```

[House Report 115-681]
[From the U.S. Government Publishing Office]

115th Congress    }                                    {       Report
                        HOUSE OF REPRESENTATIVES
 2d Session       }                                    {      115-681

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

 
                     VA BILLING ACCOUNTABILITY ACT

                                _______
                                

  May 18, 2018.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

    Mr. Roe of Tennessee, from the Committee on Veterans' Affairs, 
                        submitted the following

                              R E P O R T

                        [To accompany H.R. 1972]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 1972) to amend title 38, United States Code, to 
authorize the Secretary of Veterans Affairs to waive the 
requirement of certain veterans to make copayments for hospital 
care and medical services in the case of an error by the 
Department of Veterans Affairs, and for other purposes, having 
considered the same, report favorably thereon with an amendment 
and recommend that the bill as amended do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     5
Background and Need for Legislation..............................     5
Hearings.........................................................     5
Subcommittee Consideration.......................................     6
Committee Consideration..........................................     6
Committee Votes..................................................     6
Committee Correspondence.........................................
Committee Oversight Findings.....................................     7
Statement of General Performance Goals and Objectives............     7
New Budget Authority, Entitlement Authority, and Tax Expenditures     7
Earmarks and Tax and Tariff Benefits.............................     7
Committee Cost Estimate..........................................     7
Congressional Budget Office Estimate.............................     7
Federal Mandates Statement.......................................     9
Advisory Committee Statement.....................................     9
Constitutional Authority Statement...............................     9
Applicability to Legislative Branch..............................     9
Statement on Duplication of Federal Programs.....................     9
Disclosure of Directed Rulemaking................................     9
Section-by-Section Analysis of the Legislation...................    10
Changes in Existing Law Made by the Bill as Reported.............    11

    The amendment is as follows:
    Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``VA Billing Accountability Act''.

SEC. 2. AUTHORITY OF SECRETARY OF VETERANS AFFAIRS TO WAIVE REQUIREMENT 
                    OF CERTAIN VETERANS TO MAKE COPAYMENTS FOR CARE AND 
                    SERVICES IN THE CASE OF DEPARTMENT OF VETERANS 
                    AFFAIRS ERROR.

  (a) Hospital Care, Nursing Home Care, and Medical Services.--Section 
1710(f)(3) of title 38, United States Code, is amended by adding at the 
end the following new subparagraph:
  ``(G) The Secretary may waive the requirement of a veteran to make a 
payment under this subsection or subsection (g) if--
          ``(i) an error committed by the Department or an employee of 
        the Department was the cause of delaying notification sent to 
        the veteran of the requirement to make the payment; and
          ``(ii) the veteran received such notification later than 180 
        days after the date on which the veteran received the care or 
        services for which the payment was required.''.
  (b) Medications.--Section 1722A of such title is amended--
          (1) by redesignating subsection (c) as subsection (d); and
          (2) by inserting after subsection (b) the following new 
        subsection (c):
  ``(c) The Secretary may waive the requirement of a veteran to make a 
payment under this section if--
          ``(1) an error committed by the Department or an employee of 
        the Department was the cause of delaying notification sent to 
        the veteran of the requirement to make the payment; and
          ``(2) the veteran received such notification later than 180 
        days after the date on which the veteran received the 
        medication for which the payment was required.''.
  (c) Billing Procedures.--
          (1) In general.--Subchapter I of chapter 17 of such title is 
        amended by adding at the end the following new section:

``Sec. 1709C. Procedures for copayments

  ``(a) Care at Department Facility.--(1) In requiring a veteran to 
make a payment for care or services provided at a medical facility of 
the Department pursuant to this chapter, including sections 1710 and 
1722A, the Secretary shall provide to such veteran a notification of 
such required payment by not later than 180 days after the date on 
which the veteran receives the care or services for which payment is 
required.
  ``(2) If the Secretary does not provide to a veteran a notification 
of the required payment by the date required under paragraph (1), the 
Secretary may not collect such payment, including through a third-party 
entity, unless the Secretary provides the veteran the following:
          ``(A) Information regarding how to apply for a waiver 
        described in section 1710(f)(3)(G) or section 1722A(c) of this 
        title, as appropriate.
          ``(B) Information regarding how to establish a payment plan 
        with the Secretary.
          ``(C) Opportunity to make such a waiver or establish such a 
        payment plan.
  ``(b) Care at Non-Department Facility.--(1) In requiring a veteran to 
make a payment for care or services provided at a non-Department 
facility pursuant to this chapter or other provision of law, the 
Secretary shall provide to such veteran a notification of such required 
payment by not later than 18 months after the date on which the veteran 
receives the care or services for which payment is required.
  ``(2) If the Secretary does not provide to a veteran a notification 
of the required payment by the date required under paragraph (1), the 
Secretary may not collect such payment, including through a third-party 
entity, unless the Secretary provides the veteran the following:
          ``(A) Information regarding how to apply for a waiver 
        described in paragraph (3).
          ``(B) Information regarding how to establish a payment plan 
        with the Secretary.
          ``(C) Opportunity to make such a waiver or establish such a 
        payment plan.
  ``(3) The Secretary may waive the requirement of a veteran to make a 
payment for care or services provided at a non-Department facility 
pursuant to this chapter or other provision of law if--
          ``(A) an error committed by the Department, an employee of 
        the Department, or a non-Department facility was the cause of 
        delaying the notification sent to the veteran of the 
        requirement to make the payment; and
          ``(B) the veteran received such notification after the period 
        described in paragraph (1).''.
          (2) Clerical amendment.--The table of sections at the 
        beginning of such chapter is amended by inserting after the 
        item relating to section 1709B the following new item:

``1709C. Procedures for copayments.''.

  (d) Improvement of Procedures.--Not later than 180 days after the 
date of the enactment of this Act, the Secretary of Veterans Affairs 
shall--
          (1) review the copayment billing internal controls and 
        notification procedures of the Department of Veterans Affairs; 
        and
          (2) improve such controls and procedures, including pursuant 
        to the amendments made by this Act.

