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[Senate Report 115-212]
[From the U.S. Government Publishing Office]

                                                     Calendar No. 273
115th Congress    }                                    {       Report
                                 SENATE
 2d Session       }                                    {      115-212

======================================================================

 
                  CARING FOR OUR VETERANS ACT OF 2017

                                _______
                                

                 March 7, 2018.--Ordered to be printed

                                _______
                                

         Mr. Isakson, from the Committee on Veterans' Affairs,
                        submitted the following

                              R E P O R T

                         [To accompany S. 2193]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs (hereinafter, 
``Committee''), having considered an original bill, S. 2193, to 
amend title 38, United States Code (hereinafter, ``U.S.C.''), 
to improve health care for veterans, and for other purposes, 
having considered the same, reports favorably thereon and 
recommends that the bill do pass.

                              Introduction

    On January 12, 2017, Senator Heller introduced S. 113, the 
proposed Maximizing Efficiency and Improving Access to 
Providers at the Department of Veterans Affairs Act. S. 113 
would require the Secretary of Veterans Affairs to carry out a 
pilot program to increase the use of medical scribes to 
maximize the efficiency of physicians at medical facilities of 
the Department of Veterans Affairs (hereinafter, ``VA''). 
Senator Tester was an original cosponsor. The bill was referred 
to the Committee.
    On January 12, 2017, Senator Heller introduced S. 114, the 
proposed VA Choice and Quality Employment Act of 2017. S. 114 
would require VA to submit an annual report on performance 
awards and bonuses awarded to certain high-level VA employees. 
Senator Casey was an original cosponsor. Senators Collins and 
King were later added as cosponsors. The bill was referred to 
the Committee.
    On January 12, 2017, Senator Heller introduced S. 115, the 
proposed Veterans Transplant Coverage Act. S. 115 would amend 
title 38, U.S.C., to authorize the Secretary of Veterans 
Affairs to provide for an operation on a live donor for 
purposes of conducting a transplant procedure for a veteran. 
Senator Cornyn was later added as a cosponsor. The bill was 
referred to the Committee.
    On March 9, 2017, Senator Murray introduced S. 591, the 
proposed Military and Veteran Caregiver Services Improvement 
Act of 2017. S. 591 would expand eligibility for the program of 
comprehensive assistance for family caregivers to include 
veterans who were injured or fell ill in the line of duty prior 
to September 11, 2001; include child care, financial planning, 
and legal services in the program of comprehensive assistance 
for family caregivers; authorize the transfer of entitlement to 
Post-9/11 education assistance to family members by veterans 
who are in the program of comprehensive assistance for family 
caregivers, without regard to length-of-service requirements; 
expand eligibility for special compensation for members of the 
uniformed services with catastrophic injuries or illnesses 
requiring assistance in everyday living; authorize the VA to 
provide certain caregiver assistance to family caregivers of a 
member in receipt of monthly special compensation; authorize 
flexible work schedules or telework for Federal employees who 
are caregivers of veterans; designate a veteran participating 
in the program of comprehensive assistance for family 
caregivers as an adult with a special need for purposes of the 
lifespan respite care program; establish an interagency working 
group to review policies relating to the caregivers of veterans 
and members of the Armed Forces; and require studies on members 
of the Armed Forces who commenced service after September 11, 
2001, and veterans who have incurred a serious injury or 
illness, including a mental health injury, and their 
caregivers. Senators Baldwin, Bennet, Blumenthal, Brown, 
Cantwell, Collins, Coons, Durbin, Franken, King, Murphy, 
Sanders, Schatz, Shaheen, Tester, and Warner were original 
cosponsors. Senators Booker, Cardin, Casey, Cortez Masto, 
Duckworth, Hirono, Kaine, Manchin, Markey, Menendez, Merkley, 
Nelson, Peters, Stabenow, Van Hollen, Warren, and Wyden were 
later added as cosponsors. The bill was referred to the 
Committee.
    On April 25, 2017, Senator Ernst introduced S. 925, the 
proposed Veterans E-Health and Telemedicine Support Act of 
2017, or VETS Act of 2017. S. 925 would authorize VA health 
care professionals to provide treatment to patients via 
telemedicine regardless of where the covered health care 
professional or the patient is located. Senator Hirono was an 
original cosponsor, and Senators Booker, Boozman, Grassley, 
Hassan, Hatch, Kennedy, Rounds, Shaheen, Tester, Tillis, and 
Udall were later added as cosponsors. The bill was referred to 
the Committee.
    On May 17, 2017, Senator Baldwin introduced S. 1153, the 
proposed Veterans Acquiring Community Care Expect Safe Services 
Act of 2017, or Veterans ACCESS Act. S. 1153 would require VA 
to prohibit or suspend certain health care providers from 
providing non-VA health care services to veterans. Senator 
Moran was an original cosponsor. The bill was referred to the 
Committee.
    On May 25, 2017, Senator Crapo introduced S. 1279, the 
proposed Veterans Health Administration Reform Act of 2017. 
S. 1279 would authorize VA to furnish health care from non-VA 
health care providers through the establishment of a Care in 
the Community program. This program would include the creation 
of an education program on health care options from VA and a 
training program for the administration of non-VA health care. 
S. 1279 would also make the reimbursement for emergency 
treatment and urgent care furnished in a non-VA facility more 
generous. Senator Risch was later added as a cosponsor. The 
bill was referred to the Committee.
    On June 8, 2017, Senator Brown introduced S. 1319, the 
proposed Community Care Competency Act of 2017. S. 1319 would 
require VA to establish a continuing medical education program 
for non-VA medical professionals who treat veterans to increase 
knowledge and recognition of medical conditions common to 
veterans. Senator Durbin was later added as a cosponsor. The 
bill was referred to the Committee.
    On June 8, 2017, Senator Tester introduced S. 1325, the 
proposed Better Workforce for Veterans Act of 2017. S. 1325 
would amend VA authorities to improve the hiring, recruiting, 
and training of employees by removing the limitation on 
recruitment, relocation, or retention incentives. Senators 
Crapo, Hassan, Kaine, McCaskill, and Moran, were original 
cosponsors, and Senator Nelson was later added as a cosponsor. 
The bill was referred to the Committee.
    On June 27, 2017, Senator Sullivan introduced S. 1449, the 
proposed Serving our Rural Veterans Act of 2017. S. 1449 would 
authorize payment by the VA for training and supervision of 
medical residents and interns at non-VA facilities. S. 1449 
would also require VA to carry out a pilot program to establish 
or affiliate with residency programs at facilities operated by 
Indian tribes, tribal organizations, and the Indian Health 
Service (hereinafter, ``IHS''). Senator Tester was an original 
cosponsor. The bill was referred to the Committee.
    On July 20, 2017, Senator Hoeven introduced S. 1611, the 
proposed Veterans Access to Long Term Care and Health Services 
Act. S. 1611 would authorize VA to enter into Veterans Care 
Agreements (hereinafter, ``VCAs'') with health care providers 
to furnish hospital care, medical services, or extended care 
services if VA is unable to furnish the care. Senator Rounds 
was an original cosponsor, and Senator Cassidy was later added 
as a cosponsor. The bill was referred to the Committee.
    On September 28, 2017, Senator Cassidy introduced S. 1871, 
the proposed VA Provider Equity Act. S. 1871 would make a 
doctor of podiatric medicine eligible for any supervisory 
position to the same degree as a Veterans Health Administration 
(hereinafter, ``VHA'') physician, and would increase the pay 
grade of podiatrists to match the compensation of other VHA 
surgeons, physicians, and dentists. Senators Baldwin, Donnelly, 
Grassley, Heitkamp, Peters, Shaheen, and Stabenow were later 
added as cosponsors. The bill was referred to the Committee.
    On September 27, 2017, Senator Blumenthal introduced 
S. 1873, the proposed Veteran Partners' Efforts to Enhance 
Reintegration Act, or Veteran PEER Act. S. 1873 would require 
the Secretary of Veterans Affairs to carry out a program to 
establish peer specialists in Patient Aligned Care Teams 
(hereinafter, ``PACT'') at VA medical centers (hereinafter, 
``VAMC''). Senator Blunt was an original cosponsor, and 
Senators Baldwin, Brown, Collins, Hassan, Heller, Rounds, 
Warren, and Wicker were later added as cosponsors. The bill was 
referred to the Committee.
    On November 15, 2017, Senator Baldwin introduced S. 2134, 
the proposed Andrew White Veterans Community Care Opioid Safety 
Act. S. 2134 would require VA to establish processes to ensure 
the safe practice of prescribing opioids by non-VA providers. 
Senators Blumenthal, Brown, Capito, Manchin, Moran, and Tester 
were original cosponsors, and Senator Hassan was later added as 
a cosponsor. The bill was referred to the Committee.

                           Committee Hearing

    On May 17, 2017, the Committee held a hearing on 
legislation pending before the Committee. Testimony was 
received by Jennifer S. Lee, M.D., Deputy Under Secretary for 
Health for Policy and Services, Veterans Health Administration, 
U.S. Department of Veterans Affairs; Louis J. Celli, Jr., 
Director, National Veterans Affairs and Rehabilitation 
Division, The American Legion; Kayda Keleher, Associate 
Director, National Legislative Service, Veterans of Foreign 
Wars; Adrian Atizado, Deputy National Legislative Director, 
Disabled American Veterans; Allison Jaslow, Executive Director, 
Iraq and Afghanistan Veterans of America; and J. David Cox, 
National President, American Federation of Government 
Employees.
    On June 7, 2017, the Committee held a hearing to examine 
the Veterans Choice Program and the future of care in the 
community. Testimony was received by the Honorable David J. 
Shulkin, M.D., Secretary of Veterans Affairs, Department of 
Veterans Affairs; Jeff Steele, Assistant Director, National 
Legislative Division, The American Legion; Adrian Atizado, 
Deputy National Legislative Director, Disabled American 
Veterans; Carlos Fuentes, Director of the National Legislative 
Service, Veterans of Foreign Wars; and Gabriel Stultz, 
Legislative Counsel, Paralyzed Veterans of America.
    On July 11, 2017, the Committee held a hearing on 
legislation pending before the Committee, including two draft 
bills authored by Senators Isakson and Tester, primarily on the 
future of non-Department of Veterans Affairs health care. The 
draft legislation from the Chairman and Ranking Member largely 
informed the original bill reported from the Committee, which 
became S. 2193, the Caring for Our Veterans Act (hereinafter, 
``the Committee bill''). Testimony was received by Baligh 
Yehia, M.D., Deputy Under Secretary for Health for Community 
Care, Veterans Health Administration, Department of Veterans 
Affairs; Louis J. Celli, Director, National Veterans Affairs 
and Rehabilitation Division, The American Legion; Amy Webb, 
National Legislative Policy Advisor, AMVETS; Adrian Atizado, 
Deputy National Legislative Director, Disabled American 
Veterans; and Gabriel Stultz, Legislative Counsel, Paralyzed 
Veterans of America.

                           Committee Meeting

    After reviewing the testimony from the foregoing hearings, 
the Committee met in open session on November 29, 2017, to 
consider the original bill, including provisions derived from 
the legislation noted above, including the two draft bills 
authored by Senators Isakson and Tester. The Committee voted, 
by roll call vote, to report favorably to the Senate the 
original bill at the Committee meeting.

                Summary of the Original Bill as Reported

    The original bill as reported, consists of 57 sections, 
summarized below.
    Section 1 provides a short title.

       TITLE I--DEVELOPING AN INTEGRATED HIGH-PERFORMING NETWORK

            SUBTITLE A--ESTABLISHING COMMUNITY CARE PROGRAMS

    Section 101 would amend section 1703 of title 38, U.S.C., 
to establish a Veterans Community Care Program.
    Section 102 would authorize VA to enter into VCAs with 
providers in the community to provide health care to veterans.
    Section 103 would authorize VA to enter into VCAs with 
State Veterans Homes.
    Section 104 would require VA to establish guidelines for 
health care access and standards for quality.
    Section 105 would authorize access to walk-in care for 
eligible veterans.
    Section 106 would require VA to perform market area 
assessments at least every 4 years and to submit a strategic 
plan for Congress at least every 4 years regarding an 
assessment of health care demand and capacity.
    Section 107 would apply the TRICARE contractor and 
subcontractor compliance directive, Directive 2014-01 of the 
Office of Federal Contract Compliance Programs of the 
Department of Labor (hereinafter, ``DOL''), to VCAs established 
in section 102.
    Section 108 would authorize VA to deny, suspend, or revoke 
the eligibility of a non-VA health care provider to participate 
in the Veterans Community Care Program if the provider was 
previously removed from employment by VA or had their medical 
license revoked.

         SUBTITLE B--PAYING PROVIDERS AND IMPROVING COLLECTIONS

    Section 111 would establish a prompt payment process and 
standards to which VA should adhere when paying non-VA 
providers and require claims to be processed by a contracted 
third party administrator or other non-VA entity.
    Section 112 would authorize VA to pay for services not 
subject to an agreement.
    Section 113 would authorize VA to collect from a third 
party for care provided to non-veterans and authorize VA to 
seek collections when it pays for care rather than just 
furnishes it.
    Section 114 would authorize VA to enter into an agreement 
with a third party entity to electronically process health care 
claims from community providers.

              SUBTITLE C--EDUCATION AND TRAINING PROGRAMS

    Section 121 would require VA to develop and administer an 
education program to inform veterans about their health care 
options.
    Section 122 would require VA to develop and administer a 
training program for VA employees and contractors on how to 
administer non-VA health care programs.
    Section 123 would establish a program to provide continuing 
medical education to non-VA medical professionals.

   SUBTITLE D--OTHER MATTERS RELATING TO NON-DEPARTMENT OF VETERANS 
                           AFFAIRS PROVIDERS

    Section 131 would require VA to establish processes to 
ensure safe opioid prescribing practices by non-VA providers.
    Section 132 would authorize VA to share certain medical 
record information with non-VA entities for purposes of 
providing health care and with third parties for the recovery 
of the cost of certain care.
    Section 133 would require competency standards for non-VA 
health care providers that treat injuries or illnesses in 
clinical areas that VA has a special expertise.

          SUBTITLE E--OTHER NON-DEPARTMENT HEALTH CARE MATTERS

    Section 141 would require VA to submit to Congress a 
justification for any new supplemental appropriations request 
submitted outside of the standard budget process.
    Section 142 would authorize VA, beginning in fiscal year 
(hereinafter, ``FY'') 2019, to use any remaining amounts in the 
Veterans Choice Fund to pay for any health care services under 
chapter 17 of title 38, U.S.C., through non-VA providers.
    Section 143 would provide a sunset date for the Veterans 
Choice Program of December 31, 2018.
    Section 144 would repeal and replace existing authorities 
to account for changes made by section 101 of the Committee 
bill to consolidate and create the Veterans Community Care 
Program.

TITLE II--IMPROVING DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE DELIVERY

                    SUBTITLE A--PERSONNEL PRACTICES

                         PART I--ADMINISTRATION

    Section 201 would create a new authority to authorize VA 
health care professionals to practice telemedicine regardless 
of the location of the provider or patient during the 
treatment.
    Section 202 would make a podiatrist eligible for any 
supervisory position to the same degree as a VHA physician, and 
would increase the pay grade of podiatrists to match the 
compensation of other VHA surgeons, physicians, and dentists.
    Section 203 would include certified clinical perfusionists 
in the list of excepted positions and convert such positions to 
full title 38 status.
    Section 204 would amend the statutory requirements for the 
position of the Chief Officer of the Readjustment Counseling 
Service (hereinafter, ``RCS'').
    Section 205 would make an exception for increasing the 
compensation scale and raises for VAMC directors and directors 
of Veterans Integrated Service Networks (hereinafter, 
``VISNs'').
    Section 206 would require VA to identify and fully staff 
all mental health vacancies and all primary care and mental 
health vacancies in PACTs.
    Section 207 would require VA to make certain staffing 
capacity information publicly available on a VA Internet 
website.
    Section 208 would require VA to integrate peer specialists 
into PACT.
    Section 209 would require VA to establish a pilot program 
to increase the use of medical scribes at VA facilities.
    Section 210 would express the sense of Congress that VA 
should make the resolution of staffing shortages a priority.

                    PART II--EDUCATION AND TRAINING

    Section 211 would require VA to increase the number of 
graduate medical education (hereinafter, ``GME'') positions by 
up to 1,500 and authorize VA to pay for the time the residents 
are training at non-VA facilities.
    Section 212 would require VA to establish a pilot program 
to establish or affiliate with GME residency programs at 
facilities operated by Indian tribes, tribal organizations, and 
the IHS in rural areas.
    Section 213 would authorize VA to reimburse any board-
certified advanced practice registered nurse (hereinafter, 
``APRN'') up to $1,000 per year for continuing professional 
education.
    Section 214 would increase the maximum amount of payments 
that VA could make for participants of VA's Education Debt 
Reduction Program (hereinafter, ``EDRP'').
    Section 215 would authorize VA to establish a demonstration 
program on training and employment of alternative dental health 
care providers for dental health care services for veterans in 
rural and underserved communities.

                   PART III--OTHER PERSONNEL MATTERS

    Section 221 would establish an exception to a previous 
limitation on awards and bonuses for recruitment, relocation, 
and retention.
    Section 222 would require VA to submit an annual report on 
performance awards and bonuses awarded to certain high-level VA 
employees.
    Section 223 would expand the definition of compensation to 
include pay earned by employees when performing duties 
authorized by the Secretary or when the employee is approved to 
use annual, sick, family medical, military, or court leave, or 
other paid absences for which pay is not already regulated.
    Section 224 would establish a higher maximum amount of 
basic pay for registered nurses.

         SUBTITLE B--IMPROVEMENT OF UNDERSERVED FACILITIES OF 
                             THE DEPARTMENT

    Section 231 would require VA to develop criteria for the 
designation of certain VA medical facilities as underserved and 
a plan to address the problem of underserved facilities.
    Section 232 would require VA to establish a pilot program 
to provide tuition reimbursement and loan repayment for VA 
health care providers at underserved facilities.
    Section 233 would require VA to establish a program to 
furnish mobile deployment teams to underserved facilities.
    Section 234 would require VA to consider Vet Center 
employees eligible for EDRP.

                  SUBTITLE C--CONSTRUCTION AND LEASES

    Section 241 would modify the definitions of major medical 
facility project and major medical facility lease.
    Section 242 would authorize VA to enter into agreements 
with other Federal agencies for planning, designing, 
constructing, and/or leasing shared medical facilities.
    Section 243 would modify the review process in VA's 
issuance of enhanced-use leases.
    Section 244 would authorize VA to spend no more than $117.3 
million on the East Bay Community Based Outpatient Clinic, the 
Central Valley Engineering and Logistics support facility, and 
enhanced flood plain mitigation as part of the realignment of 
medical facilities in Livermore, California.

                 SUBTITLE D--OTHER HEALTH CARE MATTERS

    Section 251 would direct VA to issue grants to non-VA 
entities to study the feasibility of using wellness programs in 
providing mental health counseling to veterans and their family 
members using Vet Centers.
    Section 252 would authorize VA to provide for transplant 
procedures on live donors regardless of whether the donor is a 
veteran.
    Section 253 would express the sense of the Senate that VHA 
should not be privatized.

                      TITLE III--FAMILY CAREGIVERS

    Section 301 would expand eligibility for VA's Program of 
Comprehensive Assistance for Family Caregivers, in two phases, 
to all eras of veterans.
    Section 302 would require VA to implement an information 
technology (hereinafter, ``IT'') system that fully supports the 
Family Caregiver Program and allows for data assessment and 
comprehensive monitoring.
    Section 303 would modify the requirements for VA's annual 
report to Congress on the Family Caregiver Program.

                   TITLE IV--APPROPRIATION OF AMOUNTS

    Section 401 would authorize and appropriate $1 billion to 
VA to be used for educational assistance for providers, the 
increase of GME positions, and recruitment, relocation, and 
retention incentives.
    Section 402 would authorize and appropriate $4 billion to 
be used for the Veterans Choice Fund.

                       Background and Discussion

       TITLE I--DEVELOPING AN INTEGRATED HIGH-PERFORMING NETWORK

            SUBTITLE A--ESTABLISHING COMMUNITY CARE PROGRAMS

Sec. 101. Establishment of Veterans Community Care Program.

    Section 101 of the Committee bill, an original provision, 
would amend section 1703 of title 38, U.S.C., to provide VA the 
authority to build a network of providers in the community. 
Access to the network would be dependent on whether the veteran 
and their VA provider agree it would be in the best interest of 
the veteran to utilize non-VA care, or if the quality and 
access of a VA medical service line does not equal the quality 
standards in the community and VA access guidelines.
    Background. Section 1710 of title 38, U.S.C., requires VA 
to provide hospital care and medical services to eligible 
veterans. Section 1703 of title 38, U.S.C., authorizes VA to 
contract with non-VA facilities and providers to furnish 
hospital or medical services to eligible veterans when VA is 
not capable of providing economical care because of 
geographical inaccessibility or due to an inability to furnish 
such care or services required. Sections 1725 and 1728 of title 
38, U.S.C., authorize VA to reimburse for certain types of 
care, such as emergency treatment, at non-VA facilities. 
Section 1786 of title 38, U.S.C., authorizes VA to provide 
necessary post-delivery care and services. Section 8111 of 
title 38, U.S.C., authorizes VA to enter into sharing 
agreements at other government facilities. Section 8153 of 
title 38, U.S.C., authorizes a VA facility to enter into a 
contract or agreement with non-VA health care entities to 
secure health care services that are either unavailable or not 
cost-effective to provide at a VA facility. Section 101 of 
Public Law (hereinafter, ``P.L.'') 113-146, the Veterans 
Access, Choice, and Accountability Act of 2014 (hereinafter, 
``P.L. 113-146''), authorized veterans to receive care in the 
community if they would wait more than 30 days for care in a VA 
facility or lived more than 40 miles from a VA facility 
(hereinafter, ``Veterans Choice Program'').
    Committee Bill. Section 101(a)(1) would amend Section 1703 
of title 38, U.S.C., to authorize care at non-VA facilities. 
Section 1703(a), as amended, would establish the Veterans 
Community Care Program to provide veterans with care in the 
community under certain circumstances and direct the Secretary 
to provide care coordination for veterans using the program. At 
a minimum, VA would ensure appointments are scheduled, ensure 
continuity of care, coordinate with adjacent regions should a 
veteran receive care in an adjoining network, and ensure a 
veteran does not experience a lapse of care or has an unusual 
or excessive burden in accessing care. The Committee expects 
that VA will execute all reasonable actions to ensure that a 
veteran receives a seamless transition from VA to community 
care and back to VA. The Committee believes that for this 
program to be a success for veterans, VA must provide high-
quality customer service at every point in the process and 
truly put a veteran's best interest at the forefront of this 
endeavor.
    Section 1703(b), as amended, would define that a covered 
veteran for the purposes of this section is a veteran enrolled 
under section 1705 of title 38, U.S.C., or is not enrolled but 
is otherwise entitled to care at VA.
    Section 1703(c), as amended, would specify that eligible 
non-VA health care providers would be providers who participate 
in the Medicare program, Federally Qualified Health Centers 
(hereinafter, ``FQHCs''), facilities funded by IHS, or the 
Department of Defense (hereinafter, ``DOD'').
    Section 1703(d), as amended, would provide care in the 
community when VA does not offer the service the veteran needs, 
if the veteran resides in a state that does not have a full-
service VA medical facility, or the veteran was eligible for 
the Veterans Choice Program, as of the day before the date of 
enactment of the Committee bill, because they lived more than 
40 miles from a VA facility. Additionally, if the veteran and 
the veteran's primary care provider agree that it would be in 
the best medical interest of the veteran, they would receive 
care in the community. In determining whether care in the 
community is necessary, the provider should consider the 
driving distance between the veteran and the facility that 
provides the service the veteran needs; the nature of the care 
required; the frequency of the treatments needed; whether VA 
provides the service needed; whether the appointment can be 
provided within the access standards established by VA or a 
time frame a provider determines is clinically necessary; the 
veteran faces an unusual or excessive burden to access hospital 
care or services; or other conditions as determined by VA. The 
Committee does not intend for this to be an exhaustive list in 
determining the circumstances in which a veteran would be 
eligible for care in the community. The conditions specified in 
this subsection represent some factors the VA primary care 
provider and the veteran should take into consideration when 
determining whether to seek care in the community. The 
Committee also does not intend that the conversation between 
the veteran and their provider must be an in-person meeting. 
The conversation of where to receive care could be over the 
phone, through electronic mail, or with a representative of the 
provider.
    Section 1703(e), as amended, would, in paragraph (1), 
authorize the Secretary to furnish hospital care, medical 
services, or extended care services through a health care 
provider specified in subsection (c) if a VA medical service 
line is not providing care that meets the access guidelines and 
standards for quality as established by the Secretary.
    When measuring access, subparagraph (B) would require the 
Secretary to measure access of the VA medical service line when 
compared with the same medical service line at a different VA 
facility. Subparagraph (B) would also require the Secretary to 
measure quality at a VA medical service line by comparing it 
with two or more distinct quality measures at non-VA medical 
services lines. The Committee intends that as VA is able to 
compare more VA medical service line quality measures with the 
same quality measures in the community, that the scope of 
measurements will become more robust.
    Section 1703(e) would require that not more than three 
medical service lines at any one VA facility be eligible under 
the authority provided under paragraph (1). Further, the 
authority provided in paragraph (1) would be limited to not 
more than 36 medical service lines nationwide. This means that 
not more than 36 instances of this authority may be used 
concurrently. The Committee believes that given the 
requirements in 1703(g), as amended, 36 medical service lines 
is a manageable number for VA to facilitate this authority and 
the concurrent remediation of a triggered service line.
    Authority provided in paragraph (1) of 1703(e) would cease 
when the remediation described in subsection (g) is complete. 
The Committee intends that VA will take every measure to ensure 
a smooth transition of care back to VA for the veteran.
    Section 1703(e) would require VA to publish in the Federal 
Register yearly and take all reasonable steps to provide direct 
notice to veterans affected by the authority provided in 
paragraph (1). VA would be required to provide to veterans the 
time period during which care could be accessed in the 
community under this authority; the location or locations such 
care in the community can be accessed; and the clinical 
services available at each location under this authority. The 
Committee intends that this information be clear and concise so 
that no veteran is unsure of where to seek health care 
services.
    Finally, it would be at the election of a veteran to use 
care in the community under the authority provided in section 
1703(e)(1).
    Section 1703(f), as amended, would provide for a clinical 
appeals process similar to the appeals process a veteran may 
follow in appealing a clinical decision for care provided 
within a VA facility. The Committee intends that this clinical 
appeals process be expedient so that no veteran faces an undue 
delay in health care services. The Committee strongly 
encourages VA to establish one clinical appeals process to be 
applied across VHA.
    Section 1703(g), as amended, would require that not later 
than 30 days after VA determines that a medical service line is 
providing untimely care when compared with the same service 
line at other VA facilities or has deficient quality when 
compared with community providers, an assessment be submitted 
to Congress of the factors that led the Secretary to make such 
a determination. Included in that assessment must be a plan 
with specific actions, and the time to complete them, the 
Secretary intends to take to remediate the service line. The 
Committee intends that while veterans are provided the 
opportunity to seek community care under new section 101(e) 
that VA engage in robust efforts to remediate the service line.
    Section 1703(g)(1)(A)-(G) sets forth the actions the 
Secretary should consider when developing the assessment 
required under 1703(g). Included among the actions the 
Secretary should consider to remediate the service line are 
special hiring authorities, including EDRP and recruitment, 
relocation and retention incentives; utilizing direct hiring 
authority; providing improved training opportunities; acquiring 
improved equipment; making structural modifications to the 
facility used by the service line; and other actions the 
Secretary considers appropriate. The Committee intends that the 
Secretary utilize all appropriate authorities to address 
deficiencies in a service line.
    Section 1703(g)(2) would require the Secretary to identify 
those individuals at the local, VISN, and Central Office-levels 
responsible for the remediation efforts for a service line 
identified under new section 1703(e). The Committee believes 
that this level of accountability is necessary to ensure that 
appropriate actions are being taken to successfully remediate a 
service line.
    Section 1703(g)(3) would require that within 180 days after 
the assessment required in 1703(g)(1), the Secretary submit to 
Congress a report on the progress of that medical service line 
in complying with the access guidelines and meeting the 
standards of quality established by the Secretary and any other 
actions the Secretary will take to ensure the service line is 
remediated. Further, 1703(g)(4) would require an annual 
analysis of the remediation actions and costs of such actions 
taken with respect to every service line triggered under 
1703(e). These reporting requirements signal the Committee's 
intended level of oversight over the remediation process.
    The Committee intends that the remediation of service lines 
be vigorously undertaken with the ultimate goal of veterans 
having access to a high-quality level of care at VA.
    Section 1703(h), as amended, would direct the Secretary to 
establish access guidelines under section 1703B and quality 
standards under section 1703C for measuring whether the 
conditions under which medical care is authorized to be 
furnished through non-VA entities is met.
    The Secretary would be directed to ensure these guidelines 
and standards, established under paragraph (1), provide 
veterans, VA employees, and community health care providers 
with relevant comparative information.
    This subsection would also direct the Secretary to consult 
with Federal entities, including the DOD and the Department of 
Health and Human Services (hereinafter, ``HHS''), the private 
sector, and nongovernmental entities in establishing the 
guidelines and standards.
    No later than 270 days after the bill's enactment, the 
Secretary would be required to submit a report to Congress 
detailing the access guidelines and quality standards 
established under paragraph (1) and their development. At least 
every 3 years, the Secretary would be required to conduct a 
review of the guidelines and standards established under 
paragraph (1), and submit a report to Congress if there are any 
modifications.
    This subsection would also direct the Secretary to ensure 
that community providers furnishing medical services under the 
authority of the Community Care program are able to meet the 
access guidelines and quality standards that the Secretary 
establishes under paragraph (1).
    Section 1703(i), as amended, would allow VA to develop a 
tiered network to ensure high-quality health care, medical 
services, or extended care services would be available to 
veterans under this section. However, in developing a tiered 
network, VA is directed to not prioritize one provider over 
others in another tier.
    Section 1703(j), as amended, would direct VA to enter into 
contracts to establish a network of health care providers. The 
section would also direct VA, to the extent practicable, to 
allow veterans to self-schedule appointments for care in the 
community using smartphone technology and direct VA, to the 
extent practicable, to schedule appointments for veterans in 
the community. However, the Committee intends that VA give 
consideration to the contractor performing the scheduling if a 
particular VAMC is not able to schedule in-house. In addition, 
section 1703(j) would direct VA to terminate a contract if an 
entity is not meeting certain criteria. Under the Veterans 
Choice Program, VA did not require a Third Party Administrator 
(hereinafter, ``TPA'') to monitor the time an individual is on 
hold or establish a standard for TPAs to adhere to. The 
Committee expects the Secretary to require future contractors 
under the Veterans Community Care Program to monitor the period 
of time an individual is placed on hold, assess the average 
time an individual is on hold disaggregated by geographic area 
and establish hold-time standards for contractors to adhere to. 
Further, a TPA that provided call center services for the 
Veterans Choice Program was not precluded from establishing a 
policy that limited the ability for an individual to 
troubleshoot more than three claims. Medical providers that 
accepted veterans under the Veterans Choice Program expressed 
deep frustration at this policy because it limited the ability 
of medical providers to troubleshoot multiple outstanding 
claims. The Committee expects the Secretary to require future 
contractors under the Veterans Community Care Program to not 
limit the amount of claims an individual can troubleshoot per 
call. Section 1703(j) would also require VA to allow providers 
treating veterans under a contract or agreement under title 38, 
U.S.C., the ability to continue to provide care through the 
Veterans Community Care Program. Finally, section 1703(j) would 
require that when VA provides notice to an entity that is 
failing to meet contractual obligations, it would also provide 
a report to the Senate and House Veterans' Affairs Committees 
on such failure. Contractors have demonstrated significant 
challenges in executing their obligations under the Veterans 
Choice Program, to the detriment of the health care services 
provided to veterans. As such, the Committee believes that 
veterans would benefit with Congress' greater visibility into 
whether non-VA providers are meeting contractual obligations.
    Section 1703(k), as amended, would direct that the rates VA 
would pay for care in the community may not exceed the rates 
established by the Centers for Medicare and Medicaid Services 
(hereinafter, ``CMS''). The section gives VA flexibility with 
the rates for highly rural areas, the State of Alaska, and 
States with an All-Payer Model Agreement with CMS. The section 
would direct VA to negotiate rates that are not covered by CMS 
and, to the greatest extent practicable, use a value-based 
reimbursement model to promote the provision of high-quality 
care. While VA would be allowed to enter into value-based 
agreements, the Committee intends for the agreements with IHS 
to be based on the IHS fee schedule and not a value-based 
agreement.
    Section 1703(l), as amended, would direct VA to bill 
veterans' other health insurance for non-service connected 
conditions treated through the Veterans Community Care Program. 
Section 1703(m), as amended, would require that a veteran not 
pay more for care received through the Veterans Community Care 
Program than they would for care received in a VA facility. 
Section 1703(n), as amended, would require VA to monitor the 
types of care and services provided under the authorities in 
this section and submit annual reports to Congress. Section 
1703(o), as amended, would direct that VA cannot limit the type 
of care and services provided under the Veterans Community Care 
Program. Section 1703(p), as amended, would define a medical 
service line and appropriate committees of Congress.
    Section 101(a)(2) would provide for a clerical amendment to 
the table of contents at the beginning chapter 17 of title 38, 
U.S.C.
    Section 101(b) would provide an effective date for the 
Veterans Community Care Program. The section would be effective 
30 days after VA submits a report required under section 
101(q)(2) of P.L. 113-146 or on the date on which VA 
promulgates regulations, whichever is later. Section 101(c) 
would direct VA to prescribe regulations within 1 year of 
enactment.
    Section 101(d) would require VA to continue existing 
contracts, memorandum of agreements, and memorandum of 
understanding VA had entered into prior to the enactment of 
this act with Alaska Native and American Indian health systems 
and any agreements VA entered into with the Native Hawaiian 
health care system under section 103 of P.L. 113-146. It is the 
intent of this Committee that this legislation not supercede 
the authorities and agreements put into place to support these 
unique populations of veterans.

Sec. 102. Authorization of agreements between Department of Veterans 
        Affairs and non-VA providers.

    Section 102 of the Committee bill would authorize VA to 
enter into agreements to provide hospital care, medical care or 
extended care services on behalf of veterans.
    Background. Under section 1703 of title 38, U.S.C., VA can 
enter into contracts for hospital care and medical services in 
non-VA facilities when VA 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.
    Committee Bill. Section 102(a) would create a new section 
1703A to authorize VA to purchase hospital care, medical 
services and extended care services as authorized by chapter 17 
when VA cannot furnish such care itself or through existing 
contracts or sharing agreements. Section 1703A(a)(2)(A) would 
authorize VA to use VCAs when the Secretary, or any VA official 
authorized by the Secretary, determines the veteran's medical 
condition, the travel involved, the nature of the care or 
services required, or a combination of these factors make the 
use of VA facilities or existing contracts or sharing 
agreements impracticable or inadvisable.
    It is the Committee's intent that section 102 would improve 
VA's flexibility to meet veterans' demand for hospital care, 
medical services and extended care services by authorizing VA 
to enter into VCAs that, in general, would not be subject to 
competition or other requirements associated with Federal 
contracts.
    Section 1703A(a)(2)(B) would set forth requirements for 
review of VCAs, including the requirement to review each VCA of 
material size for at least 6 months within 2 years of it going 
into effect, and no less often than every 4 years thereafter, 
to determine if it is practical or advisable to provide such 
care or services within VA or through a contract or sharing 
agreement. While the Committee believes this authority is 
necessary to provide veterans high-quality and timely care in 
instances when VA cannot provide the health care services 
needed, it is the Committee's intent that this authority be 
limited and routinely reviewed to determine whether the VCA 
contractors would more appropriately be part of VA's network of 
providers.
    Section 1703A(a)(3)(A) would authorize the Secretary to 
determine whether a VCA is of ``material size'' except for 
those for extended care services. Such VCAs would be considered 
to be of ``material size'' if they exceed $5 million annually. 
It is the Committee's intent that these agreements be reviewed 
to ensure that taxpayer dollars are being spent appropriately, 
that certain VCAs might be more appropriately be made part of 
the VA's community care network and that veterans are receiving 
high-quality and timely care under the agreement.
    Section 1703A(a)(3)(B) would authorize the Secretary to 
adjust the dollar amounts previously determined to be of 
``material size'' by publishing a new amount in the Federal 
Register to account for changes in the cost of health care 
based upon recognized health care market surveys and other 
available data.
    Section 1703A(b) defines entities and providers that would 
be eligible to provide services under a VCA. Eligible providers 
would include participants of the United States Medicare and 
Medicaid programs or other providers the VA Secretary deems 
appropriate.
    Section 1703A(c) would require the Secretary to establish 
in regulation a process for the certification or 
recertification of eligible entities or providers. VA would 
include as part of its certification plan: deadlines for 
actions on applications for certification; standards for 
approval or denial of a certification, duration of a 
certification, revocation of a certification, and 
recertification of an eligible entity or provider; require the 
denial of a certification if the provider is excluded under 
other Federal laws from furnishing care or services for the 
Federal government; and procedures for screening entities and 
providers for the risk of fraud, waste, and abuse. The 
Committee intends that this process be straightforward and 
without undue burden on providers.
    Section 1703A(d) would establish VCA rates, to the maximum 
extent practicable, to be Medicare rates. Section 1703A(e) 
would establish the terms of the Veterans Extended Care 
Agreements to specify the rates VA would reimburse, ensure the 
return of medical records to VA, ensure that the provider does 
not attempt to collect compensation from a third party or 
health care plan for extended care services provided under the 
agreements, ensure that only care authorized by VA would be 
provided under the agreement, and would establish a methodology 
for providers to submit bills to VA. Section 1703A(f) would 
establish the circumstances under which an agreement could be 
discontinued or not renewed. Section 1703A(g) would direct VA 
to establish a procedure to monitor the quality of care 
provided through the agreements. Section 1703A(h) would direct 
VA to establish procedures for providers to present disputes 
related to the agreements.
    Section 1703A(i) would set forth the applicability of 
Federal laws. VCAs would not be treated as an award for the 
purpose of Federal laws that would require the use of 
competitive procedures to furnish care and services or a 
Federal contract for the acquisition of goods or services for 
purposes of Federal laws governing Federal contracts for the 
acquisition of goods or services.
    Section 1703A(i)(2)(A) notes that VCAs would not be subject 
to any law for which Medicare servicers or suppliers are not 
subject. Section 1703A(j) would require that veterans treated 
under VCAs be subject to the same terms as if they had been 
treated in a VA facility. Section 1703A(k) would require that 
the Secretary promulgate regulations to carry out section 102.
    Section 102(b) would make a clerical change to add section 
1703A to the table of contents for chapter 17 of title 38, 
U.S.C.

Sec. 103. Conforming amendments for State veterans homes.

    Section 103 of the Committee bill would amend section 
1745(a) of title 38, U.S.C., to align VA's procurement 
authority with State Veterans Homes to match that provided for 
in Section 103 of the Committee Bill.
    Background. Under section 1745 of title 38, U.S.C., VA can 
enter into contracts or agreements with state veterans homes to 
provide nursing home care for eligible veterans.
    Committee Bill. Section 103(a) would make conforming 
technical amendments to section 1745(a) of title 38, U.S.C., to 
reflect the new authority provided to VA for the procurement of 
hospital care, medical services, and extended care services 
that, in general, would not be subject to the competition or 
other requirements associated with Federal contracts, while 
still subjecting eligible entities and providers to all laws 
that protect against employment discrimination or that 
otherwise ensure equal employment opportunities.
    Section 1745(a), as amended, would delete the reference to 
agreements under section 1720(c)(1), which provide for 
agreements with non-VA nursing homes.
    Section 1745(a) would add a new subsection (4)(A) providing 
that the Secretary or a designated VA official may enter into 
agreements with State Veterans Homes to provide nursing home 
services to eligible veterans that are not subject to the use 
of competitive contracting practices for furnishing hospital 
care and medical services.
    Section 1745(a) would add a new subsection (B)(i) 
specifying that a State Veterans Home that enters into an 
agreement under section 1745(a) of title 38, U.S.C., is not 
subject to any provision of law to which service providers and 
suppliers of the Medicare program under title XVIII of the 
Social Security Act (42 U.S.C. 1395 et seq.) are not subject in 
executing an agreement under this section.
    Section 1745(a) would add a new subsection (B)(ii)(I) 
specifying that a State Veterans Home that enters into an 
agreement under section 1745(a) of title 38, U.S.C., is subject 
to all provisions of law regarding integrity, ethics, or fraud 
that subject a person to criminal or civil penalties.
    Section 1745(a) would add a new subsection (B)(ii)(II) 
specifying that a State Veterans Home that enters into an 
agreement under section 1745(a) of title 38, U.S.C., is subject 
to all provisions of law that protect against employment 
discrimination or that otherwise ensure equal employment 
opportunities.
    Section 1745(a) would add a new subsection (B)(iii) 
specifying that a State Veterans Home that enters into an 
agreement under section 1745(a) of title 38, U.S.C., is not to 
be treated as a Federal contractor or subcontractor for 
purposes of chapter 67 of title 41, U.S.C. (known as the 
``McNamara-O'Hara Service Contract Act of 1965'').
    Finally, section 103(b) would specify that the new 
provisions in section 1745(a), as amended by section 103(a), 
shall apply to care provided on or after the date the Secretary 
makes effective the regulations that carry out Section 103.

Sec. 104. Access guidelines and standards for quality.

    Section 104 of the Committee bill, an original provision, 
would, through a new section 1703B in title 38, U.S.C., direct 
VA to consult with other pertinent Federal entities to examine 
health care access measurements and establish local 
benchmarking access guidelines. Section 104 would also create a 
new section 1703C directing VA to establish standards for 
quality for hospital care, medical services or extended care 
services provided at VA facilities and non-VA facilities.
    Background. In April 2017, VA introduced a new website, 
www.accesstova.va.gov, to increase transparency on patient wait 
times and quality of care data. VA provides the wait times of 
veterans for certain types of care and services and publishes 
those wait times, by facility, on its website. When data is 
available, the VA website also compares the wait time to the 
average wait time in the community to determine whether the 
wait time for care at VA is better than or worse than the 
average wait for care in the local community.
    VA also tracks the quality of care delivered within its 
facilities and provides the information on its access and 
quality website, as well as reports certain measures to the CMS 
Hospital Compare website. In a Government Accountability Office 
(hereinafter, ``GAO'') report titled ``VA Should Improve the 
Information It Publicly Reports on the Quality of Care at Its 
Medical Facilities,'' GAO found that VA reports health care 
quality measures on two separate VA websites, the access and 
quality website and an older website. As of June 2017, the 
access and quality website provided information on 15 of the 
110 measures that VA reports on its older website. 
Additionally, GAO found that VA may not be ensuring that the 
health care quality measures are both complete and accurate. 
GAO recommended that VA report a broader range of health care 
quality measures in an accessible and understandable manner on 
its website and conduct a systematic assessment across VAMCs to 
ensure the accuracy and completeness of the data used to inform 
the health care quality metrics. The Committee recognizes that 
VA plans to expand the access and quality website to include 
additional measures and encourages VA to continue to focus its 
efforts on ensuring the content is accessible and 
understandable for veterans seeking to make informed decisions 
about where they receive their health care. The Committee also 
expects the access guidelines and standards for quality 
established under this section to be incorporated into the 
access and quality website where applicable.
    Committee Bill. Section 104(a) would add new sections 1703B 
and 1703C to title 38, U.S.C., to direct VA to create access 
guidelines and standards for quality of health care veterans 
receive from VA and non-VA providers.
    Section 1703B would direct VA to develop local benchmarking 
access guidelines that would be used to inform both providers 
and veterans when making clinical decisions regarding the 
timeliness of veterans care. When developing these guidelines, 
VA would be directed to consult with other pertinent Federal 
entities, including, but not limited to, DOD, HHS, and CMS, to 
study health care access measurements.
    Section 1703C would direct VA to implement standards for 
quality that apply to care provided at VA and non-VA 
facilities. Specifically, 1703C(a) would direct VA to develop 
standards for the quality of care provided under section 1703, 
as amended by section 101 of the Committee bill, in 
coordination with other pertinent Federal entities, including, 
but not limited to, DOD, HHS, and CMS. In developing these 
standards, VA is to consider existing health care quality 
measures that are applied to public and private health care 
systems. VA would be directed to collect and consider data, 
such as, a survey of veterans to assess their satisfaction with 
their care; datasets that include, at a minimum, timely care, 
effective care, safety (including complications, readmissions, 
and death), and efficiency with which the care was provided.
    Section 1703C(b) would direct VA to not later than 1 year 
after the standards for quality are established to publish the 
ratings for those quality measures on the CMS Hospital Compare 
website. To ensure VA has the most up to date standards of 
quality, section 1703C(b) would also direct VA to publish 
potential changes to the standards for quality in the Federal 
Register, not later than 2 years after establishing the initial 
standards for quality.
    In establishing access guidelines and standards for 
quality, the Committee directs VA to consider the nature of 
care provided to veterans and the profile of the patient 
receiving that care. For instance, veterans with spinal cord 
injuries may be readmitted for wound care more than veterans 
with other injuries.
    Section 104(b) would provide a clerical amendment to amend 
the table of sections in Chapter 17 of title 38, U.S.C.

Sec. 105. Access to walk-in care.

    Section 105 of the Committee bill, an original provision, 
would direct the Secretary to establish procedures and 
regulations to ensure eligible veterans are able to access 
walk-in care from qualifying non-VA entities or providers.
    Background. P.L. 113-146 amended chapter 17 of title 38, 
U.S.C. to allow veterans to seek and receive medical care from 
non-VA entities if VA cannot schedule an appointment within 30 
days of the clinically indicated date, their residence is more 
than 40 miles from a VA facility with a primary care physician, 
or they are faced with an unusual or excessive burden to travel 
to the closest VA medical facility. The goal of P.L. 113-146 
was to expand veterans' access to timely and quality care, 
particularly when a VA facility was unable to provide it. In 
April 2017, VA began a pilot program in Phoenix to allow 
veterans to seek non-emergency and non-urgent care at CVS 
``Minute Clinics.'' The purpose of the program is to help 
veterans receive care in a convenient manner at these 
facilities when ``clinically appropriate.''
    Committee Bill. Section 105 would amend chapter 17 of title 
38, U.S.C. by creating a new section 1725A to provide walk-in 
care from non-VA entities or providers. The Committee's intent 
in authorizing access to walk-in care is to offer veterans 
convenient care for non-urgent health care needs.
    Section 1725A(a) would direct the Secretary to establish 
procedures and regulations to ensure eligible veterans are able 
to access walk-in care from qualifying non-VA entities or 
providers. The Committee believes that the Secretary should 
make clear what health care conditions are non-urgent and 
establish a mechanism, such as, an advice line, to help 
veterans determine whether care under this section is 
appropriate to meet their health care needs.
    Section 1725A(b) would define eligible veterans as those 
who are enrolled under chapter 1705(a) of title 38, U.S.C. and 
who have been enrolled and have received medical care from VA 
within the 24-month period preceding the furnishing of walk-in 
care under this new program.
    Section 1725A(c) would direct that a qualifying non-VA 
entity or provider is one that has entered into a contract with 
the Secretary in order to provide these services, and section 
1725A(d) would allow veterans to seek walk-in care at FQHCs 
when appropriate. It is the Committee's intent that the 
authority in this section be exercised nation-wide, among 
several types of entities or providers to ensure adequate 
coverage, so that all veterans have the option of utilizing 
this convenient, walk-in care. Section 1725A(e) would direct 
the Secretary to ensure there is a continuity of care for 
veterans receiving walk-in care, including a mechanism to 
receive medical records from the walk-in clinics.
    Section 1725A(f) would establish the procedures for copays 
for walk-in care. Those veterans not required to pay a 
copayment for VA medical services would have access to two 
walk-in visits per year without requiring a copayment. All 
visits thereafter would require a copayment determined by a 
sliding copayment scale as established by the Secretary. 
Veterans who are required to pay a copayment for medical 
services provided by VA, would be required to pay their regular 
copayments for the first two walk-in visits within a calendar 
year and would be required to pay a higher copayment, as 
determined by the Secretary, for additional visits. It is the 
Committee's expectation that the higher copayment amount not 
exceed $50 per visit.
    Section 1725A(g) would require the Secretary to publish 
regulations and rules, to carry out Section 105, no later than 
1 year after the enactment of the bill. Section 1725A(h) would 
define walk-in care as non-emergent care provided by a 
qualifying non-VA entity or provider that furnishes episodic 
care and not longitudinal management of conditions.
    Section 105(b) would provide an effective date as the date 
on which final regulations are promulgated. Section 105(c) 
would provide a clerical amendment to amend the table of 
sections in Chapter 17 of title 38, U.S.C.

Sec. 106. Strategy regarding the Department of Veterans Affairs High 
        Performing Integrated Health Care Network.

