II 114th CONGRESS 2d Session S. 3401 IN THE SENATE OF THE UNITED STATES September 27, 2016 Mr. Crapo introduced the following bill; which was read twice and referred to the Committee on Veterans' Affairs A BILL To amend title 38, United States Code, to consolidate and expand the provision of health care to veterans through non-Department of Veterans Affairs health care providers, and for other purposes.

1. Short title This Act may be cited as the Improving Veterans Care in the Community Act of 2016 . 2. Sense of Congress It is the sense of Congress that— (1) the Department of Veterans Affairs should remain the primary means by which eligible veterans access health care; (2) the Veterans Health Administration needs a simple tool by which it can send veterans into the community to receive health care when appropriate; and (3) it is appropriate to send veterans into the community for health care when— (A) it is in the best medical interest of the veteran; (B) the veteran does not have access to a medical facility of the Department without an undue travel burden; (C) the nearest medical facility of the Department does not provide the service the veteran needs and the veteran faces an undue travel burden to receive the service from another medical facility of the Department; or (D) the Secretary of Veterans Affairs determines that it is appropriate. 3. Establishment of Care in the Community Program of Department of Veterans Affairs to consolidate and expand the provision of health care to veterans through non-Department of Veterans Affairs providers (a) Establishment of program (1) In general Subchapter I of chapter 17 of title 38, United States Code, is amended by inserting after section 1703 the following new section: 1703A. Care in the Community Program (a) In general (1) There is established a consolidated program to furnish care and services specified in subsection (e) to veterans through individuals and entities specified in subsection (c), including through the use of contracts or agreements entered into under this section to furnish such care and services. Such program may be referred to as the Care in the Community Program . (b) Requirement To receive care To receive care or services under this section, a veteran must be enrolled in the patient enrollment system of the Department established and operated under section 1705 of this title. (c) Individuals and entities specified Individuals and entities specified in this paragraph are the following: (1) Any health care provider that is participating in the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) or the Medicaid program under title XIX of such Act ( 42 U.S.C. 1396 et seq. ), including any physician furnishing services under such a program. (2) The Department of Defense, including pursuant to agreements entered into under section 8111 of this title. (3) The Indian Health Service. (4) Institutions affiliated with the Department under section 7302 of this title. (5) Providers of care under the Alaska Native Health Care System. (6) Federally-qualified health centers (as defined in section 1905(l)(2)(B) of the Social Security Act ( 42 U.S.C. 1396d(l)(2)(B) )). (7) Any individual or entity with which the Secretary has entered into a contract or agreement under section 8153 of this title. (8) Any other individual or entity that meets criteria established by the Secretary for purposes of this section. (d) Eligibility for certain services (1) (A) A veteran is eligible for hospital care and medical services under subsection (e)(9) if— (i) the veteran does not live within 40 miles of a medical facility of the Department, including a community-based outpatient clinic; (ii) the veteran requires care or services that are not available at any medical facility of the Department, including a community-based outpatient clinic, within 40 miles from the residence of the veteran; (iii) the veteran resides— (I) in a State without a medical facility of the Department that provides— (aa) hospital care; (bb) emergency medical services; and (cc) surgical care rated by the Secretary as having a surgical complexity of standard; and (II) more than 20 miles from a medical facility of the Department described in subclause (I); (iv) the veteran— (I) resides in a location, other than a location in Guam, American Samoa, or the Republic of the Philippines, that is within 40 miles of a medical facility of the Department, including a community-based outpatient clinic; and (II) (aa) is required to travel by air, boat, or ferry to reach each medical facility described in subclause (I) that is within 40 miles of the residence of the veteran; or (bb) faces an unusual or excessive burden in traveling to such a medical facility of the Department based on— (AA) geographical challenges; (BB) environmental factors, such as roads that are not accessible to the general public, traffic, or hazardous weather; (CC) a medical condition that impacts the ability to travel; or (DD) other factors, as determined by the Secretary; (v) the veteran would be required to wait longer than a period specified by the Secretary to receive hospital care or medical services from the Department; or (vi) a health care provider of the Department determines that it is in the medical interest of the veteran to access hospital care or medical services outside of the Department. (B) Any distance specified under subparagraph (A) shall be calculated based on distance traveled. (C) The period specified by the Secretary under subparagraph (A)(v) shall be 30 days unless the Secretary— (i) prescribes regulations specifying a different period, which may include a different period for each area of specialty care; and (ii) publishes such different period or periods in the Federal Register and on an Internet Web site of the Department. (D) Veterans who meet eligibility criteria set forth under the pilot program