  Amendment in the Nature of a Substitute to H.R. 1972 Offered by Mr. 
                         Rutherford of Florida

  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``VA Billing Accountability 
Act''.

SEC. 2. AUTHORITY OF SECRETARY OF VETERANS AFFAIRS TO WAIVE REQUIREMENT 
                    OF CERTAIN VETERANS TO MAKE COPAYMENTS FOR CARE AND 
                    SERVICES IN THE CASE OF DEPARTMENT OF VETERANS 
                    AFFAIRS ERROR.

  (a) Hospital Care, Nursing Home Care, and Medical Services.--
Section 1710(f)(3) of title 38, United States Code, is amended 
by adding at the end the following new subparagraph:
  ``(G) The Secretary may waive the requirement of a veteran to 
make a payment under this subsection or subsection (g) if--
          ``(i) an error committed by the Department or an 
        employee of the Department was the cause of delaying 
        notification sent to the veteran of the requirement to 
        make the payment; and
          ``(ii) the veteran received such notification later 
        than 180 days after the date on which the veteran 
        received the care or services for which the payment was 
        required.''.
  (b) Medications.--Section 1722A of such title is amended--
          (1) by redesignating subsection (c) as subsection 
        (d); and
          (2) by inserting after subsection (b) the following 
        new subsection (c):
  ``(c) The Secretary may waive the requirement of a veteran to 
make a payment under this section if--
          ``(1) an error committed by the Department or an 
        employee of the Department was the cause of delaying 
        notification sent to the veteran of the requirement to 
        make the payment; and
          ``(2) the veteran received such notification later 
        than 180 days after the date on which the veteran 
        received the medication for which the payment was 
        required.''.
  (c) Billing Procedures.--
          (1) In general.--Subchapter I of chapter 17 of such 
        title is amended by adding at the end the following new 
        section:

``Sec. 1709C. Procedures for copayments

  ``(a) Care at Department Facility.--(1) In requiring a 
veteran to make a payment for care or services provided at a 
medical facility of the Department pursuant to this chapter, 
including sections 1710 and 1722A, the Secretary shall provide 
to such veteran a notification of such required payment by not 
later than 180 days after the date on which the veteran 
receives the care or services for which payment is required.
  ``(2) If the Secretary does not provide to a veteran a 
notification of the required payment by the date required under 
paragraph (1), the Secretary may not collect such payment, 
including through a third-party entity, unless the Secretary 
provides the veteran the following:
          ``(A) Information regarding how to apply for a waiver 
        described in section 1710(f)(3)(G) or section 1722A(c) 
        of this title, as appropriate.
          ``(B) Information regarding how to establish a 
        payment plan with the Secretary.
          ``(C) Opportunity to make such a waiver or establish 
        such a payment plan.
  ``(b) Care at Non-Department Facility.--(1) In requiring a 
veteran to make a payment for care or services provided at a 
non-Department facility pursuant to this chapter or other 
provision of law, the Secretary shall provide to such veteran a 
notification of such required payment by not later than 18 
months after the date on which the veteran receives the care or 
services for which payment is required.
  ``(2) If the Secretary does not provide to a veteran a 
notification of the required payment by the date required under 
paragraph (1), the Secretary may not collect such payment, 
including through a third-party entity, unless the Secretary 
provides the veteran the following:
          ``(A) Information regarding how to apply for a waiver 
        described in paragraph (3).
          ``(B) Information regarding how to establish a 
        payment plan with the Secretary.
          ``(C) Opportunity to make such a waiver or establish 
        such a payment plan.
  ``(3) The Secretary may waive the requirement of a veteran to 
make a payment for care or services provided at a non-
Department facility pursuant to this chapter or other provision 
of law if--
          ``(A) an error committed by the Department, an 
        employee of the Department, or a non-Department 
        facility was the cause of delaying the notification 
        sent to the veteran of the requirement to make the 
        payment; and
          ``(B) the veteran received such notification after 
        the period described in paragraph (1).''.
          (2) Clerical amendment.--The table of sections at the 
        beginning of such chapter is amended by inserting after 
        the item relating to section 1709B the following new 
        item:

``1709C. Procedures for copayments.''.
  (d) Improvement of Procedures.--Not later than 180 days after 
the date of the enactment of this Act, the Secretary of 
Veterans Affairs shall--
          (1) review the copayment billing internal controls 
        and notification procedures of the Department of 
        Veterans Affairs; and
          (2) improve such controls and procedures, including 
        pursuant to the amendments made by this Act.

                          Purpose and Summary

    H.R. 1972, as amended, the ``VA Billing Accountability 
Act'' would authorize the Department of Veterans Affairs (VA) 
to waive copayment requirements for certain veterans under 
certain conditions. Representative Lloyd Smucker of 
Pennsylvania introduced H.R. 1972 on April 6, 2017.

                  Background and Need for Legislation

    Section 1710(f) of title 38 United States Code (U.S.C.) 
requires VA to assess copayments for health care services to 
veterans whose income exceeds certain limits and to veterans 
who choose not to complete a financial assessment upon 
enrolling in the VA healthcare system.\1\
---------------------------------------------------------------------------
    \1\Health Benefit Copays. U.S. Department of Veterans Affairs 
Health Benefits. https://www.va.gov/healthbenefits/cost/copays.asp. 
Accessed May 10, 2018.
---------------------------------------------------------------------------
    On June 1, 2015, Members of the Wisconsin and Minnesota 
Congressional delegation were notified that VA officials at the 
Minneapolis VA Medical Center had initiated a review of past 
processes on veteran inpatient copayments charges for the years 
2011-2015.\2\ As part of the review, VA had uncovered more than 
one thousand instances where veterans were not billed for 
inpatient services VA provided to them and, as a result, VA 
immediately began assessing thousands of dollars of copayments 
for each of those veterans for care received during that 
period.\3\ Initially, these charges were added to the veterans' 
monthly billing statements. However, VA later suspended 
accounts for the affected veterans and reached out via 
telephone to explain their account status and provide them with 
information about applying for waivers or repayment plans. VA 
claimed to have 6 years to bring an action against a veteran 
and no authority to waive copayment collections, according to 
conversations that Committee staff had with VA regarding this 
incident.