    Section 106 of the Committee bill, a freestanding original 
provision, would require the Secretary to perform market area 
assessments at least every 4 years and prescribe the elements 
that need to be included in the assessments. Section 106 of the 
Committee bill would also direct VA to submit a strategic plan 
to Congress every 4 years. The strategic plan would provide 
information on the health care capacity provided at each VA 
facility, the capacity provided through community care 
providers, and the demand for health care disaggregated by 
geographic market areas.
    Background. VA intends to perform market area assessments 
to analyze the health care demand and service-delivery capacity 
in each of its 96 health care markets.\1\ The methodology for 
the market area assessments was developed and validated through 
recent pilots in three market areas. Private-sector experts 
will enable VA market-assessment teams to assess the current 
and future veteran demand for medical care, the health care 
services available at VA, and the health care services 
available in the local community.\2\ While the Committee is 
pleased VA is conducting this assessment, the Committee 
believes VA needs a more coordinated approach and a plan to 
utilize the assessments to better manage the health care 
provided under laws administered by VA.
---------------------------------------------------------------------------
    \1\``VA Market Area Health System Optimization;'' briefing to 
Senate Committee on Veterans' Affairs, September 25, 2017.
    \2\Statement of Regan L. Crump, Assistant Deputy Under Secretary 
for Health for Policy and Planning, House Committee on Veterans' 
Affairs, October 12, 2017.
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    Committee Bill. Section 106 would require VA to conduct 
quadrennial market area assessments and develop an analytically 
sound strategic plan based on information provided in the 
market area assessments. Specifically, section 106(a) would 
direct VA to conduct market area assessments every 4 years that 
would include an assessment of the demand for health care from 
VA disaggregated by geographic area; an inventory of the health 
care capacity at VA facilities; the capacity, number of 
providers, geographic location of the providers and types of 
care and services to be provided at non-VA facilities; capacity 
assessment from other Federal direct delivery systems and non-
contracted health care providers regarding their ability to 
provide care to veterans; VA academic affiliates providing care 
to veterans; the effects on the capacity of health care by the 
access guidelines and standards for quality established under 
section 1703(h), as amended by section 101; and the number of 
appointments for care at VA and non-VA facilities. This section 
would direct VA to submit the market area assessments to the 
appropriate committees of Congress. Section 106(a) further 
directs VA to use the market area assessment to determine the 
capacity of the provider networks established under section 
1703(j), as amended by section 101, and to inform the 
President's Budget Request for VA. Section 106(a) would take 
effect September 30, 2018.
    Section 106(b) would direct VA to submit to Congress a 
strategic plan 1 year after enactment of the Committee bill and 
every 4 years thereafter that would specify a 4-year forecast 
for the demand for health care from VA by geographic location; 
the capacity to provide health care at each facility; and the 
capacity of care to be provided through community providers. 
When developing the strategic plan, VA should consider access 
guidelines and standards for quality developed under section 
1703(h), as amended by section 101; market area assessments; 
VA's needs in providing services for conditions that are 
related to military service where there is limited community 
expertise; consult with relevant stakeholders in the Federal 
government, private sector, members of Congress, veterans 
service organizations, and other policy experts; identify 
emerging trends, issues, or potential opportunities that could 
affect health care for veterans; develop recommendations for 
short-term and long-term priorities for health care delivered 
by VA; conduct a survey of veterans who have used the system to 
gauge their satisfaction with VHA; and other matters VA 
considers appropriate. Section 106(c) would define the 
appropriate committees of Congress.

Sec. 107. Applicability of Directive of Office of Federal Contract 
        Compliance Programs.

    Section 107 of the Committee bill, a freestanding original 
provision, would set forth the applicability of the DOL Office 
of Federal Contract Compliance Programs (hereinafter, 
``OFCCP'') on provider agreements and agreements for state 
homes, to mirror the applicability of contractors under the 
TRICARE Program.
    Background. Executive Order (hereinafter, ``E.O.'') 11246 
charges DOL with protecting the rights of workers employed by 
Federal contractors from discrimination on the basis of their 
race, color, religion, sex, sexual orientation, gender 
identity, or national origin with the responsibility of 
ensuring equal employment opportunities.
    In 2014, due to confusion over applicability of the E.O. on 
TRICARE subcontractors under section 1072 of title 10, U.S.C., 
DOL established a 5-year moratorium on enforcement of the 
obligations required of TRICARE subcontractors. During this 
moratorium, DOL said it would work with other Federal agencies 
to clarify the coverage of health care providers under Federal 
statutes applicable to subcontractors.
    Committee Bill. Section 107(a) would apply the same 
moratorium on enforcement of obligations required of TRICARE 
subcontractors to those entities that enter into VCAs, as 
established under section 102 of the Committee bill, and 
agreements for state homes found in section 1745(a) of title 
38, U.S.C., as amended by section 103. Section 107(b) would 
prohibit the directive described in subsection (a) from being 
altered or rescinded before May 7, 2019. Section 107(c) would 
define the TRICARE Program. It is the intent of the Committee 
that DOL collaborate with VA to clarify the E.O.'s coverage of 
health care providers.

Sec. 108. Prevention of certain health care providers from providing 
        non-Department health care services to veterans.

    Section 108 of the Committee bill, a freestanding provision 
derived from S. 1153, would require the Secretary to deny, 
suspend, or revoke the eligibility of a non-VA health care 
provider to participate in the community care program if the 
provider was previously removed from employment by VA or had 
their medical license revoked.
    Background. While VA does have controls in place to ensure 
that only high quality providers provide care to veterans in 
the community, it is limited to checking the Department of 
Health and Human Services' List of Excluded Individuals and 
Entities and checking to ensure the providers have a current 
and unrestricted license. While VA does take these steps to 
ensure they only have high quality providers, VA does not take 
the next step to check whether the provider has ever had their 
license revoked. In addition, under the current practice at VA, 
a former VA employee who was terminated from employment at VA, 
but has not yet been reported to their state licensing board, 
may still be able to provide care to veterans through contracts 
or agreements with the VA.
    Committee Bill. Section 108 would direct VA to deny, 
suspend, or revoke the eligibility of a non-VA provider to 
participate in VA's community care program if the provider was 
previously removed from employment at VA or had their license 
revoked. Specifically, section 108(a) would direct VA, 1 year 
after enactment of the bill, to deny, revoke, or suspend a 
provider's ability to provide care in the community if that 
provider was removed from employment at VA because their 
conduct resulted in their inability to deliver safe and 
appropriate health care or violated the requirements of their 
medical license that resulted in the loss of their license. 
Section 108(b) would allow VA to deny, suspend, or revoke the 
eligibility of a provider to participate in VA's community care 
programs if the provider is under investigation by their state 
medical licensing board and VA believes it is necessary to 
protect the health, safety, and welfare of veterans. Section 
108(c) would direct VA to deny, suspend, or revoke a provider's 
ability to participate in VA's care in the community programs 
if that provider has been suspended from service as a health 
care provider in VA.
    Section 108(d) would direct that, 2 years after enactment, 
GAO submit a report to Congress on VA's implementation of this 
section. The section directs that elements that should be 
included in that report are the aggregate number of providers 
denied, suspended, or revoked from delivering care in the 
community; an evaluation on the impact on patient access to 
care under VA's community care programs; an explanation of VA's 
coordination with state medical boards and whether those boards 
were involved in implementation of this section; and other 
recommendations to complement eligibility criteria of VA health 
care providers and health care providers eligible to provide 
care through VA's community care programs. Section 108(e) would 
define ``non-Department health care services'' to be services 
provided under subchapter I of Chapter 17 of title 38, U.S.C.; 
section 101 of P.L. 113-146; purchased through the Medical 
Community Care Account; or purchased with funds deposited in 
the Veterans Choice Fund.

                      SUBTITLE B--PAYING PROVIDERS

Sec. 111. Prompt Payment to Providers.

    Section 111 of the Committee bill, an original provision, 
would establish a new section 1703D of title 38, U.S.C., to 
require VA to adhere to a specified prompt payment standard 
when paying for hospital care, medical services, or extended 
care services furnished by health care entities or providers 
under this chapter.
    Background. P.L. 113-146 included the sense of Congress 
that VA should comply with the Prompt Payment Rule, section 
1315 of title 5, Code of Federal Regulations, or any similar 
regulation or ruling. The sense of Congress expressed that this 
should apply to VA payment for health care to non-VA providers. 
The law also required that VA implement a claims processing 
system that complies with the Prompt Payment Act in chapter 39 
of title 31, U.S.C.
    A May 2016 GAO report, ``Proper Plan Needed to Modernize 
System for Paying Community Providers,'' indicated that 
according to VA FY 2015 data, it processed about 66 percent of 
claims within 30 days or less. According to GAO, VHA did not 
pay interest penalties on most late payments to community 
providers until an Office of General Counsel opinion was issued 
in October 2015, indicating that the Prompt Payment Act does 
apply to VA care in the community claims.
    Committee Bill. Section 111(a) would establish new section 
1703D of title 38, U.S.C. Subsection (a) of this new section 
would require VA to pay for hospital care, medical services, or 
extended care services furnished under chapter 17 of title 38, 
U.S.C., within 45 calendar days of receipt of a clean paper 
claim or 30 calendar days of receipt of a clean electronic 
claim. If a claim is denied, VA would be required to notify the 
health care provider or entity regarding the reason for denial 
and any additional information required within 45 calendar days 
of denial of a paper claim and 30 calendar days of denial of an 
electronic claim. These claims should be paid, denied, or 
adjudicated within 30 calendar days from the receipt of the 
requested information.
    Under subsection (b) of new section 1703D of title 38, 
U.S.C., health care providers or entities furnishing care or 
services would be required to submit claims for payment to VA 
not later than 180 days after the date on which the care was 
furnished. Subsection (c) would require that sections 3729 
through 3733 of title 31, U.S.C., apply to fraudulent claims 
submitted to VA, and if the Secretary determines that a health 
care entity or provider submitted a fraudulent claim, the 
Secretary would be required to bar them from providing care 
under this chapter.
    Section (d) would require that any claim that has not been 
denied with notice, made pending with notice, or paid to the 
health care entity or provider by VA within the time periods 
specified in subsection (a) be overdue. VA would be authorized, 
consistent with chapter 39 of title 31, U.S.C., to require that 
interest be paid on clean claims. Interest would be determined 
in accordance with the rate established by the Secretary of the 
Treasury under section 3902 of title 31 and published in the 
Federal Register.
    Section (d)(3) would require VA to annually submit to 
Congress a report on payment of overdue claims under this 
subsection, disaggregated by paper and electronic claims. The 
reports would be required to include the amount paid in overdue 
claims, disaggregated by the amount of the overdue claim and 
the amount of interest paid on such overdue claim, the number 
of overdue claims and the average number of days late each 
claim was paid, disaggregated by VA facility and VISN.
    Section (e) would require VA to deduct the amount of any 
overpayment from payments due to a health care entity or 
provider after making reasonable efforts to notify the provider 
or entity of the right to dispute or request a compromise.
    Section 1703D(f) of title 38, U.S.C., would require VA to 
provide health care entities and providers furnishing care 
under this chapter with a list of information required to 
establish a clean claim. This information should be determined 
after consultation with public and private sector health care 
entities. Entities and providers must be notified of any 
changes to the information required not later than 30 days 
before the modifications take effect.
    Section 1703D(g) of title 38, U.S.C., would require VA to 
act through a non-VA entity to process claims for compensation 
for hospital care, medical services, or extended care services 
furnished by a health care entity under chapter 17 of title 38, 
U.S.C. This could include a non-VA entity that is under 
contract or agreement for the program established under section 
1703(a) to title 38, U.S.C., or a non-VA entity that 
specializes in such processing for other Federal agency health 
care systems.
    Section 1703D(h) of title 38, U.S.C., would require VA, 
with 90 days of enactment, to submit to Congress a report on 
the feasibility and advisability of adopting a funding 
mechanism similar to what is utilized by other Federal agencies 
to allow a contracted entity to act as a fiscal intermediary 
for the Federal Government to distribute or pass through 
Federal funds for certain hospital care, medical services, or 
extended care services that are non-underwritten. VA may 
coordinate with DOD, HHS, and the Department of the Treasury in 
developing this report.
    Under the Veterans Choice Program, third-party contracting 
entities pay health care providers for the cost of care, and VA 
reimburses the contracting entities. The Committee encourages 
VA to examine whether this construct would be appropriate to 
continue under the Veterans Community Care Program, as 
established in Section 101 of the Committee bill.
    Section 1703D(i) of title 38, U.S.C., would define ``clean 
electronic claim'' as the transmission of data for purposes of 
payment of covered health care expenses submitted to VA that 
contains all of the required data elements necessary for 
accurate adjudication. It would define ``clean paper claim'' as 
a paper claim for payment of covered health care expenses 
submitted to VA that contains all of the required data elements 
necessary for accurate adjudication. This subsection would 
define ``fraudulent claims'' as an intentional and deliberate 
misrepresentation of a material fact or facts by a health care 
entity or provider made to receive a claim that was not legally 
payable to the provider. It would also define ``health care 
entity or provider'' as any non-VA health care entity or 
provider. Section 111(b) would provide for a clerical amendment 
to insert 1703D in the table of sections.
    In an effort to maximize VA's resources and time to provide 
health care to veterans, the Committee recommends the VA 
leverage industry partners--via third party administrators--to 
process all non-VA health care claims. The Committee further 
recognizes the VA's need to oversee claims processing 
undertaken by non-VA employees. As such, the Committee 
encourages the VA to develop policies allowing for prepayment 
claim reviews which entails the random selection of claims for 
manual review by VA to ensure the accuracy of claims 
processing.

Sec. 112. Authority to pay for authorized care not subject to an 
        agreement.

    Section 112 of the Committee bill, an original provision, 
would add a new section to Subchapter IV of chapter 81 to 
authorize the Secretary to compensate non-VA providers for 
medical care they provided to a veteran, despite those 
providers not being a party to the contract, agreement, or 
other arrangement that furnishes that care.
    Background. Through the course of providing medical care 
for certain conditions, it is common for treating physicians to 
collaborate with colleagues for care that is clinically 
necessary. In the case of medical care for veterans, a non-VA 
provider may not have a formal agreement with VA to provide 
care to veterans but still operate in collaboration with an 
entity or provider who does. For example, during a surgery, a 
hospital may have a formal agreement with VA to provide care, 
but the anesthesiologist may not, so he or she would generate a 
separate bill for VA.
    Committee Bill. Section 112(a) would provide the Secretary 
with the authority to pay non-VA providers for care the 
Secretary has determined is clinically necessary, 
notwithstanding the absence of formalized contracts, 
agreements, or other arrangements to provide such care. It also 
would require the Secretary to take reasonable efforts to enter 
into contracts, agreements, or other arrangements with such 
providers to ensure that any future care is provided subject to 
some type of formalized agreement. Section 112(b) would provide 
for a clerical amendment to insert the item addressed in 
Section 112(a) into the table of sections at the beginning of 
chapter 81.
    With this provision, the Committee intends for VA to pay 
for non-VA medical care that the Secretary considers necessary 
regardless of the relationship the non-VA providers have with 
VA. The Committee also expects that after paying for such care, 
VA would make reasonable attempts to establish formalized 
agreements with those providers to ensure that future care they 
provide is subject to such agreements.

Sec. 113. Improvement of authority to recover the cost of services 
        furnished for non-service-connected disabilities.

    Section 113 of the Committee bill, an original provision, 
would amend section 1729 of title 38, U.S.C., to authorize VA 
to collect from a third party for care furnished to non-
veterans. It would also authorize VA to seek collections when 
VA pays for care, rather than furnishes it, and remove 
duplicative language regarding VA's authority to collect from 
other health insurance for treatment of a non-service-connected 
disability.
    Background. Section 1729 of title 38, U.S.C. authorizes VA 
to collect reasonable charges from a third party, to the extent 
the veteran would be eligible, for care or services furnished 
to veterans for a non-service-connected disability. In some 
cases, VA pays for the care, but does not furnish it. In 
addition, in some circumstances, VA furnishes care to non-
veterans, including certain Civilian Health and Medical Program 
of the Department of Veterans Affairs (hereinafter, 
``CHAMPVA'') beneficiaries and in emergency situations. 
However, the current statute does not explicitly authorize VA 
to collect reasonable charges related to the cost of care for 
individuals who are not veterans.
    Committee Bill. Section 113(a) would authorize VA to 
collect from a third party for care furnished to non-veterans 
by amending section 1729 of title 38, U.S.C., to refer to 
``individuals'' instead of ``veterans.''
    Section 113(b) would amend section 1729(a)(1) of title 38, 
U.S.C., to authorize VA to seek collections when VA pays for 
care, rather than furnishes it.
    Section 113(c) would amend section 1729(a)(2)(D) to remove 
duplicative language. Paragraph 2 of the subsection states that 
VA's authorization to collect applies to a non-service-
connected disability that meets criteria established in the 
following subparagraphs. Current subparagraph (D) restates that 
the statute applies to veterans who do not have a service-
connected disability and who are entitled to care, or payment 
of the expenses of care, under a health plan contract. The 
Committee bill would eliminate the duplicative reference to 
non-service-connected disability. It is the Committee's 
understanding that this change simply removes duplicative 
language and will have no impact on how VA interprets or 
implements its authority to collect from third parties.

Sec. 114. Processing of Claims for Reimbursement Through Electronic 
        Interface.

    Section 114 of the Committee bill, an original and 
freestanding provision, would authorize VA to enter into an 
agreement with a third-party entity to process health care 
claims for reimbursement using an electronic interface.
    Background. VA currently processes claims for non-VA care 
and does not utilize an electronic interface. VA's current 
process includes manual steps and does not include an online 
portal for use by community providers to check the status of 
their claims.
    Committee Bill. Section 114 would authorize VA to enter 
into an agreement with a third-party entity to utilize an 
electronic interface to process claims for reimbursement for 
health care provided under the laws administered by the 
Secretary.
    As noted in Section 111 of this report, the Committee 
recommends the VA leverage industry partners to process all 
non-VA health care claims. The Committee also encourages the VA 
to develop policies allowing for prepayment claim review to 
ensure the accuracy of claims processing.

              SUBTITLE C--EDUCATION AND TRAINING PROGRAMS

Sec. 121. Education program on health care options.

    Section 121 of the Committee bill, a freestanding provision 
derived from S. 1279, would add a new section to title 38, 
U.S.C., requiring the Secretary to develop and administer an 
education program that informs veterans of their health care 
options.
    Background. Veterans have numerous options for how they 
receive health care, including directly from VA providers at VA 
facilities, from VA-reimbursed community providers, and from 
providers of their choice through private insurance, Medicare, 
Medicaid, the TRICARE program, IHS, and tribal health programs. 
While VA offers a wide range of information on its website 
aimed at informing veterans on their options for health care, 
VA does not currently operate a program designed to educate 
veterans about enrollment priority, financial obligations for 
care, interaction between insurance and health care, and where 
to direct complaints about health care received.
    Committee Bill. Section 121(a) would direct VA to develop 
and administer an education program to teach veterans about 
their health care options through VA. The Committee intends 
that VA ensure that veterans are provided clear guidance on how 
to compare health care options available to them. The Committee 
expects that during the implementation of the Caring for Our 
Veterans Act, veterans will have questions comparing VA to 
community care options for which they qualify. As such, the 
Committee directs VA to provide guidance on how to interpret 
and utilize access guidelines and standards for quality to 
inform a veteran's health care decision.
    Section 121(b) would direct that the required elements of 
the training program include education about eligibility 
criteria for care, enrollment priority groups, and financial 
obligations for receiving services; teaching veterans about the 
interaction between health insurance (including Medicare, 
Medicaid, and the TRICARE program.) and VA health care; and 
information about where to direct complaints about health care 
received.
    Section 121(c) would require the Secretary to ensure that 
materials produced through the program are made available to 
veterans who may not have Internet access. The Committee 
expects VA to make a good-faith effort to communicate with 
veterans through various mediums about their health care 
options through VA.
    Section 121(d) would require the Secretary to evaluate the 
effectiveness of the education program and annually submit a 
report to Congress on the findings of the evaluation.
    Section 121(e) defines the terms ``Medicaid,'' 
``Medicare,'' and ``TRICARE program.''

Sec. 122. Training program for administration of non-Department of 
        Veterans Affairs health care.

    Section 122 of the Committee bill, a freestanding provision 
derived from S. 1279, would add a new section to title 38, 
U.S.C., requiring the Secretary to establish a training program 
for VA employees and contractors on how to administer non-VA 
health care.
    Background. VA has relied on non-VA entities to provide 
health care to veterans for many years, but the reliance 
increased after implementation of P.L. 113-146. Despite the 
increasing use of non-VA providers to provide care for 
veterans, there is no mechanism for providing VA employees and 
non-VA providers with information they need to most effectively 
treat veterans.
    Committee Bill. With section 122, the Committee intends to 
better educate VA employees and contractors to ensure veterans 
have as positive a health care experience as possible.
    Section 122(a) would direct which non-VA health care 
programs would be covered as part of the proposed training 
program. These include the program to reimburse for non-VA 
emergency room care; the Veterans Community Care Program under 
section 1703, as amended by section 101; and the management of 
opioid prescriptions by non-VA providers pursuant to 
improvements under section 131.
    Section 122(b) would require the Secretary to evaluate the 
effectiveness of the training program annually and submit the 
findings of the evaluation to Congress.

Sec. 123. Continuing medical education for non-Department medical 
        professionals.

    Section 123 of the Committee bill, a freestanding provision 
which is derived from S. 1319, would establish a program to 
provide continuing medical education to non-VA providers. The 
program would be accredited in as many states as possible, 
conforming to the rules and regulations of state medical 
licensing agencies and medical credentialing organizations.
    Background. Health care providers are usually required 
under state law to meet education requirements in order to 
retain their state medical license. For example, all but five 
states require physicians to meet continuing medical education 
requirements in cycles that range between annual and every 4 
years. These requirements are intended to ensure that health 
care providers stay current on medical technology, treatment 
procedures, and medical research findings to provide the 
highest quality care to their patients. Community health care 
providers for veterans must ensure they meet state continuing 
medical education requirements, sometimes by self-financing the 
training.
    Committee Bill. Section 123(a) would direct the topics to 
be addressed within the proposed program. Specifically, the 
program would include education on identifying and treating 
mental and physical conditions of veterans and their family 
members; VA's health care system; and any other matters the 
Secretary considers appropriate.
    Section 123(b) would establish parity between medical 
professionals treating veterans outside VA and those within VA 
on the continuing medical education material provided, in order 
to support core competencies throughout the community.
    Section 123(c) would direct how the program would be 
administered. The Secretary would determine the curriculum and 
number of credit hours to be provided, ensure the program would 
be accredited in as many states as practicable, and be provided 
at no cost to non-VA medical professionals. The Secretary would 
also monitor utilization of the program, evaluate its 
effectiveness, and report annually to Congress on findings in 
these areas. Section 123(d) defines the term ``non-Department 
medical professional.''
    This section underscores the Committee's belief that 
educated community health care providers are better positioned 
to deliver high-quality care and services to veterans than 
providers who lack an understanding of the specific needs of 
veterans. The Committee also recognizes that by providing 
continuing medical education at no cost, community providers 
may be more likely to work with VA to provide care and services 
to veterans.

   SUBTITLE D--OTHER MATTERS RELATING TO NON-DEPARTMENT OF VETERANS 
                           AFFAIRS PROVIDERS

Sec. 131. Establishment of processes to ensure safe opioid prescribing 
        practices by non-Department of Veterans Affairs health care 
        providers.

    Section 131 of the Committee bill, a freestanding provision 
derived from S. 2134, would establish the processes by which VA 
ensures that non-VA health care providers participating in the 
Community Care program are safely prescribing opioids.
    Background. P.L. 114-198, the Jason Simcakoski Memorial and 
Promise Act (hereinafter, ``P.L. 114-198''), amended section 
1701 of title 38, U.S.C., to modify the agency's opioid 
prescribing guidelines, increasing oversight and accountability 
in VA's pain management and prescription services for veterans. 
Despite these efforts, the prescribing methods of contract 
providers may not meet the same rigorous safety standards. A 
July 2017 VA Office of Inspector General (hereinafter, ``OIG'') 
report on opioid prescribing by community providers found that 
many are not subject or do not adhere to VA's opioid safety 
reforms. The report also found that VA was not consistently 
tracking veteran's prescription history and information from 
community providers.
    Committee Bill. Section 131 would direct the Secretary to 
create processes and guidelines to ensure community providers 
adhere to the same standards as VA in safely prescribing 
opioids. Section 131(a) would direct the Secretary to certify 
that community providers review the agency's guidelines for 
prescribing opioids as set forth by P.L. 114-198. Section 
131(b) would direct the Secretary to establish a process for 
information sharing with community providers to include 
veterans complete prescription history on their electronic 
health records.
    Section 131(c) would require all providers participating in 
the new VA Community Care Program to submit opioid 
prescriptions to VA for prior authorization or directly to a VA 
pharmacy for dispensing, and would require VA to record and 
monitor the prescriptions. The subsection includes exceptions 
in cases where there is an immediate medical need for the 
prescription or when obtaining a prescription at a VA pharmacy 
would impose undue hardship on the veteran. The Secretary is 
required to report quarterly to Congress on community 
providers' compliance and noncompliance. It is the Committee's 
intent that this section serve as an oversight measure by 
directing the Secretary to monitor and report community 
providers who are not following the proper safety guidelines 
and regulations for dispensing opioids.
    Section 131(d) would ensure that VAMC and VISN directors 
have authority to take appropriate action against community 
providers they believe are using prescribing practices 
inconsistent with the standards of appropriate and safe care. 
Subsection (e) would provide the authority to deny or revoke 
eligibility of non-VA providers based on their opioid 
prescribing practices. The Committee believes that opioid 
prescribing among community providers must be closely monitored 
and regulated, and that these sections would provide the agency 
with the authority and tools to evaluate and manage contracts 
with community providers based on criteria to meet safety 
standards. Subsection (f) would provide a definition for a 
covered health care provider as a non-VA provider who provides 
health care to veterans under laws administered by VA.

Sec. 132. Improving information sharing with community providers.

    Section 132 of the Committee bill, an original provision, 
would amend the existing provision in section 7332(b)(2)(H) 
regarding VA's ability to disclose protected health information 
to community providers and create a new exception in 
subparagraph (I) that would allow VA to share records with 
third parties to recover or collect reasonable charges for care 
provided.
    Background. Under section 7332 of title 38, U.S.C., VA must 
keep confidential, with certain exceptions, medical records 
connected to patient activities associated with substance use 
disorders, human immunodeficiency virus infections, and sickle 
cell anemia.
    Committee Bill. Section 132 would amend section 7332(b)(2) 
of title 38, U.S.C., by striking subparagraph (H) to insert 
three new paragraphs. It would add a new paragraph (H)(i) 
providing that the Secretary could share records with non-VA 
providers for the purpose of furnishing hospital care, medical 
services, or extended care services to patients.
    Section 7332(b)(2), as amended, would replace the existing 
paragraph (H)(ii) with a new paragraph providing that the 
entity to which such a protected record is disclosed may not 
disclose to another party or use the protected record for a 
purpose other than that for which the disclosure was made.
    Section 7332(b)(2) would add a new paragraph (I) providing 
authority to VA to disclose medical records for purposes of 
recovering or collecting reasonable charges from the patients' 
other health plan contracts or other responsible third parties 
for care furnished by VA to a patient for a non-service 
connected disability.

Sec. 133. Competency standards for non-Department of Veterans Affairs 
        health care providers.

    Section 133 of the Committee bill, a freestanding original 
provision, would require the Secretary to establish competency 
standards and requirements for non-VA providers that treat 
injuries or illnesses in clinical areas that VA has a special 
expertise.
    Background. The 2016 bi-partisan Commission on Care final 
report recognized,

        . . . the VA health care system has valuable strengths, 
        including some unique and exceptional clinical programs 
        and services tailored to the needs of the millions of 
        veterans who turn to VA for care. For example, VHA's 
        behavioral health programs, particularly with their 
        integration of behavioral health and primary care, are 
        largely unrivalled, and profoundly important to many 
        who have suffered from the effects of battle and for 
        whom VHA is a safety net.

    With an increase in medical services provided by non-VA 
providers, there is a concern that community providers may not 
be able to provide the same level and quality of care, 
particularly in treating the unique nature of the injuries and 
illnesses among veterans.
    Committee Bill. Section 133(a) would direct VA to establish 
competency standards and requirements for non-VA providers. 
These standards and requirements would be for clinical areas 
for which VA has clinical expertise, such as traumatic brain 
injury, military sexual trauma, and post traumatic stress 
disorder. Section 133(b) would require that these standards and 
requirements be met, through training or other means 
established by the Secretary, as a condition upon entering into 
a contract under the Veterans Community Care Program.
    With this provision, it is the intent of the Committee to 
require the Secretary to ensure community providers meet the 
same competency and quality standards of VA.

          SUBTITLE E--OTHER NON-DEPARTMENT HEALTH CARE MATTERS

Sec. 141. Plans for Use of Supplemental Appropriations Required.

    Section 141 of the Committee bill, a freestanding original 
provision, would direct the Secretary to provide additional 
information to Congress when the Secretary requests funding 
outside the standard budget process.
    Background. VA has demonstrated a lack of ability to 
effectively anticipate funding requirements and utilization 
timelines for their community care programs, most notably for 
the Veterans Choice Program as created in P.L. 113-146. In mid-
2017, with little notice provided to Congress, VA provided 
guidance to VA medical facilities that Choice-related community 
care would need to be triaged as a result of dwindling money in 
the Veterans Choice Fund. As a result, P.L. 115-46, the VA 
Choice and Quality Employment Act of 2017 (hereinafter, ``P.L. 
115-46''), authorized and appropriated $2.1 billion into the 
Veterans Choice Fund in mid-August, to prevent a delay in care 
for veterans. More recently, VA notified Congress that the $2.1 
billion, which VA believed would take 6 months to exhaust, 
would be expended in mid-January 2018.
    Committee Bill. Section 141 would require that when the 
Secretary submits a request for funding outside the standard 
annual budget process, it must come 45 days prior to the date 
that any veteran program would be impacted, and must include a 
justification for the request, including a detailed business 
plan for execution and timeline for how long the additional 
funding is projected to last. Further, the Secretary must 
certify that the request was developed using a sound actuarial 
analysis. While the Committee is supportive of providing 
community care to veterans, the Committee also expects VA to 
utilize taxpayer dollars responsibly, and make appropriate and 
sufficient requests through the standard Federal budgeting 
process.

Sec. 142. Veterans Choice Fund flexibility.

    Section 142 of the Committee bill, an original provision, 
would amend section 802 of P.L. 113-146 to authorize VA, 
beginning in FY 2019, to use remaining amounts in the Veterans 
Choice Fund to pay for any health care services under Chapter 
17 of title 38, U.S.C., at non-VA facilities or through non-VA 
providers furnishing care in VA facilities.
    Background. Section 802 of P.L. 113-146 authorized the 
Veterans Choice Fund to fund the Veterans Choice Program. 
Section 802 authorized and appropriated $10 billion for the 
Veterans Choice Fund to be available until expended for the 
Veterans Choice Program. In 2017, P.L. 115-46 authorized and 
appropriated $2.1 billion into the Veterans Choice Fund, to 
remain available until expended. When VA indicated to the 
Committee that the $2.1 billion in the Veterans Choice Fund 
would be expended in mid-January 2018. Congress appropriated an 
additional $2.1 billion in P.L. 115-96, a bill to make 
continuing appropriations (hereinafter, ``P.L. 115-96''). 
Section 402 of the Committee bill would provide an additional 
$4 billion for the Veterans Choice Fund.
    Committee Bill. Section 142 would authorize the Secretary, 
beginning in FY 2019, to use the remaining funds in the 
Veterans Choice Fund to pay for any health care services 
described in Chapter 17 of title 38, U.S.C., provided at non-VA 
facilities or through non-VA providers in VA facilities. The 
Committee intends the funds in the Veterans Choice Fund to be 
used for non-Veterans Choice Program care only after the new 
community care program established under section 101 of the 
Committee bill is fully implemented.

Sec. 143. Sunset of Veterans Choice Program.

    Section 143 of the Committee bill, an original provision, 
would amend section 101(p) of P.L. 113-146 to end the 
Secretary's authority to administer the Veterans Choice Program 
after December 31, 2018.
    Background. Section 101 of P.L. 113-146 established the 
Veterans Choice Program. Section 101(p) authorized the program 
until funds appropriated for the Veterans Choice Program were 
expended or 3 years after the date of enactment of the law. 
Section 2 of P.L. 115-26, an Act to amend the Veterans Access, 
Choice, and Accountability Act of 2014, eliminated that end 
date.
    Committee Bill. Section 143 would remove the Secretary's 
authority to furnish care and services under section 101(p) of 
P.L. 113-146 after December 31, 2018.

Sec. 144. Conforming amendments.

    Section 144 of the Committee bill, an original provision, 
would amend existing authorities to account for changes made by 
section 101 of the bill to consolidate and create the Veterans 
Community Care Program.
    Background. VA currently uses several different authorities 
within title 38, U.S.C., to provide care for veterans in the 
community, such as sections 8111 and 8153. In addition, Section 
101 of the Committee bill would amend section 1703 of title 38, 
U.S.C., and section 102 of the Committee bill would provide VA 
with new statutory authority to enter into provider agreements. 
Certain sections of law referencing section 1703 would need to 
be amended to reflect the new authority.
    Committee Bill. Section 144 would make conforming 
amendments to other sections of the United States Code. 
Specifically, section 144(a)(1) would amend the authorities 
allowing VA to provide outpatient dental services at non-VA 
facilities; allowing VA Readjustment Counseling Centers to 
enter into contracts to provide care; and clarify the 
facilities referenced in VA's burial plot allowance. Section 
144(a)(2) would amend the Social Security Act to ensure the 
proper reference regarding hospitals that receive payments from 
the Medicare program if those hospitals provide inpatient care 
to veterans for procedures that the local VA facility is not 
able to provide. Section 144(a)(3) would amend P.L. 103-466, 
the Veterans Benefits Improvements Act of 1994, to ensure the 
appropriate reference to continue VA's authority to use 
contracts to diagnose or treat veterans with Gulf War Illness. 
Section 144(b) would establish the effective date for 
subsection (a) as the date described in section 101(b).

TITLE II--IMPROVING DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE DELIVERY

                    SUBTITLE A--PERSONNEL PRACTICES

                         PART I--ADMINISTRATION

Sec. 201. Licensure of health care professionals of the Department of 
        Veterans Affairs providing treatment via telemedicine.

    Section 201 of the Committee bill, which is derived from 
S. 925, would add a new section to title 38, U.S.C., providing 
VA with authority for its covered health care professionals to 
provide health care services to a patient no matter where the 
provider or patient is located using telemedicine services.
    Background. Telemedicine has proven to help VA deliver 
health care services to veterans located in areas where VA or 
private sector health care providers may be unavailable or for 
veterans who are, for whatever reason, unable to travel to a 
health care provider. Therefore, telemedicine has the potential 
to enable VA to provide timelier, convenient service to 
veterans. Codifying VA's ability to provide such services via 
telemedicine, whether the veteran or provider is located in the 
same or different states, whether or not they are in a Federal 
building, the veteran's home, or VA facility, will aide VA in 
using its resources most efficiently. There exists no explicit 
authorization for the provision of telemedicine services by VA. 
Under section 7301 of title 38, U.S.C., VA is charged with 
providing medical and hospital services for the medical care 
and treatment of veterans. Under section 1722B of title 38, 
U.S.C., VA may waive copayments for veterans who receive 
telehealth and telemedicine services under the laws 
administered by the Secretary.
    Committee Bill. Section 201(a) would amend chapter 17 of 
title 38, U.S.C., to add a new section 1730B regarding the 
licensure of covered health care professionals to provide 
telemedicine services. Section 1730B(a) would provide covered 
VA health care professionals with the ability to practice in 
any state, notwithstanding the location of the health care 
provider or the patient, when the treatment is occurring by 
telemedicine.
    Section 1730B(b)(1) would require that the ``covered health 
care professional'' eligible to provide services under Section 
1730B be an employee of the VA appointed under title 38 or 
title 5. Section 1730B(b)(2) would require that the ``covered 
health care professional'' eligible to provide services under 
Section 1730B be authorized by the Secretary to provide health 
care under Chapter 17 of title 38, U.S.C. Section 1730B(b)(3) 
would require that the ``covered health care professional'' 
eligible to provide services under Section 1730B be required to 
adhere to all of VA's standards of quality related to the 
provision of medicine. Section 1730B(b)(4) would require that 
the ``covered health care professional'' eligible to provide 
services under section 1730B be required to hold ``an active, 
current, full, and unrestricted license, registration, or 
certification in a State to practice the health care profession 
of the health care professional.''
    Section 1730B(c) would provide that neither the covered 
health care professional nor the patient are required to be 
located in a Federal Government facility during the health care 
services conducted by telemedicine. Section 1730B(d)(1) would 
provide that this section's provisions supersede any and all 
laws of any State that are inconsistent with the section. 
Section 1730B(d)(2) would provide that no State may take action 
to deny or revoke the license or other credential of a covered 
health care professional because the professional has engaged 
or intends to engage in an action covered by subsection (a). 
Section 1730B(e) would clarify that this bill is not intended 
to remove, limit, or otherwise affect a covered health care 
professional's obligations under the Controlled Substances Act 
(21 U.S.C. 801 et seq.).
    Section 201(b) bill would amend the table of sections at 
the beginning of chapter 17 of title 38, U.S.C., to add the new 
section 1730B.
    Finally, section 201(c) would require VA, not later than 1 
year after the earlier of either the date services under the 
new section begin or the regulations to carry out the section 
are promulgated, submit to Congress a report on veteran and 
provider satisfaction with the program, statistics on the 
program's use, as well as any savings to VA from the program's 
use.
    As VA noted in its proposed rule 82 FR 45756, ``to furnish 
care to all beneficiaries and use its resources most 
efficiently, VA needs to operate its telehealth program with 
health care providers who will provide services via telehealth 
to beneficiaries in States in which they are not licensed, 
registered, certified, or located, or where they are not 
authorized to furnish care using telehealth. Currently, doing 
so may jeopardize these providers' credentials, including fines 
and imprisonment for unauthorized practice of medicine, because 
of conflicts between VA's need to provide telehealth across the 
VA system and some States' laws or licensure, registration, 
certification, or other requirements that restrict or limit the 
practice of telehealth.'' Additionally, consonant with the 
definition of ``State'' in subsection 101(20) of title 38, 
U.S.C., no political subdivision of a state may attempt to 
abrogate the authority granted in subsection 1730B.
    The Committee does not intend for this section to create 
any coverage for non-VA employed health care providers. They 
are not subject to the same rigorous oversight and 
accountability standards that VA-employed health care 
professionals are.
    The Committee supports the use of this authority, 
particularly for the purposes of addressing the mental health 
needs of veterans and preventing veteran suicide. Further 
development of VA's telemental health delivery hubs throughout 
the Nation should proceed apace to offer veterans more 
convenient treatment options. To further the goals of this 
Committee bill, we urge VA to ensure that covered health care 
providers can maximally benefit from telework or other suitable 
work arrangements.
    The Committee additionally believes that rural veterans are 
particularly suited to benefit from this authority. However, 
the Committee is aware that there are significant barriers to 
rural veterans taking advantage of this authority, particularly 
as a result of the lack of a robust Internet or wireless 
infrastructure in many parts of the country. To that end, the 
Committee calls on VA to work with partners in the community, 
such as veterans service organizations or local governments, to 
find innovative ways to help these veterans benefit from this 
authority. VA should examine whether these organizations could 
establish veteran-cost-free telemedicine delivery areas in 
their facilities, particularly for veterans who lack access to 
Internet or wireless services, as a way to help maximize the 
use of the services and help veterans feel comfortable with 
this modality of care.

Sec. 202. Role of podiatrists in Department of Veterans Affairs.

    Section 202 of the Committee bill, which is derived from 
S. 1871, would amend chapter 74 of title 38, U.S.C., by adding 
a new section 7413 to make podiatrists eligible for any 
supervisory position in VHA to the same degree that a physician 
appointed under section 7401(1) is eligible and would increase 
the pay grade of podiatrists to match the compensation of VHA 
surgeons, physicians, and dentists. This section would require 
the Secretary to establish standards to ensure that specialists 
appointed to supervisory VHA positions do not provide direct 
clinical oversight for purposes of peer review or practice 
evaluation for providers of other clinical specialties.
    Background. The Committee is concerned VA is experiencing 
recruitment and retention issues for podiatrists. According to 
a February 2017 VA white paper on podiatry pay, the podiatrist 
compensation package has remained unchanged since 1976, except 
for those changes that include adjustments for basic pay and 
locality rates. VA indicated there is a growing health care 
demand for primary and specialty podiatric services, especially 
among veterans suffering from polytraumatic injuries and spinal 
cord injuries, in addition to the approximately 1.8 million 
veterans who are at risk of major foot wounds, infection, and 
amputation. According to CBO, VA employs about 400 podiatrists 
nationwide at an average salary of $130,000. Under this 
section, CBO anticipates that the base salary for podiatrists 
would increase by about 15 percent to $150,000 and VA would be 
able to hire an additional 30 podiatrists because the increased 
salary would make working for VA more attractive.
    Committee Bill. Section 202(a) would make a podiatrist 
eligible for any supervisory position to the same degree as a 
VHA physician. This section requires the Secretary to establish 
standards to ensure that specialists appointed to supervisory 
VHA positions do not provide direct clinical oversight for 
purposes of peer review or practice evaluation for providers of 
other clinical specialties. Section 202(b) increases the pay 
grade of podiatrists to match the compensation of other VHA 
surgeons, physicians, and dentists. The Committee expects these 
changes to aid in the recruitment and retention of podiatrists 
at VHA.

Sec. 203. Modification of treatment of certified clinical perfusionists 
        of the Department.

    Section 203 of the Committee bill, an original provision, 
would amend sections 7401 and 7455 of title 38, U.S.C., to 
include certified clinical perfusionists in the list of 
excepted positions and convert such positions to full title 38 
status.
    Background. Perfusionists are members of a surgical team 
providing highly specialized care during open heart surgery 
through the operation of the cardiopulmonary bypass machine 
(heart-lung machine). Currently, perfusionists are designated 
as title 38 hybrid employees and fall under the medical 
instrument technician qualification standard which limits their 
General Schedule level and salary. VA has experienced 
difficulty recruiting and retaining perfusionists, requiring 
some VAMCs to contract for perfusionist services.
    Committee Bill. Section 203 would amend sections 7401 and 
7455 of title 38, U.S.C., to provide certified clinical 
perfusionists in the list of excepted positions and convert 
such positions to full title 38 status to assist in the 
recruitment and retention of highly skilled perfusionists.

Sec. 204. Amending statutory requirements for the position of the Chief 
        Officer of the Readjustment Counseling Service.

    Section 204 of the Committee bill, which is derived from 
S. 1325, would amend section 7309(b)(2) of title 38, U.S.C., to 
remove the requirement that the Chief Officer of the RCS have 
at least 3 years of experience in providing and administrating 
direct counseling services or outreach service that is 
specifically within RCS.
    Background. Section 7309(b)(2) of title 38, U.S.C., 
provides the statutory requirements for an individual to be 
eligible for hiring as the Chief Officer of the RCS.
    Committee Bill. Section 204 would amend section 7309(b)(2) 
of title 38, U.S.C., by removing the requirement that the Chief 
Officer of the RCS have provided counseling or outreach as well 
as been an administrator in the RCS, specifically. No changes 
are made to the other requirements that the individual have 
advanced degrees in mental health or social work, have 3 years 
of experience providing direct counseling services and 3 years 
administering such services, meet the quality standards and 
requirements of VA, and be a combat veteran of the Armed 
Forces.
    VA has stated that the pool of applicants for the position 
of RCS Chief Officer has been unhelpfully narrowed by the 
requirements of sections 7309(b)(2)(B) and (C). This has led to 
extended periods without a permanent Chief Officer of the RCS. 
As noted by the February 2017 Department of Veterans Affairs 
Advisory Committee on the Readjustment of Veterans' Annual 
Report, the Chief Officer position had been vacant from 
December 31, 2012 until May 2016. While the bill removes the 
requirement that the individual have a minimum of 3 years of 
employment specifically in the RCS as a direct counselor and 3 
years as an administrator, it is the Committee's expectation 
that VA will continue to look to promote from within and ensure 
the unique culture and services provided by RCS flourish in the 
future. The Committee will conduct oversight over the 
administration of the RCS to ensure that the readjustment needs 
of combat veterans and other eligible veterans and their family 
members are met appropriately. Key to that is the promotion of 
the psychosocial readjustment counseling offered at RCS 
facilities in combination with the combat experience required 
of its employees; the Chief Officer of RCS must be fully 
experienced in this culture.

Sec. 205. Technical amendment to appointment and compensation system 
        for directors of medical centers and directors of Veterans 
        Integrated Service Networks.

    Section 205 of the Committee bill, an original provision, 
would amend section 7404(d) of title 38, U.S.C., to make an 
exception for increasing the compensation scale and raises for 
VAMC directors and directors of VISNs.
    Background. P.L. 115-41, the Department of Veterans Affairs 
Accountability and Whistleblower Protection Act of 2017 
(hereinafter, ``Accountability Act''), allowed VA to directly 
appoint VAMC directors and directors of VISNs. While the bill 
included a conforming amendment to section 7404(a) of title 38, 
U.S.C., the bill did not include a conforming amendment to 
section 7404(d) of title 38, U.S.C., to allow for higher pay 
for these individuals.
    Committee Bill. Section 205 would amend section 7404(d) of 
title 38, U.S.C., to make an exception for increasing the 
compensation scale and raises for VAMC directors and directors 
of VISNs.

Sec. 206. Identification and staffing of certain health care vacancies.

    Section 206 of the Committee bill, a freestanding original 
provision, would require the Secretary to identify and fully 
staff certain VA vacancies and submit a report within 210 days 
on progress made in filling such vacancies.
    Background. Because of its decentralized structure, VHA is 
unable to determine a point-in-time count of VA mental health 
vacancies and primary care and mental health vacancies in the 
VA's PACTs. This information is essential for VHA to be able to 
address any systematic understaffing problems that may exist 
within service lines across VISNs or at certain types of VAMCs. 
Also, despite VA's knowledge of health care provider vacancies 
in the past, VHA has been slow to fill them.
    Committee Bill. Section 206(a) would require the Secretary 
to identify and fully staff within 180 days VA mental health 
vacancies, as well as primary care and mental health vacancies 
in VA PACTs.
    Section 206(b) would require the Secretary to submit a 
report to Congress within 210 days specifying whether VA has 
complied with the requirements of this section and, if not, how 
many vacancies remain, and why VA was unable to fill them.
    With this provision, the Committee expects VA to 
aggressively address understaffing issues before they reach 
crisis levels.

Sec. 207. Department of Veterans Affairs personnel transparency.

    Section 207 of the Committee bill, a freestanding original 
provision, would require the Secretary to make staffing 
capacity information and data, such as vacancies and active job 
postings, publicly available on a VA website.
    Background. P.L. 113-146 requires the OIG to annually 
determine the five occupations within VHA for which there are 
the largest staffing shortages. A May 2014 OIG report, that 
preceded the requirements of P.L. 113-146, addressing ongoing 
concerns on VA's scheduling practices and excessive wait times 
acknowledged staffing shortages as one of many contributing 
factors. Concerns on inadequate staffing and hiring practices 
have been identified in OIG reports dating back to 2013. To 
date, the OIG has conducted its fourth report as required by 
P.L. 113-146 and its most recent analysis from September 2017 
determined that for critical need occupations, a significant 
percentage of the total gains continues to be offset by staff 
losses and that VHA still does not have adequate, comprehensive 
operational staffing models for critical need occupations.
    Committee Bill. Section 207 would require the Secretary to 
make staffing capacity information publicly available on a VA 
website. This provision would also require the information to 
be updated monthly, a semi-annual OIG review, and an annual 
report to Congress. The Committee intends that this information 
will assist VA in filling vacancies and provide greater 
transparency for stakeholders and Congress into challenges VA 
is having in recruiting and retaining personnel.

Sec. 208. Program on establishment of peer specialists in Patient 
        Aligned Care Team settings within medical centers of Department 
        of Veterans Affairs.

    Section 208 of the Committee bill, a freestanding 
provision, which is derived from S. 1873, would require the 
Secretary to carry out a program to establish peer specialists 
in PACTs at VAMCs.
    Background. VA has used peer specialists to assist veterans 
who are in treatment for mental health and substance abuse 
disorders. Peer specialists are veterans who are VA employees 
that serve as part of a care management team that promotes 
veterans' recovery by sharing their own recovery stories, 
providing encouragement, and teaching skills needed for 
successful recovery. The limited authority for utilizing the 
peer support model in the primary care setting has hindered the 
VA's ability to effectively engage veterans who would benefit 
from mental health or substance use treatment services. The 
stigma associated with veterans seeking care for mental health 
and substance use may result in veterans missing a key entry 
point to the effective VA peer support model of care.
    Committee Bill. Section 208(a) would require the Secretary 
to establish a program to place not fewer than two peer 
specialists in PACTs at VAMCs to promote mental health, 
behavioral health, and substance use disorder care in primary 
care settings.
    Section 208(b) would require the Secretary to establish the 
program in not fewer than 25 VAMCs by December 31, 2018, and 50 
VAMCs by December 31, 2019.
    Section 208(c)(1) would require the Secretary to locate the 
program in not fewer than 5 VAMCs that are designated as 
polytrauma centers and not fewer than 10 VAMCs that are not 
designated as polytrauma centers.
    Section 208(c)(2) would require the Secretary to consider 
the feasibility and advisability of selecting VAMCs to operate 
the program in areas that are rural or underserved, not in 
close proximity to an active duty military installation, and 
different geographic locations, such as census tracts 
established by the Bureau of the Census.
    Section 208(d) would require the Secretary to ensure that 
in carrying out the program the needs of female veterans are 
specifically considered and addressed and female peer 
specialists are made available to female veterans treated at 
each location.
    Section 208(e) would require the Secretary to consider ways 
in which the peer specialists at each location can conduct 
outreach to community health care providers who are providing 
services to veterans as well as the veterans receiving 
services.
    Section 208(f)(1) would require the Secretary to submit to 
Congress a report on the pilot program no later than 180 days 
after commencement and every 180 days thereafter until the 
Secretary determines the program is being carried out at the 
last location selected under subsection 208(c). The report 
would be required to include the findings and conclusions of 
the Secretary with respect to the program, an assessment of the 
program's benefits to veterans and family members, and an 
assessment of the effectiveness of outreach described in 
subsection 208(e).
    Section 208(f)(2) would require the Secretary to submit to 
Congress a final report on the pilot program no later than 180 
days after the Secretary determines the program is being 
carried out at the last location selected under subsection 
208(c). The report would detail the Secretary's recommendations 
as to the feasibility and advisability of expanding the program 
to additional locations.
    With section 208, the Committee intends to examine the 
value of utilizing the peer support model in primary care 
settings.

