I

107TH CONGRESS

1ST SESSION H. R. 1911

To establish a demonstration project to provide for Medicare reimbursement

for health care services provided to certain Medicare-eligible veterans

in selected facilities of the Department of Veterans Affairs.

IN THE HOUSE OF REPRESENTATIVES

MAY 17, 2001

Mr. SAXTON (for himself, Mr. MORAN of Kansas, Mr. ANDREWS, Mr.

LOBIONDO, and Mr. KING) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the

Committees on Veterans’ Affairs and Energy and Commerce, for a period

to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee

concerned

A BILL

To establish a demonstration project to provide for Medicare

reimbursement for health care services provided to certain Medicare-eligible veterans in selected facilities 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 Medicare Re5 imbursement Demonstration Act of 2001’’.
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1 SEC. 2. FINDINGS.

2 The Congress makes the following findings:

3 (1) The health care system of the Department

4 of Veterans Affairs enrolls veterans in 7 designated

5 priority groups and provides health care services to

6 veterans based upon these priority groups, with pri7 ority group 1 given the highest priority and priority

8 group 7 given the lowest.

9 (2) Due to budgetary limitations in moneys ap10 propriated to the Department of Veterans Affairs

11 for veterans health care, certain veterans in lower

12 priority groups could face limitations in access to

13 health care from the Department of Veterans Af14 fairs.

15 (3) Veterans participating in the health care

16 system of the Department of Veterans Affairs and

17 served under the lower priority groups 5, 6, and 7

18 are either low-income veterans whose annual income

19 and net worth are below established thresholds, vet20 erans whose incomes are above the thresholds and

21 do not have service-connected disabilities that qualify

22 them for priority care in that health care system, or

23 other eligible veterans not already covered in groups

24 1–4.

25 (4) Allowing medicare-eligible veterans in these

26 lower priority groups to utilize their medicare bene-
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1 fits in the health care system of the Department of

2 Veterans Affairs provides veterans greater access to

3 health care services and greater flexibility in choos4 ing their health care providers.

5 (5) Allowing these veterans to utilize their

6 medicare benefits in the health care system of the

7 Department of Veterans Affairs also provides health

8 care facilities of the Department of Veterans Affairs

9 greater flexibility in serving veterans.

10 (6) All veterans should have access to necessary

11 health care, and this Act takes the next step in dem12 onstrating the value of medicare subvention, and

13 demonstrates the commitment of Congress, to an

14 improved Department of Veterans Affairs health

15 care system for the Nation’s veterans and to ensur16 ing access to such health care by veterans.

17 (7) The Department of Veterans Affairs is not

18 sufficiently funded to enable the entirety of the vet19 eran population of 25,500,000 veterans to gain ac20 cess to health care furnished by the Department.

21 (8) The Department of Veterans Affairs re22 ceives funding adequate to furnish health care only

23 to those veterans who, in all likelihood, will be en24 rolled for such health care annually, based only on

25 eligibility rules contained in chapter 17 of title 38,
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1 United States Code, and without regard to indi2 vidual veterans who may have access to health care

3 benefits through the medicare program or through

4 other means.

5 SEC. 3. ESTABLISHMENT OF MEDICARE SUBVENTION DEM6 ONSTRATION PROJECT FOR VETERANS.

7 Title XVIII of the Social Security Act (42 U.S.C.

8 1395 et seq.) is amended by adding at the end the fol9 lowing:

10 ‘‘MEDICARE SUBVENTION DEMONSTRATION PROJECT FOR

11 VETERANS

12 ‘‘SEC. 1897. (a) DEFINITIONS.—In this section:

13 ‘‘(1) ADMINISTERING SECRETARIES.—The term

14 ‘administering Secretaries’ means the Secretary and

15 the Secretary of Veterans Affairs acting jointly.

16 ‘‘(2) DEMONSTRATION PROJECT.—The term

17 ‘demonstration project’ means the demonstration

18 project carried out under this section.

19 ‘‘(3) DEMONSTRATION SITE.—

20 ‘‘(A) IN GENERAL.—Subject to subpara21 graph (B), the term ‘demonstration site’ means

22 a Veterans Affairs medical facility that pro23 vides, alone or in conjunction with other facili24 ties under the jurisdiction of the Secretary of

25 Veterans Affairs and affiliated public or private

26 entities—
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1 ‘‘(i) in the case of a coordinated care

2 health plan, the health care benefits pre3 scribed in subsection (c)(3) to targeted

4 medicare-eligible veterans residing within

5 the service area; and

6 ‘‘(ii) in the case of health care bene7 fits being provided on a fee-for-service

8 basis, the health care benefits prescribed in

9 subsection (d)(2) to targeted medicare-eli10 gible veterans.

