inspections have highlighted that VA has had a history of
challenges in administering its purchased care programs.
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 lacked adequate processes to manage funds and
oversee program execution.''\13\ The Government Accountability
Office (GAO) has found similar problems with community care
programs. Most recently, in March 2017, GAO found that veterans
who were referred to Choice for routine care because such care
was not available through a VA medical facility in a timely
manner could potentially wait up to 81 calendar days to obtain
Choice care.\14\ GAO also found that VA had failed to establish
standardized processes and procedures for Choice, to issue
program guidance, and to track or monitor how long it took VA
medical centers to refer a veteran to Choice (a process which
GAO found was duplicative and could take as long as 21
days).\15\
---------------------------------------------------------------------------
\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 the Honorable Michael Missal, Inspector General, U.S. Department of
Veterans Affairs).
\13\Ibid.
\14\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).
\15\Ibid.
---------------------------------------------------------------------------
The Committee concurs with the IG and GAO regarding the
long history of challenges with regard to VA community care
programs. The Committee also concurs with VA's assessment about
the need to consolidate VA's multiple community care programs
and authorities in order to create a more seamless network of
care in VA medical facilities and in the community to better
serve veterans and achieve improved health outcomes, patient
satisfaction, care coordination, and efficiency.\16\
Accordingly, Title I of the bill would establish a permanent VA
Care in the Community Program (the Program) to provide hospital
care, medical services, and extended care to veteran patients
through contracts or agreements with network providers. In this
program, VA would be required to establish regional networks of
community providers and to coordinate the care veterans receive
through network providers as well as provide case management,
where appropriate. A veteran would be eligible to receive
primary care through the Program if VA is unable to assign that
veteran to a primary care provider in a VA medical facility and
would be eligible to receive specialty care through the Program
if that veteran is referred by his/her primary care provider.
In determining whether or not to provide specialty care to a
veteran in a VA medical facility rather than through the
Program, VA would be required to consider whether the VA
medical facility is within a reasonable distance of the
veteran's residence and to take into account any unusual or
excessive travel burdens and geographical or environmental
challenges the veteran may face, the veteran's medical
condition, and the recommendation of the veteran's primary care
provider. Once a veteran is referred to a community provider
through the Program, VA would be required to ensure that the
veteran receives care through the completion of an episode of
care including specialty and ancillary services and to ensure
appropriate medical documentation of such care is returned to
VA. VA would be required to establish a process to review
disagreements regarding the eligibility of a veteran to receive
care or services from a community provider using the Program.
Under the Program, community providers would be reimbursed in
accordance with Medicare rates with certain exceptions allowed
for, for example, highly rural areas, Alaska, states with all-
payer models, and federal or tribal entities. In addition, VA
would be authorized to enter into value-based reimbursement
models. To ensure the care veterans receive through the Program
is high quality, VA would be required to develop quality
standards to track the quality of network providers.
---------------------------------------------------------------------------
\16\May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet.
``A Consolidated and Modernized VA Community Care Program.''
---------------------------------------------------------------------------
Title I of the bill would require the Program to be funded
out of the Community Care account established by the Surface
Transportation and Veterans Health Care Choice Improvement Act
of 2015 (Public Law 114-41; 129 STAT. 443) and stipulate that
remaining funds, if any, in the Veterans Choice Fund
established by the Veterans Access, Choice, and Accountability
Act of 2014 (Public Law 113-146; 128 STAT. 1754) to be
transferred to the Community Care account one year after
enactment. Importantly, it would also terminate VA's existing
care in the community programs and authorities upon
commencement of the Program, which would occur no later than
one year after enactment via interim final regulations after VA
has certified to Congress that each community care provider and
VA employee is trained to furnish care under the Program and
has established standard, written guidance with respect to the
policies and procedures of the Program.
The Committee strongly believes that VA's ability to
accurately process timely payments to community provider
providers in compliance with the prompt payment rule is
critical to the Program's success and to ensuring access to
community care for the increasing number of veterans who rely
on it. However, 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.\17\ 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.\18\ These findings were echoed in
testimony GAO provided 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.''\19\ As such, Title I of the bill would also
establish a prompt payment standard in which claims are
required to be submitted 180 days after care is provided (or a
network provider is paid by a contractor) and clean paper
claims are either paid or denied within 45 days of receipt and
clean electronic claims are either paid or denied within 30
days of receipt. If a claim is denied and additional
information has been submitted, adjudication would be required
within 30 days of receipt. Pursuant to this authority, VA would
be required to pay interest payments for overdue claims, allow
for the recovery of overpayments through deductions of future
payments or refunds from the claimant, and prohibited from
requiring receipt of medical records as a requisite for
payment. Title I of the bill would also require VA to establish
a Center for Innovation to test and develop innovative pilot
models for payment and service delivery for community care. The
Committee believes this could potentially reduce expenditures
while preserving or enhancing the quality of care furnished by
VA.
---------------------------------------------------------------------------
\17\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.
\18\Ibid.
\19\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).
---------------------------------------------------------------------------
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 Veterans Access, Choice,
and Accountability Act of 2014 (Public Law 113-146; 128 STAT.
1754) 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 community providers
who are small or unaccustomed to federal contracting. VA has
requested legislative authority to enter into non FAR-based
provider agreements since 2015.\20\ 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.''\21\ 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.''\22\ 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. Title I of the bill would authorize VA to enter into
provider agreements to deliver care to veteran patients when
furnishing such care at VA facilities is impractical or
inadvisable for a particular veteran and such care is not
available from a community provider under a traditional FAR-
based contract or sharing agreement. This provider agreement
authority would be limited to not more than $5 million for
community providers furnishing homemaker or home health aide
services and to not more than $2 million for other community
providers. VA would be required to establish a process to
certify eligible providers and ensure they meet certain terms,
conditions, and quality standards. Importantly, Title I of the
bill would stipulate that provider agreements under this
authority are not subject to competitive procedures and are
exempted from any provision of law that Medicare providers are
exempted from but are subject to the Civil Rights Act of 1964.
Title I of the bill would also modify VA's authority to enter
into agreements with State Veterans Homes by stipulating that
such agreements are not subject to competitive procedures or
laws that Medicare providers are exempt from but are subject to
all laws regarding integrity, ethics, fraud, and that would
protect against employment discrimination.
---------------------------------------------------------------------------
\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.
\21\Ibid.
\22\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).
---------------------------------------------------------------------------
The Committee is committed to ensuring that the care
provided through the Program supplements but does not supplant
the care provided in VA medical facilities and that VA
continues to provide timely, high quality care to veterans both
in the community and in VA. To that end, Title I of the bill
would also require VA to conduct periodic (defined as not less
often than once every three years) capacity and commercial
market assessments in each Veterans Integrated Service Network
and VA medical facility to identify gaps in care and recommend
how such gaps could be filled via changing how care is
furnished and/or building or realigning VA resources or
personnel.
Section 109. Transplant procedures with live donors and related
services
VA has offered solid organ transplant services for eligible
veteran patients since 1962 and bone marrow transplant services
for eligible veteran patients since 1982.\23\ 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.\24\
---------------------------------------------------------------------------
\23\VA National Transplant Program. https://www.va.gov/health/
services/transplant/ Accessed October 30, 2017.
\24\Ibid.
---------------------------------------------------------------------------
The Veterans Access, Choice, and Accountability Act of 2014
(Public Law 113-146; 128 STAT. 1754) created the Choice program
to increase access to care in the community for veteran
patients unable to receive care at VA medical facilities due to
long waiting times for VA appointments or lengthy travel
distances to VA medical facilities. 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.\25\ Mr. Nelson's non-veteran
son, Austin, was willing and able to serve as Mr. Nelson's live
donor.\26\ 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.\27\\28\ 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.\29\ 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.\30\
---------------------------------------------------------------------------
\25\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).
\26\Ibid.
\27\Ibid.
\28\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.
\29\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).
\30\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.\31\ 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. Consistent with those goals,
section 109 of the bill would authorize veterans to obtain a
transplant outside of the region of the Organ Procurement and
Transplantation Network if veteran's primary care provider
opines that there is a medically compelling reason and also
authorize VA to support the cost of a donor transplant
operation, including perioperative care and care performed in a
non-VA facility, for a live donor who is not a veteran but who
is donating an organ for a veteran.
---------------------------------------------------------------------------
\31\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.
---------------------------------------------------------------------------
TITLE II--OTHER ADMINISTRATIVE MATTERS
Section 201. Reimbursement for emergency ambulance services
While VA has experienced long-standing difficulties
complying with prompt pay rules in general, VA has had
particular challenges issuing timely reimbursement for
ambulance providers. In June 2015, American Medical Response,
the nation's largest single ambulance provider, testified
before the Subcommittee on Health that they have had
``consistent difficulty'' receiving reimbursement from VA and,
despite working with VA for a year, had a payment backlog
totaling approximately $12 million.\32\ Section 201 of the bill
would require VA to reimburse an ambulance provider or other
emergency transport service for providing transportation to a
veteran for purposes of receiving emergency medical care at a
community facility if the request for transportation was made
as a result of the sudden onset of a medical condition of such
a nature that it meets the prudent layperson standard and the
veteran is transported to the most appropriate medical
facility.
---------------------------------------------------------------------------
\32\United States Cong. House Committee on Veterans' Affairs.
``Assessing VA's Ability to Promptly Pay Non-VA Providers.'' June 3,
2015. 114th Cong. 1st sess. Washington: GPO, 2017 (statement for the
record from American Medical Response).
---------------------------------------------------------------------------
Section 202. Improvement of care coordination for veterans through
exchange of certain medical records
Since fiscal year 2014, VA community care appointments have
increased by 61 percent overall and by 41 percent as a
percentage of total VA appointments.\33\ In FY 2016 alone, 25.5
million appointments--or 30 percent of all VA appointments--
occurred in the community rather than in VA medical
facilities.\34\ Given the dramatic increase in VA community
care demand in recent years and the need to ensure that the
care veterans receive both in VA medical facilities and in the
community is effectively coordinated to ensure quality, the
Committee believes that it is critically important for VA and
community providers to be able to share pertinent medical
record information about the veteran patients they are jointly
treating while also ensuring appropriate protections are in
place to secure patient privacy.
---------------------------------------------------------------------------
\33\January 11, 2017, MyVA Advisory Committee Meeting, Georgetown
University, Washington, D.C.
\34\Ibid.
---------------------------------------------------------------------------
Accordingly, section 202 of the bill would amend section
7332 of title 38 U.S.C. to permit VA to share confidential
medical information with a public or private health care
provider in order to provide care or treatment to a shared
patient and to a third party in order to recover (or collect)
reasonable charges for care furnished to a veteran for a non-
service connected disability with the stipulation that such
sharing must be in accordance with relevant health record
privacy laws (including HIPPA). 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 203. Elimination of copayment offset
As a condition for receiving VA health care services,
veterans with income greater than VA income thresholds must
agree to pay a copayment for care VA provides that is not
related to a service-connected condition.\35\ Section 1729 of
title 38 United States Code authorizes VA to bill a veteran's
private (third party) health insurance reasonable charges for
treatment of a veteran's non service-connected conditions and
to reduce any copayment amounts such veteran would otherwise
owe to VA dollar for dollar based on the collection from the
private insurer.\36\ Funds collected by VA from private
insurers are deposited in the VA Medical Care Collections Fund
(MCCF) and used to augment VA's medical care accounts and cover
expenses incurred by VA as a result of first and third-party
collections. VA estimates that approximately twenty-three
percent of veterans enrolled in the VA health care system pay
copayments to VA for treatment in connection with a non-service
connected condition have billable private insurance plans.\37\
According to VA, the practice of reducing a veteran's copayment
amounts using money from such veteran's private insurer ``. . .
reduces the total collections received by VA that is available
for use in providing direct medical care and does not align
with standard health care industry practice.''\38\ The
Committee concurs with VA's assessment.
---------------------------------------------------------------------------
\35\VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-347.
\36\Ibid.
\37\Ibid.
\38\Ibid.
---------------------------------------------------------------------------
As such, section 203 of the bill would eliminate the
current requirement for VA to offset a veteran's copayment with
amounts recovered from the veteran's third party insurance. VA
estimates that this will result in improved collections
totaling approximately $62 million.\39\ While the Committee
does not believe that eliminating the requirement for VA to
offset a veterans copayment amount with collections from
private insurance companies is, on its own, sufficient to
incentive a veteran to abandon his/her other health insurance,
the Committee intends to closely monitor how the number of
veteran patients with other health insurance and MCCF
collection rates are impacted by enactment of this section of
the bill.
---------------------------------------------------------------------------
\39\Ibid.
---------------------------------------------------------------------------
Section 204. Use of Department of Veterans Affairs Medical Care
Collections Fund for certain improvements in collections
The Balanced Budget Act of 1997 (Public Law 105-33; 111
STAT. 251) established the VA MCCF and required that amounts
collected or recovered after June 30, 1997, be deposited into
the MCCF and used to furnish medical care and services to
eligible veterans and to cover expenses incurred to collect
amounts owed by first or third parties for the medical care and
services furnished by VA.\40\ VA's fiscal year 2018 budget
submission notes that the Department has re-estimated
collections in 2017 and 2018 downward due to broader healthcare
payer changes that have resulted in third-party payers
proposing reductions to their reimbursement levels.\41\ The
Committee is increasingly concerned that VA is not sufficiently
collecting revenue from first and third party payers. As a
result, section 204 of the bill would include automatic data
processing and information technology improvements as an MCCF
expense allowed in the billing, auditing, and collecting of
such revenues.
---------------------------------------------------------------------------
\40\VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-173.
\41\VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-174.
---------------------------------------------------------------------------
Section 205. Department of Veterans Affairs health care productivity
improvement
The Committee believes it is important that VA achieves and
maintains a high level of productivity among VA clinicians in
order to maximize veteran access to care and ensure a prudent
use of taxpayer dollars. However, recent analyses have called
into question how well VA tracks provider productivity and how
productive they are compared to their non-VA counterparts. For
example, the 2015 Independent Assessment of the Health Care
Delivery Systems and Management Processes of the Department of
Veterans Affairs found that VA specialty providers are less
productive than their private sector counterparts on two
industry measures--encounters and relative value units
(RVUs).\42\ RVUs are a commonly used measure of a provider's
productivity that take into account the time, technical skill,
mental effort, and stress that are needed for a clinician to
provide a given clinical service.\43\ More recently, the
Government Accountability Office released a report in 2017,
which found that VA lacks complete and accurate information on
clinical productivity and efficiency because VA's existing
productivity metrics and efficiency models do not account for
all providers and clinical services, may not accurately reflect
the intensity of clinical workloads or staffing levels, and may
be adversely impacted by inaccurate data.\44\ GAO also found
that VA Central Office does not systematically oversee
productivity and efficiency and, thus, cannot ensure that low
productivity and clinical inefficiencies are addressed at
individual VA medical facilities or identify and correct
patterns that could increase productivity and efficiency across
the VA health care system. Accordingly, section 205 of the bill
would require VA to track RVUs for all VA providers, to ensure
that all VA providers attending training on clinical procedure
coding, and to establish RVU-based performance standards as
well as remediation plans to address low clinical productivity
and inefficiency.
---------------------------------------------------------------------------
\42\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.
\43\January 12, 2015, National Health Policy Forum, ``The Basics:
Relative Value Units,'' https://www.nhpf.org/library/the-basics/
Basics_RVUs_01-12-15.pdf.
\44\GAO-17-480, May 2017, ``Improvements Needed in Data and
Monitoring of Clinical Productivity and Efficiency,'' https://
www.gao.gov/assets/690/684869.pdf.
---------------------------------------------------------------------------
Section 206. Licensure of health care professionals of the Department
of Veterans Affairs providing treatment via telemedicine
As a national, integrated health care system, the Veterans
Health Administration (VHA) has a responsibility to ensure that
veteran patients receive access to care no matter where the
veteran patient is located.\45\ 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.\46\
---------------------------------------------------------------------------
\45\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.
\46\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.''\47\ 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.\48\\49\
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.''\50\ 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.\51\ Veteran patients who have had experience with
VA telemedicine programs have demonstrated improved health
outcomes, including decreases in hospital admissions.\52\
---------------------------------------------------------------------------
\47\VA Telehealth Services. https://www.telehealth.va.gov/ Accessed
October 30, 2017.
\48\Ibid.
\49\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.
\50\Ibid.
\51\Ibid.
\52\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.\53\ 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.\54\
---------------------------------------------------------------------------
\53\Ibid.
\54\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.\55\ 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.''\56\ Despite this rulemaking, VA
testified during a 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.''\57\
---------------------------------------------------------------------------
\55\Ibid.
\56\Ibid.
\57\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).
---------------------------------------------------------------------------
Therefore, section 206 of the bill would 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 and 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. 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.''\58\ Section 206 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.
---------------------------------------------------------------------------
\58\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 207. Establishment of processes to ensure safe opioid
prescribing practices by non-Department of Veterans Affairs
health care providers
Overdose deaths involving prescriptions have quintupled
since 1999. Between 1999 and 2016 more than 200,000 deaths were
attributed to overdoses from prescription drugs.\59\ The opioid
epidemic has impacted veterans and overdose deaths among
veterans remain elevated when compared to the civilian
population. 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.\60\
---------------------------------------------------------------------------
\59\Prescription Opioid Overdose Data, Centers for Disease Control
and Prevention; https://www.cdc.gov/drugoverdose/data/overdose.html.
\60\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.
---------------------------------------------------------------------------
Over the past several years, VA has implemented purchased
care programs to enable veterans to access care by non-
department providers in the community. This care includes the
management of chronic pain conditions for which veterans are
prescribed opioids.\61\ This raises the potential for
inconsistencies in management between the community provider
and guidelines promulgated by VA increasing risk to the
veteran. Moreover, medical information may not be shared
between the community provider and VA further exacerbating such
risks.\62\ GAO recommended that community providers receive and
review the guidelines in the OSI, that VA implement a process
to share up to date veterans' medication records with community
providers, require community providers to submit opioid
prescriptions to a VA pharmacy with recordation of the
prescription in the VA electronic health record, and to ensure
that if a community provider's provider prescribing practices
are in conflict OSI guidelines, that actions are taken to
ensure the safety of the veteran.\63\
---------------------------------------------------------------------------
\61\Ibid.
\62\Ibid.
\63\Ibid.
---------------------------------------------------------------------------
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 207 of
the bill would require VA to provide OSI guidelines to
community providers and certify that the community providers
have reviewed the guidelines and to implement a process to
ensure that community providers receive a veteran's relevant
history including all medications. It would further require
that opioid prescriptions be filled at a VA pharmacy, or at a
community pharmacy only if prior authorization has been
received (with an exception for certain urgent or emergent
circumstances). Section 2017 would also require that opioid
prescriptions be recorded in the electronic health record and
that community providers whose prescribing practices are
inconsistent with OSI requirements or violate licensing
guidelines are removed from VA community care networks.