Sec. 209. Pilot program on increasing the use of medical scribes to 
        maximize the efficiency of physicians at medical facilities of 
        the Department of Veterans Affairs.

    Section 209 of the Committee bill, a freestanding 
provision, which is derived from S. 113, would require VA to 
establish a pilot program to evaluate the use of medical 
scribes by VA physicians.
    Background. The Joint Commission, which is a non-profit 
organization that accredits and certifies health care 
organizations, including VA, defines a scribe as ``an 
unlicensed person hired to enter information into the 
electronic medical record or chart at the direction of a 
physician or practitioner . . . Scribes are used most 
frequently, but not exclusively, in emergency departments where 
they accompany the physician or practitioner and record 
information into the medical record, with the goal of allowing 
the physician or practitioner to spend more time with the 
patient and have accurate documentation.\3\''
---------------------------------------------------------------------------
    \3\The Joint Commission, https://www.jointcommission.org/
standards--information/jcfaq details.aspx?StandardsFAQId=1206, accessed 
December 11, 2017.
---------------------------------------------------------------------------
    According to the Journal of the American Board of Family 
Medicine, ``Available evidence suggests medical scribes may 
improve clinician satisfaction, productivity, time-related 
efficiencies, revenue, and patient--clinician interactions.'' 
However, because a significant amount of research on the use of 
medical scribes has not been conducted, there are limits on the 
reliability of the evidence from the small number of studies 
that have been done.\4\
---------------------------------------------------------------------------
    \4\``The Use of Medical Scribes in Health Care Settings: A 
Systematic Review and Future Directions.'' Cameron G. Shultz, PhD, MSW 
and Heather L. Holmstrom, MD; May-June 2015; http://www.jabfm.org/
content/28/3/371.full.
---------------------------------------------------------------------------
    Committee Bill. Section 209(a) of the Committee bill would 
require VA to carry out a pilot program to increase the use of 
medical scribes to maximize the efficiency of physicians at VA 
medical facilities.
    Sections 209(b) and 209(c) would require VA to carry out 
the pilot program for 18 months at not fewer than five VA 
medical facilities at which the Secretary has determined have a 
high volume of patients or that are located in and at which the 
Secretary has determined there is a shortage of physicians and 
the physicians have high caseloads.
    Section 209(d) would require VA to enter into a contract 
for purposes of carrying out the pilot with one or more 
appropriate nongovernmental entities. An appropriate 
nongovernmental entity is defined as an entity that trains and 
employs professional medical scribes who specialize in the 
collection of medical data entry into electronic health 
records.
    Section 209(e) would require VA to collect data on the 
pilot program in an effort to determine its effectiveness in 
increasing the efficiency of VA physicians. This data should 
include the average wait time for a veteran to receive care 
from a physician prior the pilot's implementation and the 
average wait time for such care after implementation; the 
average number of patients that such physician is able to see 
daily prior to implementation and the average number of 
patients such physician is able to see daily after 
implementation; the average amount of time such physician 
spends daily on documentation prior to implementation and the 
average amount of time such physician spends on documentation 
daily after implementation; the satisfaction and retention 
scores of each such physician prior to the pilot's 
implementation and after; the patient satisfaction scores for 
each such physician prior to the pilot's implementation and 
after; and the patient satisfaction scores for their health 
care experience both before and after the pilot's 
implementation.
    Section 209(f) would require VA to submit to Congress a 
report on the pilot program no later than 180 days after 
commencement and every 180 days thereafter for the duration of 
the pilot program. The report would be required to include the 
number of VA medical facilities participating in the pilot and 
an assessment of the effects that participation in the pilot 
program has had on each medical facility, including maximizing 
the efficiency of physicians at each facility, reducing average 
wait times for appointments, improving access of patients to 
electronic medical records, mitigating physician shortages by 
increasing the productivity of physicians, all data collected 
under subsection (e), and recommendations from the Secretary 
with respect to extending or expanding the pilot program.
    Section 209(g) would define medical scribe as a member of 
the medical team hired and trained specifically and exclusively 
to perform documentation in an electronic health record to 
maximize the productivity of a physician.
    This pilot is an effort to continue to evaluate ways to 
increase physician efficiency and better serve veterans. 
Increasing physician efficiency could especially benefit 
medical facilities that have a shortage of physicians and those 
physicians with a high caseload.

Sec. 210. Sense of Congress regarding Department of Veterans Affairs 
        staffing levels.

    Section 210 of the Committee bill, a freestanding original 
provision, would express the Sense of Congress that VA should 
make resolution of staffing shortages a top priority.
    Background. While VA has acknowledged staffing shortages as 
a significant problem in the past, those shortages persist 
while VA initiates other organizational efforts.
    Committee Bill. Section 210(a) would describe Congressional 
findings that VA needs to fill at least 35,000 positions and 
that not filling those positions cause delays in veterans 
receiving benefits and services. Section 210(b) would express 
the Sense of Congress that VA should prioritize filling vacant 
positions.
    It is not clear to the Committee that VA has taken the 
issue of staffing shortages seriously. This provision 
emphasizes the importance with which the Committee believes VA 
should be treating this fundamental problem, as the health of 
millions of veterans depends on sufficiently staffed health 
care facilities.

                    PART II--EDUCATION AND TRAINING

Sec. 211. Graduate Medical Education and Residency.

    Section 211 of the Committee bill, a freestanding original 
provision, would require VA to increase the number of GME 
positions by up to 1,500 positions at facilities that include 
non-VA facilities.
    Background. Section 7302 of title 38, U.S.C., requires VA 
to carry out education and training programs, including medical 
residency programs. According to VA, it has the largest 
education and training program for health professionals in the 
United States. VA indicates that an estimated 70 percent of 
physicians in the United States have received training from VA.
    P.L. 93-82, the Veterans Health Care Expansion Act of 1973, 
authorized VA to enter into agreements with academic affiliates 
to administer resident salary and benefits. It also authorized 
VA to only reimburse academic affiliates for the cost of the 
time period in which the resident is training at a VA facility.
    P.L. 113-146 required VA to increase its number of GME 
residency positions by up to 1,500 over a 5-year period, 
beginning in 2015. P.L. 114-315, the Jeff Miller and Richard 
Blumenthal Veterans Health Care and Benefits Improvement Act of 
2016, extended the timeline by an additional 5 years. The law 
requires that when adding these positions, VA prioritize 
primary care, mental health, and other specialties determined 
appropriate, while also establishing these new positions in VA 
facilities without a GME program or in communities with a high 
concentration of veterans.
    Committee Bill. Section 211(a) would require VA to increase 
the number of GME residency positions by up to 1,500 in the 10-
year period beginning on the date of enactment. VA would be 
authorized to add these positions not only at VA facilities, 
but also at facilities operated by an Indian tribe, tribal 
organization, or IHS; an FQHC; a community health center; a DOD 
facility; or another health care facility the Secretary 
considers appropriate. VA would be authorized to pay stipends 
and benefits to these residents, regardless of whether they are 
placed in a VA facility. When determining residency positions, 
the Secretary would be required to consider several factors, 
including whether the facility is located in a rural location, 
whether the local community is medically underserved, and the 
ratio of veterans to VA health care providers in the area 
surrounding a facility. When determining specialties to be 
included in the residency positions, the Secretary would also 
be required to consider the types of specialties that improve 
quality and coverage of services to veterans and whether the 
specialty is included in VA's most recent staffing shortage 
determination.
    Section 211(b) would require residents to submit 
applications to VA with an agreement to commit to a period of 
obligated service in return for stipend and benefit support.
    Section 211(c) would require VA to notify individuals in 
writing upon their acceptance into the program.
    Section 211(d) would require the residents and VA to have 
an agreement in writing regarding the terms of the residency, 
including by requiring a service obligation equal to the number 
of years of stipend support.
    Section 211(e) would authorize VA to prescribe conditions 
of employment, including training and amount and terms of pay.
    Section 211(f) would require residents to fulfill a period 
of obligated service as a full-time employee of VA in the 
clinical practice of the participant's profession or in another 
health-care section assigned by VA. VA would be required to 
notify individuals of their commencement date of service no 
later than 60 days prior.
    Section 211(g) would establish penalties for those who fail 
to accept payment or instruct the educational institution in 
which the person is enrolled not to accept payment for a 
residency agreed to under subsection (d) and for residents who 
fail to fulfill their service obligation as a result of 
dismissal for disciplinary reasons, voluntary termination of 
residency, or loss of state license, registration, or 
certification to practice their health care profession.
    Section 211(h) would authorize VA to recover funds, 
according to the specified formula, from those who breach their 
agreement.
    Section 211(i) would require VA to submit to Congress an 
annual report detailing the positions filled under this 
section, as well as the location, associated academic 
affiliate, and any challenges faced in filling the positions.
    The Committee understands that VA's authorization to only 
pay for the time the resident is training at VA limits VA's 
ability to create additional GME positions. In providing this 
additional authority, the intent is to provide more residents 
with the opportunity to train at VA, and in return, provide 
them with the opportunity for full-time employment at VA. The 
Committee recognizes that there are challenges to recruitment 
and retention, including in rural facilities, and understands 
that additional resources and incentives for training and 
hiring physicians may be beneficial for VA.

Sec. 212. Pilot program to establish or affiliate with graduate medical 
        residency programs at facilities operated by Indian tribes, 
        tribal organizations, and the Indian Health Service in rural 
        areas.

    Section 212 of the Committee bill, a freestanding provision 
which is derived from S. 1449, would require VA to establish a 
pilot program to establish or affiliate with GME programs at 
specified non-VA facilities.
    Background. VA is only authorized to fund GME programs 
within VA facilities; however, both native and non-native 
veterans in some states, such as Alaska, Montana, and Hawaii, 
rely heavily on health care provided through facilities 
operated by Indian tribes, tribal organizations, or IHS. These 
entities provide care to veterans through a memorandum of 
understanding, national reimbursement agreement, and agreements 
entered into under sections 102 and 103 of P.L. 113-146. Due to 
the rural nature of many of these facilities, recruitment of 
health care providers can be difficult.
    Committee Bill. Within the 1,500 new GME positions required 
by Section 211, section 212(a)-(d) would require VA, in 
consultation with IHS, to carry out an 8-year pilot program to 
establish or affiliate with GME residency training programs at 
five facilities operated by an Indian tribe, a tribal 
organization, or the IHS that is located in a rural or remote 
area. Section 212(e) would require VA to reimburse 
participating facilities for specified expenses associated with 
the pilot program. Section 212(f) would require residents 
participating in the program to fulfill a period of obligated 
service and would be eligible for student loan repayment 
through VA and IHS. Any period of obligated service required 
would be served concurrently with any required service under 
the loan repayment programs. Section 212(g) would require that 
participants in the pilot program be considered a position 
referred to in section 211(a)(1) for purposes of the limitation 
on the number of authorized new positions. Section 211(h) would 
require VA to submit to Congress a report on the feasibility 
and advisability of expanding the pilot program and making it 
permanent, 3 years before the termination of the program.
    This pilot program is intended to assist with recruiting 
health care providers in areas that face recruitment challenges 
and strengthen VA partnerships with other facilities that serve 
a large number of veterans. It will also provide additional 
opportunities for residents to gain specific rural health 
experience.

Sec. 213. Reimbursement of continuing professional education 
        requirements for board certified advanced practice registered 
        nurses.

    Section 213 of the Committee bill, an original provision, 
would amend section 7411 of title 38, U.S.C., to require VA to 
reimburse continuing professional education expenses for APRNs.
    Background. Section 7411 of title 38, U.S.C., requires VA 
to reimburse full-time, board-certified physicians or dentists 
appointed under section 7401(1) of title 38, U.S.C., for 
continuing professional education up to $1,000 per year. This 
does not include APRNs. VA has indicated that it agrees with 
recommendations from the National Institute of Health and other 
health care organizations on the value of continuing education 
for APRNs and its important role in the provision of high-
quality care.
    Committee Bill. Section 213 would amend section 7421 of 
title 38, U.S.C., to require VA to reimburse APRNs for up to 
$1,000 per year for continuing medical education expenses.

Sec. 214. Increase in maximum amount of debt that may be reduced under 
        Education Debt Reduction Program of Department of Veterans 
        Affairs.

    Section 214 of the Committee bill, an original provision, 
would increase the maximum amount of loan repayment that can be 
provided to medical professionals under VA's EDRP.
    Background. Section 7683 of title 38, U.S.C., provides VA 
with the authority to carry out EDRP, which provides 
educational assistance to VHA employees. EDRP has enabled VHA 
to incentivize employees to work for VA or remain with VA by 
assisting in the payment of educational debt.
    With passage of P.L. 113-146, Congress raised the maximum 
amount of loan repayment under EDRP from $60,000 to $120,000 
over a 5-year period with not more than $24,000 being paid in 
any 1 year of participation of the Program. Despite this 
effort, VHA still faces challenges in incentivizing employees 
to remain with the Agency because private-sector loan repayment 
programs are more generous.
    Committee Bill. Section 214(a) of the Committee bill would 
increase the maximum amount of loan repayment from $120,000 to 
$240,000, and increase the maximum yearly payment under EDRP 
from $24,000 to $48,000. The Committee believes maximum use of 
this authority will assist VA in attracting high-quality 
providers.
    Section 214(b) would require a study, within 1 year of 
enactment, on the demand for educational debt reduction, to be 
submitted to the Senate and House Committees on Veterans' 
Affairs. Included in the study would be the requirement that VA 
consider vacancies within VHA that are EDRP-eligible, the types 
of medical professionals in demand in the nation and VA 
projections on the number and type of medical professions that 
meet veteran demand.

Sec. 215. Demonstration program on training and employment of 
        alternative dental health care providers for dental health care 
        services for veterans in rural and other underserved 
        communities.

    Section 215 of the Committee bill, a freestanding original 
provision, would authorize the Secretary to carry out a 
demonstration program to establish programs to train and employ 
alternative dental health care providers.
    Background. Coupled with the shortage of dental 
professionals at VA, veterans who reside in rural areas face 
increased barriers to accessing dental services. According to 
the VHA Office of Rural Health's May 2017's ``Lessons Learned: 
A Rural Case Study, Challenges Increasing Access to Dental Care 
Among Rural Veterans'':

        For individuals living in rural communities, including 
        Veterans, oral health is a significant public health 
        issue due to the documented disparities associated with 
        access and use of dental services. More specifically, 
        rural Veterans face numerous barriers accessing dental 
        services, including lack of transportation, 
        affordability, and limited access to dental providers. 
        These individuals are more likely to report an unmet 
        dental need and only access dental services in response 
        to discomfort or pain. The limited availability of 
        dental services also contributes to oral health 
        disparities by reducing access to dental care.

    The Centers for Disease Control and Prevention reports that 
nearly 70 percent of Americans over the age of 65 have been 
diagnosed with a form of periodontal disease. While some 
conditions include inflammation of the gums, others are more 
serious and result in damage to the soft tissue and/or bone. 
Poor oral health can negatively affect a veteran's emotional 
well-being as well as his or her ability to speak or eat.
    Committee Bill. In order to address the barriers to rural 
veterans accessing dental services, Section 215(a) would 
authorize the Secretary to carry out a demonstration program to 
establish programs to train and employ alternative dental 
health care providers to increase access to dental health care 
services for veterans who are entitled to VA dental health care 
services and reside in rural and other underserved areas.
    Section 215(b) would prioritize demonstration sites in 
States that do not have a VA facility that offers on-site 
dental services. Section 215(c) would authorize dental services 
via telehealth when appropriate and feasible. Section 215(d) 
would authorize the appropriation of such sums as are necessary 
to carry out the demonstration program.
    Section 215(e) would define ``alternative dental health 
care providers'' the same as the term is defined in section 
340G-1(a)(2) of the Public Health Service Act (section 256g-
1(a)(2) of title 42, U.S.C.). Section 340G-1(a)(2) defines 
``alternative dental health care providers'' as community 
dental health coordinators, advance practice dental hygienists, 
independent dental hygienists, supervised dental hygienists, 
primary care physicians, dental therapists and dental health 
aides.

                   PART III--OTHER PERSONNEL MATTERS

Sec. 221. Exception on limitation on awards and bonuses for 
        recruitment, relocation, and retention.

    Section 221 of the Committee bill, which is derived from 
S. 1325, would amend section 705(a) of P.L. 113--146 to remove 
recruitment, relocation, or retention incentives from the 
calculation of the annual aggregate of awards and bonuses 
payable by the Secretary.
    Background. Section 705(a) of P.L. 113--146 limited the 
Secretary to an annual aggregate of $360,000,000 for the 
payment of awards and bonuses. Section 951(a) of P.L. 114-198 
amended section 705(a) of P.L. 113-146 to limit the Secretary 
to an annual aggregate of $230,000,000 for FYs 2017 through 
2018, $225,000,000 for FYs 2019 through 2021, and $360,000,000 
for FYs 2022 through 2024 for the payment of awards and 
bonuses.
    Committee Bill. Section 221 would amend section 705(a) of 
P.L. 113--146 to remove recruitment, relocation, or retention 
incentives from the calculation of the annual aggregate of 
awards and bonuses payable by the Secretary.
    The Committee believes that these particular incentives are 
valuable tools for VA's employee recruitment and retention 
needs and their use should not be hampered by being aggregated 
with other employee awards and bonuses.

Sec. 222. Annual report on performance awards and bonuses awarded to 
        certain high-level employees of the Department.

    Section 222 of the Committee bill, which is derived from 
S. 114, would amend chapter 7 of title 38, U.S.C., by adding a 
new section 726 to require the Secretary to submit an annual 
report on the performance awards and bonuses presented to 
regional office directors, directors of VAMCs, and directors of 
VISNs.
    Background. As VA has come under scrutiny in recent years, 
Congress has brought greater accountability to the agency and 
focused more on the performance awards and bonuses for Senior 
Executive Service employees at the VA. Furthermore, Members of 
Congress have in-depth insights about how their local VA 
facilities are performing through accounts from their 
constituents and interactions with local VA leadership. The 
Committee believes that Members advocating for their 
constituents and veterans, as well as the American public, are 
owed a level of transparency on bonuses that are funded by 
taxpayer dollars. Therefore, this section would require an 
annual report on bonuses of local VA officials so Members and 
the public can ensure bonuses are awarded to top performers.
    Committee Bill. Section 222(a) would amend chapter 7 of 
title 38, U.S.C., by adding a new section 726 to require the 
Secretary to submit an annual report on the performance awards 
and bonuses presented to regional office directors, directors 
of VAMCs, and directors of VISNs. Each report shall include the 
amount of each award or bonus, the job title of each recipient, 
and the location where each recipient individual works. Section 
222(b) would provide for a clerical amendment to insert new 
section 726 in the table of sections at the beginning of 
chapter 7.

Sec. 223. Authority to regulate additional pay for certain health care 
        employees of the Department.

    Section 223 of the Committee bill, an original provision, 
would amend section 7454 of title 38, U.S.C., by expanding the 
definition of compensation to include pay earned by employees 
when performing duties authorized by the Secretary or when the 
employee is approved to use annual, sick, family medical, 
military, or court leave, or other paid absences for which pay 
is not already regulated.
    Background. This section would allow VA to better regulate 
the pay for title 38 hybrid employees and title 5 health care 
workers. Hybrid employees are covered by title 38 for 
appointment, advancement, and certain pay matters and covered 
by title 5 for performance appraisal, leave, hours of duty, 
adverse actions, probationary period, reemployment rights, 
reduction-in-force, and retirement rules. In 2005, the U.S. 
Court of Federal Claims found VA liable in a class action law 
suit (Quimby et al. v. U.S.) for weekend pay and night 
differential during periods of leave and other paid time off 
for two categories of VA employees: registered nurses, 
physician assistants, and dental auxiliaries; and title 38 
hybrid employees. The court ruled that the Secretary does not 
have authority under section 7454 of title 38, U.S.C., or other 
statute to regulate the weekend pay and night differential for 
hybrid employees during periods of leave and absence, as hybrid 
employees receive leave and other benefits under title 5 not 
title 38.
    In 2012, the court ruled against VA in a companion case 
(Adams et al. v. U.S.) in which the plaintiffs alleged that VA 
title 5 health care workers who are appointed under section 
7408 of title 38 and receive weekend pay under section 7454 of 
title 38 were wrongfully deprived of weekend pay during periods 
of leave and other paid absence. Again, the contention was that 
the Secretary does not have authority under section 7454 of 
title 38 to regulate weekend pay for periods of leave and 
absence for employees using leave under title 5. This section 
would give VA this authority.
    Committee Bill. Section 223 would amend section 7454 of 
title 38, U.S.C., by expanding the definition of compensation 
to include pay earned by employees when performing duties 
authorized by the Secretary or when the employee is approved to 
use annual, sick, family medical, military, or court leave, or 
other paid absences for which pay is not already regulated. 
This section would allow the Secretary to issue policy 
prohibiting weekend pay and night differential for periods of 
leave consistent with government-wide regulations.

Sec. 224. Modification of pay cap for nurses.

    Section 224 of the Committee bill, an original provision, 
would amend section 7451(c) of title 38, U.S.C., to establish a 
higher maximum amount of basic pay for registered nurses up to 
level III of the Executive Schedule and for registered nurses 
serving as a nurse executive or a grade for the position of 
certified nurse anesthetists up to level I of the Executive 
Schedule.
    Background. According to the OIG FY 2017 VHA occupational 
staffing shortages report, the occupational series with the 
second largest staffing shortage is nurses. Medical officers 
and nurses have been the top two critical need occupations 
since the OIG first began the reports in 2014. According to the 
FY 2017 VHA nurse staffing report to Congress, the second most 
frequently identified reason for nurses leaving is for 
advancement (unique opportunity elsewhere). The report 
indicates that VHA nurses have an average turnover rate of 9.9 
percent and an average vacancy rate of 8.7 percent. Currently, 
the maximum rate of basic pay for nurses for any grade may not 
exceed the rate of basic pay established for positions at level 
IV of the Executive Service.
    Committee Bill. Section 224 of the Committee bill would 
amend paragraph (2) of section 7451(c) of title 38, U.S.C., to 
increase the pay cap for registered nurses. Specifically, the 
new paragraph 2 of section 7451(c) would raise the rate of 
basic pay for a registered nurse serving as a nurse executive 
or a certified registered nurse anesthetist not to exceed level 
I of the Executive Schedule under section 5312 of title 5, 
U.S.C. The rate of basic pay for all other registered nurses 
would be increased not to exceed level III of the Executive 
Schedule under section 5314 of title 5, U.S.C.

  SUBTITLE B--IMPROVEMENT OF UNDERSERVED FACILITIES OF THE DEPARTMENT

Sec. 231. Development of criteria for designation of certain medical 
        facilities of the Department of Veterans Affairs as underserved 
        facilities and plan to address problem of underserved 
        facilities.

    Section 231 of the Committee bill, a freestanding original 
provision, would require the Secretary to consider a number of 
facility characteristics in developing criteria to designate 
those facilities as underserved, with VISN directors using the 
criteria to determine annually which facilities in their 
networks meet the designation. It would also require the 
Secretary to submit an annual plan to Congress for addressing 
the problem of underserved facilities.
    Background. In accordance with P.L. 113-146, veterans are 
eligible to receive care within their community if their local 
VA facility cannot schedule an appointment within 30 days of 
the clinically indicated date. While this is one metric VHA 
uses to assess clinical capacity within individual VHA 
facilities, it does not comprehensively measure the extent to 
which those facilities are medically underserved. HHS' Health 
Resources and Services Administration uses geographic, 
population, and facility-based criteria to designate Health 
Professional Shortage Areas, which indicate provider shortages 
in primary care, dental health, or mental health.
    Section 231(a) would require the Secretary to develop 
criteria within 180 days to designate VAMCs, ambulatory care 
facilities, and community based outpatient clinics as 
underserved facilities.
    Section 231(b) lists the considerations the Secretary would 
need to take when developing criteria for designating 
facilities as underserved. Considerations include the ratio of 
veterans to health care providers in a geographic area; the 
range of clinical specialties covered; whether the local 
community is medically underserved; the type, number, and age 
of open consults; and whether the facility is meeting VA wait-
time goals.
    Section 231(c) would require VISN directors to annually 
perform an analysis to determine which facilities within the 
VISN qualify as underserved pursuant to the criteria developed 
under subsection (a).
    Section 231(d) would require the Secretary to submit a plan 
to Congress addressing the problem of underserved facilities. 
The plan would be required to address a number of topics, 
including increasing personnel or temporary personnel 
assistance; providing special hiring incentives, using direct 
hiring authority; and improving training opportunities.
    Committee Bill. In order to address a range of problems 
across VHA programs, it is critical for VISN and facility 
leadership to be aware of facilities that are in need of 
resources. The Committee expects VHA leaders to use the data 
required by this provision to better target resources to where 
the needs exist.

Sec. 232. Pilot program on tuition reimbursement and loan repayment for 
        health care providers of the Department of Veterans Affairs at 
        underserved facilities.

    Section 232 of the Committee bill, a freestanding original 
provision, would require the Secretary to create a pilot 
program to provide tuition reimbursement and loan repayment to 
medical students and health care providers in exchange for 
their commitment to working in underserved VHA facilities.
    Committee Bill. In order to address a range of problems 
across VHA programs, it is critical for VISN and facility 
leadership to be aware of facilities that are in need of 
resources. The Committee expects VHA leaders to use the data 
required by this provision to better target resources to where 
the needs exist.
    Background. VHA facilities with staff vacancies face 
challenges in providing timely health care to the veterans they 
serve. In addition, approximately 25 percent of all U.S. 
veterans reside in rural communities, where basic and 
preventative health care may not be available. In particular, 
these communities have fewer physicians, hospitals, and other 
health care delivery resources. The National Health Services 
Corps operates two programs--a scholarship program and a loan 
repayment program--to provide financial incentives to certain 
students and health care practitioners in exchange for 
commitment to work in underserved communities. While VA's EDRP 
aims to fill clinical positions that are difficult to recruit 
or retain by offering student loan reduction payments, it does 
not have a particular focus on addressing the recruitment and 
retention challenges that rural facilities face.
    Committee Bill. Section 232(a) would require the Secretary 
to commence a pilot program to assess the feasibility and 
advisability of providing tuition reimbursement and loan 
repayment to medical students and health care providers who 
commit to serving in underserved facilities within 90 days of 
enactment.
    Section 232(b) would set the duration of the pilot program 
at 6 years from the date of commencement.
    Section 232(c) would require the Secretary to select no 
fewer than three VAMCs and seven ambulatory care facilities or 
community based outpatient clinics located in at least eight 
different states to participate in the pilot program. No fewer 
than two of the VAMCs and five of the ambulatory care 
facilities or community based outpatient clinics would be 
located in states or United States territories that are among 
the ten states or territories with the highest percentage of 
land designated as highly rural by the Department of 
Agriculture or the highest percentage of enrolled veterans 
living in rural, highly rural, or insular island areas. 
Participating facilities would be required to be located in not 
fewer than eight states.
    Section 232(d) would designate half of the amount spent on 
the program to be for tuition reimbursement or loan repayment 
for individuals practicing in a general practice position. The 
other half would be for individuals practicing in a specialist 
position or in an occupation included in the most recent 
staffing shortage determination by the VA OIG.
    Section 232(e) would authorize the Secretary to provide an 
individual attending medical school with full tuition 
reimbursement in exchange for a 5-year commitment to serve at 
an underserved facility.
    Section 232(f) would authorize the Secretary to provide 
individuals who commit to serving 3 years at an underserved 
facility with up to $50,000 student loan repayment. Current VHA 
health care providers at underserved facilities may receive up 
to $30,000 student loan repayment. The Committee intends that 
this increased loan repayment authority be used to incentivize 
providers to work in underserved facilities at VA.
    Section 232(g) describes the procedure for the United 
States to recoup amounts provided to pilot participants who 
fail to satisfy the period of obligated service and would 
require that any individual who fails to fulfill the required 
period of obligated service be liable to the United States for 
any amount that has been paid on the individual's behalf, 
reduced by the proportion that the number of days served for 
completion of the period of obligated service bears to the 
total number of days in the period of obligated service of such 
individual.
    Section 232(h) would require the Secretary to ensure that 
hiring done under the pilot program is expedited.
    Section 232(i) would ensure continued program participation 
by pilot participants selected because they work in occupations 
included in the VA OIG staffing shortage determination, in 
cases where their occupations are no longer included in the 
determination.
    Section 232(j) would require the Secretary to submit to 
Congress annually a report on the pilot program. The report 
would be required to include the number of participants, the 
number of facilities where participants are located, the number 
of program applicants, and the five most common occupations of 
participants, other than general practice. The Committee 
expects that if the Secretary believes modifications should be 
made to improve the pilot program, that the Secretary recommend 
such changes in the annual report, if not sooner.
    Section 232(k) defines the terms ``enrolled veteran'' and 
``underserved facility.''
    Staff vacancies in rural and medically underserved areas 
continue to be a challenge VHA has not been able to address 
sufficiently. The Committee expects VHA to make a concerted 
effort to carry out the pilot program required in Section 232 
with open-mindedness about if and how such a program could be 
expanded nationwide.

Sec. 233. Program to furnish mobile deployment teams to underserved 
        facilities.

    Section 233 of the Committee, a freestanding original 
provision, bill would establish a program to provide mobile 
deployment teams of medical personnel to underserved 
facilities.
    Background. P.L. 113-146 was enacted in response to widely-
reported scheduling irregularities at VA. That legislation 
sought to relieve strain on the VA health care system by 
allowing some veterans to opt-in to community care. It also 
sought to bolster VA's internal capacity to provide care by 
providing increased funding for the hiring of medical 
professionals and authorizing clinic leases so that veterans 
could get care closer to home. Finally, it gave the Secretary 
improved tools for removing poor-performing employees. 
Subsequent legislation, such as the Accountability Act, further 
provided the Secretary with the tools necessary to hold 
employees accountable. While VA has made great progress in 
remediating problem areas in health care delivery and improving 
local facility management, challenges remain.
    Committee Bill. The Committee believes that mobile 
deployment teams, made up of a diversified group of personnel 
to address urgent and emergent challenges in VHA, would assist 
VA in addressing problem-areas quickly and succinctly. These 
teams could investigate, solve, recommend and carry-out actions 
to address problems at VA medical facilities.
    Section 233(a) would establish a program to furnish mobile 
deployment teams of medical personnel to underserved 
facilities. It is the Committee's intent that these mobile 
deployment teams assist VA facilities with urgent and emergent 
challenges that prevent or will prevent the furnishing of high-
quality and timely health care to veterans. For example, if a 
local facility is experiencing challenges scheduling consults, 
the Committee believes that a multi-disciplinary team 
dispatched to address consult challenges would help mitigate 
scheduling problems before patient care is affected. In this 
instance, team members might include: information technology 
personnel, training personnel, scheduling personnel, quality 
personnel, human resources personnel, and public affairs 
personnel to address veterans' concerns. It is the Committee's 
intent that the use of a mobile deployment team not be 
considered punitive, but rather a tool to supplement existing 
VA resources at any given facility. The Committee also believes 
that better communication between the Central Office of the 
Department, VISN and local facilities would assist in 
mitigating problems before they become a crisis.
    Section 233(b) would establish elements that the Secretary 
must consider when determining whether to furnish mobile 
deployment teams, including: the medical positions of greatest 
need at underserved facilities; the size and composition of 
teams to be deployed; and any other elements the Secretary 
considers necessary for effective oversight of the mobile 
deployment program.
    Section 233(c) would require the annual analysis conducted 
under section 231(c) of the Committee bill to form mobile 
deployment teams that are composed of the most needed medical 
personnel for underserved facilities.
    Section 233(d) would define ``underserved facility'' that 
meets the criteria established under Section 231 of the 
Committee bill.

Sec. 234. Inclusion of Vet Center employees in education debt reduction 
        program of Department of Veterans Affairs.

    Section 234 of the Committee bill, a freestanding original 
provision, would direct the Secretary to ensure clinical staff 
working at Vet Centers are eligible to participate in EDRP 
under chapter 76 of title 38, U.S.C.
    Background. Section 7682, title 38, U.S.C. establishes 
eligibility for EDRP. Employees must be serving in a direct-
patient care service or a service incident to a direct-patient 
care position for which retention or recruitment is difficult 
and the principal or interest balance on their loan must be for 
paying the costs related to a course of education or training 
related to that position.
    Committee Bill. Section 234(a) of the Committee bill would 
direct the Secretary to ensure that Vet Center employees are 
eligible for EDRP. Section 234(b) also directs the Secretary to 
submit a report to Congress on the number of participants in 
the program, who work at Vet Centers, no later than 1 year 
after the enactment of the bill. Section 234(c) would define 
the term ``Vet Center'' as having the same meaning of the term 
in section 1712A(h) of title 38, U.S.C. Vet Centers address a 
critical clinical need for veterans with a high risk for mental 
health issues. Therefore, the Committee believes this provision 
reflects that the same recruitment and retention tools should 
be made available and a priority for clinical staff at these 
facilities.

                  SUBTITLE C--CONSTRUCTION AND LEASES

Sec. 241. Definition of major medical facility project and major 
        medical facility lease.

    Section 241 of the Committee bill, an original provision, 
would amend section 8101 of title 38, U.S.C., to redefine the 
term ``medical facility'' and would amend section 8104 of title 
38, U.S.C., to redefine the terms ``major medical facility 
project'' and ``major medical facility lease.''
    Background. Section 8101(3) of title 38, U.S.C., defines 
``medical facility'' as ``any facility or part thereof which 
is, or will be, under the jurisdiction of the Secretary for the 
provision of health-care services (including hospital, nursing 
home, or domiciliary care or medical services), including any 
necessary building and auxiliary structure, garage, parking 
facility, mechanical equipment, trackage facilities leading 
thereto, abutting sidewalks, accommodations for attending 
personnel, and recreation facilities associated therewith.'' 
Section 8101(3) has never been amended.
    Section 8104(a)(3)(A) of title 38, U.S.C., defines ``major 
medical facility project'' as ``a project for the construction, 
alteration, or acquisition of a medical facility involving a 
total expenditure of more than $10,000,000.'' Section 
8104(a)(3)(A) was last amended in P.L. 109-461, the Veterans 
Benefits, Health Care, and Information Technology Act of 2006, 
when the limit was increased from $7 million to $10 million.
    Section 8104(a)(3)(B) of title 38, U.S.C., currently 
defines a ``major medical facility lease'' as a lease for space 
at an average annual rent of more than $1 million. Section 
8104(a)(3)(B) was last amended in P.L. 110-387, the Veterans' 
Mental Health and Other Care Improvements Act of 2008, when the 
annual rent amount was increased from $600,000 to $1 million.
    Committee Bill. Section 241(a) would amend section 8101(3) 
of title 38, U.S.C., to expand the term ``medical facility'' to 
include any facility or part thereof which is, or will be, 
under the jurisdiction of the Secretary, or as otherwise 
authorized by law, for the provision of health care services 
and includes an outpatient clinic under the definition.
    Section 241(b) would amend section 8104(a)(3)(A) of title 
38, U.S.C., to increase the limit above which a project is 
considered a major medical facility project requiring 
Congressional authorization from $10 million to $20 million. 
The definition would exclude an acquisition by exchange, non-
recurring maintenance projects, or a shared Federal medical 
facility for which VA's estimated share does not exceed $20 
million.
    Section 241(c) would amend section 8104(a)(3)(B) of title 
38, U.S.C., to define the term ``major medical facility lease'' 
to align with the rental value used by the General Services 
Administration under section 3307(a)(2) of title 40, U.S.C., 
and is subject to annual adjustment in accordance with section 
3307(h) of title 40, U.S.C. The FY 2017 General Services 
Administration annual prospectus threshold is $2,850,000,000.

Sec. 242. Facilitating sharing of medical facilities with other Federal 
        agencies.

    Section 242 of the Committee bill, an original provision, 
would create a new section 8111B of title 38, U.S.C., to 
authorize the Secretary to enter into agreements with other 
Federal agencies for planning, designing, constructing, or 
leasing shared medical facilities. It would authorize the 
Secretary to transfer to another Federal agency amounts 
appropriated for minor construction projects, major 
construction projects, and leased projects. Funds transferred 
to VA from other Federal agencies could be used for planning, 
designing, or constructing a shared medical facility for minor 
construction projects, major construction projects, and leased 
projects.
    Background. Established by section 583 of P.L. 108-136, 
National Defense Authorization Act for Fiscal Year 2004, the 
VA/DOD Joint Executive Committee (hereinafter, ``JEC'') 
recommends to the Secretaries of the Departments a strategic 
direction for the joint coordination and sharing efforts 
between and within the two Departments. The VA/DOD Construction 
Planning Committee established under the JEC provides a 
formalized structure to facilitate cooperation and 
collaboration for shared medical facilities that are mutually 
beneficial to both Departments. Even with this collaborative 
structure in place, VA and DOD continue to encounter challenges 
when attempting to plan and construct joint medical facility 
projects. Differing definitions and thresholds for construction 
project accounts and differing authorization and appropriations 
requirements for each Department create significant barriers to 
planning future joint medical facility projects.
    Committee Bill. Section 242(a) would amend subchapter I of 
chapter 81 of title 38, U.S.C., by creating a new section 
8111B. Section 8111B(a) authorizes the Secretary to enter into 
agreements with other Federal agencies for planning, designing, 
constructing, or leasing shared medical facilities with the 
goal of improving access to, and quality and cost effectiveness 
of, health care provided by VA and other Federal agencies. 
These facilities will be managed by the Under Secretary for 
Health.
    Section 8111B(b) would authorize the Secretary to transfer 
to another Federal agency amounts appropriated for minor 
construction projects, major construction projects, and leased 
projects.
    Section 8111B(c) would allow funds transferred to VA from 
other Federal agencies to be used for planning, designing, or 
constructing a shared medical facility for minor construction 
projects, major construction projects, and leased projects. 
Amounts transferred into VA will be available for the same time 
period as amounts in the account to which those amounts are 
transferred.
    Section 242(b) would provide a clerical amendment to the 
table of sections at the beginning of chapter 81 of title 38, 
U.S.C.
    The Committee understands the challenges inherent in joint 
medical facility projects and anticipates this new authority 
would lead to an increase in collaboration between DOD and VA 
on eligible physical infrastructure projects.

Sec. 243. Review of enhanced-use leases.

    Section 243 of the Committee bill, an original provision, 
would amend section 8162(b)(6) of title 38, U.S.C., to require 
the Office of Management and Budget (hereinafter, ``OMB'') to 
review each enhanced-use lease before the lease goes into 
effect to determine whether the lease is in compliance with 
section 8162(b)(5) of title 38, U.S.C.
    Background. Under section 8162(b)(6) of title 38, U.S.C., 
the Secretary is prohibited from entering into an enhanced-use 
lease without certification in advance in writing by the 
Director of OMB that such lease complies with the requirements 
of section 8162.
    Committee Bill. Section 243 would modify the OMB's role in 
enhanced-use leases executed by VA. OMB would review whether 
the lease is in compliance with enhanced-use lease regulations, 
not grant approval. The Committee expects this change will 
reduce the administrative burden of the previous certification 
requirement and decrease the time required to complete the OMB 
process.

Sec. 244. Authorization of certain major medical facility projects of 
        the Department of Veterans Affairs.

    Section 244 of the Committee bill, a freestanding original 
provision, would authorize not more than $117,300,000 for 
Phases III and V of the realignment of facilities in Livermore, 
California, and would require a detailed project proposal and 
accounting of current and future expenditures for the project.
    Background. In its FY 2018 budget submission, VA requested 
$117,300,000 for the construction of Phases III and V of the 
realignment and closure project in Livermore, California. Phase 
III is the construction of a new East Bay Community Based 
Outpatient Clinic in Fremont, California. The facility will be 
approximately 80,000 gross square feet and will include site 
enhancements such as parking, utilities, flood plain 
mitigation, and landscaping as appropriate. Phase V is the 
construction of an approximately 20,000 gross square feet 
Central Valley Engineering and Logistics Support Facility, 
which will be collocated with the Phase I community living 
center and Phase II Community Based Outpatient Clinic, and will 
include site enhancements such as parking, utilities, flood 
plain mitigation, and landscaping as appropriate. The overall 
project has been appropriated $55,430,000 in fiscal year 2010 
for design funds and $139,000,000 in FY 2016 for the Phase II 
Community Based Outpatient Clinic in New Central Valley, 
California.
    Committee Bill. Section 244(a) would authorize the 
construction of the new East Bay Community Based Outpatient 
Clinic and all associated site work, utilities, parking, and 
landscaping, construction of the Central Valley Engineering and 
Logistics support facility, and enhanced flood plain mitigation 
at the Central Valley and East Bay Community Based Outpatient 
Clinics as part of the realignment of medical facilities in 
Livermore, California, in an amount not to exceed $117,300,000.
    Section 244(b) would authorize the appropriation of 
$117,300,000 for FY 2018 or the year in which funds are 
appropriated for the Construction, Major Projects account, for 
the project authorized in section 244(a).
    Section 244(c) would require the Secretary to submit to the 
House and Senate Committees on Veterans' Affairs within 90 days 
a detailed project proposal, line item accounting of 
expenditures, any future obligations for the project, a 
justification for the expenditures, and any agreements with a 
non-VA Federal entity to provide construction services for the 
project.

                 SUBTITLE D--OTHER HEALTH CARE MATTERS

Sec. 251. Program on use of wellness programs as complementary approach 
        to mental health care for veterans and family members of 
        veterans.

    Section 251 of the Committee bill would, a freestanding 
original provision, provides VA with authority to provide 
grants to public and private nonprofit entities for the purpose 
of determining whether wellness programs will improve veterans' 
well-being and quality of life.
    Background. This section would require VA to carry out a 
program to assess the feasibility and advisability of using 
wellness programs to complement the provision of mental health 
care to certain veterans and family members of veterans. The 
section operationalizes this by creating a grant fund for 
public and private nonprofit entities to study the benefits of 
complementary wellness programs to better care for veterans and 
improve their well-being and quality of life. Veterans eligible 
to participate are those eligible for counseling under section 
1712A(a)(1)(c) of title 38, U.S.C. Under current law, VA's 
Readjustment Counseling Service does not have the ability to 
provide grants to public or private non-profit entities.
    Committee Bill. Section 251(a)(1) would provide authority 
to carry out a program to assess the feasibility and 
advisability of using wellness programs to complement the 
provision of mental health care to certain veterans and family 
members of veterans. Veterans eligible to participate are those 
eligible for counseling under section 1712A(a)(1)(c) of title 
38, U.S.C.
    Section 251(a)(2) bill would establish the matters that the 
program will assess. Specifically, the program would look at 
coordination between governmental and community providers in 
delivering mental health care to eligible veterans and family 
members; enhancing outreach and coordination of outreach by 
providers to eligible veterans and family members; use of 
wellness programs by providers complementary to mental health 
care from VA; whether such wellness programs are effective in 
enhancing the quality of life and well-being of veterans and 
family members; whether the wellness programs increase the 
adherence of eligible veterans to the primary mental health 
services they receive from VA; whether the wellness programs 
have an impact on the veterans' sense of well-being; and 
whether the wellness programs are effective in encouraging the 
veterans to adopt a more healthy lifestyle.
    Section 251(b) would establish that the Secretary shall 
carry out the program for 3 years beginning 1 year after the 
Committee bill is enacted. Section 251(c) would establish that 
the Secretary shall carry out the program at VA facilities 
providing mental health care to eligible veterans and family 
members.
    Section 251(d)(1) would establish that public or private 
nonprofit entities seeking grant awards shall do so by 
submitting an application to the Secretary as the Secretary 
sees fit.
    Section 251(d)(2) would describe what the grant proposal 
applications must contain.
    Section 251(d)(2)(A) would describe the plan to coordinate 
activities under the program between providers of services to 
veterans to enhance veteran care. Specifically, the plan would 
provide awareness of VA's benefits and health care services; 
outreach efforts to increase veterans' use of VA services; and 
educational efforts to inform veterans of the benefits of 
healthy and active lifestyle.
    Section 251(d)(2)(B) would require a statement of 
understanding that the entity will be required to report to the 
Secretary on data and performance measures necessary to 
evaluate individual outcomes and facilitate evaluations among 
entities participating. Section 251(d)(2)(C) would enable the 
Secretary to collect other information as required. Section 
251(e)(1) would require the entity awarded a grant to use the 
award for the purposes prescribed by the Secretary. Section 
251(e)(2) would require the entity awarded a grant to use the 
award only to furnish services to the individuals specified in 
section 1712A(a)(1)(c) of title 38, U.S.C. for such purposes as 
described in section 251(e)(1).
    Section 251(f) would require VA, not later than 180 days 
after the commencement of the program and every 180 days 
thereafter, to submit to Congress a report on the Secretary's 
findings and conclusions on the program for the 180 preceding 
days and an assessment of the benefits of the program for 
veterans and their family members during the 180 preceding 
days. Further, not later than 180 days after the end of the 
program, the Secretary shall submit to Congress a report 
detailing the Secretary's recommendations as to the 
advisability of continuing or expanding the program.
    Section 251(g) defines the term ``wellness'' as having the 
meaning as described by the Secretary in such regulations as 
the Secretary will promulgate.

Sec. 252. Authorization to provide for operations on live donors for 
        purposes of conducting transplant procedures for veterans.

    Section 252 of the Committee bill, which is derived from 
S. 115, would add a new section to Chapter 17 of title 38, 
U.S.C., to allow VA to provide transplant procedures with live 
donors at VA facilities or non-VA facilities regardless of 
whether the live donor is a veteran.
    Background. VA has been providing solid organ transplant 
procedures on veterans since 1962 and bone marrow transplant 
procedures since 1982. While transplant care and treatment is 
provided at 1,065 outpatient clinics and 170 VAMCs, 13 VAMCs 
are designated VA Transplant Centers. In limited circumstances, 
VA will provide treatment to non-veterans for emergency 
conditions or some VA facilities may treat dependents covered 
under the CHAMPVA Program. Under current law, VA cannot perform 
a transplant procedure on a live donor that is not a veteran 
because that person is not eligible for care or treatment at 
VA.
    Committee Bill. Section 252 would allow VA to provide 
transplant procedures with live donors at VA facilities or in 
the community. Specifically, section 252(a) would add a new 
section to chapter 17 of title 38, U.S.C., section 1788. 
Section 1788(a) would allow VA to provide transplant procedures 
to a veteran with a live donor if the donor is not a veteran or 
not otherwise eligible for health care in VA. Section 1788(b) 
would direct VA to provide the care and services to the donor 
required in connection with the transplant procedure. Section 
1788(c) would allow VA to provide the transplant procedures 
through a VA community care program and would deem the donor an 
individual eligible for VA's community care program for the 
purposes of the transplant procedure. Section 252(b) would make 
a clerical change to add section 1788 to the table of contents 
for chapter 17 of title 38, U.S.C.

Sec. 253. Sense of the Senate.

    Section 253, a freestanding original provision, would 
express the Senate's concern to preserve VHA's network of care, 
ensure it is effectively resourced, and oppose any efforts to 
privatize the system.
    Committee Bill. Section 253 would express the Senate's 
concern to preserve VHA's network of care, ensure it is 
effectively resourced, and oppose any efforts to privatize the 
system.