11 ‘‘(B) EXCLUSION.—The term ‘demonstra12 tion site’ shall not include the entire catchment

13 area of a Veterans Integrated Services Network

14 (VISN).

15 ‘‘(4) MEDICARE HEALTH CARE SERVICES.—The

16 term ‘medicare health care services’ means items or

17 services covered under part A or B of this title.

18 ‘‘(5) TARGETED MEDICARE-ELIGIBLE VET19 ERAN.—The term ‘targeted medicare-eligible vet20 eran’ means an individual who—

21 ‘‘(A) is a veteran (as defined in section

22 101 of title 38, United States Code) who is eli23 gible for care and services under paragraph (5),

24 (6), or (7) of section 1705(a) of title 38, United

25 States Code;
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1 ‘‘(B) has attained age 65;

2 ‘‘(C) is entitled to, or enrolled for, benefits

3 under part A of this title; and

4 ‘‘(D) is enrolled for benefits under part B

5 of this title.

6 ‘‘(6) TRUST FUNDS.—The term ‘trust funds’

7 means the Federal Hospital Insurance Trust Fund

8 established in section 1817 and the Federal Supple9 mentary Medical Insurance Trust Fund established

10 in section 1841.

11 ‘‘(7) VETERANS AFFAIRS MEDICAL FACILITY.—

12 The term ‘Veterans Affairs medical facility’ means a

13 medical facility as defined in section 8101 of title

14 38, United States Code.

15 ‘‘(b) DEMONSTRATION PROJECT.—

16 ‘‘(1) IN GENERAL.—

17 ‘‘(A) ESTABLISHMENT.—The admin18 istering Secretaries are authorized to establish

19 a demonstration project (under agreements en20 tered into by the administering Secretaries)

21 under which the Secretary shall reimburse the

22 Secretary of Veterans Affairs, from the trust

23 funds, for medicare health care services fur24 nished to targeted medicare-eligible veterans.
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1 ‘‘(B) AGREEMENT.—Any agreement en2 tered into under this paragraph shall include at

3 a minimum—

4 ‘‘(i) a detailed description of the

5 health care benefits to be provided to the

6 participants of the demonstration project

7 established under this section;

8 ‘‘(ii) a description of the eligibility

9 rules for participation in the demonstration

10 project, including any criteria established

11 under subsection (e), any premiums estab12 lished for a coordinated care health plan,

13 and any cost-sharing arrangements;

14 ‘‘(iii) a description of how the dem15 onstration project will satisfy the require16 ments under this title;

17 ‘‘(iv) a description of the demonstra18 tion sites selected under paragraph (2);

19 ‘‘(v) a description of how reimburse20 ment requirements under subsection (k),

21 maintenance of effort requirements under

22 subsection (l), and the annual reconcili23 ation under subsection (m) will be imple24 mented in the demonstration project;
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1 ‘‘(vi) a statement that the Secretary

2 shall have access to all data of the Depart3 ment of Veterans Affairs that the Sec4 retary determines is necessary to conduct

5 independent estimates and audits of the

6 maintenance of effort requirement under

7 subsection (l), the annual reconciliation

8 under subsection (m), and related matters

9 required under the demonstration project;

10 ‘‘(vii) a statement that the Comp11 troller General of the United States shall

12 have access to all data of the Department

13 of Veterans Affairs that the Comptroller

14 General determines is necessary to carry

15 out the reporting requirements under sub16 sections (m) or (n).

17 ‘‘(viii) a description of any require18 ment that the Secretary waives pursuant

19 to subsection (c)(4) or (d)(4); and

20 ‘‘(ix) a certification, provided after re21 view by the administering Secretaries, that

22 any facility or entity described in sub23 section (a)(3)(A) that is receiving pay24 ments by reason of the demonstration

25 project has sufficient—
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1 ‘‘(I) resources and expertise to

2 provide, consistent with payment re3 quirements under subsection (k), the

4 health care benefits required to be

5 provided to beneficiaries under the

6 demonstration project (as established

7 under subsections (c)(3) and (d)(2));

8 and

9 ‘‘(II) information and billing sys10 tems in place to ensure—

11 ‘‘(aa) accurate and timely

12 submission of claims for health

13 care benefits to the Secretary;

14 and

15 ‘‘(bb) that providers of

16 health care services that are not

17 affiliated with the Department of

18 Veterans Affairs are reimbursed

19 by the Secretary of Veterans Af20 fairs in a timely and accurate

21 manner.

22 ‘‘(C) SEPARATE AGREEMENTS FOR CO23 ORDINATED CARE AND FEE-FOR-SERVICE.—The

24 administering Secretaries shall enter into sepa25 rate agreements with regard to demonstration
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1 sites operating under a coordinated care health

2 plan model and a fee-for-service model, and

3 shall include in each agreement only such infor4 mation that is applicable to that model.

