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103D CONGRESS

1ST SESSION H. R. 3122

To amend title 38, United States Code, to revise and improve the longterm care programs of the Department of Veterans Affairs.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 22, 1993

Mr. STUMP (for himself, Mr. SMITH of New Jersey, Mr. BILIRAKIS, Mr.

HUTCHINSON, and Mr. LINDER) introduced the following bill; which was

referred to the Committee on Veterans’ Affairs

A BILL

To amend title 38, United States Code, to revise and improve

the long-term care programs of the Department of Veterans Affairs.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Veterans’ Long-Term

5 Care Act of 1993’’.

6 SEC. 2. DEFINITION OF LONG-TERM CARE.

7 Section 1701 of title 38, United States Code, is

8 amended by adding at the end the following:
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1 ‘‘(10) The term ‘long-term care’ means a continuum

2 of institutional and noninstitutional programs and services

3 that provide comprehensive restorative care and support

4 services through a time period generally exceeding 90

5 days. Such term includes the following care and services

6 authorized to be provided by the Secretary:

7 ‘‘(A) Nursing home care.

8 ‘‘(B) Domiciliary care.

9 ‘‘(C) State home care.

10 ‘‘(D) Hospital-based home care.

11 ‘‘(E) Adult day health care.

12 ‘‘(F) Hospice care.

13 ‘‘(G) Respite care.

14 ‘‘(H) Social support services.

15 ‘‘(I) Non-institutional alternatives pilot pro16 gram.

17 ‘‘(J) Community residential care.

18 ‘‘(K) Rehabilitative services.

19 ‘‘(L) Care provided through Geriatric Research,

20 Education, and Clinical Centers.

21 ‘‘(M) Care provided through Geriatric Evalua22 tion and Management Programs.

23 ‘‘(N) Provision of intermediate medicine.

24 ‘‘(O) Any other services that the Secretary de25 termines to be needed on a long-term basis.’’.
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1 SEC. 3. ELIGIBILITY CRITERIA FOR LONG-TERM CARE.

2 (a) IN GENERAL.—(1) Chapter 17 of title 38, United

3 States Code, is amended—

4 (A) by redesignating section 1711 as section

5 1710A; and

6 (B) by inserting after such section the following

7 new section 1711:

8 ‘‘§ 1711. Eligibility for long-term care

9 ‘‘(a) The Secretary shall furnish long-term care which

10 the Secretary determines is medically needed—

11 ‘‘(1) to any veteran for a service-connected dis12 ability;

13 ‘‘(2) to any veteran who has a service-connected

14 disability rated at 50 percent or more, for any dis15 ability;

16 ‘‘(3) to any veteran who is eligible for pension

17 from the Department, for any disability; and

18 ‘‘(4) to any veteran for any disability resulting

19 from treatment by the Department.

20 ‘‘(b) The Secretary shall furnish long-term care which

21 the Secretary determines is medically needed to any vet22 eran enrolled in a long-term care coinsurance plan under

23 subsection (f).

24 ‘‘(c) Subject to subsection (e), the Secretary shall fur25 nish long-term care which the Secretary determines is

26 medically needed—
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1 ‘‘(1) to any veteran who has a service-connected

2 disability rated at less than 50 percent, for any dis3 ability;

4 ‘‘(2) to any veteran whose annual income (as

5 determined under section 1503 of this title) is less

6 than three times the maximum income amount for

7 eligibility of that veteran for pension, for any disabil8 ity;

9 ‘‘(3) to any veteran who has a catastrophic ill10 ness (as determined by the Secretary) resulting from

11 a nonservice-connected disability;

12 ‘‘(4) to any veteran who is a veterans’ continu13 ing care center resident under section 8119 of this

14 title, for treatment provided by the medical center

15 associated with that veterans’ continuing care center

16 to obviate the need for institutional care; and

17 ‘‘(5) to any veteran who needs such care as a

18 follow-on to hospitalization in a Department medical

19 center, for a period not exceeding six months from

20 the termination of hospitalization.