                      TITLE III--FAMILY CAREGIVERS

Sec. 301. Expansion of family caregiver program of Department of 
        Veterans Affairs

            Subsec. 301(a)(1). Expansion of family caregiver program of 
                    Department of Veterans Affairs.
    Section 301(a)(1) of the Committee bill, which is derived 
from S. 591, would expand eligibility for VA's Program of 
Comprehensive Assistance for Family Caregivers.
    Background. The Caregivers and Veterans Omnibus Health 
Services Act of 2010 was signed into law on May 5, 2010. It 
established the Program of General Caregiver Support Services 
and the Program of Comprehensive Assistance for Family 
Caregivers. The Program of Comprehensive Assistance for Family 
Caregivers (hereinafter, ``the Program'') provides additional 
support services to caregivers beyond what is provided through 
the Program of General Caregiver Support Services, including a 
monthly financial stipend, health care coverage through 
CHAMPVA, counseling and mental health services, respite care, 
and technical assistance. The Program is only available to 
veterans who have serious injuries (including traumatic brain 
injury, psychological trauma, or other mental disorder) 
incurred or aggravated in the line of duty in the active 
military, naval, or air service on or after September 11, 2001.
    In September 2014, GAO released a report on the Program 
titled ``Actions Needed to Address Higher-Than-Expected Demand 
for the Family Caregiver Program.'' The report noted, 
``Caregivers enable those for whom they are caring to live 
better quality lives and can contribute to faster 
rehabilitation and recovery.'' Supporting caregiving activities 
not only ensures equity of services and benefits available to 
the caregivers of our most seriously injured veterans, it may 
further enable veterans to remain at home rather than admitting 
them to a potentially more expensive institutional setting, 
such as a nursing home.
    Prior to the Program's implementation, VA initially 
estimated that 4,000 caregivers would be approved for the 
program; however, as of November 2, 2017, 21,990 caregivers had 
been approved. GAO's 2014 report on the Program made specific 
recommendations for improvement. Among its recommendations, GAO 
recommended that VA ``expedite the process for identifying and 
implementing an [IT] system that fully supports the program and 
will enable [VHA] program officials to comprehensively monitor 
the program's workload, including data on the status of 
applications, appeals, home visits, and the use of other 
support services, such as respite care.'' GAO also recommended 
that the VA Secretary direct the Under Secretary for Health 
``to use data from the IT system, once implemented, as well as 
other relevant data to formally reassess how key aspects of the 
program are structured and to identify and implement 
modifications as needed to ensure that the program is 
functioning as envisioned so that caregivers can receive the 
services they need in a timely manner.''
    Committee Bill. Section 301(a)(1) would amend section 1720G 
of title 38, U.S.C., to require VA to expand eligibility for 
the Program to all eras of veterans in two phases. The first 
phase of expanded eligibility would begin during the 2-year 
period beginning on the date on which the VA Secretary submits 
to Congress a certification that VA has fully implemented an IT 
system to support the Program. Section 301(a)(1)(B) of the 
Committee bill would require VA to submit the certification 
date in the Federal Register within 30 days to ensure public 
notification. The first phase includes veterans with a serious 
injury incurred or aggravated in the line of duty in the active 
military, naval, or air service on or before May 7, 1975. The 
second phase of eligibility would begin 2 years after the first 
phase. This includes those injured in the line of duty after 
May 7, 1975, and before September 11, 2001.
    The current eligibility criteria creates an inequity 
between post-9/11 veterans and pre-9/11 veterans. However, VA 
has encountered numerous challenges in implementing the 
program, and it is clear improvements are needed to ensure the 
program is meeting the needs of those currently enrolled and 
can sustain an increase in eligible veterans. The Committee 
bill ensures those improvements are made prior to expansion to 
pre-9/11 veterans and their caregivers.
    For example, the Program's expansion in two phases, as 
required by this section, is intended to ensure the Program 
does not get overwhelmed and continues to operate as intended, 
providing services in a timely manner, while enrolling those 
who have become newly eligible. The publication of the VA 
Secretary's certification date in the Federal Register is 
intended to ensure veterans are notified of the Program's 
impending expansion.
            Subsec. 301(a)(2). Expansion of needed services in 
                    eligibility criteria.
    Section 301(a)(2) of the Committee bill, which is derived 
from S. 591, would expand the Program's eligibility criteria 
for needed services.
    Background. Current law, section 1720G of title 38, U.S.C., 
provides that veterans eligible for the Program must be in need 
of personal care services because of an inability to perform 
one or more activities of daily living, a need for supervision 
or protection based on symptoms or residuals of neurological or 
other impairment or injury, or such other matters as the 
Secretary considers appropriate.
    Committee Bill. Section 301(a)(2) would amend subsection 
(a)(2)(C) of section 1720G of title 38, U.S.C., to include a 
need for regular or extensive instruction or supervision 
without which the ability of the veteran to function in daily 
life would be seriously impaired among the criteria considered 
for needed personal care services. It is the intent of the 
Committee to ensure the Program is consistently inclusive of 
the caregiving needs required by mental health conditions, 
traumatic brain injuries or other conditions with which 
eligible veterans may be diagnosed.
            Subsec. 301(a)(3). Expansion of services provided.
    Section 301(a)(3) of the Committee bill, which is derived 
from S. 591, would expand the services provided to caregivers 
under the Program to include legal and financial planning 
services.
    Background. In 2014, the RAND Corporation released a 
report, ``Hidden Heroes: America's Military Caregivers,'' which 
examined characteristics of military caregivers and services 
available to them. The report indicates that, of the military 
caregiver-specific programs identified by RAND, few provide 
long-term planning assistance, including legal and financial 
planning, for military caregivers.
    Committee Bill. Section 301(a)(3) would amend subsection 
(a)(3)(A)(ii) of section 1720G of title 38, U.S.C., to require 
VA to include financial planning services and legal services 
related to the needs of injured veterans and their caregivers 
as among the services provided to caregivers. The section makes 
clear that VA should provide these services through the use of 
contracts with or the provision of grants to public or private 
entities.
    While section 301(a)(3) would require that financial 
planning and legal services be offered to caregivers in the 
Program, it is the Committee's intent that VA and VA employees 
not provide these services, but instead partner with public or 
private entities. It is also the Committee's intent that, to 
the maximum extent practicable, VA should utilize partnerships 
that will provide the services pro bono.
            Subsec. 301(a)(4). Modification of stipend calculation.
    Section 301(a)(4) of the Committee bill, which is derived 
from S. 591, would expand the number of factors VA should 
consider when determining the amount and degree of personal 
care services provided for certain veterans.
    Background. Currently, there are three levels of caregiver 
stipends based on the amount and degree of personal care 
services provided. This was established pursuant to section 
1720G of title 38, U.S.C. According to current regulations, the 
stipend payment is based on the number of hours of caregiving 
required by the veteran. The maximum stipend is based on the 
requirement of 40 hours of caregiving each week, the median 
stipend is based on the requirement of 25 hours of caregiving 
each week, and the lowest stipend is based on the requirement 
of 10 hours of caregiving each week. In order to determine the 
degree of personal care services required by the veteran, VA 
evaluates the veteran and establishes a clinical rating based 
on specific criteria regarding the ability to perform 
activities of daily living and the need for supervision or 
protection based on symptoms or residuals of neurological or 
other impairment or injury.
    Committee Bill. Section 301(a)(4) would amend subsection 
(a)(3)(C) of section 1720G of title 38, U.S.C., to ensure VA is 
considering the assessment by the family caregiver of the needs 
and limitations of the veteran; the extent to which the veteran 
can function safely and independently in the absence of such 
supervision, protection, or instruction; and the amount of time 
required for the family caregiver to provide such supervision, 
protection, or instruction to the veteran when determining the 
amount and degree of personal care services provided for a 
veteran whose need for personal care services is based on a 
need for supervision or protection or regular instruction or 
supervision under subsection (a)(2)(C) of section 1720G of 
title 38, U.S.C.
    The Committee understands that these determinations are 
made at the VAMC level and the intent is to ensure consistency 
by VA in determining the amount of hours of caregiving required 
by the veteran.
            Subsec. 301(a)(5). Periodic evaluation of need for certain 
                    services.
    Section 301(a)(5) of the Committee bill, which is derived 
from S. 591, would require VA to periodically evaluate the 
needs of the veteran and the skills of the family caregiver to 
determine if additional instruction, preparation, training, or 
technical support is needed.
    Background. Under section 1720G of title 38, U.S.C., VA is 
required to provide instruction, preparation, and training for 
family caregivers to provide care to veterans, in addition to 
ongoing technical support to address routine, emergency, and 
specialized caregiving needs of the family caregiver.
    Committee Bill. Section 301(a)(5) would amend subsection 
(a)(3) of section 1720G of title 38, U.S.C., to require that, 
in providing instruction, preparation, and training under 
subparagraph (A)(i)(I) of that section and technical support 
under subparagraph (A)(i)(II) of that section to each approved 
family caregiver, the Secretary periodically evaluate the needs 
of the veteran and the skills of the family caregiver to 
determine if additional instruction, preparation, training, or 
technical support is necessary.
    The requirement for periodic evaluation of this support 
will ensure that caregivers have ongoing access to resources 
and support for their unique needs as they care for veterans, 
especially given that a veteran's needs and caregiving 
techniques and best practices may change over time.
            Subsec. 301(a)(6). Use of primary care teams.
    Section 301(a)(6) of the Committee bill, which is derived 
from S. 591, would require the VA Secretary to collaborate with 
the veteran's primary care team when evaluating applications 
for the Program, to the extent practicable.
    Background. Under subsection (a)(5) of section 1720G of 
title 38, U.S.C., when reviewing applications submitted jointly 
by the veteran and family caregiver, VA is required to evaluate 
the veteran to identify the personal care services required and 
to determine whether the requirements could be significantly or 
substantially satisfied through personal care services from a 
family member. The determination for a veteran's approval for 
the Program is a clinical decision; however, there is no 
statutory requirement that VA include the veteran's primary 
care team in the evaluation.
    Committee Bill. Section 301(a)(6) would amend subsection 
(a)(5) of section 1720G of title 38, U.S.C., to require that 
the Secretary evaluate each application submitted jointly by an 
eligible veteran and family member in collaboration with the 
veteran's primary care team to the maximum extent practicable.
    Though the veteran's primary care team maintains the 
veteran's treatment once in the Program, it is the intent of 
the Committee to ensure multidisciplinary input in the initial 
evaluation process, when possible.
            Subsec. 301(a)(7). Assistance for family caregivers.
    Section 301(a)(7) of the Committee bill, which is derived 
from S. 591, would authorize VA, in providing caregiver 
services required under current law, to partner with Federal 
agencies, States, and private, non-profit, and other entities 
to provide the assistance.
    Background. There are numerous public and private entities 
that provide caregiver services. According to VA's FY 2016 
annual report to Congress on assistance and support services 
for caregivers, VA has contracted and collaborated with non-
profit organizations to provide the family caregivers' core 
curriculum training and optional additional training 
opportunities. VA has also indicated that it works with respite 
care providers in communities to provide that service to 
veterans in the Program.
    Committee Bill. Section 301(a)(7) would amend subsection 
(a) of section 1720G of title 38, U.S.C., to authorize VA to 
enter into contracts, provider agreements, and memoranda of 
understanding with Federal agencies, States, and private, non-
profit, and other entities to provide family caregiver services 
required by section 1720G of title 38, U.S.C. The VA Secretary 
may provide assistance under this authority only if it is 
reasonably accessible to the family caregiver and is 
substantially equivalent or better in quality to similar 
services provided by VA. In addition, the Secretary could 
provide fair compensation to entities that provide assistance 
under this authority.
    The Committee recognizes that other entities provide 
services the Program is required to provide, including respite 
care, and that VA in some cases is already partnering with 
these other entities to provide services. It is the Committee's 
intent that, if appropriate in order to provide the services 
and they are equivalent or better in quality to similar 
services provided by VA, VA continues to utilize its authority 
to partner with entities. This could ensure availability of 
services and could reduce any duplication.
            Subsec. 301(b). Modification of definition of personal care 
                    services.
    Section 301(b) of the Committee bill, which is derived from 
S. 591, would modify the definition of personal care services.
    Background. Subsection (d)(4) of section 1720G of title 38, 
U.S.C., defines ``personal care services'' as services that 
provide the veteran assistance with one or more independent 
activities of daily living (subsection (d)(4)(A) of section 
1720G of title 38, U.S.C.) and any other non-institutional 
extended care (subsection (d)(4)(B) of section 1720G of title 
38, U.S.C.).
    Committee Bill. Section 301(b)(1) would strike 
``independent'' in subsection (d)(4)(A) of section 1720G of 
title 38, U.S.C., and amend subsection (d)(4) to include 
supervision or protection based on symptoms or residuals of 
neurological or other impairment or injury and regular or 
extensive instruction or supervision without which the ability 
of the veteran to function in daily life would be seriously 
impaired.
    This section is consistent with changes made by sections 
301(a)(2) and 301(a)(4) of the Committee bill, which recognize 
the need for regular or extensive instruction or supervision 
within the definition of personal care services and ensure the 
consideration of these personal care needs when determining the 
caregiver stipend.

Sec. 302. Implementation of information technology system of Department 
        of Veterans Affairs to assess and improve the family caregiver 
        program.

    Section 302 of the Committee bill, a freestanding provision 
derived from S. 591, would require VA to implement a new IT 
system and conduct ongoing monitoring and modifications after 
the system is implemented.
    Background. The requirement that VA implement a new IT 
system that can easily retrieve data that will allow all 
aspects of the Program to be assessed and comprehensively 
monitored, that can manage data, and that has the ability to 
integrate with other relevant VHA IT systems, is consistent 
with recommendations made by GAO in its September 2014 report. 
The report indicated that the IT system currently utilized, the 
Caregiver Application Tracker, was developed quickly due to 
time constraints on implementing the Program. VA initially 
expected the Program to be much smaller, and the Caregiver 
Application Tracker was not designed to manage a high volume of 
information. As a result, VA is not able to effectively monitor 
and assess the Program.
    Committee Bill. Section 302 would outline requirements for 
implementing an IT system. Section 302(a) of the Committee bill 
would require VA to implement an IT system that fully supports 
the Program and allows for data assessment and comprehensive 
monitoring of the Program not later than June 1, 2018. The IT 
system would also be required to include the ability to easily 
retrieve data that will allow for comprehensive monitoring of 
all aspects of the Program and workload trends, in addition to 
the ability to manage data with respect to a number of 
caregivers that is greater than the number of caregivers 
expected to apply for the Program, and the ability to integrate 
the system with other relevant VHA IT systems. These 
requirements are consistent with the GAO recommendations, and 
it is the Committee's understanding that the process for 
developing the new IT system to support the Program is already 
underway.
    Section 302(b) of the Committee bill would require VA to 
use the IT system to assess key aspects of the Program within 
180 days of implementation. Section 302(c) of the Committee 
bill would require VA to also use the IT system for ongoing 
monitoring and assessment, including data on the status of 
applications and the use by caregivers of support services such 
as respite care. In addition, VA would be required to identify 
and implement necessary modifications to ensure the Program is 
functioning as intended and providing veterans and caregivers 
with services in a timely manner. These requirements are also 
consistent with the recommendations made by GAO. In order for 
expansion of the Program to begin, the Secretary must certify 
to the Committee on Veterans' Affairs of the Senate and House 
of Representatives and the Comptroller General that the IT 
system has been implemented. Section 302(d)(3) of the Committee 
bill would require VA to submit the certification, along with a 
description of its implementation and utilization for program 
monitoring not later than June 1, 2019.
    Section 302(d)(1) of the Committee bill would require VA, 
within 90 days of enactment, to submit a report to the 
Committee on Veterans' Affairs of the Senate and House of 
Representatives and the Comptroller General, providing an 
update on the status of the planning, development, and 
deployment of the IT system. The section would also require 
that the report include an assessment of the needs of family 
caregivers and veterans who would be eligible for the Program, 
as expanded, as well as resources needed for their inclusion.
    The intent of this requirement is to ensure proper 
preparation for the expansion. The Committee expects to be kept 
up to date on the progress of the IT system implementation and 
deployment and be informed of any changes to the timeline. By 
including GAO as a recipient of the report, GAO will have the 
opportunity to review VA's progress in implementing its 
recommendations, as required by section 302(d)(2) of the 
Committee bill. The Committee understands that GAO's audit 
quality control processes require GAO to at least annually 
follow up on, track, and record the extent to which GAO's 
recommendations have been implemented. The Committee expects 
GAO to follow up on its recommendations for the Program more 
often than annually and to periodically inform the Committees 
on VA's implementation status until VA has taken the 
appropriate corrective actions to address GAO's findings and 
recommendations. The Committee also directs the Comptroller 
General to notify the Committee on Veterans' Affairs of the 
Senate and the House of Representatives once it has verified 
that the recommended actions have been implemented and, to the 
extent possible, that the desired outcomes are being achieved, 
within 45 days of that determination.

Sec. 303. Modifications to annual evaluation report on caregiver 
        program of Department of Veterans Affairs.

    Section 303 of the Committee bill, which is derived from 
S. 591, would amend requirements for VA's annual evaluation 
report on VA's caregiver programs.
    Background. P.L. 111-163, the Caregivers and Veterans 
Omnibus Health Services Act of 2010, requires VA to submit an 
annual report to the Committees on Veterans' Affairs of the 
Senate and House of Representatives. Currently, VA is required 
to report on both the Program of Comprehensive Assistance for 
Family Caregivers and the Program of General Caregiver Support 
and include information regarding the number of caregivers 
receiving assistance, the cost to VA to provide such 
assistance, a description of outcomes achieved by the program, 
an assessment of their effectiveness and efficiency, and 
recommendations for legislative or administrative action. For 
the Program of Comprehensive Assistance for Family Caregivers, 
VA is also required to report on outreach activities carried 
out, in addition to an assessment of the manner in which 
resources are expended.
    Committee Bill. Section 303 would amend subparagraph 
(A)(iv) of section 101(c)(2) of the Caregivers and Veterans 
Omnibus Health Services Act of 2010 to require that VA's annual 
evaluation report on the Program of Comprehensive Assistance 
for Family Caregivers and the Program of General Caregiver 
Support include a description of any barriers veterans or 
caregivers experience in accessing and receiving care and 
services. It would also amend subparagraph (B) of such section 
to require that the report on the Program of Comprehensive 
Assistance for Family Caregivers also include an evaluation of 
the sufficiency and consistency of the training provided to 
family caregivers. The additional information on barriers to 
care and services and the sufficiency and consistency of 
training will help further inform the Committee on the 
effectiveness of the Program and potential issues that may need 
to be addressed.

                  TITLE IV--APPROPRIATIONS OF AMOUNTS

Sec. 401. Appropriation of amounts for health care from Department of 
        Veterans Affairs.

    Section 401 of the Committee bill, a freestanding original 
provision, would provide $1 billion for the Secretary to 
administer EDRP, increase the number of GME residency 
positions, and allow for recruitment, retention and relocation 
incentives as authorized under section 221 of the Committee 
bill.
    Background. Section 801 of P.L. 113-146, authorized and 
appropriated $5 billion in funding to increase access to care 
at VA facilities and improve the physical infrastructure of VA 
facilities.
    Committee Bill. Section 401(a) would provide $1 billion in 
funding for the Secretary to administer EDRP, increase the 
number of graduate medical education residency positions, and 
implement section 221 of the Committee bill.
    Section 401(b) would provide that the funds would be 
available without fiscal year limitation. Section 401(c) would 
direct that the funds be used to increase the number of 
graduate medical education residency positions, and allow for 
recruitment, retention and relocation incentives as authorized 
under section 221 of the Committee bill. Section 401(d) would 
direct that the Secretary provide the appropriate committees of 
Congress with a funding plan describing how the Secretary would 
intend to use the amounts appropriated in subsection 401(a). 
Section 401(e) would make explicit that the funds provided in 
subsection 401(a) are to supplement and not supplant other 
funding provided to EDRP. Section 401(f) would direct the 
Secretary to provide the appropriate committees of Congress 
with a report describing how the Secretary has obligated the 
amounts appropriated in subsection 401(a) as of the date of the 
submission of the report. Section 401(g) would define the 
appropriate committees of Congress.

Sec. 402. Appropriation of Amounts for the Veterans Choice Program.

    Section 402 of the Committee bill, a freestanding original 
provision, would provide an additional $4 billion for the 
Veterans Choice Program.
    Background. Section 101 of P.L. 113-146 authorized veterans 
to receive care in the community if they would wait more than 
30 days for care in a VA facility or lived more than 40 miles 
from a VA facility. However, funding for care provided under 
the Veterans Choice Program was tied to $10 billion in funding 
provided in the Veterans Choice Fund as created by section 802 
of P.L. 113-146. In July 2017, when VA indicated that the funds 
for Veterans Choice Program were close to being depleted, 
Congress provided an additional $2.1 billion in funding for the 
Veterans Choice Program. In December 2017, after VA indicated 
funds for the Veterans Choice Program would be depleted in 
January 2018, Congress appropriated an additional $2.1 billion.
    Committee Bill. Section 402(a) would provide an additional 
$4 billion in funding for the Veterans Choice Program. Section 
402(b) would direct that the funds would be available until 
expended or the date specified in section 802(c)(4), December 
31, 2018, as amended by section 142 of the Committee bill.

                      Committee Bill Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee, based on 
information supplied by the Congressional Budget Office 
(hereinafter, ``CBO''), estimates that enactment of the 
Committee bill would, relative to current law, increase 
discretionary spending by $43.3 billion over 5 years and 
increase mandatory spending by $5.6 billion over 10 years. 
Enactment of the Committee bill would impose a governmental 
mandate, as defined by the Unfunded Mandates Reform Act, that 
would limit the application of State laws but would not result 
in additional spending or any significant loss in revenue.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                               Congressional Budget Office,
                                  Washington, DC, January 17, 2018.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 2193, the Caring for 
Our Veterans Act of 2017.
    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.

S. 2193--Caring for Our Veterans Act of 2017

    Summary: S. 2193 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 make changes to VA's 
health care programs and compensation of employees, including 
expanding the caregivers program, increasing pay for employees, 
and reimbursing medical staff for professional training. In 
total, CBO estimates that implementing the bill would cost 
$43.3 billion over the 2018-2022 period, assuming appropriation 
of the necessary amounts.
    In addition, S. 2193 would directly appropriate $4 billion 
for the Veterans Choice Program (VCP) and $1 billion to provide 
educational assistance for health professionals at VA. The bill 
also would expand VA's authority to enter into leases for 
medical facilities. In total, CBO estimates that enacting the 
bill would increase direct spending by $5.6 billion over the 
2018-2027 period.
    Pay-as-you-go procedures apply because enacting S. 2193 
would affect direct spending. Enacting the bill would not 
affect revenues.
    CBO estimates that enacting S. 2193 would not increase net 
direct spending or on-budget deficits by more than $2.5 billion 
in any of the four consecutive 10-year periods beginning in 
2028.
    S. 2193 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, 
the bill 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 S. 2193 are shown in Table 1. The costs of 
this legislation fall within budget function 700 (veterans 
benefits and services).

                                Table 1.--Estimated Budgetary Effects of S.2193,  The Caring for Our Veterans Act of 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                      By fiscal year, in millions of dollars--
                                                           ---------------------------------------------------------------------------------------------
                                                             2018    2019    2020     2021     2022   2023  2024  2025  2026  2027  2018-2022  2018-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                     INCREASES IN SPENDING SUBJECT TO APPROPRIATION
Estimated Authorization Level.............................     811   7,300   9,880   12,966   15,642   N/A   N/A   N/A   N/A   N/A    46,599        N/A
Estimated Outlays.........................................     638   6,342   9,213   12,249   14,895   N/A   N/A   N/A   N/A   N/A    43,337        N/A
 
                                                              INCREASES IN DIRECT SPENDING
Estimated Budget Authority................................   5,000       0       0      140      140   140   140   140   140   140     5,280      5,980
Estimated Outlays.........................................     558   3,599     145      169      197   247   284   118   132   132     4,668      5,581
--------------------------------------------------------------------------------------------------------------------------------------------------------
N/A = not applicable.

    Basis of estimate: For this estimate, CBO assumes that the 
bill will be enacted near the beginning of 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.

Spending subject to appropriation

    CBO estimates that implementing S. 2193 would cost $43.3 
billion over the 2018-2022 period, subject to appropriation of 
the necessary amounts (see Table 2). Most of the bill's 
estimated costs stem from provisions that would expand 
community health care for veterans, increase eligibility and 
benefits for caregivers, and increase pay for medical staff.
    Veterans Community Care Program. Section 101 would 
establish the Veterans Community Care Program (VCCP) under 
which VA would be required to enter into contracts to 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.

 Table 2.--Estimate of the Effects on Spending Subject to Appropriation of S.2193,  The Caring for Our Veterans
                                                   Act of 2017
----------------------------------------------------------------------------------------------------------------
                                                                    By fiscal year, in millions of dollars--
                                                              --------------------------------------------------
                                                               2018   2019    2020     2021     2022   2018-2022
----------------------------------------------------------------------------------------------------------------
                                 INCREASES IN SPENDING SUBJECT TO APPROPRIATION
 
Veterans Community Care Program
    Estimated Authorization Level............................   200   1,900   3,800    5,600    7,000    18,500
    Estimated Outlays........................................   200   1,700   3,500    5,300    6,600    17,300
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
Expansion of Family Caregivers Program
    Estimated Authorization Level............................    11      12     341    1,069    1,968     3,401
    Estimated Outlays........................................    10      11     298      962    1,815     3,096
Pay Caps for Nurses
    Estimated Authorization Level............................   400     480     580      680      790     2,930
    Estimated Outlays........................................   350     460     550      650      760     2,770
Walk-In Clinics
    Estimated Authorization Level............................     *      82     170      333      438     1,023
    Estimated Outlays........................................     *      71     156      306      414       947
Agreements for State Veterans Homes
    Estimated Authorization Level............................     0      80     110      130      160       480
    Estimated Outlays........................................     0      70     100      130      150       450
Prompt Payment to Providers
    Estimated Authorization Level............................     3      55      68       89      111       326
    Estimated Outlays........................................     3      48      64       84      106       305
Shared Medical Facilities
    Estimated Authorization Level............................   100     100     100      107      107       514
    Estimated Outlays........................................     4      19      49       75       91       238
Staffing Vacant Medical Positions
    Estimated Authorization Level............................    15      59      54       56       58       242
    Estimated Outlays........................................    13      53      53       54       57       230
Reimbursement for Education of Nurses
    Estimated Authorization Level............................    34      34      34       34       34       170
    Estimated Outlays........................................    30      33      33       33       33       162
Transplant Donors
    Estimated Authorization Level............................     2      17      35       47       49       150
    Estimated Outlays........................................     2      15      32       44       47       140
Compensation for Medical Directors
    Estimated Authorization Level............................     0      16      21       26       29        92
    Estimated Outlays........................................     0      14      20       25       28        87
Modify Threshold for Major Medical Facilities
    Estimated Authorization Level............................    16      16      16       36       36       120
    Estimated Outlays........................................     1       3       8       28       32        72
Mobile Deployment Teams
    Estimated Authorization Level............................     6      10      15       20       26        77
    Estimated Outlays........................................     5       9      14       19       25        72
Podiatrists
    Estimated Authorization Level............................     9      10      10       12       13        54
    Estimated Outlays........................................     8      10      10       12       13        53
Peer Specialist Program
    Estimated Authorization Level............................     4       9       9       10       10        42
    Estimated Outlays........................................     3       8       9       10       10        40
Demonstration Program on Dental Care
    Estimated Authorization Level............................     4       5       5        5        6        25
    Estimated Outlays........................................     3       5       5        5        6        24
Pilot Program for Tuition Reimbursement
    Estimated Authorization Level............................     4       4       4        5        5        22
    Estimated Outlays........................................     3       4       4        5        5        21
Coordinated-Care Program
    Estimated Authorization Level............................     0       5       5        5        0        15
    Estimated Outlays........................................     0       4       5        5        1        15
Pay for Perfusionists
    Estimated Authorization Level............................     1       1       1        1        1         5
    Estimated Outlays........................................     1       1       1        1        1         5
Studies, Reports, and Training
    Estimated Authorization Level............................     2       5       2        1        1        11
    Estimated Outlays........................................     2       4       2        1        1        10
                                                              --------------------------------------------------
    Total Changes in Spending Subject to Appropriation
        Estimated Authorization..............................   811   7,300   9,880   12,966   15,642    46,599
        Estimated Outlays....................................   638   6,342   9,213   12,249   14,895    43,337
----------------------------------------------------------------------------------------------------------------
* = less than $500,000.

    Under this program, subject to appropriations, VA would be 
required to provide care through those networks, at the 
veteran's discretion, in the following situations:

     VA does not offer the care needed,
     The veteran resides in New Hampshire, or
     The veteran, as of the day before enactment, lives 
40 miles away from a VA medical facility.

    VA also would be required to provide such community care if 
the veteran's primary care provider and the veteran agree it is 
in the best medical interest of the veteran to do so, based on 
criteria to be developed by VA that consider the nature and 
frequency of the needed care and how accessible that care is to 
the veteran. In addition, VA would be authorized to offer 
community care if it determines that a VA medical center is not 
meeting the standards for timeliness and quality that would be 
developed by the department for different types of care. 
Section 101 would require VA to promulgate regulations to 
implement the program within 1 year.
    The VCCP would replace an existing program that authorizes 
VA to provide community care to veterans with service-connected 
disabilities (SCDs) when VA does not offer the needed care or 
when that care is geographically inaccessible to the veteran 
and to women veterans who need hospital care. Under its 
existing program, VA currently spends roughly $9 billion a year 
for community care (excluding emergency care). CBO expects the 
VCCP could cost several times more than the existing program 
although several factors would limit the rate and ultimate 
extent of cost growth. Cost would be higher because:

     VA would be required, subject to appropriations, 
rather than authorized to provide community care,
     The number of eligible veterans would be several 
times larger than the number eligible for the current program,
     The criteria for offering community care would be 
broader, and
     The convenience of community care could encourage 
more veterans to enroll in the VA health care system.

    However, CBO expects these factors would limit the rate and 
ultimate extent of cost growth:

     A greater number of enrolled veterans receiving 
community care could shorten wait times for care provided in VA 
facilities, and thus reduce the number of veterans that need to 
be referred to community care because VA care is not available 
in a timely fashion.
     Many of the regulations that need to be written to 
implement the program could curtail use. For instance, VA would 
probably require all veterans to be seen by a VA caregiver 
before being referred for community care.
     The community care networks could be limited in 
size and scope, particularly in more rural areas, reducing the 
accessibility of such care.
     VA might implement the program slowly, as happened 
with the VCP.

    To estimate the cost of this program over the next 5 years, 
CBO focused primarily on the extent to which the number of 
veterans eligible for VCCP would be larger than those eligible 
for the existing community care program. The currently eligible 
population--veterans with SCDs and women veterans needing 
hospital care--represents about 30 percent of enrolled 
veterans. Under VCCP, the eligible population would more than 
triple because all enrolled veterans would be eligible.
    After accounting for the factors that might restrict use, 
CBO estimates that in the early years of the program, the newly 
eligible population would use community care at about half the 
rate of veterans in the current community care program. In 
addition, CBO expects that the program would be implemented 
gradually. On that basis, CBO estimates that implementing 
section 101 would cost $17.3 billion over the 2018-2022 period.
    Veterans Care Agreements. Section 102 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. Such agreements would:

     Exempt VA from using the competitive bidding 
procedures as required under the FAR,
     Require VA to verify that those community 
providers meet the conditions for certification, and
     Require VA to periodically review the necessity of 
the agreements.

    Under current law, VA must comply with the FAR for 
agreements and contracts with community health care and 
extended-care providers. The FAR is an extensive and complex 
set of rules governing the federal government's purchasing 
processes. 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. This bill 
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 
102 would give VA the legal authority to continue to provide 
about 40 percent (or $4 billion annually) of that community 
health care. After adjusting for inflation and accounting for 
existing appropriations, CBO estimates that implementing this 
section would cost $17.3 billion over the 2018-2022 period.
    Expansion of the Family Caregivers Program. Section 301 
would expand access to the Family Caregivers Program, which 
provides stipends, health insurance, respite care, training, 
and other forms of support to caregivers of eligible veterans 
enrolled in the program. Veterans are eligible for the program 
if they require assistance in activities of daily living, such 
as bathing, eating, or grooming, as a result of injuries 
incurred during military service on or after September 11, 
2001. Section 301 would open that program in two stages to 
eligible veterans of any era and would expand its benefits to 
include legal and financial-planning services. In total, CBO 
estimates that implementing section 301 would cost $3.1 billion 
over the 2018-2022 period.
    Under stage one, eligible veterans who were injured during 
service on or before May 7, 1975, could enter the Family 
Caregivers Program. That stage would begin within 2 years of 
enactment (after VA develops and certifies a new information 
technology [IT] system to track benefits, as required under 
section 302). Stage two would begin 2 years after stage one and 
would open the program to the remaining eligible veterans--
those injured during service after May 7, 1975, and before 
September 11, 2001. For the purposes of this estimate, CBO 
assumes that the bill will be enacted near the beginning of 
calendar year 2018, that stage one of the proposal will begin 
early in 2020, and that stage two will begin early in 2022.
    In 2016, costs for the Family Caregivers Program totaled 
$493 million, about $19,000 per participating veteran. Most of 
that cost resulted from monthly stipends paid to caregivers. 
Stipends are based on the hours of daily care the veteran 
requires and the prevailing wage for home health aides. In 
2016, the annual stipends paid under the program ranged from 
$7,800 to $30,000 and averaged roughly $20,000. Caregivers also 
are eligible to participate in the Civilian Health and Medical 
Program of the Department of Veterans Affairs (CHAMPVA), a 
program run by VA that provides health insurance for dependents 
and survivors of certain disabled veterans. In addition, the 
Family Caregivers Program provides up to 30 days of respite 
care each year as well as training and 15 other support 
services. In 2016, costs under the Family Caregivers Program 
for CHAMPVA and the remaining services averaged about $2,600 
per veteran.
    CBO's estimate of the cost of expanding the caregivers 
program is based on the patterns of use and the average costs 
of the existing program and the number of veterans with 
significant, service-connected disabilities in the cohorts that 
would be newly eligible. Furthermore, to account for the 
advanced age of the newly eligible veterans, the estimate 
reflects the following findings from a 2014 RAND study:\1\
---------------------------------------------------------------------------
    \1\Rajeev Ramchand and others, Hidden Heroes: America's Military 
Caregivers (RAND Corporation, 2014), www.rand.org/pubs/
research_reports/RR499.html.

     Disabled veterans rely more heavily on assistance 
for daily activities as they age,
     Older veterans tend to rely on older caregivers, 
and
     Health care costs for caregivers increase with 
age.

    For stage one, CBO estimates that about 22,000 additional 
veterans would participate in the program in 2020, increasing 
to roughly 46,000 by 2022. CBO expects that the youngest would 
be in their late 60s. After factoring in a heavier reliance on 
caregiver assistance for activities of daily living and higher 
health care costs for an older group of caregivers, CBO 
estimates that the average cost per participant in 2020 would 
be about $30,500. However, VA already provides respite care to 
assist some caregivers through its General Caregiver Program, 
which provides limited support services to caregivers of 
eligible veterans from all eras. Accounting for those current 
benefits in the estimate reduces the average added cost per 
participant to $30,000. After accounting for gradual 
implementation and incorporating annual inflation, CBO 
estimates that stage one of the proposal would cost $2.6 
billion over the 2020-2022 period.
    For stage two, CBO estimates that about 30,000 additional 
veterans would use the Family Caregivers Program in 2022. 
Because those veterans would be younger than the group under 
the initial expansion, they would have less need for caregiver 
assistance (with a correspondingly lower stipend amount) and 
the caregivers would be younger (and have lower CHAMPVA costs). 
After accounting for existing benefits under the General 
Caregiver Program, the average incremental cost per participant 
in 2022 would be $29,000, about 12 percent lower than the cost 
for participants under stage one in that year. After factoring 
in a gradual implementation for the second stage of expansion 
and incorporating annual inflation, CBO estimates that the 
additional costs for stage two of the Family Caregivers Program 
would be $417 million in 2022. Those costs would rise to 
billions of dollars a year by the end of the 10-year window, 
CBO estimates.
    In addition, CBO estimates that roughly 30,000 caregivers 
in the current Family Caregivers Program (for veterans injured 
during service on or after September 11, 2001) would receive 
legal and financial support services. On the basis of the 
resources necessary to provide counseling under the existing 
program, CBO estimates an average annual cost of $130 per 
beneficiary for legal and financial services. CBO estimates a 
cost of $15 million over the 2018-2022 period to provide those 
benefits to individuals eligible for the Family Caregivers 
Program under current law. The costs of providing that 
additional benefit for newly eligible enrollees in the Family 
Caregivers Program under this provision are included in the 
estimates above for adding those people to the program.
    Furthermore, in anticipation of the surge of new 
applications upon expansion of the Family Caregivers Program, 
VA would need to hire and train additional staff to manage the 
program (to staff a caregiver support line, provide outreach, 
and monitor the program). On the basis of program data from 
2014 and adjusting for inflation, CBO estimates overhead costs 
of about $400 per participant to process 22,000 new 
applications starting in 2020. As a result, CBO estimates the 
additional overhead costs would be $17 million over the 2018-
2022 period.
    Pay Caps for Nurses. Section 224 would increase the maximum 
rate of pay for registered nurses at VA to executive level III 
($172,100 in 2017) from the current maximum of executive level 
IV ($161,900 in 2017)--an increase of 6.3 percent. VA employs 
roughly 68,000 registered nurses. CBO expects that such a 
change would result in average pay for registered nurses 
increasing by that same percentage, from $89,000 to $94,600 in 
2017. In addition, the higher pay level could help ameliorate 
VA's current difficulties in recruiting and retaining 
registered nurses and would thus increase the total number of 
nurses employed by VA. Using data from VA on hiring and 
retaining nurses, CBO estimates that, under section 224, VA 
would employ roughly 71,000 registered nurses by 2022 (or a 4 
percent increase above current staffing). On that basis, CBO 
estimates that implementing section 224 would cost $2.8 billion 
over the 2018-2022 period for increased compensation for 
registered nurses.
    Section 224 also would increase the maximum rate of pay for 
nurse executives at VA to executive level I ($207,800 in 2017) 
from the current maximum of executive level IV ($161,900 in 
2017)--an increase of 28 percent. VA employs about 160 nurse 
executives at average salaries of $136,995. CBO expects that VA 
would gradually increase the salaries of the nurse executives 
to reach a 28 percent increase, on average, by 2022. As a 
result, CBO estimates that increasing the cap for nurse 
executives would cost $16 million over the 2018-2022 period. In 
total, CBO estimates that implementing section 224 would cost 
$2.8 billion over the 2018-2022 period.
    Walk-In Clinics. Within a year of enactment, section 105 
would require VA to provide access to walk-in clinics operated 
by non-VA entities for veterans actively using the VA health 
care system. For their first two visits to a private clinic in 
any year, veterans' copayments would be limited to the amount, 
if any, required at VA facilities, as determined by the 
department. For subsequent visits, the veterans would be 
required to make copayments in an amount set by the department.
    Using information from VA, CBO estimates that the 
department would reimburse about 2.7 million claims for visits 
to walk-in clinics each year, at an average of $200 per visit. 
After adjusting for time to prepare the regulations and a 
gradual implementation, CBO estimates that implementing section 
105 would cost $947 million over the 2018-2022 period.
    Agreements for State Veterans Homes. Section 103 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. VA pays SVHs the full 
cost of care for veterans with an SCD rating of 70 percent or 
more, under a contract or agreement. For all other veterans, VA 
pays SVHs a grant based on 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 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 nearly triple VA's 
reimbursements to SVHs for veterans with SCDs of 70 percent or 
more.
    As a result, after factoring in a gradual phase out of 
existing non-FAR agreements, CBO estimates that enacting this 
provision would cost $450 million over the 2018-2022 period. 
The additional costs from waiving the FAR requirements would 
begin in 2019. Because appropriations have already been 
provided for such agreements in 2018, we estimate no additional 
funding would be necessary in that year.
    Prompt Payment to Providers. Section 111 would establish 
standards for prompt payment of claims for reimbursement for 
health care provided to veterans in the community, and it would 
require VA to enter into a contract or agreement with a 
nondepartment entity to process those claims. In total, CBO 
estimates, implementing this section would cost $305 million 
over the 2018-2022 period.
    Expedited Processing of Claims. Currently, department 
standards require VA to process 90 percent of claims for 
reimbursement of non-VA health care within 30 days. However, VA 
has been unable to meet such standards. Under section 111, VA 
would be required to reimburse non-VA providers within 30 to 45 
days of receiving a completed claim form. On the basis of a 
report by the Government Accountability Office and information 
from VA, CBO estimates that the department would need 340 
additional claims processors at an average annual compensation 
of $51,000 to meet the expedited time frame for reimbursing 
existing non-VA health care. After factoring in the period for 
VA to prepare regulations in 2018, CBO estimates that 
expediting the processing of claims for such health care would 
cost $62 million over the 2018-2022 period.
    Contracted Claims Processors. Section 111 also would 
require VA to outsource the processing of claims for non-VA 
health care. Currently, VA employs about 2,000 claims 
processors for that purpose at an average compensation of 
$51,000. CBO expects that the costs for using contractors 
rather than VA employees would be the same; therefore, no 
additional costs are estimated for replacing existing VA claims 
processors with contractors.
    Upon entering into contracts for claims processors, CBO 
expects that VA would offer current existing claims processors 
the following options:

     Accept placement in another vacant local position 
at VA,
     Relocate to a position that already exists in 
another VA location, or
     Voluntarily separate from VA employment.

    CBO estimates that placing one-third (or about 600) of the 
claims processors in other local positions would present 
minimal costs for administrative duties to select and train the 
staff. CBO expects that the other two-thirds (about 1,100 
claims processors) would relocate or voluntarily end their 
employment at VA. Using information from VA, CBO estimates that 
the average cost for relocation or incentive payments for 
voluntary separation would be $20,000 per employee. As a 
result, CBO estimates that relocating or ending employment for 
VA claims processors would cost $24 million over the 2019-2020 
period.
    Processing New Claims. In order to handle the additional 
claims of the VCCP established under section 101 of the 
legislation, CBO estimates that VA would gradually expand the 
contract discussed above to account for the more than doubling 
of non-VA health care. By 2022, an additional 2,230 processors 
would be needed at an average annual compensation of $51,000. 
After factoring in a gradual implementation of the program, 
adding those claims processors would cost about $220 million 
over the 2018-2022 period.
    Shared Medical Facilities. Section 242 would allow VA to 
enter into agreements with other federal departments to 
construct shared medical facilities.
    Implementing this section could reduce VA's share of the 
cost of some construction projects and some projects would no 
longer require legislative authorization. Using information 
from VA, CBO estimates that the total cost for such major 
construction projects would average about $100 million each 
year. On that basis, CBO estimates costs of $225 million over 
the 2018-2022 period for additional construction projects.
    Section 242 also would expand VA's authority to enter into 
leases for medical facilities. CBO estimates that VA would 
enter into one additional lease each year, with a total annual 
rent payment of $3 million. For those leases, VA would record 
obligations of $7 million each year as it enters those 
contracts at a cost of $13 million over the 2021-2022 period 
for additional leases. Entering into those leases also would 
increase direct spending; which is discussed below under the 
heading ``Direct Spending.''
    In total, CBO estimates section 242 would cost $238 million 
over the 2018-2022 period.
    Staffing Vacant Medical Positions. Within 180 days of 
enactment, section 206 would require VA to identify and fill 
vacant positions in the areas of mental health care (such as 
psychologists, psychiatrists, and additional therapists and 
counselors) and staff on Patient Aligned Care Teams or PACTs 
(such as mental health professionals and primary care 
physicians). PACTs use a team-based model of care to address 
the comprehensive needs of patients receiving health care at VA 
medical centers.
    VA has advertised vacant positions for mental health 
professionals and primary care physicians. CBO estimates about 
130 vacant positions for mental health professionals and 130 
positions for primary care physicians in PACTs would be filled 
under this section. Using information from VA, CBO expects an 
average compensation of $120,000 for a mental health care 
provider and $220,000 for a primary care physician in 2018. VA 
would probably need to offer special recruitment incentives 
(such as hiring bonuses) to meet the hiring deadline under this 
proposal. Under current law, VA offers up to 25 percent of the 
rate of basic pay as a recruitment bonus. Such onetime bonuses 
would amount to roughly $23,000 for mental health providers and 
$43,000 for physicians. After accounting for the expected 
growth in wages, CBO estimates that implementing this section 
would cost $230 million over the 2018-2022 period.
    Reimbursement for Education of Nurses. Section 213 would 
require VA to reimburse nurses for up to $1,000 of the cost of 
continuing professional education. Under current law, VA is 
only required to reimburse physicians and dentists for such 
costs. However, the department currently reimburses registered 
nurses an average of $500 per year. VA employs roughly 68,000 
registered nurses. CBO estimates that this provision would 
increase reimbursement for continuing professional education by 
$500 per nurse, on average. As a result, CBO estimates that 
implementing this section would cost $162 million over the 
2018-2022 period.
    Transplant Donors. Section 252 would allow VA to cover 
costs related to organ transplant procedures for veterans and 
their living donors 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). For procedures that take place at 
nondepartment facilities, VA reimburses donors only for 
transportation and lodging. In 2017, VA provided 560 organ 
transplants, most of which occurred at VATCs. Of those 
operations, about 200 were for kidney transplants and about 20 
were with living donors.
    Section 252 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 (HHS), CBO estimates 
that under this section 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 costs for transportation reimbursements of about 
$4 million each year. Based on the expectation that VA would 
implement the bill gradually, CBO estimates that implementing 
section 252 would have a net cost of $140 million over the 
2018-2022 period.
    Compensation for Medical Directors. Section 205 would 
remove the cap on basic pay for directors of regional and 
medical facilities at the department. Under current law, the 
salary for those positions is capped at level V of the 
executive schedule. CBO expects that this section would allow 
VA to offer competitive pay (based on compensation in the 
private market) for those positions. VA employs about 130 
directors at an average compensation amount of $282,000 in 
2017. On average, compensation for medical directors in the 
private sector is about $320,000. As a result of the increase 
in salary, CBO estimates that VA would be able to fully staff 
the 140 medical director positions by 2021. After factoring in 
a 1-year delay and additional hiring, CBO estimates that 
implementing this provision would cost $87 million over the 
2018-2022 period.
    Modify Threshold for Major Medical Facilities. Section 241 
would expand the authority of VA to construct and lease medical 
facilities.
    Section 241 would allow VA to construct medical facilities 
with total costs of up to $20 million without legislative 
authorization. Under current law, VA must receive legislative 
authorization to construct medical facilities with total 
expenses above $10 million.
    Using information on planned construction projects in VA's 
2018 budget submission, CBO estimates that implementing this 
section would authorize one additional construction project 
each year with an average cost of $16 million. On that basis, 
CBO estimates costs of $36 million over the 2018-2022 period 
for construction of new facilities.
    In addition, this section would expand VA's authority to 
enter into leases for medical facilities. CBO estimates that VA 
would enter into six additional leases each year with a total 
annual rent payment of $7 million. In that case, VA would 
record obligations of $20 million each year as it enters those 
contracts at a cost of $36 million over the 2021-2022 period 
for additional leases. CBO estimates that this authority also 
would increase direct spending, which is discussed below under 
the heading ``Direct Spending.''
    In total, CBO estimates implementing section 241 would cost 
$72 million over the 2018-2022 period.
    Mobile Deployment Teams. Section 233 would require VA to 
establish a program to provide mobile deployment teams of 
medical personnel to provide health care at underserved VA 
facilities. On the basis of costs in the private-sector to 
operate mobile clinics, CBO estimates start-up costs of 
$300,000 per team and annual costs to operate each mobile 
clinic of $375,000. In addition, CBO estimates a medical team 
of three physicians would cost $450,000 per clinic. CBO expects 
that VA would implement this program gradually, starting with 
five mobile deployment teams in 2018 and growing to 25 by 2022. 
As a result, CBO estimates that implementing this section would 
cost $72 million over the 2018-2022 period.
    Podiatrists. Section 202 would add podiatrists to the same 
pay schedule as physicians and dentists and thereby increase 
their pay. Currently, VA employs about 400 podiatrists 
nationwide at an average annual salary of about $130,000. On 
the basis of information from VA about the average increase 
necessary for podiatrists to move to a pay schedule comparable 
to that of physicians and dentists, CBO estimates that the base 
salary for podiatrists would increase by about 15 percent to 
$150,000 in 2018. In addition, using data on hiring from VA, 
CBO estimates that VA would be able to hire an additional 30 
podiatrists because the increased pay would make working at VA 
more attractive. After accounting for projected pay raises, CBO 
estimates that implementing the provision would cost $53 
million over the 2018-2022 period.
    Peer Specialist Program. Section 208 would require that VA 
establish a program to include at least two peer specialists in 
PACTs to promote services for mental health, substance use 
disorders, and behavioral health in primary care. The program 
would require a rapid rollout, being implemented in at least 25 
medical centers in 2018 and in at least 50 medical centers in 
2019. CBO expects the department would implement the program in 
two PACTs per medical center. Using information from VA, CBO 
estimates that the 200 additional peer specialists by 2019 
would receive an average salary of $41,000. After adjusting for 
wage growth, CBO estimates that implementing this section would 
cost $40 million over the 2018-2022 period.
    Demonstration Program on Dental Care. Section 215 would 
require VA to establish a demonstration program to increase 
veterans' access to dental care that would require hiring and 
training alternative dental health providers. Those employees 
would include community dental health coordinators, advance 
practice dental hygienists, independent dental hygienists, 
supervised dental hygienists, primary care physicians, dental 
therapists, dental health aides, and any other health 
professionals that the Secretary determines appropriate.
    Based on the scope of a similar demonstration program 
operated by HHS, CBO expects that developing and operating the 
program would require two additional full-time employees at 
each facility to engage in research, training, and assessment 
of the program. Based on the costs of similar proposals, CBO 
expects this program would operate within 10 medical facilities 
and that the annual cost per staff person would be $100,000 in 
2018 and $11 million over the 2018-2022 period.
    CBO expects that the use of alternative dental care 
providers would increase VA's delivery of dental care to 
veterans. CBO estimates VA would hire two additional dental 
health providers at each of the 10 medical facilities at an 
average compensation of $150,000. As a result, CBO estimates 
that hiring additional dental health providers would cost $14 
million over the 2018-2022 period.
    In total, implementing section 215 would cost $24 million 
over the 2018-2022 period.
    Pilot Program for Tuition Reimbursement. Section 232 would 
require VA to carry out a 6-year pilot program to repay the 
education loans of certain physicians. Eligible physicians 
would include those who are licensed as well as those in their 
last year of residency who agree to work at VA for a certain 
period in rural locations. The department would be required to 
select employees in at least three medical centers and seven 
ambulatory care facilities.
    The program would pay up to the full amount of the medical 
loans for newly licensed physicians and up to $50,000 of loans 
for current physicians at VA. For this estimate, CBO expects 
that VA would repay the loans of 50 physicians in each year of 
the pilot program, and that one-third of the participants would 
be newly licensed physicians and two-thirds would be 
established physicians at VA. Based on information from the 
National Center for Education Statistics and the Association of 
American Medical Colleges, newly licensed physicians would have 
an estimated average education loan debt of $170,000 in 2017. 
For established physicians, CBO expects that VA would reimburse 
about $40,000 of their student loan debt. After factoring in 
the growth in costs for higher education, CBO estimates that 
implementing the pilot program would cost $21 million over the 
2018-2022 period.
    Coordinated-Care Program. Section 251 would require VA to 
provide grants to certain public or nonprofit entities. Grant 
recipients would coordinate wellness care for veterans 
receiving mental health care from VA. The grantees also would 
assess the usefulness of coordinating such care and report on 
that assessment. That program would begin a year after 
enactment and continue for 3 years.
    Based on VA's implementation of other programs of similar 
scope (such as using meditation for veterans with Post 
Traumatic Stress Disorder), CBO expects that VA would award 
grants to coordinate care at 10 VA medical facilities and that 
each grant would cover the costs of about four employees to 
deliver services and analyze and report to the Congress on the 
results of their efforts. CBO estimates that the average 
compensation for those employees would be about $120,000 in 
2018. In total, after accounting for inflation, CBO estimates 
the cost to implement the program would be $15 million over the 
2018-2022 period.
    Pay for Perfusionists. Section 203 would increase the 
maximum salary for perfusionists employed by VA by exempting 
them from certain salary limitations. (Perfusionists are 
medical professionals responsible for operating heart-lung 
machines during cardiac surgery.) Currently VA employs 28 
perfusionists (in the 41 VA medical facilities offering the 
type of cardiac surgery requiring such services) at an average 
salary of $101,000. On the basis of information from VA, CBO 
estimates that implementing this proposal would increase the 
salary of perfusionists at the department by 18 percent. As a 
result, CBO also expects that VA would see higher retention and 
recruitment for this position, resulting in a 20 percent 
increase in staff--an additional 6 perfusionists by 2022. In 
total, CBO estimates that implementing this section would cost 
$5 million over the 2018-2022 period.
    Studies, Reports, and Training. S. 2193 would require VA to 
conduct studies, issue reports, and provide training for staff. 
Based on the costs of similar activities, CBO estimates that 
meeting those requirements would cost $10 million over the 
2018-2022 period.

