I
103D CONGRESS
2D SESSION
H. R. 4788
To amend title 38, United States Code, to reform and simplify criteria
for eligibility for health care provided by the Department of Veterans
Affairs, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
JULY 19, 1994
Mr. STUMP (for himself, Mr. SMITH of New Jersey, Mr. BILIRAKIS, Mr.
RIDGE, Mr. SPENCE, Mr. HUTCHINSON, Mr. EVERETT, Mr. BUYER, Mr.
QUINN, Mr. BACHUS of Alabama, Mr. LINDER, Mr. KING, and Mr.
STEARNS) introduced the following bill; which was referred to the Com-
mittee on Veterans’ Affairs
A BILL
To amend title 38, United States Code, to reform and sim-
plify criteria for eligibility for health care provided by
the Department of Veterans Affairs, and for other pur-
poses.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Veterans’ Health Care
Eligibility Reform Act of 1994’’.
SEC. 2. VETERANS HEALTH CARE ELIGIBILITY REFORM.
Chapter 17 of title 38, United States Code, is amend-
ed as follows:
(1) Section 1701 is amended by adding at the
end the following new paragraphs:
‘‘(10) The term ‘continuum of health care’ in-
cludes specialized treatment and rehabilitative serv-
ices of the Department, including comprehensive
prevention and health screening programs and serv-
ices to treat needs of disabled veterans with spinal
cord dysfunction, blindness, prosthetics, and mental
illness.
‘‘(11) The term ‘noninstitutional long-term
care’ includes the following services:
‘‘(A) Hospital-based home care.
‘‘(B) Adult day health care.
‘‘(C) Fee basis care.
‘‘(D) Hospice care.
‘‘(E) Homemaker services.
‘‘(F) Home health aid.
‘‘(G) Case management services.
‘‘(H) Congregate meals.
‘‘(I) Home delivered meals.
‘‘(J) Senior center services.
‘‘(K) Shopping and transportation services.
‘‘(L) Phone check services.’’.
(2) Section 1710(a)(1) is amended by striking
out ‘‘shall furnish’’ and all that follows through
‘‘which the’’ and inserting in lieu thereof ‘‘shall fur-
nish a continuum of health care (including hospital
care, outpatient medical services provided on an out-
patient or ambulatory basis, and noninstitutional
long-term care) which the’’.
(3) Subchapter II is amended by inserting after
section 1710 the following new section:
‘‘§ 1710A. Institutional long-term care for certain vet-
erans
‘‘(a) The Secretary shall provide institutional nursing
home care to any veteran who is described in subpara-
graph (A) or (D) of section 1710(a)(1), or in subpara-
graph (C) of section 1712(a)(1), of this title or who is
in receipt of pension from the Secretary.
‘‘(b) If a veteran who is provided nursing home care
by reason of subsection (a) is also eligible for payment
for the costs of nursing home care under a State plan title
XIX of the Social Security Act, the Secretary shall be enti-
tled to recover from that State plan the amount that the
State plan would pay for that care if provided by an au-
thorized provider. For purposes of this subsection, the vet-
eran shall be deemed to have paid any deductible or
copayment otherwise required as a condition of payment
by the State plan.’’.
(4) Section 1710(d) is amended by inserting
‘‘1710A or’’ after ‘‘section’’.
(5) Subchapter III is amended by inserting
after section 1729 the following new section:
‘‘§ 1729A. Medicare coverage and reimbursement
‘‘(a) For purposes of any program administered by
the Secretary of Health and Human Services under title
XVIII of the Social Security Act, a Department facility
shall be deemed to be a Medicare provider.
‘‘(b)(1) A VA medical center (or group of medical
centers) shall be considered to be a Medicare HMO.
‘‘(2) For purposes of this section, the term ‘Medicare
HMO’ means an eligible organization under section 1876
of the Social Security Act.
‘‘(c) In the case of care for a non-service-connected
disability that is provided to a veteran who is eligible for
benefits under the Medicare program under title XVIII of
the Social Security Act, the Secretary of Health and
Human Services shall reimburse a Department health-care
facility providing services as a Medicare provider or Medi-
care HMO in the same amounts and under the same terms
and conditions as that Secretary reimburses other Medi-
care providers or Medicare HMOs, respectively. The Sec-
retary of Health and Human Services shall include with
each such reimbursement a Medicare explanation of bene-
fits.
‘‘(d) In the case of a veteran whose eligibility for hos-
pital care from the Department is by reason of section
1710(a)(2) of this title, the Secretary shall, when provid-
ing care to the veteran for which the Secretary receives
reimbursement under this section, require the veteran to
pay to the Department any applicable deductible or
copayment that is not covered by Medicare.’’.