21 ‘‘(d) Subject to subsection (d), the Secretary may fur22 nish long-term care which the Secretary determines is

23 medically needed to any veteran not described in sub24 section (a), (b), or (c), subject to the availability of staff

25 and facilities.
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1 ‘‘(e)(1) The Secretary may not furnish long-term care

2 under this section to a veteran who is eligible for such

3 care under subsection (c) or (d) unless the veteran agrees

4 to pay to the United States the applicable long-term care

5 copayment prescribed under paragraph (2).

6 ‘‘(2) The Secretary shall establish by regulation a

7 schedule of long-term care copayments for the purposes

8 of this section. A veteran who is furnished long-term care

9 under this section and who is required under paragraph

10 (1) to agree to pay a long-term care copayment to the

11 United States in order to be furnished such care shall be

12 liable to the United States for the amount applicable to

13 that veteran under the schedule prescribed under this sub14 section. In the case of a veteran enrolled in the long-term

15 care coinsurance plan under subsection (f), copayments

16 may be waived or may be lower than copayments for veter17 ans not so enrolled.

18 ‘‘(3) A copayment required to be paid under this sec19 tion may be paid by the veteran from any insurance cov20 erage that would be available to the veteran if the care

21 for which the payment is required was provided in a non–

22 Government facility.

23 ‘‘(f)(1) The Secretary shall establish by regulation a

24 long-term care coinsurance plan for the purposes of this

25 section. The plan shall provide for enrollment of veterans
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1 and the assessment and collection of premiums from veter2 ans who are enrolled. The Secretary shall determine en3 rollment periods and the requirements for enrollment.

4 ‘‘(2) The amount of the premiums under the coinsur5 ance plan shall be established by the Secretary taking into

6 consideration the needs of veterans and the needs of the

7 Department. The Secretary may establish different pre8 miums for veterans based upon such factors as the Sec9 retary determines appropriate, including cost-of-living dif10 ferences in different geographic regions and income level

11 of veterans. For veterans whose annual income is greater

12 than the maximum income amount for eligibility of that

13 veteran for pension, but less than three times that

14 amount, the Secretary shall establish a premium scale

15 based upon a veteran’s ability to pay.

16 ‘‘(g)(1)(A) Notwithstanding any condition, limitation,

17 or other provision of title XVIII of the Social Security Act,

18 a facility of the Department through which long-term care

19 is provided shall be deemed for the purposes of this section

20 to be a Medicare participating provider with respect to

21 long-term care (as defined in section 1701(9) of this title),

22 and when such a facility provides long-term care covered

23 under title XVIII of the Social Security Act to a veteran

24 who is entitled to benefits under that title, amounts for

25 such care shall be paid to the Secretary as a Medicare
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1 participating provider, but in accordance with rates deter2 mined under subparagraph (B).

3 ‘‘(B) Reimbursement for long-term care provided

4 under this section shall be based upon a methodology

5 which is agreed upon by the Secretary and the Secretary

6 of Health and Human Services and which provides (i) ap7 propriate flexibility to the directors of the medical facilities

8 to take into account local conditions and needs and the

9 actual costs to the facility, and (ii) an overall reimburse10 ment applicable to each such facility for any fiscal year

11 that is less than the otherwise applicable amount that

12 would be allowed under title XVIII of the Social Security

13 Act for the care provided.

14 ‘‘(2)(A) Notwithstanding any condition, limitation, or

15 other provision of title XIX of the Social Security Act,

16 if a facility of the Department is providing long-term care

17 to an individual who would be entitled to medical assist18 ance under a State plan under such title with respect to

19 such care if the care were provided by a qualified medicaid

20 participating provider, such facility shall be deemed for

21 the purposes of this section to be a qualified medicaid par22 ticipating provider with respect to such care. Amounts for