Section 208. Assessment of health care furnished by the Department to
veterans who live in territories
Veterans in Puerto Rico, the U.S. Virgin Islands, the
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 often 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 208 of the bill would
require VA to report on the care provided to veterans in Puerto
Rico, the U.S. Virgin Islands, the American Samoa, Guam, and
the Northern Mariana Islands and include whether it would be
feasible for VA to establish a medical facility in any
territory that does not contain such a facility.
Section 209. Oversight and accountability of financial processes of
Department of Veterans Affairs
Since Choice was established in 2014, VA has returned to
Congress several times seeking additional, ``emergency''
appropriations to keep the program operational in the face of
funding shortfalls. Most recently, on December 12, 2017,
Secretary Shulkin predicted without additional funding by the
end of the year, veterans would see a ``dramatic impact'' on
their overall healthcare.\64\ The Committee contends that these
repeated requests for additional appropriations are outside the
scope what would typically constitute an ``emergency''
designation and believe VA must improve its community care
accounting, bringing all projections for care purchased from
the community back into the standard budget request process.
Section 209 of the bill would require VA to submit a
justification to any request for supplemental appropriations,
based upon sound actuarial analysis. It would require VA's
Chief Financial Officer to certify the sufficiency, to the
extent possible, of VA's annual budget submission to provide
benefits and health services to veterans, as required by law.
---------------------------------------------------------------------------
\64\December 12, 2017. Letter from the Honorable David J. Shulkin
M.D., Secretary of the U.S. Department of Veterans Affairs to the
Honorable David P. Roe, Chairman of the Committee on Veterans' Affairs
of the U.S. House of Representatives. https://veterans.house.gov/
uploadedfiles/roe.pdf.
---------------------------------------------------------------------------
Sec. 210. Authority for Department of Veterans Affairs Center for
Innovation for Care and Payment
As a nationwide system, VA has struggled to maximize
efficiency of payment and care in its clinics and hospitals.
Some areas have seen improvement, while others have fallen
behind. Section 210 of the bill would address this by amending
subchapter I of chapter 17, as amended by section 122, by
authorizing a ``Center for Innovation for Care and Payment.''
Through this center, the Secretary could 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. The programs could
be carried out in locations appropriate for the intended
purpose of the programs, and no pilot shall last longer than
five years. The Secretary would be required to obtain advice
from the VA special Medical Advisory Group in the development
and implementation of any pilot. In implementing the pilot
programs, the Secretary would be authorized 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. The Secretary would only be
allowed to act upon any such waiver after Congress enacts a
bill or joint resolution approving the action. The Secretary
would be required to conduct an evaluation of each model tested
and make such information public.
TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS
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. These programs include the Education
Debt Repayment Program (EDRP) and the Health Professions
Scholarship Program (HPSP). Physician remains the top position
in VA's mission critical positions shortage despite these
programs, with VA indicating a need to hire more than one
thousand additional physicians in fiscal year 2017.\65\ VA's
considerable recruitment and retention issues are worsened by
an aging workforce that is becoming increasingly retirement-
eligible.\66\
---------------------------------------------------------------------------
\65\United States Cong. House Committee on Veterans' Affairs.
Oversight Hearing. March 22, 2017. 115th Cong. 1st sess. Washington:
GPO, 2017 (Question for the Record response from the U.S. Department of
Veterans Affairs.)
\66\United States Cong. House Committee on Veterans' Affairs.
Legislative Hearing. March 16, 2016. 114th Cong. 2nd sess. Washingtoon:
GPO, 2016. (Testimony from the Partnership for Public Service.)
---------------------------------------------------------------------------
To help alleviate the shortage of physicians and increases
the number of young physicians working at VA, section 301 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--Establishment of Department of Veterans Affairs Specialty
Education Loan Re-payment Program
The average medical education debt is approximately
$192,000 for a 2017 graduate.\67\ VA's current loan repayment
program is offered just before a resident completes training or
has completed training in exchange for service at a VA
facility. The Veterans Integrated Service Network (VISN)
determines how much EDRP funds are allotted to each facility
and each facility director is authorized to offer up to $24,000
annually in exchange for service. The timing of the offer
presents potential obstacles as VA is competing with other
professional and financial opportunities for physicians. The
salaries offered by other practices are competitive with VA,
and the anticipated salary is high enough so that the burden of
a loan payment may not appear onerous.\68\ Moreover, because of
VHA human resource policies for hiring physicians, for example,
firm offers cannot be made until physical examinations and
credentialing are completed, the earliest of which are 120 days
prior to starting a position, many senior resident physicians
are offered positions earlier than VA\69\ thus obviating the
ability to present the EDRP to potential hires. Lastly, the
EDRP program is effectuated at the local level based on local
needs, therefore does not have a mechanism for VA to direct
funds to recognized needed specialties on a national level.
---------------------------------------------------------------------------
\67\AAMC Medical School Graduation Questionnaire. https://
www.aamc.org/download/481784/data/2017gqallschoolssummaryreport.pdf.
\68\Medscape Physician Compensation Report 2917. https://
www.medscape.com/slideshow/compensation-2017-overview-6008547#4.
\69\Darves, B, Physician Job-Search Timeline: Delayed Approach Not
Advised; The New England Journal of Medicine, October 8, 2014.
---------------------------------------------------------------------------
Section 302 would establish a new loan repayment program
for medical or osteopathic student educational loans for newly
graduated medical students, or residents with at least 2 years
of training remaining, 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, this would make the
loan repayment is more economically meaningful and allow VA to
fund specialty positions in shortage areas, develop a
predictable future physician workforce, and ensure a cadre of
young physicians are able to join VA's physician workforce.
Section 303--Veterans Healing Veterans Medical Access and Scholarship
Program
In order to assist VA in recruiting veteran physicians,
section 303 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 the four
traditional black medical schools. 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 military discharge who are
not eligible for GI Bill benefits but who meet the minimum
admission requirement for medical school and apply for the
entering class of 2019. 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.
Hearings
There were no Subcommittee hearings held on H.R. 4242, as
amended.
On October 24, 2017, the full Committee conducted a
legislative hearing on a number of bills including a draft bill
that was later introduced as H.R. 4242.
The following witnesses testified:
The Honorable Jim Banks, U.S. House of
Representatives, 3rd District, Indiana; The Honorable
Mike Gallagher, U.S. House of Representatives, 8th
District, Wisconsin; The Honorable John R. Carter, U.S.
House of Representatives, 31st District, Texas; The
Honorable Glenn Thompson, U.S. House of
Representatives, 5th District, Pennsylvania; The
Honorable Neal P. Dunn, U.S. House of Representatives,
2nd District, Florida; The Honorable Andy Barr, U.S.
House of Representatives, 6th District, Kentucky; The
Honorable David J. Shulkin, M.D., Secretary, U.S.
Department of Veterans Affairs, who was accompanied by
Carolyn Clancy M.D, the Executive in Charge of the
Veterans Health Administration, and Laurie Zephyrin
M.D., MPH, MBA, the Acting Deputy Under Secretary for
Health for Community Care for the Veterans Health
Administration; Adrian M. Atizado, Deputy National
Legislative Director, Disabled American Veterans;
Roscoe G. Butler, Deputy Director for Health Care,
Veterans Affairs and Rehabilitation Division, The
American Legion; and, Kayda Keleher, Associate
Director, National Legislative Service, Veterans of
Foreign Wars of the United States.
Statements for the record were submitted by:
American Federation of Government Employees, AFL-CIO;
American Health Care Association; American Medical
Association; AMVETS; Concerned Veterans of America;
Fleet Reserve Association; Got Your 6; Health IT Now;
Iraq and Afghanistan Veterans of America; Military
Officers Association of America; Military Order of the
Purple Heart; National Alliance on Mental Illness;
National Guard Association of the United States; Nurses
Organization of Veterans Affairs/Association of VA
Psychologist Leaders/Association of VA Social Workers/
Veterans Healthcare Action Campaign; Paralyzed Veterans
of America; Reserve Officers Association; University of
Pittsburgh; Vietnam Veterans of America; and, the
Wounded Warrior Project.
Subcommittee Consideration
There was no Subcommittee consideration of H.R. 4242, as
amended.
Committee Consideration
On December 19, 2017, the full Committee met in open markup
session, a quorum being present, and ordered H.R. 4242, as
amended, to be reported favorably to the House of
Representatives by roll call vote.
During consideration of the bill, the following amendments
were considered en bloc and agreed to via voice:
An amendment offered by Representative John
Rutherford of Florida to improve VA's ability to
recruit physicians and dentists through scholarship and
educational loan repayment programs.
An amendment offered by Representative Neal Dunn of
Florida to authorize veterans to obtain a transplant
outside such veteran's Organ Procurement and
Transplantation Network region if veteran's primary
care provider opines that there is a medically
compelling reason and authorize VA to support the cost
of a donor transplant operation for a live donor who is
not a veteran but who is donating an organ to a
veteran.
An amendment offered by Representative Mike Coffman
of Colorado to require community care providers to be
aware of and comply with VA's Opioid Safety Initiative.
An amendment offered by Representative Jenniffer
Gonzalez-Colon of Puerto Rico to require VA to report
on health services provided veterans in the Northern
Mariana Islands, Puerto Rico, American Samoa, Guam, and
the Virgin Islands.
An amendment offered by Representative Julia Brownley
of California to require VA to use actuarial analysis
based on accurate demand forecasting, to certify
financial projections, to limit supplemental budget
requests unless absolutely necessary, and--when
requesting supplemental appropriations or any other
request outside the standard budget process--to provide
justification for such request.
An amendment offered by Representative Gus Bilirakis
of Florida to require VA to certify that community care
providers have not been excluded from participating in
federally funded health programs.
During consideration of the bill, the following amendments
were considered:
An amendment offered and then withdrawn by
Representative Elizabeth Esty of Connecticut to require
VA to establish a center of excellence for the
prevention, diagnosis, mitigation, treatment, and
rehabilitation of health conditions related to exposure
to burn pits and other environmental exposures.
An amendment offered and then withdrawn by
Representative Elizabeth Esty of Connecticut to expand
the Comprehensive Assistance for Family Caregivers
program to caregivers of pre-9/11 veterans.
An amendment offered by Representative David P. Roe
of Tennessee, the Chairman of the full Committee, to:
(1) authorize, rather than require, VA to provide
deference to a veteran when resolving disputes
regarding primary care provider designations; (2)
establish a process to transition veterans between VA
and community primary care providers; and (3) authorize
VA to incorporate values-based productivity models and
take non-clinical duties like training and research
into account when establishing performance standards.
The amendment was agreed to by voice vote.
An amendment offered and then withdrawn by
Representative David P. Roe of Tennessee, the Chairman
of the full Committee, to set a community care
authorization level for fiscal years 2019 through 2022.
An amendment offered by Representative David P. Roe
of Tennessee, the Chairman of the full Committee, to
create a Center for Innovation for Care and Payment.
The amendment was agreed to by voice vote.
An amendment offered by Representative Mark Takano of
California to require Veteran Care Agreements to be
subject to Federal Acquisition Regulations. The
amendment was not agreed to by voice vote.
An amendment offered by Representative Mark Takano of
California to set the minimum level of VA employees at
405,386 as of September 30, 2019. The amendment was not
agreed to by a recorded vote of 9 yeas to 14 noes.
An amendment offered by Representative Mark Takano of
California to establish an Office of Non-VA Delivered
Medical Care Accountability. The amendment was not
agreed to by voice vote.
An amendment offered by Representative Ann Kuster of
New Hampshire to require VA to consider whether a
veteran resides in a state with no VA medical center
when establishing eligibility criteria for any program
that furnishes primary or specialty care through a
community provider. The amendment was agreed to by
voice vote.
An amendment offered by Representative Julia Brownley
of California to amend the authorization of
appropriations for VA major medical facility leases by
requiring the Committees on Veterans' Affairs of the
Senate and House of Representatives to adopt
resolutions approving the leases. The amendment was not
agreed to by a recorded vote of 9 yeas to 14 noes.
An amendment in the nature of a substitute offered by
Representative Tim Walz of Minnesota, the Ranking
Member of full Committee. The amendment in the nature
of a substitute was not agreed to by a recorded vote of
9 yeas to 14 noes.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives require the Committee to list the recorded
votes on motions to report legislation and amendments thereto.
During the full Committee markup of H.R. 4242, as amended, on
December 19, 2017, four recorded votes were taken and are
described below.
An amendment offered by Representative Mark Takano of
California to set the minimum level of VA employees at 405,386
as of September 30, 2019, was not agreed to by a recorded vote
of 9 yeas to 14 noes. The names of the Members who voted for
and against are as follows:
An amendment offered by Representative Julia Brownley of
California to amend the authorization of appropriations for VA
major medical facility leases by requiring the Committees on
Veterans' Affairs of the Senate and House of Representatives to
adopt resolutions approving the leases was not agreed to by a
recorded vote of 9 yeas to 14 noes. The names of the Members
who voted for and against are as follows:
An amendment in the nature of a substitute offered by
Representative Tim Walz of Minnesota, the Ranking Member of
full Committee, was not agreed to by a recorded vote of 9 yeas
to 14 noes. The names of the Members who voted for and against
are as follows:
A motion by Representative Gus Bilirakis of Florida, the
Vice Chairman of the Committee on Veterans' Affairs, to report
H.R. 4242, as amended, favorably to the House of
Representatives was agreed to by a recorded vote of 14 yeas and
9 noes. The names of the Members who voted for and against the
motion are as follows:
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 improve the provision of timely,
quality care to veteran patients through both VA medical
facilities and VA community care providers.
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 adopts as its
own the estimate of new budget authority, entitlement
authority, or tax expenditures or revenues contained in the
cost estimate prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Earmarks and Tax and Tariff Benefits
H.R. 4242, as amended, 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 adopts as its own the cost estimate on H.R.
4242, as amended, prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Congressional Budget Office Cost Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
for H.R. 4242, as amended, provided by the Congressional Budget
Office pursuant to section 402 of the Congressional Budget Act
of 1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, February 15, 2018.
Hon. Phil Roe, M.D.,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 4242, the VA Care
in the Community Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Ann E.
Futrell.
Sincerely,
Keith Hall,
Director.
Enclosure.
H.R. 4242--VA Care in the Community Act
Summary: H.R. 4242 would increase the use of community
health care and long-term care by the Department of Veterans
Affairs (VA) by broadening eligibility for such care and
allowing VA to enter into agreements with health care providers
in the private sector without complying with the Federal
Acquisition Regulation (FAR). The bill also would change VA's
coverage of ambulance services and transplant operations at
nondepartment facilities. In addition, H.R. 4242 would allow VA
to repay loans for and provide scholarships to its medical
staff. In total, CBO estimates that implementing the bill would
cost $38.8 billion over the 2018-2022 period, assuming
appropriation of the necessary amounts.
Enacting the bill would not affect direct spending or
revenues; therefore, pay-as-you-go procedures do not apply.
CBO estimates that enacting H.R. 4242 would not increase
net direct spending or on-budget deficits in any of the four
consecutive 10-year periods beginning in 2028.
H.R. 4242 would impose an intergovernmental mandate as
defined in the Unfunded Mandates Reform Act (UMRA) by
preempting state laws that prohibit VA physicians from
practicing telemedicine to treat veterans across state lines.
Although it would limit the application of state regulations,
that mandate would impose no duty on state governments that
would result in additional spending or any significant loss of
revenues.
The bill contains no private-sector mandates as defined in
UMRA.
Estimated cost to the Federal Government: The estimated
budgetary effects of H.R. 4242 are shown in the following
table. The costs of this legislation fall within budget
function 700 (veterans benefits and services).
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------
2018 2019 2020 2021 2022 2018-2022
----------------------------------------------------------------------------------------------------------------
INCREASES IN SPENDING SUBJECT TO APPROPRIATION
VA Care in the Community Program:
Estimated Authorization Level............. 200 2,000 4,200 6,700 8,800 21,900
Estimated Outlays......................... 200 1,700 3,900 6,200 8,300 20,300
Veterans Care Agreements:
Estimated Authorization Level............. * 4,400 4,500 4,700 4,800 18,400
Estimated Outlays......................... * 3,800 4,300 4,500 4,700 17,300
Agreements for State Veterans Homes:
Estimated Authorization Level............. 0 80 110 130 160 480
Estimated Outlays......................... 0 70 100 130 150 450
Center for Innovation for Care and Payment:
Estimated Authorization Level............. 2 3 86 131 128 350
Estimated Outlays......................... 2 3 75 122 124 326
Ambulance Services:
Estimated Authorization Level............. 0 57 78 80 83 298
Estimated Outlays......................... 0 50 73 77 81 281
Transplant Donors:
Estimated Authorization Level............. 2 17 35 47 49 150
Estimated Outlays......................... 2 15 32 44 47 140
Health Professional Scholarship Program:
Estimated Authorization Level............. 0 0 4 6 6 16
Estimated Outlays......................... 0 0 3 6 6 15
Loan Repayment for Medical Specialists:
Estimated Authorization Level............. 1 3 3 3 3 13
Estimated Outlays......................... 1 3 3 3 3 13
Health Care Productivity:
Estimated Authorization Level............. 1 2 2 2 2 9
Estimated Outlays......................... 1 2 2 2 2 9
Scholarship Program:
Estimated Authorization Level............. 0 2 2 2 2 8
Estimated Outlays......................... 0 2 2 2 2 8
Total Changes in Spending Subject to
Appropriation:
Estimated Authorization Level......... 206 6,564 9,020 11,801 14,033 41,624
Estimated Outlays..................... 206 5,645 8,490 11,086 13,415 38,842
----------------------------------------------------------------------------------------------------------------
* = between zero and $500,000; VA = Department of Veterans Affairs.
Basis of estimate: For this estimate, CBO assumes that the
bill will be enacted early in calendar year 2018 and that the
estimated amounts will be appropriated each year. Estimated
outlays are based on historical spending patterns for the
affected programs.
VA Care in the Community Program. Section 102 would
establish the VA Care in the Community Program. Through that
program, the department would establish networks of health care
providers outside of VA to furnish hospital care, medical
services, and extended-care services to veterans enrolled in
the VA health care system. Under the program, subject to
appropriations, VA would be required to pay for care through
those networks if VA cannot assign the veteran to a suitable
primary care physician or a Patient Aligned Care Team (PACT) at
a VA medical facility. Assignment may be unsuitable in the
following situations:
The veteran would face excessive challenges
in receiving care at a VA medical facility because of
geographic, environmental, or medical factors;
The veteran believes that the assignment to
a particular primary care physician or PACT at a VA
medical facility would result in unsatisfactory health
care;
The veteran would face long wait times for
care at a VA medical facility; or
The veteran resides in a state without a
full-service medical facility (such as Alaska, Hawaii,
or New Hampshire).