5 ‘‘(2) NUMBER OF DEMONSTRATION SITES.—

6 ‘‘(A) IN GENERAL.—Subject to the suc7 ceeding provisions of this paragraph, the dem8 onstration project established under this section

9 shall be conducted in not more than 10 dem10 onstration sites, designated jointly by the ad11 ministering Secretaries.

12 ‘‘(B) EQUAL NUMBER OF COORDINATED

13 CARE AND FEE-FOR-SERVICE SITES.—The ad14 ministrating Secretaries shall—

15 ‘‘(i) ensure that the number of dem16 onstration sites operated under a coordi17 nated care health plan model equals the

18 number of demonstration sites operated

19 under a fee-for-service model; and

20 ‘‘(ii) attempt to ensure that the vol21 ume of medicare health care services pro22 vided under the demonstration project at

23 demonstration sites operated under a co24 ordinated care health plan model is the

25 same as the volume of such services pro-
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1 vided at demonstration sites operated

2 under a fee-for-service model.

3 ‘‘(C) RESTRICTION.—A demonstration site

4 may not operate under both a coordinated care

5 health plan model and a fee-for-service model.

6 ‘‘(D) DEMONSTRATION SITES IN RURAL

7 AREAS.—At least 1 of each of the following

8 demonstration sites shall be selected for inclu9 sion in the demonstration project:

10 ‘‘(i) A demonstration site that is oper11 ated under a coordinated care health plan

12 model and that serves a predominantly

13 rural area.

14 ‘‘(ii) A demonstration site that is op15 erated under a fee-for-service model and

16 that serves a predominantly rural area.

17 ‘‘(3) RESTRICTION ON NEW OR EXPANDED FA18 CILITIES.—No new Veterans Affairs medical facili19 ties may be built or expanded with funds from the

20 demonstration project.

21 ‘‘(4) DURATION.—

22 ‘‘(A) COORDINATED CARE HEALTH PLAN

23 MODEL.—The authority of the administering

24 Secretaries to conduct the demonstration
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1 project under a coordinated care health plan

2 model shall—

3 ‘‘(i) begin on January 1, 2003; and

4 ‘‘(ii) terminate on the earlier of—

5 ‘‘(I) the date which is 3 years

6 after the date enrollment in a coordi7 nated care health plan begins at any

8 demonstration site using such a

9 model; or

10 ‘‘(II) December 31, 2006.

11 ‘‘(B) FEE-FOR-SERVICE MODEL.—The au12 thority of the administering Secretaries to con13 duct the demonstration under a fee-for-service

14 model shall—

15 ‘‘(i) begin on January 1, 2004; and

16 ‘‘(ii) terminate on the earlier of—

17 ‘‘(I) the date which is 3 years

18 after the date that health care bene19 fits begin to be provided at any dem20 onstration site using such a model; or

21 ‘‘(II) December 31, 2007.

22 ‘‘(c) COORDINATED CARE HEALTH PLAN MODEL.—

23 ‘‘(1) IN GENERAL.—The Secretary of Veterans

24 Affairs shall establish and operate coordinated care

25 health plans in order to provide the health care ben-
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1 efits prescribed in paragraph (3) to targeted medi2 care-eligible veterans enrolled in the demonstration

3 project consistent with part C of this title.

4 ‘‘(2) OPERATION BY OR THROUGH A DEM5 ONSTRATION SITE.—Any coordinated care health

6 plan established in accordance with paragraph (1)

7 shall be operated by or through a demonstration

8 site.

9 ‘‘(3) HEALTH CARE BENEFITS.—

10 ‘‘(A) IN GENERAL.—Subject to subpara11 graph (B), the Secretary of Veterans Affairs

12 shall prescribe the health care benefits to be

13 provided to a targeted medicare-eligible veteran

14 enrolled in a coordinated care health plan under

15 the demonstration project.

16 ‘‘(B) MINIMUM BENEFITS.—The benefits

17 prescribed by the Secretary of Veterans Affairs

18 pursuant to subparagraph (A) shall include at

19 least all medicare health care services that are

20 required to be provided by a Medicare+Choice

21 organization under part C.

22 ‘‘(4) MEDICARE REQUIREMENTS.—

23 ‘‘(A) IN GENERAL.—

24 ‘‘(i) REQUIREMENTS.—Except as pro25 vided under clause (ii), a coordinated care
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1 health plan operating under the dem2 onstration project shall meet all require3 ments applicable to a Medicare+Choice

4 plan under part C of this title and regula5 tions pertaining thereto, and any other re6 quirements for receiving payments under

7 this title, except that the prohibition of

8 payments to Federal providers of services

9 under sections 1814(c) and 1835(d), and

10 paragraphs (2) and (3) of section 1862(a),

11 shall not apply.