     By December 31, 2018, section 302 would require VA 
to develop and implement an IT system to track and assess data 
from the Family Caregiver Program. VA reports that it is 
currently working to enhance its existing IT system for 
tracking caregivers to allow for an easier application process 
and for tracking stipend awards and other benefits. As a 
result, CBO estimates that this requirement would mostly codify 
existing practice and would have no budgetary effect. However, 
the provision also includes assessment and reporting 
requirements that CBO estimates would cost $2 million over the 
2018-2022 period.
     Section 104 would require that VA establish 
benchmark guidelines for access to health care at VA medical 
facilities. Such guidelines would assist medical providers on 
whether to refer veterans into the community for health care. 
The section also would establish quality standards for health 
care at the department. CBO estimates that this section would 
cost $1 million over the 2018-2022 period.
     Starting in 2019 and every 2 years thereafter, 
section 106 would require that VA conduct market area 
assessments on the health care services provided by the 
department. Every 4 years, this section also would require VA 
to develop a strategic plan to meet the demand for health care 
provided by the department. CBO estimates that implementing 
this section would cost $1 million over the 2018-2022 period.
     Other provisions, including sections 108, 121, 
122, 123, 201, 207, and 222 would require periodic reports on 
education and training programs, personnel, telemedicine, and 
performance awards and bonuses for employees at VA. 
Furthermore, section 231 would require VA to develop criteria 
to assess underserved facilities. In total, CBO estimates that 
those reports and criteria would cost $6 million over the 2018-
2021 period.

Direct spending

    S. 2193 would appropriate funds for the Veterans Choice 
Program and for health care at VA. In addition, the bill would 
increase VA's ability to lease medical facilities without 
subsequent legislative authorization. On that basis, CBO 
estimates that the legislation would increase direct spending 
by $5.6 billion over the 2018-2027 period (see Table 3).
    Veterans Choice Program. Section 402 would appropriate $4 
billion for VCP, which pays for certain veterans to receive 
health care from participating providers in the private sector. 
For fiscal year 2018, VCP has about $4 billion in available 
funds, which CBO estimates will be completely committed in 
2018. Under current law, the program will terminate once its 
funding is exhausted. CBO expects that enacting this provision 
would extend the life of VCP through most of 2019. On that 
basis, CBO estimates that section 402 would increase direct 
spending by $4 billion over the 2018-2027 period.

                        Table 3.--Estimate of the Effects on Direct Spending of S.2193, T he Caring for Our Veterans Act of 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                          By fiscal year, in millions of dollars--
                                                                   -------------------------------------------------------------------------------------
                                                                     2018    2019   2020  2021  2022  2023  2024  2025  2026  2027  2018-2022  2018-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              INCREASES IN DIRECT SPENDING
 
Veterans Choice Program
    Budget Authority..............................................   4,000       0     0     0     0     0     0     0     0     0     4,000      4,000
    Estimated Outlays.............................................     500   3,500     0     0     0     0     0     0     0     0     4,000      4,000
Health Professionals Education Assistance Program
    Budget Authority..............................................   1,000       0     0     0     0     0     0     0     0     0     1,000      1,000
    Estimated Outlays.............................................      58      99   145   163   170   178   187     0     0     0       635      1,000
Major Medical Facilities
    Estimated Budget Authority....................................       0       0     0   100   100   100   100   100   100   100       200        700
    Estimated Outlays.............................................       0       0     0     4    19    49    69    84    94    94        23        413
Shared Medical Facilities
    Estimated Budget Authority....................................       0       0     0    40    40    40    40    40    40    40        80        280
    Estimated Outlays.............................................       0       0     0     2     8    20    28    34    38    38        10        168
                                                                   -------------------------------------------------------------------------------------
    Total Changes in Direct Spending
        Estimated Budget Authority................................   5,000       0     0   140   140   140   140   140   140   140     5,280      5,980
        Estimated Outlays.........................................     558   3,599   145   169   197   247   284   118   132   132     4,668      5,581
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Health Professionals Education Assistance Program. Section 
401 would appropriate $1 billion for reimbursing employees at 
VA for their professional education. Specifically, the 
appropriations would be used to increase the number of graduate 
medical residents at VA (under sections 202 and 203 of this 
bill), increase bonuses and awards for VA employees (under 
section 204), and increase the payments for reducing student 
loan debt for certain VA staff (under section 213). CBO 
estimates that the appropriated amounts would be sufficient to 
fund those programs through 2024. Beyond that year, CBO 
estimates that the increased program costs would continue, 
subject to appropriation of the necessary amounts. CBO 
estimates section 401 would increase direct spending by $1 
billion over the 2018-2027 period.
    Major Medical Facilities. Sections 241 would expand VA's 
authority to enter into leases for medical facilities. 
(Provisions also would expand the authority to construct 
medical facilities, discussed above under the heading 
``Spending Subject to Appropriation.'') In total, CBO estimates 
that enacting this section would increase direct spending by 
$413 million over the 2018-2027 period.
    VA classifies its contracts for acquiring such facilities 
as operating leases and thus records its obligations for lease 
payments on an annual basis over the term of each lease. 
However, CBO has reviewed several contracts and has concluded 
that they are akin to government purchases of facilities built 
specifically for VA's use--but instead of being financed by the 
Treasury, they rely on third-party financing (that is, funds 
raised by a nonfederal entity), which is generally more 
expensive.\2\ That conclusion is based on those leases having 
many of the following key features:

    \2\For more information on the budgetary treatment of third-party 
financing, see Congressional Budget Office, Third-Party Financing of 
Federal Projects (June 2005), www.cbo.gov/publication/16554.

     The facilities are designed and constructed to the 
unique specifications of the government;
     The facilities are constructed at the request of 
the federal government;
     The leases on the newly constructed facilities are 
long term--usually 20 years;
     Payments from the federal government are the only 
or the primary source of income for the facilities;
     The term of the contractual agreements coincides 
with the term of the private partner's financing instrument for 
developing and constructing the facility (that is, a facility 
financed with a 20-year bond will have a 20-year lease term);
     The federal government commits to make fixed 
annual payments that are sufficient to service the debt 
incurred to develop and construct the facility, regardless of 
whether the agency continues to occupy the facility during the 
guaranteed term of the lease; and
     The fixed payments over the life of the lease are 
sufficient to retire the debt for the facility.\3\
---------------------------------------------------------------------------
    \3\See testimony of Robert A. Sunshine, Deputy Director, 
Congressional Budget Office, before the House Committee on Veterans' 
Affairs, The Budgetary Treatment of Medical Facility Leases by the 
Department of Veterans Affairs (June 27, 2013), www.cbo.gov/
publication/44368.

    Thus, although those transactions are structured as leases, 
they are essentially government purchases. Under the normal 
procedures governing the budgetary treatment of the purchase of 
capital assets, budget authority should be available and 
obligations should be recorded at the time the acquisitions are 
initiated, and amounts recorded should equal the full 
development and construction costs of the medical facilities. 
Instead, VA records a small fraction of those costs as 
obligations when it awards the contracts for such transactions.
    To the extent that the full costs of developing and 
constructing the facilities exceeds the relatively small amount 
that VA would initially record as obligations against its 
appropriation, CBO treats the legislative authorization for 
those transactions as contract authority--a type of budget 
authority that allows an agency to enter into a contract and 
incur an obligation before receiving an appropriation for those 
activities. Because the contract authority would be provided in 
an authorizing bill, rather than in an appropriation act, the 
resulting spending is categorized as direct spending (as 
distinguished from discretionary spending, which results from 
appropriation acts).
    In addition, at the time the contracts are signed, VA 
typically obligates some amounts from available appropriations; 
those costs are considered discretionary.
    Section 241 would allow VA to enter into leases without 
legislative authorization for medical facilities with annual 
lease payments of up to $1.5 million. Under current law, VA 
must receive legislative authorization to lease medical 
facilities with annual rent payments in excess of $1 million.
    After reviewing VA's 2018 budget request for leases of 
medical facilities, CBO estimates that enacting this provision 
would allow VA to enter into six additional leases, on average, 
each year. In total, the annual rent payments for those leases 
would be about $7 million. CBO expects that the initial 
contracts for those facilities would be entered into starting 
in 2021 and that similar contracts would be signed each year 
thereafter.
    When the government leases a facility the lessor charges 
the government for the cost to construct the facility plus 
interest on those costs over the period it takes to recover 
them through the lease payments. CBO's estimate of direct 
spending reflects an amount equal to the cost of constructing 
the facilities, plus the net present value of the portion of 
lease costs attributable to interest rates that would exceed 
U.S. Treasury interest rates. (Borrowing costs equivalent to 
the amount of Treasury interest that would be paid if the 
equipment was financed with appropriated funds are not included 
in our estimate because, for the enforcement of Congressional 
budget rules, changes in Treasury interest costs are not 
counted as a cost or savings related to any particular 
legislative provision.) CBO's estimate of outlays reflects its 
judgment as to when the facilities would be provided--typically 
over a 6-year period.
    On that present value basis for each lease over the term of 
the lease agreement, CBO estimates that enacting this provision 
would increase direct spending by $413 million over the 2021-
2027 period.\4\
---------------------------------------------------------------------------
    \4\A present value is a single number that expresses a flow of past 
and future income or payments in terms of an equivalent lump sum 
received or paid today. The value depends on the rate of interest, 
known as the discount rate, used to translate past and future cash 
flows into current dollars. CBO calculated costs for the 20-year leases 
by discounting the expected annual rent payments using the rate on 
Treasury securities of comparable maturity.
---------------------------------------------------------------------------
    Shared Medical Facilities. Section 242 would allow VA to 
enter into sharing agreements with other federal agencies to 
lease medical facilities. VA's portion of the annual rent 
payments for leased medical facilities could be lowered by 
enough that some leases would no longer require legislative 
authorization. Using information from VA, CBO estimates that, 
on average, this section would allow construction of one 
medical facility each year with an average annual rent payment 
of $3 million. CBO expects that VA would enter into the first 
such contract in 2021 and that similar contracts would take 
effect each year thereafter. On a present value basis for each 
lease over the term of the lease agreement, CBO estimates that 
enacting this section would increase direct spending by $168 
million over the 2021-2027 period.
    Pay-As-You-Go Considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget-reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. The net changes in outlays that are subject to those 
pay-as-you-go procedures are shown in Table 4.

 Table 4.--CBO Estimate of Pay-As-You-Go Effects of S.2193, The Caring for Our Veterans Act of 2017, as Ordered
                   Reported by the Senate Committee on Veterans' Affairs on November 29, 2017
----------------------------------------------------------------------------------------------------------------
                                                   By fiscal year, in millions of dollars--
                             -----------------------------------------------------------------------------------
                              2018   2019   2020  2021  2022  2023  2024  2025  2026  2027  2018-2022  2018-2027
----------------------------------------------------------------------------------------------------------------
                                      NET INCREASE IN THE ON-BUDGET DEFICIT
 
Statutory Pay-As-You-Go        558   3,599   145   169   197   247   284   118   132   132     4,668      5,581
 Impact.....................
----------------------------------------------------------------------------------------------------------------

Increase in long-term direct spending and deficits

    CBO estimates that enacting the draft bill would not 
increase net direct spending or on-budget deficits by more than 
$2.5 billion in any of the four consecutive 10-year periods 
beginning in 2028.

Mandates

    S. 2193 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, the bill 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 November 13, 2017, CBO 
transmitted a cost estimate for H.R. 4243, the VA Asset and 
Infrastructure Review Act of 2017, as ordered reported by the 
House Committee on Veterans' Affairs on November 8, 2017. 
Sections 201 and 204 in H.R. 4243 are similar to sections 241 
and 242 of S. 2193 and the estimated costs for both sections 
are the same.
    On November 8, 2017, CBO transmitted a cost estimate for 
H.R. 1133, the Veterans Transplant Coverage Act of 2017, as 
ordered reported by the House Committee on Veterans' Affairs on 
July 19, 2017. H.R. 1133 is similar to section 252 of S. 2193 
and the estimated costs are the same.
    On July 24, 2017, CBO transmitted a cost estimate for 
H.R. 1058, the VA Provider Equity Act, as ordered reported by 
the House Committee on Veterans' Affairs on July 19, 2017. The 
language in H.R. 1058 that affects podiatrists is similar to 
section 202 of S. 2193 and the estimated costs are the same.
    Estimate prepared by: Federal Costs: Ann E. Futrell; 
Mandates: Zachary Byrum.
    Estimate approved by: H. Samuel Papenfuss, Deputy Assistant 
Director for Budget Analysis.

                      Regulatory Impact Statement

    In compliance with paragraph 11(b) of rule XXVI of the 
Standing Rules of the Senate, the Committee on Veterans' 
Affairs has made an evaluation of the regulatory impact that 
would be incurred in carrying out the Committee bill. The 
Committee finds that the Committee bill would not entail any 
regulation of individuals or businesses or result in any impact 
on the personal privacy of any individuals and that the 
paperwork resulting from enactment would be minimal.

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7(b) of rule XXVI of the 
Standing Rules of the Senate, the following is a tabulation of 
votes cast in person or by proxy by members of the Committee on 
Veterans' Affairs at its November 29, 2017, meeting. Twenty-two 
amendments to the Committee Bill were voted on by members.
    Chairman Isakson called up nineteen amendments to be 
considered en bloc. The amendments were sponsored by Senators 
Sullivan, Heller, Cassidy, Rounds, Sanders, Blumenthal, Moran, 
Tillis, and Brown. The amendments were agreed to by voice vote.
    An amendment by Senator Moran would have replaced sections 
of the Committee Bill regarding community care, access and 
quality standards, prompt pay, access to walk-in care, a 
strategy for care provided by VHA, authorization of 
appropriations for care provided in VHA, and the appropriation 
of $4 billion for the Veterans Choice Program. In addition, the 
amendment would have added provisions to the Committee Bill 
relating to continuity of care, payment rates for care in the 
community, and a center of innovation for care and payments. 
This amendment was not agreed to by voice vote and Senator 
Moran requested that he be recorded as voting aye.
    An amendment by Senator Cassidy would have removed a 
section of the Committee Bill that allowed veterans to file a 
disability compensation claim for adverse medical events for 
care received in the community. This amendment was not agreed 
to by voice vote.
    The Committee also discussed amendments sponsored by 
Senator Sanders but did not vote on those amendments because 
they were withdrawn.
    The Committee Bill, as amended during the Committee 
meeting, was agreed to by a roll call vote.

 
----------------------------------------------------------------------------------------------------------------
                Nays                                 Senator                                 Yeas
----------------------------------------------------------------------------------------------------------------
                                 X   Mr. Moran
                                     Mr. Boozman                                                              X
                                     Mr. Heller                                                               X
                                     Mr. Cassidy                                                              X
                                     Mr. Rounds                                                               X
                                     Mr. Tillis                                                               X
                                     Mr. Sullivan                                                             X
                                     Mr. Tester                                                               X
                                     Mrs. Murray                                                              X
                                     Mr. Sanders                                                              X
                                     Mr. Brown                                                                X
                                     Mr. Blumenthal                                                           X
                                     Ms. Hirono                                                    X (by proxy)
                                     Mr. Manchin                                                              X
                                     Mr. Isakson, Chairman                                                    X
----------------------------------------------------------------------------------------------------------------
1                                    TALLY                                                                   14
----------------------------------------------------------------------------------------------------------------

                             Agency Reports

    On May 17, 2017, Jennifer S. Lee, M.D., Deputy Under 
Secretary for Health for Policy and Services, Veterans Health 
Administration; on July 11, 2017, Baligh Yehia, M.D., Deputy 
Under Secretary for Health for Community Care, Veterans Health 
Administration from the Department of Veterans Affairs appeared 
before the Committee on Veterans' Affairs and submitted 
testimony on various bills incorporated into the Committee 
bill. Excerpts from those statements are below:

STATEMENT OF DR. JENNIFER S. LEE, DEPUTY UNDER SECRETARY FOR HEALTH FOR 
   POLICY AND SERVICES VETERANS HEALTH ADMINISTRATION DEPARTMENT OF 
                            VETERANS AFFAIRS

    Good morning, Chairman Isakson, Ranking Member Tester, and 
Members of the Committee. Thank you for inviting us here today 
to present our views on several bills that would affect the 
Department of Veterans Affairs' (VA) programs and services. 
Joining me today is Ms. Margaret Kabat, National Director, 
Caregiver Support Program, Veterans Health Administration 
(VHA); Phil Parker; Acting Associate Deputy Assistant 
Secretary, Office of Acquisition and Logistics, Office of 
Acquisition, Logistics, and Construction (OALC); Mr. James 
Ruhlman, Assistant Director for Policy & Procedures, Veterans 
Benefits Administration (VBA); Ms. Meghan Flanz, Interim 
General Counsel; Dave McLenachen, Director, Appeals Management 
Office, VBA; and Donnie Hachey, Chief Counsel for Operations, 
Board of Veterans Appeals (BVA).
    There are a number of bills on the agenda today, and we are 
unable at this time to provide views and cost estimates on a 
few of these provisions. Specifically, we do not have cost 
estimates on S. 543 and S. 764.

S. 591--MILITARY AND VETERAN CAREGIVERS SERVICE IMPROVEMENT ACT OF 2017

    S. 591 would expand eligibility for VA's Program of 
Comprehensive Assistance for Family Caregivers, expand benefits 
available to participants under such program, enhance special 
compensation for certain members of the uniformed services who 
require assistance, and make other amendments to increase the 
provision of benefits.
    The Caregivers and Veterans Omnibus Health Services Act of 
2010, Public Law 111-163, signed into law on May 5, 2010, 
provided expanded support and benefits for caregivers of 
eligible and covered Veterans. While the law authorized certain 
support services for caregivers of covered Veterans of all 
eras, other benefits were authorized only for qualified family 
caregivers of eligible Veterans who incurred or aggravated a 
serious injury in the line of duty on or after September 11, 
2001. These new benefits for approved family caregivers, 
provided under the Program of Comprehensive Assistance for 
Family Caregivers, include a monthly stipend paid directly to 
designated primary family caregivers and medical care under 
CHAMPVA for designated primary family caregivers who are not 
eligible for TRICARE and not entitled to care or services under 
a health-plan contract.
    Section 2 of S. 591, the Military and Veteran Caregiver 
Services Improvement Act of 2017, would remove ``on or after 
September 11, 2001'' from the statutory eligibility criteria 
for the Program of Comprehensive Assistance for Family 
Caregivers, and thereby expand eligibility under the program to 
Veterans of all eras who otherwise meet the applicable 
eligibility criteria. Family caregivers could not receive 
assistance under this expanded eligibility until FYs 2018, 
2020, or 2022 depending on the monthly stipend tier for which 
their eligible Veteran qualifies. Section 2 would also add ``or 
illness'' to the statutory eligibility criteria, and thereby 
expand eligibility to include those Veterans who require a 
caregiver because of an illness incurred or aggravated in the 
line of duty. In addition, the bill would expand the bases upon 
which a Veteran could be deemed to be in need of personal care 
services, to include ``a need for regular or extensive 
instruction or supervision without which the ability of the 
Veteran to function in daily life would be seriously 
impaired.''
    This section would also expand the assistance available to 
primary family caregivers under the Program of Comprehensive 
Assistance for Family Caregivers to include child care 
services, financial planning and legal services ``relating to 
the needs of injured and ill Veterans and their caregivers,'' 
and respite care that includes peer-oriented group activities. 
The bill would ensure that in certain circumstances VA accounts 
for the family caregiver's assessment and other specified 
factors in determining the primary family caregiver's monthly 
stipend amount. In addition, the bill would require VA to 
periodically evaluate the needs of the eligible Veteran and the 
skills of the family caregiver to determine if additional 
instruction, preparation, training, or technical support is 
needed, and it would require certain evaluation be done in 
collaboration with the Veteran's primary care team to the 
maximum extent practicable.
    Section 2 would also authorize VA, in providing assistance 
under the Program of Comprehensive Assistance for Family 
Caregivers, to ``enter into contracts, provider agreements, and 
memoranda of understanding with Federal agencies, states, and 
private, nonprofit, and other entities'' in certain 
circumstances. It would expand the definition of family member 
to include a non-family member who does not provide care to the 
Veteran on a professional basis, and it would amend the 
definition of ``personal care services.'' The bill would also 
end the Program of General Caregiver Support Services on 
October 1, 2022, but would ensure that all of its activities 
are carried out under the Program of Comprehensive Assistance 
for Family Caregivers. Finally, the bill would amend the annual 
reporting requirements for the Program of Comprehensive 
Assistance for Family Caregivers.
    In September 2013, VA sent a report to the Committees on 
Veterans' Affairs of the Senate and House of Representatives 
(as required by Section 101(d) of Public Law 111-163) on the 
feasibility and advisability of expanding the Program of 
Comprehensive Assistance for Family Caregivers to family 
caregivers of Veterans who incurred or aggravated a serious 
injury in the line of duty before September 11, 2001. In that 
report, VA noted that expanding the Program of Comprehensive 
Assistance for Family Caregivers would allow equitable access 
to seriously injured Veterans from all eras (who otherwise meet 
the program's eligibility criteria) and their approved family 
caregivers.
    In the report, however, VA noted difficulties with making 
reliable projections of the cost effect of opening the Program 
of Comprehensive Assistance for Family Caregivers to eligible 
Veterans of all eras, but estimated a population range of 
32,000 to 88,000 additional Veterans in the first year 
(estimated for FY 2014), at a cost of $1.8 billion to $3.8 
billion in the first year (estimated for FY 2014). After VA 
provided this report to Congress, the RAND Corporation 
published a report titled, ``Hidden Heroes: America's Military 
Caregivers,'' which estimates a significantly larger eligible 
population (1.5 million) that may be eligible if the program 
were expanded to caregivers of pre-9/11 Veterans and those 
qualifying due to illness. VA's estimates in its 2013 report 
did not account for expansion to eligible Veterans with an 
illness incurred or aggravated in the line of duty, other 
Veterans who would become eligible for the program based on the 
amendments in section 2, or the additional assistance that 
would become available to primary family caregivers under the 
bill. This estimate also did not factor in a phased 
implementation of stipend expansion, as contemplated by the 
bill.
    VA cannot responsibly provide a position in support of 
expanding the Program of Comprehensive Assistance for Family 
Caregivers without a realistic consideration of the resources 
necessary to carry out such an expansion, including an analysis 
of the future resources that must be available to fund other 
core direct-to-Veteran health care services. This is especially 
true as VA presses to strengthen mental health services and 
ensure the fullest possible access to care across the system.
    We wish to make it very clear that VA believes an expansion 
of those benefits that are currently limited by era of service 
would result in equitable access to the Program of 
Comprehensive Assistance for Family Caregivers for long-
deserving caregivers of those who have sacrificed greatly for 
our Nation. However, VA cannot endorse this measure before 
further engaging with Congress on these fiscal constraints, 
within the context of all of VA health care programs.
    Additionally, before expanding eligibility under the 
Program, we believe it prudent for VA to ensure that the 
current eligibility criteria are applied in a consistent manner 
across the program. For example, the National Caregiver Support 
Program is undergoing an internal review to evaluate 
consistency in revocations and reductions from the Program and 
standardize communication with Veterans and Caregivers. On 
April 17, 2017, VA suspended certain VA-initiated revocations 
in order to carry out this review.
    VA welcomes further discussion of these issues with the 
Committee.
    Section 3 of this bill proposes to add a new section 3319A 
to title 38 to authorize individuals who are eligible for and 
participating in a program of comprehensive assistance for 
family caregivers under 38 U.S.C. Sec. 1720G(a) the opportunity 
to transfer their unused Post-9/11 GI Bill education benefits 
to their dependents. Veterans may complete the transfer of 
entitlement any time during the 15-year period beginning on the 
date of their last discharge or release from active duty. There 
is no length of service requirement, and the monthly rate of 
educational assistance would be the same rate payable to the 
individual making the transfer. The Secretary would be 
authorized to prescribe regulations to carry out this section. 
We note that the Survivors' and Dependents' Educational 
Assistance (DEA) program, or chapter 35, currently offers 
education and training benefits to eligible dependents of 
members of the Armed Forces and Veterans who have a service-
connected disability rated as permanently and totally 
disabling, including individuals who are eligible for a program 
of comprehensive assistance for family caregivers. Assistance 
includes up to 45 months of full-time benefits.
    VA supports the intent of section 3 to take care of 
caregivers; however, VA cannot support this section as written. 
The transfer of entitlement provisions of the Post-9/11 GI Bill 
were established as a recruitment and retention tool for the 
uniformed services. As such, the Department of Defense (DOD) 
determines eligibility for transfer of entitlement. If enacted, 
the proposed legislation would require VA to develop procedures 
to receive requests to transfer entitlement for certain 
individuals, determine eligibility, and award benefits for the 
transfer of entitlement program. However, VA notes that 
Congress would need to identify appropriate offsets for the 
cost of this legislation
    Additionally, under the proposed section 3319A, dependents 
would receive the same rate of payment as otherwise payable to 
the individual making the transfer. This is different than the 
rate payable for a dependent child using transferred 
entitlement under section 3319. Currently, a dependent child is 
awarded benefits as if the individual making the transfer were 
not on active duty. As such, a child is entitled to the monthly 
housing allowance stipend even though the individual 
transferring benefits is still on active duty. Under the 
proposed legislation, a child would not be eligible for the 
housing allowance while the individual described in 38 U.S.C. 
Sec. 1720G(a)(2) is on active duty. This change would impact 
the Long-Term Solution for processing Post-9/11 GI Bill claims, 
as VA would have to make system modifications in order to apply 
a blended set of rules for claims involving transferred 
education benefits.
    Section 4(a) would amend 37 U.S.C. 439, providing for 
special compensation for members of the uniformed services with 
catastrophic injuries or illnesses requiring assistance in 
everyday living, by amending the definition of covered members 
to include those Servicemembers who have a serious injury or 
illness that was incurred or aggravated in the line of duty and 
are in need of personal care services as a result of such 
injury or illness. Section 4(b) would further amend section 439 
by requiring VA to provide family caregivers of a Servicemember 
in receipt of monthly special compensation the assistance 
available to family caregivers of eligible Veterans under 38 
U.S.C. Sec. 1720G(a)(3)(A), other than the monthly caregiver 
stipend. VA would provide assistance under this subsection in 
accordance with a memorandum of understanding (MOU) between VA 
and DOD, and an MOU between VA and the Secretary of Homeland 
Security. VA would be required to ensure that a family 
caregiver in receipt of assistance under this subsection is 
able to transition seamlessly to the receipt of assistance 
under 38 U.S.C. Sec. 1720G. Section 4(c) would require DOD, in 
collaboration with VA, to ensure that members of the uniformed 
services in receipt of monthly special compensation are aware 
of the eligibility of such members for family caregiver 
assistance. Section 4(d) would define the term ``serious injury 
or illness,'' which would replace the term ``catastrophic 
injury or illness,'' to mean an injury, disorder, or illness 
that (1) renders the afflicted person unable to carry out one 
or more activities of daily living; (2) renders the afflicted 
person in need of supervision or protection due to the 
manifestation by such person of symptoms or residuals of 
neurological or other impairment or injury; (3) renders the 
afflicted person in need of regular or extensive instruction or 
supervision in completing two or more instrumental activities 
of daily living; or (4) otherwise impairs the afflicted person 
in such manner as the Secretary of Defense or Homeland Security 
prescribes.
    Regarding section 4 of the bill, VA defers to DOD and the 
Department of Homeland Security regarding sections 4(a), 4(c), 
and 4(d). VA does not support section 4(b) because DOD already 
provides many of the services and supports available under VA's 
Program of Comprehensive Assistance for Family Caregivers 
including health care coverage, mental health services, and 
respite care. Requiring VA to provide services under its 
program would result in a duplication of efforts.
    Section 5 would authorize the Office of Personnel 
Management (OPM) to promulgate regulations under which a 
covered employee, which would include a caregiver defined in 38 
U.S.C. Sec. 1720G or a caregiver of an individual receiving 
compensation under 37 U.S.C. Sec. 439, to use a flexible 
schedule or compressed schedule or to telework. VA defers to 
OPM on this section.
    Section 6 would amend the Public Health Service Act (42 
U.S.C. Sec. 300ii), which governs lifespan respite care, to 
amend the definition of ``adult with a special need'' to 
include a Veteran participating in the family caregiver program 
under 38 U.S.C. Sec. 1720G(a). It would also amend the 
definition of ``family caregiver'' to include family caregivers 
under 38 U.S.C. Sec. 1720G. Furthermore, in awarding grants or 
cooperative agreements to eligible state agencies to furnish 
lifespan respite care, HHS would be required to work in 
cooperation with the interagency working group on policies 
relating to caregivers of Veterans established under section 7 
of this bill. Section 6 would also authorize appropriations of 
$15 million for FYs 2017 through 2022 for these grants. VA 
defers to HHS on this section.
    Section 7 would establish an interagency working group on 
policies relating to caregivers of Veterans and Servicemembers. 
The working group would be composed of a chairperson selected 
by the President, and representatives from VA, DOD, HHS 
(including the Centers for Medicare & Medicaid Service), and 
the Department of Labor. The working group would be authorized 
to consult with other advisors as well. The working group's 
duties would include regularly reviewing policies relating to 
caregivers of Veterans and Servicemembers, coordinating and 
overseeing the implementation of policies relating to these 
caregivers, evaluating the effectiveness of such policies, 
developing standards of care for caregiver and respite 
services, and others. Not later than December 31, 2017, and 
annually thereafter, the working group would be required to 
submit to Congress a report on policies and services relating 
to caregivers of Veterans and Servicemembers.
    VA generally supports a working group that would provide a 
forum for analyzing and evaluating different issues that family 
caregivers of Veterans and Servicemembers face. Such a working 
group would be ideally suited to considering in depth the types 
of issues other provisions of this bill are intended to address 
and would also be able to evaluate emerging issues.
    The Department of Justice advises, however, the bill's 
method for selecting members of the working group raises 
Appointment Clause concerns, which DOJ will convey in greater 
detail under separate cover.
    We also note several technical concerns with the 
legislation in terms of the creation of the working group, its 
role, the potential applicability of the Federal Advisory 
Committee Act to such a group, and which agency (if any) would 
be responsible for initiating, managing, and funding the 
working group. We would be happy to discuss these issues with 
you upon your request.
    Section 8(a) would require VA to conduct a longitudinal 
study on Servicemembers who began their service after September 
11, 2001. VA would be required to award a grant to or enter 
into a contract with an appropriate entity unaffiliated with VA 
to conduct the study. Within 1 year of the date of the 
enactment of the Act, VA would be required to submit to the 
Committees on Veterans' Affairs a plan for the conduct of the 
study. Not later than October 1, 2021, and not less frequently 
than once every 4 years thereafter, VA would be required to 
submit to the Committees on Veterans' Affairs a report on the 
results of the study. Section 8(b) would require VA to provide 
for the conduct of a comprehensive study on Veterans who have 
incurred a serious injury or illness and individuals who are 
acting as caregivers for Veterans. VA would be required to 
award a grant to or enter into a contract with an appropriate 
entity unaffiliated with VA to conduct the study. The study 
would be required to include the health of the Veteran and the 
impact of the caregiver on the health of the Veteran, the 
employment status of the Veteran and the impact of the 
caregiver on that status, the financial status and needs of the 
Veteran, the use by the Veteran of VA benefits, and any other 
information VA considers appropriate. No later than 2 years 
after the date of the enactment of this Act, VA would be 
required to submit to the Committees on Veterans' Affairs a 
report on the results of this study.
    VA does not support section 8, as it would duplicate 
research in several ongoing or in-development studies. DOD and 
VA have a collaboration on the Millennium Cohort Study, a 
longitudinal cohort study that has and will continue to produce 
findings on health issues of multiple eras of military service. 
The Million Veterans Program creates a repository of clinical 
and genetic information on Veterans, including post-9/11 
Veterans, which will provide data for targeted studies on 
health for years to come. VA's Cooperative Studies Program is 
developing a study on the respiratory health of Gulf War and 
post-9/11 Veterans. Finally, a study of the life transitions of 
military Servicemembers who served in Iraq or Afghanistan is 
funded and in development.
    VA estimates section 8 would cost $4.3 million in FY 2018, 
$17.5 million over 5 years, and $34 million over 10 years, with 
additional close out expenses of $3.3 million in FY 2028 for a 
total cost of $37.3 million.

  DRAFT--VETERAN PARTNERS' EFFORTS TO ENHANCE REINTEGRATION (PEER) ACT

    The draft bill would require the Secretary to phase in and 
conduct a program whereby peer specialists would be included in 
patient aligned care teams at VAMCs to promote the use and 
integration of mental health services in a primary care 
setting. Not later than 180 days after the date of enactment, 
this program would have to be established at not fewer than 10 
VAMCs. By not later than 2 years from the date of enactment, it 
would have to be in place at not fewer than 25 VAMCs. Under the 
bill, the Secretary would be directed to consider specified 
factors when selecting sites for this program, but, not fewer 
than five would have to be established at VA designated 
Polytrauma Centers, and not fewer than ten would have to be 
established at other VAMCs. The draft bill would also require 
that all peer specialist programs established under this 
mandate: (1) ensure that the needs of female Veterans are 
considered and addressed; and (2) include female peer 
specialists. Finally, this measure would establish initial, 
periodic, and final Congressional reporting requirements, as 
detailed in the bill.
    VA has no objection to the bill, but notes that it is not 
necessary because VA already has the authority to execute this 
program. However, we would require additional funding to 
implement it. We also note that a few technical changes are 
needed for clarity. This legislation, if enacted, would 
complement VA's ongoing pilot program (commenced in 2014) 
whereby peer support through peer specialists has been extended 
beyond traditional mental health sites of care to include 
Veterans receiving mental health care in primary care settings. 
Under the pilot program, trained peer specialists work with VA 
primary care teams to, in general terms, help improve the 
health and well-being of other Veterans being treated in VA 
primary care settings. All 25 sites now have assigned one peer 
specialist to work in Primary Care at least 10 hours per week. 
The first cohort of eight sites began seeing Veterans in 
primary care in January 2016, the second cohort of eight began 
in August 2016, and the final nine sites began April 1, 2017. 
To date, the peers in this program have provided services to 
more than 3,000 Veterans. The response from Veterans, peers, 
and primary care clinicians has been overwhelmingly positive. 
Sites made a 1- year commitment to participate in the project, 
and VA will have a formal program evaluation based on clinical 
and other outcomes in 2018. It is likely that some of the 
existing sites will not be able to continue the pilot program 
after FY 2017 without additional funding.
    The bill specifies program participation of female peer 
specialists. I am pleased to report that women peer specialists 
are already well represented, with 16.2 percent of the national 
peer specialist workforce being women. While at first glance 
16.2 percent may seem a low rate, please bear in mind that this 
figure is higher than the percentage of Veterans seeking 
services through VA who are women. We do recognize, however, 
that the current number of women Veteran peer specialists in 
the pilot is unevenly distributed across the country, with some 
VAMCs having greater difficulty than others in attracting 
qualified applicants.
    Also, it is unclear if the peers will address substance use 
disorders under the umbrella of their mental health duties. 
Given the comorbidity of these issues, the need for integration 
of substance use disorder identification and care, the need for 
overdose prevention and links as needed to Medication Assisted 
Treatment for opioid use disorders, and the need to increase 
the numbers of Veterans achieving long-term recovery, we 
recommend that this be clarified and, if possible, included.
    We estimate this bill would cost $4.94 million in FY 2018, 
$25.99 million over 5 years, and $55.48 million over 10 years.

             DRAFT--SERVING OUR RURAL VETERANS ACT OF 2017

    The draft bill would amend 38 U.S.C. Sec. 7406(c) to 
authorize training and supervision of residents at facilities 
operated by an Indian tribe, a tribal organization, or the 
Indian Health Service, Federally-qualified health centers, and 
community health centers. It would also direct VA, in 
consultation with the Director of the Indian Health Service, to 
carry out a pilot program to establish graduate medical 
education residency training programs at such facilities and to 
affiliate with established programs. VA would be required to 
carry out the pilot program at not more than four covered 
facilities and would carry out the pilot program for a period 
of 8 years beginning on the date that is 180 days after the 
date of enactment. VA would be required to reimburse certain 
costs associated with the program and to enter into agreements 
with individuals participating in the pilot program under which 
they would agree to serve a period of 1 year at a covered 
facility (including a VA facility) service for each year in 
which the individual participates in the pilot program. The 
bill would provide terms related to breach of the agreement, 
loan repayment, and concurrent service. VA would be required to 
submit a report to the Committees on Veterans' Affairs of the 
House of Representatives and the Senate not later than 3 years 
before the termination of the pilot program on the feasibility 
and advisability of expanding the pilot program to additional 
locations and making the pilot program or any part of it 
permanent. The draft bill would authorize to be appropriated to 
VA $20 million per year to carry out the pilot program and 
would also authorize appropriations for the Secretary of HHS, 
acting through the Director of the Indian Health Service, and 
to VA such sums as may be necessary to cover loan repayments 
under each agency's respective loan repayment programs.
    VA supports the draft bill in principle. VA strongly 
supports the imperative to build Graduate Medical Education 
capacity in rural and underserved areas with the strategic 
intent to address a geographically inequitable distribution of 
the Nation's physician and clinical workforce.
    While we appreciate the purpose of this bill, it is likely 
that a relatively small proportion of the patients seen by 
residents in such programs would be Veterans, yet VA would 
incur much of the burden for program initiation and maintenance 
including resident salaries, faculty time and development, 
curriculum development, and recruitment efforts.
    Under the draft bill, a medical resident who participates 
in the pilot program would be eligible for participation in the 
Indian Health Service Loan Repayment Program under section 108 
of the Indian Health Care Improvement Act (section 1616a of 
title 25, U. S. C.) and the VA Education Debt Reduction 
Program. The draft bill also would include a period of 
obligated service (1 year of service at VA for each year of 
participation in the program). VA supports such a loan 
repayment and obligated service scheme, but recommends 
requiring 2 years of service for each year of program 
participation. Moreover, because residents typically receive a 
salary and are not obligated, post-residency, to perform 
services as a result of participating in a residency program, 
VA requests the authority to concurrently provide educational 
loan repayment to residents in the program(s) as a tool to 
recruit highly qualified residents.
    VA fundamentally believes that supporting the practice of 
rural health care in the United States is crucial to fulfilling 
its mission to provide the highest quality care for Veterans 
and that we must include within our broad health professions 
education portfolio a focus on rural health in order to meet 
our statutory mission to provide medical education for VA and 
for the Nation. VA endorses educating all physicians regarding 
the unique health needs of Veterans and providing clinical 
training opportunities in rural health care delivery systems.
    VA estimates the cost of implementation at four sites would 
be $20.3 million in FY 2018, $90.6 million over 5 years, and 
$201.8 million over 10 years.
    Mr. Chairman and Members of the Committee, this concludes 
my statement. I would be happy to answer any questions you may 
have.
                                ------                                

 STATEMENT OF BALIGH R. YEHIA, M.D., DEPUTY UNDER SECRETARY FOR HEALTH 
   FOR COMMUNITY CARE, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF 
                            VETERANS AFFAIRS

    Good morning, Chairman Isakson, Ranking Member Tester, and 
Members of the Committee. Thank you for inviting us here today 
to present our views on several bills that would affect the 
Department of Veterans Affairs' (VA or Department) programs and 
services. Joining me today is Dr. Tom Lynch, Assistant Deputy 
Under Secretary for Health Clinical Operations, Veterans Health 
Administration (VHA); Brad Flohr, Senior Advisor for 
Compensation Services, Veterans Benefits Administration; and 
Carin Otero, Assistant Deputy Assistant Secretary for Human 
Resources Policy and Planning, Human Resources and 
Administration.
    This written statement includes VA's views on eleven 
significant bills on important topics. Because of the timing of 
receipt of two of the bills, we are not able to provide formal 
views in this statement on S. 1279, the Veterans Health 
Administration Reform Act of 2017 or the draft bill, ``The 
Department of Veterans Affairs Quality Employment Act of 
2017.'' We also will follow up with the Committee on one 
section (section 10) of the Veterans Choice Act of 2017. We 
look forward to providing views at a later time and discussing 
these bills with you today.

                S. 115--VETERANS TRANSPLANT COVERAGE ACT

    S. 115 would add section 1788 to Title 38, authorizing the 
Secretary of Veterans Affairs (Secretary) to provide for an 
operation on a live donor to carry out a transplant procedure 
for an eligible Veteran, notwithstanding that the live donor 
may not be eligible for VA health care. VA would be required to 
provide to a live donor any care or services before and after 
conducting the transplant procedure that may be required in 
connection with the transplant.
    VA supports S. 115, contingent on the provision of 
additional resources to support implementation, although we 
recommend some clarifications in the bill language. We believe 
it would be appropriate to limit the duty and responsibility to 
furnish follow-on care and treatment of a living donor to 2 
years after the procedure is performed by a VA facility. This 
would be consistent with the recommendations of the United 
Network for Organ Sharing and the Organ Procurement and 
Transplant Network. We further recommend that the duty to 
provide follow-on care and treatment should be limited to that 
which is ``directly related to'' the living donor procedure 
(rather than what ``may be required in connection with such 
procedure,'' as the bill would provide).
    There are other potential issues related to organ 
transplantation that the bill does not address that we would be 
pleased to discuss with the Committee in its contemplation of 
this proposal.
    We estimate the bill as written would cost $1.8 million in 
Fiscal Year (FY) 2018, $9.7 million over 5 years, and $21.5 
million over 10 years.

    S. 1153--VETERANS ACQUIRING COMMUNITY CARE EXPECT SAFE SERVICES 
                          (ACCESS) ACT OF 2017

    S. 1153 would require the Secretary of Veterans Affairs to 
deny or revoke eligibility of certain health care providers to 
provide non-VA health care services to Veterans. The bill 
would, in general, require that the Secretary deny or revoke 
the eligibility of a health care provider to provide non-
Department health care services if the Secretary determines 
that: (1) the provider was removed from employment at VA due to 
conduct that violated a policy relating to the safe and 
appropriate delivery of health care; (2) the provider violated 
the requirements of a medical license; (3) the provider had a 
Department credential revoked that would impact that provider's 
ability to provide safe and appropriate health care; or, (4) 
the provider violated a law for which a term of imprisonment of 
more than 1 year may be imposed. The bill would permit, but not 
require, the denial, revocation, or suspension of the 
eligibility of a health care provider to furnish non-Department 
health care when the Secretary has a reasonable belief that 
such action is necessary to immediately protect the health, 
safety, or welfare of Veterans and: (1) the provider is under 
investigation by the medical licensing board of a State in 
which the provider is licensed or practices; (2) the provider 
has entered into a settlement agreement for a disciplinary 
charge related to the practice of medicine; or, (3) the 
Secretary otherwise determines that such action is appropriate 
under the circumstances. The bill would require that the 
Secretary suspend the eligibility of a health care provider to 
provide non-Department care if that provider is suspended from 
serving as a health care provider of the Department. The bill 
also would require that the Secretary review, within 1 year of 
enactment, each non-Department health care provider to identify 
whether he or she was an employee of the Department to 
determine if the provider meets any of the criteria for denial, 
revocation, or suspension of eligibility. Finally, the bill 
would require the Comptroller General to submit a report to 
Congress within 2 years of enactment on the implementation of 
these authorities and its effects.
    VA supports the proposed legislation in principle and would 
appreciate the opportunity to work with Congress to develop a 
proposal that builds upon similar requirements already in place 
without creating the unnecessary administrative burdens we 
believe the bill would produce, as these burdens could 
negatively impact Veterans' access to quality care. Currently, 
VA procures most community care using Third Party 
Administrators (TPA), under Patient Centered Community Care 
(PC3)/Choice contracts, which include the development and 
maintenance of an adequate provider network of high quality, 
credentialed/certified health care providers. VA monitors 
adherence by performing quality checks through the use of a 
Quality Assurance Plan (QASP). As part of the QASP, VA utilizes 
a ``three lines of defense'' model to oversee the credentialing 
and certification process of network health care providers. 
These lines of defense involve both VA and the TPA performing 
ongoing reviews to ensure the quality of the providers in the 
network. Additionally, VA requires the contractor to report to 
VA, not more than 15 days after being notified, of the loss of 
or other adverse impact to a network provider's certification, 
credentialing, privileging, or licensing. Future acquisitions 
will carry similar criteria as they pertain to review of 
provider licensure and credentialing, as VA remains committed 
to developing contracts for high performing networks.
    Because of the measures already in place to ensure that VA 
only utilizes the highest quality providers in the community, 
VA is concerned that the administrative requirements of this 
legislation as written would have the potential to adversely 
impact Veteran access to community care as well as limit 
current and future contractors' ability to timely recruit and 
retain qualified providers within their networks.
    VA also has concerns relating to due process protections 
under the bill. To the extent VA relies on any fact that had 
not been established through a complete and fair process 
satisfying the requirements of due process (e.g., a criminal 
conviction, or a full investigation and determination by a 
State licensing board), the Agency's decision should be 
appealable. VA does not have an existing process that could 
accommodate such appeals. Affected providers must be given 
notice and an opportunity to be heard to contest such 
determinations or beliefs in order to satisfy due process 
requirements, but it is unclear how VA would provide for this.
    VA is unable to provide a cost estimate for this proposal 
as currently written because it is unclear what additional 
administrative requirements would be needed to ensure 
appropriate review and protections are in place.