Veterans may later choose to receive care at a VA medical
facility if VA notifies them that a primary care provider or a
PACT has become available.
The bill would require VA to promulgate regulations to
implement the program within one year.
The VA Care in the Community Program is similar to the
Veterans Choice Program (VCP), which CBO expects will end in
2018. The VCP provides community care to veterans who face
excessive wait times or live 40 miles or more from a VA medical
facility. CBO estimated the costs for the VA Care in the
Community Program based on information about the VCP.
CBO expects that the VA Care in the Community Program would
cost more than the VCP for the following reasons:
Veterans would make more visits for community
health care because once they are referred for community care
they could see network providers for primary care for at least
one year without additional authorization from VA.
Veterans would be eligible for community care
under the new program in more circumstances.
However, there are several factors that CBO expects would
constrain that cost growth:
Diverting more veterans to community care could
shorten wait times at VA facilities and thus reduce the number
of veterans who would need to be referred to community care
because VA care was not available in a timely fashion.
Regulations that need to be written to implement
the program could curtail use.
Veterans would need approval from VA to receive
certain specialty services.
The size and scope of community care networks
could be limited, particularly in rural areas, reducing the
accessibility of such care.
VA might implement the program slowly, as it did
the VCP.
CBO expects that the new program would be implemented
gradually and by 2022, usage of the new program would be 30
percent greater than for the VCP. CBO estimates that eventually
usage of the new program would be about 75 percent greater than
that of the VCP.
In 2017, VA processed 8.7 million claims at a total cost of
$5 billion for community health care under the VCP. After
accounting for the increase in usage, inflation, and underlying
growth in enrollment in the VA health system, CBO estimates
that the new program would cost $8.3 billion by 2022. In total,
implementing section 102 would cost $20.3 billion over the
2018-2022 period, CBO estimates.
Veterans Care Agreements. Section 103 would allow VA to
enter into Veterans Care Agreements with health care providers
in the community to provide hospital care, medical services, or
extended care to eligible veterans. The authorization for such
agreements would exempt VA from using the competitive bidding
procedures as required under the FAR. The FAR is an extensive
and complex set of rules governing the federal government's
purchasing processes.
Under current law, VA must comply with the FAR for
agreements and contracts with community health care and
extended-care providers.
According to VA, the FAR's requirements are appropriate for
large and long-term agreements for contracted health care
services but may not be practical for case-by-case arrangements
in all regions of the United States. H.R. 4242 would allow VA
to use other agreements for certain health care services and
extended care provided outside the VA system.
For 2018, the Congress has provided roughly $10 billion for
community health care at VA (excluding the VCP). Using
information from VA, CBO estimates that implementing section
103 would give VA the legal authority to continue to provide
about 40 percent (or roughly $4 billion annually) of that
community health care. After adjusting for inflation and
accounting for existing appropriations, CBO estimates that
implementing this section would cost $17.3 billion over the
2018-2022 period.
Agreements for State Veterans Homes. Section 104 would
waive the requirements of the FAR for contracts and agreements
that VA enters into with state-run nursing homes for veterans.
Under current law, the state veterans' homes (SVHs) must fill
75 percent of their beds with veterans. Under a contract or
agreement, VA pays SVHs the full cost of care for veterans with
a service-connected disability (SCD) rating of 70 percent or
more. For all other veterans, VA pays SVHs a fixed daily
allowance.
According to VA, in 2015 the department used such
agreements to reimburse state-run nursing homes at a daily rate
of $380 for each veteran with an SCD of 70 percent or more--at
an annual cost of roughly $350 million (or 37 percent of the
total reimbursed to SVHs). However, those agreements do not
comply with the FAR, and VA does not expect to be able to enter
into new FAR-compliant agreements with any of the SVHs. In the
absence of this legislation, CBO expects that VA would
gradually phase out the use of such agreements as veterans who
are currently under that payment structure die or leave the
SVHs. Those veterans would probably be replaced by veterans
under the lower daily allowance rate of roughly $100 per
patient. By allowing VA to enter into agreements outside of the
FAR framework, CBO estimates, this proposal would more than
triple VA's reimbursements to SVHs for veterans with SCDs of 70
percent or more.
As a result, after factoring in a gradual phaseout of
existing non-FAR agreements, CBO estimates that enacting this
provision would cost $450 million over the 2018-2022 period.
The additional costs from waiving the FAR requirements would
begin in 2019. Because appropriations already have been
provided for such agreements in 2018, no additional funding
would be necessary in that year.
Center for Innovation for Care and Payment. Section 210
would require VA to establish the Center for Innovation for
Care and Payment, which would evaluate ways to reduce costs and
increase efficiency at VA medical facilities. CBO expects that
the center would pursue programs similar to those that were
tested by the Center for Medicare and Medicaid Innovation
(CMMI) operated by the Centers for Medicare & Medicaid
Services. CBO estimates that costs for the center would be
similar to those for CMMI. CBO expects any savings that
resulted from the center's efforts would not occur in the next
five years.
In 2010, CMMI received $5 million to develop models for
reducing health care costs and increasing efficiency for
Medicare. CBO expects that VA would need similar resources to
establish its program. On the basis of information from the
department regarding the availability of necessary staff, CBO
expects that it would take VA two years to establish the center
at an estimated cost of $5 million over the 2018-2019 period.
CMMI received $10 billion over the 2011-2019 period to test
its models. CBO expects that VA's costs would be proportional.
VA Health Administration costs are approximately one-tenth
those of Medicare. After factoring in a gradual implementation
period similar to that of CMMI, CBO estimates that the costs
for the center would be $321 million over the 2020-2022 period.
In total, CBO estimates that implementing section 210 would
cost $326 million over the 2018-2022 period.
Ambulance Services. Section 201 would require VA to
reimburse veterans for ambulance services under certain
conditions. Currently, VA can choose to reimburse veterans for
ambulance services when they receive emergency care at
nondepartment medical facilities. H.R. 4242 would require VA to
cover the cost of ambulance services if a delay in providing
immediate medical attention could result in death or harm to
the veteran.
Using data from the National Institutes of Health and VA,
CBO estimates that VA would reimburse veterans for about
165,000 ambulance trips each year, at an average cost of $480
per trip. The bill would require VA to pay for ambulance trips
after January 1, 2019. Thus, CBO estimates that implementing
section 201 would cost $281 million over the 2018-2022 period.
Transplant Donors. Section 109 would allow VA to cover
costs related to organ transplant procedures incurred by
veterans and their living donors for procedures at
nondepartment facilities. Currently, VA covers the medical and
service expenses (such as transportation and lodging) for
veterans and their living donors only for procedures performed
at the Department of Veterans Affairs Transplant Centers
(VATCs). Otherwise, VA reimburses donors only for
transportation and lodging. In 2017, VA provided 560 organ
transplants, most at VATCs. Of those operations, about 200 were
kidney transplants and about 20 involved living donors.
Section 109 would authorize VA to pay for transplant
procedures at various locations nationwide with minimal out-of-
pocket expenses for veterans and their living donors. As a
result, CBO expects more veterans would use VA for such
procedures and more people would be willing to donate organs.
In determining the additional number of transplant procedures,
CBO considered the other sources of health care coverage
carried by enrolled veterans and the likelihood, under this
proposal, that those veterans would instead use VA for their
transplant procedures.
Using information from the Census Bureau, VA, and the
Department of Health and Human Services, CBO estimates that
under section 109, roughly 60 additional veterans would undergo
transplants at nondepartment facilities each year, at an
average cost of $750,000 per patient. CBO estimates that VA
would cover the medical expenses of an additional 50 living
donors (some for procedures that will occur under current law
but for which VA would not pay medical expenses) each year, at
an average cost of $80,000 per donor. In addition, CBO believes
that implementing this section would allow veterans to undergo
transplants closer to home. As a result, CBO estimates a
reduction in transportation reimbursements of about $4 million
each year. Based on the expectation that VA would implement the
bill gradually, CBO estimates that implementing section 109
would have a net cost of $140 million over the 2018-2022
period.
Health Professional Scholarship Program. Section 301 would
extend the Health Professional Scholarship Program, currently
set to expire on December 31, 2019, through December 31, 2033.
At an annual cost of $5 million, the program subsidizes tuition
and educational fees and provides monthly stipends to medical
students who pursue careers at VA. After accounting for rising
tuition costs, CBO estimates that implementing section 301
would cost $15 million over the 2019-2022 period.
Loan Repayment for Medical Specialists. Section 302 would
authorize VA to repay the education loans of practitioners in
medical specialties for which the department has difficulty
recruiting. In exchange, those specialists would commit to work
for VA for two to four years. The payments could not exceed
$40,000 for each year worked or a total of $160,000 over four
years. Those limits could be waived for medical positions for
which a shortage exists because of the location or requirements
of the position.
Under a similar loan repayment program, VA can reimburse up
to $120,000 for tuition and educational fees for medical
personnel at the department. In 2016, roughly 2,000 employees
(or less than 1 percent of total employees) received an average
award of about $15,000. On the basis of participation rates and
costs of that program, CBO estimates that roughly 120 medical
practitioners in specialty areas would participate in the new
program each year and would receive an average annual award of
$23,000. After factoring in a gradual implementation period and
growth in tuition, CBO estimates that implementing section 302
would cost $13 million over the 2018-2022 period.
Health Care Productivity. Section 205 would require that VA
develop standards for using relative-value units (RVUs) to
evaluate medical services. It also would require VA to train
its health care providers to use and adhere to those standards.
RVUs are tools used by physicians participating in Medicare to
rank on a common scale the resources (such as medical supplies)
used to provide health care.
On the basis of information from VA regarding its ability
to train personnel to use RVUs in all department facilities,
CBO estimates that VA would need to hire the equivalent of 10
full-time clinicians at an average annual compensation of
$150,000 to develop standards and provide ongoing training and
support. CBO expects that VA would develop an internal website
to train its medical providers to use RVUs. CBO estimates that
development of the website would cost less than $500,000.
As a result, CBO estimates that implementing section 205
would cost $9 million over the 2018-2022 period.
Scholarship Program. Section 303 would require VA to fully
cover the costs of medical school for 18 eligible veterans.
Under this scholarship program, VA would pay for tuition,
books, fees, technical equipment, rotations, and reasonable
living expenses for newly separated veterans who enter medical
school in 2019. Veterans who are entitled to other education
benefits provided by VA would not be eligible. Participating
veterans would be required to agree to work full time at a VA
medical facility for four years after completing medical
school.
On the basis of the average costs to attend a private
medical school, which includes tuition, books, fees, and
technical equipment, CBO estimates that annual costs would
average $69,000 per awardee. After adjusting for growth in the
costs of medical school, CBO estimates that such education
expenses would cost $5 million over the 2019-2022 period.
The Department of Defense pays monthly stipends for living
expenses to recipients of similar scholarships that currently
average $2,229 a month. On that basis, CBO estimates that
individual stipends would total roughly $25,000 over a 10.5-
month school year. After adjusting for inflation, CBO estimates
that such stipends would cost a total of $2 million over the
2019-2022 period. In addition, CBO estimates that the costs of
residency fees, off-site rotations, and reports would cost $1
million over 2020-2022 period.
In total, CBO estimates that implementing section 303 would
cost $8 million over the 2019-2022 period.
Pay-As-You-Go considerations: None.
Increase in long-term direct spending and deficits: CBO
estimates that enacting H.R. 4242 would not increase net direct
spending or on-budget deficits in any of the four consecutive
10-year periods beginning in 2028.
Mandates: H.R. 4242 would impose an intergovernmental
mandate as defined in UMRA by preempting state laws that
prohibit VA physicians from practicing telemedicine to treat
veterans across state lines. Although it would limit the
application of state regulations, that mandate would impose no
duty on state governments that would result in additional
spending or any significant loss of revenues.
The bill contains no private-sector mandates as defined in
UMRA.
Previous CBO estimates: On January 17, 2018, CBO
transmitted a cost estimate for S. 2193, the Caring for Our
Veterans Act of 2017, as ordered reported by the Senate
Committee on Veterans' Affairs on December 5, 2017. Sections
102, 103, and 242 in S. 2193 are similar to sections 103, 104,
and 109 of H.R. 4242 and the estimated costs for those sections
are the same for each bill.
Estimate prepared by: Federal costs: Ann E. Futrell;
Mandates: Andrew Laughlin.
Estimate approved by: Leo Lex; Deputy Assistant Director
for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 4242, as amended, 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.
4242, as amended.
Statement of Constitutional Authority
Pursuant to Article I, section 8 of the United States
Constitution, H.R. 4242, as amended 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. 4242, as amended, 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 section 3(g) of H. Res. 5, 115th Cong. (2017),
the Committee finds that no provision of H.R. 4242, as amended,
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. 4242, as amended, contains no
directed rulemaking that would require the Secretary to
prescribe regulations.
Section-by-Section Analysis of the Legislation
TITLE I--IMPROVED ACCESS FOR VETERANS TO NONDEPARTMENT OF VETERANS
AFFAIRS MEDICAL CARE
Sec 101. Assignment of veterans to primary care providers
Section 101 of the bill would amend Section 1706 of Title
38, U.S.C., by adding a new subsection (d).
Section 1706(d) requires VA to assign each eligible veteran
to a PACT team of the Department, or a dedicated primary care
provider of the department. This section also defines the term
``eligible veteran''.
Section 102. Establishment of VA Care in the Community Program
Section 102(a) of the bill would amend section 1703 of
title 38, U.S.C., by inserting after section 1703 a new section
1703A:
Section 1703A(a) of the bill would establish a permanent
authority for the VA Care in the Community program to provide
hospital care, medical services and extended care to eligible
veterans through contracts and agreements. Under this section,
VA would coordinate the care provided to eligible veterans
through regional networks of community providers, which are to
be periodically assessed for capacity.
Section 1703A(b) allows for a veteran to choose a provider
from among network providers located in a regional network (or
adjacent network, if closer) if VA does not have an available
or accessible primary care provider for the veteran. Upon this
election, a veteran may utilize this primary care provider for
a period of one year and shall not be counted twice against a
VA primary care provider's panel size. Should a VA primary care
provider become available, the veteran will be given an option
to be reassigned. This section requires VA to consider the
following when determining if a VA provider is available for
assignment: if the veteran faces unusual excessive burden such
as geographical challenges, environmental factors, or medical
conditions; if the veteran reasonably believes the assigned
care team is detrimental to the patient-provider relationship
and/or could result in suboptimal care; if the panel size of
the team is such a number that it would prevent timely access
to care or lead to sub-optimal results; or the veteran resides
in a State where the Department does not operate a full medical
facility. In an appeal of VA's assignment under this section,
VA may give deference to the veteran if the veteran reasonably
believes that their assignment would result in suboptimal care.
Under this section, specialty care requires a referral from the
veteran's primary care provider, with the ability for the
Secretary to make exceptions. VA shall determine whether
specialty care is to be sourced from a nearby VA facility,
through a network provider, or pursuant to other agreements--
with preference given to VA facilities subject to various
factors of veteran accommodation. This section requires
referrals to be processed in a standardized manner to include
the organization of a pF1rogram office at each facility. The
Secretary shall establish a process to review any disagreements
between the veteran, the Department, or provider as to
eligibility for care or services under this section. This
section also requires VA to establish procedures for
transitioning a veteran to a different primary care provider so
as to not adversely impact continuity of care, to include the
appointment of a contact to resolve issues, transfer of
relevant records, continued and coordinated treatment for
chronic or current episodes of care.
Section 1703A(c) establishes that care shall be authorized
through the completion of an episode of care to include all
specialty and ancillary services deemed necessary. This section
requires VA to provide case management for the veteran, when
appropriate, and allows for case management to be provided
through the network. Under this section, VA is authorized to
pay non-network providers who provide care as part of an
episode of care and VA shall take reasonable efforts to enter
into contracts or agreements with them.
Section 1703A(d) establishes that the rates for non-VA care
shall not exceed Medicare rates, with exceptions for highly
rural states that require adjusted rates. This section allows
for VA to incorporate value-based reimbursement models and for
VA to establish a schedule of fees for care not covered under
Medicare. VA may also negotiate higher rates pursuant to an
agreement with a tribal or federal entity.
Section 1703A(e) establishes a 180 day requirement for
claim submissions and states that all parties shall pay or
notify of denial of a claim no later than 45 days for ``clean''
claims and 30 days for electronic claims with an additional 30
days to respond. If a claim is overdue, the penalty will be
prorated daily, accrue from overdue date, computed at U.S.
Treasury interest rate, and shall be resolved in subsequent
billing or no later than 30 days of determination. This section
states that the receipt of medical records is not required for
payment, but the provider must attest to the provision of care
or services.
Section 1703A(f) establishes that veterans who would pay a
copay within the VA system would pay the same amount if
receiving care from the community network. This section also
requires VA to seek reimbursement from other non-government
health care plans for non-service-connected condition care.
Section 1703A(g) requires network providers to provide
medical records to veterans upon request and to the VA upon
completion of care. Likewise, VA shall provide medical records
as needed to network providers. VA shall also ensure medical
records can be shared in an electronic format and community
providers can have access to them.
Section 1703A(h) requires VA to ensure that existing VA
identification cards are sufficient for receiving community
care and specifically prohibits VA from creating a separate
card for the program.
Section 1703A(i) states that formulary prescriptions can be
submitted by community providers to the VA in the same manner,
utilizing the same credentials, as community providers would
submit to any retail pharmacy.
Section 1703A(j) requires the Secretary to use the quality
of care standards as set by the Centers for Medicare & Medicaid
Services (CMS) or other standards as determined by the
Secretary.
Section 1703A(k) requires VA to assess, no less than once
every three years, the capacity of each department medical
center, identify gaps and how they will be filled, and forecast
short and long term demands and how they impact network
composition. VA shall also include commercial health care
market assessment for services available within designated
catchment areas.
Section 1703A(l) requires VA to plan for the allocation of
funds within the Medical Community Care accounts.
Section 1703A(m) requires VA to provide an annual report
for the next three years detailing rates paid as an exception
to the Medicare rates.
Section 1703A(n) establishes definitions for the terms:
clean claim, covered claimant, covered payer, eligible veteran,
and fraudulent claim.
Section 102(b) provides conforming amendments to the bill.
Section 102(c) provides definitions for the following
terms: Network Provider, VA Care in the Community.
Section 102(d) requires that the bill may not be construed
to affect obligations entered into via prior agreements or
contracts.
Sec. 103. Veterans Care Agreements
Section 103 of the bill would amend Section 1706 of Title
38, U.S.C., by inserting after section 1703A, added by section
102, a new section 1703B--Veterans Care Agreements with non-
network providers:
Section 1703B(a) authorizes the use of provider agreements
in addition to contracts for care and services when contracts
are impractical or inadvisable. This section requires VA to
review each agreement once during the 18-month period beginning
six months after entering an agreement and each four-year
period after any agreement that exceeds $3 million for a
provider that furnishes homemaker or home health aide services,
or $1 million for any other provider.