23 such care shall be paid in accordance with rates deter24 mined under subparagraph (B).
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1 ‘‘(B) Reimbursement for long-term care provided

2 under this section shall be based upon a methodology

3 which is agreed upon by the Secretary and the Secretary

4 of Health and Human Services and which provides (i) ap5 propriate flexibility to the directors of the medical facilities

6 to take into account local conditions and needs and the

7 actual costs to the facility, and (ii) an overall reimburse8 ment applicable to each such facility for any fiscal year

9 that is less than the otherwise applicable amount that

10 would be allowed under title XIX of the Social Security

11 Act for the care provided.

12 ‘‘(h) Amounts received by the Secretary under this

13 section as premiums or copayments shall be deposited into

14 the Long-Term Care Revolving Fund.’’.

15 (2) The table of sections at the beginning of such

16 chapter is amended by striking out the item relating to

17 section 1711 and inserting in lieu thereof the following:

‘‘1710A. Care during examinations and in emergencies.

‘‘1711. Eligibility for long-term care.’’.

18 (3) The Secretary of Veterans Affairs and the Sec19 retary of Health and Human Services shall enter into an

20 agreement to establish methodologies for medicare and

21 medicaid reimbursement rates under subsection (g) of sec22 tion 1711 of title 38, United States Code, as added by

23 paragraph (1), not later than six months after the date

24 of the enactment of this Act.
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1 (b) CONFORMING AMENDMENTS TO SECTION

2 1710.—Section 1710 of such title is amended as follows:

3 (1) Subsection (a) is amended—

4 (A) in paragraph (1)(A), by striking out ‘‘,

5 and may furnish nursing home care,’’;

6 (B) in paragraph (2), by striking out ‘‘and

7 nursing home care’’; and

8 (C) in paragraph (3), by striking out ‘‘and

9 nursing home care’’ and ‘‘and may furnish such

10 nursing home care as authorized under section

11 1720 of this title’’.

12 (2) Subsection (b) is repealed.

13 (3) Subsection (c) is amended by striking out

14 ‘‘or nursing home care’’ in the first sentence.

15 (4) Subsection (d) is repealed.

16 SEC. 4. CONTRACTS FOR LONG-TERM CARE.

17 (a) IN GENERAL.—Chapter 17 of title 38, United

18 States Code, is amended—

19 (1) by redesignating section 1704 as 1705; and

20 (2) by inserting after section 1703 the following

21 new section:

22 ‘‘§ 1704. Contracts for long-term care in non-Depart23 ment facilities

24 ‘‘(a) In carrying out section 1711 of this title, the

25 Secretary may contract for needed long-term care for vet-
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1 erans eligible for long-term care under section 1711 of this

2 title when Department facilities are geographically inac3 cessible, lack sufficient capacity, or are otherwise not ca4 pable of furnishing needed care or when the Secretary de5 termines that it would be more economical to contract for

6 such care than to provide it through Department facilities.

7 The authority to enter into a contract under this section

8 shall be subject to the availability of appropriations.

9 ‘‘(b) No veteran may be transferred or admitted to

10 any institution for long-term care under this chapter un11 less the institution has been determined by the Secretary

12 to meet such standards as the Secretary may prescribe.

13 The standards prescribed and any report of inspection of

14 institutions furnishing care to veterans under this section

15 made by or for the Secretary shall, to the extent possible,

16 be made available to all Federal, State, and local agencies

17 charged with the responsibility of licensing or otherwise

18 regulating or inspecting such institutions.

19 ‘‘(c) In applying the provisions of section 2(b)(1) of

20 the Service Contract Act of 1965 (41 U.S.C. 351(b)(1))

21 with respect to any contract entered into under this sec22 tion to provide long-term care of veterans, the payment

23 of wages not less than those specified in section 6(b) of

24 the Fair Labor Standards Act of 1938 (29 U.S.C. 206(b))
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1 shall be deemed to constitute compliance with such provi2 sions.