---------------------------------------------------------------------------
    \2\United States Cong. House Committee on Veterans' Affairs 
Subcommittee on Health. Legislative Hearing. November 17, 2015. 114th 
Cong. 1st sess. Washington: GPO, 2015 (statement from the Honorable 
John Kline, U.S. House of Representatives, 2nd Congressional District, 
Minnesota).
    \3\Ibid.
---------------------------------------------------------------------------
    Section 2 of the bill would authorize VA to waive the 
requirement that a veteran make a copayment if an error 
committed by VA was the cause of a delayed copayment 
notification to the veteran and the veteran received such 
notification later than 180 days (18 months in the case of a 
community care facility) after the date on which the veteran 
received the care or services. It would also prohibit VA from 
collecting copayments from veterans if the veteran was not 
notified of such copayment in a timely manner unless the 
veteran is provided with both information about applying for a 
waiver and establishing a payment plan and the opportunity to 
make such a waiver or establish such a repayment plan. Finally, 
it would require VA to review and improve copayment billing 
internal controls and notification procedures.

                                Hearings

    On September 26, 2017, the Subcommittee on Health conducted 
a legislative hearing on a number of bills including H.R. 1972.
    The following witnesses testified:
          The Honorable Debbie Dingell, U.S. House of 
        Representatives, 12th District, Michigan; The Honorable 
        Beto O'Rourke, U.S. House of Representatives, 16th 
        Congressional District, Texas; The Honorable Derek 
        Kilmer, U.S. House of Representatives, 6th 
        Congressional District, Washington; The Honorable Steve 
        King, U.S. House of Representatives, 4th Congressional 
        District, Iowa; The Honorable Lloyd Smucker, U.S. House 
        of Representatives, 16th Congressional District, 
        Pennsylvania; The Honorable Mike Coffman, U.S. House of 
        Representatives, 6th Congressional District, Colorado; 
        The Honorable Steve Stivers, U.S. House of 
        Representatives, 15th Congressional District, Ohio; The 
        Honorable Ron DeSantis, U.S. House of Representatives, 
        6th Congressional District, Florida; The Honorable John 
        Rutherford, U.S. House of Representatives, 4th 
        Congressional District, Florida; Keronica Richardson, 
        Assistant Director of Women and Minority Veterans 
        Outreach for the National Security Division of The 
        American Legion; Amy Webb, National Legislative Policy 
        Advisor for AMVETS; and, Harold Kudler M.D., Acting 
        Assistant Deputy Under Secretary for Health for Patient 
        Care Services for the Veterans Health Administration of 
        the U.S. Department of Veterans Affairs, accompanied by 
        Catherine Biggs-Silvers, Executive Director for 
        Mission, Planning, and Analysis for the Human Resources 
        and Administration of the U.S. Department of Veterans 
        Affairs.
    Statements for the record were submitted by:
          Blinded Veterans Association, Veterans of Foreign 
        Wars of the United States, Disabled American Veterans, 
        Paralyzed Veterans of America, Justice for Vets, and, 
        Make a Difference America.

                       Subcommittee Consideration

    There was no Subcommittee consideration of H.R. 1972.

                        Committee Consideration

    On May 8, 2018, the full Committee met in open markup 
session, a quorum being present, and ordered H.R. 1972, as 
amended, to be reported favorably to the House of 
Representatives by voice vote. During consideration of the 
bill, the following amendment was considered and agreed to by 
voice vote:
          An amendment in the nature of a substitute offered by 
        Representative John Rutherford of Florida.

                            Committee Votes

    In compliance with clause 3(b) of rule XIII of the Rules of 
the House of Representatives, there were no recorded votes 
taken on amendments or in connection with ordering H.R. 1972, 
as amended, reported to the House. A motion by Representative 
Tim Walz of Minnesota, Ranking Member of the Committee on 
Veterans' Affairs, to report H.R. 1972, as amended, favorably 
to the House of Representatives was adopted by voice vote.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII and clause 
(2)(b)(1) of rule X of the Rules of the House of 
Representatives, the Committee's oversight findings and 
recommendations are reflected in the descriptive portions of 
this report.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are to improve VA's copayment billing 
internal controls and notification procedures.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee adopts as its 
own the estimate of new budget authority, entitlement 
authority, or tax expenditures or revenues contained in the 
cost estimate prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

                  Earmarks and Tax and Tariff Benefits

    H.R. 1972, as amended, does not contain any Congressional 
earmarks, limited tax benefits, or limited tariff benefits as 
defined in clause 9 of rule XXI of the Rules of the House of 
Representatives.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate on H.R. 
1972, as amended, prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 1972, as amended, provided by the Director of the 
Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, May 16, 2018.
Hon. Phil Roe, M.D.,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 1972, the VA 
Billing Accountability Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann E. 
Futrell.
            Sincerely,
                                                Keith Hall,
                                                          Director.
     Enclosure.

H.R. 1972--VA Billing Accountability Act

    Summary: H.R. 1972 would allow the Department of Veterans 
Affairs (VA) to waive the copayments charged for medical care 
when veterans are not notified of the charges for a significant 
period of time. CBO estimates that implementing the bill would 
reduce collections by $141 million over the 2019-2023 period. 
Assuming VA continued to provide the same level of health care, 
additional funding totaling $141 million would have to be 
appropriated, and spending would total $135 million.
    Enacting the bill would not affect direct spending or 
revenues; therefore, pay-as-you-go procedures do not apply.