Section 1703B(b) establishes the requirements for network
provider participation under the program.
Section 1703B(c) requires VA to establish a process for
certification of network providers under the program or to
adopt a process already administered by another Federal
department or agency.
Section 1703B(d) requires that agreements be applied in the
same manner as Section 1703A of Title 38, U.S.C.
Section 1703B(e) stipulates that network providers are not
subject to any provision that providers of Medicare and
Medicaid are not subject to, as well as other provisions of law
regarding integrity, ethics, fraud, protection of
whistleblowers, and Title VII of the Civil Rights Act of 1964.
Section 1703B(f) states that agreements can be terminated
by VA or the provider at such time and upon such notice as
required by the Secretary.
Section 1703B(g) requires VA to establish administrative
procedures to handle disputes, and states that entities must
exhaust administrative procedures before pursuing judicial
review.
Section 1703B(h) states that, in the course of an episode
of care, VA may compensate a non-network provider who provides
care as part of that treatment.
Section 1703B(i) requires VA to submit a report at the
beginning of each fiscal year on all provider agreements
entered into the prior year. The reporting requirement sunsets
five years after the date of enactment.
Section 1703B(j) requires VA to utilize quality of care
standards set forth by CMS or as determined by the Secretary.
Section 1703B(k) states that the authority to enter into
and terminate agreements shall not be delegated to below the
VISN Director or Director of a Network Contracting Office.
Section 1703B(l) provides definitions for the following
terms: Appropriate Congressional Committees, Eligible Veteran.
Section 103(b) provides a clerical amendment to this
section.
Sec. 104. Modification of authority to enter into agreements with state
homes to provide nursing home care
Section 104(a) allows for the use of agreements under the
program.
Section 104(b) exempts VA from certain competitive
procedures and states that providers are not subject to any
provision that providers of Medicare or Medicaid are not
subject to. This section also states that other provisions of
law regarding integrity, ethics, or fraud apply.
Section 104(c) requires VA to establish, through
regulations, an effective date to be published in the Federal
Register no later than 30 days prior to such date.
Sec. 105. Electronic interface for processing of claims
Section 105(a) establishes requirements for VA's Chief
Information Officer to put in place an IT system to receive,
process, and pay claims and outlines the capabilities required
of such an IT system.
Section 105(b) ensures that all federal information
protection requirements are met.
Section 105(c) allows for VA to enter into a contract for
the purposes of this section.
Section 105(d) sets definitions for the following terms:
electronic protected health information, covered non-department
health care providers, secure development requirements, VA Care
in the Community Program.
Sec. 106. Funding for VA Care in the Community Program
Section 106(a) requires all funds for Section 1703B to be
derived from the Medical Community Care Account.
Section 106(b) requires that all unobligated amounts from
Sec. 802 of PL 113-146 shall be transferred to the Medical
Community Care Account on the later of the following: one year
after enactment; or, the date on which the Secretary certifies
implementation of Section 1703A to Congress.
Section 106(c) defines the VA Care in the Community
Program.
Sec. 107. Termination of certain provisions authorizing care to
veterans through non-Department of Veterans Affairs providers
Section 107(a)(1) of the bill would amend Section 1703 of
Title 38, U.S.C., adding a new subsection (e):
Section 1703(e) of title 38, U.S.C., terminates Section
1703 of Title 38, U.S.C., upon VA's certification that 1703A is
fully implemented. This section also includes conforming
amendments regarding dental care, readjustment counseling,
death in a department facility and Medicare provider
agreements.
Section 107(b) repeals an authority for VA to contract for
scarce medical specialists.
Section 107(c) sets an effective date for amendments under
this section of the date on which the Secretary certifies that
Section 1073A of Title 38 is fully implemented.
Sec. 108. Implementation and transitions
Section 108(a) states that implementation of Sections 1703A
and 1703B of title 38, U.S.C., shall commence no later than one
year after enactment and that VA shall prescribe interim final
rules. The same date applies to the transfer of funds, as
required by section 106(b).
Section 108(b) requires the Secretary to certify that
providers and employees are trained to furnish care and
services under this program. This section requires VA to
establish written guidance on policies and procedures for the
program.
Sec. 109. Transplant procedures with live donors and related services
Section 109(a) of the bill would amend subchapter I of
chapter 17 of title 38, U.S.C. by inserting after Section 1703B
of title 38, U.S.C., Section 1703C--``Transplant Procedures
with Live Donors and Related Services.''
Section 1703C(a) of subchapter I, if a veteran is eligible
for a transplant procedure from the Department, the Secretary
may provide for a transplant operation on a live donor
notwithstanding the live donor's eligibility for health care
from the VA.
Section 1703C(b) of subchapter I authorizes VA to support
the cost of a donor transplant operation, including
perioperative care for a live donor who is not a veteran but
who is donating an organ for a veteran.
Section1703C(c) of subchapter I would allow for non-VA
facilities to be used for transplant operations on living
donors as long as the transplant center is in compliance with
regulations prescribed by the Centers for Medicare and Medicaid
Services.
TITLE II--OTHER ADMINISTRATIVE MATTERS
Sec. 201. Reimbursement for emergency ambulance services
Section 201(a) of the bill amends Section 1725(c) of title
38, U.S.C., by adding at the end a new paragraph:
Section 1725(c)(5) of title 38, U.S.C., delineates
circumstances for reimbursement of ambulance services and sets
a prudent layperson determination of the need for ambulance
services.
Section 201(b) sets an effective date of January 1, 2019.
Sec. 202. Improvement of care coordination for veterans through
exchange of certain medical records
Section 202 amends Section 7332(b) of title 38, U.S.C. to
allow for the provision of medical health information to non-
Department entities to provide treatment and to any third party
in order to recover or collect charges for non-service
connected care.
Sec. 203. Elimination of copay offset
Section 203(a) amends Section 7329(a) of title 38, U.S.C.,
to eliminate the offset of a veteran copay from amounts covered
from a third party.
Section 203(b) sets an effective date on the date of
enactment.
Sec. 204. Use of Department of Veterans Affairs Medical Care
Collections Fund for certain improvements in collections
Section 204 amends Section 1729A(c)(1)(B) of title 38,
U.S.C., to allow funds to be utilized for automatic data
processing or IT improvements.
Sec. 205. Department of Veterans Affairs health care productivity
improvement
Section 205(a) amends Subchapter I of chapter 17 of title
38, U.S.C., by inserting after Section 1705A a new section,
Section 1705B-- ``Management of health care'':
Section 1705B(a) requires VA to track relative value units
for all VA providers.
Section 1705B(b) requires VA providers to attend coding
training.
Section 1705B(c) requires VA to establish performance
standards based on nationally recognized relative value unit
standards.
Section 1705B(d) defines the following terms: department
provider, relative value unit.
Section 205(b) provides a clerical amendment for this
section.
Section 205(c) requires VA to submit a report regarding
implementation of this section by no later than one year after
enactment.
Sec. 206. Licensure of Health Care Professionals of the Department of
Veterans Affairs Providing Treatment via Telemedicine
Section 206(a) amends Chapter 17 of title 38, U.S.C., by
inserting after section 1730A a new section, Section 1730B--
``Licensure of Health Care Professionals Providing Treatment
via Telemedicine.''
Section 1730B(a) provides that any licensed covered
professional may provide telemedicine services in any state
regardless of where the provider or patient is located.
Section 17030B(b) states that the authorities under this
section applies regardless of whether the covered provider or
patient is located in a Federal facility.
Section 1730B(c) states that all provisions of the
Controlled Substances Act apply.
Section 1730B(d) defines the term ``covered health care
professional.''
Section 206(b) provides a clerical amendment for this
section.
Section 206(c) requires VA, by no later than one year after
enactment, to submit a report to Congress on the effectiveness
of telemedicine within VA. This report shall include an
assessment of patient and provider satisfaction, the effect on
access, patient utilization, productivity, wait times, and
utilization of facilities. This report shall include amount of
and types of appointments, as well as any savings achieved.
Sec. 207 Establishment of processes to ensure safe opioid prescribing
practices by non-Department of Veterans Affairs health care
providers
Section 207(a) of the bill would require VA to provide
Opioid Safety Initiative (OSI) guidelines to community
providers and certify that the community providers have
reviewed the guidelines.
Section 207(b) would implement a process to ensure that
community providers receive a veteran's relevant history
including all medications.
Section 207(c) would further require that opioid
prescriptions be filled at a VA pharmacy or a community
pharmacy only if prior authorization has been received (with an
exception for certain urgent or emergent circumstances), that
opioid prescriptions be recorded in the electronic health
record and monitored.
Section 207(d) requires that community providers whose
prescribing practices are inconsistent with OSI requirements or
violate licensing guidelines are removed from VA community care
networks.
Section 207(e) authorizes VA to revoke or deny eligibility
under this bill for providers who violate do not comply with
the Opioid Safety Initiative.
Section 207(f) defines the term ``Covered Health Care
Provider.''
Sec. 208 Assessment of health care furnished by the Department to
Veterans who live in the territories
Section 208 requires VA to submit a report, by no later
than 180 days after enactment of this bill, on the health
services provided to veterans in the US territories: Northern
Mariana Islands, Puerto Rico, American Samoa, Guam, and the
Virgin Islands. The report will also address the feasibility of
constructing any medical facilities in any of the above
territories that do not have such a facility.
Sec. 209 Oversight and accountability of financial processes of
Department of Veterans Affairs
Section 209(a) of the bill would require VA to submit a
justification to any request for supplemental appropriations,
based upon sound actuarial analysis.
Section 209(b) requires that whenever the Secretary submits
a supplemental funding request, the Secretary shall, not later
than 45 days before the date on which such budgetary issue
would start affecting a program or service, submit to Congress
a justification for the request and how long the requested
appropriations are expected to meet the needs of VA.
Section 209(c) would require VA's Chief Financial Officer
to certify the sufficiency, to the extent possible, of VA's
annual budget submission to provide benefits and health
services to veterans, as required by law.
Sec. 210 Authority for Department of Veterans Affairs Center for
Innovation for Care and Payment
Section 210(a) amends subchapter I of chapter 17, as
amended by section 122, by inserting after section 1703B of
title 38, U.S.C., as added by section 103, Section 1703C of
title 38, U.S.C.,--``Center for Innovation for Care and
Payment.''
Section 1703C(a) authorizes the Secretary 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.
Section 1703C(b) requires that no pilot under this section
shall last longer than five years.
Section 1703C(c) requires that the programs be carried out
in locations appropriate for the intended purpose of the
programs.
Section 1703C(d) states that the funding for the pilot
programs shall come from appropriations provided in advance for
VHA and IT systems.
Section 1703C(e) requires the Secretary to publish
information and take all reasonable action to give notice to
veterans eligible to participate in the pilot programs.
Section 1703C(f) authorizes the Secretary 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. The Secretary would only be
allowed to act upon any such waiver after Congress enacts a
bill or joint resolution approving the action.
Section 1703C(g) states that if the Secretary fails to
follow the waiver provisions, the waiver shall not apply.
Section 1703C(h) requires the Secretary to conduct an
evaluation of each model tested, and Section 1703C(i) requires
the Secretary to coordinate and consult with the Under
Secretary for Health and the VA Special Medical Advisory Group
regarding the pilot programs.
Section 1703C(j) states that should the program be
positively evaluated according to subsection (f) the Secretary
may, through rulemaking, expand the duration and scope of the
model being tested.
TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS
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 inserting at the end new paragraph (6).
Section 7612(b)(6)(A) would require the Secretary 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 the Secretary determines that staffing shortage of
dentists and physicians is lower than 500.
Section 7612(b)(6)(B) requires the Secretary to award
scholarships in an amount equal to not less than 10 percent of
the staffing shortage.
Section 7612(b)(6)(C) States that the Secretary's agreement
to provide 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.
Section 7612(b)(6)(D) The Secretary may give preference to
applicants who are veterans.
Section 7612(b)(6)(E) On an annual basis, the Secretary
shall provide to appropriate educational institutions
information material about the availability of scholarships.
Section 301(b) 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 from December 21,
2019, to December 31, 2033.
Sec. 302 Establishment of Department of Veterans Affairs Specialty
Education Loan Repayment Program
Section 302(a) 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.''
Section 7691 of subchapter VIII establishes a loan
repayment program to incentivize individuals employed in the
Veterans Health Administration to pursue education and training
in medical specialties for which the Secretary determines there
is a shortage.
Section7692 of subchapter VIII outlines the purpose of the
Specialty Education Loan Repayment Program.
Section 7693(a) of subchapter VIII outlines eligibility for
the participation in the Specialty Education Loan Repayment
Program.
Section 7693(b) of subchapter VIII states that the
Secretary may give preference to veterans in this program.
Section 7693(c) of subchapter VIII outlines which expenses
are allowed to be covered under this section.
Section 7694 of subchapter VIII outlines the manner in
which the Specialty Education Loan Repayment Program are to be
made.
Section 7695 of subchapter VIII allows each participant who
completes their residency to select their location of
employment from a list of medical facilities of the VHA.
Section 7696(a) of subchapter VIII outlines the terms of
the service obligation for the Specialty Education Loan
Repayment Program.
Section 7696(b) of subchapter VIII states 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, the Secretary, 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.
Section 7696(c) of subchapter VIII defines the formula by
which VA may seek monetary collections from an employee who
violates the terms of obligated service under this section.
Section 7697 of subchapter VIII allows 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.
Sec. 303 Veterans Healing Veterans Medical Access and Scholarship
Program
Section 303(a) establishes that the Secretary shall carry
out a pilot program under which the Secretary 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 303(b) outlines the eligibility requirements for
the Veterans Healing Veterans Medical Access and Scholarship
Program.
Section 303(c) requires 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 (A) tuition
for four years; (B) books, fees, and technical equipment; (C)
fees associated with the National Residency Match Program; (D)
two away rotations performed during the fourth year at a VA
medical facility; and (E) 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 303(d)(1) outlines the terms of the agreement for
eligible veterans who accept funding for medical education
under this section.
Section 303(d)(2) 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 303(e) allows covered schools to accept more than
two eligible veterans for the entering class of 2019.
Section 303(f) states that no later than December 31, 2020,
and annually thereafter for three years, the Secretary shall
submit to Congress a full report on the pilot program.
Section 303(g) defines ``covered medical schools'' as
Teague-Cranston medical schools and the medical schools of
Historically Black Colleges and Universities.
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 II--GENERAL BENEFITS
* * * * * * *
CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
SUBCHAPTER I--GENERAL
Sec.
1701. Definitions.
1702. Presumptions: psychosis after service in World War II and
following periods of war; mental illness following service in
the Persian Gulf War.
1703. Contracts for hospital care and medical services in non-Department
facilities.
1703A. VA Care in the Community Program.
1703B. Veterans Care Agreements with non-network providers.
1703C. Center for Innovation for Care and Payment.
1703C. Transplant procedures with live donors and related services.
1704. Preventive health services: annual report.
1705. Management of health care: patient enrollment system.
1705A. Management of health care: information regarding health-plan
contracts.
1705B. Management of health care: productivity.
1706. Management of health care: other requirements.
1707. Limitations.
1708. Temporary lodging.
1709. Comprehensive policy on reporting and tracking sexual assault
incidents and other safety incidents.
1709A. Teleconsultation.
1709B. Evaluations of mental health care and suicide prevention
programs.
SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL
TREATMENT
1710. Eligibility for hospital, nursing home, and domiciliary care.
1710A. Required nursing home care.
1710B. Extended care services.
1710C. Traumatic brain injury: plans for rehabilitation and
reintegration into the community.
1710D. Traumatic brain injury: comprehensive program for long-term
rehabilitation.
1710E. Traumatic brain injury: use of non-Department facilities for
rehabilitation.
1711. Care during examinations and in emergencies.
1712. Dental care; drugs and medicines for certain disabled veterans;
vaccines.
1712A. Eligibility for readjustment counseling and related mental health
services.
1712C. Dental insurance plan for veterans and survivors and dependents
of veterans.
1712B. Counseling for former prisoners of war.
[1713. Renumbered.]
1714. Fitting and training in use of prosthetic appliances; guide dogs;
service dogs.
1715. Tobacco for hospitalized veterans.
1716. Hospital care by other agencies of the United States.
1717. Home health services; invalid lifts and other devices.
1718. Therapeutic and rehabilitative activities.
1719. Repair or replacement of certain prosthetic and other appliances.
1720. Transfers for nursing home care; adult day health care.
1720A. Treatment and rehabilitative services for persons with drug or
alcohol dependency.
1720B. Respite care.
1720C. Noninstitutional alternatives to nursing home care.
1720D. Counseling and treatment for sexual trauma.
1720E. Nasopharyngeal radium irradiation.
1720F. Comprehensive program for suicide prevention among veterans.
1720G. Assistance and support services for caregivers.
1720H. Mental health treatment for veterans who served in classified
missions.
SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS
1721. Power to make rules and regulations.
1722. Determination of inability to defray necessary expenses; income
thresholds.
1722A. Copayment for medications.
1722B. Copayments: waiver of collection of copayments for telehealth and
telemedicine visits of veterans.
1723. Furnishing of clothing.
1724. Hospital care, medical services, and nursing home care abroad.
1725. Reimbursement for emergency treatment.
1726. Reimbursement for loss of personal effects by natural disaster.
1727. Persons eligible under prior law.
1728. Reimbursement of certain medical expenses.
1729. Recovery by the United States of the cost of certain care and
services.
1729A. Department of Veterans Affairs Medical Care Collections Fund.
1729B. Consolidated patient accounting centers.
1730. Community residential care.
1730A. Prohibition on collection of copayments from catastrophically
disabled veterans.
1730B. Licensure of health care professionals providing treatment via
telemedicine.
SUBCHAPTER IV--HOSPITAL CARE AND MEDICAL TREATMENT FOR VETERANS IN THE
REPUBLIC OF THE PHILIPPINES
1731. Assistance to the Republic of the Philippines.
1732. Contracts and grants to provide for the care and treatment of
United States veterans by the Veterans Memorial Medical
Center.
1733. Supervision of program by the President.
1734. Hospital and nursing home care and medical services in the United
States.
1735. Definitions.
SUBCHAPTER V--PAYMENTS TO STATE HOMES
1741. Criteria for payment.
1742. Inspections of such homes; restrictions on beneficiaries.
1743. Applications.
1744. Hiring and retention of nurses: payments to assist States.
1745. Nursing home care and medications for veterans with service-
connected disabilities.