3 ‘‘(d) In arranging to provide adult day health care

4 and other health-related services in noninstitutional set5 tings under section 1711 of this title, the Secretary may

6 provide in-kind assistance (through the services of Depart7 ment employees and the sharing of other Department re8 sources) to a facility furnishing such services to veterans

9 under this chapter. Any such in-kind assistance shall be

10 provided under a contract between the Secretary and the

11 facility concerned. The Secretary may provide such assist12 ance only for use solely in the furnishing of adult day

13 health care or other health-related services and only if,

14 under such contract, the Department receives reimburse15 ment for the full cost of such assistance, including the cost

16 of services and supplies and normal depreciation and am17 ortization of equipment. Such reimbursement may be

18 made by reduction in the charges to the United States

19 or by payment to the United States. Any funds received

20 through such reimbursement shall be credited to funds al21 lotted to the Department facility that provided the assist22 ance.’’.

23 (b) CLERICAL AMENDMENT.—The table of sections

24 at the beginning of such chapter is amended by striking
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1 out the item relating to section 1704 and inserting in lieu

2 thereof the following:

‘‘1704. Contracts for long-term care in non-Department facilities.

‘‘1705. Preventive health services: annual report.’’.

3 SEC. 5. SOCIAL SUPPORT SERVICES.

4 (a) IN GENERAL.—Chapter 17 of title 38, United

5 States Code, is amended by inserting after section 1720D

6 the following new section:

7 ‘‘§ 1720E. Social support services

8 ‘‘As part of a program of long-term care for a vet9 eran, the Secretary may provide social support services,

10 including personal care and homemaker services, if needed

11 to enable the veteran to reside in the home, or another

12 noninstitutional setting, while receiving care under section

13 1710, 1711, or 1712 of this title.’’.

14 (b) CLERICAL AMENDMENT.—The table of sections

15 at the beginning of such chapter is amended by inserting

16 after the item relating to section 1720D the following new

17 item:

‘‘1720E. Social support services.’’.

18 SEC. 6. LONG-TERM CARE FACILITIES.

19 (a) VETERANS’ SERVICE AREAS.—Chapter 81 of title

20 38, United States Code, is amended by inserting after sec21 tion 8116 the following new sections:
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1 ‘‘§ 8117. Veterans’ service areas for provision of long2 term care

3 ‘‘(a) The Secretary shall designate geographic areas

4 (to be known as ‘veterans’ service areas’) throughout the

5 United States as areas in which the complete range of

6 long-term care services will be available to veterans. Such

7 areas shall be established based on the number of veterans

8 in an area and their health needs and on traveltime to

9 various facilities.

10 ‘‘(b)(1) Not later than six months after the date of

11 the enactment of this section, the Secretary shall submit

12 to Congress a report on the Secretary’s plan for the imple13 mentation of this section and the provisions of chapter 17

14 of this title relating to long-term care. The Secretary shall

15 set forth in the report the plans of the Secretary for ensur16 ing by October 1, 1999, that there is available within each

17 service area designated under subsection (a) all of the

18 services considered to be long-term care for the purposes

19 of chapter 17 of this title and that such services are avail20 able in each such area in an appropriate balance of serv21 ices for the needs of veterans in that area.

22 ‘‘(2) The Secretary shall use the authority provided

23 in section 1704 of this title as appropriate to ensure that

24 the plan is fully complied with.

25 ‘‘(c)(1) The Secretary shall on a regular basis assess

26 the need for new long-term care facilities for the Depart-
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1 ment in each veterans’ service area. In assessing the need

2 for construction or acquisition of new facilities for the De3 partment in any veterans’ service area, the Secretary shall

4 assess and take into consideration other Government fa5 cilities in the area and facilities available in the community

6 so as to avoid duplication of existing long-term care capac7 ity.