12 ‘‘(ii) WAIVER.—Except with respect to

13 any requirement described in subparagraph

14 (B), the Secretary is authorized to waive

15 any requirement described in clause (i), or

16 approve equivalent or alternative ways of

17 meeting such a requirement, but only if

18 such waiver or approval—

19 ‘‘(I) reflects the unique status of

20 the Department of Veterans Affairs as

21 an agency of the Federal Government;

22 and

23 ‘‘(II) is necessary to carry out, or

24 improve the efficiency of, the dem25 onstration project.
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1 ‘‘(B) BENEFICIARY PROTECTIONS AND

2 OTHER MATTERS.—A coordinated care health

3 plan shall comply with the requirements of part

4 C of this title that relate to beneficiary protec5 tions and other related matters, including such

6 requirements relating to the following areas:

7 ‘‘(i) Enrollment and disenrollment.

8 ‘‘(ii) Nondiscrimination.

9 ‘‘(iii) Information provided to bene10 ficiaries.

11 ‘‘(iv) Cost-sharing limitations.

12 ‘‘(v) Appeal and grievance procedures.

13 ‘‘(vi) Provider participation.

14 ‘‘(vii) Access to services.

15 ‘‘(viii) Quality assurance and external

16 review.

17 ‘‘(ix) Advance directives.

18 ‘‘(x) Other areas of beneficiary protec19 tions that the Secretary determines are ap20 plicable to a coordinated health care plan

21 operating under the demonstration project.

22 ‘‘(d) FEE-FOR-SERVICE MODEL.—

23 ‘‘(1) IN GENERAL.—The Secretary of Veterans

24 Affairs shall establish and operate a demonstration

25 site in order to provide, on a fee-for-service basis,
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1 the medicare health care services prescribed in para2 graph (2) to targeted medicare-eligible veterans

3 under the demonstration project in a manner con4 sistent with this title.

5 ‘‘(2) HEALTH CARE BENEFITS.—The admin6 istering Secretaries shall prescribe the medicare

7 health care services available to a targeted medicare8 eligible veteran at a demonstration site operating

9 under a fee-for-service model.

10 ‘‘(3) COST-SHARING.—The Secretary of Vet11 erans Affairs shall establish cost-sharing require12 ments for targeted medicare-eligible veterans that

13 receive medicare health care services under a fee-for14 service model at a demonstration site. Such cost15 sharing requirements shall be the same as those re16 quired under this title.

17 ‘‘(4) MEDICARE REQUIREMENTS.—

18 ‘‘(A) IN GENERAL.—Except as provided

19 under subparagraph (B), any entity or health

20 care provider that provides medicare health care

21 services under the demonstration project on a

22 fee-for-service basis shall meet all of the re23 quirements under this title, except that the pro24 hibition of payments to Federal providers of

25 services under sections 1814(c) and 1835(d),
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1 and paragraphs (2) and (3) of section 1862(a),

2 shall not apply.

3 ‘‘(B) WAIVER.—The Secretary is author4 ized to waive any requirement described under

5 subparagraph (A), or approve equivalent or al6 ternative ways of meeting such a requirement,

7 but only if such waiver or approval—

8 ‘‘(i) reflects the unique status of the

9 Department of Veterans Affairs as an

10 agency of the Federal Government; and

11 ‘‘(ii) is necessary to carry out, or im12 prove the efficiency of, the demonstration

13 project.

14 ‘‘(5) VERIFICATION OF ELIGIBILITY.—

15 ‘‘(A) IN GENERAL.—The Secretary of Vet16 erans Affairs shall establish procedures for de17 termining whether an individual is eligible to re18 ceive medicare health care services on a fee-for19 service basis under the demonstration project.

20 ‘‘(B) RESTRICTION.—No payments shall

21 be made under this section for any medicare

22 health care service provided to an individual on

23 a fee-for-service basis under the demonstration

24 project unless the individual has been deter25 mined to be eligible for the service pursuant to
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1 the procedures established under subparagraph

2 (A).

3 ‘‘(e) DEMONSTRATION SITE REQUIREMENTS.—The

4 Secretary of Veterans Affairs may operate a coordinated

5 care health plan at a demonstration site, may provide

6 medicare health care services using the fee-for-service

7 model at a demonstration site, and may authorize a dem8 onstration site to submit claims for payment under the

9 demonstration project only after the Secretary of Veterans

10 Affairs submits to the committees of jurisdiction of Con11 gress a report setting forth a plan for the establishment

12 of such demonstration site and for the oversight by the

13 Secretary of Veterans Affairs of the demonstration project

14 conducted at such demonstration site. The administering

15 Secretaries may not implement the plan until the Sec16 retary of Veterans Affairs has received from the Inspector

17 General of the Department of Health and Human Serv18 ices, and has forwarded to Congress, certification that—

19 ‘‘(1) the—

20 ‘‘(A) cost accounting and related trans21 action systems of the Veterans Health Adminis22 tration provide cost information and encounter

