79–006 

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 


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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— 


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‘‘(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: 

‘‘§ 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 


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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 


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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. 


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‘‘(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. 


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‘‘(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 


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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 shortand 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 


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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. 


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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: 

‘‘§ 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. 


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‘‘(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. 


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‘‘(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 


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‘‘(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 


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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-DepartVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00014 Fmt 6659 Sfmt 6621 E:\HR\OC\HR585.XXX HR585

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ment 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 FA- CILITIES.— 

(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 


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(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: 

‘‘§ 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: 


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‘‘(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: 

‘‘§ 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 


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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: 

‘‘§ 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. 


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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. 


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(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 VetVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00020 Fmt 6659 Sfmt 6621 E:\HR\OC\HR585.XXX HR585

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erans 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: 

‘‘§ 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 


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‘‘(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 


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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) 

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tist 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 

‘‘§ 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’). 

‘‘§ 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. 

‘‘§ 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 


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‘‘(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. 

‘‘§ 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. 

‘‘§ 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. 

‘‘§ 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. 


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‘‘§ 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. 


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(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; 


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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. 

(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. 

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 


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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). 5 January 11, 2017, MyVA Advisory Committee Meeting, Georgetown University, Washington, 

D.C. 6May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet. ‘‘A Consolidated and Modernized VA Community Care Program.’’ 7 Ibid. 

8 Ibid. 

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. 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). 

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

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

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

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 


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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. 16May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet. ‘‘A Consolidated and Modernized VA Community Care Program.’’ 

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

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 MediVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00030 Fmt 6659 Sfmt 6602 E:\HR\OC\HR585.XXX HR585

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17GAO–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). 

care 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. 

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 

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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). 

quire 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. 

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 [nonChoice 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 subVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00032 Fmt 6659 Sfmt 6602 E:\HR\OC\HR585.XXX HR585

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23 VA National Transplant Program. https://www.va.gov/health/services/transplant/ 

Accessed October 30, 2017. 24 Ibid. 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. 

ject 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. 

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

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 


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27 Ibid. 28Fox 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-payfor-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. 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. 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). 

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

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. 

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 


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33 January 11, 2017, MyVA Advisory Committee Meeting, Georgetown University, Washington, D.C. 34 Ibid. 35 VA Fiscal Year 2018 Budget Submission, Volume 2, VHA–347. 36 Ibid. 37 Ibid. 

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. 

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. 

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 serviceconnected 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 serviceconnected 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 


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38 Ibid. 39 Ibid. 40 VA Fiscal Year 2018 Budget Submission, Volume 2, VHA–173. 41 VA Fiscal Year 2018 Budget Submission, Volume 2, VHA–174. 42 CMS Alliance to Modernize Healthcare Federally Funded Research and Development Center, September 1, 2015, ‘‘Independent Assessment of the Health Care Delivery Systems and 

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. 

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. 

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. 

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 


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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. 44GAO-17-480, May 2017, ‘‘Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency,’’ https://www.gao.gov/assets/690/684869.pdf. 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. 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. 

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. 

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

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 


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51 Ibid. 52 Ibid. 53 Ibid. 54 Ibid. 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). 

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

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

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

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 physiVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00038 Fmt 6659 Sfmt 6602 E:\HR\OC\HR585.XXX HR585

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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). 59Prescription Opioid Overdose Data, Centers for Disease Control and Prevention; https:// 

www.cdc.gov/drugoverdose/data/overdose.html. 60Department 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. 61 Ibid. 62 Ibid. 63 Ibid. 

cians 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. 

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

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

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 


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64December 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. 

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. 

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 


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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.) 67 AAMC Medical School Graduation Questionnaire. https://www.aamc.org/download/ 

481784/data/2017gqallschoolssummaryreport.pdf. 

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

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 


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68Medscape Physician Compensation Report 2917. https://www.medscape.com/slideshow/ 

compensation-2017-overview-6008547#4. 69Darves, B, Physician Job-Search Timeline: Delayed Approach Not Advised; The New England Journal of Medicine, October 8, 2014. 

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. 

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 


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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. 


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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 

Gonza ́lez-Colo ́n 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 


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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. 


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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: 


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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: 


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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: 


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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: 


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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. 


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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 


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By fiscal year, in millions of dollars— 

2018 2019 2020 2021 2022 2018–2022 

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: 


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• 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 extendedcare 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, 


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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 nonFAR 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. 


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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, 


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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 


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$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 

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ices 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 

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tionship 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. 


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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. 


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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. 


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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. 


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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. 


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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 


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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). 


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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 


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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): 


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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. 


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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 

* * * * * * * 

§ 1701. Definitions 

For the purposes of this chapter— 


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(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. 


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(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. 


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(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. 

* * * * * * * 

§ 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 DeVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00076 Fmt 6659 Sfmt 6601 E:\HR\OC\HR585.XXX HR585

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partment 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. 


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§ 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. 


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(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— 


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(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; 


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(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. 