8 ‘‘(2) The Secretary shall include the Secretary’s find9 ings and recommendations under paragraph (1) in each

10 report of the Secretary under section 8107 of this title.

11 ‘‘(d) The Secretary shall ensure that not less than

12 one-third of the amount programmed for major construc13 tion projects in the budget of the Department for any fis14 cal year, and not less than one-third of the amount obli15 gated for minor construction projects in any fiscal year,

16 are for projects and activities relating to long-term care

17 until such time as the Secretary determines that the ap18 propriate mix of long-term care facilities and services are

19 available in each veterans’ service area.

20 ‘‘§ 8118. Long-term care fund

21 ‘‘(a) There is hereby established on the books of the

22 Treasury the Veterans’ Long-Term Care Fund. The fund

23 shall be administered by the Secretary of Veterans Affairs.
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1 ‘‘(b) Assets of the fund shall consist of amounts de2 posited in the fund pursuant to section 1711 of this title

3 and any amounts that may be appropriated to the fund.

4 ‘‘(c) The Secretary may use the assets of the fund

5 for the provision of long-term care services to veterans and

6 for construction, acquisition, and alteration of long-term

7 care facilities (including site preparation).

8 ‘‘(d) Obligations from the fund may only be made to

9 the extent provided in appropriation Acts.’’.

10 (b) CLERICAL AMENDMENT.—The table of sections

11 at the beginning of such chapter is amended by inserting

12 after the item relating to section 8116 the following new

13 item:

‘‘8117. Veterans’ service areas for provision of long-term care.

‘‘8118. Long-term care fund.’’.

14 SEC. 7. VETERANS’ CONTINUING CARE CENTERS.

15 (a) AUTHORITY TO ALLOW USE OF DEPARTMENT

16 PROPERTY.—Chapter 81 of title 38, United States Code,

17 is amended by inserting after section 8118 (as added by

18 section 6) the following new section:

19 ‘‘§ 8119. Veterans’ continuing care centers

20 ‘‘(a)(1) The Secretary, using the authority to enter

21 into enhanced-use leases under section 8162 of this title,

22 may enter into agreements to permit the establishment,

23 on property of the Department, of residential facilities for

24 veterans. Such agreements may be entered into with pri-
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1 vate sector entities, with entities of State or local govern2 ment, or with other Federal departments or agencies.

3 ‘‘(2) Such a facility shall be available as a residence—

4 ‘‘(A) for veterans whose requirements for long5 term care are such that they would otherwise require

6 nursing home care (or another form of institutional

7 care), with consequent loss of functional independ8 ence; and

9 ‘‘(B) for veterans with respect to whom the

10 Secretary determines, in any case, that the condition

11 of the veteran is such that the veteran would be

12 most appropriately served in the setting provided by

13 such a facility.

14 ‘‘(3) In this section—

15 ‘‘(A) a facility established on property of the

16 Department pursuant to this section is referred to

17 as a ‘veterans’ continuing care center’;

18 ‘‘(B) an agreement under this section for the

19 establishment of such a facility is referred to as a

20 ‘veterans’ continuing care center agreement’; and

21 ‘‘(C) an entity with which the Secretary enters

22 into such an agreement is referred to as a ‘partici23 pating entity’.

24 ‘‘(4) A veterans’ continuing care center agreement

25 shall provide for the colocation of the veterans’ continuing
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1 care center covered by the agreement with a Department

2 medical center, outpatient clinic, or nursing home.

3 ‘‘(b)(1) Each veterans’ continuing care center agree4 ment shall provide that residence in the veterans’ continu5 ing care center covered by the agreement shall, subject

6 to space limitations, be available to any veteran covered

7 by subsection (a)(2) who meets the financial qualification

8 requirements of the participating entity.

9 ‘‘(2) Acceptance of a veteran for residence in a veter10 ans’ continuing care center shall include acceptance for

11 residence with the veteran of the veteran’s spouse (if any)

12 or other person designated by the veteran as the veteran’s

13 primary caretaker.