    CBO estimates that enacting H.R. 1972 would not increase 
net direct spending or on-budget deficits in any of the four 
consecutive 10-year periods beginning in 2029.
    H.R. 1972 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
    Estimated cost to the Federal Government: The estimated 
budgetary effect of H.R. 1972 is shown in the following table. 
The costs of the legislation fall within budget function 700 
(veterans benefits and services).

----------------------------------------------------------------------------------------------------------------
                                                          By fiscal year, in millions of dollars--
                                          ----------------------------------------------------------------------
                                             2018      2019      2020      2021      2022      2023    2019-2023
----------------------------------------------------------------------------------------------------------------
                                 INCREASES IN SPENDING SUBJECT TO APPROPRIATION
 
Estimated Authorization Level............         0        29        28        28        28        28        141
Estimated Outlays........................         0        25        27        27        28        28        135
----------------------------------------------------------------------------------------------------------------

    Basis of estimate: For this estimate, CBO assumes that H.R. 
1972 will be enacted near the beginning of fiscal year 2019 and 
that the estimated amounts will be appropriated each year. 
Estimated outlays are based on historical spending patterns for 
the affected programs.
    VA charges copayments to certain veterans for medical care 
and services authorized by the department. H.R. 1972 would 
allow VA to waive those copayments for veterans who are 
notified of their liability more than 180 days after receiving 
medical care or medication at a department facility or 18 
months after an appointment at a non-VA facility. The 
copayments are deposited in the Medical Care Collections Fund 
and, subject to appropriation, are spent to provide medical 
care for veterans. CBO expects that any reduction in 
collections would require VA to request additional funding in 
order to provide the same level of health care to veterans.
    On the basis of information from VA about its billing 
practices, CBO estimates that roughly 4 percent of the $660 
million in copayments collected by the department each year 
would be waived due to delayed notification. As a result of 
those foregone collections, CBO estimates that implementing 
this bill and continuing to provide the same level of health 
care to veterans would cost $135 million over the 2019-2023 
period, assuming appropriation of the necessary amounts.
    Pay-As-You-Go Considerations: None.
    Increase in long-term direct spending and deficits: CBO 
estimates that enacting H.R. 1972 would not increase net direct 
spending or on-budget deficits in any of the four consecutive 
10-year periods beginning in 2029.
    Mandates: H.R. 1972 contains no intergovernmental or 
private-sector mandates as defined in UMRA.
    Estimate prepared by: Federal costs: Ann E. Futrell; 
Mandates: Andrew Laughlin.
    Estimate reviewed by: Sarah Jennings, Chief, Defense, 
International Affairs, and Veterans' Affairs Cost Estimates 
Unit; Leo Lex, Deputy Assistant Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R 1972, as amended, prepared by the 
Director of the Congressional Budget Office pursuant to section 
423 of the Unfunded Mandates Reform Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
1972, as amended.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, H.R. 1972, as amended, is authorized by Congress' 
power to ``provide for the common Defense and general Welfare 
of the United States.''

                  Applicability to Legislative Branch

    The Committee finds that H.R. 1972, as amended, does not 
relate to the terms and conditions of employment or access to 
public services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

              Statement on Duplication of Federal Programs

    Pursuant to clause 3(c)(5) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that no provision 
of H.R. 1972, as amended, establishes or reauthorizes a program 
of the Federal Government known to be duplicative of another 
Federal program, a program that was included in any report from 
the Government Accountability Office to Congress pursuant to 
section 21 of Public Law 111-139, or a program related to a 
program identified in the most recent Catalog of Federal 
Domestic Assistance.

                   Disclosure of Directed Rulemaking

    Pursuant to section 3(i) of H. Res. 5, 115th Cong. (2017), 
the Committee estimates that H.R. 1972, as amended, contains no 
directed rulemaking that would require the Secretary to 
prescribe regulations.

             Section-by-Section Analysis of the Legislation

Section 1. Short title

    Section 1 of the bill would establish a short title for 
H.R. 1972, as amended, of the ``VA Billing Accountability 
Act.''

Section 2. Authority of Secretary of Veterans Affairs to waive 
        requirement of certain veterans to make copayments for care and 
        services in the care of Department of Veterans Affairs

    Section 2(a) of the bill would amend section 1710(f)(3) of 
title 38 U.S.C. by adding at the end a new subparagraph 
1710(f)(3)(G).
    The new subparagraph 1710(f)(3)(G)(a) would authorize VA to 
waive the requirement of a veteran to make a payment under this 
section of section (g) if a VA error was the cause of a delayed 
notification sent to the veteran of the requirement to make the 
payment and the veteran received such notification later than 
180 days after the date on which the veteran received the care 
or services for which the payment was required.
    Section 2(b) of the bill would amend section 1722A of title 
38 U.S.C. by redesignating subsection (c) as subsection (d) and 
by inserting after subsection (b) a new subsection (c).
    The new subsection 1722(A)(c) would authorize VA to waive 
the requirement of a veteran to make a copayment under this 
section if an error committed by VA or a VA employee was the 
cause of delaying notification sent to the veteran of the 
requirement to make the payment and the veteran received such 
notification later than 180 days after the date on which the 
veteran received the medication for which the payment was 
required.
    Section 2(c) of the bill would amend subchapter I of 
chapter 17 of title 38 U.S.C. by adding at the following new 
section, ``1709C. Procedures for copayments.'' It would also 
amend the table of sections at the beginning of chapter 17 of 
title 38 U.S.C. by inserting after the item relating to section 
1709B the following new item: ``1709C. Procedure for 
copayments.''.