SEC. 3. PLAN FOR ENTITLEMENT TO INSTITUTIONAL NURS-
ING HOME CARE FOR OTHER VETERANS.
(a) ESTABLISHMENT OF PLAN.—The Secretary of
Veterans Affairs shall develop a plan to implement (over
a specified period of years) the provision of institutional
long-term care for any veteran described in subsection (b).
The plan may provide for the provision of institutional
long-term care through facilities of the Department of
Veterans Affairs or through a long-term care insurance
contract, or a combination thereof. In specifying benefits,
or a proposed range of benefits, under the plan, the Sec-
retary shall consider a representative range of the dif-
ferent types of health benefits provisions (which include
cost-sharing) typically offered as long-term institutional
care coverage in the small employer health coverage mar-
ket.
(b) COVERED VETERANS.—The plan shall propose to
cover any veteran not covered by section 1710A of title
38, United States Code, as added by section 2, who—
(1) has a service-connected disability rated at
less than 50 percent;
(2) has an annual income (as determined under
section 1503 of such title) that does not exceed three
times 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
such title;
(3) has a catastrophic nonservice-connected dis-
ability (as defined by the Secretary); or
(4) requires institutional long-term care as a
follow up to inpatient care, as authorized under sec-
tion 1720 of this title.
(c) PREMIUMS AND COPAYMENTS.—The plan shall
include the establishment of a schedule of premiums and
copayments for care provided through Department of Vet-
erans Affairs institutional care programs in effect on the
day before the date of the enactment of this Act. The plan
shall specify a range of premiums and copayments that
would apply based upon different combinations of levels
of payments by the Government, copayments, and pre-
miums, as specified in the plan.
(d) LONG-TERM CARE INSURANCE CONTRACT.—For
purposes of this section, the term ‘long-term care insur-
ance contract’ means any insurance contract issued if—
(1) the only insurance protection provided
under the contract is coverage of institutional long-
term care services (as specified in the contract) and
benefits incidental to such coverage,
(2) the maximum benefit under the policy for
expenses incurred for any day does not exceed $200,
(3) the contract does not cover expenses in-
curred for services or items to the extent that such
expenses are reimbursable under title XVIII of the
Social Security Act or would be so reimbursable but
for the application of a deductible or coinsurance
amount,
(4) the contract is guaranteed renewable,
(5) the contract does not have any cash surren-
der value, and
(6) all refunds of premiums, and all policy-
holder dividends or similar amounts, under the con-
tract are to be applied as a reduction in future pre-
miums or to increase future benefits.
(e) REPORT TO CONGRESS.—Not later than Septem-
ber 30, 1996, the Secretary shall submit to Congress a
report on the plan. The report shall include—
(1) a cost analysis, including a range of pre-
miums and copayments and Government cost-shar-
ing;
(2) a discussion of the cost of establishing a
long-term care insurance program for veterans de-
scribed in subsection (b) using contract authority (if
such contract authority is provided by law); and
(3) a draft of legislation to make any necessary
changes in law to enable the Department to imple-
ment the plan.
SEC. 4. ENROLLMENT SYSTEM FOR OTHER PERSONS.
(a) IN GENERAL.—(1) Title 38, United States Code,
is amended by inserting after chapter 17 the following new
chapter:
‘‘CHAPTER 18—VA GROUP HEALTH PLAN
‘‘Sec.
‘‘1801. Definitions.
‘‘1802. VA Group Health Plan.
‘‘1803. Enrollment.
‘‘1804. Limitation on preexisting conditions.
‘‘1805. Plan to be self supporting.
‘‘1806. Annual report.
‘‘§ 1801. Definitions
‘‘For purposes of this chapter:
‘‘(1) The term ‘eligible veteran’ means any vet-
eran other than a veteran eligible for health care
under section 1710(a)(1) of this title.
‘‘(2) The term ‘VA enrollee’ means an individ-
ual enrolled in the VA Group Health Plan.
‘‘§ 1802. VA Group Health Plan
‘‘(a) The Secretary shall administer a program of
health insurance under this chapter to be known as the
VA Group Health Plan. The Secretary may provide such
insurance directly or may contract with an insurance pro-
vider in the private sector for the provision of such insur-
ance. The plan may be established as a single, nation-wide
plan or as a composite of regional health insurance plans.