14 ‘‘(c) Under a veterans’ continuing care center agree15 ment, the participating entity shall agree to—

16 ‘‘(1) construct or otherwise establish on the

17 property covered by the agreement a residential fa18 cility that includes individual, handicap-accessible

19 apartment units;

20 ‘‘(2) provide by contract with each resident for

21 specified nonmedical services (which may include

22 meals, housekeeping, recreation, security, 24-hour

23 monitoring, and transportation); and

24 ‘‘(3) provide case management services to the

25 veteran’s spouse (or other primary caretaker des-
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1 ignated under subsection (b)(2)) for the manage2 ment of necessary health care services required by

3 the spouse (or other designated primary caretaker)

4 from sources outside the Department.

5 ‘‘(d) A veteran who is accepted for residence in a vet6 erans’ continuing care center shall enter into a lease

7 agreement with the participating entity for at least one

8 year.

9 ‘‘(e) In entering into agreements under this section,

10 the Secretary shall, in order to make veterans’ continuing

11 care centers affordable to low-income veterans, give prior12 ity, in selecting participating entities, to agreements with

13 entities that would establish facilities through which public

14 housing subsidies would be available to residents.

15 ‘‘(f) The Secretary shall establish, at each Depart16 ment facility that has colocated with it a veterans’ con17 tinuing care center, a team of primary care providers to

18 be known as the Veterans’ Continuing Care Center Health

19 team. Each such team shall, at a minimum, consist of a

20 physician and a home-health nurse and shall be respon21 sible for maintaining access of the veterans’ continuing

22 care center residents to appropriate health care services

23 and for home health visits at the center.

24 ‘‘(g)(1) Before entering into any veterans’ continuing

25 care center agreement, the Secretary shall submit to the
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1 congressional veterans’ affairs committees notice in writ2 ing of the Secretary’s intention to enter into the agree3 ment. Each such notice shall include the following:

4 (A) Identification of the property involved.

5 (B) A description of the proposed veterans’ con6 tinuing care center.

7 (C) A statement of the number of veterans who

8 would be residents at the proposed center.

9 (D) A statement of the projected costs of the

10 proposed center.

11 ‘‘(2) If a proposed veterans’ continuing care center

12 agreement for which a notice is submitted under para13 graph (1) is not executed within one year from the date

14 on which such notice is submitted, the Secretary shall sub15 mit to the congressional veterans’ affairs committees no16 tice in writing that the proposed agreement has not been

17 executed. Any such notice shall include an identification

18 of the specific reasons why the agreement was not exe19 cuted.

20 ‘‘(h) The Secretary shall submit to the congressional

21 veterans’ affairs committees a report on the first year’s

22 operation of each veterans’ continuing care center. Each

23 such report shall be submitted not later than 30 days after

24 the one-year anniversary of the date on which the veter-
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1 ans’ continuing care center began operation. Each such

2 report shall set forth—

3 ‘‘(1) the cost to the Department of the veter4 ans’ continuing care center;

5 ‘‘(2) any cost savings to the Department that

6 are derived from the avoidance of institutionalization

7 of veterans residing at the center;

8 ‘‘(3) degree of use by veterans of the center;

9 ‘‘(4) the types of health-care services used by

10 residents of the center; and

11 ‘‘(5) any plans of the Secretary for expansion of

12 the center or for creation of additional centers.

13 ‘‘(i) The provisions of section 8163, 8168, and 8169

14 of this title shall not apply with respect to a veterans’ con15 tinuing care center agreement under this section. ’’.

16 (b) CLERICAL AMENDMENT.—The table of sections

17 at the beginning of such chapter is amended by inserting

18 after the item relating to section 8118 (as added by sec19 tion 6) the following new item:

‘‘8119. Veterans’ continuing care centers.’’.

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