    The new section 1709C(a) would require VA to provide a 
veteran who is required to make a payment for care or services 
provided at a VA medical facility pursuant to chapter 17 of 
title 38 U.S.C. with a notification of such required payment by 
not later than 180 days after the date on which the veteran 
receives the care or services for which such payment is 
required. In the event VA does not provide such veteran a 
notification of the required payment by the date required, it 
would also prohibit VA from collecting such payment, including 
through a third party entity, unless VA provides the following: 
information regarding how to apply for a waiver described in 
section 1710(f)(3)(G) or section 1722A(c) of title 38 U.S.C., 
as appropriate; information regarding how to establish a 
payment plan with VA; and the opportunity to make such a waiver 
or establish such a payment plan.
    The new section 1709C(b) would require VA to provide to a 
veteran who is required to make a payment for care or services 
pursuant to chapter 17 of title 38 U.S.C. a notification of 
such required payment. Such notification would be required by 
not later than 18 months after the date on which the veteran 
receives the care or services for which payment is required. In 
the event that VA does not provide such a notification, it 
would also prohibit VA from collecting such payment, including 
through a third party entity, unless VA provides the following: 
information regarding how to apply for a waiver as described 
below; information regarding how to establish a payment plan 
with VA; and the opportunity to make such a waiver or establish 
such a payment plan. It would further prohibit the requirement 
of a veteran to make a payment for care or services provided at 
a community facility pursuant to chapter 17 of title 38 U.S.C. 
or other provision of law if an error committed by VA, a VA 
employee, or a community facility was the cause of delaying the 
notification sent to the veteran of the requirement to make the 
payment; and the veteran received such notification after the 
required period.
    Section 2(d) of the bill would require VA, not later than 
180 days after the date of enactment of the Act, to review the 
copayment billing internal controls and notification procedures 
of VA and improve such controls and procedures, including 
pursuant to the amendments made by this Act.

         Changes in Existing Law Made by the Bill, as Reported

    In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, and existing law in which no 
change is proposed is shown in roman):

                      TITLE 38, UNITED STATES CODE

           *       *       *       *       *       *       *
PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *

   CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE

                          SUBCHAPTER I--GENERAL

Sec.
1701. Definitions.
     * * * * * * *
1709C. Procedures for copayments.
     * * * * * * *

SUBCHAPTER I--GENERAL

           *       *       *       *       *       *       *

Sec. 1709C. Procedures for copayments

  (a) Care at Department Facility.--(1) In requiring a veteran 
to make a payment for care or services provided at a medical 
facility of the Department pursuant to this chapter, including 
sections 1710 and 1722A, the Secretary shall provide to such 
veteran a notification of such required payment by not later 
than 180 days after the date on which the veteran receives the 
care or services for which payment is required.
  (2) If the Secretary does not provide to a veteran a 
notification of the required payment by the date required under 
paragraph (1), the Secretary may not collect such payment, 
including through a third-party entity, unless the Secretary 
provides the veteran the following:
          (A) Information regarding how to apply for a waiver 
        described in section 1710(f)(3)(G) or section 1722A(c) 
        of this title, as appropriate.
          (B) Information regarding how to establish a payment 
        plan with the Secretary.
          (C) Opportunity to make such a waiver or establish 
        such a payment plan.
  (b) Care at Non-department Facility.--(1) In requiring a 
veteran to make a payment for care or services provided at a 
non-Department facility pursuant to this chapter or other 
provision of law, the Secretary shall provide to such veteran a 
notification of such required payment by not later than 18 
months after the date on which the veteran receives the care or 
services for which payment is required.
  (2) If the Secretary does not provide to a veteran a 
notification of the required payment by the date required under 
paragraph (1), the Secretary may not collect such payment, 
including through a third-party entity, unless the Secretary 
provides the veteran the following:
          (A) Information regarding how to apply for a waiver 
        described in paragraph (3).
          (B) Information regarding how to establish a payment 
        plan with the Secretary.
          (C) Opportunity to make such a waiver or establish 
        such a payment plan.
  (3) The Secretary may waive the requirement of a veteran to 
make a payment for care or services provided at a non-
Department facility pursuant to this chapter or other provision 
of law if--
          (A) an error committed by the Department, an employee 
        of the Department, or a non-Department facility was the 
        cause of delaying the notification sent to the veteran 
        of the requirement to make the payment; and
          (B) the veteran received such notification after the 
        period described in paragraph (1).

SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL 
                               TREATMENT

Sec. 1710. Eligibility for hospital, nursing home, and domiciliary care

  (a)(1) The Secretary (subject to paragraph (4)) shall furnish 
hospital care and medical services which the Secretary 
determines to be needed--
          (A) to any veteran for a service-connected 
        disability; and
          (B) to any veteran who has a service-connected 
        disability rated at 50 percent or more.
  (2) The Secretary (subject to paragraph (4)) shall furnish 
hospital care and medical services, and may furnish nursing 
home care, which the Secretary determines to be needed to any 
veteran--
          (A) who has a compensable service-connected 
        disability rated less than 50 percent or, with respect 
        to nursing home care during any period during which the 
        provisions of section 1710A(a) of this title are in 
        effect, a compensable service-connected disability 
        rated less than 70 percent;
          (B) whose discharge or release from active military, 
        naval, or air service was for a disability that was 
        incurred or aggravated in the line of duty;
          (C) who is in receipt of, or who, but for a 
        suspension pursuant to section 1151 of this title (or 
        both a suspension and the receipt of retired pay), 
        would be entitled to disability compensation, but only 
        to the extent that such veteran's continuing 
        eligibility for such care is provided for in the 
        judgment or settlement provided for in such section;
          (D) who is a former prisoner of war, who was awarded 
        the medal of honor under section 3741, 6241, or 8741 of 
        title 10 or section 491 of title 14, or who was awarded 
        the Purple Heart;
          (E) who is a veteran of the Mexican border period or 
        of World War I;
          (F) who was exposed to a toxic substance, radiation, 
        or other conditions, as provided in subsection (e); or
          (G) who is unable to defray the expenses of necessary 
        care as determined under section 1722(a) of this title.