           S. 1325--BETTER WORKFORCE FOR VETERANS ACT OF 2017

    The draft bill, ``Better Workforce for Veterans Act of 
2017,'' contains a number of provisions intended to improve the 
authorities of the Secretary to hire, recruit, and train 
employees of the Department.
    Section 101(a) would create a new section 718 that would 
authorize the Secretary to recruit and appoint qualified recent 
graduates and post-secondary students to competitive service 
positions within the Department, notwithstanding certain 
provisions of Title 5. The Secretary would only be authorized 
to appoint no more than a number equal to 15 percent of the 
number of hires made into professional and administrative 
occupations at the GS-11 level or below (or equivalent) during 
the previous fiscal year. The Secretary would be required to 
develop regulations governing this authority. To the extent 
practicable, the Secretary would be required to publicly 
advertise positions available under this section within certain 
constraints.
    VA supports the concept of this provision, but also would 
like to note that the Administration authored a similar 
proposal that would be applicable to all agencies, and 
transmitted it for consideration in the FY 2018 National 
Defense Authorization Act (FY 2018 NDAA). This would provide 
greater flexibility to hire students and recent college 
graduates, providing an immediate opportunity for new employees 
to begin their careers with VA. The Administration would prefer 
a Government-wide solution that would provide a significant 
recruitment benefit if all agencies were able to utilize it.
    Section 101(b) would create a new section 719 that would 
require the Secretary to prescribe regulations to allow for 
excepted service appointments of certain students and recent 
graduates leading to conversion to career or career conditional 
employment.
    VA defers to OPM on implementation of this provision as an 
important element to implementing the program authorized by 
section 101(a) for certain students and interns. OPM would be 
best suited to provide any necessary technical drafting 
assistance to align these authorities with OPM's current 
Government-wide Pathways Program.
    Section 102 would amend section 3304(a)(3)(B) of Title 5 to 
permit the Secretary to appoint directly for positions for 
which there is a severe shortage of highly qualified 
candidates. OPM would have the authority to determine what 
positions would qualify, as well as having the ability to 
delegate the authority to make those determinations.
    VA supports this provision as this would provide greater 
flexibility to directly reach applicants when we have a severe 
shortage of highly qualified candidates. This would help the 
Department address some of its most critical vacancies.
    Section 103 would create a new section 712 to authorize the 
Secretary to appoint a former Federal employee to a high-demand 
position within the Department for which the former Federal 
employee is highly qualified without regard to provisions 
concerning competitive appointments. The former Federal 
employee could be appointed to a position at a higher grade or 
with more promotion potential than the position the employee 
previously held. Within 18 months of enactment, the Inspector 
General of the Department would be required to conduct an audit 
of the use of this authority by the Secretary and report to 
Congress on the results of that audit.
    VA defers to OPM on this provision. Currently, we could 
hire someone non-competitively to a position at the same level 
they previously held, while this provision would allow VA to 
hire someone to a higher level than they previously held. 
Therefore, implementation would need to be measured, with 
appropriate controls in place to prevent misuse.
    Section 104 would create a new section 720 to require the 
Secretary to develop and implement a resume-based application 
method for applications for appointment to senior executive 
positions within VA. The application would have to be, to the 
extent practicable, comparable to the resume-based application 
method for the Senior Executive Service (SES) developed by the 
Office of Personnel Management (OPM), and would have to be used 
for initial applications for a position as a senior executive 
to the extent such use will be more efficient and effective and 
less burdensome for all participants. The Secretary would be 
authorized to make an initial career appointment of an 
individual to a position as a senior executive if a review 
board convened by VA certifies the executive and managerial 
qualifications of the individual.
    At this time, VA does not support this provision because we 
do not believe it is necessary. Resume-based application is 
allowed under current rules, and VA would like to maintain 
flexibility in hiring and assessment. VA currently uses a 
resume-based system for executive recruitment for its medical 
center Director positions, and with the recently enacted 
Department of Veterans Affairs Accountability and Whistleblower 
Protection Act of 2017 (Public Law 115-41), signed June 23, 
2017, VA now has direct hiring authority for these and VISN 
Director positions. We continuously evaluate our hiring 
methods, timeframes, and outcomes to identify opportunities for 
improvement, and we would be happy to share our findings with 
the Committee.
    Section 105 would establish a new section 721 that would 
require the Secretary to establish and periodically review a 
single database that lists each vacant position in VA that the 
Secretary determines is critical to VA's mission, difficult to 
fill, or both. If the Secretary determines that an applicant 
for a position listed in the database is qualified for such 
position, but the Secretary does not select such applicant, the 
Secretary, at the election of the applicant, would be required 
to consider the applicant for other, similar vacant positions 
listed in the database. If the Secretary did not fill a vacant 
position listed in the database after an appropriate time (as 
determined by the Secretary), the Secretary would be required 
to ensure that applicants who were not selected for other 
positions but who meet the qualification requirements are 
considered. The Secretary would also be required to use the 
database to assist in filling such positions. Within 1 year of 
enactment, the Secretary would be required to submit a report 
to Congress on the use and efficacy of the database established 
under this section.
    We support the concept of identifying and maintaining a 
database of vacancies, but do not support this particular 
provision. VA completed the implementation of a commercial 
software product as the core foundation to our new enterprise 
automated human resources system. We will implement an 
enhancement in FY 2018 to manage positions, which will provide 
real-time vacancy information. With the systems we currently 
have in place and in development, we believe we can meet the 
intent of this provision without legislation, and in a way that 
is less administratively burdensome.
    Section 106 would create a new section 722 that would 
require the Secretary to measure and collect information on 
indicators of hiring effectiveness concerning certain 
identified factors related to recruiting and hiring candidates, 
as well as the satisfaction of employees, newly hired 
employees, and applicants. To the extent practicable, and in a 
manner protecting personally identifiable information, the 
Secretary would be required to collect and report data 
disaggregated by facility and VISN to ensure the data is 
collected from human resources offices throughout VA. The 
Secretary would be required to submit an annual report to 
Congress on the information collected, and to make such 
information publicly available.
    As written, we do not support this provision. We are 
concerned the vagueness of the language could result in 
application to virtually every aspect of the recruitment 
process. The terminology in this provision includes subjective 
terms, and we believe some provisions may be inconsistent 
internally. In addition, these provisions could be inconsistent 
with other agencies' recruitment and hiring information. We 
have a number of technical comments and recommendations and 
would be glad to share those with the Committee. We also would 
request that the Committee solicit OPM for technical drafting 
assistance on this provision.
    Section 107 would create a new section 723 requiring the 
Secretary to develop and carry out a standardized, anonymous, 
voluntary exit survey for career and non-career employees who 
voluntarily separate from VA. The survey would have to ask 
questions regarding the reasons for leaving, any efforts made 
to retain the individual, the extent of job satisfaction and 
engagement, the intent of the employee to remain in or leave 
Federal employment, and other matters considered appropriate by 
the Secretary. The Secretary would be required to share the 
results of the survey with the directors and managers VA 
facilities and VISNs, and the Secretary would be required to 
report annually on the aggregate results of the exit survey.
    We do not support this provision because we believe it is 
unnecessary, given that we already use exit surveys that 
capture almost all of the content this legislation would 
require.
    Section 108 would amend section 2108(1) of Title 5 
concerning Veteran preference so that any Veteran who served a 
total of more than 180 days would qualify, rather than only 
those who served more than 180 consecutive days.
    We note that this provision would amend title 5 and apply 
to the entire Federal government. As a result, we defer to OPM 
on this provision.
    Section 109 would amend section 705(a) of the Veterans 
Access, Choice, and Accountability Act of 2014 to clarify that 
recruitment, relocation, or retention incentives are not 
subject to the limitations on awards and bonuses available in 
the Department.
    VA supports this provision. Currently, the limitations on 
awards and bonuses include recruitment, retention, and 
relocation incentives, which have severely limited the 
Department's ability to offer incentives to hire and retain 
critical positions. Under these limitations, the Department has 
attempted to reserve the bulk of the funds that are available 
to provide incentives to positions, particularly medical 
professionals with specialized skills and expertise that would 
be difficult or impossible to replace. This has resulted in an 
inequitable treatment among employees, as there are fewer 
resources available for those otherwise deserving and equally 
dedicated employees.
    If this authority were enacted, VA would reallocate funds 
already appropriated for recruitment and retention of highly 
qualified employees.
    Section 110 would amend section 7309 of Title 38 to remove 
the requirements that the Chief Officer of VA's Readjustment 
Counseling Service (RCS) must have at least 3 years of 
experience providing direct counseling services or outreach 
services through RCS, as well as 3 years of experience 
administrating direct counseling services or outreach services 
through RCS.
    VA supports this provision. This would provide greater 
flexibility to appoint the Chief Officer of RCS, which oversees 
VA's Vet Centers, a critical component to providing Veterans 
and Servicemembers readjustment counseling and other services.
    There would be no costs associated with this provision.
    Section 111 would require, within 120 days of the date of 
the enactment of this Act, the Secretary to submit a report to 
Congress on vacancies within the Veterans Health 
Administration. This report would have to include vacancies of 
personnel appointed under section 7401 of title 38, vacancies 
of human resource specialists in VHA, a description of any 
impediments to filling certain vacancies, and an update on the 
implementation of several plans and reports.
    We do not believe section 111 is necessary, but we do not 
oppose this requirement. Until the system enhancement 
previously mentioned is implemented in FY 2018, collecting this 
information is a manual and intensive effort. As a result, we 
are concerned that the 120 day deadline would be difficult to 
meet. We believe that we would be in a better position to 
gather this information within the next year.
    Section 201 would create a new section 724 providing that 
for any reduction in force by VA, competing employees would be 
released with due effect to the following in order of priority: 
tenure of employment, military preference, efficiency or 
performance ratings, and length of service.
    We do not oppose section 201 because this would only change 
the order of consideration for how reductions in force would 
occur. However, we would defer to OPM, to ensure that reduction 
in force procedures remain consistent across the Government. We 
note that for hybrid title 38 positions, we think it would be 
appropriate to also consider the level and type of licensure, 
as well as the scope of practice, in making such 
determinations.
    Section 202 would create a new section 725 authorizing the 
Secretary to arrange, with the agreement of a private-sector 
organization, for the temporary assignment of VA employees to 
such organization to occupy a position in that organization and 
for the private sector employee who held that position to 
temporarily occupy the position of the VA employee. In essence, 
these employees would be trading positions for a temporary 
period. The VA employee would return to work for the 
Department, and if either employee failed to carry out the 
agreement, the employee would be liable to the United States 
for payment of all expenses of the assignment, with certain 
exceptions; such liability would be a debt that could be waived 
if the Secretary determined collecting it would be against 
equity and good conscience and not in the best interests of the 
United States. The VA employee would be prohibited from using 
pre-decisional, draft deliberative, or other information for 
the benefit or advantage of the private sector organization. 
Assignments would be for periods between 3 months and 4 years. 
VA employees assigned to the private sector organization would 
be considered, during the period of assignment to be on detail 
to a regular work assignment in the Department for all 
purposes. The private sector employee assigned to VA employment 
would generally not be considered a Federal employee with 
certain exceptions and would have other constraints imposed 
upon the scope of that employee's work with the Department. The 
private sector organization would be prohibited from charging 
VA, as direct or indirect costs under a Federal contract, for 
the pay or benefits paid by the organization to the employee 
assigned to VA. The Secretary would be required to take into 
account certain considerations in operating this program.
    In theory, VA supports the concept of rotational 
assignments for professional development, and notes that the 
Administration submitted, in the context of the FY 2018 NDAA, a 
similar proposal to provide government-wide authority for 
industry exchange programs. We note, however, that the 
potential for conflicts of interest in this provision are 
significant, notwithstanding the language in the bill 
attempting to limit this. There are several areas where this 
provision is ambiguous, and we would appreciate the opportunity 
to discuss this further with the Committee prior to taking a 
position on this section. We would recommend that the Committee 
work with the Office of Government Ethics on the appropriate 
language to address issues related to conflicts of interest.
    Section 203 would amend section 7306 to allow for the 
appointment of VISN Directors in addition to medical center 
Directors to suit the needs of the Department. It would also 
remove the requirement for these Directors to be qualified 
doctors of medicine, or doctors or dental surgery or dental 
medicine. It would further amend that section to allow the 
Secretary to establish qualifications for these Directors and 
appoint them under this authority. The Secretary and the 
Director would be required to enter into an agreement that 
permits employees appointed under this authority to transfer to 
SES positions in other Federal agencies and to be deemed career 
appointees who are not subject to competition or certification 
by a qualifications review board.
    Section 207 of the Department of Veterans Affairs 
Accountability and Whistleblower Protection Act of 2017 (Public 
Law 115-41), signed June 23, 2017, significantly amended VA's 
authority to hire directly VISN and medical center Directors. 
In this context, we would like the opportunity to discuss this 
proposal further with OPM and the Committee to consider the 
effects of these proposed changes before taking a position on 
this section.
    Section 204 would create a new subchapter VII in chapter 74 
concerning pay for medical center Directors and VISN Directors. 
The new section 7481 would provide that pay for these Directors 
would consist of basic pay and market pay, which would be 
determined by the Secretary on a case-by-case basis and consist 
of pay intended to reflect the needs of the Department with 
respect to recruitment and retention of such Directors. The 
bill would impose other requirements in terms of determining 
market pay under this section. The Secretary would be required, 
not less frequently than once every 2 years, to set forth 
within defined parameters Department-wide minimum and maximum 
amounts for total pay for Directors, and to publish such limits 
in the Federal Register. Pay under this section would be 
considered pay for all purposes, including retirement benefits. 
A decrease in the pay of a Director resulting from an 
adjustment in market pay could not be considered an adverse 
action, while a decrease resulting from an involuntary 
reassignment in connection with a disciplinary action would not 
be subject to appeal or judicial review. The OPM Director would 
be required to undertake periodic reviews of the Secretary's 
determinations and certify to Congress each year whether or not 
the market pay is in accordance with the requirements of this 
section. If the Director determined the amounts were not in 
accordance with the requirements of this section, the Director 
would report to Congress on such determination as soon as 
practicable after making such determination.
    We appreciate the Committee's interest in this regard. 
Similar to section 203, we note that given the recent change 
(Public Law 115-41) in our appointment authority for VISN and 
medical center Directors, we would like to discuss this 
proposal further with OPM and the Committee prior to taking a 
position on the specific provisions in this section. We 
anticipate there would be additional costs to implement this 
section.
    Section 205 would create a new section 7413 that would 
require the Secretary to provide to VHA human resources 
professionals training on how best to recruit and retain VHA 
employees. The Secretary would provide such training in a 
manner considered appropriate considering budget, travel, and 
other constraints. The Secretary would be required to ensure 
that each VHA human resources professional received such 
training as soon as practicable after being hired and annually 
thereafter. The Secretary would be required to ensure that a 
medical center Director, VISN Director, or senior officer at 
Central Office certified that the professional completed such 
training. The Secretary would be required to report annually on 
the training provided under this authority, including the cost 
of such training, and the number of professionals who receive 
such training.
    We do not support section 205 because VA already has the 
authority to conduct such training. VA provides training to 
human resources professionals currently, and we are concerned 
that the specific requirements in this provision could 
constrain our ability to adapt training to emerging needs. We 
also have some technical concerns with this provision that we 
will share with the Committee.
    Section 206 would require the Secretary to include 
education and training of marriage and family therapists and 
licensed professional mental health counselors in carrying out 
the education and training programs conducted under section 
7302(a)(1). The Secretary would be required, to the degree 
practicable, to ensure that the licensing and credentialing 
standards for therapists and counselors participating in this 
program are the same as the licensing and credentialing 
standards for eligibility of other participants in the program. 
Finally, the Secretary would be required to apportion funding 
for education and training equally among the professions 
included in the program.
    In general, we currently have the authority to carry out 
this section. VA has already established training programs for 
licensed professional mental health counselors and marriage and 
family therapists. We are concerned with the potential effect 
this could have on the quality of the education and training 
standards, and we would appreciate the opportunity to discuss 
this further with the Committee. We are also concerned that the 
language, particularly in subsection (c) of this provision, is 
too prescriptive and could limit VA's flexibility to adjust 
training needs and resources to meet operational needs.
    Section 207 would require, within 180 days of the date of 
enactment of this Act, the Secretary and the Surgeon General to 
enter into a memorandum of understanding (MOU) for the 
assignment of not fewer than 500 commissioned officers of the 
Regular Corps of the Public Health Service to VA. The Secretary 
would reimburse the Surgeon General for expenses incurred in 
assigning commissioned officers to VA. Within 1 year of 
enactment, the Secretary and Surgeon General would each be 
required to submit to Congress a report on the MOU and the 
commissioned officers assigned under this authority.
    We do not support this provision because it is unnecessary. 
VA and the Department of Health and Human Services (HHS) signed 
an MOU earlier this year to allow for commissioned officers of 
the Public Health Service to serve in VA. We would like the 
opportunity to discuss this further with the Committee and HHS 
to determine what, if any, legislative authority we need in 
this area.
    Section 208(a) and (b) would require, within 1 year of the 
date of enactment of this Act, the Under Secretary for Health 
to develop a comprehensive competency assessment tool for VHA 
human resources employees to assess the knowledge of such 
employees on how employees appointed under section 7401(1) are 
treated differently than employees appointed under other 
authorities. Within 2 years of the date of enactment of this 
Act, and once every 2 years thereafter, the Secretary would 
have to submit a certification to Congress as to whether an 
assessment of all VHA human resources employees was conducted 
and whether such employees used the results of such assessment 
to identify and address competency gaps. Within 18 months of 
the date of enactment of this Act, the Under Secretary for 
Health would be required to evaluate the extent to which these 
training strategies are effective at improving the skills and 
competencies of VHA human resources employees.
    Section 208(c) would require, within 1 year of enactment, 
the Under Secretary for Health to establish clear lines of 
authority that provide the Assistant Deputy Under Secretary for 
Health for Workforce Services the ability to oversee and hold 
the heads of the human resources offices of VA medical centers 
accountable for implementing initiatives to improve human 
resources processes and for ensuring employees undertake the 
assessment required under subsection (a). Within 1 year of 
enactment of this Act, the Secretary would be required to 
clarify the lines of authority and processes for the Under 
Secretary for Health and the Assistant Secretary for Human 
Resources and Administration with respect to overseeing holding 
the VISN and VA medical center Directors accountable for the 
consistent application of Federal classification policies.
    Section 208(d) would require the Secretary to ensure the 
Under Secretary for Health and the Assistant Secretary for 
Human Resources and Administration are responsible for 
monitoring the status of corrective actions taken at human 
resources offices of VA medical centers and that such actions 
are implemented.
    Section 208(e) would require the Secretary to ensure that 
meaningful distinctions are made in performance ratings for VHA 
employees.
    Section 208(f) would require, within 1 year of enactment of 
this Act, the Under Secretary for Health and the Assistant 
Secretary for Human Resources and Administration to develop a 
plan to implement a modern information technology (IT) system 
to support employee performance management processes.
    Section 208(g) would require, within 1 year of enactment of 
this Act, the Under Secretary for Health to establish clear 
lines of authority and accountability for developing, 
implementing, and monitoring strategies for improving employee 
engagement across VHA. The Under Secretary for Health would be 
required to report to Congress on whether VHA should establish 
an employee engagement office at the headquarters level with 
appropriate oversight of VISN and VA medical center employee 
engagement initiatives.
    We do not believe this section is necessary. We are 
currently implementing the requirements of these provisions 
based on the recommendation of a Government Accountability 
Office (GAO) report (GAO 17-30). We also have some technical 
concerns we believe need to be addressed, and we will be glad 
to provide those to the Committee.
    Section 208(h) would require, within 1 year of enactment, 
the Comptroller General to examine the overlapping functions of 
human resource structures within VHA and the Office of the 
Assistant Secretary of Human Resources, whether there are 
opportunities to centralize offices and tasks that are 
duplicative, and whether the use of multiple hiring structures 
has had an effect on the speed with which VA hires new 
employees. The Comptroller General would report to Congress on 
the Comptroller General's findings.
    VA defers to the Comptroller General on this provision.
    Section 209 would require, within 120 days of enactment of 
this Act, the Secretary to report to Congress on the effect the 
freeze on the hiring of Federal civilian employees ordered by 
the President on January 23, 2017, has had on the ability of VA 
to provide care and services to Veterans.
    We do not believe this is necessary, and do not support it, 
as the hiring freeze was only in effect, at most, for a limited 
number of positions not related to patient care or access. We 
also do not believe it would be possible to identify to any 
meaningful degree any effects that may have occurred as a 
result of the hiring freeze.
    Section 210 would require, within 180 days of enactment of 
this Act, the Secretary to report to Congress on how the 
Secretary plans to implement the portions of the plan of the 
OPM Director to reduce the size of the Federal workforce 
through attrition as it pertains to VA.
    We believe this provision is unnecessary. VA is working to 
implement an agency reform plan, consistent with the OMB 
Director's requirements. We are looking at how we will be 
filling administrative positions that become vacant, along with 
other potential actions, and will be updating these plans and 
assessments in the future. We would be happy to share with the 
Committee the plan the Department submits to OMB when it is 
available.
    Section 211 would require, within 180 days of enactment of 
this Act, the Secretary to publish online information on 
staffing levels for nurses at each VA medical facility. The 
head of each medical facility would be required to update the 
information as changes to the staffing level of nurses at the 
facility occur. The Secretary would be required to consult with 
Centers for Medicare & Medicaid Services in developing the 
information required by this section. The Secretary would be 
required to submit a report to Congress discussing and 
assessing the use by medical center Directors of authorities to 
provide nurses pay that reflects market conditions, the 
adequacy of training resources for nurse recruiters, the key 
recruitment and retention incentives of VHA for nurses, and 
other factors.
    We do not support this provision for two major reasons. 
First, the staffing levels referenced in the bill are not 
defined. Second, the actual number of nurses varies on an 
almost daily basis given the volatility in terms of staffing. 
It would be incredibly cumbersome to maintain this information 
and update it in real time. We already report to Congress each 
year on efforts to provide nurses greater pay, and this report 
would be duplicative of that effort.
    Section 212 would require, within 1 year of enactment of 
this Act, the Secretary, in consultation with the OPM Director, 
to ensure that the job description, position classification, 
and grade for each position as a police officer or firefighter 
in VA are in accordance with standards for the classification 
of such positions prepared by OPM. The Secretary would be 
required to develop a staffing model for the positions of 
police officers and firefighters within the Department. The VA 
Inspector General would be required to conduct an audit of VA's 
efforts to recruit and retain police officers and firefighters 
and report to the Secretary and Congress on the audit's 
findings. Finally, the Secretary would be required to report to 
Congress on the use by medical center Directors of special pay 
incentives to recruit and retain trained and qualified police 
officers and the steps the Secretary plans to take to address 
the critical shortage of police officers throughout the 
Department.
    We have some concerns with this provision. We believe the 
reviews required by this section could require a considerable 
amount of resources. We would like the opportunity to discuss 
this proposal further with the Committee and OPM to determine 
what we may be able to do currently to address the Committee's 
concerns and interests in this matter.
    Section 213 would require, within 1 year of enactment of 
this Act, the VA Inspector General to complete a study on how 
VHA communicates its directives, policies, and handbooks to the 
field, including the compliance with such documents, and the 
effectiveness of each VISN in disseminating information to 
employees within the Network and Veterans served by the 
Network.
    The Department defers to the Inspector General on this 
provision.
    As noted above, VA will be providing follow-up views for 
the record on S. 1279, the Veterans Health Administration 
Reform Act, the draft Department of Veterans Affairs Quality 
Employment Act of 2017, and section 10 of the Veterans Choice 
Act of 2017.

                  S. XXXX--VETERANS CHOICE ACT OF 2017

    The draft Veterans Choice Act of 2017 contains a number of 
provisions intended to improve VA's community care program. 
Community care has helped significantly expand access to care 
for Veterans nationally and plays an important role in VA's 
effort to build a modern, integrated health care network.
    Section 3(a) of the bill would amend section 1703 of title 
38 to authorize the Veterans Choice Program. Under this 
Program, all enrolled Veterans would be eligible to elect to 
receive hospital care, medical services, mental health 
services, and certain diagnostic services, outpatient dental 
services, and diagnostic services from specified eligible 
providers. These services could be provided through 
telemedicine, at the election of the Veteran. The Secretary 
would be required to enter into consolidated, competitively bid 
regional contacts with health care organizations or third party 
administrators to establish networks of eligible providers for 
the purpose of providing sufficient access to care and 
services. The bill would define various responsibilities for 
these organizations or administrators, including enrolling 
covered Veterans, conducting referrals and authorizations, 
customer service, and maintaining an interoperable electronic 
health record. These parties would be required to leverage 
advanced technology to allow Veterans to make their own 
appointments, including online and through smart phone 
applications. Veterans who need assistance making their 
appointments could receive assistance from the organization or 
administrator or the Secretary. The organizations or 
administrators would be required to meet capability, capacity, 
and access standards established by the Secretary, including 
those established pursuant to sections 9 and 10 of this bill. 
Providers who currently furnish care or services under another 
authority would be offered the opportunity to furnish care and 
services through this Program.
    Under the Veterans Choice Program, the rates paid for care 
or services could not exceed the Medicare rate, except in 
highly rural areas, in the State of Alaska, in a State with an 
All-Payer Model Agreement that became effective on January 1, 
2014, or at other rates established by the Secretary if no 
Medicare rate exists. The Secretary would be authorized to 
recover from a third party for any care furnished for a non-
service-connected disability, and the Secretary would be 
responsible for paying the copayment, deductible, or 
coinsurance charged to the Veteran for care or services. 
Veterans could not be required to pay a greater amount for 
receiving care or services than they would if they had received 
comparable care or services at a VA medical facility or from a 
VA medical provider.
    The proposed amendments to section 1703 would impose other 
requirements. For example, VA would have to ensure the Veterans 
Health Identification Card issued to every enrolled Veteran 
includes the words ``Choice eligible'' and additional 
information needed to serve as an identification card for the 
Program. Additionally, the Secretary would be required to 
monitor a number of quality and access standards related to the 
care furnished under this Program. These changes would become 
effective upon the termination of the current Veterans Choice 
Program operated pursuant to section 101 of the Veterans 
Access, Choice, and Accountability Act of 2014.
    We support many of the principles in the proposed section 
1703. We appreciate that the section's eligibility criteria 
would be simple to administer by making every enrolled Veteran 
eligible to participate. We also appreciate the flexibility in 
terms of eligible providers, and the regional network model 
generally matches our current plans with the Community Care 
Network solicitation. We also appreciate the section's 
recognition of the importance of ensuring quality care is 
furnished to Veterans through this Program.
    However, we have some significant concerns with certain 
provisions of proposed section 1703. In many areas, there are 
provisions that are overly prescriptive and that would narrow 
the Secretary's authority to adjust to evolving situations. For 
example, the Secretary would be prohibited from directing 
Veterans to certain health care providers. While we support 
Veterans' choosing their own providers, we understand that many 
Veterans do not express a specific preference for an individual 
provider, and this language could restrict our ability to 
direct Veterans to high-performing providers who are available. 
Also, the responsibilities of the regional networks are too 
specific--we would prefer the language be silent on these 
matters so that we can adjust responsibilities between VA and 
our regional networks to ensure the best services are available 
for Veterans. Furthermore, the language concerning payment 
rates is too limiting. There will be situations where VA will 
need to pay more than the Medicare rate other than in highly 
rural areas, the State of Alaska, and States with All-Payer 
Model Agreements. We have serious concerns with the language in 
proposed 1703(h), which would require the Secretary to pay the 
amount of a Veteran's copayment, deductible, or coinsurance. 
This would be inconsistent with private sector and VA's current 
practice. Section 1729 currently provides that Veterans are not 
required to pay a copayment, deductible, or coinsurance 
required under the terms of their health insurance for care and 
services furnished by the Department. Moreover, requiring the 
Department to pay a Veteran's copayment, deductible, or 
coinsurance could significantly increase the Department's 
expenses, including its administrative costs, in ways that we 
cannot currently project given the variability in insurance 
plans and payment responsibilities for the millions of Veterans 
with such insurance. While we support the principle of ensuring 
quality care, we are concerned that some of the language in 
proposed 1703(l) would be too prescriptive, and we would prefer 
more general language.
    Requiring that the words ``Choice eligible'' appear on a 
Veterans Health Identification Card (VHIC), as provided for in 
proposed section 1703(k), would create redundancy and be 
extremely costly. The bill would make any enrolled Veteran 
eligible for Choice, and all enrolled Veterans are issued 
VHICs, so any person with a VHIC would already establish his or 
her eligibility by virtue of having the VHIC. Requiring 
Veterans to have a VHIC with the words ``Choice eligible'' 
would also produce greater demands on Veterans who would have 
to come to a VA facility to receive an updated version of their 
VHIC.
    Finally, we are concerned that there is no transition 
period contemplated by section 3(a)(3). The new 1703 would take 
effect immediately upon the expiration of the current Veterans 
Choice Program, based on the exhaustion of the Veterans Choice 
Fund. We believe that either a clear timeline (such as 1 year 
from enactment) or an event within the Department's control 
(such as the publication of regulations) would be preferable 
for the transition between the current Choice Program and the 
future Choice Program. We also may encounter problems where 
individual authorizations made under the current 1703 would no 
longer have any legal authority for payment upon this 
transition, as this provision would completely rewrite section 
1703. While the Department would try to reduce the potential 
for this issue, we would not be able to eliminate this problem.
    Section 3(b) would prohibit VA from entering into or 
renewing any contract or agreement under a non-Department 
provider program, which would include the current Veterans 
Choice Program; the Patient-Centered Community Care (PC3) 
program; the Project Access Received Closer to Home (ARCH) 
program; VA's retail pharmacy network; agreements entered into 
with DOD, IHS, or other Federal agencies; agreements entered 
into with academic affiliates of VA; agreements to furnish 
care, including on a fee basis; or agreements with non-
governmental entities. If the Secretary continued to administer 
any of these programs after the date on which the new Veterans 
Choice Program begins, they could only be administered under 
that Program. The Secretary would be required to ensure 
continuity of care by making services available through 
regional contracts or other agreements entered into under the 
new Veterans Choice Program.
    We are very concerned with this provision and do not 
support it. It would require VA to renegotiate, reissue, or 
terminate every agreement and contract, regardless of the terms 
or conditions of such an agreement permitting extensions or 
other flexible authorities. We believe this could affect such 
agreements as those with DOD, IHS, and tribal health programs, 
as well as with our academic affiliates and contractors. This 
would include thousands of agreements, would be very difficult 
and costly to do, and would not produce any clear, tangible 
benefit. If these agreements would also now be subject to the 
limitations in proposed section 1703, this provision could put 
conditions on these agreements that would be unacceptable to 
certain providers or in certain areas. This could also 
potentially impact our relationships with certain providers, 
such as IHS and tribal health programs, which require 
consultation prior to changes. We also note, given the breadth 
of section 3(b)(4)(E), that extended care services procured 
from the community would be included, but note that the 
language for the Veterans Choice Program in section 1703 does 
not address such services; as a result, it is unclear what 
terms and conditions would apply to these services.
    Section 4 would establish a new section 1703A authorizing 
VA to enter into Veterans Care Agreements (VCA). VCAs could be 
entered into when the Secretary is not feasibly able to furnish 
hospital care, medical services, or extended care services at 
VA facilities or when such care or services are not available 
under the Veterans Choice Program. Providers could opt to enter 
into a VCA, at the discretion of the eligible provider. The 
eligibility of Veterans for care would be the same as if they 
received care in a VA facility. The Secretary would be 
prohibited from directing Veterans seeking care or services to 
health care providers who have entered into contracts or 
sharing agreements under different authorities, except for 
Veterans Choice Agreements authorized under section 101 of the 
Veterans Access, Choice, and Accountability Act of 2014 or 
under the regional contracts or other arrangements made under 
section 1703, as revised by section 3 of this bill.
    The Secretary would be required to establish a process for 
the certification of eligible providers. VCAs would have to 
include certain terms, including accepting payment at Medicare 
rates (except in highly rural or underserved areas), accepting 
payment as payment in full, and other terms and conditions. 
Each VCA would permit the provider to submit to the Secretary 
clinical justification for any services furnished without 
authorization when seeking payment, and the Secretary would 
review these submissions on a case-by-case basis in determining 
whether or to pay the provider for such services. The Secretary 
would be required to review periodically VCAs of a material 
size to determine whether it is feasible and advisable to 
furnish the care and services at a VA facility or through 
contracts or sharing agreements. VCAs would not be subject to 
laws requiring competitive procedures in selecting the party 
with which to enter the agreement. Parties entering into a VCA 
would not be treated as a Federal contractor by the Office of 
Federal Contract Compliance Programs (OFCCP) of the Department 
of Labor, and they would not be subject to any laws that such a 
provider would not be subject to 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.), except for 
laws applying to integrity, ethics, fraud, or that subject a 
person to civil or criminal penalties. Title VII of the Civil 
Rights Act of 1964 (42 U.S.C. 2000c et seq.) would apply to 
parties entering into a VCA. The Secretary would be required to 
establish a system or systems, consistent with those used by 
the Centers for Medicare and Medicaid Services, to monitor the 
quality of care provided and would be required to establish 
administrative procedures for dispute resolution. The Secretary 
would be required to prescribe an interim final rule within 1 
year of enactment to carry out this section.
    We generally support this provision, but have some concerns 
we would like to address. In particular, proposed section 
1703A(a)(2)(A)(ii) would prohibit the Secretary from entering 
into a VCA if care or services are available under the new 
Veterans Choice Program. Although we appreciate the intent of 
this provision, we believe there may be situations where the 
clinical need of the Veteran will require the use of a VCA 
notwithstanding the availability of such services under the 
Choice Program. For example, a Veteran may require a certain 
type of orthopedic procedure, and while orthopedics in general 
are ``available'' under a contract, the specific procedure or a 
specialist may not be included within the contract, or would 
only be available at a lesser quality. In other situations, a 
Veteran may elect to receive care from a certain provider that 
would be ideally suited to furnishing the care required, but 
who is not a member of the network. We want to ensure we have 
flexibility in situations like these to deliver the care the 
Veteran requires in a timely and appropriate way. We also note 
these provisions apply for when the Secretary may ``enter 
into'' agreements, rather than ``use'' agreements. We have 
found, through our experience with the current Veterans Choice 
Program that it is more efficient to enter into these 
agreements before they are needed to ensure that there is no 
delay in the receipt of care by eligible Veterans. We believe 
the language could be modified slightly to impose restrictions 
on the utilization of VCAs to ensure the integrity and use of 
the network of providers under the new Veterans Choice Program.
    Proposed section 1703A(e)(2) is unclear, and depending upon 
what the intent is, we may or may not support it. If the 
provision is intended to simply allow providers to submit 
claims for care that was unconnected or unrelated to the 
services VA originally authorized, we are concerned this could 
create situations where VA pays for services that were neither 
authorized nor clinically needed. This would create a 
significant administrative burden on both the providers and VA. 
If, on the other hand, this is intended to apply only in 
limited circumstances for care that VA would have authorized, 
then we have no objection to it.
    Regarding proposed section 1703A(g), VA agrees with the 
idea of monitoring how VCAs are utilized by VA. However, we are 
concerned that the threshold for when an agreement for the 
purchase of extended care services is considered to be of 
``material size,'' i.e., exceeding ``$1,000,000 annually,'' is 
too low. Costs for long term extended care and nursing home 
care costs can easily exceed this level. The threshold also 
does not account for providers who may have a national 
presence.
    Section 5(a) would establish a new section 1703B concerning 
payment of non-Department health care providers. Specifically, 
VA would be required to comply with the provisions in this 
section and in chapter 39 of title 31 (the Prompt Payment Act). 
Non-Department providers would be required to submit a claim 
for reimbursement within 180 days, and the Secretary would have 
to pay claims according to specified time standards or else 
interest would accrue on the amount owed. If a provider submits 
a clean claim, VA would have to pay the claim within 30 days if 
it was submitted electronically or 45 days if it was submitted 
other than electronically. If a claim were not clean, the 
Secretary would have to inform the provider within 10 days on 
the steps that would be needed to make it clean. By January 1, 
2020, the Secretary would only be authorized to accept claims 
electronically except in certain circumstances.
    We generally support section 5(a), but have some concerns 
with a few of the provisions. For example, we think there 
should be more flexibility to accept paper claims from smaller 
providers, such as Homemaker/Home Health Aides. We are also 
concerned that, as written, this language could require that 
late payments of providers who have entered into contracts with 
the Regional Networks could subject VA to interest payments, 
even though VA has no privity of contract with these providers 
and is paying the Network on time. Finally, we do not believe 
the Committee had transactions between VA and other Federal 
entities in mind when it included a prompt payment standard in 
the draft bill. An exception could be added in this section to 
address this issue.
    Section 5(b) would require the Secretary, not later than 2 
years after the date of the enactment of this Act, to enter 
into an agreement with a third-party entity to process claims 
for reimbursement through an electronic interface.
    We are concerned about the intended scope of this 
provision. If the electronic interface processing the claims is 
only preparing them for adjudication and approval by VA, we do 
not support this provision because VA is currently working on a 
process internally that would perform this function. If the 
term ``process'' is intended to cover adjudication and payment 
as well, we would like to discuss with the Committee our 
reservations about such an arrangement and propose potential 
alternatives instead.
    Section 6 would amend section 1745 to authorize the 
Secretary to enter into agreements with State Veterans Homes 
that would not be subject to laws requiring competitive 
procedures in selecting the party with which to enter the 
agreement. State Homes entering into these agreements would not 
be subject to any laws that such a provider would not be 
subject to 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.), except for laws applying to 
integrity, ethics, fraud, or that subject a person to civil or 
criminal penalties. Title VII of the Civil Rights Act of 1964 
(42 U.S.C. 2000c et seq.) would apply to State homes entering 
into these agreements. These changes would become effective 
upon the Secretary's publishing regulations to implement these 
new authorities.
    We generally support section 6, although, we have similar 
concerns to those we expressed regarding section 4 with respect 
to the applicability of certain laws.
    Section 7 would amend section 1705 to require the 
Secretary, upon the enrollment of a Veteran in the VA health 
care system, to assign the Veteran to a dedicated primary care 
provider of the Department, unless the Veteran elects to choose 
a primary care provider from among the health care providers 
furnishing care in the network established under the new 
Veterans Choice Program.
    We do not support section 7 because this would require all 
enrolled Veterans to be enrolled in provider panels, even if we 
do not furnish care to those Veterans. We typically only assign 
Veterans to a panel once they have expressed interest in 
receiving care from the Department. We are concerned that 
assigning other Veterans to panels will complicate our 
projection models for demand and our estimates for resources 
for our facilities. We are also concerned that the ability of a 
Veteran to elect to choose a primary care provider from among 
VA's network of community providers could allow for the control 
and coordination of care, including the authorization of care 
(and the obligation of Federal funds), to move to a non-Federal 
agent, which presents issues concerning the proper use of 
appropriated funds.
    Section 8 would require the Secretary to enter into 
national contracts with private health care providers to make 
dialysis treatments available in the community. Veterans would 
be able to choose the provider from which they would receive 
dialysis services. Under subsection (c), the Secretary could 
not pay more than the Medicare rate for the same dialysis 
services or treatment.
    While we support the intent of this proposal, we are 
concerned that this could potentially limit the Department's 
ability to furnish dialysis care. This provision would limit VA 
to paying the Medicare rate; we currently pay more than the 
Medicare rate in certain circumstances, and it is unclear if we 
could enter into contracts for the same care at a reduced rate. 
If we were unable to enter into these contracts, VA would not 
be able to provide this essential clinical service.
    Section 9 would require VA to establish a demand profile 
with respect to each health service furnished under the laws 
administered by the Secretary. The demand profile would have to 
include various factors, such as the number of requests for 
services, the number of appointments (both in VA and the 
community), the capacity of the Department to provide such 
services, and an assessment of the need for community care for 
the service. The Secretary would use these profiles to inform 
the capability and capacity of the provider networks 
established in the new Veterans Choice Program. Within 120 days 
of the date of enactment of this Act, the Secretary would be 
required to submit to Congress a strategic plan with a 5 year 
forecast on the demand for care and the Department's capacity 
and capability to satisfy that demand within its facilities. 
The Secretary would have to update the strategic plan annually.
    VA agrees in concept with the provisions in section 9; 
however, we believe this provision is not necessary as VA has 
currently embarked upon a national market-by-market assessment 
effort that will produce the same level of information called 
for in the bill. VA's market-by-market assessment is in 
response to a requirement in section 240 of Division A of 
Public Law 114-223, the ``Military Construction, Veterans 
Affairs, and Related Agencies Appropriations Act, 2017.'' That 
law requires VA to develop a national realignment strategy. As 
a result, the assessment of VA's 98 marketplaces across the 
United States is currently underway.
    Section 10 would require the Secretary to establish uniform 
access standards for furnishing health care services, including 
through community providers, for urgent care, routine care, 
referral or specialty care, and wellness or preventive care. 
These access standards would have to include the average time a 
Veteran is expected to wait to receive an appointment, the 
average time a Veteran is expected to drive to arrive at an 
appointment, the average time a Veteran is expected to wait at 
a facility to receive health care services, and such other 
factors as the Secretary considers appropriate. The Secretary 
would be required to coordinate with DOD, the Department of 
Health and Human Services (HHS), private entities, and other 
non-governmental entities in establishing these standards. The 
Secretary would be required to submit a report to Congress 
within 120 days of the date of the enactment of this Act 
detailing the standards established under this section.
    We do not have views on section 10 at this time.
    Section 11 would require the Secretary, within 1 year of 
enactment, to procure a commercial, off-the-shelf electronic 
health record platform that conforms to the standards of 
interoperability required under section 713 of the National 
Defense Authorization Act for Fiscal Year 2014. The bill would 
define a number of requirements for this system, including its 
interoperability with DOD's systems and private sector systems 
and compliance with national standards identified by the VA and 
the DOD Interagency Program Office in collaboration with HHS' 
Office of the National Coordinator for Health Information 
Technology.
    VA does not believe section 11 is necessary because the 
Secretary has already announced his intention to procure a 
commercial system for VA's Electronic Health Record capability. 
Similar to our concern with other provisions, we note that the 
specificity in this provision could limit the Secretary's 
ability to ensure this new system is responsive to Veterans' 
needs.
    Finally, section 12 would make various conforming 
amendments to reflect the changes made by section 3 of this 
bill by updating references in other statutes to VA's community 
care authorities.
    We support section 12 as a measure to consolidate VA's 
community care programs.
    We are unable to provide cost estimates on the bill at this 
time but will follow up after the hearing with any estimates we 
can develop and our thoughts on the potential budget 
implications. We will also provide technical comments for your 
consideration.

    S. XXXX--IMPROVING VETERANS ACCESS TO COMMUNITY CARE ACT OF 2017

    The draft Improving Veterans Access to Community Care Act 
of 2017 also contains a number of provisions intended to 
improve VA's community care program.
    Section 101(a)(1) would create a new section 1703A, 
establishing the Veterans Community Care Program. Many of the 
terms and conditions governing this Program would be similar to 
those applicable to the existing Veterans Choice Program. Under 
this new Program, hospital care and medical services would be 
furnished to eligible Veterans at the election of the Veteran 
through contracts or agreements with eligible providers. The 
Secretary would be responsible for coordinating care and 
services, including ensuring that an eligible Veteran receives 
an appointment for care and services within the wait-time goals 
of the Veterans Health Administration (VHA). To be eligible 
under the Program, Veterans would have to be enrolled in VA 
health care and meet one of the following criteria: reside in a 
location, other than Guam, American Samoa, or the Republic of 
the Philippines that requires the Veteran to travel by air, 
boat or ferry to reach a VA medical facility; be enrolled in 
Project ARCH; the Veteran and the Veteran's VA provider 
determine the Veteran should be eligible based upon the 
eligibility criteria in the current Veterans Choice Program, 
namely being unable to schedule an appointment within the 
clinically indicated timeframe, residing more than 40 miles 
driving distance from the nearest VA medical facility with a 
full-time primary care physician, residing within a State 
without a full-service VA medical center, or facing an unusual 
or excessive burden in accessing services from a VA medical 
facility. The Veteran and provider could also determine whether 
the Veteran should be eligible under the Program based upon a 
compelling reason that the Veteran needs to receive care and 
services from a non-Department facility. The Secretary would be 
required to establish a process to review any disagreement 
between Veterans and their providers, and the Secretary would 
make the final determination as to the eligibility of the 
Veteran.
    While we appreciate the intent of the eligibility criteria 
for Veterans, we are concerned with how this program is 
structured. We fully agree that the provider-patient 
relationship should be the basis for eligibility to receive 
community care. However, the draft bill would combine this 
approach with the current administrative eligibility criteria 
in the Choice Program. We believe this would result in an 
ultimately confusing ``hybrid'' standard that would be 
difficult for providers to apply. In addition, we believe 
continuing to use administrative criteria would be 
inappropriate, as they are arbitrary in nature and not informed 
by the patient-provider relationship. The proposed approach 
would also be unduly limiting in terms of the types of clinical 
factors that a provider could consider; for example, a Veteran 
who lived across the street from a full-service VA medical 
center with no wait times and who was fully ambulatory would 
not appear to qualify under any of these provisions, and yet 
the Veteran may require a certain type of service that would be 
best delivered by a community provider. We would like to work 
with the Committee to better understand the underlying issue 
that proposed subsection (b)(2), concerning the review of 
provider determinations, is intended to address.
    Under section 1703A, providers would have to meet the same 
eligibility criteria in the current Veterans Choice Program to 
participate in the new Program, including maintaining the same 
or similar credentials and licenses as VA providers. The 
Secretary would be authorized to create a tiered provider 
network, but would not be able to prioritize providers in a 
tier over providers in any other tier in a manner that limits 
the choice of an eligible Veteran to select that provider. The 
Secretary would be required to enter into contracts with 
eligible providers for furnishing care and services, but before 
entering into such a contract, the Secretary would be required, 
to the maximum extent practicable and consistent with the 
requirements of this section, to furnish care and services with 
eligible providers pursuant to sharing agreements, existing 
contracts, or other processes available for procuring care. In 
this section, the term ``contract'' would have the definition 
given that term in subpart 2.101 of the Federal Acquisition 
Regulations. Providers would be paid under a negotiated rate 
that, to the extent practicable, would not exceed the Medicare 
rate, with limited exceptions for highly rural areas, Alaska, 
and States with an All-Payer Model Agreement. Eligible 
providers would be prohibited from collecting any amount 
greater than the negotiated rate. The Secretary would be 
authorized in negotiating rates to incorporate the use of 
value-based reimbursement models to promote the provision of 
high-quality care. The Secretary would be authorized to collect 
from third-parties the costs of furnishing care for non-
service-connected disabilities under this section, and such 
collections would be deposited into the Medical Community Care 
account and remain available until expended.
    We do not support the provision requiring providers to 
maintain the same or similar credentials and licenses as VA 
providers; while this is a requirement in the current Veterans 
Choice Program, we have found it to be administratively 
difficult (and at times impossible) to implement in certain 
situations. We believe strongly in the importance of ensuring 
our providers furnish quality care, but recommend a different 
approach than this obligation. We are also concerned that some 
of the language regarding the terms of the agreements with 
providers contemplates a direct relationship between VA and the 
providers, rather than a relationship between VA and a network 
administrator, and a separate relationship between the 
administrator and the provider. Similarly, we do not support 
the provision that would require the deposit of collected funds 
into the Medical Community Care account. Funds collected by VA 
under sections 1725 and 1729 of title 38, and section 2651 of 
title 42 are currently deposited in the Medical Care 
Collections Fund, where they may be used to support both VA and 
community care. We believe creating a separate collection 
account would be duplicative and would limit our funding 
flexibility. Finally, we note that referencing the definition 
of ``third party'' in section 1729 produces a narrower effect 
than if the definition in section 1725 were referenced.
    The Secretary would be required to provide Veterans 
information about this Program upon their enrollment and when 
they become eligible based on a determination between the 
Veteran and his or her provider. The Secretary would be 
required to ensure that follow up care, including specialty and 
ancillary services deemed necessary, are furnished through the 
Program at the election of the Veteran. Veterans would be 
required to pay a copayment for care under this Program, but 
the copayment could be no more than what the Veteran would owe 
if such care or services were furnished directly by the 
Department. The Secretary would also be required to establish a 
claims processing system to ensure prompt and accurate payment 
of bills and claims for authorized care. Under subsection (j), 
a Veteran's election to receive care under this Program would 
serve as written consent for purposes of section 7332(b)(1), 
which governs the disclosure of certain protected health 
information. Providers would be required under subsection 
(k)(1) to submit copies of the Veteran's medical records upon 
the completion of the provision of such care and services, but 
these records could not be required prior to reimbursement. 
Under subsection (m), the Secretary would be required to track 
missed appointments to ensure the Department does not pay for 
care or services that were not rendered.
    We note that subsection (j) is no longer needed given the 
amendments to section 7332 made by Public Law 115-26. In terms 
of subsection (k)(1), we believe it would be better for the 
records to be required as determined by the Secretary to ensure 
that the records are provided in a timely fashion and that care 
provided by VA and others is informed. We also recommend 
against including subsection (m), regarding the tracking of 
missed appointments, as our experience with the current 
Veterans Choice Program has proven this difficult to implement. 
We have taken other precautions to ensure the Department is not 
paying for care and services that were not provided, and we 
believe this approach is more suitable for the legislation's 
intent.
    Section 101(a)(3) would terminate the current Veterans 
Choice Program authority and make other conforming amendments.
    We do not support this provision, as the Department will 
need a transition period during which it can prepare for the 
future of community care while still ensuring Veterans receive 
care through the current Choice Program.
    Section 101(a)(4) would require a report within 1 year of 
the date of enactment of this Act providing information about 
services rendered under the new Program.
    We note that subparagraph (D) of this provision would 
require a report on the results of a survey of Veterans who 
have received care or services under this program. Given the 
time it may take us to develop a survey, VA may not be able to 
gather meaningful information in the time between OMB approval 
of the information collection and the reporting deadline. 
Regarding subparagraph (E), which would require an assessment 
of the effect of furnishing care and services under new section 
1703A on wait times, we have not found reliable data that would 
support a firm assessment through the current Choice Program, 
and we believe we would encounter the same issues under this 
proposal.
    Section 101(b) would provide that services under various 
programs and authorities be considered services under the 
Veterans Community Care Program established under the new 
section 1703A, including PC3, contracts through VA's retail 
pharmacy network, VCAs, and health care agreements with other 
Federal and non-Federal agencies.
    We are not sure exactly what it means for services under 
another program to be ``considered'' services under the 
Veterans Community Care Program. If this would require that all 
of the agreements and programs identified in this subsection 
meet the terms and conditions of the Veterans Community Care 
Program, we would not support that requirement.
    Section 101(c) would state that all amounts required to 
carry out the new Program would be derived from the Medical 
Community Care account, and that all amounts in the Veterans 
Choice Fund would be transferred to the Medical Community Care 
account. Section 802 of the Veterans Access, Choice, and 
Accountability Act of 2014 would be repealed, and conforming 
amendments would be made to section 4003 of the Surface 
Transportation and Veterans Health Care Choice Improvement Act 
of 2015.
    We agree with the importance of consolidating funding for 
community care, but we recommend that the transfer of funds 
from and the repeal of the Veterans Choice Fund only apply to 
unobligated funds and provide a delayed effective date to 
support the transition from the current program to the future 
program.
    Section 101(d) would require, within 90 days of the 
enactment of this Act, the Secretary to establish consistent 
criteria and standards for furnishing non-Department care, 
including the eligibility requirements of providers and 
reimbursement rates (which, to the extent practicable, would be 
the Medicare rate). These standards would not apply to the 
Veterans Community Care Program established under section 
101(a)(1).
    We support the intent of subsection (d). We have minor 
technical recommendations that we would be pleased to discuss 
with the Committee.
    Section 101(e) would require the Secretary to establish a 
working group to assess the feasibility and advisability of 
considering under subsection (b) services under health care 
agreements with health care providers of the Indian Health 
Service (IHS) and tribal health programs to be provided under 
the Veterans Community Care Program. The working group would 
include representatives of IHS, tribal health programs, and 
Veterans who receive services from either IHS or tribal health 
programs. Within 180 days of enactment of this Act, the working 
group would be required to submit a report to the Secretary on 
the feasibility and advisability of considering such services 
to be services under the Veterans Community Care Program, and 
within 90 days of receiving this report, the Secretary would be 
required to submit a report to Congress on the feasibility and 
advisability of implementing the working group's 
recommendations.
    We do not oppose greater coordination and discussion with 
IHS or tribal health programs, but we do not believe the 
timelines in the legislation are realistic. We also do not 
believe it is necessary to require this coordination in law, as 
we are already working with these groups to improve cultural 
understanding and resource sharing. We also note that the 
Federal Advisory Committee Act (FACA) would likely apply to the 
working group, given the inclusion of non-government personnel.
    Section 102(a) would create a new section 1703B regarding 
prompt payment of providers. It would require substantially the 
same things required by section 5(a) of the draft Veterans 
Choice Act of 2017, with a few exceptions. For example, this 
bill would authorize the Secretary to accept claims and medical 
records submitted other than electronically if the Secretary 
determines the provider is unable to submit claims or medical 
records electronically. It would also authorize the Secretary 
to accept non-electronic claims if the Secretary determines 
doing so is necessary for the timely processing of claims due 
to a failure or serious malfunction of the electronic interface 
of the Department (required in section 102(b)) for submitting 
claims.
    As discussed with respect to section 5(a) of the draft 
Veterans Choice Act of 2017, we generally support these 
provisions and appreciate the flexibility contained in this 
version.
    Section 102(b) would require, not later than January 1, 
2019, the Chief Information Officer of the Department to 
establish an electronic interface for health care providers to 
submit claims for reimbursement under section 1703B. The bill 
would define various requirements in terms of functions of the 
interface and protection of information. By January 1, 2018, or 
before entering into a contract to procure or design and build 
such an interface, the Secretary would be required to conduct 
an analysis to determine whether it would be better to build or 
buy such an interface and submit a report on such analysis to 
Congress. The bill would define various requirements of this 
analysis and report, and the Secretary would not be authorized 
to spend any amounts to procure or design and build the 
electronic interface until 60 days after the required report is 
submitted to Congress.
    We are concerned about the intended scope of this 
provision. If the electronic interface processing the claims is 
only preparing them for adjudication and approval by VA, we do 
not support this provision because VA is currently working on a 
process internally that would perform this function. If the 
provision is intended to cover adjudication and payment as 
well, we would like to discuss with the Committee our 
reservations about such an arrangement and propose potential 
alternatives instead. We also caution that the deadline in 
subsection (b)(2) of January 1, 2018, for making a decision to 
internally design and build or enter into a contract to procure 
an electronic interface is likely too soon, given the 
uncertainty regarding community care funding, continuing 
developments of the design of the new EHR, and the potential 
implications to other information technology projects.
    Section 103 would amend 38 U.S.C. Sec. 1151(a) by adding a 
paragraph that would require VA to pay compensation if a 
Veteran's disability or death was caused by hospital care or 
medical services furnished under proposed section 1703A of 
title 38, United States Code, and the proximate cause of the 
disability or death was carelessness, negligence, lack of 
proper skill, error in judgment, or similar instance of fault 
by the provider or an event not reasonably foreseeable.
    VA fully supports ensuring that Veterans have access to 
high quality care, and that they are made whole in the event of 
a medical error. However, VA does not support this provision as 
written based on several concerns. First, section 103 would 
expand section 1151(a) to require VA benefit payments where the 
``proximate cause'' of a Veteran's disability or death was the 
negligence of a non-Department health care provider or an 
unforeseeable event occurring during treatment by such a 
provider. The ``term 'proximate cause' is used to label 
generically the judicial tools used to limit a person's 
responsibility for the consequences of that person's own acts. 
At bottom, the notion of proximate cause reflects 'ideas of 
what justice demands, or of what is administratively possible 
and convenient.''' Holmes v. Sec. Investor Prot. Corp., 503 
U.S. 258, 268 (1992) (quoting W. Keeton, D. Dobbs, R. Keeton, & 
D. Owen, Prosser and Keeton on Law of Torts Sec. 41, p. 264 
(5th ed. 1984)). Section 103 would make the Federal government 
liable for disability or death that is the proximate result of 
a non-Department medical provider's negligence or an 
unforeseeable event. This is contrary to the basic principle of 
American law, which holds an individual legally responsible for 
injuries caused by his or her negligent conduct.
    Second, VA adjudicators would be required to develop 
evidence regarding care that is not provided by VA employees or 
in VA facilities, including DOD and other Federal health care 
providers and academic affiliates, and to determine whether a 
Veteran's disability was proximately caused by negligence on 
the part of the community provider or an unforeseeable event 
occurring during non-Department medical care. See 38 U.S.C. 
Sec. 5103A. This would entail gathering medical and other 
records from community providers as well as expert medical 
opinions about whether the event that occurred during the non-
Department treatment was not foreseeable. This development 
burden of obtaining and evaluating evidence from non-Department 
providers and facilities can be expected to slow the 
adjudication of other Veterans' claims for benefits and 
potentially add to the disability compensation backlog.
    Third, under 38 U.S.C. '1151(b), a recovery under the 
Federal Tort Claims Act as a result of a judgment or settlement 
for a disability or death for which compensation is awarded 
under 38 U.S.C. Sec. 1151(a) results in a suspension of the 
section 1151 benefits until the amount of the judgment or 
settlement is recouped. In contrast, section 103 does not 
provide for a suspension of compensation for any recovery by a 
Veteran or Veteran's survivors from the non-Department provider 
as a result of a private lawsuit based upon the same disability 
or death. As a result, a Veteran or a Veteran's survivor could 
receive a recovery of both section 1151 benefits and tort 
damages based upon a judgment or settlement. This would create 
an inequity by allowing duplicative recovery for the same 
disability or death for persons whose entitlement is based on 
care furnished by community providers.
    We have not yet had time to estimate the costs for section 
103. However, we do know that, in FY 2016, 2.2 million Veterans 
received care from community providers under existing VA 
statutory authorities. During the first three quarters of FY 
2017, 1.2 million Veterans have received such care. VA 
purchases care from more than 500,000 community providers, and 
the number continues to grow. VA's FY 2018 budget requests a 13 
percent increase in funding for community care. As a result, VA 
could potentially be liable for section 1151 benefits for any 
of these 2 million Veterans who suffer additional disability or 
death due to negligence or an unforeseeable event caused by 
community care provided by community providers despite the 
absence of a causal connection between the additional 
disability or death and VA medical treatment.
    Section 104 would add a sunset provision to section 1703 of 
title 38 terminating that program on December 31, 2018. It 
would make other conforming amendments similar to those 
proposed in section 12 of the draft Veterans Choice Act of 
2017.
    We support section 104.
    Section 201 would add a new section 1703C to authorize the 
Secretary to enter into VCAs, similar to the authority that 
would be provided under section 4 of the draft Veterans Choice 
Act of 2017. However, there are a few differences in the 
proposed section 1703C that section 201 would create. First, 
the draft Veterans Choice Act of 2017 would require that care 
be unavailable under the Veterans Choice Program established in 
that draft bill prior to entering into a VCA, while the 
Improving Veterans Access to Community Care Act of 2017 has no 
such limitation. The draft Veterans Choice Act of 2017 would 
authorize providers to opt out of a VCA, but the Improving 
Veterans Access to Community Care Act of 2017 does not include 
this provision. The draft Veterans Choice Act of 2017 would 
limit the ability of the Secretary to direct patients to 
providers that have entered into contracts or agreements under 
other authorities, while the Improving Veterans Access to 
Community Care Act of 2017 does not include such a restriction. 
The draft Improving Veterans Access to Community Care Act of 
2017 would include greater flexibility in terms of the Medicare 
rate through inclusion of the phrase ``to the extent 
practicable'' in prescribing the rates the Secretary would pay 
under VCAs. While we believe the draft Veterans Choice Act of 
2017 would allow the Secretary, on a case-by-case basis, to 
determine whether or not to pay for care not authorized, the 
Improving Veterans Access to Community Care Act of 2017 would 
allow the Secretary to pay a provider who provides services in 
the course of treatment pursuant to an agreement with the 
Secretary but is not a party to the agreement. Finally, the 
draft Veterans Choice Act of 2017 would state uniformly that 
the OFCCP would not have authority over parties to a VCA, 
while, through section 205, the Improving Veterans Access to 
Community Care Act of 2017 would apply the limits established 
for the TRICARE Program in Directive 2014-01 of OFCCP to any 
health care provider entering into an agreement or contract 
with VA under section 1703A, 1703C, or 1745.
    We support section 201 and prefer those provisions that 
differ from the draft Veterans Choice Act of 2017.
    Section 205 would apply the OFCCP moratorium to VA, and VA 
supports that provision. We recommend against including a 
specific deadline, as that would allow flexibility in the event 
that the OFCCP Directive is further revised. Many of the 
technical concerns we identified with the draft Veterans Choice 
Act of 2017 regarding VCAs apply here as well, and we look 
forward to working with the Committee and the Department of 
Labor to address concerns.
    Section 202 would modify VA's authority under section 1745 
and is identical to section 6 of the draft Veterans Choice Act 
of 2017.
    VA's views on that provision apply here as well.
    Section 203 would amend section 106 of the Veterans Access, 
Choice, and Accountability Act of 2014 to require that, at the 
beginning of each fiscal year, the Secretary to transfer to VHA 
an amount equal to the estimated amount required to furnish 
hospital care, medical services, and other health care through 
non-Department providers during the fiscal year. The Secretary 
would be authorized to make adjustments to the amount 
transferred to accommodate variances in demand for such care 
and services from non-Department providers.
    We support section 203 because this would provide greater 
flexibility to adjust resource allocations based upon actual 
demand.
    Section 204 would create a new section 1730B, which would 
allow the Secretary, notwithstanding sections 1341(a)(1) and 
1501 of title 31, to record an obligation of the United States 
for non-Department care on the date on which a claim for 
payment is approved, rather than the date on which the care or 
services are authorized.
    VA understands this provision is intended to bring the 
Department closer to industry practices in terms of allocating 
resources for care and developing better estimates concerning 
our community care liabilities. VA appreciates the Committee's 
willingness to engage on this issue given our prior discussions 
on this, and we look forward to working with you further on 
this proposal.
    Section 205 of the bill is discussed above in the analysis 
of section 201, and the Department's views on this provision 
are provided in that discussion.
    We are unable to provide cost estimates on the bill at this 
time, but will follow up after the hearing with any estimates 
we can develop and our thoughts on the potential budget 
implications. We will also provide technical comments for your 
consideration.