23 data regarding health care delivered at each

24 demonstration site (or delivered by any entity

25 or health care provider with which the Sec-
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1 retary of Veterans Affairs has a contract or

2 sharing agreement) on an inpatient and out3 patient basis; and

4 ‘‘(B) cost information and encounter data

5 provided by such systems is accurate, reliable,

6 and consistent across all the demonstration

7 sites;

8 ‘‘(2) the Secretary of Veterans Affairs has

9 minimized the risk that any amount appropriated to

10 the Department of Veterans Affairs will be required

11 to meet any obligation of the demonstration sites

12 under the demonstration project to a targeted medi13 care-eligible veteran by developing a credible plan—

14 ‘‘(A) based on market surveys, data from

15 the Decision Support System, actuarial anal16 ysis, and other appropriate methods; and

17 ‘‘(B) taking into account the level of pay18 ment under subsection (k) and the costs of

19 health care benefits provided at the demonstra20 tion sites with regard to each demonstration

21 site;

22 ‘‘(3) each demonstration site has the capacity

23 to provide to a sufficient number of targeted medi24 care-eligible veterans, at a minimum—
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1 ‘‘(A) under the coordinated care health

2 plan model, the health care benefits prescribed

3 in subsection (c)(3); or

4 ‘‘(B) under the fee-for-service model, the

5 health care benefits prescribed in subsection

6 (d)(2); and

7 ‘‘(4) the Veterans Affairs medical facility ad8 ministering the demonstration site has sufficient sys9 tems and safeguards in place to minimize any risk

10 that instituting the coordinated care health plan

11 model or the fee-for-service model will result in

12 reducing—

13 ‘‘(A) the quality of care delivered to par14 ticipants in the demonstration project; or

15 ‘‘(B) the quality of, or the access to, care

16 to veterans not participating in the demonstra17 tion project.

18 ‘‘(f) VOLUNTARY PARTICIPATION.—Participation of a

19 targeted medicare-eligible veteran in the demonstration

20 project shall be voluntary, subject to the capacity of par21 ticipating demonstration sites and the annual limitations

22 on medicare payments specified in subsection (k)(4), and

23 shall be subject to such terms and conditions as the ad24 ministering Secretaries may establish.
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1 ‘‘(g) CREDITING OF PAYMENTS.—A payment re2 ceived by the Secretary of Veterans Affairs under the dem3 onstration project shall be credited to the applicable De4 partment of Veterans Affairs medical appropriation unless

5 the Secretary of Veterans Affairs has a compelling reason

6 to do otherwise. Any such payment received during a fiscal

7 year for services provided during a prior fiscal year may

8 be obligated by the Secretary of Veterans Affairs during

9 the fiscal year during which the payment is received.

10 ‘‘(h) WAIVER OF CERTAIN VA REQUIREMENTS.—

11 Notwithstanding any other provision of law, the Secretary

12 of Veterans Affairs shall furnish medicare health care

13 services to targeted medicare-eligible veterans pursuant to

14 the demonstration project.

15 ‘‘(i) INSPECTOR GENERAL.—Nothing in any agree16 ment entered into under subsection (b) shall limit the In17 spector General of the Department of Health and Human

18 Services from investigating any matters regarding the ex19 penditure of funds under this title for the demonstration

20 project, including compliance with the provisions of this

21 title and all other relevant laws.

22 ‘‘(j) REPORT.—

23 ‘‘(1) IN GENERAL.—At least 30 days prior to

24 the commencement of the demonstration project (for

25 both the coordinated care health plan model and the
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1 fee-for-service model), the administering Secretaries

2 shall submit a copy of any agreement entered into

3 under subsection (b) to the committees of jurisdic4 tion of Congress.

5 ‘‘(2) SUBSEQUENT WAIVER OF MEDICARE RE6 QUIREMENTS.—If the Secretary waives any require7 ment under subsection (c)(4) or (d)(4) that was not

8 described in any agreement submitted to the com9 mittees of jurisdiction of Congress under paragraph

10 (1), the Secretary shall submit a report to such com11 mittees describing such waiver.

12 ‘‘(k) PAYMENTS BASED ON REGULAR MEDICARE

13 PAYMENT RATES.—

14 ‘‘(1) AMOUNT.—Subject to the succeeding pro15 visions of this subsection and subsection (m), the

16 Secretary shall reimburse the Secretary of Veterans

17 Affairs for health care benefits provided under the

18 demonstration project at the following rates:

19 ‘‘(A) COORDINATED CARE HEALTH

20 PLANS.—In the case of health care benefits pro21 vided under the demonstration project to a tar22 geted medicare-eligible veteran enrolled in a co23 ordinated care health plan, at a rate equal to

24 95 percent of the amount paid to a

25 Medicare+Choice organization under part C for
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1 an enrollee in a Medicare+Choice plan offered

2 by such organization (as risk adjusted under

3 section 1853(a)(1)(B)).