SUBCHAPTER VI--SICKLE CELL ANEMIA
1751. Screening, counseling, and medical treatment.
1752. Research.
1753. Voluntary participation; confidentiality.
1754. Reports.
SUBCHAPTER VII--TRANSFERRED]
[1771 to 1774. Renumbered.]
SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS
1781. Medical care for survivors and dependents of certain veterans.
1782. Counseling, training, and mental health services for immediate
family members and caregivers.
1783. Bereavement counseling.
1784. Humanitarian care.
1784A. Examination and treatment for emergency medical conditions and
women in labor.
1785. Care and services during certain disasters and emergencies.
1786. Care for newborn children of women veterans receiving maternity
care.
1787. Health care of family members of veterans stationed at Camp
Lejeune, North Carolina.
SUBCHAPTER I--GENERAL
* * * * * * *
Sec. 1701. Definitions
For the purposes of this chapter--
(1) The term ``disability'' means a disease, injury, or other
physical or mental defect.
(2) The term ``veteran of any war'' includes any veteran
awarded the Medal of Honor.
(3) The term ``facilities of the Department'' means--
(A) facilities over which the Secretary has direct
jurisdiction;
(B) Government facilities for which the Secretary
contracts; and
(C) public or private facilities at which the
Secretary provides recreational activities for patients
receiving care under section 1710 of this title.
(4) The term ``non-Department facilities'' means facilities
other than Department facilities.
(5) The term ``hospital care'' includes--
(A)(i) medical services rendered in the course of the
hospitalization of any veteran, and (ii) travel and
incidental expenses pursuant to the provisions of
section 111 of this title;
(B) such mental health services, consultation,
professional counseling, marriage and family
counseling, and training for the members of the
immediate family or legal guardian of a veteran, or the
individual in whose household such veteran certifies an
intention to live, as the Secretary considers
appropriate for the effective treatment and
rehabilitation of a veteran or dependent or survivor of
a veteran receiving care under the last sentence of
section 1781(b) of this title; and
(C)(i) medical services rendered in the course of the
hospitalization of a dependent or survivor of a veteran
receiving care under the last sentence of section
1781(b) of this title, and (ii) travel and incidental
expenses for such dependent or survivor under the terms
and conditions set forth in section 111 of this title.
(6) The term ``medical services'' includes, in addition to
medical examination, treatment, and rehabilitative services,
the following:
(A) Surgical services.
(B) Dental services and appliances as described in
sections 1710 and 1712 of this title.
(C) Optometric and podiatric services.
(D) Preventive health services.
(E) Noninstitutional extended care services,
including alternatives to institutional extended care
that the Secretary may furnish directly, by contract,
or through provision of case management by another
provider or payer.
(F) In the case of a person otherwise receiving care
or services under this chapter--
(i) wheelchairs, artificial limbs, trusses,
and similar appliances;
(ii) special clothing made necessary by the
wearing of prosthetic appliances; and
(iii) such other supplies or services as the
Secretary determines to be reasonable and
necessary.
(G) Travel and incidental expenses pursuant to
section 111 of this title.
(7) The term ``domiciliary care'' includes necessary medical
services and travel and incidental expenses pursuant to the
provisions of section 111 of this title.
(8) The term ``rehabilitative services'' means such
professional, counseling, and guidance services and treatment
programs as are necessary to restore, to the maximum extent
possible, the physical, mental, and psychological functioning
of an ill or disabled person.
(9) The term ``preventive health services'' means--
(A) periodic medical and dental examinations;
(B) patient health education (including nutrition
education);
(C) maintenance of drug use profiles, patient drug
monitoring, and drug utilization education;
(D) mental health preventive services;
(E) substance abuse prevention measures;
(F) immunizations against infectious diseases,
including each immunization on the recommended adult
immunization schedule at the time such immunization is
indicated on that schedule;
(G) prevention of musculoskeletal deformity or other
gradually developing disabilities of a metabolic or
degenerative nature;
(H) genetic counseling concerning inheritance of
genetically determined diseases;
(I) routine vision testing and eye care services;
(J) periodic reexamination of members of likely
target populations (high-risk groups) for selected
diseases and for functional decline of sensory organs,
together with attendant appropriate remedial
intervention; and
(K) such other health-care services as the Secretary
may determine to be necessary to provide effective and
economical preventive health care.
(10) The term ``recommended adult immunization schedule''
means the schedule established (and periodically reviewed and,
as appropriate, revised) by the Advisory Committee on
Immunization Practices established by the Secretary of Health
and Human Services and delegated to the Centers for Disease
Control and Prevention.
(11) The term ``network provider'' means any of the following
health care providers that have entered into a contract or
agreement under which the provider agrees to furnish care and
services to eligible veterans under section 1703A of this
title:
(A) Any health care provider or supplier 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.
(B) Any provider of items and services receiving
payment under a State plan under title XIX of such Act
(42 U.S.C. 1396 et seq.) or a waiver of such a plan.
(C) 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))).
(D) The Department of Defense.
(E) The Indian Health Service.
(F) Any health care provider that is an academic
affiliate of the Department.
(G) Any health care provider not otherwise covered
under any of subparagraphs (A) through (F) that meets
criteria established by the Secretary for purposes of
such section.
(12) The term ``VA Care in the Community Program'' means the
program under which the Secretary furnishes hospital care or
medical services to veterans through network providers pursuant
to section 1703A of this title.
* * * * * * *
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.
(e) The authority of the Secretary to carry out this section
terminates on the date on which the Secretary certifies to the
Committees on Veterans' Affairs of the House of Representatives
and the Senate that the Secretary is fully implementing section
1703A of this title.
Sec. 1703A. VA Care in the Community Program
(a) Program.--(1) Subject to the availability of
appropriations for such purpose, hospital care, medical
services, and extended care services under this chapter shall
be furnished to an eligible veteran through contracts or
agreements authorized under subsection (d), or contracts or
agreements, including national contracts or agreements,
authorized under section 8153 of this title or any other
provision of law administered by the Secretary, with network
providers for the furnishing of such care and services to
veterans.
(2) Subject to subsection (b), an eligible veteran may select
a provider of such care or services from among network
providers.
(3) The Secretary shall coordinate the furnishing of care and
services under this section to eligible veterans.
(4)(A) In carrying out this section, the Secretary shall
establish regional networks of network providers. The Secretary
shall determine, and may modify, such regions based on the
capacity and market assessments of Veterans Integrated Service
Networks conducted under subsection (k) or upon recognized
need.
(B) The Secretary may enter into one or more contracts for
the purposes of managing the operations of the regional
networks and for the delivery of care pursuant to this section.
(C) The Secretary shall--
(i) verify upon enrollment, and annually thereafter,
that network providers have not been excluded from
participation in other federally funded health care
programs; and
(ii) submit to the Committees on Veterans' Affairs of
the House of Representatives and the Senate an annual
report on the results of such verifications.
(b) Primary and Specialty Care.--(1)(A) If the Secretary is
unable to assign an eligible veteran to a patient-aligned care
team or dedicated primary care provider under section 1706(d)
of this title because the Secretary determines such a care team
or provider at a Department facility is not available--
(i) the Secretary shall consult with the veteran
regarding available primary care providers from among
network providers that are located in the regional
network in which the veteran resides or a regional
network that is adjacent to the regional network in
which the veteran resides; and
(ii) the veteran may select one of the available
primary care providers to serve as the dedicated
primary care provider of the veteran.
(B) In determining whether a patient-aligned care team or
dedicated provider under section 1706(d) of this title is
available for assignment to a veteran, the Secretary shall take
into consideration each of the following:
(i) Whether the veteran faces an unusual or excessive
burden in accessing such patient-aligned care team or
dedicated provider at a medical facility of the
Department including with respect to--
(I) geographical challenges;
(II) environmental factors, including roads
that are not accessible to the general public,
traffic, or hazardous weather;
(III) a medical condition of the veteran; or
(IV) such other factors as determined by the
Secretary.
(ii) Whether the veteran reasonably believes that the
assignment of a particular care team or provider to the
veteran would detrimentally affect the patient-provider
relationship and result in sub-optimal care to the
veteran.
(iii) Whether the panel size of the care team or
provider is at such a number that it would result in
difficulty for the veteran in accessing timely care or
in sub-optimal care to the veteran.
(iv) Whether the veteran resides in a State where the
Department does not operated a full-service medical
facility.
(C) If the Secretary determines that a patient-aligned care
team or dedicated primary care provider at a Department
facility has become available for assignment to an eligible
veteran who had been assigned to a network provider under
subparagraph (A), the Secretary shall provide the veteran with
the option of reassignment to the team or provider at the
Department facility.
(D) In the case of an eligible veteran who is assigned to a
network provider under subparagraph (A), the Secretary shall
reevaluate such assignment not earlier than one year after a
veteran makes a selection under subparagraph (A)(ii), and on an
annual basis thereafter, to--
(i) determine whether the Secretary is able to assign
to the veteran a patient-aligned care team or dedicated
primary care provider under section 1706(d) of this
title; and
(ii) in consultation with and upon approval of the
veteran, make such assignment if able.
(2)(A)(i) Except as provided in clause (ii), the Secretary
may only furnish specialty hospital care, medical services, or
extended care services to an eligible veteran under this
section pursuant to a referral for such specialty care or
services made by the primary care provider of the veteran.
(ii) The Secretary may designate specialties which shall be
exempt from the requirement under clause (i).
(B) The Secretary shall determine whether to furnish
specialty hospital care, medical services, or extended care
services to an eligible veteran pursuant to subparagraph (A)--
(i) at a medical facility of the Department that is
within a reasonable distance of the residence of the
veteran, as determined by the Secretary;
(ii) by a network provider that, to the greatest
extent practicable, is located in the regional network
in which the veteran resides or a regional network that
is adjacent to the regional network in which the
veteran resides; or
(iii) pursuant to an agreement described in
subparagraph (C).
(C) An agreement described in this subparagraph is an
agreement entered into by the Secretary with a network provider
under which--
(i) specialty hospital care, medical services, or
extended care services are furnished to an eligible
veteran pursuant to subparagraph (A)--
(I) at a medical facility of the Department
by a network provider possessing the
appropriate credentials, as determined by the
Secretary; or
(II) at a facility of a network provider by a
health care provider of the Department; and
(ii) such specialty care or services are so furnished
either--
(I) in accordance with this section with
respect to fees and payments for care and
services furnished under subsection (a); or
(II) at no cost to the United States.
(D) In making the determination under subparagraph (B), the
Secretary shall give priority to medical facilities and health
care providers of the Department but shall take into account--
(i) whether the veteran faces an unusual or excessive
burden in accessing such specialty hospital care,
medical services, or extended care services at a
medical facility of the Department, including with
respect to--
(I) geographical challenges;
(II) environmental factors, such as roads
that are not accessible to the general public,
traffic, or hazardous weather;
(III) a medical condition of the veteran; or
(IV) such other factors as determined by the
Secretary;
(ii) whether the primary care provider of the veteran
recommends that such specialty hospital care, medical
services, or extended care services should be furnished
by a network provider;
(iii) whether the veteran resides in a State where
the Department does not operate a full-service medical
facility; and
(iv) in the case of a veteran who requires an organ
or bone marrow transplant, whether the veteran 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.
(E) The Secretary shall ensure that each medical facility of
the Department processes referrals for specialty hospital care,
medical services, or extended care services in a standardized
manner, including with respect to the organization of the
program office responsible for such referrals.
(F) In carrying out this section, the Secretary shall
establish a process to review any disagreement between an
eligible veteran and the Department, or between an eligible
veteran and a health care provider of the Department, regarding
the eligibility of the veteran to receive care or services from
a network provider under this section or the assignment of a
primary care provider of the Department to the veteran. In
reviewing a disagreement under such process with respect to the
availability of and assignment to a patient aligned care team
or dedicated primary care provider, the Secretary may give
deference to the veteran with respect to any determination
under subsection (b)(1)(B)(ii).
(G)(i) The Secretary shall develop procedures to ensure that
assigning a veteran to a patient-aligned care team or dedicated
primary care provider under subparagraph (A), (C), or (D) does
not adversely affect the continuity or quality of care for the
veteran during the transition.
(ii) Procedures under clause (i) shall provide for--
(I) the appointment of a contact in the Department
for the veteran who shall provide information to the
veteran and resolve issues regarding the transition;
(II) the transfer of relevant medical records;
(III) coordination of care between providers;
(IV) the continued treatment of chronic or current
episodes of care (by means including medication,
subspecialty care, and ancillary services); and
(V) any other action the Secretary determines is
necessary.
(c) Episodes of Care.--(1) The Secretary shall ensure that,
at the election of an eligible veteran who receives hospital
care, medical services, or extended care services from a
network provider in an episode of care under this section, the
veteran receives such care or services from that network
provider, another network provider selected by the veteran, or
a health care provider of the Department, through the
completion of the episode of care, including all specialty and
ancillary services determined necessary by the provider as part
of the treatment recommended in the course of such care or
services. In making such determination with respect to
necessary specialty and ancillary services provided by a
network provider, the network provider shall consult with the
Secretary, acting through the program office of the appropriate
medical facility.
(2) In cases of episodes of care that the Secretary
determines case management to be appropriate, the Secretary
shall provide case management to an eligible veteran who
receives hospital care, medical services, or extended care
services from a network provider for such episodes of care. The
Secretary may provide such case management through the Veterans
Health Administration or through an entity that manages the
operations of the regional networks pursuant to subsection
(a)(4)(B).
(d) Care and Services Through Contracts and Agreements.--(1)
The Secretary shall enter into contracts or agreements,
including national contracts or agreements for, but not limited
to, dialysis, for furnishing care and services to eligible
veterans under this section with network providers.
(2)(A) In entering into a contract or agreement under
paragraph (1) with a network provider, the Secretary shall--
(i) negotiate rates for the furnishing of care and
services under this section; and
(ii) reimburse the provider for such care and
services at the rates negotiated pursuant to clause (i)
as provided in such contract or agreement.
(B)(i) Except as provided in paragraph (3), 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) In determining the rates under the Medicare Program
under title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) for purposes of clause (i), in the case of care or
services furnished by a provider of services with respect to
which such rates are determined under a fee schedule to which
the area wage index under section 1886(d)(3)(E) of the Social
Security Act (42 U.S.C. 1395ww(d)(3)(E)) applies, such area
wage index so applied to such provider of services may not be
less than 1.00.
(C) In carrying out paragraph (2), the Secretary may
incorporate the use of value-based reimbursement models to
promote the provision of high-quality care.
(3)(A) With respect to the furnishing of care or services
under this section to an eligible veteran who resides in a
highly rural area (as defined under the rural-urban commuting
area codes developed by the Secretary of Agriculture and the
Secretary of Health and Human Services), the Secretary of
Veterans Affairs may negotiate a rate that is more than the
rate paid by the United States as described in paragraph
(2)(B).
(B) 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.
(C) With respect to furnishing care or services under this
section in a State with an All-Payer Model Agreement under the
Social Security Act that became effective on or after January
1, 2014, the Medicare payment rates under paragraph (2)(B)
shall be calculated based on the payment rates under such
agreement, or any such successor agreement.
(D) With respect to furnishing care or services under this
section in a location in which the Secretary determines that
adjusting the rate paid by the United States as described in
paragraph (2)(B) is appropriate, the Secretary may negotiate
such an adjusted rate.
(E) With respect to furnishing care or services under this
section in a location or in a situation in which an exception
to the rates paid by the United States 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 applies, the
Secretary may follow such exception.
(F) With respect to furnishing care or services under this
section for care or services not covered under the Medicare
Program under title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.), the Secretary shall establish a schedule of fees
for such care or services.
(G) With respect to furnishing care or services under this
section pursuant to an agreement with a tribal or Federal
entity, the Secretary may negotiate a rate that is more than
the rate paid by the United States as described in paragraph
(2)(B).
(4) For the furnishing of care or services pursuant to a
contract or agreement under paragraph (1), a network provider
may not collect any amount that is greater than the rate
negotiated pursuant to paragraph (2)(A).
(5)(A) If, in the course of an episode of care under this
section, any part of care or services is furnished by a medical
provider who is not a network provider, the Secretary may
compensate such provider for furnishing such care or services.
(B) The Secretary shall make reasonable efforts to enter into
a contract or agreement under this section with any provider
who is compensated pursuant to subparagraph (A).
(e) Prompt Payment Standard.--(1) The Secretary shall ensure
that claims for payments for hospital care, medical services,
or extended care services furnished under this section are
processed in accordance with this subsection, regardless of
whether such claims are--
(A) made by a network provider to the Secretary;
(B) made by a network provider to a regional network
operated by a contractor pursuant to subsection
(a)(4)(B); or
(C) made by such a regional network to the Secretary.
(2) A covered claimant that seeks payment for hospital care,
medical services, or extended care services furnished under
this section shall submit to the covered payer a claim for
payment not later than--
(A) with respect to a claim by a network provider,
180 days after the date on which the network provider
furnishes such care or services; or
(B) with respect to a claim by a regional network
operated by a contractor, 180 days after the date on
which the contractor pays the network provider for
furnishing such care or services.
(3) Notwithstanding chapter 39 of title 31 or any other
provision of law, the covered payer shall pay a covered
claimant for hospital care, medical services, or extended care
services furnished under this section--
(A) in the case of a clean claim submitted to the
covered payer on paper, not later than 45 calendar days
after receiving the claim; or
(B) in the case of a clean claim submitted to the
covered payer electronically, not later than 30
calendar days after receiving the claim.
(4)(A) If the covered payer denies a claim submitted by a
covered claimant under paragraph (1), the covered payer shall
notify the covered claimant of the reason for denying the claim
and the additional information, if any, that may be required to
process the claim--
(i) in the case of a clean claim submitted to the
covered payer on paper, not later than 45 calendar days
after receiving the claim; or
(ii) in the case of a clean claim submitted to the
covered payer electronically, not later than 30
calendar days after receiving the claim.
(B) Upon receipt by the covered payer of additional
information specified under subparagraph (A) relating to a
claim, the covered payer shall pay, deny, or otherwise
adjudicate the claim, as appropriate, not later than 30
calendar days after receiving such information.
(5)(A) If the covered payer has not paid a covered claimant
or denied a clean claim for payment by the covered claimant
under this subsection during the appropriate period specified
in this subsection, such clean claim shall be considered
overdue.
(B) If a clean claim for payment by a covered claimant is
considered overdue under subparagraph (A), in addition to the
amount the covered payer owes the covered claimant under the
claim, the covered payer shall owe the covered claimant an
interest penalty amount that shall--
(i) be prorated daily;
(ii) accrue from the date the payment was overdue;
(iii) be payable at the time the claim is paid; and
(iv) be computed at the rate of interest established
by the Secretary of the Treasury, and published in the
Federal Register, for interest payments under
subsections (a)(1) and (b) of section 7109 of title 41
that is in effect at the time the covered payer accrues
the obligation to pay the interest penalty amount.