  (3) In the case of a veteran who is not described in 
paragraphs (1) and (2), the Secretary may, to the extent 
resources and facilities are available and subject to the 
provisions of subsections (f) and (g), furnish hospital care, 
medical services, and nursing home care which the Secretary 
determines to be needed.
  (4) The requirement in paragraphs (1) and (2) that the 
Secretary furnish hospital care and medical services, the 
requirement in section 1710A(a) of this title that the 
Secretary provide nursing home care, the requirement in section 
1710B of this title that the Secretary provide a program of 
extended care services, and the requirement in section 1745 of 
this title to provide nursing home care and prescription 
medicines to veterans with service-connected disabilities in 
State homes shall be effective in any fiscal year only to the 
extent and in the amount provided in advance in appropriations 
Acts for such purposes.
  (5) During any period during which the provisions of section 
1710A(a) of this title are not in effect, the Secretary may 
furnish nursing home care which the Secretary determines is 
needed to any veteran described in paragraph (1), with the 
priority for such care on the same basis as if provided under 
that paragraph.
  (b)(1) The Secretary may furnish to a veteran described in 
paragraph (2) of this subsection such domiciliary care as the 
Secretary determines is needed for the purpose of the 
furnishing of medical services to the veteran.
  (2) This subsection applies in the case of the following 
veterans:
          (A) Any veteran whose annual income (as determined 
        under section 1503 of this title) does not exceed the 
        maximum annual rate of pension that would be applicable 
        to the veteran if the veteran were eligible for pension 
        under section 1521(d) of this title.
          (B) Any veteran who the Secretary determines has no 
        adequate means of support.
  (c) While any veteran is receiving hospital care or nursing 
home care in any Department facility, the Secretary may, within 
the limits of Department facilities, furnish medical services 
to correct or treat any non-service-connected disability of 
such veteran, in addition to treatment incident to the 
disability for which such veteran is hospitalized, if the 
veteran is willing, and the Secretary finds such services to be 
reasonably necessary to protect the health of such veteran. The 
Secretary may furnish dental services and treatment, and 
related dental appliances, under this subsection for a non-
service-connected dental condition or disability of a veteran 
only (1) to the extent that the Secretary determines that the 
dental facilities of the Department to be used to furnish such 
services, treatment, or appliances are not needed to furnish 
services, treatment, or appliances for dental conditions or 
disabilities described in section 1712(a) of this title, or (2) 
if (A) such non-service-connected dental condition or 
disability is associated with or aggravating a disability for 
which such veteran is receiving hospital care, or (B) a 
compelling medical reason or a dental emergency requires 
furnishing dental services, treatment, or appliances (excluding 
the furnishing of such services, treatment, or appliances of a 
routine nature) to such veteran during the period of 
hospitalization under this section.
  (d) In no case may nursing home care be furnished in a 
hospital not under the direct jurisdiction of the Secretary 
except as provided in section 1720 of this title.
  (e)(1)(A) A Vietnam-era herbicide-exposed veteran is eligible 
(subject to paragraph (2)) for hospital care, medical services, 
and nursing home care under subsection (a)(2)(F) for any 
disability, notwithstanding that there is insufficient medical 
evidence to conclude that such disability may be associated 
with such exposure.
  (B) A radiation-exposed veteran is eligible for hospital 
care, medical services, and nursing home care under subsection 
(a)(2)(F) for any disease suffered by the veteran that is--
          (i) a disease listed in section 1112(c)(2) of this 
        title; or
          (ii) any other disease for which the Secretary, based 
        on the advice of the Advisory Committee on 
        Environmental Hazards, determines that there is 
        credible evidence of a positive association between 
        occurrence of the disease in humans and exposure to 
        ionizing radiation.
  (C) Subject to paragraph (2) of this subsection, a veteran 
who served on active duty between August 2, 1990, and November 
11, 1998, in the Southwest Asia theater of operations during 
the Persian Gulf War is eligible for hospital care, medical 
services, and nursing home care under subsection (a)(2)(F) for 
any disability, notwithstanding that there is insufficient 
medical evidence to conclude that such disability may be 
associated with such service.
  (D) Subject to paragraphs (2) and (3), a veteran who served 
on active duty in a theater of combat operations (as determined 
by the Secretary in consultation with the Secretary of Defense) 
during a period of war after the Persian Gulf War, or in combat 
against a hostile force during a period of hostilities after 
November 11, 1998, is eligible for hospital care, medical 
services, and nursing home care under subsection (a)(2)(F) for 
any illness, notwithstanding that there is insufficient medical 
evidence to conclude that such condition is attributable to 
such service.
  (E) Subject to paragraph (2), a veteran who participated in a 
test conducted by the Department of Defense Deseret Test Center 
as part of a program for chemical and biological warfare 
testing from 1962 through 1973 (including the program 
designated as ``Project Shipboard Hazard and Defense (SHAD)'' 
and related land-based tests) is eligible for hospital care, 
medical services, and nursing home care under subsection 
(a)(2)(F) for any illness, notwithstanding that there is 
insufficient medical evidence to conclude that such illness is 
attributable to such testing.
  (F) Subject to paragraph (2), a veteran who served on active 
duty in the Armed Forces at Camp Lejeune, North Carolina, for 
not fewer than 30 days during the period beginning on August 1, 
1953, and ending on December 31, 1987, is eligible for hospital 
care and medical services under subsection (a)(2)(F) for any of 
the following illnesses or conditions, notwithstanding that 
there is insufficient medical evidence to conclude that such 
illnesses or conditions are attributable to such service:
          (i) Esophageal cancer.
          (ii) Lung cancer.
          (iii) Breast cancer.
          (iv) Bladder cancer.
          (v) Kidney cancer.
          (vi) Leukemia.
          (vii) Multiple myeloma.
          (viii) Myelodysplastic syndromes.
          (ix) Renal toxicity.
          (x) Hepatic steatosis.
          (xi) Female infertility.
          (xii) Miscarriage.
          (xiii) Scleroderma.
          (xiv) Neurobehavioral effects.