4 ‘‘(B) FEE-FOR-SERVICE MODEL.—In the

5 case of a medicare health care service pre6 scribed in subsection (d)(2) that is provided at

7 a demonstration site operating under a fee-for8 service model, at a rate equal to 95 percent of

9 the amounts that otherwise would be payable

10 under this title on a noncapitated basis for such

11 service if the demonstration site was not part of

12 this demonstration project, was participating in

13 the medicare program, and imposed charges for

14 such service.

15 ‘‘(2) EXCLUSION OF CERTAIN AMOUNTS.—In

16 computing the amount of payment under paragraph

17 (1), the following amounts shall be excluded:

18 ‘‘(A) DISPROPORTIONATE SHARE HOS19 PITAL ADJUSTMENT.—Any amount attributable

20 to an adjustment under section 1886(d)(5)(F).

21 ‘‘(B) DIRECT GRADUATE MEDICAL EDU22 CATION PAYMENTS.—Any amount attributable

23 to a payment under section 1886(h).
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1 ‘‘(C) INDIRECT MEDICAL EDUCATION AD2 JUSTMENT.—Any amount attributable to the

3 adjustment under section 1886(d)(5)(B).

4 ‘‘(D) PERCENTAGE OF CAPITAL PAY5 MENTS.—67 percent of any amounts attrib6 utable to payments for capital-related costs

7 under medicare payment policies under section

8 1886(g).

9 ‘‘(3) PERIODIC PAYMENTS FROM MEDICARE

10 TRUST FUNDS.—Payments under this subsection

11 shall be made—

12 ‘‘(A) on a periodic basis consistent with

13 the periodicity of payments under this title; and

14 ‘‘(B) in appropriate part, as determined by

15 the Secretary, from the trust funds.

16 ‘‘(4) ANNUAL LIMIT ON MEDICARE PAY17 MENTS.—

18 ‘‘(A) COORDINATED CARE HEALTH PLAN

19 MODEL.—Subject to subparagraphs (C) and

20 (D), the total amount paid to the Department

21 of Veterans Affairs under this subsection for

22 enrollees in coordinated care health plans for

23 any of the 3 consecutive 12-month periods (the

24 first of which begins on the date that enroll25 ment in such a plan begins at any demonstra-
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1 tion site) shall be equal to an amount deter2 mined appropriate by the administering Secre3 taries.

4 ‘‘(B) FEE-FOR-SERVICE MODEL.—Subject

5 to subparagraphs (C) and (D), the total

6 amount paid to the Department of Veterans Af7 fairs under this subsection for health care bene8 fits provided on a fee-for-service basis at a dem9 onstration site for any of the 3 consecutive 12-

10 month periods (the first of which begins on the

11 date that benefits begin to be provided at any

12 demonstration site using the fee-for-service

13 model) shall be equal to an amount determined

14 appropriate by the administering Secretaries.

15 ‘‘(C) NO PAYMENTS FOR BENEFITS PRO16 VIDED AFTER TERMINATION DATE.—No

17 amounts shall be paid to the Department of

18 Veterans Affairs under this section for health

19 care benefits provided under the demonstration

20 project after the date that the project termi21 nates pursuant to subparagraph (A)(ii) or

22 (B)(ii) of subsection (b)(4).

23 ‘‘(D) CAP.—The sum of the amounts paid

24 to the Department of Veterans Affairs under

25 this section during each of the 12-month peri-
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1 ods described in subparagraph (A) shall not ex2 ceed $50,000,000.

3 ‘‘(l) MAINTENANCE OF EFFORT.—

4 ‘‘(1) IN GENERAL.—The Secretary may not re5 imburse the Secretary of Veterans Affairs, from the

6 trust funds, for medicare health care services fur7 nished under the demonstration project to targeted

8 medicare-eligible veterans at a demonstration site in

9 a year until the expenditures during that year by the

10 Department of Veterans Affairs for such services

11 provided at that site to individuals that meet the

12 definition of a targeted medicare-eligible veteran

13 under subsection (a)(4) (without regard to subpara14 graph (D) of such subsection) exceeds such expendi15 tures at the site for such services provided to such

16 individuals during a baseline period determined by

17 the administering Secretaries.

18 ‘‘(2) RULE OF CONSTRUCTION.—The criteria

19 for eligiblity for health care benefits furnished to

20 veterans by the Secretary of Veterans Affairs is es21 tablished under chapter 17 of title 38, United States

22 Code, and nothing in this section shall be construed

23 to add additional criteria for such eligiblity.