under section 403 of the Veterans’ Mental Health and Other Care Improvements Act of 2008 ( Public Law 110–387 ; 38 U.S.C. 1703 note) (commonly known as Project Arch ), as in effect on the day before the termination of such program, are eligible for care and services under subsection (e)(9). (2) (A) A veteran is eligible for reimbursement for emergency treatment furnished under subsection (e)(15) at a non-Department facility— (i) if the veteran is an active Department health-care participant who is personally liable for emergency treatment furnished the veteran in a non-Department facility, for any emergency treatment furnished such veteran; or (ii) if the treatment was for— (I) an adjudicated service-connected disability; (II) a non-service-connected disability associated with and held to be aggravating a service-connected disability; (III) any disability of a veteran if the veteran has a total disability permanent in nature from a service-connected disability; or (IV) any illness, injury, or dental condition of a veteran who— (aa) is a participant in a vocational rehabilitation program (as defined in section 3101(9) of this title); and (bb) is medically determined to have been in need of care or treatment to make possible the veteran's entrance into a course of training, or prevent interruption of a course of training, or hasten the return to a course of training which was interrupted because of such illness, injury, or dental condition. (B) A veteran is an active Department health-care participant if the veteran received care under this chapter within the 24-month period preceding the furnishing of such emergency treatment. (C) A veteran is personally liable for emergency treatment furnished the veteran in a non-Department facility if the veteran— (i) is financially liable to the provider of emergency treatment for that treatment; (ii) has no entitlement to care or services under a health-plan contract (determined, in the case of a health-plan contract as defined in subsection (j)(2)(B) or (j)(2)(C), without regard to any requirement or limitation relating to eligibility for care or services from any department or agency of the United States); and (iii) has no other contractual or legal recourse against a third party that would, in whole, extinguish such liability to the provider. (e) Care and services Care and services specified in this subsection are the following: (1) Hospital care or medical services furnished to a veteran for the treatment of— (A) a service-connected disability; (B) a disability for which a veteran was discharged or released from the active military, naval, or air service; or (C) a disability of a veteran who has a total disability permanent in nature from a service-connected disability. (2) Medical services for the treatment of any disability of— (A) a veteran described in section 1710(a)(1)(B) of this title; (B) a veteran who— (i) has been furnished hospital care, nursing home care, domiciliary care, or medical services; and (ii) requires medical services to complete treatment incident to such care or services; or (C) a veteran described in section 1710(a)(2)(E) of this title, or a veteran who is in receipt of increased pension, or additional compensation or allowances based on the need of regular aid and attendance or by reason of being permanently housebound (or who, but for the receipt of retired pay, would be in receipt of such pension, compensation, or allowance), if the Secretary has determined, based on an examination by a physician employed by the Department (or, in areas where no such physician is available, by a physician carrying out such function under a contract or fee arrangement), that the medical condition of such veteran precludes appropriate treatment in Department facilities. (3) Hospital care or medical services in a non-Department facility for the treatment of medical emergencies which pose a serious threat to the life or health of a veteran receiving medical services in a Department facility or nursing home care under section 1720 of this title until such time following the furnishing of care in the non-Department facility as the veteran can be safely transferred to a Department facility. (4) Hospital care for women veterans. (5) Hospital care, or medical services that will obviate the need for hospital admission, for veterans in a State (other than the Commonwealth of Puerto Rico) not contiguous to the contiguous States, except that the annually determined hospital patient load and incidence of the furnishing of medical services to veterans hospitalized or treated at the expense of the Department in Government and non-Department facilities in each such noncontiguous State shall be consistent with the patient load or incidence of the furnishing of medical services for veterans hospitalized or treated by the Department within the 48 contiguous States and the Commonwealth of Puerto Rico. (6) Diagnostic services necessary for determination of eligibility for, or of the appropriate course of treatment in connection with, furnishing medical services at independent Department outpatient clinics to obviate the need for hospital admission. (7) Outpatient dental services and treatment, and related dental appliances, for a veteran described in section 1712(a)(1)(F) of this title. (8) Diagnostic services (on an inpatient or outpatient basis) for observation or examination of a person to determine eligibility for a benefit or service under laws administered by the Secretary. (9) Hospital care and medical services for veterans described in subsection (d)(1). (10) Hospital care and medical services, including counseling and related mental health services under section 1712A, for veterans meeting eligibility criteria for such care and services under the Patient-Centered Community Care program of the Department, as in effect on the day before the effective