          (xv) Non-Hodgkin's lymphoma.
  (2)(A) In the case of a veteran described in paragraph 
(1)(A), hospital care, medical services, and nursing home care 
may not be provided under subsection (a)(2)(F) with respect 
to--
          (i) a disability that is found, in accordance with 
        guidelines issued by the Under Secretary for Health, to 
        have resulted from a cause other than an exposure 
        described in paragraph (4)(A)(ii); or
          (ii) a disease for which the National Academy of 
        Sciences, in a report issued in accordance with section 
        3 of the Agent Orange Act of 1991, has determined that 
        there is limited or suggestive evidence of the lack of 
        a positive association between occurrence of the 
        disease in humans and exposure to a herbicide agent.
  (B) In the case of a veteran described in subparagraph (C), 
(D), (E), or (F) of paragraph (1), hospital care, medical 
services, and nursing home care may not be provided under 
subsection (a)(2)(F) with respect to a disability that is 
found, in accordance with guidelines issued by the Under 
Secretary for Health, to have resulted from a cause other than 
the service or testing described in such subparagraph.
  (3) In the case of care for a veteran described in paragraph 
(1)(D), hospital care, medical services, and nursing home care 
may be provided under or by virtue of subsection (a)(2)(F) only 
during the following periods:
          (A) Except as provided by subparagraph (B), with 
        respect to a veteran described in paragraph (1)(D) who 
        is discharged or released from the active military, 
        naval, or air service after January 27, 2003, the five-
        year period beginning on the date of such discharge or 
        release.
          (B) With respect to a veteran described in paragraph 
        (1)(D) who is discharged or released from the active 
        military, naval, or air service after January 1, 2009, 
        and before January 1, 2011, but did not enroll to 
        receive such hospital care, medical services, or 
        nursing home care pursuant to such paragraph during the 
        five-year period described in subparagraph (A), the 
        one-year period beginning on the date of the enactment 
        of the Clay Hunt Suicide Prevention for American 
        Veterans Act.
          (C) With respect to a veteran described in paragraph 
        (1)(D) who is discharged or released from the active 
        military, naval, or air service on or before January 
        27, 2003, and did not enroll in the patient enrollment 
        system under section 1705 of this title on or before 
        such date, the three-year period beginning on January 
        27, 2008.
  (4) For purposes of this subsection--
          (A) The term ``Vietnam-era herbicide-exposed 
        veteran'' means a veteran (i) who served on active duty 
        in the Republic of Vietnam during the during the period 
        beginning on January 9, 1962, and ending on May 7, 
        1975, and (ii) who the Secretary finds may have been 
        exposed during such service to dioxin or was exposed 
        during such service to a toxic substance found in a 
        herbicide or defoliant used for military purposes 
        during such period.
          (B) The term ``radiation-exposed veteran'' has the 
        meaning given that term in section 1112(c)(3) of this 
        title.
  (5) When the Secretary first provides care for veterans using 
the authority provided in paragraph (1)(D), the Secretary shall 
establish a system for collection and analysis of information 
on the general health status and health care utilization 
patterns of veterans receiving care under that paragraph. Not 
later than 18 months after first providing care under such 
authority, the Secretary shall submit to Congress a report on 
the experience under that authority. The Secretary shall 
include in the report any recommendations of the Secretary for 
extension of that authority.
  (f)(1) The Secretary may not furnish hospital care or nursing 
home care (except if such care constitutes hospice care) under 
this section to a veteran who is eligible for such care under 
subsection (a)(3) of this section unless the veteran agrees to 
pay to the United States the applicable amount determined under 
paragraph (2) or (4) of this subsection.
  (2) A veteran who is furnished hospital care or nursing home 
care under this section and who is required under paragraph (1) 
of this subsection to agree to pay an amount to the United 
States in order to be furnished such care shall be liable to 
the United States for an amount equal to--
          (A) the lesser of--
                  (i) the cost of furnishing such care, as 
                determined by the Secretary; or
                  (ii) the amount determined under paragraph 
                (3) of this subsection; and
          (B) before September 30, 2019, an amount equal to $10 
        for every day the veteran receives hospital care and $5 
        for every day the veteran receives nursing home care.
  (3)(A) In the case of hospital care furnished during any 365-
day period, the amount referred to in paragraph (2)(A)(ii) of 
this subsection is--
          (i) the amount of the inpatient Medicare deductible, 
        plus (ii) one-half of such amount for each 90 days of 
        care (or fraction thereof) after the first 90 days of 
        such care during such 365-day period.
  (B) In the case of nursing home care furnished during any 
365-day period, the amount referred to in paragraph (2)(A)(ii) 
of this subsection is the amount of the inpatient Medicare 
deductible for each 90 days of such care (or fraction thereof) 
during such 365-day period.
  (C)(i) Except as provided in clause (ii) of this 
subparagraph, in the case of a veteran who is admitted for 
nursing home care under this section after being furnished, 
during the preceding 365-day period, hospital care for which 
the veteran has paid the amount of the inpatient Medicare 
deductible under this subsection and who has not been furnished 
90 days of hospital care in connection with such payment, the 
veteran shall not incur any liability under paragraph (2) of 
this subsection with respect to such nursing home care until--
          (I) the veteran has been furnished, beginning with 
        the first day of such hospital care furnished in 
        connection with such payment, a total of 90 days of 
        hospital care and nursing home care; or
          (II) the end of the 365-day period applicable to the 
        hospital care for which payment was made,
        whichever occurs first.
  (ii) In the case of a veteran who is admitted for nursing 
home care under this section after being furnished, during any 
365-day period, hospital care for which the veteran has paid an 
amount under subparagraph (A)(ii) of this paragraph and who has 
not been furnished 90 days of hospital care in connection with 
such payment, the amount of the liability of the veteran under 
paragraph (2) of this subsection with respect to the number of 
days of such nursing home care which, when added to the number 
of days of such hospital care, is 90 or less, is the difference 
between the inpatient Medicare deductible and the amount paid 
under such subparagraph until--
          (I) the veteran has been furnished, beginning with 
        the first day of such hospital care furnished in 
        connection with such payment, a total of 90 days of 
        hospital care and nursing home care; or
          (II) the end of the 365-day period applicable to the 
        hospital care for which payment was made,
whichever occurs first.