(6)(A) If the covered payer overpays a covered claimant for
hospital care, medical services, or extended care services
furnished under this section--
(i) the covered payer shall deduct the amount of any
overpayment from payments due to the covered claimant
after the date of such overpayment; or
(ii) if the covered payer determines that there are
no such payments due after the date of the overpayment,
the covered claimant shall refund the amount of such
overpayment not later than 30 days after such
determination.
(B)(i) Before deducting any amount from a payment to a
covered claimant under subparagraph (A), the covered payer
shall ensure that the covered claimant is provided an
opportunity--
(I) to dispute the existence or amount of any
overpayment owed to the covered payer; and
(II) to request a compromise with respect to any such
overpayment.
(ii) The covered payer may not make any deduction from a
payment to a covered claimant under subparagraph (A) unless the
covered payer has made reasonable efforts to notify the covered
claimant of the rights of the covered claimant under subclauses
(I) and (II) of clause (i).
(iii) Upon receiving a dispute under subclause (I) of clause
(i) or a request under subclause (II) of such clause, the
covered payer shall make a determination with respect to such
dispute or request before making any deduction under
subparagraph (A) unless the time required to make such a
determination would jeopardize the ability of the covered payer
to recover the full amount owed to the covered payer.
(7) Notwithstanding any other provision of law, the Secretary
may, except in the case of a fraudulent claim, false claim, or
misrepresented claim, compromise any claim of an amount owed to
the United States under this section.
(8) This subsection shall apply only to payments made on a
claims basis and not to capitation or other forms of periodic
payments to network providers.
(9) A network provider that provides hospital care, medical
services, or extended care services to an eligible veteran
under this section may not seek any payment for such care or
services from the eligible veteran.
(10) With respect to making a payment for hospital care or
medical services furnished to an eligible veteran by a network
provider under this section--
(A) the Secretary may not require receipt by the
veteran or the Department of a medical record under
subsection (g) detailing such care or services before a
covered payer makes a payment for such care or
services; and
(B) the Secretary may require that the network
provider attests to such care or services so provided
before a covered payer makes a payment for such care or
services.
(f) Cost-sharing.--(1) 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 under this chapter.
(2) 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 under this chapter.
(3) 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 this title, the Secretary shall recover or
collect reasonable charges for such care or services from a
health-plan contract described in section 1705A in accordance
with such section 1729.
(g) Medical Records.--(1) The Secretary shall ensure that any
network provider that furnishes care or services under this
section to an eligible veteran--
(A) upon the request of the veteran, provides to the
veteran the medical records related to such care or
services; and
(B) upon the completion of the provision of such care
or services to such veteran, provides to the Department
the medical records for the veteran furnished care or
services under this section in a timeframe and format
specified by the Secretary for purposes of this
section, except the Secretary may not require that any
payment by the Secretary to the eligible provider be
contingent on such provision of medical records.
(2) To the extent practicable, the Secretary shall submit to
a network provider that furnishes care or services under this
section to an eligible veteran the medical records of such
eligible veteran that are maintained by the Department and are
relevant to such care or services.
(3) To the extent practicable, the Secretary shall--
(A) ensure that the medical records shared under
paragraphs (1) and (2) are shared in an electronic
format accessible by network providers and the
Department through an Internet website; and
(B) provide to network providers access to the
electronic patient health record system of the
Department, or successor system, for the purpose of
furnishing care or services under this section.
(h) Use of Card.--The Secretary shall ensure that the veteran
health identification card, or such successor identification
card, includes sufficient information to act as an
identification card for an eligible entity or other non-
Department facility. The Secretary may not use any amounts made
available to the Secretary to issue separate identification
cards solely for the purpose of carrying out this section.
(i) Prescription Medications.--(1) With respect to
requirements relating to the licensing or credentialing of a
network provider, the Secretary shall ensure that the network
provider is able to submit prescriptions for pharmaceutical
agents on the formulary of the Department to pharmacies of the
Department in a manner that is substantially similar to the
manner in which the network provider submits prescriptions to
retail pharmacies.
(2) Nothing in this section shall be construed to affect the
process of the Department for filling and paying for
prescription medications.
(j) Quality of Care.--In carrying out this section, the
Secretary shall use the quality of care standards set forth or
used by the Centers for Medicare & Medicaid Services or other
quality of care standards, as determined by the Secretary.
(k) Capacity and Commercial Market Assessments.--(1) On a
periodic basis, but not less often than once every three years,
the Secretary shall conduct an assessment of the capacity of
each Veterans Integrated Service Network and medical facility
of the Department to furnish care or services under this
chapter. Each such assessment shall--
(A) identify gaps in furnishing such care or services
at such Veterans Integrated Service Network or medical
facility;
(B) identify how such gaps can be filled by--
(i) entering into contracts or agreements
with network providers under this section or
with entities under other provisions of law;
(ii) making changes in the way such care and
services are furnished at such Veterans
Integrated Service Network or medical facility,
including but not limited to--
(I) extending hours of operation;
(II) adding personnel; or
(III) expanding space through
construction, leasing, or sharing of
health care facilities; and
(iii) the building or realignment of
Department resources or personnel;
(C) forecast, based on future projections and
historical trends, both the short- and long-term demand
in furnishing care or services at such Veterans
Integrated Service Network or medical facility and
assess how such demand affects the needs to use such
network providers;
(D) include a commercial health care market
assessment of designated catchment areas in the United
States conducted by a nongovernmental entity; and
(E) consider the unique ability of the Federal
Government to retain a presence in an area otherwise
devoid of commercial health care providers or from
which such providers are at a risk of leaving.
(2) The Secretary shall submit each assessment under
paragraph (1) to the Committees on Veterans' Affairs of the
House of Representatives and the Senate and shall make each
such assessment publicly available.
(l) Allocation of Funds.--The Secretary shall develop a plan
for the allocation of funds in the Medical Community Care
account.
(m) Reports on Rates.--Not later than December 31, 2019, and
annually thereafter during each of the subsequent three years,
the Secretary shall submit to the Committees on Veterans'
Affairs of the House of Representatives and the Senate a report
detailing, for the fiscal year preceding the fiscal year during
which the report is submitted, the rates paid by the Secretary
for hospital care, medical services, or extended care services
under this section that, pursuant to subsection (d)(3), are
more than the rates described in subsection (d)(2)(B) for the
same care or services.
(n) Definitions.--In this section:
(1) The term ``clean claim'' means a claim
submitted--
(A) to the covered payer by a covered
claimant for purposes of payment by the covered
payer of expenses for hospital care or medical
services furnished under this section;
(B) that contains substantially all of the
required elements necessary for accurate
adjudication, without requiring additional
information from the network provider; and
(C) in such a nationally recognized format as
may be prescribed by the Secretary for purposes
of paying claims for hospital care or medical
services furnished under this section.
(2) The term ``covered claimant'' means--
(A) a network provider that submits a claim
to the Secretary for purposes of payment by the
Secretary of expenses for hospital care or
medical services furnished under this section;
or
(B) a regional network operated by a
contractor pursuant to subsection (a)(4)(B)
that submits a claim to the Secretary for
purposes of reimbursement for a payment made by
the contractor to a network provider for
hospital care or medical services furnished
under this section.
(3) The term ``covered payer'' means--
(A) a regional network operated by a
contractor pursuant to subsection (a)(4)(B)
with respect to a claim made by a network
provider to the contractor for purposes of
payment by the contractor of expenses for
hospital care or medical services furnished
under this section; or
(B) the Secretary with respect to--
(i) a claim made by a network
provider to the Secretary for purposes
of payment by the Secretary of expenses
for hospital care or medical services
furnished under this section; and
(ii) a claim made by a regional
network operated by a contractor
pursuant to subsection (a)(4)(B) for
purposes of reimbursement for a payment
described by subparagraph (A).
(4) The term ``eligible veteran'' means a veteran
who--
(A) is enrolled in the patient enrollment
system of the Department established and
operated under section 1705(a) of this title;
and
(B) has--
(i) been furnished hospital care or
medical services at or through a
Department facility on at least one
occasion during the two-year period
preceding the date of the determination
of eligibility; or
(ii) requested a first-time
appointment for hospital care or
medical services at a Department
facility.
(5) The term ``fraudulent claim'' means a claim by a
network provider for reimbursement under this section
that includes an intentional and deliberate
misrepresentation of a material fact or facts that is
intended to induce the Secretary to pay an amount that
was not legally owed to the provider.
Sec. 1703B. Veterans Care Agreements with non-network providers
(a) Veterans Care Agreements.--(1) In addition to furnishing
hospital care, medical services, or extended care services
under this chapter at facilities of the Department or under
contracts or agreements entered into pursuant to section 1703A
of this title or any other provision of law other than this
section, the Secretary may furnish such care and services to
eligible veterans through the use of agreements, to be known as
``Veterans Care Agreements'', entered into under this section
by the Secretary with eligible non-network providers.
(2) The Secretary may enter into a Veterans Care Agreement
under this section with an eligible non-network provider if the
Secretary determines that--
(A) the provision of the hospital care, medical
services, or extended care services at a Department
facility is impracticable or inadvisable because of the
medical condition of the veteran, the travel involved,
or the nature of the care or services required, or a
combination of such factors; and
(B) such care or services are not available to be
furnished by a non-Department health care provider
under a contract or agreement entered into pursuant to
a provision of law other than this section.
(3)(A) In accordance with subparagraphs (C) and (D), the
Secretary shall review each Veterans Care Agreement with a non-
network provider to determine whether it is practical or
advisable to, instead of carrying out such agreement--
(i) provide at a Department facility the hospital
care, medical services, or extended care services
covered by such agreement; or
(ii) enter into an agreement with the provider under
section 1703A of this title to provide such care or
services.
(B) If the Secretary determines pursuant to a review of a
Veterans Care Agreement under subparagraph (A) that it is
practical or advisable to provide hospital care, medical
services, or extended care services at a Department facility,
or enter into an agreement under section 1703A of this title to
provide such care or services, as the case may be, the
Secretary--
(i) may not renew the Veterans Care Agreement; and
(ii) shall take such actions as are necessary to
implement such determination.
(C) This paragraph shall apply with respect to Veterans Care
Agreements entered into with a non-network provider whose gross
annual revenue, as determined under subsection (b)(1),
exceeds--
(i) $3,000,000, in the case of a provider that
furnishes homemaker or home health aide services; or
(ii) $1,000,000, in the case of any other provider.
(D) The Secretary shall conduct each review of a Veterans
Care Agreement under subparagraph (A) as follows:
(i) Once during the 18-month period beginning on the
date that is six months after date on which the
agreement is entered into.
(ii) Not less than once during each four-year period
beginning on the date on which the review under
subparagraph (A) is conducted.
(b) Eligible Non-network Providers.--A provider of hospital
care, medical services, or extended care services is eligible
to enter into a Veterans Care Agreement under this section if
the Secretary determines that the provider meets the following
criteria:
(1) The gross annual revenue of the provider under
contracts or agreements entered into with the Secretary
in the year preceding the year in which the provider
enters into the Veterans Care Agreement does not
exceed--
(A) $5,000,000 (as adjusted in a manner
similar to amounts adjusted pursuant to section
5312 of this title), in the case of a provider
that furnishes homemaker or home health aide
services; or
(B) $2,000,000 (as so adjusted), in the case
of any other provider.
(2) The provider is not a network provider and does
not otherwise provide hospital care, medical services,
or extended care services to patients pursuant to a
contract entered into with the Department.
(3) The provider is--
(A) a 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));
(B) a physician or supplier that has enrolled
and entered into a participation agreement
under section 1842(h) of such Act (42 U.S.C.
1395u(h));
(C) a provider of items and services
receiving payment under a State plan under
title XIX of such Act (42 U.S.C. 1396 et seq.)
or a waiver of such a plan;
(D) 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)); or
(E) a center for independent living (as
defined in section 702 of the Rehabilitation
Act of 1973 (29 U.S.C. 796a)).
(4) The provider is certified pursuant to the process
established under subsection (c)(1).
(5) Any additional criteria determined appropriate by
the Secretary.
(c) Provider Certification.--(1) The Secretary shall
establish a process for the certification of eligible providers
to enter into Veterans Care Agreements under this section that
shall, at a minimum, set forth the following:
(A) Procedures for the submission of applications for
certification and deadlines for actions taken by the
Secretary with respect to such applications.
(B) Standards and procedures for the approval and
denial of certifications and the revocation of
certifications.
(C) Procedures for assessing eligible providers based
on the risk of fraud, waste, and abuse of such
providers similar to the level of screening under
section 1866(j)(2)(B) of the Social Security Act (42
U.S.C. 1395(j)(2)(B)) and the standards set forth under
section 9.104 of title 48, Code of Federal Regulations,
or any successor regulation.
(D) Requirement for denial or revocation of
certification if the Secretary determines that the
otherwise eligible provider is--
(i) 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); or
(ii) identified as an excluded source on the
list maintained in the System for Award
Management, or any successor system.
(E) Procedures by which a provider whose
certification is denied or revoked under the procedures
established under this subsection will be identified as
an excluded source on the list maintained in the System
for Award Management, or successor system, if the
Secretary determines that such exclusion is
appropriate.
(2) To the extent practicable, the Secretary shall establish
the procedures under paragraph (1) in a manner that takes into
account any certification process administered by another
department or agency of the Federal Government that an eligible
provider has completed by reason of being a provider described
in any of subparagraphs (A) through (E) of subsection (b)(4).
(3) The Secretary shall--
(A) verify upon enrollment, and annually thereafter,
that eligible providers have not been excluded from
participation in other federally funded health care
programs; and
(B) submit to the Committees on Veterans' Affairs of
the House of Representatives and the Senate an annual
report on the results of such verifications.
(d) Terms of Agreements.--Subsections (d), (e), (f), and (g)
of section 1703A of this title shall apply with respect to a
Veterans Care Agreement in the same manner such subsections
apply to contracts and agreements entered into under such
section.
(e) Exclusion of Certain Federal Contracting Provisions.--(1)
Notwithstanding any other provision of law, the Secretary may
enter into a Veterans Care Agreement using procedures other
than competitive procedures.
(2)(A) Except as provided in subparagraph (B) and unless
otherwise provided in this section, an eligible non-network
provider that enters into a Veterans Care Agreement under this
section is not subject to, in the carrying out of the
agreement, any provision of law that providers of services and
suppliers under the original Medicare fee-for-service program
under parts A and B of title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) or the Medicaid program under title
XIX of such Act (42 U.S.C. 1396 et seq.) are not subject to.
(B) In addition to the provisions of laws covered by
subparagraph (A), an eligible non-network provider shall be
subject to the following provisions of law:
(i) Any applicable law regarding integrity, ethics,
or fraud, or that subject a person to civil or criminal
penalties.
(ii) Section 1352 of title 31, except for the filing
requirements under subsection (b) of such section.
(iii) Section 4705 or 4712 of title 41, and any other
applicable law regarding the protection of
whistleblowers.
(iv) Section 4706(d) of title 41.
(v) Title VII of the Civil Rights Act of 1964 (42
U.S.C. 2000e et seq.) to the same extent as such title
applies with respect to the eligible non-network
provider in providing care or services through an
agreement or arrangement other than under a Veterans
Care Agreement.
(f) Termination of a Veterans Care Agreement.--(1) An
eligible non-network provider may terminate a Veterans Care
Agreement with the Secretary under this section at such time
and upon such notice to the Secretary as the Secretary may
specify for purposes of this section.
(2) The Secretary may terminate a Veterans Care Agreement
with an eligible non-network provider under this section at
such time and upon such notice to the provider as the Secretary
may specify for the purposes of this section, if the Secretary
determines necessary.
(g) Disputes.--(1) The Secretary shall establish
administrative procedures for providers with which the
Secretary has entered into a Veterans Care Agreement to present
any dispute arising under or related to the agreement.
(2) Before using any dispute resolution mechanism under
chapter 71 of title 41 with respect to a dispute arising under
a Veterans Care Agreement under this section, a provider must
first exhaust the administrative procedures established by the
Secretary under paragraph (1).
(h) Authority to Pay for Other Authorized Services.--(1) If,
in the course of an episode of care for which hospital care,
medical services, or extended care services are furnished to an
eligible veteran pursuant to a Veterans Care Agreement, any
part of such care or services is furnished by a medical
provider who is not an eligible non-network provider or a
network provider, the Secretary may compensate such provider
for furnishing such care or services.
(2) The Secretary shall make reasonable efforts to enter into
a Veterans Care Agreement with any provider who is compensated
pursuant to paragraph (1).
(i) Annual Reports.--(1) Not later than December 31 of the
year following the fiscal year in which the Secretary first
enters into a Veterans Care Agreement under this section, and
each year thereafter, the Secretary shall submit to the
appropriate congressional committees an annual report that
includes a list of all Veterans Care Agreements entered into as
of the date of the report.
(2) The requirement to submit a report under paragraph (1)
shall terminate on the date that is five years after the date
of the enactment of this section.
(j) Quality of Care.--In carrying out this section, the
Secretary shall use the quality of care standards set forth or
used by the Centers for Medicare & Medicaid Services or other
quality of care standards, as determined by the Secretary.
(k) Delegation.--The Secretary may delegate the authority to
enter into or terminate a Veterans Care Agreement to an
official of the Department at a level not below the Director of
a Veterans Integrated Service Network or the Director of a
Network Contracting Office.
(l) Definitions.--In this section:
(1) The term ``appropriate congressional committees''
means--
(A) the Committees on Veterans' Affairs of
the House of Representatives and the Senate;
and
(B) the Committees on Appropriations of the
House of Representatives and the Senate.
(2) The term ``eligible veteran'' has the meaning
given such term in section 1703A(m) of this title.
Sec. 1703C. 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.--(1) In carrying out
this subsection, 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 section. 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.
(2) The Secretary may only provide for an operation at a non-
Department of Veterans Affairs transplant center pursuant to
paragraph (1) if the center is in compliance with regulations
prescribed by the Centers for Medicare & Medicaid Services
applicable to transplant centers.
Sec. 1703D. 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 at the center of the care
team (including family members and other caregivers) 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.
(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 a report 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
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 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 VA Care in the Community Act.
(2) 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.
(3)(A) If the Secretary determines that the 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)(A) 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 the pilot program under
subparagraph (A)(ii), for purposes of clauses (vi) and (vii) of
subsection (f)(2)(A), 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 Consultation.--(1) The Secretary shall
consult with 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. 1705B. Management of health care: productivity
(a) Relative Value Unit Tracking.--The Secretary shall track
relative value units for all Department providers.
(b) Clinical Procedure Coding Training.--The Secretary shall
require all Department providers to attend training on clinical
procedure coding.