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(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; 


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(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 


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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 

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payment 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. 


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(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. 


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(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. 


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§ 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. 


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(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— 


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(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. 


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(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— 


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(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. 

§ 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 nonDepartment facility pursuant to such an agreement solely for the 

purposes of receiving such operation, care, and services at the nonDepartment 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. 

§ 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. 


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(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 


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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 ofVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00094 Fmt 6659 Sfmt 6603 E:\HR\OC\HR585.XXX HR585

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fered 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 patientcenteredness 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— 


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(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. 

* * * * * * * 

§ 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. 

§ 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 DeVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00096 Fmt 6659 Sfmt 6601 E:\HR\OC\HR585.XXX HR585

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partment (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 substanceuse 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. 


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(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 


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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 patientaligned 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 

* * * * * * * 

§ 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— 


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(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). 

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ices, treatment, or related dental appliances to a veteran under 

this section through private facilities for which the Secretary has 

contracted øunder clause (1), (2), or (5) of section 1703(a) of this 

title¿ under the VA Care in the Community Program may not ex- ceed $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 øand 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 øin 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; 


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(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. 

§ 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— 


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(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. 


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(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 ø(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 conVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00104 Fmt 6659 Sfmt 6601 E:\HR\OC\HR585.XXX HR585

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tract 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 

* * * * * * * 

§ 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. 


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(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 healthplan 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 

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ment 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 


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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). 


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(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. 

* * * * * * * 

§ 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 


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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 thirdparty 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). 


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(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 


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(D) a person obligated to provide, or to pay the expenses 

of, health services under a health-plan contract. 

§ 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 


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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). 

* * * * * * * 

§ 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 

* * * * * * * 

§ 1745. Nursing home care and medications for veterans 

with service-connected disabilities 

(a)(1) The Secretary shall enter into øa 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 


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(ii) is in need of such care. 

(2) Payment under each øcontract (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 øcontract (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 serviceconnected 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. 

* * * * * * * 


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CHAPTER 23—BURIAL BENEFITS 

* * * * * * * 

§ 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 øin 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, 

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ployer 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 

* * * * * * * 

§ 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. 


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(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 decisionmaking 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. 


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(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. 


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(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. 

* * * * * * * 

ø7409. Contracts for scarce medical specialist services.¿ 

* * * * * * * 

SUBCHAPTER I—APPOINTMENTS 

* * * * * * * 

ø§ 7409. Contracts for scarce medical specialist services 

ø(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. 

ø(b) Institutions and persons with whom the Secretary may enter 

into contracts under subsection (a) are the following: 

ø(1) Schools and colleges of medicine, osteopathy, dentistry, 

podiatry, optometry, and nursing. 

ø(2) Clinics. 

ø(3) Any other group or individual capable of furnishing such 

scarce medical specialist services.¿ 

* * * * * * * 

CHAPTER 76—HEALTH PROFESSIONALS EDUCATIONAL 

ASSISTANCE PROGRAM 

* * * * * * * 

SUBCHAPTER I—GENERAL 

§ 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— 


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(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; øand¿ 

(5) the education debt reduction program provided for in subchapter VII of this chapterø.¿; 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. 

* * * * * * * 

§ 7603. Application and acceptance 

(a)(1) To apply to participate in the Educational Assistance Program under subchapter II, III, V, øor 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 asVerDate Sep 11 2014 04:08 Mar 07, 2018 Jkt 079006 PO 00000 Frm 00120 Fmt 6659 Sfmt 6601 E:\HR\OC\HR585.XXX HR585

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sistance under the program and have not completed the course of 

education or training undertaken under such program. 

§ 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, øor 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, øor 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, øor VI¿ VI, or VIII of 

this chapter or as the Secretary may require consistent with 

the provisions of this chapter. 

SUBCHAPTER II—SCHOLARSHIP PROGRAM 

* * * * * * * 

§ 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’’.) 


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(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. 


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(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 


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serve any additional period of obligated service that is prescribed 

by the Secretary under section 7616(b)(4)(B) of this title. 

* * * * * * * 

§ 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. 

ø(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 patientcare services, during a period of time determined under regulations prescribed by the Secretary. 

ø(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<phi>(t-s/t) 

In such formula: 

(A) ‘‘A’’ is the amount the United States is entitled to recover. 


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(B) ‘‘<phi>’’ 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. 

* * * * * * * 

§ 7619. Expiration of program 

The Secretary may not furnish scholarships to new participants 

in the Scholarship Program after øDecember 31, 2019¿ December 

31, 2033. 

* * * * * * * 

SUBCHAPTER IV—ADMINISTRATIVE MATTERS 

§ 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, øand¿ 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. 


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(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. 

§ 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, øand 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, øand per participant 

in the Education Debt Reduction Program¿ per participant in 


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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 

§ 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’’). 

§ 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. 

§ 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. 


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(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. 

§ 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. 

§ 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. 

§ 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 


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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. 