date under section 3(j)(2) of the Improving Veterans Care in the Community Act of 2016 . (11) Hospital care and medical services for veterans at medical facilities of the Indian Health Service or under the Tribal Health Program pursuant to sharing agreements entered into between the Department and the Indian Health Service, Indian tribes, or tribal organizations. (12) Hospital care and medical services for veterans at medical facilities of the Department of Defense pursuant to sharing agreements entered into between the Department of Veterans Affairs and the Department of Defense. (13) Hospital care and medical services for veterans at other non-Department facilities pursuant to sharing agreements entered into between the Department of Veterans Affairs and such facilities. (14) Hospital care and medical services for veterans at institutions affiliated with the Department under section 7302 of this title pursuant to contracts entered into with such institutions. (15) Reimbursement for payment made by veterans described in subsection (d)(2), or on behalf of such veterans, for emergency treatment furnished such veterans in non-Department facilities. (f) Referral for services (1) Except as provided in paragraph (2), a veteran is required to obtain a referral from a primary care provider of the Department to receive specialty care services under this section. Any such referral shall be reviewed by the director of the medical facility at which the primary care physician is located. (2) (A) A veteran described in any of clauses (i) through (v) of subsection (d)(1)(A) is not required to obtain a referral for specialty care services furnished under subsection (e)(9). (B) In the case of a veteran described in subparagraph (A), the Secretary, through the Non-VA Care Coordination Program of the Department, shall notify the primary care provider of the veteran of the specialty care appointment and ensure that the primary care provider receives materials from the specialty care provider necessary to update the medical record of the veteran as appropriate. (g) Payment rates (1) Subject to paragraph (2), the Secretary shall establish uniform rates for payment or reimbursement for care and services under this section. (2) In entering into contracts or agreements under this section with individuals and entities specified in subsection (c), the Secretary shall— (A) negotiate rates for the furnishing of care and services under this section; and (B) reimburse the individual or entity for such care and services at the rates negotiated pursuant to subparagraph (A) as provided in such contract or agreement. (3) (A) Except as provided in subparagraph (B), rates negotiated under paragraph (2)(A) shall not be more than the rates paid by the United States to a provider of services (as defined in section 1861(u) of the Social Security Act ( 42 U.S.C. 1395x(u) )) or a supplier (as defined in section 1861(d) of such Act ( 42 U.S.C. 1395x(d) )) under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) for the same care or services. (B) (i) The Secretary may negotiate a rate that is more than the rate paid by the United States as described in subparagraph (A) with respect to the furnishing of care or services under this section to a veteran who resides in a highly rural area. (ii) With respect to furnishing care or services under this section in Alaska, the Alaska Fee Schedule of the Department of Veterans Affairs shall be followed, except for when another payment agreement, including a contract or provider agreement, is in place. (iii) With respect to furnishing care or services under this section in a State with an All-Payer Model Agreement under section 1814(b)(3) of the Social Security Act ( 42 U.S.C. 1395f(b)(3) ) that became effective on January 1, 2014, the Medicare payment rates under subparagraph (A) shall be calculated based on the payment rates under such agreement. (iv) In this subparagraph, the term highly rural area means an area located in a county that has fewer than seven individuals residing in that county per square mile. (h) Administration (1) Except as provided in paragraph (2), the Secretary shall be responsible for administering the Care in the Community Program through the Non-VA Care Coordination Program of the Department. (2) The Non-VA Care Coordination Program, through each medical center of the Department, shall be responsible for handling the day-to-day administration of the Care in the Community Program, including finding providers, scheduling appointments, paying providers, and disseminating information to providers. (i) Outreach The Non-VA Care Coordination Program, through each medical center of the Department, shall be responsible for conducting outreach to health care providers and veterans located in the area covered by the medical center regarding care and services available under the Care in the Community Program. (j) Definitions In this section: (1) The term emergency treatment means medical care or services furnished, in the judgment of the Secretary— (A) when Department or other Federal facilities are not feasibly available and an attempt to use them beforehand would not be reasonable; (B) when such care or services are rendered in a medical emergency of such nature that a prudent layperson reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health; and (C) until— (i) such time as the veteran can be transferred safely to a Department facility or other Federal facility and such facility is capable of accepting such transfer; or (ii) such time as a Department facility or other Federal facility accepts such transfer if— (I) at the time the veteran could have been transferred safely to a Department facility or other Federal facility, no Department facility or other Federal facility agreed to accept such transfer; and (II) the non-Department facility in which such medical care or