(c) Performance Standards.--(1) The Secretary shall establish
for each Department facility--
(A) in accordance with paragraph (2), standardized
performance standards based on nationally recognized
relative value unit production standards applicable to
each specific profession in order to evaluate clinical
productivity at the provider and facility level;
(B) remediation plans to address low clinical
productivity and clinical inefficiency; and
(C) an ongoing process to systematically review the
content, implementation, and outcome of the plans
developed under subparagraph (B).
(2) In establishing the performance standards under paragraph
(1)(A), the Secretary may--
(A) incorporate values-based productivity models; and
(B) take into account non-clinical duties, including
with respect to training and research.
(d) Definitions.--In this section:
(1) The term ``Department provider'' means an
employee of the Department whose primary
responsibilities include furnishing hospital care or
medical services, including a physician, a dentist, an
optometrist, a podiatrist, a chiropractor, an advanced
practice registered nurse, and a physician's assistant
acting as an independent provider.
(2) The term ``relative value unit'' means a unit for
measuring workload by determining the time, mental
effort and judgment, technical skill, physical effort,
and stress involved in delivering a procedure.
Sec. 1706. Management of health care: other requirements
(a) In managing the provision of hospital care and medical
services under section 1710(a) of this title, the Secretary
shall, to the extent feasible, design, establish and manage
health care programs in such a manner as to promote cost-
effective delivery of health care services in the most
clinically appropriate setting.
(b)(1) In managing the provision of hospital care and medical
services under such section, the Secretary shall ensure that
the Department (and each geographic service area of the
Veterans Health Administration) maintains its capacity to
provide for the specialized treatment and rehabilitative needs
of disabled veterans (including veterans with spinal cord
dysfunction, blindness, amputations, and mental illness) within
distinct programs or facilities of the Department that are
dedicated to the specialized needs of those veterans in a
manner that (A) affords those veterans reasonable access to
care and services for those specialized needs, and (B) ensures
that overall capacity of the Department to provide such
services is not reduced below the capacity of the Department
(and each geographic service area of the Veterans Health
Administration), nationwide, to provide those services, as of
October 9, 1996. The Secretary shall carry out this paragraph
in consultation with the Advisory Committee on Prosthetics and
Special Disabilities Programs and the Committee on Care of
Severely Chronically Mentally Ill Veterans.
(2) For purposes of paragraph (1), the capacity of the
Department (and each geographic service area of the Veterans
Health Administration) to provide for the specialized treatment
and rehabilitative needs of disabled veterans (including
veterans with spinal cord dysfunction, traumatic brain injury,
blindness, prosthetics and sensory aids, and mental illness)
within distinct programs or facilities shall be measured for
seriously mentally ill veterans as follows (with all such data
to be provided by geographic service area and totaled
nationally):
(A) For mental health intensive community-based care,
the number of discrete intensive care teams constituted
to provide such intensive services to seriously
mentally ill veterans and the number of veterans
provided such care.
(B) For opioid substitution programs, the number of
patients treated annually and the amounts expended.
(C) For dual-diagnosis patients, the number treated
annually and the amounts expended.
(D) For substance-use disorder programs--
(i) the number of beds (whether hospital,
nursing home, or other designated beds)
employed and the average bed occupancy of such
beds;
(ii) the percentage of unique patients
admitted directly to outpatient care during the
fiscal year who had two or more additional
visits to specialized outpatient care within 30
days of their first visit, with a comparison
from 1996 until the date of the report;
(iii) the percentage of unique inpatients
with substance-use disorder diagnoses treated
during the fiscal year who had one or more
specialized clinic visits within three days of
their index discharge, with a comparison from
1996 until the date of the report;
(iv) the percentage of unique outpatients
seen in a facility or geographic service area
during the fiscal year who had one or more
specialized clinic visits, with a comparison
from 1996 until the date of the report; and
(v) the rate of recidivism of patients at
each specialized clinic in each geographic
service area of the Veterans Health
Administration.
(E) For mental health programs, the number and type
of staff that are available at each facility to provide
specialized mental health treatment, including
satellite clinics, outpatient programs, and community-
based outpatient clinics, with a comparison from 1996
to the date of the report.
(F) The number of such clinics providing mental
health care, the number and type of mental health staff
at each such clinic, and the type of mental health
programs at each such clinic.
(G) The total amounts expended for mental health
during the fiscal year.
(3) For purposes of paragraph (1), the capacity of the
Department (and each geographic service area of the Veterans
Health Administration) to provide for the specialized treatment
and rehabilitative needs of disabled veterans within distinct
programs or facilities shall be measured for veterans with
spinal cord dysfunction, traumatic brain injury, blindness, or
prosthetics and sensory aids as follows (with all such data to
be provided by geographic service area and totaled nationally):
(A) For spinal cord injury and dysfunction
specialized centers and for blind rehabilitation
specialized centers, the number of staffed beds and the
number of full-time equivalent employees assigned to
provide care at such centers.
(B) For prosthetics and sensory aids, the annual
amount expended.
(C) For traumatic brain injury, the number of
patients treated annually and the amounts expended.
(4) In carrying out paragraph (1), the Secretary may not use
patient outcome data as a substitute for, or the equivalent of,
compliance with the requirement under that paragraph for
maintenance of capacity.
(5)(A) Not later than April 1 of each year, the Secretary
shall submit to the Committees on Veterans' Affairs of the
Senate and House of Representatives a report on the Secretary's
compliance, by facility and by service-network, with the
requirements of this subsection. Each such report shall include
information on recidivism rates associated with substance- use
disorder treatment.
(B) In preparing each report under subparagraph (A), the
Secretary shall use standardized data and data definitions.
(C) Each report under subparagraph (A) shall be audited by
the Inspector General of the Department, who shall submit to
Congress a certification as to the accuracy of each such
report.
(6)(A) To ensure compliance with paragraph (1), the Under
Secretary for Health shall prescribe objective standards of job
performance for employees in positions described in
subparagraph (B) with respect to the job performance of those
employees in carrying out the requirements of paragraph (1).
Those job performance standards shall include measures of
workload, allocation of resources, and quality-of-care
indicators.
(B) Positions described in this subparagraph are positions in
the Veterans Health Administration that have responsibility for
allocating and managing resources applicable to the
requirements of paragraph (1).
(C) The Under Secretary shall develop the job performance
standards under subparagraph (A) in consultation with the
Advisory Committee on Prosthetics and Special Disabilities
Programs and the Committee on Care of Severely Chronically
Mentally Ill Veterans.
(c) The Secretary shall ensure that each primary care health
care facility of the Department develops and carries out a plan
to provide mental health services, either through referral or
direct provision of services, to veterans who require such
services.
(d)(1) Except as provided in section 1703A of this title, in
furnishing primary care under this chapter, the Secretary shall
assign each eligible veteran to--
(A) a patient-aligned care team of the Department; or
(B) a dedicated primary care provider of the
Department as a part of any other model of providing
consistent primary care determined appropriate by the
Secretary.
(2) Each patient-aligned care team of the Department shall
consist of a team of health care professionals of the
Department who--
(A) provide to each eligible veteran comprehensive
primary care in partnership with the veteran; and
(B) manage and coordinate comprehensive hospital care
and medical services consistent with the goals of care
agreed upon by the veteran and team.
(3) The Secretary shall ensure that an eligible veteran is
not simultaneously assigned to more than one patient-aligned
care team or dedicated primary care provider under this
subsection at a single location, including by establishing
procedures in the event a primary care provider retires or is
otherwise no longer able to treat the veteran. In the case of
an eligible veteran who resides in more than one location, the
Secretary may assign such veteran to a patient-aligned care
team or dedicated primary care provider at each such location.
(4) The term ``eligible veteran'' means a veteran who--
(A) is enrolled in the patient enrollment system of
the Department established and operated under section
1705(a) of this title; and
(B) has--
(i) been furnished hospital care or medical
services at or through a Department facility on
at least one occasion during the two-year
period preceding the date of the determination
of eligibility; or
(ii) requested a first-time appointment for
hospital care or medical services at a
Department facility.
* * * * * * *
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] under the VA Care in the
Community Program 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] and the VA
Care in the Community Program (with respect to such a year
beginning on or after the date on which the Secretary commences
implementation of the VA Care in the Community Program) 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] under the VA Care in the Community Program 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 with private facilities that is available to the
Secretary [(under sections 1703(a)(2) and 1710(a)(1)(B) of this
title)] (under the VA Care in the Community Program) 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.
* * * * * * *
SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS
* * * * * * *
Sec. 1725. Reimbursement for emergency treatment
(a) General Authority.--(1) Subject to subsections (c) and
(d), the Secretary shall reimburse a veteran described in
subsection (b) for the reasonable value of emergency treatment
furnished the veteran in a non-Department facility.
(2) In any case in which reimbursement is authorized under
subsection (a)(1), the Secretary, in the Secretary's
discretion, may, in lieu of reimbursing the veteran, make
payment of the reasonable value of the furnished emergency
treatment directly--
(A) to a hospital or other health care provider that
furnished the treatment; or
(B) to the person or organization that paid for such
treatment on behalf of the veteran.
(b) Eligibility.--(1) A veteran referred to in subsection
(a)(1) is an individual who is an active Department health-care
participant who is personally liable for emergency treatment
furnished the veteran in a non-Department facility.
(2) A veteran is an active Department health-care participant
if--
(A) the veteran is enrolled in the health care system
established under section 1705(a) of this title; and
(B) the veteran received care under this chapter
within the 24-month period preceding the furnishing of
such emergency treatment.
(3) A veteran is personally liable for emergency treatment
furnished the veteran in a non-Department facility if the
veteran--
(A) is financially liable to the provider of
emergency treatment for that treatment;
(B) has no entitlement to care or services under a
health-plan contract (determined, in the case of a
health-plan contract as defined in subsection (f)(2)(B)
or (f)(2)(C), without regard to any requirement or
limitation relating to eligibility for care or services
from any department or agency of the United States);
(C) has no other contractual or legal recourse
against a third party that would, in whole, extinguish
such liability to the provider; and
(D) is not eligible for reimbursement for medical
care or services under section 1728 of this title.
(c) Limitations on Reimbursement.--(1) The Secretary, in
accordance with regulations prescribed by the Secretary,
shall--
(A) establish the maximum amount payable under
subsection (a);
(B) delineate the circumstances under which such
payments may be made, to include such requirements on
requesting reimbursement as the Secretary shall
establish; and
(C) provide that in no event may a payment under that
subsection include any amount for which the veteran is
not personally liable.
(2) Subject to paragraph (1), the Secretary may provide
reimbursement under this section only after the veteran or the
provider of emergency treatment has exhausted without success
all claims and remedies reasonably available to the veteran or
provider against a third party for payment of such treatment.
(3) Payment by the Secretary under this section on behalf of
a veteran to a provider of emergency treatment shall, unless
rejected and refunded by the provider within 30 days of
receipt, extinguish any liability on the part of the veteran
for that treatment. Neither the absence of a contract or
agreement between the Secretary and the provider nor any
provision of a contract, agreement, or assignment to the
contrary shall operate to modify, limit, or negate the
requirement in the preceding sentence.
(4)(A) If the veteran has contractual or legal recourse
against a third party that would only, in part, extinguish the
veteran's liability to the provider of the emergency treatment,
and payment for the treatment may be made both under subsection
(a) and by the third party, the amount payable for such
treatment under such subsection shall be the amount by which
the costs for the emergency treatment exceed the amount payable
or paid by the third party, except that the amount payable may
not exceed the maximum amount payable established under
paragraph (1)(A).
(B) In any case in which a third party is financially
responsible for part of the veteran's emergency treatment
expenses, the Secretary shall be the secondary payer.
(C) A payment in the amount payable under subparagraph (A)
shall be considered payment in full and shall extinguish the
veteran's liability to the provider.
(D) The Secretary may not reimburse a veteran under this
section for any copayment or similar payment that the veteran
owes the third party or for which the veteran is responsible
under a health-plan contract.
(5) In delineating the circumstances under which
reimbursement may be made under this section for ambulance
services for an individual, the Secretary shall treat such
services as emergency services for which reimbursement may be
made under this section if the Secretary determines that--
(A) the request for ambulance services was made as a
result of the sudden onset of a medical condition of
such a nature that a prudent layperson who possesses an
average knowledge of health and medicine--
(i) would have reasonably expected that a
delay in seeking immediate medical attention
would have been hazardous to the life or health
of the individual; or
(ii) could reasonably expect the absence of
immediate medical attention to result in
placing the health of the individual in serious
jeopardy, the serious impairment of bodily
functions, or the serious dysfunction of any
bodily organ or part; and
(B) the individual is transported to the most
appropriate medical facility capable of treating such
medical condition.
(d) Independent Right of Recovery.--(1) In accordance with
regulations prescribed by the Secretary, the United States
shall have the independent right to recover any amount paid
under this section when, and to the extent that, a third party
subsequently makes a payment for the same emergency treatment.
(2) Any amount paid by the United States to the veteran (or
the veteran's personal representative, successor, dependents,
or survivors) or to any other person or organization paying for
such treatment shall constitute a lien in favor of the United
States against any recovery the payee subsequently receives
from a third party for the same treatment.
(3) Any amount paid by the United States to the provider that
furnished the veteran's emergency treatment shall constitute a
lien against any subsequent amount the provider receives from a
third party for the same emergency treatment for which the
United States made payment.
(4) The veteran (or the veteran's personal representative,
successor, dependents, or survivors) shall ensure that the
Secretary is promptly notified of any payment received from any
third party for emergency treatment furnished to the veteran.
The veteran (or the veteran's personal representative,
successor, dependents, or survivors) shall immediately forward
all documents relating to such payment, cooperate with the
Secretary in the investigation of such payment, and assist the
Secretary in enforcing the United States right to recover any
payment made under subsection (c)(3).
(e) Waiver.--The Secretary, in the Secretary's discretion,
may waive recovery of a payment made to a veteran under this
section that is otherwise required by subsection (d)(1) when
the Secretary determines that such waiver would be in the best
interest of the United States, as defined by regulations
prescribed by the Secretary.
(f) Definitions.--For purposes of this section:
(1) The term ``emergency treatment'' means medical
care or services furnished, in the judgment of the
Secretary--
(A) when Department or other Federal
facilities are not feasibly available and an
attempt to use them beforehand would not be
reasonable;
(B) when such care or services are rendered
in a medical emergency of such nature that a
prudent layperson reasonably expects that delay
in seeking immediate medical attention would be
hazardous to life or health; and
(C) until--
(i) such time as the veteran can be
transferred safely to a Department
facility or other Federal facility and
such facility is capable of accepting
such transfer; or
(ii) such time as a Department
facility or other Federal facility
accepts such transfer if--
(I) at the time the veteran
could have been transferred
safely to a Department facility
or other Federal facility, no
Department facility or other
Federal facility agreed to
accept such transfer; and
(II) the non-Department
facility in which such medical
care or services was furnished
made and documented reasonable
attempts to transfer the
veteran to a Department
facility or other Federal
facility.
(2) The term ``health-plan contract'' includes any of
the following:
(A) 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) An insurance program described in section
1811 of the Social Security Act (42 U.S.C.
1395c) or established by section 1831 of that
Act (42 U.S.C. 1395j).
(C) A State plan for medical assistance
approved under title XIX of such Act (42 U.S.C.
1396 et seq.).
(D) A workers' compensation law or plan
described in section 1729(a)(2)(A) of this
title.
(3) The term ``third party'' means any of the
following:
(A) A Federal entity.
(B) A State or political subdivision of a
State.
(C) An employer or an employer's insurance
carrier.
(D) An automobile accident reparations
insurance carrier.
(E) A person or entity obligated to provide,
or to pay the expenses of, health services
under a health-plan contract.
* * * * * * *
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.
(2) Paragraph (1) of this subsection applies to a non-
service-connected disability--
(A) that is incurred incident to the veteran'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 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
(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--
(A) the veteran'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.
(4) Notwithstanding any other provision of law, any amount
that the United States may collect or recover under this
section shall not affect any copayment amount a veteran is
otherwise obligated to pay under this chapter.
(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 (or the veteran'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 (or the veteran'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 by the
Secretary under this chapter;
(ii) the United States has sent written notice by
certified mail to the veteran at the veteran's last-
known address (or to the veteran'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 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
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; and
(B) that the provision of such care or services to
the veteran meets criteria generally applicable under
the health-plan contract involved.
(2) A veteran described in this paragraph is a veteran 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.
(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. 1729A. Department of Veterans Affairs Medical Care Collections
Fund
(a) There is in the Treasury a fund to be known as the
Department of Veterans Affairs Medical Care Collections Fund.
(b) Amounts recovered or collected under any of the following
provisions of law shall be deposited in the fund:
(1) Section 1710(f) of this title.
(2) Section 1710(g) of this title.
(3) Section 1711 of this title.
(4) Section 1722A of this title.
(5) Section 1725 of this title.
(6) Section 1729 of this title.
(7) Section 1784 of this title.
(8) Section 8165(a) of this title.
(9) Section 113 of the Veterans Millennium Health
Care and Benefits Act (Public Law 106-117; 38 U.S.C.
8111 note).
(10) Public Law 87-693, popularly known as the
``Federal Medical Care Recovery Act'' (42 U.S.C. 2651
et seq.), to the extent that a recovery or collection
under that law is based on medical care or services
furnished under this chapter.
(c)(1) Subject to the provisions of appropriations Acts,
amounts in the fund shall be available, without fiscal year
limitation, to the Secretary for the following purposes:
(A) Furnishing medical care and services under this
chapter, to be available during any fiscal year for the
same purposes and subject to the same limitations
(other than with respect to the period of availability
for obligation) as apply to amounts appropriated from
the general fund of the Treasury for that fiscal year
for medical care.
(B) Expenses of the Department for the
identification, billing, auditing, and collection
(including with respect to automatic data processing or
information technology improvements) of amounts owed
the United States by reason of medical care and
services furnished under this chapter.
(2) Amounts available under paragraph (1) may not be used for
any purpose other than a purpose set forth in subparagraph (A)
or (B) of that paragraph.
(d) Of the total amount recovered or collected by the
Department during a fiscal year under the provisions of law
referred to in subsection (b) and made available from the fund,
the Secretary shall make available to each Department health
care facility of the Department an amount that bears the same
ratio to the total amount so made available as the amount
recovered or collected by such facility during that fiscal year
under such provisions of law bears to such total amount
recovered or collected during that fiscal year. The Secretary
shall make available to each facility the entirety of the
amount specified to be made available to such facility by the
preceding sentence.
(e) Amounts recovered or collected under the provisions of
law referred to in subsection (b) shall be treated for the
purposes of sections 251 and 252 of the Balanced Budget and
Emergency Deficit Control Act of 1985 (2 U.S.C. 901, 902) as
offsets to discretionary appropriations (rather than as offsets
to direct spending) to the extent that such amounts are made
available for expenditure in appropriations Acts for the
purposes specified in subsection (c).