    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions you or Members of the Committee may 
have.

Title 38. Veterans' Benefits

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Part I. General Provisions

           *       *       *       *       *       *       *

                          Chapter 7. Employees

                 SUBCHAPTER I. GENERAL EMPLOYEE MATTERS

Sec.

           *       *       *       *       *       *       *

725. Annual performance plan for political appointees.
726. Annual report on performance awards and bonuses awarded to 
            certain high-level employees.

           *       *       *       *       *       *       *

Subchapter I. General Employee Matters

           *       *       *       *       *       *       *

SEC. 726. ANNUAL REPORT ON PERFORMANCE AWARDS AND BONUSES AWARDED TO 
                    CERTAIN HIGH-LEVEL EMPLOYEES

    (a) In General.--Not later than 30 days after the end of 
each fiscal year, the Secretary shall submit to the appropriate 
committees of Congress a report that contains, for the most 
recent fiscal year ending before the submittal of the report, a 
description of the performance awards and bonuses awarded to 
Regional Office Directors of the Department, Directors of 
Medical Centers of the Department, and Directors of Veterans 
Integrated Service Networks.
    (b) Elements.--Each report submitted under subsection (a) 
shall include the following with respect to each performance 
award or bonus awarded to an individual described in such 
subsection:
          (1) The amount of each award or bonus.
          (2) The job title of the individual awarded the award 
        or bonus.
          (3) The location where the individual awarded the 
        award or bonus works.
    (c) Appropriate Committees of Congress.--In this section, 
the term ``appropriate committees of Congress'' means--
          (1) the Committee on Veterans' Affairs and the 
        Committee on Appropriations of the Senate; and
          (2) the Committee on Veterans' Affairs and the 
        Committee on Appropriations of the House of 
        Representatives.

                       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.]
1703. Veterans Community Care Program.
1703A. Agreements with eligible entities or providers; 
            certification processes.
1703B. Access guidelines.
1703C. Standards for quality.
1703D. Prompt payment standard.
1704. Preventive health services: annual report.

           *       *       *       *       *       *       *

   SUBCHAPTER III. MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND 
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS

           *       *       *       *       *       *       *

1725.Reimbursement for emergency treatment.
1725A. Access to walk-in care.

           *       *       *       *       *       *       *

1730B. Licensure of health care professionals providing treatment 
            via telemedicine.

           *       *       *       *       *       *       *

SUBCHAPTER VIII. HEALTH CARE OF PERSONS OTHER THAN VETERANS

           *       *       *       *       *       *       *

1788. Transplant procedures with live donors and related 
            services.

Subchapter I. General

           *       *       *       *       *       *       *

[SEC. 1703. CONTRACTS FOR HOSPITAL CARE AND MEDICAL SERVICES IN NON-
                    DEPARTMENT FACILITIES

    [(a) When Department facilities are not capable of 
furnishing economical hospital care or medical services because 
of geographical inaccessibility or are not capable of 
furnishing the care or services required, the Secretary, as 
authorized in section 1710 of this title, may contract with 
non-Department facilities in order to furnish any of the 
following:
          [(1) Hospital care or medical services to a veteran 
        for the treatment of--
                  [(A) a service-connected disability;
                  [(B) a disability for which a veteran was 
                discharged or released from the active 
                military, naval, or air service; or
                  [(C) a disability of a veteran who has a 
                total disability permanent in nature from a 
                service-connected disability.
          [(2) Medical services for the treatment of any 
        disability of--
                  [(A) a veteran described in section 
                1710(a)(1)(B) of this title;
                  [(B) a veteran who (i) has been furnished 
                hospital care, nursing home care, domiciliary 
                care, or medical services, and (ii) requires 
                medical services to complete treatment incident 
                to such care or services; or
                  [(C) a veteran described in section 
                1710(a)(2)(E) of this title, or a veteran who 
                is in receipt of increased pension, or 
                additional compensation or allowances based on 
                the need of regular aid and attendance or by 
                reason of being permanently housebound (or who, 
                but for the receipt of retired pay, would be in 
                receipt of such pension, compensation, or 
                allowance), if the Secretary has determined, 
                based on an examination by a physician employed 
                by the Department (or, in areas where no such 
                physician is available, by a physician carrying 
                out such function under a contract or fee 
                arrangement), that the medical condition of 
                such veteran precludes appropriate treatment in 
                Department facilities.
          [(3) Hospital care or medical services for the 
        treatment of medical emergencies which pose a serious 
        threat to the life or health of a veteran receiving 
        medical services in a Department facility or nursing 
        home care under section 1720 of this title until such 
        time following the furnishing of care in the non-
        Department facility as the veteran can be safely 
        transferred to a Department facility.
          [(4) Hospital care for women veterans.
          [(5) Hospital care, or medical services that will 
        obviate the need for hospital admission, for veterans 
        in a State (other than the Commonwealth of Puerto Rico) 
        not contiguous to the contiguous States, except that 
        the annually determined hospital patient load and 
        incidence of the furnishing of medical services to 
        veterans hospitalized or treated at the expense of the 
        Department in Government and non-Department facilities 
        in each such noncontiguous State shall be consistent 
        with the patient load or incidence of the furnishing of 
        medical services for veterans hospitalized or treated 
        by the Department within the 48 contiguous States and 
        the Commonwealth of Puerto Rico.
          [(6) Diagnostic services necessary for determination 
        of eligibility for, or of the appropriate course of 
        treatment in connection with, furnishing medical 
        services at independent Department out-patient clinics 
        to obviate the need for hospital admission.
          [(7) Outpatient dental services and treatment, and 
        related dental appliances, for a veteran described in 
        section 1712(a)(1)(F) of this title.
          [(8) Diagnostic services (on an inpatient or 
        outpatient basis) for observation or examination of a 
        person to determine eligibility for a benefit or 
        service under laws administered by the Secretary.
    [(b) In the case of any veteran for whom the Secretary 
contracts to furnish care or services in a non-Department 
facility pursuant to a provision of subsection (a) of this 
section, the Secretary shall periodically review the necessity 
for continuing such contractual arrangement pursuant to such 
provision.
    [(c) The Secretary shall include in the budget documents 
which the Secretary submits to Congress for any fiscal year a 
detailed report on the furnishing of contract care and services 
during the most recently completed fiscal year under this 
section, sections 1712A, 1720, 1720A, 1724, and 1732 of this 
title, and section 115 of the Veterans' Benefits and Services 
Act of 1988 (Public Law 100-322; 102 Stat. 501).
    [(d)(1) The Secretary shall conduct a program of recovery 
audits for fee basis contracts and other medical services 
contracts for the care of veterans under this section, and for 
beneficiaries under sections 1781, 1782, and 1783 of this 
title, with respect to overpayments resulting from processing 
or billing errors or fraudulent charges in payments for non-
Department care and services. The program shall be conducted by 
contract.
    [(2) Amounts collected, by setoff or otherwise, as the 
result of an audit under the program conducted under this 
subsection shall be available, without fiscal year limitation, 
for the purposes for which funds are currently available to the 
Secretary for medical care and for payment to a contractor of a 
percentage of the amount collected as a result of an audit 
carried out by the contractor.
    [(3) The Secretary shall allocate all amounts collected 
under this subsection with respect to a designated geographic 
service area of the Veterans Health Administration, net of 
payments to the contractor, to that region.
    [(4) The authority of the Secretary under this subsection 
terminates on September 30, 2020.]

SEC. 1703. VETERANS COMMUNITY CARE PROGRAM

    (a) In General.--(1) There is established a program to 
furnish hospital care, medical services, and extended care 
services to covered veterans through health care providers 
specified in subsection (c).
    (2) The Secretary shall coordinate the furnishing of 
hospital care, medical services, and extended care services 
under this section to covered veterans, including coordination 
of, at a minimum, the following:
          (A) Ensuring the scheduling of medical appointments 
        in a timely manner and the establishment of a mechanism 
        to receive medical records from non-Department 
        providers.
          (B) Ensuring continuity of care and services.
          (C) Ensuring coordination among regional networks if 
        the covered veteran accesses care and services in a 
        different network than the regional network in which 
        the covered veteran resides.
          (D) Ensuring that covered veterans do not experience 
        a lapse resulting from errors or delays by the 
        Department or its contractors or an unusual or 
        excessive burden in accessing hospital care, medical 
        services, or extended care services.
    (b) Covered Veterans.--For purposes of this section, a 
covered veteran is any veteran who--
          (1) is enrolled in the system of annual patient 
        enrollment established and operated under section 1705 
        of this title; or
          (2) is not enrolled in such system but is otherwise 
        entitled to hospital care, medical services, or 
        extended care services under subsection (c)(2) of such 
        section.
    (c) Health Care Providers Specified.--Health care providers 
specified in this subsection are the following:
          (1) Any health care provider that is participating in 
        the Medicare program under title XVIII of the Social 
        Security Act (42 U.S.C. 1395 et seq.), including any 
        physician furnishing services under such a program.
          (2) The Department of Defense.
          (3) The Indian Health Service.
          (4) Any Federally-qualified health center (as defined 
        in section 1905(l)(2)(B) of the Social Security Act (42 
        U.S.C. 1396d(l)(2)(B))).
          (5) Any health care provider not otherwise covered 
        under any of paragraphs (1) through (4) that meets 
        criteria established by the Secretary for purposes of 
        this section.
    (d) Conditions Under Which Care Is Required To Be Furnished 
Through Non-Department Providers.--(1) The Secretary shall, 
subject to the availability of appropriations, furnish hospital 
care, medical services, and extended care services to a covered 
veteran through health care providers specified in subsection 
(c) if--
          (A) the Department does not offer the care or 
        services the veteran requires;
          (B) the Department does not operate a full-service 
        medical facility in the State in which the covered 
        veteran resides;
          (C) the covered veteran was an eligible veteran under 
        section 101(b)(2)(B) of the Veterans Access, Choice, 
        and Accountability Act of 2014 (Public Law 113-146; 38 
        U.S.C. 1701 note) as of the day before the date of the 
        enactment of the Caring for our Veterans Act of 2017; 
        or
          (D) the covered veteran and the covered veteran's 
        primary care provider agree that furnishing care and 
        services through a non-Department entity or provider 
        would be in the best medical interest of the covered 
        veteran based upon criteria developed by the Secretary.
    (2) The Secretary shall ensure that the criteria developed 
under paragraph (1)(D) include consideration of the following:
          (A) The distance between the covered veteran and the 
        facility that provides the hospital care, medical 
        services, or extended care services the veteran needs.
          (B) The nature of the hospital care, medical 
        services, or extended care services required.
          (C) The frequency that the hospital care, medical 
        services, or extended care services needs to be 
        furnished.
          (D) Whether an appointment for the hospital care, 
        medical services, or extended care services the covered 
        veteran requires is available from a health care 
        provider of the Department within the lesser of--
                  (i) the access guidelines for such hospital 
                care, medical services, or extended care 
                services as established by the Secretary; and
                  (ii) a period determined by a health care 
                provider of the Department to be clinically 
                necessary for the receipt of such hospital 
                care, medical services, or extended care 
                services.
          (E) Whether the covered veteran faces an unusual or 
        excessive burden to access hospital care, medical 
        services, or extended care services from the Department 
        medical facility where a covered veteran seeks hospital 
        care, medical services, or extended care services, 
        which shall include consideration of the following:
                  (i) Whether the covered veteran faces an 
                excessive driving distance, geographical 
                challenge, or environmental factor that impedes 
                the access of the covered veteran.
                  (ii) Whether the hospital care, medical 
                services, or extended care services sought by 
                the veteran is provided by a medical facility 
                of the Department that is reasonably accessible 
                to a covered veteran.
                  (iii) Whether a medical condition of the 
                covered veteran affects the ability of the 
                covered veteran to travel.
                  (iv) Whether there is compelling reason, as 
                determined by the Secretary, that the veteran 
                needs to receive hospital care, medical 
                services, or extended care services from a 
                medical facility other than a medical facility 
                of the Department.
                  (v) Such other considerations as the 
                Secretary considers appropriate.
    (3) If the Secretary has determined that the Department 
does not offer the care or services the covered veteran 
requires under subparagraph (A) of paragraph (1), that the 
Department does not operate a full-service medical facility in 
the State in which the covered veteran resides under 
subparagraph (B) of such paragraph, or that the covered veteran 
is described under subparagraph (C) of such paragraph, the 
decision to receive hospital care, medical services, or 
extended care services under such subparagraphs from a health 
care provider specified in subsection (c) shall be at the 
election of the veteran.
    (e) Conditions Under Which Care Is Authorized to Be 
Furnished Through Non-Department Providers.--(1)(A) The 
Secretary may furnish hospital care, medical services, or 
extended care services through a health care provider specified 
in subsection (c) to a covered veteran served by a medical 
service line of the Department that the Secretary has 
determined is not providing care that meets such quality and 
access standards as the Secretary shall develop.
    (B) In carrying out subparagraph (A), the Secretary shall--
          (i) measure access of the medical service line at a 
        facility of the Department when compared with the same 
        medical service line at different Department 
        facilities; and
          (ii) measure quality at a medical service line of a 
        facility of the Department by comparing it with two or 
        more distinct and appropriate quality measures at non-
        Department medical service lines.
    (C)(i) The Secretary may not concurrently furnish hospital 
care, medical services, or extended care services under 
subparagraph (A) with respect to more than three medical 
service lines described in such subparagraph at any one health 
care facility of the Department.
    (ii) The Secretary may not concurrently furnish hospital 
care, medical services, or extended care services under 
subparagraph (A) with respect to more than 36 medical service 
lines nationally described in such subparagraph.
    (2) The Secretary may limit the types of hospital care, 
medical services, or extended care services covered veterans 
may receive under paragraph (1) because of an access and 
quality deficiency of a medical service line in terms of the 
length of time such care and services will be available, the 
location at which such care and services will be available, and 
the clinical care and services that will be available.
    (3) The hospital care, medical services, and extended care 
services authorized under paragraph (1) with respect to a 
medical service line shall cease when the remediation described 
in subsection (g) with respect to such medical service line is 
complete.
    (4) The Secretary shall publish in the Federal Register, 
and shall take all reasonable steps to provide direct notice to 
covered veterans affected under this subsection, at least once 
each year stating the time period during which such care and 
services will be available, the location or locations where 
such care and services will be available, and the clinical 
services available at each location under this subsection in 
accordance with regulations the Secretary shall prescribe.
    (5) When the Secretary exercises the authority under 
paragraph (1), the decision to receive care or services under 
such paragraph from a health care provider specified in 
subsection (c) shall be at the election of the covered veteran.
    (f) Review of Decisions.--The review of any decision under 
subsection (d) or (e) shall be subject to the Department's 
local clinical appeals process, and such decisions may not be 
appealed to the Board of Veterans' Appeals.
    (g) Remediation of Medical Service Lines.--(1) Not later 
than 30 days after determining under subsection (e)(1) that a 
medical service line of the Department is providing hospital 
care, medical services, or extended care services that does not 
comply with the access guidelines and meet the standards of 
quality established by the Secretary, the Secretary shall 
submit to Congress an assessment of the factors that led the 
Secretary to make such determination and a plan with specific 
actions, and the time to complete them, to be taken to comply 
with such access guidelines and meet such standards of quality, 
including the following:
          (A) Increasing personnel or temporary personnel 
        assistance, including mobile deployment teams.
          (B) Special hiring incentives, including the 
        Education Debt Reduction Program under subchapter VII 
        of chapter 76 of this title and recruitment, 
        relocation, and retention incentives.
          (C) Utilizing direct hiring authority.
          (D) Providing improved training opportunities for 
        staff.
          (E) Acquiring improved equipment.
          (F) Making structural modifications to the facility 
        used by the medical service line.
          (G) Such other actions as the Secretary considers 
        appropriate.
    (2) In each assessment submitted under paragraph (1) with 
respect to a medical service line, the Secretary shall identify 
the individuals at the Central Office of the Veterans Health 
Administration, the facility used by the medical service line, 
and the central office of the relevant Veterans Integrated 
Service Network who are responsible for overseeing the progress 
of that medical service line in complying with the access 
guidelines and meeting the standards of quality established by 
the Secretary.
    (3) Not later than 180 days after submitting an assessment 
under paragraph (1) with respect to a medical service line, the 
Secretary shall submit to Congress a report on the progress of 
that medical service line in complying with the access 
guidelines and meeting the standards of quality established by 
the Secretary and any other measures the Secretary will take to 
assist the medical service line in complying with such access 
guidelines and meeting such standards of quality.
    (4) Not less frequently than once each year, the Secretary 
shall--
          (A) submit to Congress an analysis of the remediation 
        actions and costs of such actions taken with respect to 
        each medical service line with respect to which the 
        Secretary submitted an assessment and plan under 
        paragraph (1) in the preceding year, including an 
        update on the progress of each such medical service 
        line in meeting the quality and access standards 
        established by the Secretary and any other actions the 
        Secretary is undertaking to assist the medical service 
        line in complying with access guidelines and meeting 
        standards of quality as established by the Secretary; 
        and
          (B) publish such analysis on the Internet website of 
        the Department.
    (h) Access Guidelines and Standards for Quality.--(1) The 
Secretary shall establish access guidelines under section 1703B 
of this title and standards for quality under section 1703C of 
this title for furnishing hospital care, medical services, or 
extended care services to a covered veteran for the purposes of 
subsections (d) and (e).
    (2) The Secretary shall ensure that the access guidelines 
and standards for quality required by sections 1703B and 1703C 
of this title provide covered veterans, employees of the 
Department, and health care providers in the network 
established under subsection (j) with relevant comparative 
information that is clear, useful, and timely, so that covered 
veterans can make informed decisions regarding their health 
care.
    (3) The Secretary shall consult with all pertinent Federal 
entities (including the Department of Defense, the Department 
of Health and Human Services, and the Centers for Medicare & 
Medicaid Services), entities in the private sector, and other 
nongovernmental entities in establishing access guidelines and 
standards for quality as required by sections 1703B and 1703C 
of this title.
    (4) Not later than 270 days after the date of the enactment 
of the Caring for our Veterans Act of 2017, the Secretary shall 
submit to the appropriate committees of Congress a report 
detailing the access guidelines and standards for quality 
established under sections 1703B and 1703C of this title.
    (5) Not later than three years after the date on which the 
Secretary establishes access guidelines and standards for 
quality under paragraph (1) and not less frequently than once 
every three years thereafter, the Secretary shall--
          (A) conduct a review of such guidelines and 
        standards; and
          (B) submit to the appropriate committees of Congress 
        a report on the findings and any modification to the 
        access guidelines and standards for quality with 
        respect to the review conducted under subparagraph (A).
    (6) The Secretary shall ensure health care providers 
specified under subsection (c) are able to meet the applicable 
access guidelines and standards of quality established by the 
Secretary.
    (i) Tiered Network.--(1) To promote the provision of high-
quality and high-value hospital care, medical services, and 
extended care services under this section, the Secretary may 
develop a tiered provider network of eligible providers based 
on criteria established by the Secretary for purposes of this 
section.
    (2) In developing a tiered provider network of eligible 
providers under paragraph (1), the Secretary shall not 
prioritize providers in a tier over providers in any other tier 
in a manner that limits the choice of a covered veteran in 
selecting a health care provider specified in subsection (c) 
for receipt of hospital care, medical services, or extended 
care services under this section.
    (j) Contracts To Establish Networks of Health Care 
Providers.--(1) The Secretary shall enter into consolidated, 
competitively bid contracts to establish networks of health 
care providers specified in paragraphs (1) and (5) of 
subsection (c) for purposes of providing sufficient access to 
hospital care, medical services, or extended care services 
under this section.
    (2)(A) The Secretary shall, to the extent practicable, 
ensure that covered veterans are able to make their own 
appointments using advanced technology.
    (B) To the extent practicable, the Secretary shall be 
responsible for the scheduling of appointments for hospital 
care, medical services, and extended care services under this 
section.
    (3)(A) The Secretary may terminate a contract with an 
entity entered into under paragraph (1) at such time and upon 
such notice to the entity as the Secretary may specify for 
purposes of this section, if the Secretary notifies the 
appropriate committees of Congress that, at a minimum--
          (i) the entity--
                  (I) failed to comply substantially with the 
                provisions of the contract or with the 
                provisions of this section and the regulations 
                prescribed under this section;
                  (II) failed to comply with the access 
                guidelines or meet the standards of quality 
                established by the Secretary;
                  (III) is excluded from participation in a 
                Federal health care program (as defined in 
                section 1128B(f) of the Social Security Act (42 
                U.S.C. 1320a-7b(f))) under section 1128 or 
                1128A of the Social Security Act (42 U.S.C. 
                1320a-7 and 1320a-7a);
                  (IV) is identified as an excluded source on 
                the list maintained in the System for Award 
                Management, or any successor system; or
                  (V) has been convicted of a felony or other 
                serious offense under Federal or State law and 
                the continued participation of the entity would 
                be detrimental to the best interests of 
                veterans or the Department;
          (ii) it is reasonable to terminate the contract based 
        on the health care needs of veterans; or
          (iii) it is reasonable to terminate the contract 
        based on coverage provided by contracts or sharing 
        agreements entered into under authorities other than 
        this section.
    (B) Nothing in subparagraph (A) may be construed to 
restrict the authority of the Secretary to terminate a contract 
entered into under paragraph (1) under any other provision of 
law.
    (4) Whenever the Secretary provides notice to an entity 
that the entity is failing to meet contractual obligations 
entered into under paragraph (1), the Secretary shall submit to 
the Committee on Veterans' Affairs of the Senate and the 
Committee on Veterans' Affairs of the House of Representatives 
a report on such failure. Such report shall include the 
following:
          (A) An explanation of the reasons for providing such 
        notice.
          (B) A description of the effect of such failure, 
        including with respect to cost, schedule, and 
        requirements.
          (C) A description of the actions taken by the 
        Secretary to mitigate such failure.
          (D) A description of the actions taken by the 
        contractor to address such failure.
          (E) A description of any effect on the community 
        provider market for veterans in the affected area.
    (5)(A) The Secretary shall instruct each entity awarded a 
contract under paragraph (1) to recognize and accept, on an 
interim basis, the credentials and qualifications of health 
care providers who are authorized to furnished hospital care 
and medical services to veterans under a community care program 
of the Department in effect as of the day before the date of 
the enactment of the Caring for our Veterans Act of 2017, 
including under the Patient-Centered Community Care Program and 
the Veterans Choice Program under section 101 of the Veterans 
Access, Choice, and Accountability Act of 2014 (Public Law 113-
146; 38 U.S.C. 1701 note), as qualified providers under the 
program established under this section.
    (B) The interim acceptance period under subparagraph (A) 
shall be determined by the Secretary based on the following 
criteria:
          (i) With respect to a health care provider, when the 
        current certification agreement for the health care 
        provider expires.
          (ii) Whether the Department has enacted certification 
        and eligibility criteria and regulatory procedures by 
        which non-Department providers will be authorized under 
        this section.
    (6) The Secretary shall establish through regulation a 
system or systems for monitoring the quality of care provided 
to covered veterans through a network under this subsection and 
for assessing the quality of hospital care, medical services, 
and extended care services furnished through such network 
before the renewal of the contract for such network.
    (k) Payment Rates for Care and Services.--(1) Except as 
provided in paragraph (2), and to the extent practicable, the 
rate paid for hospital care, medical services, or extended care 
services under any provision in this title may not exceed the 
rate paid by the United States to a provider of services (as 
defined in section 1861(u) of the Social Security Act (42 
U.S.C. 1395x(u))) or a supplier (as defined in section 1861(d) 
of such Act (42 U.S.C. 1395x(d))) under the Medicare program 
under title XI or title XVIII of the Social Security Act (42 
U.S.C. 1301 et seq.) for the same care or services.
    (2)(A) A higher rate than the rate paid by the United 
States as described in paragraph (1) may be negotiated with 
respect to the furnishing of care or services to a covered 
veteran who resides in a highly rural area.
    (B) In this paragraph, the term ``highly rural area'' means 
an area located in a county that has fewer than seven 
individuals residing in that county per square mile.
    (3) With respect to furnishing care or services under this 
section in Alaska, the Alaska Fee Schedule of the Department of 
Veterans Affairs shall be followed, except for when another 
payment agreement, including a contract or provider agreement, 
is in effect.
    (4) With respect to furnishing hospital care, medical 
services, or extended care services under this section in a 
State with an All-Payer Model Agreement under section 
1814(b)(3) of the Social Security Act (42 U.S.C. 1395f(b)(3)) 
that became effective on or after January 1, 2014, the Medicare 
payment rates under paragraph (2)(A) shall be calculated based 
on the payment rates under such agreement.
    (5) Notwithstanding paragraph (1), the Secretary may 
incorporate, to the greatest extent practicable, the use of 
value-based reimbursement models to promote the provision of 
high-quality care.
    (6) With respect to hospital care, medical services, or 
extended care services for which there is not a rate paid under 
the Medicare program as described in paragraph (1), the rate 
paid for such care or services shall be determined by the 
Secretary.
    (l) Treatment of Other Health Care Plans.--(1) In any case 
in which a covered veteran is furnished hospital care, medical 
services, or extended care services under this section for a 
non-service-connected disability described in subsection (a)(2) 
of section 1729 of this title, the Secretary shall recover or 
collect reasonable charges for such care or services from a 
health care plan described in paragraph (2) in accordance with 
such section.
    (2) 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, under which hospital care, medical 
        services, or extended care services for individuals are 
        provided or the expenses of such care or 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.
    (m) Payment by Veteran.--A covered veteran shall not pay a 
greater amount for receiving care or services under this 
section than the amount the veteran would pay for receiving the 
same or comparable care or services at a medical facility of 
the Department or from a health care provider of the 
Department.
    (n) Monitoring of Care Provided.--(1)(A) Not later than 540 
days after the date of the enactment of the Caring for our 
Veterans Act of 2017, and not less frequently than annually 
thereafter, the Secretary shall submit to appropriate 
committees of Congress a review of the types and frequency of 
care sought under subsection (d).
    (B) The review submitted under subparagraph (A) shall 
include an assessment of the following:
          (i) The top 25 percent of types of care and services 
        most frequently provided under subsection (d) due to 
        the Department not offering such care and services.
          (ii) The frequency such care and services were sought 
        by covered veterans under this section.
          (iii) An analysis of the reasons the Department was 
        unable to provide such care and services.
          (iv) Any steps the Department took to provide such 
        care and services at a medical facility of the 
        Department.
          (v) The cost of such care and services.
    (2) In monitoring the hospital care, medical services, and 
extended care services furnished under this section, the 
Secretary shall do the following:
          (A) With respect to hospital care, medical services, 
        and extended care services furnished through provider 
        networks established under subsection (j)--
                  (i) compile data on the types of hospital 
                care, medical services, and extended care 
                services furnished through such networks and 
                how many patients used each type of care and 
                service;
                  (ii) identify gaps in hospital care, medical 
                services, or extended care services furnished 
                through such networks;
                  (iii) identify how such gaps may be fixed 
                through new contracts within such networks or 
                changes in the manner in which hospital care, 
                medical services, or extended care services are 
                furnished through such networks;
                  (iv) assess the total amounts spent by the 
                Department on hospital care, medical services, 
                and extended care services furnished through 
                such networks;
                  (v) assess the timeliness of the Department 
                in referring hospital care, medical services, 
                and extended care services to such networks; 
                and
                  (vi) assess the timeliness of such networks 
                in--
                          (I) accepting referrals; and
                          (II) scheduling and completing 
                        appointments.
          (B) Report the number of medical service lines the 
        Secretary has determined under subsection (e)(1) not to 
        be providing hospital care, medical services, or 
        extended care services that comply with the access 
        guidelines or meet the standards of quality established 
        by the Secretary.
          (C) Assess the use of academic affiliates and centers 
        of excellence of the Department to furnish hospital 
        care, medical services, and extended care services to 
        covered veterans under this section.
          (D) Assess the hospital care, medical services, and 
        extended care services furnished to covered veterans 
        under this section by medical facilities operated by 
        Federal agencies other than the Department.
    (3) Not later than 540 days after the date of the enactment 
of the Caring for our Veterans Act of 2017 and not less 
frequently than once each year thereafter, the Secretary shall 
submit to the Committee on Veterans' Affairs of the Senate and 
the Committee on Veterans' Affairs of the House of 
Representatives a report on the information gathered under 
paragraph (2).
    (o) Prohibition on Certain Limitations.--The Secretary 
shall not limit the types of hospital care, medical services, 
or extended care services covered veterans may receive under 
this section if it is in the best interest of the veteran to 
receive such hospital care, medical services, or extended care 
services, as determined by the veteran and the veteran's health 
care provider.
    (p) Definitions.--In this section:
          (1) The term ``appropriate committees of Congress'' 
        means--
                  (A) the Committee on Veterans' Affairs and 
                the Committee on Appropriations of the Senate; 
                and
                  (B) the Committee on Veterans' Affairs and 
                the Committee on Appropriations of the House of 
                Representatives.
          (2) The term ``medical service line'' means a clinic 
        within a Department medical center.

SEC. 1703A. AGREEMENTS WITH ELIGIBLE ENTITIES OR PROVIDERS; 
                    CERTIFICATION PROCESSES

    (a) Agreements Authorized.--(1)(A) When hospital care, a 
medical service, or an extended care service required by a 
veteran who is entitled to such care or service under this 
chapter is not feasibly available to the veteran from a 
facility of the Department or through a contract or sharing 
agreement entered into pursuant to another provision of law, 
the Secretary may furnish such care or service to such veteran 
by entering into an agreement under this section with an 
eligible entity or provider to provide such hospital care, 
medical service, or extended care service.
    (B) An agreement entered into under this section to provide 
hospital care, a medical service, or an extended care service 
shall be known as a ``Veterans Care Agreement''.
    (C) For purposes of subparagraph (A), hospital care, a 
medical service, or an extended care service may be considered 
not feasibly available to a veteran from a facility of the 
Department or through a contract or sharing agreement described 
in such subparagraph when the Secretary determines the 
veteran's medical condition, the travel involved, the nature of 
the care or services required, or a combination of these 
factors make the use of a facility of the Department or a 
contract or sharing agreement described in such subparagraph 
impracticable or inadvisable.
    (D) A Veterans Care Agreement may be entered into by the 
Secretary or any Department official authorized by the 
Secretary.
    (2)(A) Subject to subparagraph (B), the Secretary shall 
review each Veterans Care Agreement of material size, as 
determined by the Secretary or set forth in paragraph (3), for 
hospital care, a medical service, or an extended care service 
to determine whether it is feasible and advisable to provide 
such care or service within a facility of the Department or by 
contract or sharing agreement entered into pursuant to another 
provision of law and, if so, take action to do so.
    (B)(i) The Secretary shall review each Veterans Care 
Agreement of material size that has been in effect for at least 
six months within the first two years of its taking effect, and 
not less frequently than once every four years thereafter.
    (ii) If a Veterans Care Agreement has not been in effect 
for at least six months by the date of the review required by 
subparagraph (A), the agreement shall be reviewed during the 
next cycle required by subparagraph (A), and such review shall 
serve as its review within the first two years of its taking 
effect for purposes of clause (i).
    (3)(A) In fiscal year 2018 and in each fiscal year 
thereafter, in addition to such other Veterans Care Agreements 
as the Secretary may determine are of material size, a Veterans 
Care Agreement for the purchase of extended care services that 
exceeds $5,000,000 annually shall be considered of material 
size.
    (B) From time to time, the Secretary may publish a notice 
in the Federal Register to adjust the dollar amount specified 
in subparagraph (A) to account for changes in the cost of 
health care based upon recognized health care market surveys 
and other available data.
    (b) Eligible Entities and Providers.--For purposes of this 
section, an eligible entity or provider is--
          (1) any provider of services that has enrolled and 
        entered into a provider agreement under section 1866(a) 
        of the Social Security Act (42 U.S.C. 1395cc(a)) and 
        any physician or other supplier who has enrolled and 
        entered into a participation agreement under section 
        1842(h) of such Act (42 U.S.C. 1395u(h));
          (2) any provider participating under a State plan 
        under title XIX of such Act (42 U.S.C. 1396 et seq.); 
        or
          (3) any entity or provider not described in paragraph 
        (1) or (2) of this subsection that the Secretary 
        determines to be eligible pursuant to the certification 
        process described in subsection (c).
    (c) Eligible Entity or Provider Certification Process.--The 
Secretary shall establish by regulation a process for the 
certification of eligible entities or providers or 
recertification of eligible entities or providers under this 
section. Such a process shall, at a minimum--
          (1) establish deadlines for actions on applications 
        for certification;
          (2) set forth standards for an approval or denial of 
        certification, duration of certification, revocation of 
        an eligible entity or provider's certification, and 
        recertification of eligible entities or providers;
          (3) require the denial of certification if the 
        Secretary determines the eligible entity or provider is 
        excluded from participation in a Federal health care 
        program under section 1128 or section 1128A of the 
        Social Security Act (42 U.S.C. 1320a-7 or 1320a-7a) or 
        is currently identified as an excluded source on the 
        System for Award Management Exclusions list described 
        in part 9 of title 48, Code of Federal Regulations, and 
        part 180 of title 2 of such Code, or successor 
        regulations;
          (4) establish procedures for screening eligible 
        entities or providers according to the risk of fraud, 
        waste, and abuse that are similar to the standards 
        under section 1866(j)(2)(B) of the Social Security Act 
        (42 U.S.C. 1395cc(j)(2)(B)) and section 9.104 of title 
        48, Code of Federal Regulations, or successor 
        regulations; and
          (5) incorporate and apply the restrictions and 
        penalties set forth in chapter 21 of title 41 and treat 
        this section as a procurement program only for purposes 
        of applying such provisions.
    (d) Rates.--To the extent practicable, the rates paid by 
the Secretary for hospital care, medical services, and extended 
care services provided under a Veterans Care Agreement shall be 
in accordance with the rates paid by the United States under 
the Medicare program.
    (e) Terms of Veterans Care Agreements.--(1) Pursuant to 
regulations promulgated under subsection (k), the Secretary may 
define the requirements for providers and entities entering 
into agreements under this section based upon such factors as 
the number of patients receiving care or services, the number 
of employees employed by the entity or provider furnishing such 
care or services, the amount paid by the Secretary to the 
provider or entity, or other factors as determined by the 
Secretary.
    (2) To furnish hospital care, medical services, or extended 
care services under this section, an eligible entity or 
provider shall agree--
          (A) to accept payment at the rates established in 
        regulations prescribed under this section;
          (B) that payment by the Secretary under this section 
        on behalf of a veteran to a provider of services or 
        care shall, unless rejected and refunded by the 
        provider within 30 days of receipt, constitute payment 
        in full and extinguish any liability on the part of the 
        veteran for the treatment or care provided, and no 
        provision of a contract, agreement, or assignment to 
        the contrary shall operate to modify, limit, or negate 
        this requirement;
          (C) to provide only the care and services authorized 
        by the Department under this section and to obtain the 
        prior written consent of the Department to furnish care 
        or services outside the scope of such authorization;
          (D) to bill the Department in accordance with the 
        methodology outlined in regulations prescribed under 
        this section;
          (E) to not seek to recover or collect from a health 
        plan contract or third party, as those terms are 
        defined in section 1729 of this title, for any care or 
        service that is furnished or paid for by the 
        Department;
          (F) to provide medical records to the Department in 
        the time frame and format specified by the Department; 
        and
          (G) to meet such other terms and conditions, 
        including quality of care assurance standards, as the 
        Secretary may specify in regulation.
    (f) Discontinuation or Nonrenewal of a Veterans Care 
Agreement.--(1) An eligible entity or provider may discontinue 
a Veterans Care Agreement at such time and upon such notice to 
the Secretary as may be provided in regulations prescribed 
under this section.
    (2) The Secretary may discontinue a Veterans Care Agreement 
with an eligible entity or provider at such time and upon such 
reasonable notice to the eligible entity or provider as may be 
specified in regulations prescribed under this section, if an 
official designated by the Secretary--
          (A) has determined that the eligible entity or 
        provider failed to comply substantially with the 
        provisions of the Veterans Care Agreement, or with the 
        provisions of this section or regulations prescribed 
        under this section;
          (B) has determined the eligible entity or provider is 
        excluded from participation in a Federal health care 
        program under section 1128 or section 1128A of the 
        Social Security Act (42 U.S.C. 1320a-7 or 1320a-7a) or 
        is identified on the System for Award Management 
        Exclusions list as provided in part 9 of title 48, Code 
        of Federal Regulations, and part 180 of title 2 of such 
        Code, or successor regulations;
          (C) has ascertained that the eligible entity or 
        provider has been convicted of a felony or other 
        serious offense under Federal or State law and 
        determines the eligible entity or provider's continued 
        participation would be detrimental to the best 
        interests of veterans or the Department; or
          (D) has determined that it is reasonable to terminate 
        the agreement based on the health care needs of a 
        veteran.
    (g) Quality of Care.--The Secretary shall establish through 
regulation a system or systems for monitoring the quality of 
care provided to veterans through Veterans Care Agreements and 
for assessing the quality of hospital care, medical services, 
and extended care services furnished by eligible entities and 
providers before the renewal of Veterans Care Agreements.
    (h) Disputes.--(1) The Secretary shall promulgate 
administrative procedures for eligible entities and providers 
to present all disputes arising under or related to Veterans 
Care Agreements.
    (2) Such procedures constitute the eligible entities' and 
providers' exhaustive and exclusive administrative remedies.
    (3) Eligible entities or providers must first exhaust such 
administrative procedures before seeking any judicial review 
under section 1346 of title 28 (known as the ``Tucker Act'').
    (4) Disputes under this section must pertain to either the 
scope of authorization under the Veterans Care Agreement or 
claims for payment subject to the Veterans Care Agreement and 
are not claims for the purposes of such laws that would 
otherwise require application of sections 7101 through 7109 of 
title 41, United States Code.
    (i) Applicability of Other Provisions of Law.--(1) A 
Veterans Care Agreement may be authorized by the Secretary or 
any Department official authorized by the Secretary, and such 
action shall not be treated as--
          (A) an award for the purposes of such laws that would 
        otherwise require the use of competitive procedures for 
        the furnishing of care and services; or
          (B) a Federal contract for the acquisition of goods 
        or services for purposes of any provision of Federal 
        law governing Federal contracts for the acquisition of 
        goods or services.
    (2)(A) Except as provided in subparagraph (B), and unless 
otherwise provided in this section or regulations prescribed 
pursuant to this section, an eligible entity or provider that 
enters into an agreement under this section is not subject to, 
in the carrying out of the agreement, any law to which 
providers of services and suppliers under the Medicare program 
under title XVIII of the Social Security Act (42 U.S.C. 1395 et 
seq.) are not subject.
    (B) An eligible entity or provider that enters into an 
agreement under this section is subject to--
          (i) all laws regarding integrity, ethics, or fraud, 
        or that subject a person to civil or criminal 
        penalties; and
          (ii) all laws that protect against employment 
        discrimination or that otherwise ensure equal 
        employment opportunities.
    (3) Notwithstanding paragraph (2)(B)(i), an eligible entity 
or provider that enters into an agreement under this section 
shall not be treated as a Federal contractor or subcontractor 
for purposes of chapter 67 of title 41 (commonly known as the 
``McNamara-O'Hara Service Contract Act of 1965'').
    (j) Parity of Treatment.--Eligibility for hospital care, 
medical services, and extended care services furnished to any 
veteran pursuant to a Veterans Care Agreement shall be subject 
to the same terms as though provided in a facility of the 
Department, and provisions of this chapter applicable to 
veterans receiving such care and services in a facility of the 
Department shall apply to veterans treated under this section.
    (k) Rulemaking.--The Secretary shall promulgate regulations 
to carry out this section.

SEC. 1703B. ACCESS GUIDELINES

    The Secretary shall consult with all pertinent Federal 
entities to examine health care access measurements and 
establish localized benchmarking guidelines that can inform 
provider and veteran clinical decisionmaking. The Secretary 
shall establish such guidelines for all hospital care, medical 
services, and extended care services furnished or otherwise 
made available under laws administered by the Secretary, 
including through non-Department health care providers.