24 ‘‘(m) ANNUAL RECONCILIATION TO ASSURE NO IN25 CREASE IN COSTS TO MEDICARE PROGRAM.—
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1 ‘‘(1) MONITORING EFFECT OF DEMONSTRATION

2 PROGRAM ON COSTS TO MEDICARE PROGRAM.—

3 ‘‘(A) IN GENERAL.—The administering

4 Secretaries, in consultation with the Comp5 troller General of the United States, shall close6 ly monitor the expenditures made under the

7 medicare program under this title for targeted

8 medicare-eligible veterans at each demonstra9 tion site during the period of the demonstration

10 project compared to the expenditures that

11 would have been made for such veterans during

12 that period if the demonstration project had not

13 been conducted.

14 ‘‘(B) ANNUAL REPORTS BY THE COMP15 TROLLER GENERAL.—

16 ‘‘(i) COORDINATED CARE HEALTH

17 PLAN MODEL.—Not later than 6 months

18 after the end of each of the 3 consecutive

19 12-month periods referred to in subsection

20 (j)(4)(A), the Comptroller General of the

21 United States shall submit to the admin22 istering Secretaries and the appropriate

23 committees of Congress a report on the ex24 tent, if any, to which the costs of the Sec25 retary under the medicare program under
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1 this title for each demonstration site oper2 ating under such a model increased as a

3 result of the demonstration project during

4 the 12-month period to which the report

5 applies.

6 ‘‘(ii) FEE-FOR-SERVICE MODEL.—Not

7 later than 6 months after the end of each

8 of the 3 consecutive 12-month periods re9 ferred to in subsection (j)(4)(B), the

10 Comptroller General of the United States

11 shall submit to the administering Secre12 taries and the appropriate committees of

13 jurisdiction of Congress a report described

14 in clause (i) with respect to such a model.

15 ‘‘(2) REQUIRED RESPONSE IN CASE OF IN16 CREASE IN COSTS.—

17 ‘‘(A) IN GENERAL.—If the administering

18 Secretaries find, based on paragraph (1), that

19 the expenditures under the medicare program

20 under this title for each demonstration site in21 creased (or are expected to increase) during a

22 fiscal year because of the demonstration

23 project, the administering Secretaries shall take

24 such steps as may be needed—
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1 ‘‘(i) to recoup for the medicare pro2 gram the amount of such increase in ex3 penditures; and

4 ‘‘(ii) to prevent any such increase in

5 any succeeding fiscal year.

6 ‘‘(B) STEPS.—Such steps—

7 ‘‘(i) under subparagraph (A)(i), shall

8 include payment of an amount equal to the

9 amount of such increased expenditures by

10 the Secretary of Veterans Affairs from the

11 current medical care appropriation of the

12 Department of Veterans Affairs to the

13 trust funds; and

14 ‘‘(ii) under subparagraph (A)(ii), shall

15 include suspending or terminating the

16 demonstration project (in whole or in part)

17 or reducing the amount of payment under

18 subsection (k).

19 ‘‘(n) EVALUATION AND REPORTS.—

20 ‘‘(1) INDEPENDENT EVALUATION.—

21 ‘‘(A) IN GENERAL.—The Comptroller Gen22 eral of the United States shall conduct an eval23 uation of the demonstration project,

24 including—
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1 ‘‘(i) an evaluation of demonstration

2 sites operating under a coordinated care

3 health plan model and under a fee-for-serv4 ice model; and

5 ‘‘(ii) where appropriate, a comparison

6 of such models.

7 ‘‘(B) CONTENTS.—Any evaluation con8 ducted under subparagraph (A) shall include an

9 assessment, based on the agreement entered

10 into under subsection (b), of the following:

11 ‘‘(i) Any savings or costs to the medi12 care program under this title resulting

13 from the demonstration project.

14 ‘‘(ii) Compliance of participating dem15 onstration sites with applicable measures

16 of quality of care, compared to such com17 pliance by other entities that participate in

18 the medicare program and are not Vet19 erans Affairs medical facilities.

20 ‘‘(iii) Compliance by the Department

21 of Veterans Affairs with the requirements

22 under this title.

23 ‘‘(iv) The number of targeted medi24 care-eligible veterans opting to receive

25 health care benefits under the demonstra-
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1 tion project instead of receiving such bene2 fits through another health insurance plan

3 (including health care benefits under this

4 title).

5 ‘‘(v) A comparison of the costs of par6 ticipation of the demonstration sites in the

7 program with the reimbursements for

8 health care services provided by such sites.

9 ‘‘(vi) Any impact the demonstration

10 project has on the access to health care

11 services, or the quality of such services,

12 for—

13 ‘‘(I) targeted medicare-eligible

14 veterans receiving health care benefits

15 under the demonstration project; and

16 ‘‘(II) veterans (including targeted

17 medicare-eligible veterans) that are

18 not receiving health care benefits

19 under the demonstration project.