services was furnished made and documented reasonable attempts to transfer the veteran to a Department facility or other Federal facility. (2) The term health-plan contract includes any of the following: (A) An insurance policy or contract, medical or hospital service agreement, membership or subscription contract, or similar arrangement under which health services for individuals are provided or the expenses of such services are paid. (B) An insurance program described in section 1811 of the Social Security Act ( 42 U.S.C. 1395c ) or established by section 1831 of that Act ( 42 U.S.C. 1395j ). (C) A State plan for medical assistance approved under title XIX of such Act ( 42 U.S.C. 1396 et seq. ). (D) A workers' compensation law or plan described in section 1729(a)(2)(A) of this title. (3) The term third party means any of the following: (A) A Federal entity. (B) A State or political subdivision of a State. (C) An employer or an employer's insurance carrier. (D) An automobile accident reparations insurance carrier. (E) A person or entity obligated to provide, or to pay the expenses of, health services under a health-plan contract. . (2) Clerical amendment The table of sections at the beginning of chapter 17 of such title is amended by inserting after the item relating to section 1703 the following new item: 1703A. Care in the Community Program. . (b) Implementation (1) Initial implementation (A) In general Except as provided in subparagraph (B), during the one-year period beginning on the effective date specified in subsection (j)(1), the Secretary of Veterans Affairs shall implement the Care in the Community Program under section 1703A of title 38, United States Code, as added by subsection (a), by prioritizing the use of such Program in areas where there are medical facilities of the Department that are experiencing issues with quality of care or lack of capacity. (B) Exception for reimbursement for emergency care Reimbursement for payment made by veterans, or on behalf of such veterans, for emergency treatment furnished such veterans in non-Department facilities under section 1703A(e)(15) of such title, as so added, shall be implemented in all areas on and after the effective date specified in subsection (j)(1). (2) Full implementation (A) In general On and after the end of the one-year period described in paragraph (1)(A), the Secretary shall implement the Care in the Community Program under section 1703A of such title, as so added, in all areas. (B) Report If the Secretary is unable to implement the Care in the Community Program under section 1703A of such title, as so added, in all areas as of the date that is two years after the date of the enactment of this Act, the Secretary shall submit to Congress a report on why the Secretary is unable to implement such program in all areas. (c) Funding Amounts required to carry out the Care in the Community Program under section 1703A of title 38, United States Code, as added by subsection (a), shall be derived from the Medical Services account of the Department of Veterans Affairs or the Veterans Choice Fund under section 802 of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 1701 note), as amended by section 4 of this Act. (d) Treatment of other programs, contracts, and agreements (1) In general Any contract, sharing agreement, or other agreement entered into under any provision of law that authorizes individuals eligible for health care from the Department of Veterans Affairs to receive such care at facilities that are not facilities of the Department of Veterans Affairs shall be administered under the Care in the Community Program under section 1703A of title 38, United States Code, as added by subsection (a), on and after the effective date specified in subsection (j)(2). (2) Treatment of Patient-Centered Community Care program On and after the effective date specified in subsection (j)(2), the Secretary of Veterans Affairs may not carry out the Patient-Centered Community Care program of the Department of Veterans Affairs (commonly known as PC3 ) and shall ensure that beneficiaries under such program are able to receive care under the Care in the Community Program under section 1703A of title 38, United States Code, as added by subsection (a). (e) Patient advocacy Section 7309A of title 38, United States Code, is amended— (1) by redesignating subsections (e) and (f) as subsections (f) and (g), respectively; (2) by inserting after subsection (d) the following new subsection (e): (e) Education on non-Department care The Director shall develop and administer a program of education on the Care in the Community Program under section 1703A of this title that ensures veterans understand— (1) how the Care in the Community Program works; (2) how veterans become eligible for the Care in the Community Program; and (3) all issues regarding payment for care under the Care in the Community Program, including when the Department is the primary payer and when the Department is not the primary payer and the veteran may have to pay out of pocket. . (f) Extension of existing program Subsection (p) of section 101 of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 1701 note) is amended to read as follows: (p) Authority To furnish care and services The Secretary may not use the authority under this section to furnish care and services after the date on which the Secretary submits to Congress the certification described in section 3(j)(2) of the Improving Veterans Care in the Community Act of 2016 . . (g) Report on administrators of Choice Program (1) In general Not later than 180 days after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress a report on administrators used by the Department of Veterans Affairs to administer section 101 of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 1701 note). (2) Elements The report required by paragraph (1) shall include the following: (A) An assessment of the performance of administrators, including— (i) an examination of the ability of administrators to schedule appointments, reimburse providers in a timely manner, and meet the performance standards established by their contract with the Department of Veterans Affairs; and (ii) an assessment of the satisfaction of veterans with the work of administrators. (B) An assessment of the overlap of the work of administrators with the work of employees of the Department, especially employees at medical centers and community-based outpatient clinics and employees of the Non-VA Care Coordination Program. (C) An assessment of the resources needed by the Department to function without administrators in implementing the Care in the Community Program under section 1703A of title 38, United States Code, as added by subsection (a). (h) Repeal of superseded authority for contracts for care in non-Department facilities (1) In general Section 1703 of title 38, United States Code, is repealed. (2) Conforming amendments (A) Dental care Section 1712(a) of such title is amended— (i) in paragraph (3), by striking under clause (1), (2), or (5) of section 1703(a) of this title and inserting under section 1703A of this title ; and (ii) in paragraph (4)(A), in the first sentence, by striking section 1703 of this title each place it appears and inserting section 1703A of this title . (B) Readjustment counseling Section 1712A(e)(1) of such title is amended by striking sections 1703(a)(2) and 1710(a)(1)(B) and inserting sections 1703A and 1710(a)(1)(B) . (C) Death in Department facility Section 2303(a)(2)(B)(i) of such title is amended by striking in accordance with section 1703 and inserting under section 1703A . (D) Medicare provider agreements Section 1866(a)(1)(L) of the Social Security Act ( 42 U.S.C. 1395cc(a)(1)(L) ) is amended by striking under section 1703 of title 38 and inserting under section 1703A of title 38 . (i) Repeal of superseded authority for emergency treatment reimbursement (1) Non-service connected (A) In general Section 1725 of such title is repealed. (B) Conforming amendments (i) Medical care collections fund Section 1729A(b) of such title is amended— (I) by striking paragraph (5); and (II) by redesignating paragraphs (6) through (10) as paragraphs (5) through (9), respectively. (ii) Medical care for survivors and dependents Section 1781(a)(4) of such title is amended by striking section 1725(f) and inserting section 1703(j) . (iii) Health care for family members of veterans stationed at Camp Lejeune, North Carolina Section 1787(b)(3) of such title is amended by striking section 1725(f) and inserting section 1703(j) . (2) Service connected Section 1728 of such title is repealed. (j) Effective dates (1) Community Care Program The amendments made by subsections (a), (d), and (i) shall take effect on the date that is one year after the date of the enactment of this Act. (2) Repeal of superseded authority (A) In general The amendments made by subsection (h) shall take effect on the date on which the Secretary of Veterans Affairs certifies to Congress that the Secretary is fully implementing the Care in the Community Program under section 1703A of title 38, United States Code, as added by subsection (a). (B) Publication The Secretary shall publish the date specified in subparagraph (A) in the Federal Register not later than 90 days before such date. 4. Authorization of use of certain amounts appropriated to the Veterans Choice Fund for other non-Department of Veterans Affairs care Section 802 of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 128 Stat. 1801) is amended— (1) in subsection (c)— (A) in paragraph (1)— (i) by striking Except as provided by paragraph (3), any and inserting Any ; and (ii) by striking by the Secretary of Veterans Affairs and all that following through the period at the end and inserting “by the Secretary of Veterans Affairs— (A) to carry out section 101, including, subject to paragraph (2), any administrative requirements of such section; (B) to furnish health care to individuals under chapter 17 of title 38, United States Code, at non-Department facilities, including pursuant to non-Department provider programs other than the program under section 101; and (C) to furnish disability examinations conducted by health care providers that are not health care providers of the Department of Veterans Affairs. ; and (B) by striking paragraph (3) and inserting the following new paragraphs: (3) Treatment of amounts Amounts made available to the Secretary under this section shall be in addition to amounts made available to the Secretary in the Medical Services account of the Department of Veterans Affairs. (4) Definitions In this subsection: (A) The term non-Department facilities has the meaning given that term in section 1701 of title 38, United States Code. (B) The term non-Department provider programs has the meaning given that term in section 4002(d) of the VA Budget and Choice Improvement Act ( Public Law 114–41 ; 129 Stat. 462). ; and (2) in subsection (d)(1), by striking only for the program and all that follows through the period at the end and inserting only for the purposes specified in subsection (c)(1). . 5. Interdisciplinary panel on development of clinical appeals process for the Department of Veterans Affairs (a) In general The Secretary of Veterans Affairs shall establish an interdisciplinary panel to assist the Secretary in developing a new clinical appeals process for resolving disputes regarding health care furnished under the laws administered by the Secretary of Veterans Affairs, including health care furnished under the Care in the Community Program under section 1703A of title 38, United States Code, as added by section 3(a). (b) Duties The duties of the interdisciplinary panel established under subsection (a) are the following: (1) To create one process throughout the Veterans Health Administration for resolving clinical disputes. (2) To ensure that such process provides veterans with the ability to have an external review at his or her discretion. (3) To ensure that such process is as comprehensive and fair as processes provided by private health insurers and other Federal agencies. (c) Report Not later than one year after the date of the enactment of this Act, the Secretary shall submit to Congress a report on the activities of the interdisciplinary panel under this section. 