‘‘(b) The Secretary shall establish and carry out the
VA Group Health Plan as a managed-care plan and so
that it meets the following requirements:
‘‘(1) The plan shall be designed to be self-sus-
taining through required premiums, copayments,
deductibles, and other charges, and without appro-
priated funds.
‘‘(2) The plan shall provide such benefits as the
Secretary determines.
‘‘(c) The Secretary may award contracts under this
section for the operation of the VA Group plan.
‘‘(d) The Secretary may provide treatment in Depart-
ment facilities for any enrollee, if cost effective.
‘‘§ 1803. Enrollment
‘‘(a) The following individuals are eligible to enroll
in the VA Group Health Plan:
‘‘(1) Any eligible veteran.
‘‘(2) The spouse or child of any veteran.
‘‘(b)(1) The Secretary of Veterans Affairs shall estab-
lish an enrollment (and disenrollment) process for the VA
Group Health Plan in accordance with this subsection.
Such process shall be established in consultation with vet-
erans and other individuals to be served by the plan.
‘‘(2) For each eligible veteran, when the veteran first
becomes eligible to enroll in the VA Group Health Plan,
there shall be an initial enrollment period (of not less than
30 days) during which the veteran may enroll in the plan.
‘‘(3) The Secretary shall establish an annual period,
of not less than 30 days, during which eligible veterans
may enroll in the VA Group Health Plan.
‘‘(4) If a veteran enrolls in the VA Group Health
Plan, the veteran may at the same time enroll, as a family
enrollment, the veteran’s spouse and children in the plan.
‘‘(5) In the case of individuals who through marriage,
divorce, birth or adoption of a child, or similar cir-
cumstances, experience a change in family composition,
the Secretary shall provide for a special enrollment period
in which the individual is permitted to change the individ-
ual or family basis of coverage. The circumstances under
which such special enrollment periods are required and the
duration of such periods shall be specified by the Sec-
retary.
‘‘(6) The Secretary shall provide for a special transi-
tional enrollment period during which eligible individuals
may first enroll.
‘‘(c) Enrollment of the spouse (including a child of
the spouse) and any dependent child of an eligible veteran
shall be considered to be timely if a request for enrollment
is made either—
‘‘(1) within 30 days of the date of the marriage
or of the date of the birth or adoption of a child,
if family coverage is available as of such date, or
‘‘(2) within 30 days of the date family coverage
is first made available.
‘‘(d) Family coverage shall become effective not later
than the first day of the first month beginning after the
date of the marriage or the date of birth or adoption of
the child (as the case may be).
‘‘(e) The Secretary may terminate coverage for
nonpayment of premiums.
‘‘(f) Coverage of a spouse under a policy under this
chapter may not be canceled by reason of the death of
the veteran unless the surviving spouse remarries.
‘‘§ 1804. Limitation on preexisting conditions
‘‘(a) The VA Group Health Plan may not impose
(and an insurer under that plan may not require the Sec-
retary impose through a waiting period for coverage under
the plan or similar requirement) a limitation or exclusion
of benefits relating to treatment of a condition based on
the fact that the condition preexisted the effective date
of the plan with respect to an individual if—
‘‘(1) the condition relates to a condition that
was not diagnosed or treated within three months
before the date of coverage under the plan;
‘‘(2) the limitation or exclusion extends over
more than six months after the date of coverage
under the plan;
‘‘(3) the limitation or exclusion applies to an in-
dividual who, as of the date of birth, was covered
under the plan; or
‘‘(4) the limitation or exclusion relates to preg-
nancy.
In the case of an individual who is eligible for coverage
under a plan but for a waiting period imposed by the em-
ployer, in applying paragraphs (1) and (2), the individual
shall be treated as having been covered under the plan
as of the earliest date of the beginning of the waiting pe-
riod.
‘‘(b)(1) The Secretary, for purposes of the VA Group
Health Plan, shall waive any period applicable to a pre-
existing condition for similar benefits with respect to an
individual to the extent that the individual, before the date
of such individual’s enrollment in such plan, was covered
for the condition under any other health plan that was
in effect before such date.
‘‘(2) Paragraph (1) shall no longer apply if there is
a continuous period of more than 60 days (or, in the case
of an individual who loses coverage under a group health
plan due to termination of employment, six months) on
which the individual was not covered under a group health
plan.
‘‘(3) In applying paragraph (2), any waiting period
imposed by an employer before an employee is eligible to
be covered under a plan shall be treated as a period in
which the employee was covered under a group health
plan.
‘‘§ 1805. Plan to be self supporting
‘‘The Secretary shall administer the VA Group
Health Plan so as to ensure that no appropriated funds
are required for the operation of the plan (other than as