20 ‘‘(vii) Any impact the demonstration

21 project has on private health care providers

22 and on beneficiaries under this title that

23 are not receiving health care benefits under

24 the demonstration project.
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1 ‘‘(viii) Any effect that the demonstra2 tion project has on the enrollment in

3 Medicare+Choice plans offered by

4 Medicare+Choice organizations under part

5 C of this title in the established dem6 onstration site areas.

7 ‘‘(ix) Any impact that the exclusion of

8 the amounts described in subsection (k)(2)

9 from the reimbursement amounts under

10 the demonstration has on the Department

11 of Veterans Affairs or on targeted medi12 care-eligible veterans.

13 ‘‘(x) A description of the difficulties

14 (if any) experienced by—

15 ‘‘(I) the Department of Veterans

16 Affairs in managing the demonstra17 tion project; or

18 ‘‘(II) the Department of Health

19 and Human Services in overseeing the

20 demonstration project.

21 ‘‘(xi) Any additional elements speci22 fied in the agreement entered into under

23 subsection (b).

24 ‘‘(xii) Any additional elements that

25 the Comptroller General of the United
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1 States determines are appropriate to as2 sess regarding the demonstration project.

3 ‘‘(C) PERIODIC REPORTS.—

4 ‘‘(i) COORDINATED CARE HEALTH

5 PLAN MODEL.—With respect to the portion

6 of the demonstration project that is oper7 ating under a coordinated care health plan

8 model, the Comptroller General of the

9 United States shall submit reports on the

10 evaluation conducted under subparagraph

11 (A) to the administering Secretaries and to

12 the committees of jurisdiction of Congress

13 as follows:

14 ‘‘(I) INITIAL REPORT.—An initial

15 report shall be submitted not later

16 than 12 months after the date that

17 enrollment in a coordinated care

18 health plan begins at any demonstra19 tion site.

20 ‘‘(II) SECOND REPORT.—A sec21 ond report shall be submitted not

22 later than 30 months after such date.

23 ‘‘(III) FINAL REPORT.—A final

24 report shall be submitted not later

25 than 42 months after such date.
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1 ‘‘(ii) FEE-FOR-SERVICE MODEL.—

2 With respect to the portion of the dem3 onstration project that is operating under

4 a fee-for-service model, the Comptroller

5 General of the United States shall submit

6 reports on the evaluation conducted under

7 subparagraph (A) to the administering

8 Secretaries and to the committees of juris9 diction of Congress as follows:

10 ‘‘(I) INITIAL REPORT.—An initial

11 report shall be submitted not later

12 than 12 months after the date that

13 medicare health care services begin to

14 be provided at any demonstration site

15 using such a model.

16 ‘‘(II) SECOND REPORT.—A sec17 ond report shall be submitted not

18 later than 30 months after such date.

19 ‘‘(III) FINAL REPORT.—A final

20 report shall be submitted not later

21 than 42 months after such date.

22 ‘‘(2) REPORTS ON EXTENSION AND EXPANSION

23 OF THE DEMONSTRATION PROJECT.—

24 ‘‘(A) COORDINATED CARE HEALTH PLAN

25 MODEL.—With respect to the demonstration
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1 project that is operating under a coordinated

2 care health plan model, not later than 3 months

3 after the date of the submission of the final re4 port by the Comptroller General of the United

5 States under paragraph (1)(C)(i)(III), the ad6 ministering Secretaries shall submit to the com7 mittees of jurisdiction of Congress a report con8 taining the final recommendations of such Sec9 retaries as to—

10 ‘‘(i) whether expenditures for targeted

11 medicare-eligible veterans under the dem12 onstration project exceed the expenditures

13 that would have been incurred under the

14 medicare program under this title with re15 gard to such veterans had this section not

16 been enacted;

17 ‘‘(ii) whether the demonstration

18 project could be expanded or extended

19 without increasing the cost to the medicare

20 program under this title or to the Federal

21 Government;

22 ‘‘(iii) whether to extend the duration

23 of the demonstration project;
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•HR 1911 IH

1 ‘‘(iv) whether to increase the number

2 of demonstration sites operating under

3 such a model;

4 ‘‘(v) whether to increase the maximum

5 amount of reimbursement under the dem6 onstration project in any year; and

7 ‘‘(vi) whether the terms and condi8 tions of the demonstration project should

9 be altered if the project is extended or ex10 panded.

11 ‘‘(B) FEE-FOR-SERVICE MODEL.—With re12 spect to the demonstration project that is oper13 ating under a fee-for-service model, not later

14 than 3 months after the date of the submission

15 of the final report by the Comptroller General

16 of the United States under paragraph

17 (1)(C)(ii)(III), the administering Secretaries

18 shall submit to the committees of jurisdiction of

19 Congress a report described in subparagraph

20 (A) with respect to such model.’’.

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