6. Comptroller General reports on the Department of Veterans Affairs (a) Report on clinical operations of Veterans Health Administration Not later than one year after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress a report on the clinical operations of the Veterans Health Administration that includes an assessment of the following: (1) How such clinical operations can be enhanced. (2) What the Secretary of Veterans Affairs can do to ensure that highly trained clinical staff of the Department of Veterans Affairs are able to perform at the top of their license and are not performing tasks that should be done by support staff. (3) What the Secretary can do to improve the hiring, retaining, and training of medical support assistants of the Department. (b) Report on travel benefits program of Department Not later than one year after the date of the enactment of this Act, the Comptroller General shall submit to Congress a report on the travel benefits program of the Department under sections 111 and 111A of title 38, United States Code, that includes an assessment of the following: (1) How such program can be improved to ensure that veterans are reimbursed for travel in a timely manner. (2) What the Secretary can do to speed up the reimbursement process while protecting against fraud, waste, and abuse. (3) Whether there should be changes made to eligibility for such program. (c) Report on Office of Congressional and Legislative Affairs of Department Not later than one year after the date of the enactment of this Act, the Comptroller General shall submit to Congress a report on the structure and management of the Office of Congressional and Legislative Affairs of the Department, including an assessment of what the Secretary can do to enable the Office to provide more timely, complete responses to requests from Congress. (d) Report on payment for non-Department care Not later than one year after the date of the enactment of this Act, the Comptroller General shall submit to Congress a report on payment by the Department for health care furnished to veterans through non-Department health care providers, including an assessment of the following: (1) When the Department should be the primary payer for such care and when the Department should be the secondary payer for such care. (2) How payment by the Department for such care should function with coverage under private insurance, coverage under the Medicare program, and other health coverage options. 7. Establishment of Payment and Access Commission for Veterans Health Administration (a) Establishment Subchapter II of chapter 73 of title 38, United States Code, is amended by inserting after section 7330A the following new section: 7330B. Payment and Access Commission (a) Establishment There is established in the Veterans Health Administration a Payment and Access Commission (in this section referred to as the VHAPAC ). (b) Membership (1) The VHAPAC shall be composed of 17 members appointed by the Comptroller General of the United States. (2) (A) The membership of VHAPAC shall include the following: (i) Veterans who have received care from the Veterans Health Administration. (ii) Individuals with national recognition for their expertise with respect to— (I) Federal health programs; (II) health finance and economics; (III) actuarial science; (IV) health plans and integrated delivery systems; (V) reimbursement for health care; or (VI) health information technology. (iii) Providers of health services, public health, and other related fields. (iv) Physicians and other health professionals. (v) Individuals with expertise in the delivery of health services. (B) Members of the VHAPAC shall be appointed in a manner to provide a mix of different professions, broad geographic representation, and a balance between urban and rural representation. (C) Members described in clauses (iv) and (v) of subparagraph (A) shall include representatives of veterans, including veterans with disabilities, and caregivers. (D) Individuals who are directly involved in the provision, or management of the delivery, of items and services furnished by the Department shall not constitute a majority of the membership of the VHAPAC. (E) The Comptroller General of the United States shall establish a system for public disclosure by members of the VHAPAC of financial and other potential conflicts of interest relating to such members. (F) Members of the VHAPAC shall be treated as employees of Congress for purposes of applying title I of the Ethics in Government Act of 1978 (5 U.S.C. App.). (3) (A) The terms of members of the VHAPAC shall be for three years except that the Comptroller General of the United States shall designate staggered terms for the members first appointed. (B) Any member appointed to fill a vacancy occurring before the expiration of the term for which the member's predecessor was appointed shall be appointed only for the remainder of that term. A member may serve after the expiration of that member's term until a successor has taken office. A vacancy in the VHAPAC shall be filled in the manner in which the original appointment was made. (4) (A) While serving on the business of the VHAPAC (including travel time), a member of the VHAPAC shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule under section 5315 of title 5. (B) While serving on the business of the VHAPAC (including travel time) away from home and the member's regular place of business, a member may be allowed travel expenses, as authorized by the Chairman of the VHAPAC. (5) The Comptroller General of the United States shall designate a Chairman and Vice Chairman of the VHAPAC, at the time of appointment of each such individual as a member of the VHAPAC, for the term of appointment of such individual, except that in the case of vacancy of the Chairmanship or Vice Chairmanship, the Comptroller General may designate another member for the remainder of the term of the Chairman or Vice Chairman, as the case may be. (6) The VHAPAC shall meet at the call of the Chairman. (c) Duties (1) The VHAPAC shall— (A) review policies of the Veterans Health Administration affecting access of veterans to health care, including topics affected by the Care in the Community Program under section 1703A of this title; (B) make recommendations to Congress, the Secretary, and States concerning such access policies; and (C) by not later than March 15 of each year (beginning with 2018), submit to Congress a report containing— (i) the results of reviews conducted under subparagraph (A); (ii) recommendations made under subparagraph (B); and (iii) an examination of the implications of changes in health care delivery in the United States and in the market for health care services on health care furnished under the laws administered by the Secretary. (2) Specifically, the VHAPAC shall review and assess the following: (A) Payment policies regarding payment by the Secretary for health care furnished under the laws administered by the Secretary by non-Department providers, including— (i) the factors affecting expenditures for the efficient provision of items and services in different sectors, including the process for updating payments to medical, dental, and health professionals, hospitals, residential and long-term care providers, providers of home and community based services, Federally-qualified health centers and rural health clinics (as defined in section 1905(l) of the Social Security Act ( 42 U.S.C. 1396d(l) )), managed care entities, and providers of other covered items and services; (ii) payment methodologies; and (iii) the relationship of such factors and methodologies to access and quality of care for veterans receiving care under the laws administered by the Secretary (including how such factors and methodologies enable such veterans to obtain the services for which they are eligible, affect provider supply, and affect providers that serve a disproportionate share of low-income and other vulnerable populations). (B) Eligibility policies for receiving care under the laws administered by the Secretary, including the Care in the Community Program under section 1703A of this title. (C) Enrollment and retention processes for receiving care under the laws administered by the Secretary. (D) Policies of the Department relating to the quality of care furnished under the laws administered by the Secretary. (E) The effect of payment policies described in subparagraph (A), especially under the Care in the Community Program under section 1703A of this title, on access to items and services for veterans and the implications of changes in health care delivery in the United States and in the general market for health care items and services on such payment policies. (F) The interaction of policies of the Department, including under the Care in the Community Program, with the Medicaid and Medicare programs, private insurance, and other forms of health care coverage such as the TRICARE program (as defined in section 1072 of title 10), including with respect to how such interactions affect access to services, payments, and dual eligible individuals. (G) The effect of policies of the Department on access to covered items and services, including policies relating to transportation and preventive, acute, and long-term services and supports. (3) The VHAPAC shall— (A) review national data regarding health care furnished under the laws administered by the Secretary; and (B) submit reports and recommendations to Congress and the Secretary, including recommendations that do not require changes in law. (4) (A) The VHAPAC shall create an early-warning system to identify provider shortage areas, as well as other factors that adversely affect, or have the potential to adversely affect, access to care by, or the health care status of, veterans eligible for health care under the laws administered by the Secretary. (B) The VHAPAC shall include in the annual report required under paragraph (1)(C) a description of all areas and factors identified under subparagraph (A) with respect to the period addressed in the report. (5) (A) If the Secretary submits to Congress (or a committee of Congress) a report that is required by law and that relates to policies relating to access to health care under the laws administered by the Secretary, including with respect to payment policies for non-Department providers, the Secretary shall transmit a copy of the report to the VHAPAC. The VHAPAC shall review the report and, not later than 180 days after the date of submittal by the Secretary of the report to Congress, shall submit to the appropriate committees of Congress and the Secretary written comments on such report. Such comments may include such recommendations as the VHAPAC determines appropriate. (B) The VHAPAC shall review regulations of the Department relating to the provision of health care and may comment through submission of a report to the appropriate committees of Congress and the Secretary on any such regulations that affect access, quality, or efficiency of health care under the laws administered by the Secretary. (6) (A) The VHAPAC shall consult periodically with the