SEC. 1703C. STANDARDS FOR QUALITY

    (a) In General.--(1) The Secretary shall establish 
standards for quality, in coordination or consultation with 
entities pursuant to section 1703(h)(3) of this title, 
regarding hospital care, medical services, and extended care 
services furnished by the Department pursuant to this title, 
including through non-Department health care providers pursuant 
to section 1703 of this title.
    (2) In establishing standards for quality under paragraph 
(1), the Secretary shall consider existing health quality 
measures that are applied to public and privately sponsored 
health care systems with the purpose of providing covered 
veterans relevant comparative information to make informed 
decisions regarding their health care.
    (3) The Secretary shall collect and consider data for 
purposes of establishing the standards under paragraph (1). 
Such data collection shall include--
          (A) after consultation with veterans service 
        organizations and other key stakeholders on survey 
        development or modification of an existing survey, a 
        survey of veterans who have used hospital care, medical 
        services, or extended care services furnished by the 
        Veterans Health Administration during the most recent 
        two-year period to assess the satisfaction of the 
        veterans with service and quality of care; and
          (B) datasets that include, at a minimum, elements 
        relating to the following:
                  (i) Timely care.
                  (ii) Effective care.
                  (iii) Safety, including, at a minimum, 
                complications, readmissions, and deaths.
                  (iv) Efficiency.
    (b) Publication and Consideration of Public Comments.--(1) 
Not later than one year after the date on which the Secretary 
establishes standards for quality under subsection (a), the 
Secretary shall publish the quality rating of medical 
facilities of the Department in the publicly available Hospital 
Compare website through the Centers for Medicare & Medicaid 
Services for the purpose of providing veterans with information 
that allows them to compare performance measure information 
among Department and non-Department health care providers.
    (2) Not later than two years after the date on which the 
Secretary establishes standards for quality under subsection 
(a), the Secretary shall consider and solicit public comment on 
potential changes to the measures used in such standards to 
ensure that they include the most up-to-date and applicable 
industry measures for veterans.

SEC. 1703D. PROMPT PAYMENT STANDARD

    (a) In General.--(1) Notwithstanding any other provision of 
this title or of any other provision of law, the Secretary 
shall pay for hospital care, medical services, or extended care 
services furnished by health care entities or providers under 
this chapter within 45 calendar days upon receipt of a clean 
paper claim or 30 calendar days upon receipt of a clean 
electronic claim.
    (2) If a claim is denied, the Secretary shall, within 45 
calendar days of denial for a paper claim and 30 calendar days 
of denial for an electronic claim, notify the health care 
entity or provider of the reason for denying the claim and 
what, if any, additional information is required to process the 
claim.
    (3) Upon the receipt of the additional information, the 
Secretary shall ensure that the claim is paid, denied, or 
otherwise adjudicated within 30 calendar days from the receipt 
of the requested information.
    (4) This section shall only apply to payments made on an 
invoice basis and shall not apply to capitation or other forms 
of periodic payment to entities or providers.
    (b) Submittal of Claims by Health Care Entities and 
Providers.--A health care entity or provider that furnishes 
hospital care, a medical service, or an extended care service 
under this chapter shall submit to the Secretary a claim for 
payment for furnishing the hospital care, medical service, or 
extended care service not later than 180 days after the date on 
which the entity or provider furnished the hospital care, 
medical service, or extended care service.
    (c) Fraudulent Claims.--(1) Sections 3729 through 3733 of 
title 31 shall apply to fraudulent claims for payment submitted 
to the Secretary by a health care entity or provider under this 
chapter.
    (2) Pursuant to regulations prescribed by the Secretary, 
the Secretary shall bar a health care entity or provider from 
furnishing hospital care, medical services, and extended care 
services under this chapter when the Secretary determines the 
entity or provider has submitted to the Secretary fraudulent 
health care claims for payment by the Secretary.
    (d) Overdue Claims.--(1) Any claim that has not been denied 
with notice, made pending with notice, or paid to the health 
care entity or provider by the Secretary shall be overdue if 
the notice or payment is not received by the entity provider 
within the time periods specified in subsection (a).
    (2)(A) If a claim is overdue under this subsection, the 
Secretary may, under the requirements established by subsection 
(a) and consistent with the provisions of chapter 39 of title 
31 (commonly referred to as the ``Prompt Payment Act''), 
require that interest be paid on clean claims.
    (B) Interest paid under subparagraph (A) shall be computed 
at the rate of interest established by the Secretary of the 
Treasury under section 3902 of title 31 and published in the 
Federal Register.
    (3) Not less frequently than annually, the Secretary shall 
submit to Congress a report on payment of overdue claims under 
this subsection, disaggregated by paper and electronic claims, 
that includes the following:
          (A) The amount paid in overdue claims described in 
        this subsection, disaggregated by the amount of the 
        overdue claim and the amount of interest paid on such 
        overdue claim.
          (B) The number of such overdue claims and the average 
        number of days late each claim was paid, disaggregated 
        by facility of the Department and Veterans Integrated 
        Service Network region.
    (e) Overpayment.--(1) The Secretary shall deduct the amount 
of any overpayment from payments due a health care entity or 
provider under this chapter.
    (2) Deductions may not be made under this subsection unless 
the Secretary has made reasonable efforts to notify a health 
care entity or provider of the right to dispute the existence 
or amount of such indebtedness and the right to request a 
compromise of such indebtedness.
    (3) The Secretary shall make a determination with respect 
to any such dispute or request prior to deducting any 
overpayment unless the time required to make such a 
determination before making any deductions would jeopardize the 
Secretary's ability to recover the full amount of such 
indebtedness.
    (f) Information and Documentation Required.--(1) The 
Secretary shall provide to all health care entities and 
providers participating in a program to furnish hospital care, 
medical services, or extended care services under this chapter 
a list of information and documentation that is required to 
establish a clean claim under this section.
    (2) The Secretary shall consult with entities in the health 
care industry, in the public and private sector, to determine 
the information and documentation to include in the list under 
paragraph (1).
    (3) If the Secretary modifies the information and 
documentation included in the list under paragraph (1), the 
Secretary shall notify all health care entities and providers 
described in paragraph (1) not later than 30 days before such 
modifications take effect.
    (g) Processing of Claims.--In processing a claim for 
compensation for hospital care, medical services, or extended 
care services furnished by a health care entity or provider 
under this chapter, the Secretary shall act through--
          (1) a non-Department entity that is under contract or 
        agreement for the program established under section 
        1703(a) of this title; or
          (2) a non-Department entity that specializes in such 
        processing for other Federal agency health care 
        systems.
    (h) Report on Encounter Data System.--(1) Not later than 90 
days after the date of the enactment of the Caring for our 
Veterans Act of 2017, the Secretary shall submit to the 
appropriate committees of Congress a report on the feasibility 
and advisability of adopting a funding mechanism similar to 
what is utilized by other Federal agencies to allow a 
contracted entity to act as a fiscal intermediary for the 
Federal Government to distribute, or pass through, Federal 
Government funds for certain non-underwritten hospital care, 
medical services, or extended care services.
    (2) The Secretary may coordinate with the Department of 
Defense, the Department of Health and Human Services, and the 
Department of the Treasury in developing the report required by 
paragraph (1).
    (i) Definitions.--In this section:
          (1) The term ``appropriate committees of Congress'' 
        means--
                  (A) the Committee on Veterans' Affairs and 
                the Committee on Appropriations of the Senate; 
                and
                  (B) the Committee on Veterans' Affairs and 
                the Committee on Appropriations of the House of 
                Representatives.
          (2) The term ``clean electronic claim'' means the 
        transmission of data for purposes of payment of covered 
        health care expenses that is submitted to the Secretary 
        which contains substantially all of the required data 
        elements necessary for accurate adjudication, without 
        obtaining additional information from the entity or 
        provider that furnished the care or service, submitted 
        in such format as prescribed by the Secretary in 
        regulations for the purpose of paying claims for care 
        or services.
          (3) The term ``clean paper claim'' means a paper 
        claim for payment of covered health care expenses that 
        is submitted to the Secretary which contains 
        substantially all of the required data elements 
        necessary for accurate adjudication, without obtaining 
        additional information from the entity or provider that 
        furnished the care or service, submitted in such format 
        as prescribed by the Secretary in regulations for the 
        purpose of paying claims for care or services.
          (4) The term ``fraudulent claims'' means the 
        intentional and deliberate misrepresentation of a 
        material fact or facts by a health care entity or 
        provider made to induce the Secretary to pay a claim 
        that was not legally payable to that provider. This 
        term, as used in this section, shall not include a good 
        faith interpretation by a health care entity or 
        provider of utilization, medical necessity, coding, and 
        billing requirements of the Secretary.
          (5) The term ``health care entity or provider'' 
        includes any non-Department health care entity or 
        provider, but does not include any Federal health care 
        entity or provider.

Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical 
                               Treatment

SEC. 1712. DENTAL CARE; DRUGS AND MEDICINES FOR CERTAIN DISABLED 
                    VETERANS; VACCINES

    (a)(1) * * *

           *       *       *       *       *       *       *

    (3) The total amount which the Secretary may expend for 
furnishing, during any twelve-month period, outpatient dental 
services, treatment, or related dental appliances to a veteran 
under this section through private facilities for which the 
Secretary has contracted [under clause (1), (2), or (5) of 
section 1703(a) of this title] or entered an agreement may not 
exceed $1,000 unless the Secretary determines, prior to the 
furnishing of such services, treatment, or appliances and based 
on an examination of the veteran by a dentist employed by the 
Department (or, in an area where no such dentist is available, 
by a dentist conducting such examination under a contract or 
fee arrangement), that the furnishing of such services, 
treatment, or appliances at such cost is reasonably necessary.
    (4)(A) Except as provided in subparagraph (B) of this 
paragraph, in any year in which the President's Budget for the 
fiscal year beginning October 1 of such year includes an amount 
for expenditures for contract dental care [under the provisions 
of this subsection and section 1703 of this title] during such 
fiscal year * * *

           *       *       *       *       *       *       *

SEC. 1712A. ELIGIBILITY FOR READJUSTMENT COUNSELING AND RELATED MENTAL 
                    HEALTH SERVICES

    (a)(1)(A) * * *
    (e)(1) In furnishing counseling and related mental health 
services under subsections (a) and (b) of this section, the 
Secretary shall have available the same authority to enter into 
contracts or agreementswith private facilities that is 
available to the Secretary [(under sections 1703(a)(2) and 
1710(a)(1)(B) of this title)] in furnishing medical services to 
veterans suffering from total service-connected disabilities.

           *       *       *       *       *       *       *

SEC. 1720G. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS

    (a) Program of Comprehensive Assistance for Family 
Caregivers.--(1)(A) * * *
    (2) * * *

           *       *       *       *       *       *       *

          [(B) has a serious injury (including traumatic brain 
        injury, psychological trauma, or other mental disorder) 
        incurred or aggravated in the line of duty in the 
        active military, naval, or air service on or after 
        September 11, 2001; and]
          (B) for assistance provided under this subsection--
                  (i) before the date on which the Secretary 
                submits to Congress a certification that the 
                Department has fully implemented the 
                information technology system required by 
                section 302(a) of the Caring for our Veterans 
                Act of 2017, has a serious injury (including 
                traumatic brain injury, psychological trauma, 
                or other mental disorder) incurred or 
                aggravated in the line of duty in the active 
                military, naval, or air service on or after 
                September 11, 2001;
                  (ii) during the two-year period beginning on 
                the date on which the Secretary submitted to 
                Congress the certification described in clause 
                (i), has a serious injury (including traumatic 
                brain injury, psychological trauma, or other 
                mental disorder) incurred or aggravated in the 
                line of duty in the active military, naval, or 
                air service--
                          (I) on or before May 7, 1975; or
                          (II) on or after September 11, 2001; 
                        or
                  (iii) after the date that is two years after 
                the date on which the Secretary submits to 
                Congress the certification described in clause 
                (i), has a serious injury (including traumatic 
                brain injury, psychological trauma, or other 
                mental disorder) incurred or aggravated in the 
                line of duty in the active military, naval, or 
                air service; and
          (C) is in need of personal care services because of--
                  (i) * * *
                  (ii) a need for supervision or protection 
                based on symptoms or residuals of neurological 
                or other impairment or injury[; or] ;
                  (iii) a need for regular or extensive 
                instruction or supervision without which the 
                ability of the veteran to function in daily 
                life would be seriously impaired; or
                  (iv) [(iii)] such other matters as the 
                Secretary considers appropriate.
    (3)(A) * * *

           *       *       *       *       *       *       *

          (ii) * * *

           *       *       *       *       *       *       *

                  (IV) medical care under section 1781 of this 
                title[; and] ;
                  (V) a monthly personal caregiver stipend[.] ; 
                and
                  (VI) through the use of contracts with, or 
                the provision of grants to, public or private 
                entities--
                          (aa) financial planning services 
                        relating to the needs of injured 
                        veterans and their caregivers; and
                          (bb) legal services, including legal 
                        advice and consultation, relating to 
                        the needs of injured veterans and their 
                        caregivers.

           *       *       *       *       *       *       *

    (C)(i) * * *

           *       *       *       *       *       *       *

    (iii) In determining the amount and degree of personal care 
services provided under clause (i) with respect to an eligible 
veteran whose need for personal care services is based in whole 
or in part on a need for supervision or protection under 
paragraph (2)(C)(ii) or regular instruction or supervision 
under paragraph (2)(C)(iii), the Secretary shall take into 
account the following:
          (I) The assessment by the family caregiver of the 
        needs and limitations of the veteran.
          (II) The extent to which the veteran can function 
        safely and independently in the absence of such 
        supervision, protection, or instruction.
          (III) The amount of time required for the family 
        caregiver to provide such supervision, protection, or 
        instruction to the veteran.
    (iv) [(iii)] If personal care services are not available 
from a commercial home health entity in the geographic area of 
an eligible veteran, the amount of the monthly personal 
caregiver stipend payable under the schedule required by clause 
(i) with respect to the eligible veteran shall be determined by 
taking into consideration the costs of commercial providers of 
personal care services in providing personal care services in 
geographic areas other than the geographic area of the eligible 
veteran with similar costs of living.
    (D) In providing instruction, preparation, and training 
under subparagraph (A)(i)(I) and technical support under 
subparagraph (A)(i)(II) to each family caregiver who is 
approved as a provider of personal care services for an 
eligible veteran under paragraph (6), the Secretary shall 
periodically evaluate the needs of the eligible veteran and the 
skills of the family caregiver of such veteran to determine if 
additional instruction, preparation, training, or technical 
support under those subparagraphs is necessary.
    (4) * * *
    (5) For each application submitted jointly by an eligible 
veteran and family member, the Secretary shall evaluate (in 
collaboration with the primary care team for the eligible 
veteran to the maximum extent practicable)--

           *       *       *       *       *       *       *

    (11)(A) In providing assistance under this subsection to 
family caregivers of eligible veterans, the Secretary may enter 
into contracts, provider agreements, and memoranda of 
understanding with Federal agencies, States, and private, 
nonprofit, and other entities to provide such assistance to 
such family caregivers.
    (B) The Secretary may provide assistance under this 
paragraph only if such assistance is reasonably accessible to 
the family caregiver and is substantially equivalent or better 
in quality to similar services provided by the Department.
    (C) The Secretary may provide fair compensation to Federal 
agencies, States, and other entities that provide assistance 
under this paragraph.

           *       *       *       *       *       *       *

    (d) Definitions.--In this section:

           *       *       *       *       *       *       *

          (4) * * *
                  (A) Assistance with one or more [independent] 
                activities of daily living.
                  (B) Supervision or protection based on 
                symptoms or residuals of neurological or other 
                impairment or injury.
                  (C) Regular or extensive instruction or 
                supervision without which the ability of the 
                veteran to function in daily life would be 
                seriously impaired.
                  (D) [(B)] Any other non-institutional 
                extended care (as such term is used in section 
                1701(6)(E) of this title).

           *       *       *       *       *       *       *

   Subchapter III. Miscellaneous Provisions Relating to Hospital and 
Nursing Home Care and Medical Treatment of Veterans

           *       *       *       *       *       *       *

SEC. 1725A. ACCESS TO WALK-IN CARE

    (a) Procedures To Ensure Access to Walk-in Care.--The 
Secretary shall develop procedures to ensure that eligible 
veterans are able to access walk-in care from qualifying non-
Department entities or providers.
    (b) Eligible Veterans.--For purposes of this section, an 
eligible veteran is any individual who--
          (1) is enrolled in the health care system established 
        under section 1705(a) of this title; and
          (2) has received care under this chapter within the 
        24-month period preceding the furnishing of walk-in 
        care under this section.
    (c) Qualifying Non-Department Entities or Providers.--For 
purposes of this section, a qualifying non-Department entity or 
provider is a non-Department entity or provider that has 
entered into a contract or other agreement with the Secretary 
to furnish services under this section.
    (d) Federally-qualified Health Centers.--Whenever 
practicable, the Secretary may use a Federally-qualified health 
center (as defined in section 1905(l)(2)(B) of the Social 
Security Act (42 U.S.C. 1396d(l)(2)(B))) to carry out this 
section.
    (e) Continuity of Care.--The Secretary shall ensure 
continuity of care for those veterans who receive walk-in care 
services under this section, including through the 
establishment of a mechanism to receive medical records from 
walk-in care providers and provide pertinent patient medical 
records to providers of walk-in care.
    (f) Copayments.--(1)(A) The Secretary shall require all 
eligible veterans to pay the United States a copayment for each 
episode of hospital care and medical service provided under 
this section if otherwise required to pay a copayment under 
this title.
    (B) Those not required to pay a copayment under this title 
may access walk-in care without a copayment for the first two 
visits in a calendar year. For any additional visits, a 
copayment at an amount determined by the Secretary shall be 
paid.
    (C) For those veterans required to pay a copayment under 
title 38, they are required to pay their regular copayment for 
their first two walk-in care visits in a calendar year. For any 
additional visits, a higher copayment at an amount determined 
by the Secretary shall be paid.
    (2) After the first two episodes of care furnished to a 
veteran under this section, the Secretary may adjust the 
copayment required of the veteran under this subsection based 
upon the priority group of enrollment of the veteran, the 
number of episodes of care furnished to the veteran during a 
year, and other factors the Secretary considers appropriate 
under this section.
    (3) The amount or amounts of the copayments required under 
this subsection shall be prescribed by the Secretary by rule.
    (4) Section 8153(c) of this title shall not apply to this 
subsection.
    (g) Regulations.--Not later than one year after the date of 
the enactment of the Caring for our Veterans Act of 2017, the 
Secretary shall promulgate regulations to carry out this 
section.
    (h) Walk-in Care Defined.--In this section, the term 
``walk-in care'' means non-emergent care provided by a 
qualifying non-Department entity or provider that furnishes 
episodic care and not longitudinal management of conditions and 
is otherwise defined through regulations the Secretary shall 
promulgate.

SEC. 1729. RECOVERY BY THE UNITED STATES OF THE COST OF CERTAIN CARE 
                    AND SERVICES

    (a)[(1) Subject to the provisions of this section, in any 
case in which a veteran is furnished care or services under 
this chapter for a non-service-connected disability described 
in paragraph (2) of this subsection, the United States has the 
right to recover or collect reasonable charges for such care or 
services (as determined by the Secretary) from a third party to 
the extent that the veteran (or the provider of the care or 
services) would be eligible to receive payment for such care or 
services from such third party if the care or services had not 
been furnished by a department or agency of the United States] 
(1) Subject to the provisions of this section, in any case in 
which the United States is required by law to furnish or pay 
for care or services under this chapter for a non-service-
connected disability described in paragraph (2) of this 
subsection, the United States has the right to recover or 
collect from a third party the reasonable charges of care or 
services so furnished or paid for to the extent that the 
recipient or provider of the care or services would be eligible 
to receive payment for such care or services from such third 
party if the care or services had not been furnished or paid 
for by a department or agency of the United States..
    (2) Paragraph (1) of this subsection applies to a non-
service-connected disability--
          (A) that is incurred incident to [the veteran's] the 
        individual's employment and that is covered under a 
        workers' compensation law or plan that provides for 
        payment for the cost of health care and services 
        provided to [the veteran] the individual by reason of 
        the disability;

           *       *       *       *       *       *       *

          (D) [that is incurred by a veteran-] that is incurred 
        by an individual who is entitled to care (or payment of 
        the expenses of care) under a health-plan contract.

           *       *       *       *       *       *       *

    (3) In the case of a health-plan contract that contains a 
requirement for payment of a deductible or copayment by [the 
veteran] the individual--
          (A) [the veteran's] the individual's not having paid 
        such deductible or copayment with respect to care or 
        services furnished under this chapter shall not 
        preclude recovery or collection under this section; and

           *       *       *       *       *       *       *

    (b)(1) As to the right provided in subsection (a) of this 
section, the United States shall be subrogated to any right or 
claim that [the veteran] the individual (or [the veteran's] the 
individual's personal representative, successor, dependents, or 
survivors) may have against a third party.
    (2)(A) In order to enforce any right or claim to which the 
United States is subrogated under paragraph (1) of this 
subsection, the United States may intervene or join in any 
action or proceeding brought by [the veteran] the individual 
(or [the veteran's] the individual's personal representative, 
successor, dependents, or survivors) against a third party.
    (B) The United States may institute and prosecute legal 
proceedings against the third party if--
          (i) an action or proceeding described in subparagraph 
        (A) of this paragraph is not begun within 180 days 
        after the first day on which care or services for which 
        recovery is sought are furnished to [the veteran] the 
        individual by the Secretary under this chapter;
          (ii) the United States has sent written notice by 
        certified mail to [the veteran] the individual at [the 
        veteran's] the individual's last-known address (or to 
        [the veteran's] the individual's personal 
        representative or successor) of the intention of the 
        United States to institute such legal proceedings; and

           *       *       *       *       *       *       *

    (e) [A veteran] An individual eligible for care or services 
under this chapter--

           *       *       *       *       *       *       *

    (h)(1) Subject to paragraph (3) of this subsection, the 
Secretary shall make available medical records of [a veteran] 
an individual described in paragraph (2) of this subsection for 
inspection and review by representatives of the third party 
concerned for the sole purposes of permitting the third party 
to verify--
          (A) that the care or services for which recovery or 
        collection is sought were furnished to [the veteran] 
        the individual; and
          (B) that the provision of such care or services to 
        [the veteran] the individual meets criteria generally 
        applicable under the health-plan contract involved.
    (2) [A veteran] An individual described in this paragraph 
is [a veteran] an individual who is a beneficiary of a health-
plan contract under which recovery or collection is sought 
under this section from the third party concerned for the cost 
of the care or services furnished to [the veteran] the 
individual.

           *       *       *       *       *       *       *

SEC. 1730B. LICENSURE OF HEALTH CARE PROFESSIONALS PROVIDING TREATMENT 
                    VIA TELEMEDICINE

    (a) In General.--Notwithstanding any provision of law 
regarding the licensure of health care professionals, a covered 
health care professional may practice the health care 
profession of the health care professional at any location in 
any State, regardless of where the covered health care 
professional or the patient is located, if the covered health 
care professional is using telemedicine to provide treatment to 
an individual under this chapter.
    (b) Covered Health Care Professionals.--For purposes of 
this section, a covered health care professional is any health 
care professional who--
          (1) is an employee of the Department appointed under 
        the authority under section 7306, 7401, 7405, 7406, or 
        7408 of this title or title 5;
          (2) is authorized by the Secretary to provide health 
        care under this chapter;
          (3) is required to adhere to all standards of quality 
        relating to the provision of medicine in accordance 
        with applicable policies of the Department; and
          (4) has an active, current, full, and unrestricted 
        license, registration, or certification in a State to 
        practice the health care profession of the health care 
        professional.
    (c) Property of Federal Government.--Subsection (a) shall 
apply to a covered health care professional providing treatment 
to a patient regardless of whether the covered health care 
professional or patient is located in a facility owned by the 
Federal Government during such treatment.
    (d) Relation to State Law.--(1) The provisions of this 
section shall supersede any provisions of the law of any State 
to the extent that such provision of State law are inconsistent 
with this section.
    (2) No State shall deny or revoke the license, 
registration, or certification of a covered health care 
professional who otherwise meets the qualifications of the 
State for holding the license, registration, or certification 
on the basis that the covered health care professional has 
engaged or intends to engage in activity covered by subsection 
(a).
    (e) Rule of Construction.--Nothing in this section may be 
construed to remove, limit, or otherwise affect any obligation 
of a covered health care professional under the Controlled 
Substances Act (21 U.S.C. 801 et seq.).

           *       *       *       *       *       *       *

Subchapter V. Payments to State Homes

           *       *       *       *       *       *       *

SEC. 1745. NURSING HOME CARE AND MEDICATIONS FOR VETERANS WITH SERVICE-
                    CONNECTED DISABILITIES

    (a)(1) The Secretary shall enter into a contract [(or 
agreement under section 1720(c)(1) of this title)] (or an 
agreement) with each State home for payment by the Secretary 
for nursing home care provided in the home, in any case in 
which such care is provided to any veteran as follows:

           *       *       *       *       *       *       *

    (4)(A) An agreement under this section may be authorized by 
the Secretary or any Department official authorized by the 
Secretary, and any such action is not an award for purposes of 
such laws that would otherwise require the use of competitive 
procedures for the furnishing of hospital care, medical 
services, and extended care services.
    (B)(i) Except as provided in clause (ii), and unless 
otherwise provided in this section or regulations prescribed 
pursuant to this section, a State home that enters into an 
agreement under this section is not subject to, in the carrying 
out of the agreement, any provision of law to which providers 
of services and suppliers under the Medicare program under 
title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) 
are not subject.
    (ii) A State home that enters into an agreement under this 
section is subject to--
          (I) all provisions of law regarding integrity, 
        ethics, or fraud, or that subject a person to civil or 
        criminal penalties; and
          (II) all provisions of law that protect against 
        employment discrimination or that otherwise ensure 
        equal employment opportunities.
    (iii) Notwithstanding subparagraph (B)(ii)(I), a State home 
that enters into an agreement under this section may not be 
treated as a Federal contractor or subcontractor for purposes 
of chapter 67 of title 41 (known as the ``McNamara-O'Hara 
Service Contract Act of 1965'').

           *       *       *       *       *       *       *

Subchapter VIII. Health Care of Persons Other Than Veterans

           *       *       *       *       *       *       *

SEC. 1788. TRANSPLANT PROCEDURES WITH LIVE DONORS AND RELATED SERVICES

    (a) In General.--Subject to subsections (b) and (c), in a 
case in which a veteran is eligible for a transplant procedure 
from the Department, the Secretary may provide for an operation 
on a live donor to carry out such procedure for such veteran, 
notwithstanding that the live donor may not be eligible for 
health care from the Department.
    (b) Other Services.--Subject to the availability of 
appropriations for such purpose, the Secretary shall furnish to 
a live donor any care or services before and after conducting 
the transplant procedure under subsection (a) that may be 
required in connection with such procedure.
    (c) Use of Non-Department Facilities.--In carrying out this 
section, the Secretary may provide for the operation described 
in subsection (a) on a live donor and furnish to the live donor 
the care and services described in subsection (b) at a non-
Department facility pursuant to an agreement entered into by 
the Secretary under this chapter. The live donor shall be 
deemed to be an individual eligible for hospital care and 
medical services at a non-Department facility pursuant to such 
an agreement solely for the purposes of receiving such 
operation, care, and services at the non-Department facility.

           *       *       *       *       *       *       *

Chapter 23. Burial Benefits

           *       *       *       *       *       *       *

SEC. 2303. DEATH IN DEPARTMENT FACILITY; PLOT ALLOWANCE

    (a)(1) * * *

           *       *       *       *       *       *       *

    (2) * * *
          (A) * * *
          (B) an institution at which the deceased veteran was, 
        at the time of death, receiving--
                  (i) hospital care in accordance [with section 
                1703] with sections 1703A, 8111, and 8153 of 
                this title;

           *       *       *       *       *       *       *

Part V. Boards, Administrations, and Services

           *       *       *       *       *       *       *

Chapter 73. Veterans Health Administration-Organization and Functions

           *       *       *       *       *       *       *

Subchapter I. Organization

           *       *       *       *       *       *       *

SEC. 7309. READJUSTMENT COUNSELING SERVICE

    (a) * * *
    (b) * * *
          (2) * * *

           *       *       *       *       *       *       *

                  (B) have at least three years of experience 
                providing direct counseling services or 
                outreach services [in the Readjustment 
                Counseling Service];
                  (C) have at least three years of experience 
                administrating direct counseling services or 
                outreach services [in the Readjustment 
                Counseling Service];

           *       *       *       *       *       *       *

Subchapter III. Protection of Patient Rights

           *       *       *       *       *       *       *

SEC. 7332. CONFIDENTIALITY OF CERTAIN MEDICAL RECORDS

           *       *       *       *       *       *       *

    (b)(1) * * *
    (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:

           *       *       *       *       *       *       *

          [(H)(i) To a non-Department entity (including private 
        entities and other Federal agencies) that provides 
        hospital care or medical services to veterans as 
        authorized by the Secretary.
          [(ii) An entity to which a record is disclosed under 
        this subparagraph may not redisclose or use such record 
        for a purpose other than that for which the disclosure 
        was made.]
          (H)(i) To a non-Department entity (including private 
        entities and other Federal agencies) for purposes of 
        providing health care, including hospital care, medical 
        services, and extended care services, to patients.
          (ii) An entity to which a record is disclosed under 
        this subparagraph may not disclose or use such record 
        for a purpose other than that for which the disclosure 
        was made.
          (I) To a third party in order to recover or collect 
        reasonable charges for care furnished to, or paid on 
        behalf of, a patient in connection with a non-service 
        connected disability as permitted by section 1729 of 
        this title or for a condition for which recovery is 
        authorized or with respect to which the United States 
        is deemed to be a third party beneficiary under the Act 
        entitled ``An Act to provide for the recovery from 
        tortiously liable third persons of the cost of hospital 
        and medical care and treatment furnished by the United 
        States'' (Public Law 87-693; 42 U.S.C. 2651 et seq.; 
        commonly known as the ``Federal Medical Care Recovery 
        Act'').

           *       *       *       *       *       *       *

          Chapter 74. Veterans Health Administration-Personnel

                       SUBCHAPTER I. APPOINTMENTS

Sec.

           *       *       *       *       *       *       *

[7411.Full-time board-certified physicians and dentists: 
            reimbursement of continuing professional education 
            expenses.]
7411. Reimbursement of continuing professional education 
            expenses.
7412. Annual determination of staffing shortages; recruitment and 
            appointment for needed occupations.
7413. Treatment of podiatrists; clinical oversight standards.

           *       *       *       *       *       *       *

                       Subchapter I. Appointments

SEC. 7401. APPOINTMENTS IN VETERANS HEALTH ADMINISTRATION

           *       *       *       *       *       *       *

          (1) Physicians, dentists, podiatrists, chiropractors, 
        optometrists, registered nurses, physician assistants, 
        certified clinical perfusionists, and expanded-function 
        dental auxiliaries.

           *       *       *       *       *       *       *

SEC. 7404. GRADES AND PAY SCALES

    (a)(1)(A) * * *

           *       *       *       *       *       *       *

    (b) The grades for positions provided for in paragraph (1) 
of section 7401 of this title shall be as follows. The annual 
ranges of rates of basic pay for those grades shall be 
prescribed from time to time by Executive order as authorized 
by chapter 53 of title 5 or as otherwise authorized by law:

    [PHYSICIAN AND DENTIST SCHEDULE] PHYSICIAN AND SURGEON (MD/DO), 
   PODIATRIC SURGEON (DPM), AND DENTIST AND ORAL SURGEON (DDS, DMD) 
                                SCHEDULE

    [Physician grade.] Physician and surgeon grade.
    Dentist grade.

                             NURSE SCHEDULE

    Nurse V.

           *       *       *       *       *       *       *

 CLINICAL [PODIATRIST, CHIROPRACTOR, AND] CHIROPRACTOR AND OPTOMETRIST 
                                SCHEDULE

    Chief grade.

           *       *       *       *       *       *       *

    (c) * * *
    (d) [Except] Except for positions described in section 
7401(4) of this title and except as provided under subsection 
(e), subchapter III, and section 7457 of this title, pay for 
positions for which basic pay is paid under this section may 
not be paid at a rate in excess of the rate of basic pay 
authorized by section 5316 of title 5 for positions in Level V 
of the Executive Schedule.

           *       *       *       *       *       *       *

[SEC. 7411. FULL-TIME BOARD-CERTIFIED PHYSICIANS AND DENTISTS: 
                    REIMBURSEMENT OF CONTINUING PROFESSIONAL EDUCATION 
                    EXPENSES

    [The Secretary shall reimburse any full-time board-
certified physician or dentist appointed under section 7401(1) 
of this title for expenses incurred, up to $1,000 per year, for 
continuing professional education.]

SEC. 7411. REIMBURSEMENT OF CONTINUING PROFESSIONAL EDUCATION EXPENSES

    The Secretary shall reimburse any full-time board-certified 
advanced practice registered nurse, physician, or dentist 
appointed under section 7401(1) of this title for expenses 
incurred, up to $1,000 per year, for continuing professional 
education.

           *       *       *       *       *       *       *

SEC. 7413. TREATMENT OF PODIATRISTS; CLINICAL OVERSIGHT STANDARDS

    (a) Podiatrists.--Except as provided by subsection (b), a 
doctor of podiatric medicine who is appointed as a podiatrist 
under section 7401(1) of this title is eligible for any 
supervisory position in the Veterans Health Administration to 
the same degree that a physician appointed under such section 
is eligible for the position.
    (b) Establishment of Clinical Oversight Standards.--The 
Secretary, in consultation with appropriate stakeholders, shall 
establish standards to ensure that specialists appointed in the 
Veterans Health Administration to supervisory positions do not 
provide direct clinical oversight for purposes of peer review 
or practice evaluation for providers of other clinical 
specialties.

           *       *       *       *       *       *       *

Subchapter IV. Pay for Nurses and Other Health-Care Personnel

           *       *       *       *       *       *       *

SEC. 7451. NURSES AND OTHER HEALTH-CARE PERSONNEL: COMPETITIVE PAY

    (c)(1) * * *
    [(2) The maximum rate of basic pay for any grade for a 
covered position may not exceed the maximum rate of basic pay 
established for positions in level IV of the Executive Schedule 
under section 5316 1 of title 5. The maximum rate of basic pay 
for a grade for the position of certified registered nurse 
anesthetist pursuant to an adjustment under subsection (d) may 
exceed the maximum rate otherwise provided in the preceding 
sentence.]
    (2)(A) The maximum rate of basic pay for any grade for 
health-care personnel positions referred to in paragraphs (1) 
and (3) of section 7401 of this title (other than the positions 
of physician, dentist, and registered nurse) may not exceed the 
rate of basic pay established for positions in level IV of the 
Executive Schedule under section 5315 of title 5.
    (B) Pursuant to an adjustment under subsection (d), the 
maximum rate of basic pay for a registered nurse serving as a 
nurse executive or a grade for the position of certified 
registered nurse anesthetist may exceed the rate of basic pay 
established for positions in level IV of the Executive Schedule 
under section 5315 of title 5 but may not exceed the rate of 
basic pay established for positions in level I of the Executive 
Schedule under section 5312 of title 5.
    (C) Pursuant to an adjustment under subsection (d), the 
maximum rate of basic pay for all registered nurses not 
described in subparagraph (B) may exceed the rate of basic pay 
established for positions in level IV of the Executive Schedule 
under section 5315 of title 5 but may not exceed the rate of 
basic pay established for positions in level III of the 
Executive Schedule under section 5314 of title 5.

           *       *       *       *       *       *       *

SEC. 7454. PHYSICIAN ASSISTANTS AND OTHER HEALTH CARE PROFESSIONALS: 
                    ADDITIONAL PAY

           *       *       *       *       *       *       *

    (d) In this section, the term ``compensation'' includes all 
compensation earned by employees when performing duties 
authorized by the Secretary or when the employee is approved to 
use annual, sick, family medical, military, or court leave or 
during any other paid absence for which pay is not already 
regulated.

SEC. 7455. INCREASES IN RATES OF BASIC PAY

           *       *       *       *       *       *       *

    (c)(1) Subject to paragraph (2), the amount of any increase 
under subsection (a) in the minimum rate for any grade may not 
(except in the case of nurse anesthetists, licensed practical 
nurses, licensed vocational nurses, nursing positions otherwise 
covered by title 5, pharmacists, certified clinical 
perfusionists, and licensed physical therapists) exceed the 
maximum rate of basic pay (excluding any locality-based 
comparability payment under section 5304 of title 5 or similar 
provision of law) for the grade or level by more than 30 
percent.

           *       *       *       *       *       *       *

Chapter 76. Health Professionals Educational Assistance Program

           *       *       *       *       *       *       *

Subchapter VII. Education Debt Reduction Program

           *       *       *       *       *       *       *

SEC. 7683. EDUCATION DEBT REDUCTION

           *       *       *       *       *       *       *

    (d) Maximum Annual Amount.--(1) The amount of education 
debt reduction payments made to or for a participant under the 
Education Debt Reduction Program may not exceed [$120,000] 
''$240,000 over a total of five years of participation in the 
Program, of which not more than [$24,000] $48,000 of such 
payments may be made in each year of participation in the 
Program.

           *       *       *       *       *       *       *

Part VI. Acquisition and Disposition of Property

           *       *       *       *       *       *       *

   Chapter 81. Acquisition and Operation of Hospital and Domiciliary 
    Facilities; Procurement and Supply; Enhanced-Use Leases of Real 
                                Property

     SUBCHAPTER I. ACQUISITION AND OPERATION OF MEDICAL FACILITIES

Sec.

           *       *       *       *       *       *       *

8111A. Furnishing of health-care services to members of the Armed 
            Forces during a war or national emergency.
8111B. Authority to plan, design, construct, or lease a shared 
            medical facility.

           *       *       *       *       *       *       *

     SUBCHAPTER IV. SHARING OF MEDICAL FACILITIES, EQUIPMENT, AND 
INFORMATION

           *       *       *       *       *       *       *

8159. Authority to pay for services authorized but not subject to 
            an agreement.

           *       *       *       *       *       *       *

     Subchapter I. Acquisition and Operation of Medical Facilities

SEC. 8101. DEFINITIONS

    For the purposes of this subchapter:

           *       *       *       *       *       *       *

          (3) The term ``medical facility'' means any facility 
        or part thereof which is, or will be, under the 
        jurisdiction of the [Secretary for the provision of 
        health-care services (including hospital, nursing 
        home,] Secretary, or as otherwise authorized by law, 
        for the provision of health-care services (including 
        hospital, outpatient clinic, nursing home, or 
        domiciliary care or medical services), including any 
        necessary building and auxiliary structure, garage, 
        parking facility, mechanical equipment, trackage 
        facilities leading thereto, abutting sidewalks, 
        accommodations for attending personnel, and recreation 
        facilities associated therewith.

           *       *       *       *       *       *       *

SEC. 8104. CONGRESSIONAL APPROVAL OF CERTAIN MEDICAL FACILITY 
                    ACQUISITIONS

    (a)(1) * * *

           *       *       *       *       *       *       *

    [(3) For the purpose of this subsection:
          [(A) The term ``major medical facility project'' 
        means a project for the construction, alteration, or 
        acquisition of a medical facility involving a total 
        expenditure of more than $10,000,000, but such term 
        does not include an acquisition by exchange.
          [(B) The term ``major medical facility lease'' means 
        a lease for space for use as a new medical facility at 
        an average annual rental of more than $1,000,000.]
    (3) For purposes of this subsection:
          (A) The term ``major medical facility project'' means 
        a project for the construction, alteration, or 
        acquisition of a medical facility involving a total 
        expenditure of more than $20,000,000, but such term 
        does not include an acquisition by exchange, non-
        recurring maintenance projects of the Department, or 
        the construction, alteration, or acquisition of a 
        shared Federal medical facility for which the 
        Department's estimated share of the project costs does 
        not exceed $20,000,000.
          (B) The term ``major medical facility lease'' means a 
        lease for space for use as a new medical facility at an 
        average annual rental equal to or greater than the 
        dollar threshold for leases procured through the 
        General Services Administration under section 
        3307(a)(2) of title 40, which shall be subject to 
        annual adjustment in accordance with section 3307(h) of 
        such title.

           *       *       *       *       *       *       *

SEC. 8111B. AUTHORITY TO PLAN, DESIGN, CONSTRUCT, OR LEASE A SHARED 
                    MEDICAL FACILITY

    (a) In General.--(1) The Secretary may enter into 
agreements with other Federal agencies for the planning, 
designing, constructing, or leasing of shared medical 
facilities with the goal of improving access to, and quality 
and cost effectiveness of, health care provided by the 
Department and other Federal agencies.
    (2) Facilities planned, designed, constructed, or leased 
under paragraph (1) shall be managed by the Under Secretary for 
Health.
    (b) Transfer of Amounts to Other Federal Agencies.--(1) The 
Secretary may transfer to another Federal agency amounts 
appropriated to the Department for ``Construction, Minor 
Projects'' for use for the planning, design, or construction of 
a shared medical facility if the estimated share of the project 
costs to be borne by the Department does not exceed the 
threshold for a major medical facility project under section 
8104(a)(3)(A) of this title.
    (2) The Secretary may transfer to another Federal agency 
amounts appropriated to the Department for ``Construction, 
Major Projects'' for use for the planning, design, or 
construction of a shared medical facility if--
          (A) the estimated share of the project costs to be 
        borne by the Department is more than the threshold for 
        a major medical facility project under subsection 
        (a)(3)(A) of section 8104 of this title; and
          (B) the requirements for such a project under such 
        section have been met.
    (3) The Secretary may transfer to another Federal agency 
amounts appropriated to the applicable appropriations account 
of the Department for the purpose of leasing space for a shared 
medical facility if the estimated share of the lease costs to 
be borne by the Department does not exceed the threshold for a 
major medical facility lease under section 8104(a)(3)(B) of 
this title.
    (c) Transfer of Amounts to Department.--(1) Amounts 
transferred to the Department by another Federal agency for the 
necessary expenses of planning, designing, or constructing a 
shared medical facility for which the estimated share of the 
project costs to be borne by the Department does not exceed the 
threshold for a major medical facility project under section 
8104(a)(3)(A) of this title may be deposited in the 
``Construction, Minor Projects'' account of the Department and 
used for such necessary expenses.
    (2) Amounts transferred to the Department by another 
Federal agency for the necessary expenses of planning, 
designing, or constructing a shared medical facility for which 
the estimated share of the project costs to be borne by the 
Department is more than the threshold for a major medical 
facility project under section 8104(a)(3)(A) of this title may 
be deposited in the ``Construction, Major Projects'' account of 
the Department and used for such necessary expenses if the 
requirements for such project under section 8104 of this title 
have been met.
    (3) Amounts transferred to the Department by another 
Federal agency for the purpose of leasing space for a shared 
medical facility may be credited to the applicable 
appropriations account of the Department and shall be available 
without fiscal year limitation.
    (4) Amounts transferred under paragraphs (1) and (2) shall 
be available for the same time period as amounts in the account 
to which those amounts are transferred.

           *       *       *       *       *       *       *

     Subchapter IV. Sharing of Medical Facilities, Equipment, and 
Information

           *       *       *       *       *       *       *

SEC. 8159. AUTHORITY TO PAY FOR SERVICES AUTHORIZED BUT NOT SUBJECT TO 
                    AN AGREEMENT

    (a) In General.--If, in the course of furnishing hospital 
care, a medical service, or an extended care service authorized 
by the Secretary and pursuant to a contract, agreement, or 
other arrangement with the Secretary, a provider who is not a 
party to the contract, agreement, or other arrangement 
furnishes hospital care, a medical service, or an extended care 
service that the Secretary considers necessary, the Secretary 
may compensate the provider for the cost of such care or 
service.
    (b) New Contracts and Agreements.--The Secretary shall take 
reasonable efforts to enter into a contract, agreement, or 
other arrangement with a provider described in subsection (a) 
to ensure that future care and services authorized by the 
Secretary and furnished by the provider are subject to such a 
contract, agreement, or other arrangement.

           *       *       *       *       *       *       *

Subchapter V. Enhanced-Use Leases of Real Property

           *       *       *       *       *       *       *

SEC. 8162. ENHANCED-USE LEASES

           *       *       *       *       *       *       *

    (b)(1) * * *
    [(6) The Secretary may not enter into an enhanced-use lease 
without certification in advance in writing by the Director of 
the Office of Management and Budget that such lease complies 
with the requirements of this subchapter.]
    (6) The Office of Management and Budget shall review each 
enhanced-use lease before the lease goes into effect to 
determine whether the lease is in compliance with paragraph 
(5).

           *       *       *       *       *       *       *

                          SOCIAL SECURITY ACT

                      (42 U.S.C. 1395cc(a)(1)(L))

Title 42. The Public Health and Welfare

           *       *       *       *       *       *       *

Chapter 7. Social Security

           *       *       *       *       *       *       *

Subchapter XVIII. Health Insurance for Aged and Disabled

           *       *       *       *       *       *       *

Part E. Miscellaneous Provisions

           *       *       *       *       *       *       *

SEC. 1866. AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES

    (a) * * *
          (1) * * *

           *       *       *       *       *       *       *

                  (L) in the case of hospitals which provide 
                inpatient hospital services for which payment 
                may be made under this subchapter, to be a 
                participating provider of medical care [under 
                section 1703] under chapter 17 of title 38, in 
                accordance with such admission practices, and 
                such payment methodology and amounts, as are 
                prescribed under joint regulations issued by 
                the Secretary and by the Secretary of Veterans 
                Affairs in implementation of such section,

           *       *       *       *       *       *       *

              VETERANS' BENEFITS IMPROVEMENTS ACT OF 1994

(Public Law 103-446; 38 U.S.C. 1117 note)

           *       *       *       *       *       *       *

Title I. Persian Gulf War Veterans

           *       *       *       *       *       *       *

SEC. 104. DEVELOPMENT OF MEDICAL EVALUATION PROTOCOL.

    (a) Uniform Medical Evaluation Protocol.--(1) * * *

           *       *       *       *       *       *       *

          (4)(A) If the Secretary is unable to diagnose the 
        symptoms or illness of a veteran provided an 
        evaluation, or if the symptoms or illness of a veteran 
        do not respond to treatment provided by the Secretary, 
        the Secretary may use the authority [in section 1703] 
        in sections 1703A, 8111, and 8153 of title 38, United 
        States Code, in order to provide for the veteran to 
        receive diagnostic tests or treatment at a non-
        Department medical facility that may have the 
        capability of diagnosing or treating the symptoms or 
        illness of the veteran. The Secretary may provide the 
        veteran the travel and incidental expenses therefor 
        pursuant to the provisions of section 111 of title 38, 
        United States Code.

           *       *       *       *       *       *       *

      CAREGIVERS AND VETERANS OMNIBUS HEALTH SERVICES ACT OF 2010

               (Public Law 111-163; 38 U.S.C. 1720G note)

Title I. Caregiver Support

           *       *       *       *       *       *       *

SEC. 101. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS.

           *       *       *       *       *       *       *

    (c) Annual Evaluation Report.--
          (1) * * *
          (2) Contents.--The report required by paragraph (1) 
        shall include the following:
                  (A) * * *

           *       *       *       *       *       *       *

                          (iv) an assessment of the 
                        effectiveness and the efficiency of the 
                        implementation of such programs , 
                        including a description of any barriers 
                        to accessing and receiving care and 
                        services under such programs; and

           *       *       *       *       *       *       *

                  (B) * * *
                          (i) a description of the outreach 
                        activities carried out by the Secretary 
                        under such program[; and] ;
                          (ii) an assessment of the manner in 
                        which resources are expended by the 
                        Secretary under such program, 
                        particularly with respect to the 
                        provision of monthly personal caregiver 
                        stipends under paragraph (3)(A)(ii)(v) 
                        of such subsection (a)[.] ; and
                          (iii) an evaluation of the 
                        sufficiency and consistency of the 
                        training provided to family caregivers 
                        under such program in preparing family 
                        caregivers to provide care to veterans 
                        under such program.

           *       *       *       *       *       *       *

        VETERANS ACCESS, CHOICE, AND ACCOUNTABILITY ACT OF 2014

(Public Law 113-146; 38 U.S.C. 703 note)

           *       *       *       *       *       *       *

Title VII. Other Veterans Matters

           *       *       *       *       *       *       *

SEC. 705. LIMITATION ON AWARDS AND BONUSES PAID TO EMPLOYEES OF 
                    DEPARTMENT OF VETERANS AFFAIRS.

    (a) Limitation.--The Secretary of Veterans Affairs shall 
ensure that the aggregate amount of awards and bonuses paid by 
the Secretary in a fiscal year under chapter 45 or 53 of title 
5, United States Code, or any other awards or bonuses 
authorized under such title or title 38, United States Code, 
other than recruitment, relocation, or retention incentives, 
does not exceed the following amounts:

           *       *       *       *       *       *       *

(Public Law 113-146; 38 U.S.C. 1701 note)

           *       *       *       *       *       *       *

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.

           *       *       *       *       *       *       *

    (p) Authority to Furnish Care and Services.--The Secretary 
may not use the authority under this section to furnish care 
and services after December 31, 2018.

           *       *       *       *       *       *       *

Title VIII. Other Matters

           *       *       *       *       *       *       *

SEC. 802. VETERANS CHOICE FUND.

           *       *       *       *       *       *       *

    (c) Use of Amounts.--
          (1) In general.--Except as provided [by paragraph 
        (3)] in paragraphs (3) and (4), any amounts deposited 
        in the Veteran Choice Fund shall be used by the 
        Secretary of Veterans Affairs to carry out section 101, 
        including, subject to paragraph (2), any administrative 
        requirements of such section.

           *       *       *       *       *       *       *

          (4) Permanent authority for other uses.-Beginning in 
        fiscal year 2019, amounts remaining in the Veterans 
        Choice Fund may be used to furnish hospital care, 
        medical services, and extended care services to 
        individuals pursuant to chapter 17 of title 38, United 
        States Code, at non-Department facilities, including 
        pursuant to non-Department provider programs other than 
        the program established by section 101. Such amounts 
        shall be available in addition to amounts available in 
        other appropriations accounts for such purposes.
    (d) Appropriation and Deposit of Amounts.--
          (1) In general.--There is authorized to be 
        appropriated, and is appropriated, to the Secretary of 
        Veterans Affairs, out of any funds in the Treasury not 
        otherwise appropriated $10,000,000,000 to be deposited 
        in the Veterans Choice Fund established by subsection 
        (a). Such funds shall be available for obligation or 
        expenditure without fiscal year limitation, and only 
        for the program created under section 101 (or for 
        hospital care and medical services pursuant [to 
        subsection (c)(3)] to paragraphs (3) and (4) of 
        subsection (c) of this section).

           *       *       *       *       *       *       *

      

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