  (D) In the case of a veteran who is admitted for hospital 
care under this section after having been furnished, during the 
preceding 365-day period, nursing home care for which the 
veteran has paid the amount of the inpatient Medicare 
deductible under this subsection and who has not been furnished 
90 days of nursing home care in connection with such payment, 
the veteran shall not incur any liability under paragraph (2) 
of this subsection with respect to such hospital care until--
          (i) the veteran has been furnished, beginning with 
        the first day of such nursing home care furnished in 
        connection with such payment, a total of 90 days of 
        nursing home care and hospital care; or
          (ii) the end of the 365-day period applicable to the 
        nursing home care for which payment was made,
whichever occurs first.
  (E) A veteran may not be required to make a payment under 
this subsection for hospital care or nursing home care 
furnished under this section during any 90-day period in which 
the veteran is furnished medical services under paragraph (3) 
of subsection (a) to the extent that such payment would cause 
the total amount paid by the veteran under this subsection for 
hospital care and nursing home care furnished during that 
period and under subsection (g) for medical services furnished 
during that period to exceed the amount of the inpatient 
Medicare deductible in effect on the first day of such period.
  (F) A veteran may not be required to make a payment under 
this subsection or subsection (g) for any days of care in 
excess of 360 days of care during any 365-calendar-day period.
  (G) The Secretary may waive the requirement of a veteran to 
make a payment under this subsection or subsection (g) if--
          (i) an error committed by the Department or an 
        employee of the Department was the cause of delaying 
        notification sent to the veteran of the requirement to 
        make the payment; and
          (ii) the veteran received such notification later 
        than 180 days after the date on which the veteran 
        received the care or services for which the payment was 
        required.
  (4) In the case of a veteran covered by this subsection who 
is also described by section 1705(a)(7) of this title, the 
amount for which the veteran shall be liable to the United 
States for hospital care under this subsection shall be an 
amount equal to 20 percent of the total amount for which the 
veteran would otherwise be liable for such care under 
subparagraphs (2)(B) and (3)(A) but for this paragraph.
  (5) For the purposes of this subsection, the term ``inpatient 
Medicare deductible'' means the amount of the inpatient 
hospital deductible in effect under section 1813(b) of the 
Social Security Act (42 U.S.C. 1395e(b)) on the first day of 
the 365-day period applicable under paragraph (3) of this 
subsection.
  (g)(1) The Secretary may not furnish medical services (except 
if such care constitutes hospice care) under subsection (a) of 
this section (including home health services under section 1717 
of this title) to a veteran who is eligible for hospital care 
under this chapter by reason of subsection (a)(3) of this 
section unless the veteran agrees to pay to the United States 
in the case of each outpatient visit the applicable amount or 
amounts established by the Secretary by regulation.
  (2) A veteran who is furnished medical services under 
subsection (a) of this section and who is required under 
paragraph (1) of this subsection to agree to pay an amount to 
the United States in order to be furnished such services shall 
be liable to the United States, in the case of each visit in 
which such services are furnished to the veteran, for an amount 
which the Secretary shall establish by regulation.
  (3) This subsection does not apply with respect to the 
following:
          (A) Home health services under section 1717 of this 
        title to the extent that such services are for 
        improvements and structural alterations.
          (B) Education on the use of opioid antagonists to 
        reverse the effects of overdoses of specific 
        medications or substances.
  (h) Nothing in this section requires the Secretary to furnish 
care to a veteran to whom another agency of Federal, State, or 
local government has a duty under law to provide care in an 
institution of such government.

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

           *       *       *       *       *       *       *

Sec. 1722A. Copayment for medications

  (a)(1) Subject to paragraph (2), the Secretary shall require 
a veteran to pay the United States $2 for each 30-day supply of 
medication furnished such veteran under this chapter on an 
outpatient basis for the treatment of a non-service-connected 
disability or condition. If the amount supplied is less than a 
30-day supply, the amount of the charge may not be reduced.
  (2) The Secretary may not require a veteran to pay an amount 
in excess of the cost to the Secretary for medication described 
in paragraph (1).
  (3) Paragraph (1) does not apply--
          (A) to a veteran with a service-connected disability 
        rated 50 percent or more;
          (B) to a veteran who is a former prisoner of war;
          (C) to a veteran whose annual income (as determined 
        under section 1503 of this title) does not exceed the 
        maximum annual rate of pension which would be payable 
        to such veteran if such veteran were eligible for 
        pension under section 1521 of this title; or
          (D) to a veteran who was awarded the medal of honor 
        under section 3741, 6241, or 8741 of title 10 or 
        section 491 of title 14.
  (4) Paragraph (1) does not apply to opioid antagonists 
furnished under this chapter to a veteran who is at high risk 
for overdose of a specific medication or substance in order to 
reverse the effect of such an overdose.
  (b) The Secretary, pursuant to regulations which the 
Secretary shall prescribe, may--
          (1) increase the copayment amount in effect under 
        subsection (a); and
          (2) establish a maximum monthly and a maximum annual 
        pharmaceutical copayment amount under subsection (a) 
        for veterans who have multiple outpatient 
        prescriptions.
  (c) The Secretary may waive the requirement of a veteran to 
make a payment under this section if--
          (1) an error committed by the Department or an 
        employee of the Department was the cause of delaying 
        notification sent to the veteran of the requirement to 
        make the payment; and
          (2) the veteran received such notification later than 
        180 days after the date on which the veteran received 
        the medication for which the payment was required.
  [(c)] (d) Amounts collected under this section shall be 
deposited in the Department of Veterans Affairs Medical Care 
Collections Fund.

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