chairmen and ranking minority members of the appropriate committees of Congress regarding the agenda of the VHAPAC and progress towards achieving that agenda. (B) The VHAPAC may conduct additional reviews and submit additional reports to the appropriate committees of Congress from time to time on such topics relating to the policies and programs of the Veterans Health Administration as may be requested by the chairmen and ranking minority members of such committees and as the VHAPAC determines appropriate. (7) The VHAPAC shall transmit to the Secretary a copy of each report submitted under this subsection and shall make such reports available to the public. (8) With respect to each recommendation contained in a report submitted under paragraph (1)(C), each member of the VHAPAC shall vote on the recommendation, and the VHAPAC shall include, by member, the results of that vote in the report containing the recommendation. (9) Before making any recommendations under this section, the VHAPAC shall examine the budget consequences of such recommendations, directly or through consultation with appropriate expert entities, and shall submit with any recommendations a report on the consequences to the Federal Government of the recommendations. (10) (A) The VHAPAC shall consult with the Medicare Payment Advisory Commission established under section 1805 of the Social Security Act ( 42 U.S.C. 1395b–6 ) in carrying out its duties under this section, as the VHAPAC determines appropriate. (B) The VHAPAC and the Medicare Payment Advisory Commission shall have access to deliberations and records of the other such entity, respectively, upon the request of the other such entity. (11) The VHAPAC shall regularly consult with veterans service organizations in carrying out its duties under this section, including with respect to developing processes for carrying out such duties, and shall ensure that input from veterans service organizations is taken into account and represented in recommendations and reports prepared by the VHAPAC. (12) The authority of the VHAPAC to make recommendations under this section shall not affect, or be considered to duplicate, the authority of the Secretary to carry out Federal responsibilities with respect to programs of the Veterans Health Administration. (13) In this subsection: (A) The term appropriate committees of Congress means the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives. (B) The term veterans service organization means an organization recognized by the Secretary for the representation of veterans under section 5902 of this title. (d) Personnel (1) Subject to such review as the Comptroller General of the United States determines necessary to assure the efficient administration of the VHAPAC, the VHAPAC may— (A) employ and fix the compensation of an Executive Director (subject to the approval of the Comptroller General) and such other personnel as may be necessary to carry out the duties of the VHAPAC (without regard to the provisions of title 5 governing appointments in the competitive service); (B) seek such assistance and support as may be required in the performance of the duties of the VHAPAC from appropriate Federal and State departments and agencies; (C) enter into contracts or make other arrangements as may be necessary for the conduct of the work of the VHAPAC (without regard to section 6101 of title 41); (D) make advance, progress, and other payments which relate to the work of the VHAPAC; (E) provide transportation and subsistence for persons serving without compensation; and (F) prescribe such rules and regulations as the VHAPAC determines necessary with respect to the internal organization and operation of the VHAPAC. (2) (A) For purposes of pay (other than pay of members of the VHAPAC) and employment benefits, rights, and privileges, all personnel of the VHAPAC shall be treated as if they were employees of the United States Senate. (B) Physicians serving as personnel of the VHAPAC may be provided a physician comparability allowance by the VHAPAC in the same manner as Government physicians may be provided such an allowance by an agency under section 5948 of title 5, and for such purpose subsection (i) of such section shall apply to the VHAPAC in the same manner as it applies to the Tennessee Valley Authority. (e) Powers (1) The VHAPAC may secure directly from any Federal agency information in the possession of that agency necessary to enable the VHAPAC to carry out this section. Upon request of the Chairman, the head of that agency shall furnish that information to the VHAPAC on an agreed upon schedule. (2) In order to carry out its functions, the VHAPAC shall— (A) if possible, use existing information, both published and unpublished, collected and assessed either by personnel of the VHAPAC or under other arrangements made in accordance with this section; (B) carry out, or award grants or contracts for, original research and experimentation if existing information is inadequate; and (C) adopt procedures allowing any interested party to submit information for use by the VHAPAC in making reports and recommendations. (3) The Comptroller General of the United States shall have unrestricted access to all deliberations, records, and nonproprietary data of the VHAPAC, immediately upon request. (4) The VHAPAC shall be subject to periodic audit by the Comptroller General. (f) Funding The VHAPAC shall submit requests for appropriations in the same manner as the Comptroller General of the United States submits requests for appropriations, but amounts appropriated for the VHAPAC shall be separate from amounts appropriated for the Comptroller General. . (b) Clerical amendment The table of sections at the beginning of chapter 73 of such title is amended by inserting after the item relating to section 7330A the following new item: 7330B. Payment and Access Commission. .