* * * * * * *
Sec. 1730B. 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) 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.
(c) 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.).
(d) Covered Health Care Professional Defined.--In this
section, the term ``covered health care professional'' means a
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 quality standards
relating to the provision of telemedicine 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.
* * * * * * *
SUBCHAPTER V--PAYMENTS TO STATE HOMES
* * * * * * *
Sec. 1745. Nursing home 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)] 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)] 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)] 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 entered into
without regard to any law that would require the Secretary to
use competitive procedures in selecting the party with which to
enter into the agreement.
(B)(i) Except as provided in clause (ii) and unless otherwise
provided in this section or in 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 law to which providers of services and
suppliers are not subject under the original Medicare fee-for-
service program under parts A and B of title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.) or the Medicaid
program under title XIX of such Act (42 U.S.C. 1396 et seq.).
(ii) The exclusion under clause (i) does not apply to laws
regarding integrity, ethics, fraud, or that subject a person to
civil or criminal penalties.
(C) Title VII of the Civil Rights Act of 1964 (42 U.S.C.
2000e et seq.) shall apply with respect to a State home that
enters into an agreement under this section to the same extent
as such title applies with respect to the State home in
providing care or services through an agreement or arrangement
other than under this section.
(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.
* * * * * * *
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 of this title] under the VA Care in the
Community Program;
(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 V--BOARDS, ADMINISTRATIONS, AND SERVICES
* * * * * * *
CHAPTER 73--VETERANS HEALTH ADMINISTRATION - ORGANIZATION AND FUNCTIONS
* * * * * * *
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.
(I) To a public or private health care provider in
order to provide treatment or health care to a shared
patient.
(J) To a third party in order to recover or collect
reasonable charges for care furnished to a veteran for
a non-service-connected disability pursuant to section
1729 of this title or section 1 of Public Law 87-693
(42 U.S.C. 2651).
(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.
(4) Nothing in this section shall be construed to authorize
any provision of records in violation of relevant health record
privacy laws, including the Health Insurance Portability and
Accountability Act of 1996 (Public Law 104-191).
(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.
* * * * * * *
[7409. Contracts for scarce medical specialist services.]
* * * * * * *
SUBCHAPTER I--APPOINTMENTS
* * * * * * *
[Sec. 7409. Contracts for scarce medical specialist services
[(a) The Secretary may enter into contracts with institutions
and persons described in subsection (b) to provide scarce
medical specialist services at Department facilities. Such
services may include the services of physicians, dentists,
podiatrists, optometrists, chiropractors, nurses, physician
assistants, expanded-function dental auxiliaries, technicians,
and other medical support personnel.
[(b) Institutions and persons with whom the Secretary may
enter into contracts under subsection (a) are the following:
[(1) Schools and colleges of medicine, osteopathy,
dentistry, podiatry, optometry, and nursing.
[(2) Clinics.
[(3) Any other group or individual capable of
furnishing such scarce medical specialist services.]
* * * * * * *
CHAPTER 76--HEALTH PROFESSIONALS 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 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; preference; 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) Preference for Veterans.--In selecting individuals for
participation in the Specialty Education Loan Repayment Program
under this subchapter, the Secretary may give preference to
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.
* * * * * * *
----------
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) or
the date on which the Secretary certifies to the
Committees on Veterans' Affairs of the House of
Representatives and the Senate that the Secretary is
fully implementing section 1703A of title 38, United
States Code, whichever occurs first.
(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.
(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 II--HEALTH CARE ADMINISTRATIVE MATTERS
* * * * * * *
SEC. 208. INFORMATION IN ANNUAL BUDGET OF THE PRESIDENT ON HOSPITAL
CARE AND MEDICAL SERVICES FURNISHED THROUGH
EXPANDED USE OF CONTRACTS FOR SUCH CARE.
The materials on the Department of Veterans Affairs in the
budget of the President for a fiscal year, as submitted to
Congress pursuant to section 1105(a) of title 31, United States
Code, shall set forth the following:
(1) The number of veterans who received hospital care
and medical services under [section 101] section 1703A
of title 38, United States Code during the fiscal year
preceding the fiscal year in which such budget is
submitted.
(2) The amount expended by the Department on
furnishing care and services under such section during
the fiscal year preceding the fiscal year in which such
budget is submitted.
(3) The amount requested in such budget for the costs
of furnishing care and services under such section
during the fiscal year covered by such budget, set
forth in aggregate and by amounts for each account for
which amounts are so requested.
(4) The number of veterans that the Department
estimates will receive hospital care and medical
services under such section during the fiscal years
covered by the budget submission.
(5) The number of employees of the Department on paid
administrative leave at any point during the fiscal
year preceding the fiscal year in which such budget is
submitted.
* * * * * * *
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), 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.
[(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) 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.]
* * * * * * *
----------
SURFACE TRANSPORTATION AND VETERANS HEALTH CARE CHOICE IMPROVEMENT ACT
OF 2015
* * * * * * *
TITLE IV--VETERANS PROVISIONS
* * * * * * *
SEC. 4003. FUNDING ACCOUNT FOR NON-DEPARTMENT CARE.
Each budget of the President submitted to Congress under
section 1105 of title 31, United States Code, for fiscal year
2017 and each fiscal year thereafter shall include an
appropriations account [for non-Department provider programs
(as defined in section 2(d)) to be comprised of--]
[(1) discretionary medical services funding that is
designated for hospital care and medical services
furnished at non-Department facilities; and]
[(2) any funds transferred for such purpose from the
Veterans Choice Fund established by section 802 of the
Veterans Access, Choice, and Accountability Act of 2014
(Public Law 113-146; 128 Stat. 1802)] for the VA Care
in the Community Program (as defined in section
1701(12) of title 38, United States Code) and Veterans
Care Agreements under section 1703B of title 38, United
States Code.
* * * * * * *
----------
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] such program,
(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.
* * * * * * *
DISSENTING VIEWS
I
Earlier this year, the House Committee on Veterans' Affairs
(HVAC) began the arduous task of outlining what the future of
community care at the Department of Veterans Affairs (VA) would
look like. Community care, also sometimes referred to as non-VA
care or fee-basis care, has long been the subject of numerous
critical reports from bodies such as VA's Office of Inspector
General (VAOIG), Government Accountability Office (GAO), the
Independent Assessment,\1\ and the Commission on Care.\2\ These
reports emphasized the challenges of maintaining six separate
pathways, all with different eligibility criteria and payment
rates, to send veterans into the community for care. Not only
is this confusing to veterans, VA staff and community
providers, it is also highly inefficient. H.R. 4242 would
streamline eligibility and payment rates, among other things,
into one easy to use and administer program that would allow VA
to take advantage of economies of scale. While the Minority
generally agrees with the broad policy that is outlined in H.R.
4242, we do have several concerns.
---------------------------------------------------------------------------
\1\A congressional mandate outlined in Section 201 of Public Law
P.L. 113-146.
\2\A congressional mandate outlined in Section 202 of P.L. 113-146.
---------------------------------------------------------------------------
The most significant of these concerns is funding. The
Congressional Budget Office (CBO) issued a preliminary score
for H.R. 4242 on November 7, 2017, of nearly $40 billion over
five years. In recent years, leadership of both HVAC and the
Senate Committee on Veterans' Affairs (SVAC) have required
discretionary spending to be off-set before a bill can be voted
out of committee. As written, H.R. 4242 provides no pay-for and
was the main reason the bill was pulled from the November 8,
2017, markup agenda. A pay-for was not identified ahead of the
December 19, 2017 markup either.
In an effort to address the score, during the December 19,
2017, markup Chairman Roe offered an amendment which would
place caps on VA's Medical Community Care account. In effect,
growth of the program would be restricted to just 3 percent a
year. We believe that will not be sufficient and could lead to
rationing of community care or diversion of funds from VA's
Medical Care account. This belief is based on several factors,
including the overall growth in community care spending
(between Fiscal Year (FY) 2017 and FY 2018, obligation
authorities are expected to grow by 8.3 percent);\3\ the steady
increase in the number of authorizations for the Veterans
Choice Program (VCP) (between March and May 2017, VA issued
nearly 800,000 authorizations for VCP, which represented a 32%
increase over the same time-period in 2016);\4\ and the
projected demand for Long-Term Support and Service (LTSS),
which include high-cost services such as nursing home care and
adult day care that will continue to steadily increase as the
number of 85-year-old enrollees in VA will almost double over
the next 20 years.\5\
---------------------------------------------------------------------------
\3\Briefing from Department of Veterans Affairs' Office of
Management, June 22, 2017.
\4\United States Cong. House Committee on Veterans' Affairs,
Subcommittee on Health Hearing--``Health Programs Budget Request for
Fiscal Year 2018'' June 22, 2017. 115th Cong. 1st sess. Washington.
GPO, 2017 (Statement by Poonam Alaigh, Acting Under Secretary for
Health, Veterans Health Administration, US Department of Veterans
Affairs).
\5\VA FY 2018 Budget Submission--Vol. 2, Pg. 369 https://
www.va.gov/budget/docs/summary/
fy2018VAbudgetVolumeIImedicalProgramsAndInformationTechnology.pdf.
---------------------------------------------------------------------------
Additional factors that would significantly impact VA's
ability to deliver care in the community on an artificially
constrained budget that would include financial constraints on
VA just as demand for care is likely to expand in response to
the Republican tax plan, which not only undermines the
Affordable Care Act but triggers Medicaid funding cuts. In
fact, one in 10 veterans are on Medicaid, which is 1.75 million
veterans.\6\ Furthermore, earlier this year, documents leaked
by administration officials revealed a plan to merge the VCP
with TRICARE, a health insurance program that service members
and their families pay to use.\7\
---------------------------------------------------------------------------
\6\Callow, Andrea. Cutting Medicaid Would Hurt Veterans. Families
USA. May 2017. http://familiesusa.org/product/cutting-medicaid-would-
hurt-veterans.
\7\Yen, Hope. VA exploring idea of merging health system with
Pentagon. Federal News Radio. November 17, 2017. https://
federalnewsradio.com/veterans-affairs/2017/11/vas-quiet-plan-to-widen-
private-care-with-tricare-stirs-ire/.
---------------------------------------------------------------------------
Although we appreciate the Chairman's removal of his
amendment, this legislation continues to lack a sustainable
path to fund this permanent program. Playing tricks with
authorizing caps, either in the hearing or when this bill is
brought to the floor for final passage sends the wrong message
to VA, community providers and the veterans we are supposed to
serve. Moreover, without a plan to appropriately fund any
future community care program, we are equally concerned that
Congress will continue to kick the proverbial can down the road
and will opt instead to carry on appropriating more funding for
the flawed VCP that was only ever intended to be a temporary
measure to address VA's access to care crisis.
In addition, we are concerned the changes made to H.R. 4242
by an amendment offered by Chairman Roe does not fully address
the anxieties expressed by the Veteran Service Organizations
(VSOs) and will ultimately lead to an uneven policy application
across VA medical facilities. In mid-November, a number of VSOs
raised their concerns with Majority and Minority staff about
certain portions of the language in Section 102, Establishment
of VA Care in the Community Program of H.R. 4242. In particular
they were worried about language that from their perspective
gave veterans access to ``unfettered choice''. VSOs have been
highly critical of any attempt, or perceived attempt, to
privatize VA care.
The amendment in question sought to change language related
to veteran eligibility and the appeals process among other
things. In particular, language in the underlying bill
expressed that the Secretary ``SHALL'' give deference to the
veteran with respect to reviewing a disagreement regarding the
availability of and assignment to a patient aligned care team
or dedicated primary care provider. The Roe amendment changed
that to a ``MAY''.
Given the language now reflects an option rather than an
imperative, we are concerned that this could lead to an uneven
administrative application of the provision. Within the
veterans community there is a well-known saying to describe the
Veterans Health Administration (VHA): ``If you've been to one
VA, you've been to one VA.'' Despite the prolific use of
directives and memos across VHA, countless stakeholders have
observed the lack of standardized implementation and oversight
of policy and procedures. In fact, it is one of the reasons VA
was added to GAO's high-risk list in 2015.\8\ Had the suggested
language of the VSOs been adopted, ``SHALL give the benefit of
the doubt to the veteran when there is an approximate balance
of positive and negative evidence,'' additional opportunities
for unclear policy application could have been avoided.
---------------------------------------------------------------------------
\8\https.//www.gao.gov/assets/670/668415.pdf.
---------------------------------------------------------------------------
In addition, another amendment adopted during markup would
create a new Center for Innovation for Care and Payment.
Although we generally support looking at new methods of paying
non-VA providers and new methods for delivering health care
services to veterans to reduce expenditures and improve care
quality, we remain concerned the process for developing the
pilot program in the legislation gives the VA Secretary overly-
broad authority to waive federal law. We are also concerned
that resources intended for delivery of health care to veterans
will be diverted to pay for the pilot program without a
specific funding source designated.
The Roe amendment would not prohibit enrolled veterans with
service-connected disabilities to be billed or charged for
health care services related to service-connection under the
pilot program. It also gives the VA Secretary broad authority
to waive certain requirements under Chapter 17 of title 38 to
implement the pilot program. This includes the authority to
waive VA healthcare eligibility requirements, contracting
requirements, and standard of care requirements for community
care providers. Once granted, the waiver would not be subject
to judicial review. This waiver could easily be granted via a
privileged resolution or bill that would circumvent the House
and Senate Veterans' Affairs Committees and require only a
majority vote in each Chamber to be granted. With this special
procedure to grant a waiver, an identical procedure should at
least exist for termination of the waiver.
No specific funding was authorized for the Center, which
would be funded out of VHA's Medical Services Accounts. Since
the Center would be piloting new care delivery and billing
models, the pilot program could yield higher costs for the
delivery of care, which would take precious resources away from
the direct delivery of care by VA. Any pilot in which new care
delivery models are tested with community providers should be
funded specifically for that purpose so that funds for direct
delivery of care are not diverted to pay for pilot programs
that pay non-VA providers for care.
If this amendment had been subject to Committee process, we
would have requested views from VA and experts on the need for
granting the VA Secretary such broad authority. We would have
worked with Veteran Service Organizations to ensure the pilot
programs grant preference to delivery models that also improve
the coordination, quality, and efficiency of health care
services furnished to veterans enrolled in the VA's patient
enrollment system. We also would have had the opportunity to
determine the levels of specific purpose funding that would be
appropriate to test care delivery models under the Center's
pilot programs.
II
The continued near-flat line request for the Medical
Services account will continue the trend of VA being unable to
provide the needed services internally and forcing veterans
into the community for care. Failure to adequately fund VA so
that it is able to hire staff to fill over 45,000 provider
vacancies and address its significant infrastructure needs will
cause veterans to wait longer for appointments. Sending more
veterans for care in the community is not the panacea for all
of VA's access challenges. Community care is only intended to
fill gaps in care that VA is unable to provide due to lack of
capacity, and only accounts for approximately 30 percent of the
care delivered by VA.\9\ Provider shortages exist throughout
the U.S., and in many cases, community providers lack the
expertise or cultural competency to provide quality care to
veterans. A holistic, systems-based approach, not a narrow
focus on sending veterans for care in the community is needed
to address VHA's access-to-care challenges.
---------------------------------------------------------------------------
\9\The MITRE Corporation, Independent Assessment of the Health Care
Delivery Systems and Management Processes of the Department of Veterans
Affairs Integrated Report, xii (2015), ``VHA must adopt systems
thinking to address its most challenging problems, including access,
quality, cost, and patient experience.''
---------------------------------------------------------------------------
Democrats offered 7 amendments during markup that would
have addressed VA's internal capacity. Unfortunately, only 2 of
these 7 amendments were adopted. The 5 amendments not agreed to
addressed VA's significant staffing and provider shortages,
infrastructure needs, accountability measures for non-VA
providers, expansion of the VA Family Caregiver Program to all
generations of veterans, and authorized $1 billion for
educational assistance for providers, additional graduate
medical education residency positions, and recruitment,
relocation, and retention incentives for providers.
On November 29, 2017, the Senate Committee on Veterans'
Affairs favorably reported to the Senate legislation to reform
VA's community care program and address VA's access-to-care-
challenges. This bipartisan legislation was favorably reported
14-1. The Senate legislation addresses VA's capacity and access
challenges holistically by addressing infrastructure, provider
shortages, expanding the Comprehensive Assistance for Family
Caregiver Program, and reforming VA's community care programs.
We agree with this approach. For this reason, the Senate's
legislation and Title I of H.R. 4242 (with amendments requested
by Veteran Service Organizations) formed the basis of Ranking
Member Walz's amendment in the nature of a substitute to H.R.
4242 that was supported by Committee Democrats, but voted down
by all Committee Republicans.
The A.N.S. offered by Ranking Member Walz would expand the
Comprehensive Assistance for Family Caregiver Program to all
generations of veterans. It would authorize $1 billion to pay
for up to $240,000 per VA provider over 5 years in education
debt reduction under the Education Debt Reduction Program,\10\
lift the limit on annual awards for recruitment, relocation, or
retention incentives, establish a higher maximum amount of
basic pay for nurses, authorize a tuition reimbursement and
loan repayment pilot program for providers at underserved
facilities, and create an additional 1,500 graduate medical
residency positions. It authorizes an additional $4 billion for
the Veterans Choice Fund to pay for community care. It would
also give VA more flexibility over its construction programs by
permitting VA to perform construction on projects costing under
$20 million without congressional approval, grants VA more
flexibility to issue enhanced use leases, facilitates sharing
of medical facilities with other agencies such as the
Department of Defense, and authorizes construction on a medical
facility realignment project in Livermore, California.
---------------------------------------------------------------------------
\10\Clinical staff employed at Vet Centers would also be eligible
for EDRP.
---------------------------------------------------------------------------
An amendment to H.R. 4242 offered by Representative
Brownley would have streamlined approval for major construction
of medical facilities by permitting approval via adoption of
resolutions by the House and Senate Veterans' Affairs
Committees. Amendments offered by Rep. Takano would have set
firm hiring levels for VA so that it would be required to
immediately address the provider shortage, required non-VA
providers to follow the same contracting laws and regulations
as other government contractors, and would have established an
Office of Non-VA Delivered Medical Care Accountability in
charge of overseeing, auditing, analyzing, and investigating
non-VA delivered care. The majority did not support these
amendments.
All amendments offered by Democrats did not seek to
fundamentally alter the bipartisan community care eligibility
language. Instead, these amendments sought to holistically
address VA's access and capacity challenges by strengthening
VA's internal capacity to deliver health care to veterans, and
by reforming the community care programs--including the Choice
Program--intended to supplement VA-delivered care. Without
taking a systems approach, as recommended in the Independent
Assessment, we cannot expect to address VHA's challenges by
narrowly focusing only on offering veterans community care.
Tim Walz,
Ranking Member.
[all]