§ 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 


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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 

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vide 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 

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ment 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 

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tion 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: 


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(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 


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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 


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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 


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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 

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posited 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.— 


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(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 øsection 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. 

* * * * * * * 


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TITLE VIII—OTHER MATTERS 

* * * * * * * 

øSEC. 802. VETERANS CHOICE FUND. 

ø(a) IN GENERAL.—There is established in the Treasury of the 

United States a fund to be known as the Veterans Choice Fund. 

ø(b) ADMINISTRATION OF FUND.—The Secretary of Veterans Affairs shall administer the Veterans Choice Fund established by 

subsection (a). 

ø(c) USE OF AMOUNTS.— ø(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. 

ø(2) AMOUNT FOR ADMINISTRATIVE REQUIREMENTS.— 

ø(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. 

ø(B) INCREASE.—The Secretary may increase the amount 

set forth in subparagraph (A) with respect to the amounts 

used for administrative requirements if— 

ø(i) the Secretary determines that the amount of 

such increase is necessary to carry out section 101; 

ø(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 

ø(iii) a period of 60 days has elapsed following the 

date on which the Secretary submits the report under 

clause (ii). 

ø(C) REPORT.—A report described in this subparagraph 

is a report that contains the following: 

ø(i) A notification of the amount of the increase that 

the Secretary determines necessary under subparagraph (B)(i). 

ø(ii) The justifications for such increased amount. 

ø(iii) The administrative requirements that the Secretary will carry out using such increased amount. 

ø(3) TEMPORARY AUTHORITY FOR OTHER USES.— 

ø(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. 

ø(B) HEPATITIS C.—Of the amount specified in subparagraph (A), not more than $500,000,000 may be used by the 


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Secretary during the period described in subparagraph (C) 

for pharmaceutical expenses relating to the treatment of 

Hepatitis C. 

ø(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. 

ø(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— 

ø(i) the amounts used by the Secretary pursuant to 

subparagraphs (A) and (B); and 

ø(ii) an identification of such amounts listed by the 

non-Department provider program for which the 

amounts were used. 

ø(E) DEFINITIONS.—In this paragraph: 

ø(i) The term ‘‘appropriate congressional committees’’ means— 

ø(I) the Committee on Veterans’ Affairs and the 

Committee on Appropriations of the House of Representatives; and 

ø(II) the Committee on Veterans’ Affairs and 

the Committee on Appropriations of the Senate. 

ø(ii) The term ‘‘non-Department facilities’’ has the 

meaning given that term in section 1701 of title 38, 

United States Code. 

ø(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. 

ø(d) APPROPRIATION AND DEPOSIT OF AMOUNTS.— ø(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). 

ø(2) AVAILABILITY.—The amount appropriated under paragraph (1) shall remain available until expended. 

ø(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.¿ 

* * * * * * * 


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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 

øfor non-Department provider programs (as defined in section 2(d)) 

to be comprised of—¿ 

ø(1) discretionary medical services funding that is designated 

for hospital care and medical services furnished at non-Department facilities; and¿ 

ø(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 


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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 

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rectly 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 


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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 

øsuch 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 

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ticipating 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 


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(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 


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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 


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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 


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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 


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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 


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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 


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(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. 


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(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 

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vider 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 MED- ICAID PROVIDERS.—The Secretary may, on a case-bycase 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 


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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 SUP- PLIERS.—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 

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viders 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 


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(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. 


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(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.— 


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(A) IN GENERAL.—Subject to subparagraph (B), any 

measure specified by the Secretary under this paragraph 

must have been endorsed by the entity with a contract 

under section 1890(a). 

(B) EXCEPTION.—In the case of a specified area or medical topic determined appropriate by the Secretary for 

which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a), 

the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures 

that have been endorsed or adopted by a consensus organization identified by the Secretary. 

(C) TIME FRAME.—Not later than October 1, 2012, the 

Secretary shall publish the measures selected under this 

paragraph that will be applicable with respect to fiscal 

year 2014. 

(4) PUBLIC AVAILABILITY OF DATA SUBMITTED.—The Secretary 

shall establish procedures for making data submitted under 

paragraph (4) available to the public. Such procedures shall ensure that a hospital described in section 1886(d)(1)(B)(v) has 

the opportunity to review the data that is to be made public 

with respect to the hospital prior to such data being made public. The Secretary shall report quality measures of process, 

structure, outcome, patients’ perspective on care, efficiency, 

and costs of care that relate to services furnished in such hospitals on the Internet website of the Centers for Medicare & 

Medicaid Services. 

* * * * * * * 


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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. 

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 

Continued 

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. 

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 


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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. 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-towiden-private-care-with-tricare-stirs-ire/. 

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

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

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’’. 

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8https.//www.gao.gov/assets/670/668415.pdf. 

trative 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. 

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 


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9The 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.’’ 10 Clinical staff employed at Vet Centers would also be eligible for EDRP. 

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. 

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 


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165 

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. 

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. 

Æ 


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